Infection and Sepsis in Pregnancy

Hyperthermia after epidural analgesia in obstetrics

Sepsis during pregnancy is one of the five leading causes of maternal mortality worldwide. Early recognition and prompt treatment of maternal sepsis is necessary to improve patient outcomes. Patient education on practices that reduce infections may be helpful in decreasing rates of sepsis. Education of nurses about early signs and symptoms of sepsis in pregnancy and use of obstetric-specific tools can assist in timely identification and better outcomes. Although the Surviving Sepsis Campaign (SSC) criteria for diagnosis of sepsis in the general population are not pertinent for obstetric patients, their treatment bundles (guidelines) are applicable and can be used to guide care of obstetric patients who develop sepsis.This article is the third in a series of three that discuss the importance of sepsis and septic shock in pregnancy. This article includes case studies, treatment, prognosis, education, and prevention of maternal sepsis.

Introduction: Severe sepsis is a leading cause of death in intensive care units with mortality rates up to 30%. However, in pregnancy; the rates of severe sepsis are very low. A retrospective study from an administrative database reported the rate of sepsis in pregnancy to be about 0.3% in the year 2000. The literature with regards to outcomes of severe sepsis in pregnancy is small and mostly from single centers. Methods: Using the Nationwide Inpatient Sample 2000–2009, pregnant patients aged 18 and above were identified using ICD-9-CM codes. Severe sepsis were also identified using appropriate ICD-9CM codes as described in the literature. Outcome variables included frequency, in-hospital mortality and other outcomes. The yearly rates of pregnancies in United States were obtained from National Vital Statistics Reports. Chi square test was used to compare variables for unadjusted analysis. Results: There were total of 45,107,956 pregnancy related discharges from 2000 to 2009. Of these 19,351 (0.04%) met criteria for severe sepsis. The annual incidence of severe sepsis increased from 21 per 100,000 pregnancies in 2000 and 74 per 100,000 pregnancies in 2009. 50% of the severe sepsis was from puerperal infections. The in hospital mortality in pregnant women with severe sepsis was 6.8%; this did not change significantly from 2000 to 2009. In comparison, the in hospital mortality of severe sepsis in non pregnant women was 30.3%. Severe sepsis accounted for 23% of all deaths in pregnant women. The mean length of hospital stay was 2.6 days in pregnant women without sepsis while it was 12.9 days in those with severe sepsis. Conclusions: Severe sepsis in pregnancy is infrequent and has lower overall mortality when compared to the general population. However it accounts for approximately 25% of in-hospital pregnancy related deaths. The in-hospital mortality from severe sepsis in pregnancy has not changed from 2000 to 2009.

The Society of Australia and New Zealand (SOMANZ) published its first sepsis in pregnancy and the postpartum period guideline in 2017 (Aust N Z J Obstet Gynaecol, 57, 2017, 540). In the intervening 6 years, maternal mortality from sepsis has remained static. To update clinical practice with a review of the subsequent literature. In particular, to review the definition and screening tools for the diagnosis of sepsis. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women analysed the clinical evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system following searches of Cochrane, Medline and EMBASE. Where there were conflicting views, the authors reviewed the topic and came to a consensus. All authors reviewed the final position statement. This position statement has abandoned the use of the quick Sequential Organ Failure Assessment score (qSOFA) score to diagnose sepsis due to its poor performance in clinical practice. Whilst New Zealand has a national maternity observation chart, in Australia maternity early warning system charts and vital sign cut-offs differ between states. Rapid recognition, early antimicrobials and involvement of senior staff remain essential factors to improving outcomes. Ongoing research is required to discover and validate tools to recognize and diagnose sepsis in pregnancy. Australia should follow New Zealand and have a single national maternity early warning system observation chart.

Sepsis in pregnancy has been identified by the World Health Organization (WHO) as the third leading cause of maternal death worldwide after hemorrhage and hypertensive disorders. While there has been considerable research interest and monetary investment in sepsis research over the past 20 years, no trial to date has included the pregnant and post-partum populations. Providers must have an understanding of the normal physiologic changes that occur during pregnancy, i.e., leukocytosis, decreased blood pressure, and increased cardiac output, that can make the diagnosis of sepsis in pregnancy less obvious. These normal variations provide a challenge to the bedside clinician as the common screening tools utilized (SIRS criteria, qSOFA) will be positive during a healthy pregnancy. Additionally, providers need to have a high index of suspicion for obstetric specific complications and their treatments.

ObjectiveTo identify factors associated with progression from pregnancy‐associated severe sepsis to death in the UK.DesignA population‐based case‐control analysis using data from the UK Obstetric Surveillance System (UKOSS) and the UK Confidential Enquiry into Maternal Death (CEMD).SettingAll pregnancy care and death settings in UK hospitals.PopulationAll non‐influenza sepsis‐related maternal deaths (January 2009 to December 2012) were included as cases (n = 43), and all women who survived severe non‐influenza sepsis in pregnancy (June 2011 to May 2012) were included as controls (n = 358).MethodsCases and controls were identified using the CEMD and UKOSS. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals.Main outcome measuresOdds ratios for socio‐demographic, medical, obstetric and management factors in women who died from sepsis, compared with those who survived.ResultsFour factors were included in the final regression model. Women who died were more likely to have never received antibiotics [aOR = 22.7, 95% confidence interval (CI) 3.64–141.6], to have medical comorbidities (aOR = 2.53, 95%CI 1.23–5.23) and to be multiparous (aOR = 3.57, 95%CI 1.62–7.89). Anaemia (aOR = 13.5, 95%CI 3.17–57.6) and immunosuppression (aOR = 15.0, 95%CI 1.93–116.9) were the two most important factors driving the association between medical comorbidities and progression to death.ConclusionsThere must be continued vigilance for the risks of infection in pregnant women with medical comorbidities. Improved adherence to national guidelines, alongside prompt recognition and treatment with antibiotics, may reduce the burden from sepsis‐related maternal deaths.Tweetable abstractMedical comorbidities, multiparity and antibiotic delays increase the risk of death from maternal sepsis.

This study aims to assess the risk of morbidity associated with maternal lactic acid concentration in women with possible sepsis in pregnancy. Retrospective cohort of pregnant and postpartum patients with signs of sepsis. Morbidity outcomes were compared by lactic acid concentration. Linear regression was used to evaluate the association between lactic acid and adverse outcomes. Out of the 850 women included, 159 had lactic acid measured. Patients with lactic acid measured had higher morbidity: positive blood cultures (16.8 vs. 5.5%, p = 0.04), admission to the intensive care unit (5 vs. 0.1%, p < 0.01) or acute monitoring unit (17.2 vs. 0.9%, p < 0.01), longer hospital stay (median 3 vs. 2 days, p < 0.01), and preterm delivery (18.3 vs. 10.9%, p = 0.05). The mean lactic concentration was higher in patients admitted to the intensive care (2.6 vs. 1.6 mmol/L, p = 0.04) and telemetry unit (2.0 vs. 1.6, p = 0.03), and in those with positive blood cultures (2.2 vs. 1.6, p < 0.01). Lactic acid was positively associated with intensive care or telemetry unit admission, adjusted odds ratio per 1 mmol/L increase in lactic acid 2.34 (95% confidence interval, 1.33-4.12). Elevated lactic acid in pregnancy is associated with adverse maternal outcomes from presumed sepsis. In this cohort, lactic acid measurement was a marker of more severe infection.

This chapter discusses sepsis in pregnancy, and outlines the causes, risk factors, symptoms, investigations, and management of maternal sepsis and postpartum infections such as endometritis, septic pelvic thrombophlebitis, urinary tract infections, mastitis and breast abscess, and wound and episiotomy infection.

Sepsis is a complex, multi-organ disorder that may have catastrophic effects on the woman and fetus, resulting in the rapid deterioration of the woman's health and subsequent serious morbidity and mortality. Guidelines specifically for pregnant women are derived from research on the non-pregnant population, and a lack of hospital guidelines for the management of sepsis in pregnancy has been identified. Considerations of physiological changes that occur in pregnant women make diagnostic thresholds difficult, thus identifying the need for a standard definition of sepsis in the obstetric population. This article will discuss the diagnosis and the midwife's role in the management of sepsis in pregnancy.

Identification of Risk Factors and Prediction of Sepsis in Pregnancy Using Machine Learning Methods

The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant patients. This narrative review evaluates the presentation, scoring systems for risk stratification, diagnosis, and management of sepsis in pregnancy. Sepsis is potentially fatal, but literature for the evaluation and treatment of this condition in pregnancy is scarce. While the definition and considerations of sepsis have changed with large, randomized controlled trials, pregnancy has consistently been among the exclusion criteria. The two pregnancy-specific sepsis scoring systems, the modified obstetric early warning scoring system (MOEWS) and Sepsis in Obstetrics Score (SOS), present a number of limitations for application in the emergency department (ED) setting. Methods of generation and subsequently limited validation leave significant gaps in identification of septic pregnant patients. Management requires consideration of a variety of sources in the septic pregnant patient. The underlying physiologic nature of pregnancy also highlights the need to individualize resuscitation and critical care efforts in this unique patient population. Pregnant septic patients require specific considerations and treatment goals to provide optimal care for this particular population. Guidelines and scoring systems currently exist, but further studies are required.

Sepsis is one of the leading causes of maternal morbidity and mortality worldwide and a major public health concern, often associated with delayed diagnosis, suboptimal management, and poor perinatal outcomes. The aim of this study was to review and compare the most recently published influential guidelines on the prevention, diagnosis, and management of this complication during antenatal, intrapartum, and postpartum periods. A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Society for Maternal-Fetal Medicine (SMFM), the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ), the World Health Organization (WHO), and the Society of Obstetricians and Gynecologists of Canada (SOGC) on maternal and puerperal sepsis was carried out. RCOG, SMFM, and SOMANZ provide guidance on the diagnosis and management of sepsis in pregnancy and the puerperium, whereas the WHO and the SOGC refer only to the prevention of peripartum infections. There is a consensus among the reviewed guidelines that a detailed personal history, along with physical examination, cultures, laboratory tests, and appropriate imaging, is the mainstay in sepsis diagnosis; however, there are several discrepancies regarding the diagnostic criteria. On management, the necessity of broad-spectrum antibiotics administration, within the first hour from recognition, and early source control are underlined by RCOG, SMFM, and SOMANZ. Furthermore, adequate fluid resuscitation with crystalloids is required, targeting for a mean arterial pressure (MAP) >65 mm Hg, whereas persistent hypotension or tissue hypoperfusion should be managed with vasopressors. In addition, RCOG, SMFM, and SOMANZ agree that increased fetal surveillance is warranted in case of maternal sepsis and point out that the decision regarding the optimal time of delivery should be guided according to maternal and fetal condition. In case of preterm labor, the use of corticosteroids should be considered. Moreover, SOMANZ and SMFM recommend thromboprophylaxis for septic women. With regards to prevention of peripartum infections, the WHO recommends prophylactic antibiotic administration in case of cesarean delivery, group B Streptococcus colonization, manual placenta removal, third/fourth-degree perineal tears, and preterm premature rupture of membranes, while discouraging antibiotics in case of preterm labor with intact membranes, prelabor rupture of membranes at term, meconium-stained amniotic fluid, uncomplicated vaginal birth, episiotomy, and operative vaginal delivery. Finally, SOGC, although supporting antibiotic prophylaxis for cesarean delivery and third/fourth-degree perineal injury, does not recommend this intervention in case of manual placenta removal, postpartum dilatation, and curettage for retained products of conception, operative vaginal delivery, and cervical cerclage. Sepsis remains a significant contributor of maternal morbidity and mortality with a constantly rising global incidence, despite the advances in diagnostic and therapeutic techniques. Thus, the development of consistent international practice protocols for the prevention, timely recognition, and effective management of this complication both in pregnancy and in the puerperium seems of paramount importance to safely guide clinical practice and subsequently improve perinatal outcomes.

(Anesth Analg. 2019;129:1613–1620) Sepsis is the third leading cause of maternal morbidity and mortality, making up ∼12.7% of pregnancy-related deaths. Early identification and prompt treatment of patients can improve maternal outcomes. However, it is difficult to diagnose sepsis in pregnancy because physiological changes of pregnancy can mimic the signs of sepsis. The quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) criteria, systemic inflammatory response syndrome (SIRS) criteria, and the maternal early warning (MEW) criteria all provide different screening methods that may be useful, but their validity for the identification of early sepsis in pregnancy are unknown. Therefore, the primary objective of this multicenter case-control study was to evaluate the performance characteristics of the SIRS, qSOFA, and MEW criteria for identifying cases of early maternal sepsis during perinatal hospitalization. In addition, the authors sought to identify which of the 3 screening criteria is best used in maternal sepsis.

Internal Validation of the Sepsis in Obstetrics Score to Identify Risk of Morbidity From Sepsis in Pregnancy.

Maternal Sepsis and Septic Shock