sepsis in pregnancy

Question 1

What % of maternal deaths are from sepsis

Most common pathogen causing maternal mortality

Answer 1

11% cause of maternal mortality is sepsis

Group A beta haemolytic streptococcal (GAS) infection is the most common pathogen (25-50% of deaths from sepsis)

Question 2

SOMANZ sepsis definition

What is septic shock

Answer 2

Sepsis is broadly defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

Septic shock is defined as a subset of sepsis in which profound circulatory, cellular, and metabolic abnormalities

Question 3

omqSOFA
Adapted for pregnancy

lower normal BPS
RR or GCS is not changed in pregnancy

Answer 3

Screening tool

When 2 or the following are present

• systolic blood pressure of 90 mmHg or less
• respiratory rate of 25/min or greater
• altered mentation (any state other than ‘Alert’ on maternal observation charts). GCS are not typically formally assessed as
part of routine observations in obstetric wards

Sepsis has been
defined as an acute change in the total SOFA score of ≥2 points consequent to infection.

Question 4

omSOFA score is looking for evidence of end organ damage

Answer 4

Score 0,1,2
Respiration
Pa02/Fi02
under 400/300-400/ under 300

coagulation
Platelets
over 150 / 100-150 / under 100

liver
Bili
less then 20 / 20-23 / more 32

cardiovascular
MAP
over 70 / under 70 / requiring vasopressors

CNS
alert / rousable by voice./ rousable by pain

Renal:
Cr
under 90/ 90-120/ over 120

Question 5

If sepsis progresses, septic shock may ensue and this is associated with a substantial increase in mortality compared to sepsis alone. The clinical criteria validated to identify septic shock in non-pregnant patients include:

Answer 5

• hypotension requiring vasopressor therapy to maintain a mean
arterial pressure 65 mmHg or greater (despite adequate fluid
resuscitation)
and
• serum lactate greater than 2 mmol/L after adequate
fluid resuscitation.

Question 6

What criteria should be implemented for post partum woman?

Answer 6

Given that maternal physiology gradually returns to normal postpartum, we recommend the definition of postpartum sepsis be the same as for non-pregnant patients after the first week postpartum

Question 7

How does fever affect fetal development

Answer 7

Increase in the rate of pregnancies affected by a neural tube defect in mothers who experienced fever in the first trimester or peri-conceptually (OR 2.9)
Oral clefts were also more common in mothers with fever early in pregnancy

Congenital heart defects were weakly associated with early maternal fever early in pregnancy No effect of maternal fever on the risk of miscarriage, stillbirth and PTL

Higher risk of autism or developmental delay if fever - risk reduced if used antipyrexics (retrospective study asking mums with children with autism)

Question 8

Basic investigations

for maternal sepsis

Answer 8

MEWS chart - improves earlier detection and treatment
2X sets blood cultures - SHOULD NOT DELAY THERAPY
From different sites, from any IV access devices

Culture as clinically indicated- urine, wound, placenta, CSF, nasopharengeal, stool

Lactate (levels over 2 increase risk mortality - ok if venous or arterial)
Pregnancy specific ranges should be used to interpret results

FBC
Coags
Cr U+Es
LFTs

Fetal assessment

Question 9

Initial management of sepsis

Answer 9

Fluid resistation
Correction of hypoxia
Antimicrobials 
source control
Consideration of appropriate location of care
VTE

Question 10

Fluid resuscitation

What to use

Answer 10

Optimise circulating volume and improve tissue perfusion Preferred Normal saline
If after 1-2 L the MAP is still low then care needs to be escalated

Question 11

How to deal with influenza causing sepsis

Answer 11

Neuraminidase inhibitors are recommended for the treatment of influenza. Oseltamivir (treatment dose: 75 mg capsule twice daily for five days) has more obstetric safety data available than zanamivir and is the agent of choice in pregnancy.40
There is a low rate of transplacental transfer, estimated at between 1 and 14% of maternal concentrations in ex vivo
perfusion studies.
In the setting of H1N1 pandemic influenza, early antiviral therapy (initiation < 2 days) in pregnant women was associated with an 84% reduction in admissions to
intensive care

Question 12

What is the role of VTE in the context of sepsis

Answer 12

Big risk factor - consider UH or LMWH

Question 13

Antibiotics and breast feeding?

Answer 13

While most antibiotics are found in breast milk of a lactating woman, the relative infant dose is generally small. Breastfed infants should be monitored for side effects such as diarrhoea,
vomiting, skin rash or thrush while their mothers are being treated

Question 14

Approach to antibiotic treatment

Answer 14

Empiric antibiotic treatment within one hour

Deescalate when the source is know

Question 15

considerations on sepsis and delivery

Answer 15

(i) the presence of
intrauterine sepsis; 
(ii) the nature of the maternal sepsis and response to initial resuscitation efforts;  
(iii) the gestation of the
pregnancy and fetal status.

In the setting of intrauterine sepsis, delivery should always be considered regardless of the gestation. Corticosteroids should be
considered for fetal lung maturation but this decision needs to be balanced against the urgency of delivery

In cases of extra-uterine sepsis, efforts to treat maternal sepsis and prolong gestation should be considered at gestations remote from term, although it is reasonable to consider delivery in term pregnancies as a means of improving maternal resuscitation
efforts. Fetal wellbeing should be monitored during maternal sepsis with the most gestation-appropriate method.

Question 16

What is the anesthetists role in managing maternal sepsis?

Answer 16

• initial resuscitation and stabilisation of the patient
• transfer of the sick patient (to imaging or intensive care unit)
• intra-operative care during delivery
• anaesthesia for surgical management of sepsis

Question 17

Consideration for spinal or epidural anaesthetic with a fever

Answer 17

Except in the most extraordinary circumstances, central neuronal block should not be performed in patients with untreated systemic infection.
Patients with evidence of systemic infection may safely undergo spinal anaesthesia, provided appropriate antibiotic therapy is
initiated before dural puncture and the patient has shown a response to therapy
Spinal can safely be performed in patients at risk of a low grade transient bacteraemia after dural puncture

Spinal has a lower complication risk then epidural

Question 18

How is general anaesthetic affected by the septic obstetric patient

Answer 18

The patient has a greater metabolic oxygen demand -
A – Airway: delayed gastric emptying with increased risk of reflux and aspiration. It is recommended that women are premedicated with combination antacid antihistamine prophylaxis
(eg effervescent ranitidine 150 mg). A rapid sequence induction is also recommended.
• B – Breathing: It is recommended women receive adequate
pre-oxygenation prior to anaesthesia induction. There is reduced functional residual capacity with increased ventilation/ perfusion mismatch. It is recommended ventilation strategies
to maintain oxygenation and minimise further lung injury are employed.
• C – Circulation: It is recommended to avoid aortocaval compression using a lateral uterine tilt, ensure adequate fluid resuscitation including the appropriate use of blood products
and if required, inotropic support. Alpha adrenergic agonists (specifically noradrenaline) are the agents of choice for maintenance of uteroplacental flow.