Sepsis in Pregnancy
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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.
Treatment of sepsis and septic shock in pregnancy should follow the Surviving Sepsis Guidelines with a focus on early restoration of circulating volume, antibiotic administration within one hour of identification, and source control. Maternal health supersedes any risk to the fetus and all treatments and diagnostics must be aggressively pursued. Genitourinary infections are the most common non-obstetric cause of sepsis in the pregnant population due to compression to the ureters. Providers must also take a detailed obstetric history to identify risk factors for conditions such as endometritis and chorioamnionitis. Early consultation with the obstetrics team and maternal fetal medicine is recommended for all patients. Empiric antibiotic regimens should include coverage for gram-negative and gram-positive bacteria and tailored based on blood and urine culture data. Adjunctive corticosteroid therapy can be considered for refractory cases.
KeywordsMaternal sepsis Septic shock Sepsis 3 Organ dysfunction Hypoperfusion Vasoactive therapy Quick sequential organ failure assessment (qSOFA) Lactate levels Source control Antimicrobial therapy Refractory septic shock
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