Maternal Sepsis/Septic Shock

Clinical description

Maternal sepsis is “a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period.” a,b Sepsis occurs when the body’s response to infection causes injury to its own tissues and organs.b Definitive evidence of organ dysfunction can be difficult to determine with limited resources, but critical features that mark when infection has progressed to sepsis and which should prompt immediate action are:

1) a fast heart rate (greater than 120) 2) low blood pressure (systolic blood pressure less than 90) 3) respiratory distress (reduced oxygen saturations < 94% or respiratory rate greater than 25) 4) jaundice 5) reduced urine output (less than 0.5ml/kg//hour) 6) reduced level of consciousness There is a spectrum of disease, ranging from sepsis to septic shock. Septic shock is a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.

Signs and symptoms

History Identify the source of infection, i.e., dysuria, cough, recent abortion or delivery. Identify important risk factors such as severe anemia and HIV status. Identify antibiotic allergies.

Exam Measure vital signs to determine if sepsis is suspected using features listed above.

Careful physical examination for source of infection.

Investigations FBC, blood mcs, urine mcs, malaria, and HIV testing. Consider further microbiology investigations such as lumbar puncture or other swabs for microscopy e.g. high vaginal swab as appropriate. Consider if additional imaging is required, e.g. ultrasound, CXR

Treatment

• Airway, breathing, circulation (ABC)
• O2 (can be discontinued if normal oxygen saturations)
• Correct hypotension with IV crystalloid fluids (up to 30 ml per kg over first 3 hours, given as 500

ml rapid boluses). Caution and senior advice are required in women with pre-eclampsia or severe anaemia.

• If persistent hypotension, then consult anesthesia to give norepinephrine or phenylephrine
• If myocardial dysfunction suspected, consult Medicine and Anesthesia
• Broad spectrum intravenous antibiotics should be commenced urgently (Ceftriaxone + Flagyl or X-

Penicillin + Gentamicin + Flagyl for 7 days if source is not known). As soon as source is identified, antibiotics should be selected according to Malawi Standard Treatment Guideline recommendations.

• Remove the source. E.g. Incision and drainage, delivery, laparotomy, evacuation of retained products, as

directed by infectious source.

• Monitor response to treatment by charting the vital signs. Consider monitoring of the fetus or neonate if

appropriate.

• If not responding to initial treatment or septic shock, then transfer to HDU or ICU for intensive monitoring

aWHO statement on maternal sepsis. http://apps.who.int/iris/bitstream/10665/254608/1/WHO-RHR-17.02-eng.pdf.

bSinger M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10, cRhodes et al. Surviving Sepsis Campaign: International Guidelines for management of Sepsis and Septic Shock:

2016. Critical Care Medicine. 2017.