Sepsis in Pregnancy

SEPSIS IN
PREGNANCY
COMPOSED BY: Assoc Prof. Dr. Anjum Ara
Department of Gynae & Obstetrics
Sepsis in pregnancy is an important cause of
maternal death in UK. Severe sepsis with
acute organ dysfunction has mortality rate of
20%- 40% which increases to 60% if septic
shock develops
RISK FACTORS FOR SEPSIS
IN PREGNANCY
OBESITY
IMPAIRED GLUCOSE TOLERANCE / DIABETES
IMPAIRED IMMUNITY / IMMUNOSUPPRESANT MEDICATION
ANEMIA
VAGINAL DISCHARGE
HISTORY OF PELVIC INFECTION
HISTORY OF GROUP B STREPTOCOCCAL INFECTION
AMNIOCENTESIS & OTHER INVASIVE PROCEDURES
CERVICAL CERCLAGE
PROLONGED SPONTANEOUS RUPTURE OF MEMBRANES
GAS INFECTION IN CLOSE CONTACTS / FAMILY MEMBERS
CLINICAL FEATURES
SUGGESTIVE OF SEPSIS
FEVER / RIGORS
DIARRHOEA / VOMITING – may indicate exotoxin production (early toxic shock)
RASH (generalized streptococcal maculopapular rash)
ABDOMINAL / PELIVC PAIN & TENDERNESS
OFFENSIVE VAGINAL DISCHARGE
PRODUCTIVE COUGH
URINARY SYMPTOMS
CLINICAL SIGNS SUGGESTIVE OF SEPSIS INCLUDE ONE OR MOR
OF THE FOLLOWING:
• Pyrexia > 38°C or hypothermia < 36°C
• Tachycardia > 100 bpm
• Tachypnea > 20 breaths per minute
• Hypoxia
• Hypotension
• Oliguria
• Impaired consciousness
INVESTIGATIONS :
• Blood culture within 6 hours of identification of severe sepsis
• Serum Lactate
• Relevant imaging studies to confirm the source of infection
• Other samples for C/S as guided by clinical suspicion of the focus of infection, e.g
Throat Swab
MSU for C/S
HVS or CSF should be obtained prior to starting antibiotic therapy (as it
may become uninformative within few hours of commencing
antibiotics but must not delay antibiotic therapy.)

• Arterial blood gas measurements should be undertaken to assess for hypoxia.
• Laboratory findings suggestive if diagnosis of sepsis are:
WBC count > 12 x 109/L
Leukopenia WBC < 4 x 109/L
Plasma C. Reactive Protein > 7mg/L
Raised Lactate ≥ 4mmol/L

• Organ dysfunction variables include :
Oliguria –urine output < 0.5ml/kg/hr
(Despite adequate fluid resuscitation)
Raised creatinine > 44µmol/L
Coagulation abnormalities –
INR >1.5 sec or APTT > 60 sec
Thrombocytopenia < 100 x 109/L
Hyperbilirubinemia –
Plasma total Bilirubin > 70µmol/L
Ileus – Absent bowel sounds

WHEN SEPSIS IS SUSPECTED:
 Take expert advice of a consultant microbiologist or infectious disease physician
urgently.
INDICATIONS FOR TRANSFER TO ICU
SYSTEM INDICATION
Cardiovascular System Hypotension or raised serum lactate persisting despite fluid resuscitation,
suggesting need for inotropic support
Respiratory System Pulmonary Edema
Mechanical Ventilation
Airway Protection
Renal System Renal Dialysis
Neurological System Significantly decreased consciousness level
Miscellaneous Multi organ failure

Uncorrected acidosis
Hypothermia
Most common organism in pregnant women dying of sepsis is Group A Beta Hemolytic
Streptococcus & E-Coli.
In chorioamnionitis both gram negative & gram positive organisms are common.
Administration of intravenous broad spectrum antibiotics is recommended within 1 hour
suspicion of severe sepsis, with or without septic shock.
IF GENITAL TRACT SEPSIS IS SUSPECTED;

Prompt early treatment with a combination of high dose broad spectrum intravenous
antibiotic maybe life saving.
ROLE OF EARLY PROPHYLACTIC
ANTIBIOTIC TREATMENT :
Empirical use of broad spectrum antibiotics can prevent exotoxin production from gram
positive bacteria.
In addition to antimicrobial therapy, the source of sepsis should be dealt with , if possible.
FOR EXAMPLE: by delivery of the baby in case of chorioamnionitis.
TREATMENT IN SEVERE CASES:
Intravenous immunoglobulin (IVIG) is recommended for severe invasive

streptococcal or staphylococcal infection if other therapies have failed.
It neutralizes the super-antigen effect of exotoxins & inhibits the

production of interleukins. It is used after consultation with infectious
disease colleagues or medical microbiologists. IVIG is available from
blood transfusion department,
MONITORING OF FETUS, DECISION
ABOUT TIME & MODE OF DELIVERY:
In critically ill patients, birth of the baby may be considered if it would be beneficial for
the mother or the baby or both.
After counselling the patient, senior obstetrician should take the decision of time & mode
of delivery.
IF PRETERM DELIVERY IS ANTICIPATED, cautious considerations should be

given to the use of antenatal corticosteroid for fetal lung maturity.
During intrapartum period, continuous electronic fetal monitoring is
recommended. Changes in CTG such as; change in baseline variability or new
onset decelerations must prompt reassessment of maternal mean arterial
pressure, hypoxia and academia.
Epidural/ spinal anesthesia should be avoided in women with sepsis & a

general anesthesia will usually be required for caesarean section.
WHY IS THE FETUS AFFECTED IN A PREGNANT
WOMAN WITH MATERNAL SEPSIS ?
• Due to direct effect if infection in the fetus
• The effect of maternal illness/ shock
• Effect of maternal treatment
RISKS TO THE FETUS:

• Neonatal encephalopathy
• Cerebral palsy
Continuous electronic fetal
monitoring is recommended in
pregnant women with maternal
pyrexia (temp >38 C).
Objective evidence of
intrauterine infection is
associated with abnormal fetal
heart rate monitoring. (As
discussed earlier)
• However, electronic fetal monitoring is not a
sensitive predictor of early onset neonatal sepsis.
• Evidence regarding FBC in the presence of maternal
sepsis is insufficient.
• The mode of delivery should be individualized
depending upon the severity of the maternal illness,
duration of labour , gestational age and viability

GENERAL PROPHYLAXIS:
-Close household contacts of the woman with Group A streptococcal infection in peri-
partum period should have antibiotic prophylaxis.
-Healthcare workers who have been exposed to respiratory secretions of woman with
Group A streptococcal infection should be considered for antibiotic prophylaxis.
-Baby of the mother with GAS should also receive prophylactic antibiotics after
consultation with neonatologist.

-Group A streptococcal infection are
notifiable disease.
-Infection control team & consultant for

communicable disease should be
informed.
-Women suspected of or diagnosed with

Group A streptococcus should be isolated
in a single room to minimize the risk of
spreading to other women.

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SEPSIS IN

maternal death in UK. Severe sepsis with

acute organ dysfunction has mortality rate of

20%- 40% which increases to 60% if septic

RASH (generalized streptococcal maculopapular rash)

ABDOMINAL / PELIVC PAIN & TENDERNESS

OFFENSIVE VAGINAL DISCHARGE

• Pyrexia > 38°C or hypothermia < 36°C

• Tachycardia > 100 bpm

• Tachypnea > 20 breaths per minute

• Relevant imaging studies to confirm the source of infection

MSU for C/S

HVS or CSF should be obtained prior to starting antibiotic therapy (as it

may become uninformative within few hours of commencing

antibiotics but must not delay antibiotic therapy.)

• Laboratory findings suggestive if diagnosis of sepsis are:

WBC count > 12 x 109/L

Leukopenia WBC < 4 x 109/L

Plasma C. Reactive Protein > 7mg/L

Raised Lactate ≥ 4mmol/L

Raised creatinine > 44µmol/L

Thrombocytopenia < 100 x 109/L

Ileus – Absent bowel sounds

Neurological System Significantly decreased consciousness level

Miscellaneous Multi organ failure

IF GENITAL TRACT SEPSIS IS SUSPECTED;

Intravenous immunoglobulin (IVIG) is recommended for severe invasive

It neutralizes the super-antigen effect of exotoxins & inhibits the

IF PRETERM DELIVERY IS ANTICIPATED, cautious considerations should be

Epidural/ spinal anesthesia should be avoided in women with sepsis & a

RISKS TO THE FETUS:

sensitive predictor of early onset neonatal sepsis.

• Evidence regarding FBC in the presence of maternal

• The mode of delivery should be individualized

depending upon the severity of the maternal illness,

duration of labour , gestational age and viability

partum period should have antibiotic prophylaxis.

Group A streptococcal infection should be considered for antibiotic prophylaxis.

consultation with neonatologist.

-Infection control team & consultant for

-Women suspected of or diagnosed with

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