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Obstetric Sepsis and Management

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Abstract

Maternal sepsis remains one of the main causes of maternal morbidity and mortality. According to reports, direct obstetric infections are the third most common cause of maternal mortality, accounting for 10.7% of all maternal deaths in low-and middle-income countries and 4.7% in high-income nations. The assessment of maternal sepsis is extremely difficult due to the physiological changes and the variety of sepsis criteria. Early indications of sepsis can be difficult to detect due to typical physiological changes throughout pregnancy and maternal efforts during labor. The symptoms of sepsis such as tachycardia, tachypnea, and leukophilia are, as well, typical physiological changes that occur throughout pregnancy and childbirth. The vaginal, urinary, and respiratory tracts are frequently the sites of infection that can potentially lead to sepsis during pregnancy. Endometritis is the most typical postpartum infection linked to sepsis. In addition to the pregnancy itself, pregnant and puerperal women may be at risk for sepsis for additional reasons. In the obstetric population, sepsis clinical characteristics can differ and may also depend on the infection’s origin. A variety of diagnostic scoring systems and methods have been offered to address the challenges in the diagnosis of sepsis in the obstetric population. These scoring systems were created to help clinicians quickly assess the severity of each patient’s condition and initiate interventions, thereby lowering morbidity and death. Specific to maternity settings are MEOWS (Modified Early Obstetric Warning System) and SOS (Sepsis in Obstetrics Score). Obstetric sepsis is managed by resuscitating and stabilizing the patient, halting further deterioration, and enhancing tissue perfusion to limit or avoid organ damage. According to the widely accepted SSC (Surviving Sepsis Campaign) Guideline, the SSC Hour-1 bundle, which consists of several interventions, should be started within 1 h of the diagnosis of sepsis. Broad-spectrum antibiotics must be chosen to cover a variety of frequently implicated pathogens, including both gram-negative and gram-positive microorganisms and anaerobes, for initial therapy. A change toward a personalized care approach is consequently being developed and utilized more frequently as a result of new technologies and growing evidence.

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Significant progress has been made in reducing maternal and neonatal mortality in the past 15 years, but additional improvements will require a comprehensive approach that targets all causes of maternal and newborn mortality.1 Further reduction of maternal and newborn deaths is a priority for achieving the Sustainable Development Goals and for implementing the UN Global Strategy for Women's, Children's and Adolescents' Health, and is also critical for two strategic plans—Every Newborn: An Action Plan to End Preventable Deaths (ENAP) and the Strategies toward Ending Preventable Maternal Mortality (EPMM).
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Article
Objective To determine the incidence of maternal bacteraemia during pregnancy and for 6 weeks postpartum, describe the gestation/stage at which sepsis occurs, the causative microorganisms, antibiotic resistance and review maternal, fetal and neonatal outcome.DesignProspective review.SettingTwo tertiary referral, maternity hospitals in Dublin, Ireland.PopulationDuring 2005-2012 inclusive, 150 043 pregnant women attended and 24.4% of infants born in Ireland were delivered at the hospitals.Methods Demographic, clinical, microbiological and outcome data was collected from women with sepsis and compared with controls.Main outcome measuresIncidence, bacterial aetiology, gestation/stage at delivery, mode of delivery, antibiotic resistance, admission to augmented care, maternal, fetal and neonatal outcome.ResultsThe sepsis rate was 1.81 per 1000 pregnant women. Escherichia coli was the predominant pathogen, followed by Group B Streptococcus. Sepsis was more frequent among nulliparous women (odds ratio [OR] 1.39; 95% confidence interval [CI] 1.07-1.79) and multiple births (OR 2.04; 95% CI 0.98-4.08). Seventeen percent of sepsis episodes occurred antenatally, 36% intrapartum and 47% postpartum. The source of infection was the genital tract in 61% (95% CI 55.1-66.6) of patients and the urinary tract in 25% (95% CI 20.2-30.5). Sepsis was associated with preterm delivery (OR 2.81; 95% CI 1.99-3.96) and a high perinatal mortality rate (OR =5.78; 95% CI 2.89-11.21). Almost 14% of women required admission to augmented care. The most virulent organisms were Group A Streptococcus linked to postpartum sepsis at term and preterm Escherichia coli sepsis.Conclusions Maternal sepsis is associated with preterm birth, a high perinatal mortality rate and nulliparous women.
Article
To design an emergency department (ED) sepsis scoring system to identify risk of intensive care unit (ICU) admission in pregnant and postpartum women. The Sepsis in Obstetrics Score (S.O.S.) was created by modifying validated scoring systems in accordance with recognized physiologic changes of pregnancy. The S.O.S was applied to a retrospective cohort of pregnant and postpartum patients between February 2009 and May 2011 with clinical suspicion of sepsis. The primary outcome was ICU admission. Secondary outcomes were telemetry unit admission, length of stay, positive blood cultures, positive influenza swabs, perinatal outcome, and maternal mortality. Receiver operating characteristic (ROC) curves were constructed to estimate the optimal score for identification of risk of ICU admission. 850 eligible women were included. There were 9 ICU (1.1%) and 32 telemetry (3.8%) admissions, and no maternal deaths. The S.O.S. had an AUC of 0.97 for ICU admission. An S.O.S. ≥ 6 (maximum score 28) had an AUC of 0.92 with a sensitivity of 88.9%, a specificity of 95.2%, a positive predictive value of 16.7%, and a negative predictive value of 99.9% for ICU admission, with an adjusted odds ratio of 109 (95% confidence interval, 18 - 661). An S.O.S. ≥ 6 was independently associated with increased ICU or telemetry unit admissions, positive blood cultures, and fetal tachycardia. A sepsis scoring system designed specifically for an obstetric population appears to reliably identify patients at high risk for admission to the ICU. Prospective validation is warranted.
Article
Mortality from sepsis and septic shock remains high. Results of trials on intravenous immunoglobulins (IVIG) as adjunctive therapy for sepsis have been conflicting. This is an update of a Cochrane review that was originally published in 1999 and updated in 2002 and 2010. To estimate the effects of IVIG as adjunctive therapy in patients with bacterial sepsis or septic shock on mortality, bacteriological failure rates, and duration of stay in hospital. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), MEDLINE (1966 to December 2012), and EMBASE (1988 to December 2012). We contacted investigators in the field for unpublished data. The original search was performed in 1999 and updated in 2002 and 2008. We included randomized controlled trials comparing IVIG (monoclonal or polyclonal) with placebo or no intervention in patients of any age with bacterial sepsis or septic shock. Two authors independently assessed the studies for inclusion and undertook methodologic quality assessment and data abstraction. We conducted pre-specified subgroup analyses by type of immunoglobulin preparation. We included 43 studies that met our inclusion criteria in this updated review out of 88 potentially eligible studies. The studies included a large polyclonal IVIG trial in neonates that was concluded in 2011 and classified as ongoing in the 2010 version of this review. Pooled analysis of polyclonal and monoclonal IVIG was not done due to clinical heterogeneity. Subgroup analysis of 10 polyclonal IVIG trials (n = 1430) and seven trials on IgM-enriched polyclonal IVIG (n = 528) showed significant reductions in mortality in adults with sepsis compared to placebo or no intervention (relative risk (RR) 0.81; 95% confidence interval (CI) 0.70 to 0.93 and RR 0.66; 95% CI 0.51 to 0.85, respectively). Subgroup analysis of polyclonal IVIG in neonates, which now includes the recently concluded large polyclonal IVIG trial, showed no significant reduction in mortality for standard IVIG (RR 1.00; 95% CI 0.92 to 1.08; five trials, n = 3667) and IgM-enriched polyclonal IVIG (RR 0.57; 95% CI 0.31 to 1.04; three trials, n = 164). Sensitivity analysis of trials with low risk of bias showed no reduction in mortality with polyclonal IVIG in adults (RR 0.97; 95% CI 0.81 to 1.15; five trials, n = 945) and neonates (RR 1.01; 95% CI 0.93 to 1.09; three trials, n = 3561). Mortality was not reduced among patients (eight trials, n = 4671) who received anti-endotoxin antibodies (RR 0.99; 95% CI 0.91 to1.06) while anti-cytokines (nine trials, n = 7893) demonstrated a marginal reduction in mortality (RR 0.92; 95% CI 0.86 to 0.97). Polyclonal IVIG reduced mortality among adults with sepsis but this benefit was not seen in trials with low risk of bias. Among neonates with sepsis, there is sufficient evidence that standard polyclonal IVIG, as adjunctive therapy, does not reduce mortality based on the inclusion of the large polyclonal IVIG trial on neonates. For Ig-M enriched IVIG, the trials on neonates and adults were small and the totality of the evidence is still insufficient to support a robust conclusion of benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.
Article
A protected, triple-lumen transcervical culture method was used to recover organisms from the endometrium. At least one facultative or one anaerobic species of bacteria was recovered from 82% of the patients, and genital mycoplasmas were recovered from 76% of the women with endometritis. Bacteria together with genital mycoplasmas were present in 61% of the women, bacteria alone were present in 20%, genital mycoplasmas alone were present in 16%, and Chlamydia trachomatis was isolated from 2% of the patients. The most common organisms included Gardnerella vaginalis, Peptococcus spp., Bacteroides spp., Staphylococcus epidermidis, group B Streptococcus, and Ureaplasma urealyticum. A randomized, double-blind regimen of either piperacillin or cefoxitin was equally successful in treating the postpartum endometritis.
Article
To summarize the pathophysiology and treatment of acute lung injury and acute respiratory distress syndrome (ARDS) during pregnancy. Review of select articles from MEDLINE, including published abstracts, case reports, observational studies, controlled trials, review articles, and institutional experience. ARDS occurs in pregnancy and may have unique causes. Despite extensive clinical research to improve the management of ARDS, mortality remains high, and few strategies have shown a mortality benefit. Furthermore, in most published studies, pregnancy is an exclusionary criterion, and thus, few treatments have been adequately evaluated in obstetric populations. The treatment of ARDS in pregnancy is extrapolated from studies performed in the general ARDS patient population, with consideration given to the normal physiologic changes of pregnancy. In general, the best support of the fetus is support of the mother. From the age of viability (24-26 wks at most institutions) until full term, decisions regarding delivery should be made based primarily on the standard obstetric indications. Little evidence exists regarding the management of ARDS specifically in pregnancy, and thus, treatment approaches must be drawn from studies performed in a general patient population. A multidisciplinary approach involving maternal-fetal medicine, neonatology, anesthesiology, and intensivist clinicians is essential to optimizing maternal and fetal outcomes.
Article
To determine the utility of an initial serum lactate measurement for identifying high risk of death in patients with infection. Post-hoc analysis of a prospectively compiled registry in an urban academic hospital. Patients with (a) a primary or secondary diagnosis of infection and (b) lactate measurement who were admitted over the 18 months following hospital-wide implementation of the Surviving Sepsis Campaign guideline for lactate measurement in patients with infection and possible severe sepsis. There were 1,177 unique patients, with an in-hospital mortality of 19%. Outcome measures included acute-phase (<or=3 days) death and in-hospital death. We defined lactate ranges a priori (low, 0.0-2.0; intermediate, 2.1-3.9; high, 4.0 mmol/l or above)--and tested for linear associations with mortality by one-way analysis of variance. We determined sensitivity/specificity, odds ratios, and likelihood ratios for a lactate >or=4.0 mmol/l and performed a Bayesian analysis to determine its impact on a full range (0.01-0.99) of hypothetical pretest probability estimates for death. In-hospital mortality was 15%, 25%, and 38% in low, intermediate, and high lactate groups, respectively. Acute-phase deaths and in-hospital deaths increased linearly with lactate. An initial lactate >or=4.0 mmol/l was associated with sixfold higher odds of acute-phase death; however, a lactate level less than 4 mmol/l had little impact on probability of death. When broadly implemented in routine practice, measurement of lactate in patients with infection and possible sepsis can affect assessment of mortality risk. Specifically, an initial lactate >or=4.0 mmol/l substantially increases the probability of acute-phase death.
Shriver National Institute of Child Health and Human Development Neonatal Research Network. Early onset neonatal sepsis: the burden of group B streptococcal and E. coli disease continues
  • B J Stoll
  • N I Hansen
  • P J Sánchez
  • R G Faix
  • B B Poindexter
  • K P Van Meurs
  • Eunice Kennedy
Inpatient maternal sepsis tool. sepsistrust.org
  • Uk Sepsis The
  • Trust