Take home message:

 

1.   It‘s about time! Always think of sepsis or hemorrhage with any changes in the mother's state of health.  
2.   Use your localized Early Obstetric Warning System 
3.   Give IV antibiotics early and according to localized sepsis guidelines
4.   Noradrenaline is the vasopressor of the first choice. Think to add vasopresine in higher doses

What is sepsis ? 

  Risk factors for sepsis

  Women who are pregnant could contract an infection that can lead to sepsis at any time during their pregnancy and within   the following weeks. Although maternal sepsis can strike anyone, these factors could increase the risk:

• Miscarriage
• Abortion
• Invasive tests during pregnancy
• Cesarean section
• Preterm delivery
• Prolonged or obstructed labor
• Ruptured membranes
• GBS+
• Postpartum hemorrhage
• Stillbirth
• Retaining placenta 
• Multiple gestation
• Mastitis
• Chronic illnesses (obesity, diabetes, anemia, …)
• Higher age

  

Sepsis is responsible for 15% of all maternal deaths worldwide, and the Centers of Disease Control and Prevention (CDC) lists “infection or sepsis” as being responsible for 12.7% of pregnancy-related deaths in the U.S. This is the third most common cause, following heart disease (15.5%) and non-cardiovascular disease (14.5%).

Why the risk of sepsis in obstetrics is growing,
when the level of medicine continues to rise?

Because obstetrics are changing!

• Demographic changes of pregnant women
  • mothers are older, more often obese and with DM, …
  • more often complications of pregnancy (placental disorders, …)
• Changes in obstetric practice
  • invasive diagnostic and therapeutic techniques, …

Cormack. Anaesthesia Tutorial of The Week 235, 8th August 2011



Physiological changes in pregnancy

• hyperdynamic circulation - increased cardiac output (+40%)
• reduced SVR  

                 = already basally increased myocardial load

• increased ventilation = mild respiratory alkalosis compensated by mild metabolic acidosis
• reduction of compensatory capacities in developing acidosis in sepsis

• ureteral dilatation (smooth muscle relaxation) + uterine pressure

                 = high risk of pyuria and pyelonephritis

• decreased serum albumin - affecting colloid-osmotic pressure (susceptibility to pulmonary edema)

Signs and symptoms of sepsis

• Fever >38°C
  Hypothermia <36°C 
  Persistent tachycardia >90/min
  Tachypnea >20/min
  Leukocytosis >12.109/l or <4.109/
• Oliguria
  Diarrhoea and/or vomiting
  Lower abdominal pain
  Abnormal fetal sounds

  

Signs and symptoms of sepsis

• Fever >38°C
  Hypothermia <36°C
  Persistent tachycardia >90/min
  Tachypnea >20/min
  Leukocytosis >12.109/l or <4.109/l
• Oliguria
  Diarrhoea and/or vomiting
  Lower abdominal pain
  Abnormal fetal sounds

  

Signs and symptoms of sepsis

• Fever >38°C
  Hypothermia <36°C
  Persistent tachycardia >90/min
  Tachypnea >20/min
  Leukocytosis >12.109/l or <4.109/l
• Oliguria
  Diarrhoea and/or vomiting
  Lower abdominal pain
  Abnormal fetal sounds

• Fever >38°C
  Hypothermia <36°C
  Persistent tachycardia >90/min
  Tachypnea >20/min
  Leukocytosis >12.109/l or <4.109/l
• Oliguria
  Diarrhoea and/or vomiting
  Lower abdominal pain
  Abnormal fetal sounds

  

These parameters probably apply to pregnancy AFTER the first 20 weeks and up until the immediate postnatal period.
Under 20 weeks and more than 48 hours after delivery, it is probably safer to use the non-pregnant values, especially if the woman reports feeling unwell.


National Steering Group NSAG/WEC RCOG, January 2013

https://www.healthnavigator.org.nz/health-a-z/s/sepsis/?tab=19821
The MEOWS observation chart.

Signs and symptoms of sepsis

• Fever >38°C
  Hypothermia <36°C
  Persistent tachycardia >90/min
  Tachypnea >20/min
  Leukocytosis >12.109/l or <4.109/l
• Oliguria
  Diarrhoea and/or vomiting
  Lower abdominal pain
  Abnormal fetal sounds

Peripartum cardiomyopathy

• life-threatening condition of unclear etiology, which occurs in the peripartum period in previously healthy women
• left ventricular dysfunction with symptoms of heart failure in the last trimester of pregnancy or up to 5 months after delivery
• incidence: 1 : 4000 pregnancy

Signs and symptoms of sepsis

• Fever >38°C 

Hypothermia <36°C


Persistent tachycardia >90/min


Tachypnea >20/min


Leukocytosis >12.109/l or <4.109/l

• Oliguria

Diarrhoea and/or vomiting

Lower abdominal pain
Abnormal fetal sounds

  

Risk factors 

• age >30 years
• obesity 
• history of cardiac disease (e.g. myocarditis) 
• taking certain medications (e.g. long-term beta blockers) 
• smoking
• alcoholism
• cocaine use
• multiple pregnancy
•  poor nutrition
  Ramaraj. CLEVELAND CLINIC JOURNAL OF MEDICINE  VOLUME 76  • NUMBER 5  MAY 2009

Take home message: 

1. It‘s about time! Always think of sepsis or hemorrhage with any changes in the mother's state of health.
2. Use your localized Early Obstetric Warning System. 
3. Give IV antibiotics early and according to localized sepsis guidelines.
4. Noradrenaline is the vasopressor of the first choice. Think to add vasopresine in higher doses.

   

5.