Testing will generally be initiated by the admitting team.

Diagnostic Studies

Several sepsis criteria (heart rate >90 bpm and WBC >12,000) can be seen in pregnancy in the absence of infection and sepsis. A good rule of thumb is to require a clinical diagnosis of primary infection (including site of infection, if possible) to diagnose sepsis. Most commonly, maternal infection is diagnosed by fever with additional systemic symptoms such as chills, sweats, syncope, nausea, dyspnea, or pain at the site of infection. Evaluation for site of infection commonly includes physical examination (general and obstetric) and testing for evidence of infection at appropriate sites (CBC, CMP, lactate, UA, urine culture, blood cultures, chest x-ray, and other tests as indicated).

Treatment

As with any serious prenatal event, initiate fetal monitoring ASAP for a viable fetus. If unable to provide L&D support, arrange for prompt transfer to a tertiary center.

Prevention of infection using appropriate hand washing and sterile technique may be the most effective method of decreasing sepsis in obstetrics.⁸ Infection prophylaxis for cesarean section using either cefazolin alone or an extended-spectrum regimen (including azithromycin) is recommended to reduce postoperative maternal infection.⁹ For uncomplicated infections in pregnancy, early therapy with appropriate antibiotics may prevent severe sepsis.

When severe sepsis is present, early recognition and prompt treatment are critically important. Therapy includes fluid resuscitation, obtaining cultures (including blood cultures), and treatment with antibiotics, all within 6 hours of onset. Combinations of antibiotics IV (such as ampicillin 2 g, q 6 hrs; gentamicin 100 mg, q 8 hrs; and clindamycin 900 mg or metronidazole 500 mg q 8 hrs) should be started within 1 hour. Care may be best provided in the ICU with a Foley catheter, hourly intake and output, continuous cardiac and oxygen saturation monitoring, and frequent BP monitoring (using continuous arterial line measurements in septic shock cases). Oxygen supplementation is often required, and acetaminophen may be used to reduce excessive fever.

Fetal monitoring is appropriate when the possibility of fetal viability exists. Fetal tracings suggesting fetal hypoxia or acidosis may even be the first signs of impending maternal cardiorespiratory decompensation. Pulmonary capillary wedge pressure evaluations have been specifically suggested for monitoring appropriate fluid resuscitation in pregnancy complicated by septic shock, and early intubation with positive end-expiratory pressure and lower tidal volumes has been advocated to treat the adult respiratory distress syndrome that often follows the successful fluid resuscitation of this condition.^10,11 Steroids, though not contraindicated, are controversial. The largest randomized study showed no survival benefit in nonpregnant patients. Some authors recommend empiric therapy in pregnant patients.⁴