What is the initial management for a 35-week pregnant woman presenting with fever, chills, leukocytosis (white blood cell count elevation), mild transaminitis (elevated liver enzymes), nausea, vomiting, mild dyspnea (shortness of breath), and urinalysis showing ketones, glucose, and protein?

Management of a 35-Week Pregnant Woman with Suspected Sepsis

The initial management of this 35-week pregnant woman with fever, chills, leukocytosis, and urinary abnormalities requires immediate empiric antibiotic therapy and close maternal-fetal monitoring, as this presentation is highly concerning for sepsis with a urinary source.

Initial Assessment and Diagnosis

Concerning Features

• Fever and chills: Classic signs of infection
• Leukocytosis (WBC 29,000): Significantly elevated, indicating severe inflammatory response
• Urinalysis abnormalities: Ketones, glucose, and protein suggest urinary tract infection
• Mild transaminitis: Suggests liver involvement
• Nausea, vomiting, and mild shortness of breath: Systemic symptoms of infection
• Normal procalcitonin (0.1): Does not rule out bacterial infection in pregnancy

Differential Diagnosis

1. Pyelonephritis/Urosepsis: Most likely given urinary findings and systemic symptoms
2. Intrahepatic Cholestasis of Pregnancy (ICP): Mild transaminitis, but lacks typical pruritus
3. Acute Fatty Liver of Pregnancy (AFLP): More severe presentation typically
4. HELLP syndrome: Would expect thrombocytopenia and more severe liver dysfunction

Management Algorithm

Immediate Actions (First Hour)

1. Start broad-spectrum antibiotics immediately

   • Preferred regimen: Ampicillin 2g IV q6h PLUS gentamicin 5mg/kg IV daily
   • Alternative: Ceftriaxone 2g IV daily if aminoglycoside contraindicated
   • Do not delay antibiotics while waiting for culture results

2. Obtain critical samples before antibiotics if possible

   • Blood cultures (2 sets)
   • Urine culture
   • Complete blood count with differential
   • Comprehensive metabolic panel
   • Coagulation studies
   • Lactate level

3. Initiate maternal-fetal monitoring

   • Continuous fetal heart rate monitoring
   • Maternal vital signs q1h
   • Strict input/output monitoring

Secondary Workup (Next 2-6 Hours)

1. Additional laboratory tests

   • Total serum bile acids (to rule out ICP)
   • Blood glucose monitoring
   • Arterial blood gas if respiratory symptoms worsen
   • Repeat WBC count in 6-12 hours to assess response

2. Imaging studies

   • Renal ultrasound to evaluate for hydronephrosis or renal abscess
   • Chest X-ray with abdominal shield if respiratory symptoms persist

Ongoing Management

1. Fluid resuscitation

   • Crystalloids (normal saline or lactated Ringer's) 30 mL/kg over first 3 hours
   • Target urine output >0.5 mL/kg/hour

2. Antipyretics

   • Acetaminophen 650-1000 mg PO/IV q6h for temperature >38.3°C

3. Antiemetics

   • Ondansetron 4-8 mg IV q8h as needed for nausea/vomiting

4. Fetal assessment

   • Continuous electronic fetal monitoring
   • Obstetric consultation for delivery planning

Delivery Considerations

Indications for Immediate Delivery

• Worsening maternal condition despite appropriate therapy
• Signs of fetal distress
• Evidence of chorioamnionitis

Timing of Delivery if Stable

• At 35 weeks with suspected sepsis, delivery after initial stabilization (24-48 hours) is reasonable
• If maternal condition improves rapidly, may consider expectant management with close monitoring
• Administer antenatal corticosteroids only if delivery can be safely delayed 48 hours

Special Considerations

Antibiotic Duration

• Continue IV antibiotics until afebrile for 24-48 hours
• Complete 7-14 day course (IV or oral) based on clinical response and culture results

Monitoring for Complications

• Daily liver function tests to monitor transaminitis
• Serial WBC counts to assess response to therapy
• Repeat urinalysis after 48-72 hours of therapy

Pitfalls to Avoid

1. Delaying antibiotics while waiting for culture results - this increases mortality risk
2. Inadequate fluid resuscitation - pregnant women need aggressive hydration in sepsis
3. Overlooking fetal monitoring - sepsis increases risk of fetal distress and preterm labor
4. Misattributing symptoms to normal pregnancy - fever and leukocytosis are never normal in pregnancy
5. Failing to consider obstetric complications - such as chorioamnionitis or placental abruption

Follow-up

• After resolution of acute illness, screen for Group B Streptococcus if not previously done
• Consider suppressive antibiotic therapy until delivery if recurrent UTI history
• Ensure follow-up urinalysis and urine culture 1-2 weeks after completing antibiotics

This patient requires immediate intervention with antibiotics and supportive care, with close attention to both maternal and fetal well-being. The urinary findings strongly suggest a urinary source of infection, but the systemic symptoms indicate possible sepsis requiring aggressive management.