What is the management of suspected sepsis in pregnancy?

Management of Suspected Sepsis in Pregnancy

Initiate the SEP-1 3-hour bundle immediately upon positive sepsis screen with suspected infection: obtain blood cultures, administer broad-spectrum antibiotics within 1 hour for high-risk patients or within 3 hours for others, measure lactate, and begin aggressive fluid resuscitation with 1-2 L crystalloid. 1

Immediate Recognition and Initial Actions (0-3 Hours)

Diagnostic Approach

• Use a 3-stage screening process: First-stage alert triggers second-stage evaluation with SIRS or modified obstetric SIRS (omSIRS) criteria depending on gestational age, followed by bedside clinical assessment 1
• Consider sepsis in any pregnant patient with unexplained end-organ damage and suspected infection, regardless of fever presence 2, 3
• Critical caveat: Do NOT use lactate elevation alone to diagnose sepsis during active labor, as labor itself, hepatic disease, metformin, and bleeding can elevate lactate 1
• Normal lactate in pregnancy outside labor is <2 mmol/L 1

Antimicrobial Therapy

• Administer antibiotics within 1 hour for possible septic shock or high likelihood of sepsis 1
• For suspected infection without shock signs, antibiotics may be given within 3 hours with close monitoring 1
• Obtain blood cultures before antibiotic administration when feasible, but never delay antibiotics for cultures 1, 3

Recommended antibiotic regimens (based on 2022 Infectious Diseases Society of America review):

• Piperacillin-tazobactam as first-line 1
• Ertapenem as alternative 1
• Ceftriaxone plus metronidazole for reliable gram-positive, gram-negative, and anaerobic coverage 1
• Avoid traditional gentamicin-clindamycin-penicillin regimens due to increasing resistance patterns in Enterobacterales and Bacteroides species to early-generation β-lactams, aminoglycosides, and clindamycin 1
• If aminoglycosides are used, dose at 7 mg/kg (not 5 mg/kg) per updated 2023 CLSI breakpoints 1

Fluid Resuscitation

• Administer 1-2 L of balanced crystalloid solution within the first 3 hours for hypotension or suspected organ hypoperfusion 1, 3
• Use balanced crystalloids as first-line (NOT starches or gelatin) 3
• Continue fluid resuscitation guided by dynamic measures of preload and ongoing assessment 3

Laboratory and Source Control

• Measure serum lactate level immediately 1, 3
• Obtain appropriate cultures: blood, urine, respiratory, and others as indicated 2, 3
• Rapidly identify anatomic source of infection and perform emergency source control when indicated 3
• If uterine source suspected: Proceed with prompt delivery or evacuation of uterine contents regardless of gestational age 3

Escalation to 6-Hour Bundle (Septic Shock Management)

Indications for 6-Hour Bundle

• Persistent hypotension after fluid administration 1
• Initial lactate ≥4 mmol/L 1
• Failure to stabilize with 3-hour bundle interventions 1

Vasopressor Therapy

• Norepinephrine is the first-line vasopressor starting at 0.02 µg/kg/min, titrated to maintain MAP ≥65 mmHg 1, 3
• Consider peripheral initiation until central access established 1
• If inadequate MAP despite low-moderate norepinephrine dose (0.1-0.2 µg/kg/min), add vasopressin 0.04 units/min 1
• For cardiac dysfunction with persistent hypoperfusion, consider adding epinephrine 1
• Initiate low-dose corticosteroids (hydrocortisone 200 mg/day as 50 mg IV every 6 hours) if no response to norepinephrine or epinephrine ≥0.25 µg/kg/min for at least 4 hours 1, 3

Hemodynamic Monitoring

• Consider invasive arterial blood pressure monitoring 1
• Use non-invasive hemodynamic monitoring to guide continued fluid resuscitation until patient stabilizes or pulmonary edema develops 1
• Repeat lactate within 6 hours if initially elevated 1

Pregnancy-Specific Considerations

Antibiotic Dosing in Pregnancy

• Higher doses may be needed due to pregnancy-induced pharmacokinetic changes causing reduced plasma concentrations 1
• For β-lactams: Use prolonged infusion for maintenance after initial bolus, which reduces short-term mortality in septic shock 1
• Balance fetal safety and transplacental drug transfer when adjusting doses 1

Fetal Surveillance

• Implement continuous fetal heart rate monitoring for dual purposes: assessing fetal well-being and guiding maternal resuscitation 1, 4
• Fetal surveillance provides real-time measure of maternal end-organ perfusion 1, 4
• Expectantly manage non-reassuring fetal tracings during initial maternal stabilization, as most improve with maternal hemodynamic optimization 1, 4
• Stabilizing the mother will typically stabilize the fetus 1, 4

Maternal Positioning and Temperature

• Maintain lateral positioning in patients beyond 20 weeks gestation to reduce aortocaval compression and improve uteroplacental blood flow 1, 5
• Control maternal fever to reduce fetal oxygen consumption and prevent fetal tachycardia 1, 5

Glucose Management

• Initiate insulin therapy for persistent hyperglycemia >180 mg/dL 1
• Target glucose range 140-180 mg/dL 1
• Conduct bedside glucose measurements every 4 hours for at least 24 hours 1
• Maternal hyperglycemia leads to fetal hyperglycemia, acidosis, decreased uterine blood flow, and lower fetal oxygenation 1, 4

VTE Prophylaxis

• Administer pharmacologic VTE prophylaxis to all patients without contraindications (VTE risk up to 37% in septic patients) 1, 3
• Low-molecular-weight heparin is preferred over unfractionated heparin due to better safety profile 1
• Use unfractionated heparin only for specific circumstances (allergy to LMWH, imminent delivery) 1

Transfer and Escalation of Care

Criteria for Higher Level of Care

Transfer decisions should be made by multidisciplinary team when patient has: 1

• Persistent hypotension (MAP <65 mmHg) 1
• Need for vasopressors 1
• Persistent hypoxia (oxygen saturation <92% on room air) 1
• Altered mental status 1
• Lactate ≥4 mmol/L 1

Transfer Logistics

• Transfer to level 3 or 4 care center for pregnant patients with sepsis 1
• Level 2 centers with ICU services capable of caring for pregnant/postpartum patients may be acceptable 1
• Stabilize patient before transport; if delivery imminent, may be safer to postpone transfer until after childbirth 1
• Do not delay transport due to inability to monitor fetus—maternal stabilization is priority 1

Multidisciplinary Team Engagement

• Engage rapid response team 1
• Consult critical care provider 1
• Consult anesthesiology as indicated 1
• Consult maternal-fetal medicine as indicated 1
• Consult neonatology/pediatric provider as indicated 1

Delivery Timing

Do NOT perform immediate delivery for the sole indication of sepsis—delivery should be dictated by obstetric indications 2

Exception: If uterine source for sepsis is suspected or confirmed, perform prompt delivery or evacuation regardless of gestational age for source control 3

Common Pitfalls to Avoid

• Do not rely on fever as a diagnostic criterion—sepsis can occur without fever in pregnancy 2, 3
• Do not use lactate elevation during active labor as sepsis criterion 1
• Do not delay antibiotics for culture collection if it causes substantial delay 3
• Do not use traditional gentamicin-clindamycin regimens as first-line due to resistance patterns 1
• Do not rush to emergent delivery for fetal distress before maternal stabilization 1, 4, 2
• Do not use starches or gelatin for fluid resuscitation 3