What is the diagnosis and treatment for a pregnant woman with fever, tachycardia, severe anemia, and leukocytosis?

Maternal Sepsis with Severe Anemia in Pregnancy

This pregnant woman requires immediate blood transfusion for severe anemia (Hb 6.9 g/dL) and urgent broad-spectrum antibiotics for suspected maternal sepsis, with concurrent diagnostic workup to identify the infectious source.

Immediate Life-Threatening Priorities

Severe Anemia Management

• Transfuse 2-3 units of packed red blood cells urgently to address the hemodynamic emergency, with each unit expected to raise hemoglobin by approximately 1.5 g/dL 1
• At Hb 6.9 g/dL, this represents severe anemia requiring immediate transfusion regardless of symptoms to prevent maternal cardiac decompensation and ensure adequate fetal oxygenation 2, 1
• Establish IV access immediately and prepare for potential emergency delivery if fetal distress develops 1
• Perform transfusion in a location with immediate access to operating room capabilities 1

Sepsis Recognition and Treatment

• The combination of fever, tachycardia (114 bpm), and leukocytosis (17,400) strongly suggests maternal sepsis, which is a leading cause of maternal mortality 3
• Initiate broad-spectrum antibiotics immediately without waiting for culture results, as early antibiotic administration decreases maternal and neonatal morbidity 3, 4
• The most commonly used regimen for suspected chorioamnionitis is ampicillin and gentamicin, with daily rather than three-times-daily gentamicin dosing for greater efficacy and decreased fetal toxicity 4
• Obtain blood cultures, complete blood count with differential, and acute phase reactants before antibiotics if possible, but do not delay treatment 3, 4

Concurrent Monitoring During Stabilization

Maternal Monitoring

• Continuous vital signs monitoring including heart rate, blood pressure, temperature, and oxygen saturation 3
• Monitor for signs of hemodynamic decompensation, as severe anemia combined with sepsis significantly increases risk of maternal shock and ICU admission 5, 6
• Maintain lateral positioning (especially beyond 20 weeks gestation) to improve blood flow and oxygenation by reducing aortocaval compression 3

Fetal Assessment

• Continuous fetal heart rate monitoring throughout transfusion and initial stabilization 1
• Evaluate the fetus for anemia using middle cerebral artery peak systolic velocity (MCA-PSV) Doppler, as maternal severe anemia may indicate an underlying condition affecting the fetus 1
• Fetal heart rate tracing may be expectantly managed during initial stabilization as most will improve with maternal hemodynamic optimization 3

Diagnostic Workup During Stabilization

Anemia Investigation

• Check blood type, antibody screen, and Kleihauer-Betke test to evaluate for fetomaternal hemorrhage and alloimmunization 1
• Obtain complete blood count with indices, reticulocyte count, serum ferritin, and peripheral blood smear to investigate the underlying cause 2, 1
• Screen for hemolysis and assess for chronic disease markers 1
• Consider parvovirus B19 serology if clinically indicated 1

Infection Source Identification

• Assess for chorioamnionitis: uterine tenderness, foul-smelling or purulent amniotic fluid, maternal and fetal tachycardia 3, 4
• Evaluate for other infection sources: urinary tract infection, pneumonia, wound infection if postoperative 3
• Consider thyroid storm in the differential, which presents with fever, tachycardia out of proportion to fever, and altered mental status, though less likely given the clinical picture 3

Post-Stabilization Management

Iron Supplementation

• Initiate high-dose oral iron supplementation at 60-120 mg elemental iron daily immediately after transfusion to replenish iron stores and prevent recurrence 2, 1
• If oral iron is not tolerated or absorption is impaired, intravenous iron therapy should be considered 1
• Recheck hemoglobin within 1-2 weeks post-transfusion to ensure adequate response 2, 1
• Once hemoglobin normalizes for gestational age, reduce to maintenance dose of 30 mg/day 2, 1

Antibiotic Duration and Adjustment

• Continue antibiotics until the patient is afebrile for 24-48 hours and clinically improving 3, 4
• Adjust antibiotic regimen based on culture results and clinical response 3
• Monitor gentamicin levels with particular care because of the risk of causing fetal deafness 3

VTE Prophylaxis

• Provide pharmacologic VTE prophylaxis with low-molecular-weight heparin once hemodynamically stable, as the risk of VTE in septic patients can be as high as 37% 3
• Unfractionated heparin may be preferred if imminent delivery is anticipated 3

Obstetric Management Considerations

Delivery Timing

• Continue pregnancy with close surveillance unless maternal instability or fetal compromise necessitates delivery 1
• Cesarean delivery should be reserved for standard obstetric indications, not for sepsis alone 4
• Unless deemed necessary, delivery during active sepsis should be avoided until maternal stabilization is achieved 3

Ongoing Surveillance

• Serial hemoglobin monitoring every 1-2 weeks throughout the remainder of pregnancy 1
• Monitor for signs of worsening infection or development of complications 3
• If fetal anemia is confirmed and severe, coordinate with maternal-fetal medicine for possible intrauterine transfusion 1

Critical Pitfalls to Avoid

• Do not delay transfusion for diagnostic workup - hemoglobin of 6.9 g/dL combined with sepsis is a medical emergency requiring immediate intervention 1
• Do not delay antibiotics while awaiting culture results - early antibiotic administration is critical for reducing maternal and neonatal morbidity in sepsis 3, 4
• Do not assume severe anemia is simple iron deficiency - investigate for acute blood loss, hemolysis, or bone marrow pathology 1
• Do not overlook fetal assessment, as maternal severe anemia may reflect conditions that also affect the fetus 1
• Do not transfuse only one unit - 2-3 units are necessary for adequate correction in severe anemia 1
• Do not use three-times-daily gentamicin dosing - daily dosing has greater efficacy and decreased fetal toxicity 4