What is the recommended management of sepsis in a pregnant woman?

Management of Sepsis in Pregnancy

Sepsis in pregnancy is a medical emergency requiring immediate initiation of the SEP-1 3-hour bundle: obtain blood cultures, administer broad-spectrum antibiotics within 1 hour, measure lactate, and begin aggressive fluid resuscitation with 1-2 L of balanced crystalloid solution—all while prioritizing maternal stabilization, which will typically stabilize the fetus. 1, 2, 3, 4

Immediate Recognition and Screening (Stage 1-3 Approach)

Use a 3-stage screening framework to identify sepsis early:

• Stage 1: Initial alert for suspected infection triggers evaluation 1, 2
• Stage 2: Apply obstetrically modified SIRS (omSIRS) criteria based on gestational age and days postpartum 1, 2
• Stage 3: Bedside clinical assessment for end-organ injury using pregnancy-modified laboratory criteria 1, 2

Critical diagnostic considerations:

• Consider sepsis in any pregnant patient with unexplained end-organ damage and suspected infection, regardless of fever presence 3, 4
• Normal lactate in pregnancy (outside labor) is <2 mmol/L 1, 2
• Do NOT use lactate to diagnose sepsis during active labor—labor itself, bleeding, hepatic disease, and metformin all elevate lactate independently 1, 2
• Pregnant patients may appear deceptively well before rapid deterioration to septic shock 1, 5

The 3-Hour Bundle (Immediate Actions)

Within 1-3 hours of sepsis recognition, complete these time-sensitive interventions:

1. Obtain Cultures Before Antibiotics

• Draw blood cultures from at least two sites 2, 4
• Obtain urine, respiratory, and other cultures as clinically indicated 3, 4
• Never delay antibiotics for cultures—if obtaining cultures causes delay, give antibiotics first 2, 4

2. Measure Serum Lactate

• Obtain initial lactate level for risk stratification 2, 3, 4
• Lactate ≥4 mmol/L indicates high-risk septic shock requiring 6-hour bundle escalation 1, 2
• Repeat lactate within 6 hours to assess treatment response 1, 2

3. Administer Antibiotics Immediately

Timing is critical for mortality reduction:

• Within 1 hour for septic shock or high likelihood of sepsis 1, 2, 3, 4
• Within 3 hours for suspected infection without shock 1, 2, 4

Recommended antibiotic regimens:

• First-line: Piperacillin-tazobactam for broad gram-positive, gram-negative, and anaerobic coverage 2
• Alternative: Ertapenem 2
• Alternative: Ceftriaxone plus metronidazole 2
• Traditional obstetric regimen: Gentamicin, clindamycin, and penicillin 5

Pregnancy-specific antibiotic considerations:

• Higher doses may be needed due to increased renal clearance and expanded volume of distribution in pregnancy 2
• Plasma antibiotic concentrations are reduced by pregnancy-induced pharmacokinetic changes 2

4. Aggressive Fluid Resuscitation

• Administer 1-2 L of balanced crystalloid solution (lactated Ringer's or Plasma-Lyte) within the first 3 hours 1, 2, 4
• Use balanced crystalloids instead of normal saline to avoid hyperchloremic acidosis and acute kidney injury 1, 4
• Initial rate: 20 mL/kg over the first hour for hypotension or suspected organ hypoperfusion 5, 4

The 6-Hour Bundle (Septic Shock Management)

Escalate to the 6-hour bundle for:

• Persistent hypotension (MAP <65 mm Hg) after initial fluid resuscitation 1, 2
• Initial lactate ≥4 mmol/L 1, 2
• Failure to stabilize with 3-hour bundle interventions 2

Vasopressor Therapy

Norepinephrine is the first-line vasopressor:

• Start at 0.02 µg/kg/min 1
• Target MAP ≥65 mm Hg (though not specifically studied in pregnancy) 1, 3, 4
• Consider invasive arterial blood pressure monitoring 1
• Can be initiated peripherally until central access is obtained 1

Second-line vasopressor (refractory shock):

• Add vasopressin 0.04 units/min if MAP remains inadequate despite norepinephrine 0.1-0.2 µg/kg/min 1
• Theoretical concern about vasopressin-oxytocin receptor interaction, but remains reasonable with fetal monitoring 1

Third-line vasopressor:

• Consider epinephrine if blood pressure remains inadequate 1

Corticosteroid Therapy

• Administer hydrocortisone 200 mg/day (50 mg IV every 6 hours or continuous infusion) for patients requiring ongoing vasopressor therapy despite adequate fluid resuscitation 1, 4
• Initiate after at least 4 hours of vasopressor therapy at ≥0.25 µg/kg/min 1

Ongoing Fluid Management

• Continue fluid resuscitation using non-invasive hemodynamic monitoring guided by dynamic measures of preload 1, 4
• Stop fluids when patient stabilizes with decreasing lactate OR pulmonary edema develops 1
• Reassess volume status and tissue perfusion within 6 hours if hypotension persists or lactate ≥4 mmol/L 1

Pregnancy-Specific Management Priorities

Maternal Stabilization First

The primary objective is expedited maternal evaluation and treatment, which leads to improved uteroplacental perfusion and fetal condition: 1

• Stabilizing the mother will typically stabilize the fetus 1, 2, 6
• Do not proceed with emergent delivery for concerning fetal status until maternal stabilization is attempted 5
• Delivery should be dictated by obstetric indications, not sepsis alone 3
• Exception: If uterine source is suspected or confirmed, prompt delivery or evacuation achieves source control regardless of gestational age 4

Fetal Surveillance Strategy

Implement continuous fetal heart rate monitoring for dual purposes: 1, 2, 6

• Assess fetal well-being 1, 2, 6
• Guide maternal resuscitation efforts—fetal surveillance provides real-time measure of maternal end-organ perfusion 1, 2, 6

Management of non-reassuring fetal tracings:

• Fetal heart rate tracings may be expectantly managed during initial maternal stabilization 1, 6
• Most tracings improve with maternal hemodynamic optimization 1, 6
• Use multidisciplinary team approach considering infection source, gestational age, maternal/fetal health, and patient preferences 1

Optimize Uteroplacental Perfusion

Positioning:

• Maintain lateral positioning in patients beyond 20 weeks gestation to reduce aortocaval compression and improve blood flow 2, 6

Temperature control:

• Control maternal fever to reduce fetal oxygen consumption and prevent fetal tachycardia 2, 6

Glycemic control:

• Initiate insulin therapy for persistent hyperglycemia >180 mg/dL 2
• Target glucose range 140-180 mg/dL 2
• Maternal hyperglycemia causes fetal hyperglycemia, acidosis, decreased uterine blood flow, and lower fetal oxygenation 2, 6

Hemodynamic targets:

• Maintain MAP ≥65 mm Hg to ensure adequate uteroplacental perfusion 2, 6

Source Control and Infection Management

Rapidly identify and control the anatomic source of infection:

• Perform thorough physical examination and imaging to identify septic source 5, 4
• Surgical excision of septic foci (abscess, necrotic tissue) is essential—patients may continue to deteriorate despite appropriate antibiotics without source control 5
• Consider empiric exploratory laparotomy if source remains unclear 5
• For suspected uterine source, prompt delivery or evacuation of uterine contents achieves source control 4

Transfer and Escalation of Care

Transfer criteria requiring multidisciplinary team decision:

• Persistent hypotension (MAP <65 mm Hg) 1, 2
• Need for vasopressors 1, 2
• Persistent hypoxia (oxygen saturation <92% on room air) 1
• Altered mental status 1
• Lactate ≥4 mmol/L 1, 2

Appropriate care location:

• Transfer to level 3 or 4 care center for pregnant patients with sepsis 1, 2
• Level 2 centers with ICU services capable of caring for pregnant/postpartum patients may be acceptable 1

Transfer logistics:

• Stabilize patient before transport 1, 2
• If delivery is imminent, postpone transfer until after childbirth 1
• Do not delay transport due to inability to monitor fetus—maternal stabilization is priority 1, 2

Additional Critical Interventions

Venous Thromboembolism Prophylaxis

• Administer pharmacologic VTE prophylaxis to all patients without contraindications 1, 4
• Low-molecular-weight heparin is preferred 1
• VTE risk in septic patients reported as high as 37% 1

Oxygenation

• Ensure adequate maternal oxygenation to optimize uteroplacental oxygen delivery 2
• Monitor oxygen saturation continuously 1

Common Pitfalls to Avoid

Diagnostic pitfalls:

• Do not dismiss nonspecific symptoms in at-risk patients—pregnant women may endure sepsis challenges longer but deteriorate rapidly 1, 5
• Do not use lactate alone during labor to diagnose sepsis 1, 2
• Do not wait for fever—sepsis can occur without fever 3, 4

Management pitfalls:

• Do not delay antibiotics to obtain cultures if cultures cause delay 2, 4
• Do not delay maternal stabilization for fetal monitoring concerns 1, 2
• Do not proceed with emergent delivery before attempting maternal stabilization unless uterine source is confirmed 3, 5, 4
• Do not use normal saline—use balanced crystalloids 1, 4
• Do not use starches or gelatin for resuscitation 4

Transfer pitfalls:

• Do not delay transport due to inability to monitor fetus 1, 2
• Do not transfer unstable patients—stabilize first 1, 2