Keywords

Obstetrics, Prevention, Sepsis, Treatment

 

Authors

  1. Parfitt, Sheryl E. MSN, RNC-OB
  2. Bogat, Mary L. MSN, RNC-OB
  3. Roth, Cheryl PhD, WHNP-BC, RNC-OB, RNFA

Abstract

Abstract: Sepsis during pregnancy is one of the five leading causes of maternal mortality worldwide. Early recognition and prompt treatment of maternal sepsis is necessary to improve patient outcomes. Patient education on practices that reduce infections may be helpful in decreasing rates of sepsis. Education of nurses about early signs and symptoms of sepsis in pregnancy and use of obstetric-specific tools can assist in timely identification and better outcomes. Although the Surviving Sepsis Campaign (SSC) criteria for diagnosis of sepsis in the general population are not pertinent for obstetric patients, their treatment bundles (guidelines) are applicable and can be used to guide care of obstetric patients who develop sepsis.

 

This article is the third in a series of three that discuss the importance of sepsis and septic shock in pregnancy. This article includes case studies, treatment, prognosis, education, and prevention of maternal sepsis.

 

Article Content

Sepsis during pregnancy is one of the five leading causes of maternal mortality worldwide. Maternal morbidity and mortality are often underestimated (Al-Ostad, Kezouh, Spence, & Abenhaim, 2015). In a population-based study of sepsis rates and risk factors associated with its development during labor, birth, and postpartum in the United States, Al-Ostad et al. found that maternal sepsis was on the rise. They concluded that an improvement in recognition of signs and symptoms associated with sepsis and early, effective management and treatment could help in reducing the occurrence of sepsis and poor patient outcomes (Al-Ostad et al.). The purpose of this article is to discuss treatment options, patient prognosis, education, and prevention associated with maternal sepsis.

  
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Treatment of Sepsis

Early recognition, diagnosis, and treatment of maternal sepsis are essential in achieving best patient outcomes. The Surviving Sepsis Campaign (SSC) is a consensus committee made up of international experts. In 2004, they set definitions and guidelines for practitioners treating sepsis (Dellinger et al., 2004). This information was updated by SSC in 2008 and 2012 (Dellinger et al., 2008, 2013). In December 2015, the SSC international committee again revised their recommendations (Howell & Davis, 2017; Rhodes et al., 2017). These current recommendations include the following criteria:

 

Initial management:

 

1. Understand that sepsis and septic shock are medical emergencies; treatment and resuscitation should begin immediately.

 

2. To resuscitate sepsis-induced hypoperfusion, administer at least 30 mL/kg of intravenous (IV) crystalloid fluid within the first 3 hours.

 

3. Following initial fluid resuscitation, additional fluids should be administered based on the patient's hemodynamic status.

 

4. Advanced hemodynamic assessment should be used to determine the type of shock if the clinical examination does not lead to a clear diagnosis.

 

5. Dynamic over static variables should be used to predict fluid responsiveness.

 

6. An initial target mean arterial pressure of 65 mmHg should be used in patients with septic shock requiring vasopressors. If a vasopressor is needed, norepinephrine is the pressor of choice.

 

7. Elevated lactate levels are a marker for tissue hypoperfusion. Normalizing lactate in patients with elevated lactate levels should be included in resuscitation goals.

 

8. Appropriate microbiologic cultures should be obtained as soon as possible before starting antimicrobial therapy in patients with suspected sepsis or septic shock (two or more blood cultures are recommended with at least one drawn percutaneous and one drawn through each vascular access device, unless the device has been inserted less than 48 hours); however, antibiotic treatment should not be delayed in the event cultures are difficult to attain). Antimicrobials should be started within 1 hour of diagnosis of sepsis or septic shock.

 

9. Determine the source of the infection and begin source control interventions as rapidly as possible.

 

 

Further recommendations from the SSC can be reviewed in the full 2016 guidelines (Rhodes et al., 2017).

 

For obstetric populations, the initial and ongoing screening for potential sepsis can be challenging due to the physiologic changes of pregnancy. At this time, the SSC does not have specific screening recommendations for pregnant patients. A number of modified obstetric early warning scoring systems have been developed in an attempt to better identify the development of sepsis in pregnancy (Edwards et al., 2015). The Maternal Early Warning Trigger Tool (Shields, Wiesner, Klein, Pelletreau, & Hedriana, 2016) is one tool that may assist in accurate, timely diagnosis and treatment. It examines four main causes of maternal morbidity and serves as a guide for clinicians in prompt evaluation and treatment of patients who present with potential sepsis, cardiopulmonary disorders, hypertension, and hemorrhage (Shields et al.). At this time, professional organizations such as The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have not agreed upon which medical conditions should characterize severe maternal morbidity. They recommend that systems institute one of the existing screening tools or create their own list of diagnoses and complications that should be reviewed through a quality improvement review process (ACOG & SMFM, 2016). Maternal triggers in the nonsevere abnormal values sepsis pathway include:

 

* Temperature >= 38 [degrees]C (100.4 [degrees]F) or <= 36 [degrees]C (96.9 [degrees]F)

 

* Pulse oximeter <= 93%

 

* Maternal heart rate > 110 beats/minute or < 50 beats/minute

 

* Respiratory rate > 24/minute or < 12/minute

 

* Systolic blood pressure > 155 mmHg or < 80 mmHg

 

* Diastolic blood pressure > 105 mmHg or < 45 mmHg

 

* Altered mental status at anytime

 

* Fetal heart rate > 160 beats/minute (Shields et al., 2016).

 

 

Severe/single abnormal triggers include:

 

* Heart rate > 130 beats/minute

 

* Respiratory rate > 30

 

* Mean arterial pressure (MAP) < 55 mmHg

 

* Pulse oximeter < 90%

 

* The nurse is clinically uncomfortable with the patient's status (Shields et al., 2016).

 

 

If a woman presents with two or more of the nonsevere abnormal triggers or one of the severe/single abnormal triggers, the nurse should notify the physician immediately and draw a complete blood cell count and blood cultures. Antibiotic therapy can then be initiated. Tests to determine organ dysfunction should be performed and include lactic acid, liver and renal function tests, and potentially cardiac and pulmonary studies. Fluid resuscitation according to SSC recommendations should be initiated within 1 hour for a MAP < 65 or lactic acid level > 4 mmol/L. The Rapid Response Team should be alerted and transfer to a higher level of care ought to be considered (Shields et al., 2016).

 

Prognosis

Patients experiencing a delay in initial recognition and treatment of sepsis often experience a worse outcome than those with early detection. Preexisting comorbidities can also play a role in patient response. Once septic shock develops, overall mortality rates of patients admitted to the intensive care unit rises to approximately 20% to 28%. These patients demonstrate a poor response to IV fluid resuscitation and experience tissue hypoxia, myocardial dysfunction, high serum lactate levels, and multiple organ dysfunction (Barton & Sibai, 2012). Al-Khafaji, Sharma, and Eschun (2016) reported that mortality from multiple organ dysfunction syndrome increases up to 90% once additional organs begin to fail in septic shock. Another study of critically ill patients determined that the likelihood of mortality from sepsis was directly related to the number of organ systems that were failing, making organ failures one the most reliable predictors of patient mortality with a diagnosis of sepsis (Long, Katz, & O'Toole, 2016; Vincent, Nelson, & Williams, 2011) (Table 2).

  
Table 2 - Click to enlarge in new windowTABLE 2. Likelihood of Death Increases in Sepsis with Number of Failing Organs

Prevention and Education

Although early recognition of signs and symptoms of potential infection and sepsis has been associated with improved patient outcomes, prevention of infections is critical in decreasing the incidence of maternal sepsis. Suggested practices to prevent infections include:

 

* Increased awareness and education for clinicians and patients on signs and symptoms of infection. Pregnant women exposed to individuals with recent cases of pharyngitis or influenza should notify their physician or nurse midwife for increased observation and testing for Group A Streptococcus pyogenes.

 

* The importance of hand washing and good hygiene should be included in all patient education programs.

 

* Patients scheduled for surgical procedures should shower with an antiseptic soap prior to surgery and be administered prophylactic antibiotics.

 

* Smoking should be avoided 30 days before any surgical procedure.

 

* Women with diabetes should be educated about importance of glycemic control in prevention of infections.

 

* Prophylactic antibiotics are indicated for premature rupture of membranes <37 weeks gestation.

 

* Broad-spectrum antibiotics are indicated for pelvic and 3rd and 4th degree lacerations (Chebbo, Tan, Kassis, Tamura, & Carlson, 2016; Orr & Chien, 2015).

 

* Results of a systematic review noted that chorioamnionitis (now known as Triple I, Higgins et al., 2016) was more common in pregnancies complicated with meconium-stained amniotic fluid. Administration of antibiotics was seen as a potential option to reduce this occurrence (Siriwachirachai, Sangkomkamhang, Lumbiganon, & Laopaiboon, 2014).

 

 

Clinical Implications

Maternal sepsis can be difficult to recognize and diagnose. Educating clinicians and patients about prevention of infections is an important step in decreasing rates of sepsis. If sepsis does occur, rapid recognition and treatment has been shown to decrease morbidities and mortality. Use of obstetric-specific tools that provide protocols and checklists may assist in providing optimal care to this population, resulting in increased patient safety and improved outcomes. Further research using these tools is needed to assure ease of use by nurses, accuracy in determining whether a patient's infection is progressing to sepsis, and appropriate treatment bundles for the obstetric population.

 

Suggested Clinical Nursing Implications

 

* Understand that sepsis and septic shock are medical emergencies, and treatment and resuscitation should begin immediately (Rhodes et al., 2017). All patients with potential for sepsis should be evaluated using the following data: Vital signs, MAP, oxygen saturation, fetal heart rate, appropriate cultures, including blood cultures, laboratory values, and imaging studies to assess infection source (Albright, Ali, Lopes, Rouse, & Anderson, 2015; Bamfo, 2013; Pacheco, Saade, & Hankins, 2014; Rhodes et al.; Shields et al., 2016).

 

* Delays in treatment may lead to worse prognosis for patients (Barton & Sibai, 2012).

 

* Sepsis prevention is easier than treatment.

 

* Prevent infections with increased awareness and education for clinicians and patients about reporting recent upper airway infections, hand hygiene, smoking, diabetes, presurgical antimicrobial showers, and appropriate antibiotic usage (Chebbo et al., 2016; Orr & Chien, 2015).

 

References

 

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