In nonpregnant patients, early goal-directed therapy to maintain adequate CVP, MAP, venous oxygen saturation, and urinary output was associated with improved survival and decreased morbidity.¹² This approach included transfusion of packed red blood cells to achieve a hematocrit of at least 30 if adequate CVP is not maintained by the 6-hour limit. Pressors (dobutamine, noradrenaline, dopamine, and/or vasopressin) have all been advocated for nonpregnant patients in septic shock unresponsive to fluid/antibiotic therapy alone. While studies reporting the use of these agents in pregnancy are not available, emergency situations may require their empiric use.

Risks to Fetus

Fetal compromise in utero may occur with septic shock due to hypoperfusion of the pregnancy. Maternal fever may increase the oxygen requirements of the fetus directly and by promoting fetal tachycardia that requires additional oxygen consumption. This combination of decreased oxygen supply and increased oxygen requirements may cause fetal hypoxia. If these components of maternal sepsis cannot be quickly improved, fetal death or emergency delivery may be the only options.

Premature birth can result not only from the emergency deliveries described above; preterm labor also often results from infections and sepsis. The fetus may also have risks of infection directly harming it in utero (such as with chorioamnionitis or transplacental infection) or of neonatal infections acquired at birth.

Risks to Mother

Sepsis may cause preterm labor and delivery. Associated fetal compromise may require emergency cesarean section that could be complicated by sepsis-induced maternal hypotension, pulmonary edema, or DIC. Long-term hospitalization, morbidity, and death can be seen as a result of maternal sepsis.

Risk Factors

Sepsis in pregnancy often results from urinary tract infections (especially chronic or recurrent infections), chorioamnionitis (especially with prolonged rupture of membranes), or from post–cesarean section infections. Any source of infection that could cause sepsis in the nonpregnant patient could cause it in pregnancy. (See Table 1.)

Special Population Consideration

HIV-positive pregnant patients represent high-risk pregnancy. Infections in these patients could be manifestations of either the usual bacterial or viral infections as detailed above, or could be presentations of opportunistic infections. All HIV-positive women should be on highly active antiretroviral therapy. If they are not, risk of infection is increased along with increased risk of transmission to the fetus.¹³

For management of sepsis in this subgroup of pregnant women, expert consultation should be sought.

References

1. Joseph J, et al. Sepsis in pregnancy and early goal-directed therapy. Obstet. Med. 2009;2:93-9.
2. Ronsmans C, Graham WJ. Lancet maternal survival series steering group. Maternal mortality: Who, when, where, and why. Lancet 2006;368:1189-1200.
3. Galvagno SM Jr, Camann W. Sepsis and acute renal failure in pregnancy. Anesth. Analg. 2009;108:572-5.
4. Guinn DA, Abel DE, Tomlinson MW. Early goal-directed therapy for sepsis during pregnancy. Obstet. Gynecol. Clin. North Am. 2007;34:459-79.
5. Fernandez-Perez ER, et al. Sepsis during pregnancy. Crit. Care Med. 2005;33(10 Suppl):S286-93.
6. ACOG Practice Bulletin (Number 100): Critical Care in Pregnancy. Obstet. Gynecol. 2009;113:443-50.
7. Cardenas et al. Viral infection of the placenta leads to fetal inflammation and sensitization to bacterial products predisposing to preterm labor. J. Immunol. 2010;185:1248-57.
8. Burke J. Infection Control – A Problem for Patient Safety. N. Engl. J. Med. 2003;348:651-6.
9. Tita ATN, et al. Emerging concepts in antibiotic prophylaxis for cesarean delivery: A systematic review. Obstet. Gynecol. 2009;113:675-82.
10. Sheffield JS. Sepsis and septic shock in pregnancy. Crit. Care Clin. 2004;20:651-60.
11. Campbell LA, Klocke RA. Implications for the pregnant patient. Am. J. Respir. Crit. Med. 2001;163:1051-4.
12. Rivers E, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N. Engl. J. Med. 2001;345:1368-77.
13. Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N. Engl. J. Med. 1996;335:1621-9.