Septic shock during pregnancy

doi:10.1016/S0002-9378(88)80096-6

American Journal of Obstetrics and Gynecology

Volume 159, Issue 2, August 1988, Pages 410-416

https://doi.org/10.1016/S0002-9378(88)80096-6 Get rights and content

A multiinstitutional review of 10 pregnancies complicated by septic shock was undertaken to identify the clinical characteristics and hemodynamic alterations associated with this condition. Prolonged rupture of membranes with the subsequent development of chorioamnionitis or postpartum endometritis were risk factors that commonly preceded the diagnosis of septic shock. The majority of septic shock cases occurred during the puerperium. There were two maternal deaths in this selected series. Associated complications included pulmonary edema, adult respiratory distress syndrome, disseminated intravascular coagulation, pulmonary emboli, and cardiac arrest. The primary hemodynamic derangements were reduced systemic vascular resistance with depressed myocardial function. The mean initial systemic vascular resistance index in eight surviving women was 885 ± 253 dyne · sec/cm⁵ · m². Despite an overall presenting cardiac index of 4.20 ± 2.01 L/min/m², five patients (50%) had evidence of myocardial depression based on analysis of their left ventricular function curves. Mean arterial pressure, systemic vascular resistance, and left ventricular stroke work index all showed significant improvement after therapy. A hemodynamic algorithm based on volume therapy, inotropic agents, and peripheral vasoconstrictors is offered. This therapeutic approach is designed to optimize cardiac performance and maintenance of organ perfusion in the critically ill patient with septic hypotension during pregnancy.

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Cited by (55)

Critical care in obstetrics
2022, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
The pathophysiology of sepsis-induced cardiac dysfunction is a thoroughly investigated process that is thought to occur from a complex set of cardio-depressant effects of inflammatory interleukins, oxidative stress, mitochondrial dysfunction, and ultimately leading to necrosis apoptosis of cardiomyocytes [85,86]. In autopsy studies examining pregnant (or recently pregnant women) who have died of sepsis, left ventricular failure dysfunction was found in 50–80% of women [87,88]. The incidence of cardiovascular dysfunction in maternal sepsis, however, is poorly understood and remains a topic of active investigation.
Leading causes of intensive care unit (ICU) admission include hemorrhage, hypertensive disorders of pregnancy, and sepsis. Although the incidence of ICU admission in pregnancy may be low, this does not account for critical illness in labor and delivery or maternity unit suites, which is as high as 1–3%. Most admissions, for example, to an ICU unit occur in the postpartum period, where studies have shown a range from 62 to 92% of admissions occurring during this period. A total of 60% of maternal deaths have been reported as preventable, with a delay in diagnosis and prompt medical treatment cited as primary factors, prompting for early recognition of high-risk obstetric patients. Recently, comorbidity-based screening tools, which quantify a patient's medical comorbidity burden, have been developed and validated in predicting ICU admission and death. Noninvasive ultrasonography such as point-of-care ultrasonography becomes essential in determining hemodynamic status, guides resuscitation, and manages cardiovascular dysfunction.
Twenty-four percent of patients with clinical chorioamnionitis in preterm gestations have no evidence of either culture-proven intraamniotic infection or intraamniotic inflammation
2017, American Journal of Obstetrics and Gynecology
Citation Excerpt :
Clinical chorioamnionitis is a well-known risk factor for adverse maternal and perinatal outcomes.12-14 Affected mothers have an increased rate of endometritis,2,15 postoperative wound infections,2,16 sepsis,17,18 disseminated intravascular coagulation,19 septic pelvic thrombophlebitis,20,21 postpartum hemorrhage,22 pelvic abscess,2 and other complications.2,4,23-26 Neonatal complications include congenital sepsis11,25,27-34 as well as localized infections such as pneumonia,27,28 dermatitis,35 and otitis media.36
Recent studies on clinical chorioamnionitis at term suggest that some patients with this diagnosis have neither intraamniotic infection nor intraamniotic inflammation. A false-positive diagnosis of clinical chorioamnionitis in preterm gestation may lead to unwarranted preterm delivery.
We sought to determine the frequency of intraamniotic inflammation and microbiologically proven amniotic fluid infection in patients with preterm clinical chorioamnionitis.
Amniocentesis was performed in singleton pregnant women with preterm clinical chorioamnionitis (<36 weeks of gestation). Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas and assayed for matrix metalloproteinase-8 concentration. Microbial invasion of the amniotic cavity was defined as a positive amniotic fluid culture; intraamniotic inflammation was defined as an elevated amniotic fluid matrix metalloproteinase-8 concentration of >23 ng/mL. Nonparametric and survival techniques were used for analysis.
Among patients with preterm clinical chorioamnionitis, 24% (12/50) had neither microbiologic evidence of intraamniotic infection nor intraamniotic inflammation. Microbial invasion of the amniotic cavity was present in 34% (18/53) and intraamniotic inflammation in 76% (38/50) of patients. The most common microorganisms isolated from the amniotic cavity were the Ureaplasma species. Finally, patients without microbial invasion of the amniotic cavity or intraamniotic inflammation had significantly lower rates of adverse outcomes (including lower gestational age at delivery, a shorter amniocentesis-to-delivery interval, acute histologic chorioamnionitis, acute funisitis, and significant neonatal morbidity) than those with microbial invasion of the amniotic cavity and/or intraamniotic inflammation.
Among patients with preterm clinical chorioamnionitis, 24% had no evidence of either intraamniotic infection or intraamniotic inflammation, and 66% had negative amniotic fluid cultures, using standard microbiologic techniques. These observations call for a reexamination of the criteria used to diagnose preterm clinical chorioamnionitis.
Fever and pregnancy
2016, Anaesthesia Critical Care and Pain Medicine
Citation Excerpt :
However, if uterine content is the supposed origin of sepsis, delivery of the foetus must be considered promptly. In the study by Lee et al. [46] in 1988, foetal extraction had to be done in 40% of cases. Termination of pregnancy can be indicated for obstetrical reason, but in all other cases, foetal extraction has not proven effective for maternal prognosis, except during maternal cardiac arrest.
Severe infections during pregnancy and postpartum are rare, despite a high frequency of bacteraemia, but remain on of the leading cause of maternal death. Therapeutic guidelines validated in general population should be applied to pregnant women, with regards to their specificities: insidious clinical signs and rapid onset, clinical presentation often as respiratory failure due to physiological changes during pregnancy; most frequent causes: pneumonia, pyelonephritis, genitary tract infections; sensibility to virus, Listeria, malaria, due to immunological changes during pregnancy; caesarean section is the single most important risk factor of postpartum infection; aggressive treatment should be started promptly, including fluid infusion and early administration of vasoactive agents (Norepinephrine); broad-spectrum intravenous empirical antibiotic therapy must be established immediately (within the first hour), and chosen according to frequent microorganisms involved in sepsis during pregnancy; infectious source, mostly pelvic, is often accessible to surgery; if foetal extraction does not improve maternal outcomes, it remains necessary for obstetrical or foetal reasons and mandatory if chorioamnionitis is confirmed; specific attention should be drawn to streptococcus A invasive infection which experiments a recent resurgence and is correlated to a high morbidity and mortality for both the mother and the foetus; protocols should be written in every maternity.
Managing the risks of sepsis in pregnancy
2013, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
A study in the Netherlands9 found a case fatality rate of 7.7%. Other studies have reported rates of 12% overall maternal mortality in women admitted to the intensive care unit and 20–28% maternal mortality in those with septic shock.18,19 The UK Obstetric Surveillance system is currently carrying out a population-based case-control study to estimate the incidence of severe maternal sepsis and investigate risk factors, causes and outcomes.
Sepsis is a major cause of maternal mortality and morbidity worldwide. In the UK, sepsis is now the leading cause of direct maternal deaths. Raising awareness among healthcare professionals about the risks of maternal sepsis and the importance of early management is urgently needed. The challenge in the management of maternal sepsis is the translation of the vast knowledge gained from sequential confidential enquiries into maternal death and research findings, into clinical practice, to ensure an improvement in patient quality of care and maternal mortality and morbidity. In this chapter, I give an overview of the management of the risks of sepsis, and discuss implementation strategies that may reduce these risks.
Maternal Sepsis
2013, Obstetrics and Gynecology Clinics of North America
Citation Excerpt :
If one adds in the rates of pyelonephritis, sepsis is not at all uncommon. Pyelonephritis accounts for 3% to 4% of all antepartum admissions5 and makes up the largest proportion of the overall rare obstetric cases complicated by severe septic shock in the United States.6,7 In obstetrics, this is not a common event.
Severe sepsis and pregnancy
2012, Praticien en Anesthesie Reanimation
Les infections sévères sont rares au cours de la grossesse ou en postpartum, malgré une forte incidence de bactériémies chez les femmes enceintes. Les germes les plus souvent en cause sont l’Escherichia coli et le streptocoque B, mais les infections sont souvent polymicrobiennes. Une recrudescence des infections graves à streptocoque A est responsable d’une augmentation récente de la part relative des infections impliquées dans la mortalité maternelle des pays industrialisés. Le statut physiologique et la faible incidence des comorbidités expliquent la rareté du choc septique chez la femme enceinte ; en l’absence de données spécifiques au cours de la grossesse, la prise en charge initiale s’appuie sur les principes de réanimation précoce en tenant compte des modifications hémodynamiques et pulmonaires, responsables notamment d’une défaillance respiratoire. L’antibiothérapie à large spectre doit être ultraprécoce. L’extraction fœtale peut être indiquée pour des motifs obstétricaux mais ne modifie pas le pronostic maternel, excepté en cas d’arrêt cardiorespiratoire.
Despite a high incidence of bacteriemia in pregnant women, severe infections are uncommon during pregnancy and postpartum. The most common bacterial strains are Escherichia coli and Streptococcus B, but infections are often polymicrobial. A resurgence of group A streptococcus severe infections is responsible for a recent increase in maternal mortality related to infection in developed countries. Physiological status and low incidence of comorbidities explain that septic shock is rare in pregnancy. Initial management should be based on early resuscitation principles, taking into account the hemodynamic and respiratory changes, responsible for respiratory failure. Antibiotics should be implemented without any delay and broad spectrum-based. Delivery can be indicated for obstetric reasons but does not change maternal prognosis, except in case of cardiopulmonary arrest.

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Septic shock during pregnancy

Am J Obstet Gynecol

Prog Cardiovasc Dis

Am J Obstet Gynecol

Gram-negative bacteremia in septic shock

Clinical trial of an algorithm for outcome prediction in acute circulatory failure

Crit Care Med

Formula to estimate the approximate surface area if height and weight are known

Arch Intern Med

The study of left ventricular function in man by increasing resistance to ventricular ejection with angiotensin

Circulation

Shock