Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. In the context of peri-pregnancy, it refers to sepsis occurring during pregnancy, at delivery, or in the postpartum period (up to six weeks after delivery).
Epidemiology:
Sepsis is a leading cause of maternal morbidity and mortality worldwide, with the incidence increasing due to factors such as rising rates of cesarean sections, increased maternal age, and higher prevalence of comorbidities.
Risk Factors:
Cesarean delivery
Prolonged rupture of membranes
Instrumental delivery
Intrauterine infection
Group B Streptococcus (GBS) colonization
Anemia
Immunosuppression
Previous pelvic infections or history of sepsis
Pathophysiology:
The pathogenesis of sepsis involves a complex interaction between the pathogen and the maternal immune response, leading to widespread inflammation, tissue damage, and organ dysfunction.
Pregnancy-specific changes in the immune system and physiological adaptations can alter the presentation and progression of sepsis, complicating its diagnosis and management.
Clinical Features
Signs and Symptoms:
Fever or hypothermia
Tachycardia
Tachypnea or hypoxia
Altered mental status
Hypotension (late sign)
Signs of organ dysfunction, such as oliguria, lactic acidosis, or coagulopathy
Specific signs related to the source of infection, e.g., uterine tenderness, foul-smelling vaginal discharge, or abdominal pain
Diagnosis:
Clinical diagnosis is based on the presence of suspected or confirmed infection and evidence of organ dysfunction.
Laboratory tests to support diagnosis: complete blood count, blood cultures, lactate levels, liver enzymes, renal function tests, and coagulation profile.
Imaging studies may be required to identify the source of infection.
Immediate initiation of broad-spectrum antibiotics after obtaining cultures.
Fluid resuscitation and supportive care to maintain organ perfusion and oxygenation.
Identification and management of the source of infection, which may require surgical intervention (e.g., drainage of an abscess).
Antibiotic Therapy:
Empirical antibiotic therapy should be broad-spectrum and tailored based on the suspected source of infection, local antimicrobial resistance patterns, and adjusted according to culture results.
Consideration of pregnancy-specific safety profiles of antibiotics.
Supportive Care:
Management of organ dysfunction, including mechanical ventilation for respiratory failure, renal replacement therapy for acute kidney injury, and vasopressors for septic shock.
Close monitoring in an intensive care unit may be necessary for severe cases.
Prevention:
Identification and treatment of infections during pregnancy and the postpartum period.
Prophylactic antibiotics as indicated, for example, during cesarean delivery or for GBS colonization.
Vaccinations against influenza and pertussis during pregnancy.
Complications:
Acute respiratory distress syndrome (ARDS)
Acute kidney injury
Disseminated intravascular coagulation (DIC)
Septic shock
Maternal death
Adverse fetal outcomes, including preterm birth, fetal distress, and stillbirth
Summary
Sepsis during the peri-pregnancy period is a critical condition that poses significant risks to both the mother and the fetus. Early recognition, prompt initiation of empirical antibiotic therapy, and aggressive supportive care are crucial to improve outcomes. Understanding the unique physiological changes during pregnancy that can affect the presentation and management of sepsis is essential for medical students and healthcare professionals involved in obstetric care.
