A 22 y.o. female G2P1 at 25 weeks gestation came to the ED presenting with fever, chills, and cough that she has had for 2 days. She went to her primary care provider and received azithromycin. Her symptoms did not improve. Last night, she started having productive cough and more fever. In the emergency room, her temperature was 39.0°C, heart rate 110, blood pressure 110/80, respiratory rate 18, saturation of oxygen was 92% on room air. She appeared mildly ill. The tonsils were not enlarged. Lung auscultation exam revealed some rales in the right lower lung field. Cardiac exam showed no jugular venous distention, regular rate rhythm, no murmur. Abdomen was appropriate for 25 weeks gestation, without tenderness. No skin lesions. Her bloodwork showed WBC count 13,000. Hb 11.0. BUN 10 Cr 0.8. AST 60, ALT 68, lactic acid 2.6. Blood culture showed Gram-positive cocci.
Maternal sepsis is one of the five leading causes of maternal mortality worldwide. In a population-based, retrospective cohort study of more than 5 million women who delivered in the United States between 1998 and 2008, more than 1500 cases of sepsis were identified. This yielded an incidence of 29.4 cases per 100,000 births and a case fatality rate of 4.4%, with an increase in both incidence of sepsis and sepsis-related mortality across the study period.1 This increase is thought to be due to complications associated with advanced maternal age and obesity, assisted reproductive technologies, and invasive procedures.2
Since 2004, the Surviving Sepsis Campaign has published and updated international guidelines for the management of severe sepsis and septic shock, emphasizing the utilization of a “sepsis bundle” that includes timely, broad-spectrum antibiotic therapy and early, goal-directed therapy. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The use of systemic inflammatory response syndrome (SIRS) criteria to identify those with sepsis has fallen out of favor because of its low specificity. Therefore a combination of clinical, laboratory, radiologic, and microbiologic data is necessary for the diagnosis of sepsis. Patients may present with fever, tachycardia, and tachypnea. Arterial hypotension and signs of organ dysfunction such as altered mental status, oliguria, and skin mottling may indicate severe disease. Taking a careful history may aid in the localization of the source of infection (e.g. a productive cough and shortness of breath may suggest pneumonia, dysuria and flank pain may suggest pyelonephritis, and a painful, purulent wound may indicate soft tissue infection). Laboratory abnormalities may include leukocytosis or leukopenia, bandemia, hypoxemia, thrombocytopenia, hyperbilirubinemia, coagulopathy, acute kidney injury, and lactic acidosis.
Because of the lack of pregnancy-specific data in the management of sepsis, it is recommended that physicians follow treatment guidelines for nonpregnant adults while being cognizant of the physiologic ...