Sepsis and Pregnancy

OVERVIEW

Pregnancy results in increased susceptibility to endotoxin, metabolic acidosis and cardiovascular collapse

SOURCES OF SEPSIS

• chorioamionitis
• post partum endometritis
• UTI
• pyelonephritis
• septic abortion
• necrotizing fasciitis
• episiotomy infections

COMMON ORGANISMS

• Gram negatives > Gram positives
• Gram Negative – E.coli, Klebsiella, Enterobacter, Proteus, Pseudomonas aeruginosa, Bacteroides
• Gram Positive – Staph aureus, Group A Beta haemolytic streptococcus, Group B streptococcus, Enterococcus, Listeria monocytogenes, Clostridium, Peptostreptococuss
• Fungi

DIAGNOSTIC DIFFICULTIES

Applying the SIRS criteria to pregnancy can be problematic as there is normally:

• leucocytosis
• increased body temperature (during pregnancy and labour)
• tachycardia and tachypnoea are seen during normal labour
• already have a hyperdynamic circulation
  – warm and well perfused, high cardiac output, increased blood volume, relative increase in HR
  – these normal change in pregnancy also are present in sepsis.
• can compensate well and then quickly decompensate (like the paediatric patient)
• altered signs
  – appendicitis is more difficult to diagnose clinically due to gravid uterus displacement
  — UTI’s may be asymptomatic
  — pneumonia/LRTI’s masked as a degree of breathlessness in normal in late pregnancy

MANAGEMENT

Goals

• source control
• empiric antibiotics (imipenem)
• supportive care

Antibiotics contraindicated in pregnancy

• Tetracyclines
• Fluroquinolones
• Aminoglycosides
• Chloramphenicol
• Trimethoprim (1st trimester)
• Nitrofurantoin
• Vancomycin
• Anti-fungals – triazoles, terbinafine