Key Points

1. Stabilize and Transfer if necessary
2. Maternal Early Warning Criteria:
   • Systolic BP <90 or >160 mmHg
   • Diastolic BP >100 mmHg
   • Heart rate <50 or >120 beats per minute → 107 beats per minute in pregnancy
   • Respiratory rate <10 or >30 breaths per minute → >24 breaths per minute in pregnancy
   • Temperature (oral) <36C (96.8F) or >38C (100.4F)--> 100.6F in pregnancy
   • Oxygen saturation on room air, at sea level, <95%
   • Oliguria, <35mL/hr for greater than or equal to 2 hours
   • Maternal agitation, confusion, unresponsiveness
   • Pain out of proportion to patient presentation 
3. Leading causes of maternal sepsis include:
   • Septic abortion
   • Intraamniotic infection/chorioamnionitis/endometritis
   • pneumonia/influenza
   • Urosepsis
   • Appendicitis
   • Wound infection/necrotizing fasciitis
   • Cholecystitis 
   • Episiotomy
4. Tests to evaluate:
   • CBC with differential
   • Coagulation status
   • Comprehensive metabolic panel
   • Venous lactic acid
   • Blood cultures: two sets for anaerobes and aerobes within 3 hours of diagnosis
   • Urine output (foley catheter with urometer)
   • Pulse oximetry
   • Mental status assessment

Synopsis

Sepsis is understood as a “life-threatening organ dysfunction caused by a dysregulated host response to infection” (JAMA 2016; 315: 801– 10). Newer definitions specify sepsis as infection with organ dysfunction while septic shock is a subset in patients who require vasopressor support to maintain a mean arterial pressure greater than 65 mmHg and have serum lactate greater than 2mmol/L after adequate fluid resuscitation.

Maternal Early Warning Criteria:

• Systolic BP <90 or >160 mmHg
• Diastolic BP >100 mmHg
• Heart rate <50 or >120 beats per minute → 107 beats per minute in pregnancy
• Respiratory rate <10 or >30 breaths per minute → >24 breaths per minute in pregnancy
• Temperature (oral) <36C (96.8F) or >38C (100.4F)--> 100.6F in pregnancy
• Oxygen saturation on room air, at sea level, <95%
• Oliguria, <35mL/hr for greater than or equal to 2 hours
• Maternal agitation, confusion, unresponsiveness

Management

Management includes a high index of suspicion, adequate fluid resuscitation, and source-directed antibiotic therapy. Norepinephrine is the pressor of choice in pregnancy and is used if MAP is less than 65mmHg and if the patient is unresponsive to intravenous fluids. Dobutamine is recommended for myocardial dysfunction or hypoperfusion intravenous fluids and pressors.Key tips include: avoiding hyperglycemia (>180), controlling fever with Tylenol and cooling blankets, considering steroids for fetal lung maturity if 23-36 weeks of pregnancy, and starting VTE prophylaxis.