Sepsis in obstetrics and the role of the anaesthetist

Maternal septic shock due to Acinetobacter lwoffii infection:a case report

The incidence of Acinetobacter infections has increased in recent years. Acinetobacter infections are resistant to most antibiotics and can be found in hospitalized patients. Pregnancies complicated by severe sepsis or septic shock are associated with a higher rate of preterm labor and delivery, fetal infection, and operative delivery. This case report describes septic shock due to Acinetobacter lwoffii infection in the 31st week of gestation. A 47-year-old woman, with a gestation of 31 weeks and one day, presented with a fever, and signs of bacterial infection on laboratory tests. Although the patient was started on tazobactam/piperacillin, she went into septic shock, and was transferred to our hospital. Cesarean section was performed at a gestation of 31 weeks and 4 days because of severe maternal pneumonia and non-reassuring fetal status. A. lwoffii was detected in blood cultures collected at the previous hospital, and susceptibility to piperacillin and meropenem to A. lwoffii was confirmed. The pneumonia responded to antibiotic treatment and there were no findings of infection in the neonate. Maternal sepsis is an infrequent but important complication, causing significant maternal and fetal morbidity and fetal and neonatal mortality; therefore, early antibiotic therapy is required to improve the clinical outcome.

Critical Care Management of the Parturient with Cardiac Disease

Parturient with heart disease forms a challenging group of patients and requires specialized critical care support in the peripartum period. Maternal heart disease may remain undiagnosed till the second trimester of pregnancy, presenting frequently after 20 weeks of gestation, due to increased demands imposed on the cardiovascular system and pose a serious risk to the life of mother and fetus. Management of critically ill parturient with heart disease must be tailored according to individual assessment of the patient and requires a strategic, multidisciplinary, and protocol-based approach. A dedicated obstetric intensive care unit (ICU) and team effort are the need of the hour.

HOW TO CITE THIS ARTICLE

Garg R, Hariharan UR, Malik I. Critical Care Management of the Parturient with Cardiac Disease. Indian J Crit Care Med 2021;25(Suppl 3):S230-S240.

Short-lived sensitization of cardiovascular outcomes of postpartum endotoxemia in preeclamptic rats: Role of medullary solitary tract neuroinflammation

Preeclampsia (PE) is a pregnancy-related disorder with serious maternal complications. Considering the increased importance of postpartum infection in maternal morbidity and mortality, we investigated whether preeclamptic maternal programming alters cardiovascular consequences of endotoxemia in rats and the role of cardiac and brainstem neuroinflammation in this interaction. Preeclampsia was induced by oral administration of L-NAME (50 mg/kg/day) for 7 days starting from day 14 of conception. Changes in blood pressure, heart rate, and cardiac autonomic function caused by lipopolysaccharide (LPS, 5 mg/kg i.v.) were assessed in mothers at 3 weeks (weaning time) and 9 weeks postnatally. Compared with respective non-PE counterparts, LPS treatment of weaning PE mothers caused significantly greater (i) falls in blood pressure, (ii) rises in heart rate and left ventricular contractility (dP/dt_max), (iii) reductions in time and frequency domain indices of heart rate variability and shifts in cardiac sympathovagal balance (low-frequency/high-frequency ratio, LF/HF) towards parasympathetic dominance, and (iv) attenuation of reflex bradycardic responses measured by the vasoactive method. The intensified LPS effects in weaning PE rats subsided after 9 weeks of delivery. Immunohistochemical studies showed increased protein expression of nuclear factor kappa B (NF-κB) in brainstem neuronal pools of the nucleus of the solitary tract (NTS), but not rostral ventrolateral medulla (RVLM), in endotoxic PE weaning rats compared with non-PE rats. Cardiac NF-κB expression was increased by LPS but this was similarly noted in PE and non-PE rats. Together, preeclamptic maternal programming elicits short-term exacerbation of endotoxic cardiovascular and autonomic derangements due possibly to exaggerated NTS neuroinflammatory insult.

An Observational Cohort Study Evaluating Antimicrobial Use in Peripartum Sepsis: A Tendency towards Overdiagnosis?

(1) Background: Sepsis is the leading cause of maternal death in 11–15% of women worldwide. This emphasises the importance of administrating timely and appropriate antibiotic therapy to women with sepsis. We aimed to evaluate the appropriateness of antimicrobial prescribing in women diagnosed with peripartum sepsis. (2) Method: A prospective observational cohort study in a single Scottish health region with 12,233 annual live births. Data were collected on women diagnosed with sepsis in the peripartum period using physical and electronic medical records, drug Kardex^® (medication administration) and ward handover records. (3) Results: A sepsis diagnosis was concluded in 89 of the 2690 pregnancy cases reviewed, with a median hospital stay of four days. Good overall adherence to the local guidelines for the empiric antimicrobial treatment of sepsis was observed. Group B Streptococcus was associated with 20.8% of maternal sepsis cases, whilst in 60% of clinical specimens tested no causative pathogen was isolated. (4) Conclusion: The lack of specific and sensitive clinical markers for sepsis, coupled with their inconsistent clinical application to inform diagnosis, hindered effective antimicrobial stewardship. This was further exacerbated by the lack of positive culture isolates from clinical specimens, which meant that patients were often continued on broader-spectrum empiric treatment.

Risk factors for postpartum sepsis: a nested case-control study

Background

The Majority (99%) of maternal deaths occur in low and middle-income countries. The three most important causes of maternal deaths in these regions are postpartum hemorrhage, pre-eclampsia and puerperal sepsis. There are several diagnostic criteria used to identify sepsis and one of the commonly used criteria is systematic inflammatory response syndrome (SIRS). However, these criteria require laboratory investigations that may not be feasible in resource-constrained settings. Therefore, this study aimed to develop a model based on risk factors and clinical signs and symptoms that can identify sepsis early among postpartum women.

Methods

A case-control study was nested in an ongoing cohort of 4000 postpartum women who delivered or were admitted to the study hospital. According to standard criteria of SIRS, 100 women with sepsis (cases) and 498 women without sepsis (controls) were recruited from January to July 2017. Information related to the socio-demographic status, antenatal care and use of tobacco were obtained via interview while pregnancy and delivery related information, comorbid and clinical sign and symptoms were retrieved from the ongoing cohort. Multivariable logistic regression was performed and discriminative performance of the model was assessed using area under the curve (AUC) of the receiver operating characteristic (ROC).

Results

Multivariable analysis revealed that 1–4 antenatal visits (95% CI 0.01–0.62).

, 3 or more vaginal examinations (95% CI 1.21–3.65), home delivery (95% CI 1.72–50.02), preterm delivery, diabetes in pregnancy (95% CI 1.93–20.23), lower abdominal pain (95% CI 1.15–3.42)) vaginal discharge (95% CI 2.97–20.21), SpO2 < 93% (95% CI 4.80–37.10) and blood glucose were significantly associated with sepsis. AUC was 0.84 (95% C.I 0.80–0.89) which indicated that risk factors and clinical sign and symptoms-based model has adequate ability to discriminate women with and without sepsis.

Conclusion

This study developed a non-invasive tool that can identify postpartum women with sepsis as accurately as SIRS criteria with good discriminative ability. Once validated, this tool has the potential to be scaled up for community use by frontline health care workers.

Infección por SARS-CoV-2 en la paciente obstétrica: una perspectiva desde el cuidado crítico

La nueva infección por coronavirus (COVID-19) se constituye en el principal problema de salud pública en el mundo. Entre el 5 y el 30% de los pacientes afectados por esta enfermedad requieren manejo en una unidad de cuidado intensivo. Se han generado diferentes publicaciones con recomendaciones para la población general. Sin embargo, en la población obstétrica la evidencia científica es reducida, aún más cuando se trata de infección por COVID-19 en escenarios de cuidado intensivo obstétrico. Por esta razón, se realizó una revisión narrativa no sistemática de la literatura utilizando como fuente de información MEDLINE, sociedades científicas y los repositorios de la Organización Mundial de la Salud y el Ministerio de Salud y Protección Social de Colombia, con el objetivo de describir algunas sugerencias para el manejo de una paciente embarazada con COVID-19 en una unidad de cuidado intensivo. Se resalta que la atención debe ser realizada por un equipo interdisciplinario, bajo monitorización materna y fetal cuando corresponda, vigilando los niveles de saturación de oxígeno y la hemodinamia materna para minimizar la hipoxemia fetal. Se describen recomendaciones sobre algunos tópicos relevantes en el escenario crítico, como la intubación oportuna, la utilización adecuada de los equipos de protección personal (EPP), el manejo de la falla circulatoria, las estrategias restrictivas de fluidos y/o vasopresores, entre otros.

An Advanced Understanding of Uterine Microbial Ecology Associated with Metritis in Dairy Cows

Metritis, the inflammation of the uterus caused by polymicrobial infections, is a prevalent and costly disease to the dairy industry as it decreases milk yield, survival, and the welfare of dairy cows. Although affected cows are treated with broad-spectrum antibiotics such as ceftiofur, endometrial and ovarian function are not fully recovered, which results in subfertility and infertility. According to culture-dependent studies, uterine pathogens include Escherichia coli, Trueperella pyogenes, Fusobacterium necrophorum, and Prevotella melaninogenica. Recent studies using high-throughput sequencing observed very low relative abundance of Escherichia coli, Trueperella pyogenes, and Prevotella melaninogenica in cows with metritis. Herein, we propose that metritis is associated with a dysbiosis of the uterine microbiota, which is characterized by high abundance of Bacteroides, Porphyromonas, and Fusobacterium.

Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation

Background

There is a need for a clear and actionable definition of maternal sepsis, in order to better assess the burden of this condition, trigger timely and effective treatment and allow comparisons across facilities and countries. The objective of this study was to review maternal sepsis definitions and identification criteria and to report on the results of an expert consultation to develop a new international definition of maternal sepsis.

Methods

All original and review articles and WHO documents, as well as clinical guidelines providing definitions and/or identification criteria of maternal sepsis were included. A multidisciplinary international panel of experts was surveyed through an online consultation in March-April 2016 on their opinion on the existing sepsis definitions, including new definition of sepsis proposed for the adult population (2016 Third International Consensus Definitions for Sepsis and Septic Shock) and importance of different criteria for identification of maternal sepsis. The definition was agreed using an iterative process in an expert face-to-face consensus development meeting convened by WHO and Jhpiego.

Results

Standardizing the definition of maternal sepsis and aligning it with the current understanding of sepsis in the adult population was considered a mandatory step to improve the assessment of the burden of maternal sepsis by the expert panel. The literature review and expert consultation resulted in a new WHO consensus definition “Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, child-birth, post-abortion, or post-partum period”. Plans are in progress to validate the new WHO definition of maternal sepsis in a large international population.

Conclusion

The operationalization of the new maternal sepsis definition requires generation of a set of practical criteria to identify women with sepsis. These criteria should enable clinicians to focus on the timely initiation of actionable elements of care (administration of antimicrobials and fluids, support of vital organ functions, and referral) and improve maternal outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-017-0321-6) contains supplementary material, which is available to authorized users.

Azithromycin in Labor Lowers Clinical Infections in Mothers and Newborns: A Double-Blind Trial

BACKGROUND AND OBJECTIVES

We have recently completed a proof-of-concept trial showing that bacterial colonization decreased in women and newborns after the administration of azithromycin during labor. Here, we aim to assess the effect of the intervention on maternal and neonatal clinical infections.

METHODS

This was a double-blind, placebo-controlled randomized trial. Gambian women in labor were given either an oral dose of azithromycin (2 g) or placebo. Follow-up was conducted for 8 weeks after delivery.

RESULTS

From April 2013 to April 2014, we recruited 829 mothers and their 830 newborns. Sixteen infants died during the follow-up period (8 per arm). No maternal deaths or serious adverse events related to the intervention were reported. Maternal infections were lower in the azithromycin group (3.6% vs 9.2%; relative risk [RR], 0.40; 95% confidence interval [CI], 0.22-0.71; P = .002), as was the prevalence of mastitis (1.4% vs 5.1%; RR, 0.29; 95% CI, 0.12-0.70; P = .005) and fever (1.9% vs 5.8%; RR, 0.33; 95% CI, 0.15-0.74; P = .006). Among newborns, the overall prevalence of infections was also lower in the azithromycin group (18.1% vs 23.8%; RR, 0.76; 95% CI, 0.58-0.99; P = .052) and there was a marked difference in prevalence of skin infections (3.1% vs 6.4%; RR, 0.49; 95% CI, 0.25-0.93; P = .034).

CONCLUSIONS

Azithromycin given to women in labor decreases infections in both women and newborns during the puerperal period. Larger studies designed to evaluate the effect of the intervention on severe morbidity and mortality are warranted.

Pregnancy-associated severe sepsis

PURPOSE OF REVIEW

This article examines the contemporary knowledge and uncertainties about the burden of pregnancy-associated severe sepsis (PASS), and its manifestations, management, and outcomes.

RECENT FINDINGS

There are relatively sparse data on PASS, related in part to infrequent reports and varying use of terminology and case definitions. PASS remains rare, although its incidence appears to be rapidly rising in some high-resource countries, affecting especially women with limited resources, minorities, and those with chronic illness. High level of clinician vigilance and rapid initiation of appropriate antimicrobial therapy, coupled with effective systemic support for organ dysfunction and correction of occult and overt hypoperfusion are the keys to limit adverse outcomes. However, timely diagnosis and provision of effective care remain a challenge, with reported prevalent delay in recognition and delivery of time-sensitive care interventions among maternal decedents. The mortality rate of PASS has been rising and its case fatality, although relatively low, has remained unchanged, in contrast to the outcome gains in the general population. The long-term sequelae of PASS remain unknown.

SUMMARY

The relatively limited contemporary data on PASS suggest a rising public health hazard in the obstetric population in high-resource countries, with ongoing challenges in assuring consistent provision of time-sensitive care.

Sepsis during pregnancy or the postpartum period

Sepsis is an important cause of maternal morbidity and mortality worldwide. Early recognition and timely treatment are the key to ensuring a favourable outcome. This article reviews recent literature about definitions, pathophysiology, incidence, diagnosis, management, treatment, prevention and outcome of sepsis during pregnancy and the postpartum period.

Modified obstetric early warning scoring systems (MOEWS): validating the diagnostic performance for severe sepsis in women with chorioamnionitis

OBJECTIVE

We sought to compare the predictive power of published modified obstetric early warning scoring systems (MOEWS) for the development of severe sepsis in women with chorioamnionitis.

STUDY DESIGN

This was a retrospective cohort study using prospectively collected clinical observations at a single tertiary unit (Chicago, IL). Hospital databases and patient records were searched to identify and verify cases with clinically diagnosed chorioamnionitis during the study period (June 2006 through November 2007). Vital sign data (heart rate, respiratory rate, blood pressure, temperature, mental state) for these cases were extracted from an electronic database and the single worst composite recording was identified for analysis. Global literature databases were searched (2014) to identify examples of MOEWS. Scores for each identified MOEWS were derived from each set of vital sign recordings during the presentation with chorioamnionitis. The performance of these MOEWS (the primary outcome) was then analyzed and compared using their sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic curve for severe sepsis.

RESULTS

Six MOEWS were identified. There was wide variation in design and pathophysiological thresholds used for clinical alerts. In all, 913 women with chorioamnionitis were identified from the clinical database. In all, 364 cases with complete data for all physiological indicators were included in analysis. Five women developed severe sepsis, including 1 woman who died. The sensitivities of the MOEWS in predicting the severe deterioration ranged from 40-100% and the specificities varied even more ranging from 4-97%. The positive predictive values were low for all MOEWS ranging from <2-15%. The MOEWS with simpler designs tended to be more sensitive, whereas the more complex MOEWS were more specific, but failed to identify some of the women who developed severe sepsis.

CONCLUSION

Currently used MOEWS vary widely in terms of alert thresholds, format, and accuracy. Most MOEWS have not been validated. The MOEWS generally performed poorly in predicting severe sepsis in obstetric patients; in general severe sepsis was overdetected. Simple MOEWS with high sensitivity followed with more specific secondary testing is likely to be the best way forward. Further research is required to develop early warning systems for use in this setting.

Effect of Danzhi decoction on expression of angiogenesis factors in patients with sequelae of pelvic inflammatory disease

OBJECTIVE

To investigate the effects of traditional Chinese medicine, Danzhi decoction, on the expression angiogenesis factors in human endometrial cells during the sequelae of pelvic inflammatory disease (SPID) and explore the role of Danzhi decction in improving the blood stasis microenvironment of SPID.

METHODS

A three-dimensional (3D) co-culture system including human vascular endothelial cells (VECs), endometrial stromal cells and glandular epithelial cells was established in vitro and treated with Danzhi decoction, sterilized water and aspirin respectively. A Milliplex multifunctional liquid chip technique was used to measure the expression levels of vascular endothelial growth factor (VEGF)-A/C/D, fibroblast growth factor -1/2, angiopoietin-2, epidermal growth factor (EGF), HB-EGF, bone morphogenetic protein-9, endoglin, endothelin-1, granulocyte colony stimulating factor, hepatocyte growth factor, interleukin-8, follistatin, placenta growth factor and leptin. The location of angiogenesis factors was monitored by immunofluorescence labeling and confocal laser scanning microscope 3D reconstruction.

RESULTS

Endometrial stromal cells and glandular epithelial cells were isolated and primary cultured for establishing a 3D co-culture system. The levels of VEGF-A/C/D in Danzhi decoction group and aspirin group were significantly lower than those in mock group (P<0.05), while there was no significant difference between Danzhi decoction group and aspirin group (P>0.05). Furthermore, the alterative location of VEGF-A/C/D was observed in the cytoplasm of endometrial glandular epithelial cells.

CONCLUSIONS

Danzhi decoction may inhibit the expression of VEGF in the blood stasis microenvironment of SPID by targeting the cytoplasm of endometrial glandular epithelial cell.

Sepsis and maternal mortality

PURPOSE OF REVIEW

Despite global progress towards reducing maternal mortality, sepsis remains a leading cause of preventable maternal death. This review focuses on current measurement challenges, trends, causes and efforts to curb maternal death from sepsis in high and low-income countries.

RECENT FINDINGS

Under-reporting using routine registration data, compounded by misclassification and unreported deaths, results in significant underestimation of the burden of maternal death from sepsis. In the UK and the Netherlands the recent increase in maternal death from sepsis is mainly attributed to an increase in invasive group A streptococcal infections. Susceptibility to infection may be complicated by modulation of maternal immune response and increasing rates of risk factors such as caesarean section and obesity. Failure to recognize severity of infection is a major universal risk factor. Standardized Surviving Sepsis Campaign (SSC) recommendations for management of severe maternal sepsis are continuing to be implemented worldwide; however, outcomes differ according to models of intensive care resourcing and use.

SUMMARY

The need for robust data with subsequent analyses is apparent. This will significantly increase our understanding of risk factors and their causal pathways, which are critical to informing effective treatment strategies in consideration of resource availability.

The continuum of maternal sepsis severity: incidence and risk factors in a population-based cohort study

OBJECTIVE

To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort.

METHODS

This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors.

RESULTS

1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI = 9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR = 1.29; ≥35 years: aOR = 1.41), had ≤high-school education (aOR = 1.63), public/no-insurance (aOR = 1.22) or a cesarean section (primary: aOR = 1.99; repeat: aOR = 1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI = 4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR = 2.09), Asian (aOR = 1.59), Hispanic (aOR = 1.42), had public/no-insurance (aOR = 1.52), delivered in hospitals with <1,000 births/year (aOR = 1.93), were primiparous (aOR = 2.03), had a multiple birth (aOR = 3.5), diabetes (aOR = 1.47), or chronic hypertension (aOR = 8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR = 3.72; aOR = 4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI = 17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI = 40.8-74.4).

CONCLUSIONS

The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

Managing the risks of sepsis in pregnancy

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.