maternal sepsis - admin.learningstream.com

2/1/2021

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Maternal Sepsis

Objectives

• Identify risk factors for maternal infections

• Recognize signs and symptoms of maternal infections

• Discuss medical and nursing management of maternal infection

• Recognize risk factors and signs and symptoms of maternal sepsis

• Discuss medical and nursing management of maternal sepsis

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incidence

(CDC, 2020)

Why are pregnant & postpartum women at risk?• Normal vaginal flora

• Pregnancy is an immunosuppressed state

• Changes in physiology during pregnancy/postpartum can mask early s/s of sepsis

• Interventions during labor/postpartum

• Maternal alkaline state favors growth of microbes (Davidson et al., 2020; Lowdermilk et al., 2020)

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRIcZ7DUU-EyrBY4Sv6SIikSgDeo3zOVrupoQ&usqp=CAU

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Pregnancy Physiology - review

• Temperature can be affected by

• Increased exertion during labor

• Magnesium administration

• Epidural anesthesia

• Heart rate increases 10-15 beats above baseline

• Respiratory rate may increase

• PaCO2 decreased due to compensated respiratory alkalosis

• WBCs increase

(Davidson et al., 2020; Lowdermilk et al., 2020)

Postpartum infections

Common Types:• Chorioamionitis

• Endometritis

• Wound infection – cesarean or perineal

• Urinary tract infection (UTI)• Breast infection

• Respiratory Tract

Diagnostic Lab Orders: • CBC

• Urine cultures

• Blood and uterine tissue cultures


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Infectionrisk factors - Antepartum• History of previous venous thrombosis, UTI, mastitis, pneumonia

• Obesity

• Diabetes

• Preeclampsia

• Preexisting infection (bacterial vaginosis, HSV, chlamydia, etc.)

• Immunosuppression

• Anemia

• Malnutrition

• Smoking, alcoholism, and/or substance use disorder


infection risk factors - Intrapartum

• Cesarean birth

• Operative vaginal birth

• Episiotomy or lacerations

• Hematomas

• Prolonged ROM

• Chorioamnionitis

• Prolonged labor

• Bladder catheterization

• Internal FHR monitoring or IUPC monitoring

• Multiple vaginal exams after ROM

• Epidural analgesia/anesthesia

• Manual removing of placenta and/or retained placental fragments

• Uterine exploration after delivery

• Postpartum hemorrhage


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Chorioamnionitis/intra-amniotic infection

• Historically: an infection of the chorion, amnion, or both

• “Intra-amniotic infection" (IAI): infection with inflammation with any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua

• Usually occurs from ascending bacterial invasion from the lower genital tract to the typically sterile amniotic cavity

(ACOG, 2017)Picture from https://www.pregmed.org/chorioamnionitis.htm

Intra-Amniotic Infection (IAI) - Incidence

• Occurs in 2-5% of term deliveries

• Significant risk reduction associated with intrapartum antibiotic treatment

• GBS + mothers

• Signs and symptoms of infection in labor

• Increased risk related to:

• > 41 weeks gestation

• Low parity

• Long labor duration

• Long ROM duration• Multiple digital exams

• Use of internal monitors during labor

• Meconium stained fluid

• Genital tract pathogens

(ACOG, 2017)

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Intra-Amniotic Infection (IAI) - Presentation• Suspected intraamniotic Infection:

• Maternal temp > 39 degrees Celsius (102.2 Fahrenheit)

• Or 38-38.9 degrees Celsius (100.4-102.1 Fahrenheit) with at least 1 additional risk factor

• Isolated maternal fever:• Any maternal temperature 38-38.9

degrees Celsius (100.4-102.1 Fahrenheit)

• With no additional risk factors

• With or without persistent fever

• WBCs• Purulent cervical drainage

• Fetal tachycardia

• May be confirmed by:

• + amniotic fluid test result (gram stain or cultures)

• Placenta pathology

(ACOG, 2017)

Intra-Amniotic Infection (IAI) - Management

• Treatment should not be delayed if IAI is suspected

• Cesarean rarely indicated for infection alone

• Intrapartum antibiotics• Suspected infection

• Isolated fever - unless a different source for fever identified and documented

• Antibiotics continued postpartum based on evaluation of risk factors• Persistent fever

• Bacteremia

• Antipyretics

• Comfort measures

(ACOG, 2017)

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ACOG Antibiotic treatment recommendations

(ACOG, 2017)

Pyelonephritis

• Results from untreated cystitis • Infection progresses to the kidneys

• Most common causative agent is Escherichia coli

(Davidson et al., 2020; Lowdermilk et al., 2020) https://www.memecreator.org/static/images/memes/3852116.jpg

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UTI – May First present to unit as cystitis

• Frequency and/or urgency

• Dysuria

• Urinary retention

• Hesitancy and dribbling

• Nocturia

• Suprapubic pain

• Hematuria

• Pyuria

• Low grade fever (not always)

• Not expected: high fever and systemic symptoms

(Davidson et al., 2020; Lowdermilk et al., 2020)https://i2prod.dailyrecord.co.uk/incoming/article8099721.ece/ALTERNATES/s615b/68a0a94f2dda396ea114c3016a234617d752234c5b976f2cfef2962e133844dd.jpg

Cystitis progress to Pyelonephritis

• Lower UTI/Cystitis signs and symptoms plus

• Flank pain (unilateral or bilateral)

• Costovertebral angle tenderness

• High fever

• Chills

• Nausea, vomiting


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Urinary Tract infection (UTI)management

• Diagnosis – clean catch urine sample

• Usually treated outpatient

• Antibiotic therapy

• Analgesia

• Hydration

• Antispasmodic or urinary analgesic agents (Pyridium)

• Education: • Worsening signs and symptoms

• Importance of completing antibiotic therapy

• Hand and perineal hygiene

• Increasing fluid intake

• Frequent voiding Q2-4H

• Unsweetened cranberry juice or supplements for prevention


Maternal sepsis• Sepsis is an overexaggerated, systemic inflammatory response to an

invasive organism• Resulting in organ dysfunction

• If treatment is delayed may result in septic shock

• Occurs most commonly within 42 days postpartum

• 63% maternal deaths from sepsis are preventable

• Pregnancy related immunocompromised state increases risk

(Building U.S. Capacity to Review and Prevent Maternal Deaths, 2018; CMQCC, 2019)

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Maternal sepsis

(Building U.S. Capacity to Review and Prevent Maternal Deaths, 2018)

Maternal sepsis - etiology

• Often polymicrobial

• Common pathogens: escherichia coli, group B Streptococcus (GBS), staphylococcus aureus, group A Streptococcus pyogenes (GAS)

• Group A Streptococcus pyogenes (GAS)• Postpartum at 20-fold increased risk vs. non-obstetric population

• Exotoxins cause widespread tissue necrosis of major organs

• 60% mortality rate

• May also be viral

(Parfitt et al., 2017)

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Maternal sepsis - Potential EtiologiesAntepartum Intrapartum/

Immediate Postpartum

Post-discharge

• Septic abortion• Intraamniotic infection

(IAI)/Chorioamnionitis• Pneumonia/influenza• Pyelonephritis• Appendicitis

• Intraamniotic infection (IAI)/Chorioamnionitis

• Endometritis• Pneumonia/influenza• Pyelonephritis• Wound

infection/necrotizing fasciitis

• Pneumonia/influenza• Pyelonephritis• Wound

infection/necrotizing fasciitis

• Mastitis• Cholecystitis

(CMQCC, 2019)

Maternal sepsis - pathophysiology

• Toxins release by gram-negative (e coli) and gram-positive(staph, strep, pneumo) organisms cause heightened inflammatory response resulting in:

• Increased endothelial dysfunction

• Vascular permeability

• Septic shock


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• These changes lead to:• Hypotension

• Hemoconcentration

• Edema

• May show changes in cardiac function:• Systolic and diastolic changes in BP

• Decreased mean arterial pressure (MAP)

• Exaggerated inflammatory process can also lead to clotting abnormalities and DIC


• Impaired oxygenation to tissues• Sepsis can also change mitochondrial function

• This inhibits cellular extraction of oxygen even with normal hgb sat levels

• Problems with end-organ perfusion• Can lead to end-organ damage and death

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maternal sepsis - risk factors• Non-Caucasian race

• African American and others

• Medicaid or no insurance

• Delivery at a low-volume hospital

• < 1000 births per year

• Lack of access to prenatal care

• Low socioeconomic status

• Greater than 35 years of age

• Poor nutrition

• Tobacco use

• History of group B strep colonization or infection

• A patient who presents

• with a fever resulting from an infection prior to delivery, or

• the use of antibiotics 2 weeks prior to admission

• Anemia

• Immunosuppression

• Transfusion

• History of diabetes, obesity, HTN(Albright et al., 2016)

maternal sepsis - risk factors

Antepartum Intrapartum Postpartum

• Obesity• Poor nutrition• Chronic hypertension• Diabetes • Anemia• Decreased spleen function• Immunosuppression• Invasive procedures• History of GBS infection• Lack of prenatal care• Nonwhite ethnicity• Poverty• Primipara • Antibiotics w/in 2 weeks of delivery (includes

cesarean prophylaxis)

• Prolonged ROM• Lengthened active labor

stage• > 5 vaginal exams

during second stage of labor

• Operative vaginal birth • Unscheduled cesarean

• Retained placental fragments

• Hemorrhage• Cracked nipples• Mastitis


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Maternal Sepsis - Challenges

• Physiologic changes related to pregnancy/postpartum mask sepsis indicators seen in the non-OB population

• Early warning systems are used for non-obstetric patients

• SIRS, qSOFA

• Modified MEWS scored poorly in detecting sepsis

• Early recognition of risk factors and signs/symptoms is critical


Maternal Sepsis – Challenges

SIRS qSOFA

Any two of the following: • Temp <96.8°F or >100.4°F (<36°C or

>38°C)• WBC <4 or >12• HR >90• RR >20

Any two of the following: • RR >22• SBP <100 • Neuro changes

(CMQCC, 2019 )

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Maternal Sepsis -management

1. Early recognition

2. Notify provider

3. Prompt treatment

4. Confirm sepsis and evaluate for end organ injury

5. Escalate to higher level of care https://i.imgflip.com/292e1v.jpg

Early recognition- Clinical Presentation• Temperature

• >38.0 C (100.4 F) or

• <36.0 C (96.8 F)

• Heart rate• <50 or

• >110-120 BPM

• Respiratory rate

• <10 or

• >24-30 breaths/min

• BP

• SBP <85-90 mmHg or

• MAP <65 mmHg or

• >40 mmHg decrease in SBP

• SpO2 less than 95%

(Council on Patient Safety in Women's Healthcare, 2017; CMQCC, 2019)

https://memegenerator.net/img/instances/73513021.jpg

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Early recognition - Clinical Presentation

• Flushed, clammy or mottled skin

• Nausea and/or vomiting

• Edema (generalized)

• Oliguria or anuria • <35ml/hr x 2 hr or

• <0.5ml/kg/hour x 2 hrs

• Clotting abnormalities

• Pain

• Foul odor of body fluids or exudate

• Altered mental state

(Brown, 2018)

OB Specific Tools for initial sepsis screen

MEWS CMQCC

Any one of the following: • SBP <90 or >160• DBP >100• HR <50 or >120• RR <10 or >30• O2 sat <95• Oliguria <35ml/hr x 2hr• Agitation, confusion, unresponsiveness• HTN + unremitting headache or SOB

Positive if any 2 of 4 criteria are met: • Temp <36.0 C (96.8 F) or >38.0 C (100.4 F)• HR >110 bpm and sustained for 15 minutes• RR > 24 breaths per minute and sustained

for 15 minutes• WBC >15,000 or <4,000 or >10% immature

neutrophils (bands)

(Council on Patient Safety in Women's Healthcare, 2017; CMQCC, 2019)

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Ob Sepsis screening considerations• If suspected infection present, MAP <65 mmHg is sufficient to initiate

sepsis protocol/treatment

• Vitals + O2 sats should be repeated after 15 minutes if abnormal assessments are present and verified

• Sustained maternal HR >130 bpm is highly concerning for end organ injury

• WBCs peak 24 hours after antenatal corticosteroid administration

• Return close to baseline by 96 hours of age

(CMQCC, 2019 )

Notify Provider• Notify provider of:

• Vital sign changes

• Assessments

• Notify provider of sepsis alert

• Consult with core nurse and other team members

• Lab findings if available

• Prompt bedside evaluation by provider

(CMQCC, 2019 )

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Prompt treatment

• Initiate treatment within 1 hour of sepsis diagnosis or suspicion (while waiting for lab confirmation)

1. IV fluid resuscitation (1-2L bolus)2. Administer antibiotics3. Antipyretics

• Order labs

• Monitor intake and output

• Increase vitals/assessment frequency

• Supportive measures

(CMQCC, 2019 )

https://blog.capterra.com/wp-content/uploads/2016/06/169opv-1.jpg

Confirmation of Sepsis • Lab values:

• CBC (including immature neutrophils-bands and platelets)

• Coagulation status (prothrombin time-PT, international normalized ratio-INR, partial thromboplastin time-PTT)

• CMP (including bilirubin, creatinine)

• Lactic acid

• Bedside assessment

• Urine output (foley ideal)

• Pulse oximetry

• Mental status

(CMQCC, 2019 )https://now.uiowa.edu/sites/now.uiowa.edu/files/primary-media/AdobeStock_73684018.jpeg

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Confirmation of sepsis -Additional values/assessments• Hyperglycemia in the absence of diabetes

• Elevated liver enzymes

• Disseminated intravascular coagulation

• Positive culture from infection site or blood

(Brown, 2018; CMQCC, 2020)

Evaluate for end organ injuryMeasure of End Organ Injury Criteria (one is sufficient for diagnosis)

Respiratory Function • Acute respiratory failure – need for mechanical ventilation (invasive or noninvasive)

• PaO2/FiO2 <300

Coagulation Status • Platelets 100,000 or• INR > 1.5 or• PTT > 60 seconds

Liver Function • Bilirubin > 2mg/dL

(CMQCC, 2019 )

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Evaluate for end organ injury Cont.

Measure of End Organ Injury Criteria (one is sufficient for diagnosis)

Cardiovascular Function • Persistent hypotension after fluid administration• SBP < 85 mmHg or• MAP < 60 mmHg or• >40 mmHg decrease in SBP

Renal Function • Creatinine > 1.2 mg/DL or• Doubling of creatinine or• UO <0.5ml/kg/hr for 2 hours

Mental Status • Agitation, confusion, unresponsiveness

Lactic Acid • 2mmol/L

(CMQCC, 2019 )

Interpretation of Lab values for end organ injury

Laboratory Value Interpretation

Arterial pH < 7.39 to 7.45 Reflects an increase in lactic acid

Lactate level > 2.0 mmol/dL Reflects decreased perfusion of oxygen to cells

Creatinine > 1.0 mg/dl Reflects decrease in kidney function

Bilirubin > 4 mg/dl Reflects decrease in liver function

Platelets < 100,000 mm3 Reflects endothelial damage

INR > 1.5 or aPTT > 60 seconds Reflects coagulopathy

Glucose >120 mg/dl Reflects the stress of critical illness(Brown, 2018)

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CMQCC Maternal Sepsis evaluation flowsheet (CMQCC, 2020)

Postpartum Infection/Sepsis prevention

• Most effective treatment is prevention

• Hygiene

• Nutrition

• Strict aseptic technique during labor, birth, postpartum

• Anticipatory education

• Support after discharge

(Davidson et al., 2020)

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References• American College of Obstetricians and Gynecologists (2017). Intrapartum management of intraamniotic infection. ACOG Committee Opinion, 712.

Retrieved from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co712.pdf?dmc=1&ts=20180213T1731502898

• Brown, K. N. (2018). Sepsis and septic shock. A Critical Care Obstetrics Program offered through AWHONN.

• Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs

• Centers for Disease Control and Prevention (2020). Pregnancy mortality surveillance system. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

• CMQCC (2019). Improving diagnosis and treatment of maternal sepsis: A CMQCC quality improvement toolkit. Retrieved from www.CMQCC.org

• Council on Patient Safety in Women's Healthcare (2017). Maternal early warning criteria. Retrieved from https://safehealthcareforeverywoman.org/patient-safety-tools/maternal-early-warning-criteria/

• Davidson, M., London, M., & Ladewig, P. (2020). Olds’ maternal-newborn nursing & women’s health across the lifespan (11th ed.). Pearson Education, Inc.

• Lowdermilk, D. L., Perry, S.E., Cashion, K., & Alden, K. R. (2020). Maternity & women’s health care (12th ed.). St. Louis, MO: Elsevier.

• Parfitt, S. E., Bogat, M. L., Hering, S. L., & Roth, C. (2017). Sepsis in obstetrics: Pathophysiology and diagnostic definitions. MCN, 42(4), 194-198.

• Parfitt, S. E., Bogat, M. L., Hering, S. L., Ottley, C., & Roth, C. (2017). Sepsis in obstetrics: Clinical features and early warning tools. MCN, 42(4), 199-205.

• Simpson, K. R., Creehan, P. A., O’Brien-Abel, N., Roth, C. K., & Rohan, A. J. (2021). Perinatal Nursing (5th ed.). Philadelphia, PA: Wolters Kluwer.

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