Sepsis and Maternal Health

Lack of Coordination Among Caregivers

  • Lack of coordination among caregivers can lead to complications in treatment.

Inflammatory Response to Infection

  • Definition: Infection triggers a universal and massive inflammatory response, which is the body's normal response to pathogen invasion and trauma.
  • Components of the Response: Includes:
    • Anti-inflammatory cells
    • Attacker cells
    • System deactivators to prevent systemic immune response

Early Signs and Surge Criteria for Sepsis

  • Early signs to look for in patients include:
    1. Temperature (either high or low)
    2. White blood cell count over 12,000 or less than 4,000
    3. Respiratory rate greater than 20
    4. Heart rate greater than 90 (tachycardia)

Definition of Sepsis

  • Sepsis: A derangement of the normal inflammatory process, characterized by the dysregulation of post-response to infection, leading to life-threatening organ dysfunction.
    • Involves activation of excessive inflammatory mediators such as:
    • Cytokines
    • Prostaglandins
    • Leukotrienes
    • Complement systems

Pathophysiology of Sepsis

  • Endothelial Cell Damage: Sepsis causes endothelial cell damage leading to:
    • Impaired oxygen exchange
    • Vasodilation resulting in hypotension
    • Increased capillary permeability
    • Third spacing into the extravascular space and vital organs, causing edema
    • Increased systemic vascular resistance leading to tachycardia as the heart works harder
    • Dysfunction of clotting factors resulting in disseminated intravascular coagulation (DIC), a condition characterized by widespread clotting and bleeding.

Septic Shock

  • Definition: Septic shock is identified as sepsis with persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of over 65 mmHg.
    • If MAP is less than 65 mmHg after fluid load, it indicates septic shock.
  • Goals: Maintain an MAP in the 80s range and monitor lactate levels (levels greater than 2 are concerning even after adequate fluid resuscitation).

Multi-Organ Dysfunction in Sepsis

  • Symptoms include:
    • Altered mental status
    • Hypotension
    • Vasodilation
    • Myocardial dysfunction
    • Noncardiogenic pulmonary edema
    • Acute respiratory distress syndrome (ARDS)
    • Paralytic ileus (gut dysfunction)
    • Elevated liver enzymes (signifying potential liver failure)
    • Oliguria (decreased urine output indicating acute kidney injury)

Risk Factors for Sepsis in Obstetrics

  • Intrapartum Risk Factors:
    • Preterm premature rupture of membranes (PPROM)
    • Chorioamnionitis
    • Multiple gestation
    • Preeclampsia
    • Preterm labor
    • Pyelonephritis
    • In vitro fertilization (IVF)
    • Excessive vaginal examinations
  • Postpartum Risk Factors:
    • Retained placental products
    • Endometritis
    • Hemorrhage
    • Urinary tract infections (UTI)
  • Modes of Delivery influence risk factors:
    • Assisted vaginal deliveries (like vacuum)
    • Cesarean sections

Maternal Early Warning Signs System

  • An assessment tool used to identify maternity patients at risk for sepsis based on clinical signs like blood pressure, heart rate, respiratory status, and signs of agitation.
  • Scoring system ranges from 1 to 4, where:
    • 1 requires immediate medical attention
    • 4 indicates non-urgent concerns

Diagnostic Workup for Suspected Sepsis

  • Tests & Cultures:
    • Complete blood count (CBC) to check for immature neutrophils, bands, platelets
    • Comprehensive metabolic panel for liver and kidney function
    • Coagulation studies (PT, PTT, INR)
    • Lactate levels
    • Blood cultures should be drawn before starting antibiotics, which should be initiated within the first hour of diagnosis.
    • Additional tests: arterial blood gases (ABG), elective cultures for urine/infection evidence, imaging to identify infection source (ultrasound, chest X-ray, MRI, CT scans).

Pregnancy Complications Affecting Sepsis Diagnosis

  • Physiological changes in pregnancy complicate the diagnosis of sepsis due to:
    • Hemodilution causing lower hemoglobin levels
    • Differences in normal lab values during pregnancy compared to the non-pregnant state
    • Alterations in vital signs:
    • Blood pressure fluctuations: decreases in the second trimester, return to baseline in the third trimester
    • Pulse oximetry levels should be maintained above 95% for optimal oxygen to the placenta and fetus

Assessment Tool: SOFA

  • Sepsis Organ Failure Assessment (SOFA): A scoring system evaluating organ failure risk based on lab values including bilirubin, partial pressure of oxygen (PaO2), Glasgow coma scale, and creatinine levels. Higher scores indicate poorer outcomes and risk of hospital death.
  • Early recognition and treatment initiation are critical for preventing morbidity and mortality.

Goals of Treatment for Sepsis

  • Timely recognition and initiation of treatment within the first hour is crucial:
    • Administer fluids and antibiotics post-haste,
    • Maintain MAP above 65,
    • Keep central venous oxygenation greater than 70%
    • Monitor lactate levels to ensure they are decreasing
    • Ensure urine output is adequate (greater than 0.5 mL/kg/hr)
    • Regularly assess mental status and vital signs to detect deterioration early.

Barricades to Effective Patient Care

  • Normalization of Deviance:
    • A term describing how violating standard practices can become normalized, leading to missed signs and risks to patient safety.
    • Stay alert to warning signs and do not accept abnormal findings as the new baseline.
  • Alarm Fatigue:
    • A phenomenon where caregivers become desensitized to alarm signals, potentially leading to negligent patient care.

Summary and Case Studies

  • Continuous vigilance is required to prevent normalization of deviance and alarm fatigue. The healthcare team must remain proactive in monitoring and addressing signs of potential patient deterioration.
  • Engaging in open communication with the healthcare team and advocating for the patient's condition is crucial for optimal outcomes.

Final Thoughts

  • Always be aware of systemic failures that contribute to patient care issues and emphasize the need for diligent assessment, timely interventions, and clear communication within healthcare teams.