Maternal sepsis update

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 5 – A N T E N ATA L C A R E

Maternal Sepsis Update: Current Management and Controversies Greer O, Shah NM, Johnson MR. Maternal sepsis update: current management and controversies. TOG 2020;22:45–55. doi:10.1111/tog.12623

8% 50:1 ≥2 mmol/l MORTALITY RISK, SEPSIS IN HICS MORBIDITY:MORTALITY RATIO LACTATE – PROMPTS CRITICAL CARE INPUT

DO N' T-M IS S FA C TS

  1. Physiological changes of normal pregnancy (hyperventilation/respiratory alkalosis, vasodilatation) mimic early sepsis and delay diagnosis; pregnant women are less able to buffer sepsis-related metabolic acidosis

  2. Septic shock criteria (Sepsis-3, applied in pregnancy): vasopressor need for MAP ≥65 mmHg + lactate >2 mmol/l

  3. RCOG modifies SSC fluid resuscitation from 30 ml/kg to 20 ml/kg owing to increased pulmonary oedema risk in pregnancy

  4. Most common pathogens: E. coli & group B streptococcus; most severe outcomes: E. coli & group A streptococcus

  5. ANODE trial: single antibiotic dose post-operative vaginal delivery ↓ confirmed infection by 56%

  6. Delayed source control: 28-day mortality rises 26%→42%

  7. SOS score ≥6 → increased ICU admission likelihood; qSOFA (obstetric) ≥2 → increased mortality risk

  8. Steroids not recommended for maternal sepsis – withhold IV hydrocortisone; evidence extrapolated from general population is low quality

EVIDENCE/CONTROVERSY SNAPSHOT

Supported: ANODE prophylaxis, Sepsis Six bundle, crystalloids, source control

Unresolved: PCT-guided therapy, steroids, levosimendan, bundle mortality benefit (3 RCTs negative)

ABBREVIATION KEY

WHO — World Health Organization MAP — mean arterial pressure

HIC/LMIC — high-/low-middle-income country CVP — central venous pressure

RCOG — Royal College of Obstetricians & Gynaecologists ScvO2/SvO2 — central/mixed venous O₂ saturation

qSOFA — quick sequential organ failure assessment WCC — white cell count

SOFA — sequential organ failure assessment CRP — C-reactive protein

SOS — Sepsis in Obstetrics Score PCT — procalcitonin

MEWS — modified early warning score PCR — polymerase chain reaction

CEMACH — Confidential Enquiry into Maternal and Child Health MALDI-TOF — matrix-assisted laser desorption/ionisation time-of- flight mass spectrometry GLOSS — Global Maternal Sepsis Study ICU — intensive care unit MBRRACE — Mothers and Babies: Reducing Risk through Audits & Confidential Enquiries IVIg — intravenous immunoglobulin

NICE — National Institute for Health and Care Excellence ECMO — extracorporeal membranous oxygenation

SSC — Surviving Sepsis Campaign RCT — randomised controlled trial

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — doi:10.1111/tog.12623

Clinically reviewed by NHS obstetricians and gynaecologists

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).

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