Maternal Sepsis - admin.learningstream.com
Transcript of 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
(Davidson et al., 2020; Lowdermilk et al., 2020)
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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
(Davidson et al., 2020; Lowdermilk et al., 2020)
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
(Davidson et al., 2020; Lowdermilk et al., 2020)
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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
(Davidson et al., 2020; Lowdermilk et al., 2020)
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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
(Davidson et al., 2020; Lowdermilk et al., 2020)
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
(Parfitt et al., 2017)
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Maternal sepsis - pathophysiology
• 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
Maternal sepsis - pathophysiology
• 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
(Parfitt et al., 2017)
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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
(Parfitt et al., 2017)
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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