2/1/2021 Maternal Sepsis 1 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 2 1 2/1/2021 incidence (CDC, 2020) 3 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 https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRIcZ7DUU-EyrBY4Sv6SIikSgDeo3zOVrupoQ&usqp=CAU labor/postpartum • Maternal alkaline state favors growth of microbes (Davidson et al., 2020; Lowdermilk et al., 2020) 4 2 2/1/2021 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) 5 Postpartum infections Common Types: Diagnostic Lab Orders: • Chorioamionitis • CBC • Endometritis • Urine cultures • Wound infection – cesarean • Blood and uterine tissue or perineal cultures • Urinary tract infection (UTI) • Breast infection • Respiratory Tract (Davidson et al., 2020; Lowdermilk et al., 2020) 6 3 2/1/2021 Infection risk 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) 7 infection risk factors - Intrapartum • Cesarean birth • Internal FHR monitoring or IUPC • Operative vaginal birth monitoring • Episiotomy or lacerations • Multiple vaginal exams after ROM • Hematomas • Epidural analgesia/anesthesia • Prolonged ROM • Manual removing of placenta and/or retained placental fragments • Chorioamnionitis • Uterine exploration after delivery • Prolonged labor • Postpartum hemorrhage • Bladder catheterization (Davidson et al., 2020; Lowdermilk et al., 2020) 8 4 2/1/2021 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 9 Intra-Amniotic Infection (IAI) - Incidence • Occurs in 2-5% of term • Increased risk related to: deliveries • > 41 weeks gestation • Significant risk reduction • Low parity associated with intrapartum • Long labor duration antibiotic treatment • Long ROM duration • GBS + mothers • Multiple digital exams • Signs and symptoms of • Use of internal monitors infection in labor during labor • Meconium stained fluid • Genital tract pathogens (ACOG, 2017) 10 5 2/1/2021 Intra-Amniotic Infection (IAI) - Presentation • Suspected intraamniotic Infection: • WBCs • Maternal temp > 39 degrees Celsius • Purulent cervical drainage (102.2 Fahrenheit) • Fetal tachycardia • Or 38-38.9 degrees Celsius (100.4- • May be confirmed by: 102.1 Fahrenheit) with at least 1 additional risk factor • + amniotic fluid test result (gram stain or • Isolated maternal fever: cultures) • Any maternal temperature 38-38.9 • Placenta pathology degrees Celsius (100.4-102.1 Fahrenheit) • With no additional risk factors • With or without persistent fever (ACOG, 2017) 11 Intra-Amniotic Infection (IAI) - Management • Treatment should not be • Antibiotics continued delayed if IAI is suspected postpartum based on evaluation • Cesarean rarely indicated for of risk factors infection alone • Persistent fever • Bacteremia • Intrapartum antibiotics • Suspected infection • Antipyretics • Isolated fever - unless a different • Comfort measures source for fever identified and documented (ACOG, 2017) 12 6 2/1/2021 ACOG Antibiotic treatment recommendations (ACOG, 2017) 13 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 14 7 2/1/2021 UTI – May First present to unit as cystitis • Frequency and/or urgency • Low grade fever (not always) • Dysuria • Not expected: high fever and • Urinary retention systemic symptoms • Hesitancy and dribbling • Nocturia • Suprapubic pain • Hematuria • Pyuria (Davidson et al., 2020; Lowdermilk et al., 2020) https://i2prod.dailyrecord.co.uk/incoming/article8099721.ece/ALTERNATES/s615b/68a0a94f2dda396ea114c3016a234617d752234c5b976f2cf ef2962e133844dd.jpg 15 Cystitis progress to Pyelonephritis • Lower UTI/Cystitis signs and symptoms plus • Flank pain (unilateral or bilateral) • Costovertebral angle tenderness • High fever • Chills • Nausea, vomiting https://st1.latestly.com/wp-content/uploads/2019/08/aa-Cover-m2gvt1vn6ald8t2jjokcmkb2e5-20170616091320.Medi_-380x214.jpg (Davidson et al., 2020; Lowdermilk et al., 2020) 16 8 2/1/2021 Urinary Tract infection (UTI) management • Diagnosis – clean catch urine • Education: sample • Worsening signs and symptoms • Usually treated outpatient • Importance of completing antibiotic therapy • Antibiotic therapy • Hand and perineal hygiene • Analgesia • Increasing fluid intake • Hydration • Frequent voiding Q2-4H • Unsweetened cranberry juice or • Antispasmodic or urinary supplements for prevention analgesic agents (Pyridium) (Davidson et al., 2020; Lowdermilk et al., 2020) 17 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) 18 9 2/1/2021 Maternal sepsis (Building U.S. Capacity to Review and Prevent Maternal Deaths, 2018) 19 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) 20 10 2/1/2021 Maternal sepsis - Potential Etiologies Antepartum Intrapartum/ Post-discharge Immediate Postpartum • Septic abortion • Intraamniotic infection • Pneumonia/influenza • Intraamniotic infection (IAI)/Chorioamnionitis • Pyelonephritis (IAI)/Chorioamnionitis • Endometritis • Wound • Pneumonia/influenza • Pneumonia/influenza infection/necrotizing • Pyelonephritis • Pyelonephritis fasciitis • Appendicitis • Wound • Mastitis infection/necrotizing • Cholecystitis fasciitis (CMQCC, 2019) 21 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) 22 11 2/1/2021 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 23 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 24 12 2/1/2021 maternal sepsis - risk factors • Non-Caucasian race • History of group B strep • African American and others colonization or infection • Medicaid or no insurance • A patient who presents • Delivery at a low-volume hospital • with a fever resulting from an • < 1000 births per year infection prior to delivery, or • Lack of access to prenatal care • the use of antibiotics 2 weeks prior to admission • Low socioeconomic status • Anemia • Greater than 35 years of age • Immunosuppression • Poor nutrition • Transfusion • Tobacco use • History of diabetes, obesity, HTN (Albright et al., 2016) 25 maternal sepsis - risk factors Antepartum Intrapartum Postpartum • Obesity • Prolonged ROM • Retained placental • Poor nutrition • Lengthened active labor fragments • Chronic hypertension stage • Hemorrhage • Diabetes • > 5 vaginal exams • Cracked nipples • Anemia during second stage of • Mastitis • Decreased spleen function labor • Immunosuppression • Operative vaginal birth • Invasive procedures • Unscheduled cesarean • History of GBS infection • Lack of prenatal care • Nonwhite ethnicity • Poverty • Primipara • Antibiotics w/in 2 weeks of delivery (includes cesarean prophylaxis) (Parfitt et al., 2017) 26 13 2/1/2021 Maternal Sepsis - Challenges • Physiologic changes related to pregnancy/postpartum mask sepsis indicators seen in the non-OB population