**2.6 Clinical presentation**

In sepsis, a person's response to an infection presents as signs of infection together with acute organ dysfunction, which can lead to multiple organ failure, acidosis, and death [21]. The clinical manifestations of sepsis varies, depending on the where the infection happens, the type of organism, the pattern of acute organ dysfunction, the health status of the patient, and what happens prior to initiation of treatment. Acute organ dysfunction is most commonly seen in the respiratory and cardiovascular systems. Respiratory compromise is classically manifested as acute respiratory distress syndrome (ARDS), which is defined as hypoxemia with bilateral infiltrates of noncardiac origin. Cardiovascular compromise is manifested primarily as hypotension or an elevated serum lactate level [18]. Patients often present to the emergency department with general malaise, fever, tachycardia,

tachypnea, or altered mental status. Health professionals should look at lactate levels, white blood cell counts (leukocytosis or leukopenia), increases in plasma C-reactive protein or procalcitonin concentrations to help determine if a patient is becoming septic [2].

### **2.7 Clinical significance of lactate production**

Lactate production in sepsis is multifactorial and incompletely understood. Most patients with sepsis and elevated lactate have a hyperdynamic circulation with adequate oxygen delivery. The source of lactate production is from the rapid rate of glycolysis and increased anaerobic production that does not always take place in the muscle, so other tissues/cells are possible major contributors. Its greatest utility is as a guide to therapeutic response, an indicator of severity, and a prognostic tool for mortality [7].

#### **2.8 Management/treatment**

The management and treatment of sepsis and septic shock should be dealt with as a medical emergency. Screening patients for signs and symptoms of sepsis and septic shock helps to identify and intervene when needed [21]. Proper treatment should focus on when to intervene and being able to find the source of the infection. An important part of the initial management of sepsis is to make sure there is an aggressive assessment to identify unknown sources of infection using appropriate laboratory testing and diagnostic imaging [2]. In addition, early initiation of appropriate antimicrobial therapy after blood cultures have been taken, restoring tissue perfusion by administering the proper amount of fluids, and advanced interventions guided by assessment of the adequacy of resuscitation and resolution of organ dysfunction should be part of the initial sepsis management [21, 23].

The surviving sepsis campaign (SSC) issued guidelines for the management of sepsis and septic shock. It is divided into two sections: an initial management section and a management section. The initial management section indicates what to do within the first 6 h after the patient presents with signs and symptoms that imply sepsis, and the management section indicates what to do when the patient is transferred to the ICU. The main points of the initial management section is to make sure that cardiorespiratory resuscitation takes place and to make sure that the immediate threats of infection have been controlled. Intravenous fluids and vasopressors are used to resuscitate the patient and oxygen therapy and mechanical ventilation are used if needed [18]. For patients with hemodynamic instability, as defined by either hypotension (systolic blood pressure <90 mmHg, MAP <70 mmHg, or a decrease in systolic blood pressure of >40 mmHg from baseline) or elevated lactate concentration (≥4 mmol/L), the SSC recommends rapid administration of 30 mL/kg crystalloid fluids started within the first hour [21, 24].

To determine the type of empirical antibiotic therapy needed, many factors are considered before choosing the initial therapy; the suspected site of infection, the setting where the infection developed, medical history, and local microbial-susceptibility patterns. There is an increased chance of death if the improper therapy is chosen of if there is a delay in treatment, so intravenous broad spectrum antibiotics should be started immediately to cover all pathogens until sensitivity of the blood culture comes back [25]. The 2017 SSC recommendations state that IV antimicrobials should be started immediately, the initial choice should be broad spectrum coverage and the antibiotic spectrum should be narrowed when pathogens have been isolated and sensitivities have been established. A decrease in antibiotic usage should be considered when the patient's condition improves [26].

**69**

*Sepsis and Septic Shock*

**3.1 Introduction**

*DOI: http://dx.doi.org/10.5772/intechopen.86800*

**3. Sepsis and septic shock in obstetrics**

Septic shock is a consequence of sepsis and one of the criteria to determine if the patient is in septic shock is if the patient is hypotensive and requires vasopressor therapy even if adequate fluids have been administered [27]. In patients with septic shock, vasopressor therapy is often needed to help maintain perfusion pressure [2]. The first-line vasopressor recommended in septic shock is norepinephrine, based on multiple randomized controlled studies and meta-analysis comparing dopamine and norepinephrine. Use of norepinephrine was found to be superior with regard to mortality and adverse cardiac events [28]. Epinephrine has potent inotropic and vasoconstrictive effects, but is less commonly used as a first-line agent in septic shock, which is typically associated with a hyperdynamic circulation [7]. Vasopressin reduces the dose of catecholamine vasopressors, but does not appear to affect patient mortality [2]. It is often used as a replacement dose after initiation of norepinephrine [29].

Sepsis during pregnancy remains a leading cause of maternal morbidity and mortality worldwide [30]. In the USA, infection accounted for 14% and sepsis 4.3% of all maternal deaths between 2006 and 2010. In the UK between 2006 and 2012, genital tract sepsis accounted for 7% of all maternal deaths [8]. Even with advances in hygiene and antibiotic use, sepsis still accounts for 15% of maternal deaths a year worldwide. Due to inadequate resources and improper hygiene, it is mainly seen in low-income countries that maternal death is 3 times higher compared to high-income countries [31]. The failure to recognize sepsis and institute prompt treatment underlies most cases of maternal sepsis with poor outcomes. Pregnant women are at higher risk of developing infection due to the physiological changes that take place along with possible trauma and surgical interventions. These infections can go unnoticed until there is substantial clinical deterioration. The initial alteration of hemodynamics may be falsely attributed to labor pain or blood loss subsequent to delivery. Normal laboratory values in pregnant patients are different compared to the non-pregnant population. The definitions and criteria used to determine if a patient is in sepsis has not been fully investigated in pregnancy. There are currently efforts taking place to help implement early warning systems and revise the definition of sepsis to help diagnose sepsis earlier in a pregnant patient. It has been shown that early recognition, diagnosis and management of maternal sepsis lead to better maternal and fetal outcomes [9]. Overall, diagnosing sepsis in a pregnant woman can be very difficult due to differing normal values. In this section we will go over causes, clinical presentation,

diagnosis and treatment for sepsis and septic shock during pregnancy.

Compared to the non-pregnant population, there is currently no standard definition for severe sepsis for pregnant and peripartum women [32]. There are multiple physiological changes that occur in an obstetric patient during the antepartum and postpartum periods, which can make it difficult to identify if the patient is

Sepsis is something can occur at any time during one's pregnancy and can even happen during the postpartum period, something that everyone should be aware of [33].

**3.2 Definition of sepsis during pregnancy**

going into sepsis using the qSOFA scoring system.

**3.3 Identification and scoring systems in pregnancy**

#### *Sepsis and Septic Shock DOI: http://dx.doi.org/10.5772/intechopen.86800*

Septic shock is a consequence of sepsis and one of the criteria to determine if the patient is in septic shock is if the patient is hypotensive and requires vasopressor therapy even if adequate fluids have been administered [27]. In patients with septic shock, vasopressor therapy is often needed to help maintain perfusion pressure [2]. The first-line vasopressor recommended in septic shock is norepinephrine, based on multiple randomized controlled studies and meta-analysis comparing dopamine and norepinephrine. Use of norepinephrine was found to be superior with regard to mortality and adverse cardiac events [28]. Epinephrine has potent inotropic and vasoconstrictive effects, but is less commonly used as a first-line agent in septic shock, which is typically associated with a hyperdynamic circulation [7]. Vasopressin reduces the dose of catecholamine vasopressors, but does not appear to affect patient mortality [2]. It is often used as a replacement dose after initiation of norepinephrine [29].
