**3.3 Identification and scoring systems in pregnancy**

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].

During pregnancy, sepsis generally still follows the same rules versus a non-pregnant person, but it can be difficult to determine if a pregnant woman is in sepsis due to the changes in the baseline normal lab values seen; a non-pregnant patient's normal lab values are different compared to a pregnant patient's normal lab values. The physiological changes of pregnancy overlap with hemodynamic changes associated with the initial presentation of sepsis [9]. Before 2016, the SIRS criteria were the main source to diagnose a pregnant patient. The pitfalls with the SIRS criteria were that physiologic maternal lab values would almost result in a diagnosis of SIRS. During pregnancy, the maternal heart rate is often >100, usually due to intravascular volume changes, PCO2 is normally at 32–34 mmHg, and WBC commonly increases to 14,000 or even as high as 30,000, usually secondary to adrenocorticoid-mediated leukocytosis. After the Society of Critical Care Medicine redefined its criteria via the Sepsis-3 model, a qSOFA score was used instead of SIRS. As mentioned before, this score included three important points: altered mental status, hypotension (systolic <100 mmHg) and tachypnea (respiratory rate > 22). In terms of the qSOFA and SOFA score, there continues to be a struggle to reach a clear cut definition for pregnant patients. Due to their normal lab values, it makes it difficult to diagnose a pregnant patient with sepsis using the current definitions. For example, many patients have systolic blood pressures that are <100 mmHg and they are in no distress or their respiratory rate will increase with movement due to the extra effort it takes because of the large uterus, mainly during the third trimester [15]. With that being said, the diagnosis of sepsis during pregnancy is currently being made based on clinical suspicion, with a greater emphasis on signs of organ dysfunction rather than infection when determining the timing of intervention [33].

In the last decade, there has been development of early warning scoring systems to help identify septic patients at risk for poor outcomes. Unfortunately, many of these systems have not shown much use in the maternal population, such as the Modified Early Warning System (MEWS). These systems do not take into account the physiological changes that occur during pregnancy, something that overlaps with clinical criteria for diagnosing sepsis in the general population. Even though there is a high recommendation to develop maternal warning systems, there has been clear evidence that shows a lack of outcome benefit and validation studies have shown high sensitivity but low specificity. There needs to be further work done to improve the ability of the early warning systems to improve their ability to predict those with signs of early sepsis and at risk of deterioration. A major factor, that is, delaying the development is deciding which vital signs to use and what values are a sign of normality in the obstetric population [9].

Due to the inconsistencies in defining maternal sepsis, there are delays in diagnosis and treatment, something that can prove to be deadly to the pregnant population [15].

#### **3.4 Immunological changes during pregnancy**

During pregnancy, the maternal immune system will go through changes that will help protect the fetus from the maternal inflammatory response. There is downregulation of cell-mediated immunity, with decreased T-cell activity secondary to a decrease in numbers or reduction in the CD4/CD8 ratio, with an intact or upregulated humoral response to balance this change. Because of these changes, there is an increased chance to develop certain infections, such as Listeria, and more severe manifestations of some viral and fungal infections [34].

#### **3.5 Risk factors of sepsis during pregnancy**

Several risk factors have been identified during pregnancy, leading to the development of guidelines to help prevent sepsis in this patient population [9]. There

**71**

*Sepsis and Septic Shock*

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

are many reasons that sepsis can occur during pregnancy and postpartum. The pregnant woman can develop the same type of infections as in the non-pregnant population, but since there is a decrease in cell-mediated immune response, the infection can cause a more severe response. It is now routine to screen and treat asymptomatic bacteriuria and sexually transmitted diseases in early pregnancy and

A woman can develop an infection at many sites during the course of her pregnancy. One common area is the genitalia, where urinary tract infections are very common due to the high levels of progesterone [32]. An untreated or improperly treated urinary tract infection can lead to pyelonephritis, a common severe infection that occurs during pregnancy. It usually affects the right kidney, because of compression of the pregnant uterus, with offending organisms similar to non-

Chorioamnionitis is another cause of serious obstetric infection and is associated with increased risk of premature delivery and neonatal sepsis. The infection usually starts from the cervicovaginal area, and migrates to the amnion, decidua, and amniotic fluid. The infection is typically polymicrobial; commonly consisting of genital Mycoplasma, *Streptococcus agalactiae* and *Escherichia coli*. Risk factors for infection include prolonged labor, membrane rupture, digital vaginal examinations,

Pneumonia, which is associated with a high rate of morbidity and mortality compared to the non-pregnant population, may be caused by a bacterial, viral or fungal organism. The most common pneumonia pathogens seen in pregnancy are Varicella and Influenza A and B. Acute respiratory distress syndrome (ARDS) is a

Other risk factors include obesity, caesarean section, prolonged rupture of membranes, mastitis, poor nutrition, chronic hypertension, anemia, lack of prenatal care, immunosuppression, and diabetes mellitus [36]. All of these risk factors can cause sepsis and eventually lead to septic shock in the pregnant population.

The major contributor to sepsis during pregnancy is group A streptococcus (GAS). It spreads directly through contact with open skin sores, perineal contamination or by mucus or droplet contamination. Group B streptococcus can cause urosepsis, endometritis, mastitis, wound infections and meningitis [37]. In urinary tract infections during pregnancy, *Escherichia coli* is the most common pathogen, and if left untreated, it can lead to sepsis. *S. aureus*, *E. coli*, and anaerobes are common causes of bacteremia after cesarean section. *Listeria monocytogenes* is more classically associated with fetal loss [31]. HIV, AIDS, *Pneumocystis carinii* pneumonia, tuberculosis, and malaria are significant causes for maternal sepsis in low and middle income countries [38].

Even though the obstetric population were not specifically considered when the Surviving Sepsis Program were making the guidelines for treatment, those guidelines can still be used as a basis for treatment of sepsis and septic shock [21]. Early recognition of sepsis is associated with improved mortality and outcome. In a young, healthy pregnant patient, it may be difficult to identify sepsis and a delay in treatment may occur. With that being said a few warning signs to be considered that may alert severe sepsis include fever or hypothermia, tachycardia, tachypnea, diarrhea, vaginal discharge, leukopenia or leukocytosis, elevated lactate, metabolic

acidosis, thrombocytopenia, or other manifestations of coagulopathy [39].

possible outcome due to respiratory infections in pregnancy [31].

**3.6 Causative organisms of sepsis during pregnancy**

**3.7 Management and treatment of sepsis during pregnancy**

to administer antibiotic prophylaxis for cesarean deliveries [9, 35].

pregnant patients, *E. coli* being the major pathogen [32].

young age, and alcohol use [32].

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

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

rather than infection when determining the timing of intervention [33].

sign of normality in the obstetric population [9].

**3.4 Immunological changes during pregnancy**

**3.5 Risk factors of sepsis during pregnancy**

severe manifestations of some viral and fungal infections [34].

In the last decade, there has been development of early warning scoring systems to help identify septic patients at risk for poor outcomes. Unfortunately, many of these systems have not shown much use in the maternal population, such as the Modified Early Warning System (MEWS). These systems do not take into account the physiological changes that occur during pregnancy, something that overlaps with clinical criteria for diagnosing sepsis in the general population. Even though there is a high recommendation to develop maternal warning systems, there has been clear evidence that shows a lack of outcome benefit and validation studies have shown high sensitivity but low specificity. There needs to be further work done to improve the ability of the early warning systems to improve their ability to predict those with signs of early sepsis and at risk of deterioration. A major factor, that is, delaying the development is deciding which vital signs to use and what values are a

Due to the inconsistencies in defining maternal sepsis, there are delays in diagnosis and treatment, something that can prove to be deadly to the pregnant population [15].

During pregnancy, the maternal immune system will go through changes that will help protect the fetus from the maternal inflammatory response. There is downregulation of cell-mediated immunity, with decreased T-cell activity secondary to a decrease in numbers or reduction in the CD4/CD8 ratio, with an intact or upregulated humoral response to balance this change. Because of these changes, there is an increased chance to develop certain infections, such as Listeria, and more

Several risk factors have been identified during pregnancy, leading to the development of guidelines to help prevent sepsis in this patient population [9]. There

During pregnancy, sepsis generally still follows the same rules versus a non-pregnant person, but it can be difficult to determine if a pregnant woman is in sepsis due to the changes in the baseline normal lab values seen; a non-pregnant patient's normal lab values are different compared to a pregnant patient's normal lab values. The physiological changes of pregnancy overlap with hemodynamic changes associated with the initial presentation of sepsis [9]. Before 2016, the SIRS criteria were the main source to diagnose a pregnant patient. The pitfalls with the SIRS criteria were that physiologic maternal lab values would almost result in a diagnosis of SIRS. During pregnancy, the maternal heart rate is often >100, usually due to intravascular volume changes, PCO2 is normally at 32–34 mmHg, and WBC commonly increases to 14,000 or even as high as 30,000, usually secondary to adrenocorticoid-mediated leukocytosis. After the Society of Critical Care Medicine redefined its criteria via the Sepsis-3 model, a qSOFA score was used instead of SIRS. As mentioned before, this score included three important points: altered mental status, hypotension (systolic <100 mmHg) and tachypnea (respiratory rate > 22). In terms of the qSOFA and SOFA score, there continues to be a struggle to reach a clear cut definition for pregnant patients. Due to their normal lab values, it makes it difficult to diagnose a pregnant patient with sepsis using the current definitions. For example, many patients have systolic blood pressures that are <100 mmHg and they are in no distress or their respiratory rate will increase with movement due to the extra effort it takes because of the large uterus, mainly during the third trimester [15]. With that being said, the diagnosis of sepsis during pregnancy is currently being made based on clinical suspicion, with a greater emphasis on signs of organ dysfunction

**70**

are many reasons that sepsis can occur during pregnancy and postpartum. The pregnant woman can develop the same type of infections as in the non-pregnant population, but since there is a decrease in cell-mediated immune response, the infection can cause a more severe response. It is now routine to screen and treat asymptomatic bacteriuria and sexually transmitted diseases in early pregnancy and to administer antibiotic prophylaxis for cesarean deliveries [9, 35].

A woman can develop an infection at many sites during the course of her pregnancy. One common area is the genitalia, where urinary tract infections are very common due to the high levels of progesterone [32]. An untreated or improperly treated urinary tract infection can lead to pyelonephritis, a common severe infection that occurs during pregnancy. It usually affects the right kidney, because of compression of the pregnant uterus, with offending organisms similar to nonpregnant patients, *E. coli* being the major pathogen [32].

Chorioamnionitis is another cause of serious obstetric infection and is associated with increased risk of premature delivery and neonatal sepsis. The infection usually starts from the cervicovaginal area, and migrates to the amnion, decidua, and amniotic fluid. The infection is typically polymicrobial; commonly consisting of genital Mycoplasma, *Streptococcus agalactiae* and *Escherichia coli*. Risk factors for infection include prolonged labor, membrane rupture, digital vaginal examinations, young age, and alcohol use [32].

Pneumonia, which is associated with a high rate of morbidity and mortality compared to the non-pregnant population, may be caused by a bacterial, viral or fungal organism. The most common pneumonia pathogens seen in pregnancy are Varicella and Influenza A and B. Acute respiratory distress syndrome (ARDS) is a possible outcome due to respiratory infections in pregnancy [31].

Other risk factors include obesity, caesarean section, prolonged rupture of membranes, mastitis, poor nutrition, chronic hypertension, anemia, lack of prenatal care, immunosuppression, and diabetes mellitus [36]. All of these risk factors can cause sepsis and eventually lead to septic shock in the pregnant population.

#### **3.6 Causative organisms of sepsis during pregnancy**

The major contributor to sepsis during pregnancy is group A streptococcus (GAS). It spreads directly through contact with open skin sores, perineal contamination or by mucus or droplet contamination. Group B streptococcus can cause urosepsis, endometritis, mastitis, wound infections and meningitis [37]. In urinary tract infections during pregnancy, *Escherichia coli* is the most common pathogen, and if left untreated, it can lead to sepsis. *S. aureus*, *E. coli*, and anaerobes are common causes of bacteremia after cesarean section. *Listeria monocytogenes* is more classically associated with fetal loss [31]. HIV, AIDS, *Pneumocystis carinii* pneumonia, tuberculosis, and malaria are significant causes for maternal sepsis in low and middle income countries [38].

#### **3.7 Management and treatment of sepsis during pregnancy**

Even though the obstetric population were not specifically considered when the Surviving Sepsis Program were making the guidelines for treatment, those guidelines can still be used as a basis for treatment of sepsis and septic shock [21]. Early recognition of sepsis is associated with improved mortality and outcome. In a young, healthy pregnant patient, it may be difficult to identify sepsis and a delay in treatment may occur. With that being said a few warning signs to be considered that may alert severe sepsis include fever or hypothermia, tachycardia, tachypnea, diarrhea, vaginal discharge, leukopenia or leukocytosis, elevated lactate, metabolic acidosis, thrombocytopenia, or other manifestations of coagulopathy [39].

Pregnant women who develop sepsis are usually infected with multiple organisms. The initial choice of antibiotic should have broad spectrum coverage and base it off of guidelines and patterns of resistance [40]. The initial treatment should include coverage against Group A Streptococcus and *Escherichia coli* because they are the most common contributors to sepsis in pregnancy and responsible for a significant proportion of deaths [9].

In a septic pregnant patient, one big challenge is being able to manage fluids. The SSC guidelines recommend crystalloid at an initial 30 mL/kg bolus. This recommendation can be too aggressive in the obstetric population, but there is evidence that shows balanced crystalloid solutions are associated with a lower mortality in sepsis as compared to normal saline [41, 42].

Vasopressors can be used in sepsis mediated hypotension and septic shock. If hypotension does occur, the surviving sepsis campaign (SCC) recommends norepinephrine as the first line agent. These SCC guidelines are based on evidence from non-pregnant patients and there is little data on the effect that vasopressors have on placental blood flow in a pregnant woman [9].
