Sepsis in pregnancy

Surgical approach (source control pathways)

• Principle: early source control + antibiotics + supportive care; obstetric team leads decisions on delivery and uterine evacuation
  • Treat the cause rather than “deliver to treat sepsis” unless delivery is the source control (e.g., chorioamnionitis with fetal compromise, retained products, uterine infection).
• Common source-control interventions
  • Uterine evacuation for septic miscarriage / retained products (suction curettage ± hysteroscopy).
  • Emergency Caesarean section if obstetric indication or if intrauterine infection requires delivery as part of source control (chorioamnionitis with maternal deterioration / fetal compromise).
  • Drainage of abscess (e.g., tubo-ovarian abscess), laparoscopic/open depending on stability.
  • Debridement for necrotising soft tissue infection (perineum/abdominal wall) ± repeat look.
  • Urological source: ureteric stent/nephrostomy for obstructed infected system.
  • Line/foreign body removal if suspected source (e.g., infected cannula/central line).

Anaesthetic management (typical scenarios)

• Context: not a single operation; anaesthesia depends on required source control (e.g., evacuation of retained products, CS, abscess drainage).
• Type of anaesthesia
  • Often GA for unstable septic patient, urgent surgery, anticipated difficult airway/aspiration risk, or need for controlled ventilation and vasopressors.
  • Regional (spinal/epidural) may be appropriate only if haemodynamically stable, no significant coagulopathy/thrombocytopenia, no untreated bacteraemia concerns, and time allows; consider incremental dosing via epidural rather than single-shot spinal in borderline patients.
  • Neuraxial is relatively contraindicated in severe sepsis/shock, evolving coagulopathy, or if urgent GA required; decision is risk-benefit and senior-led.
• Airway device
  • Usually cuffed ETT (RSI) for CS/abdominal surgery or unstable sepsis; pregnancy = aspiration risk + airway oedema.
  • SGA only for short, low-risk procedures in stable patients (rare in septic pregnancy).
• Duration
  • Evacuation of retained products: ~15–45 min; CS: ~45–90 min; drainage/debridement: variable (often 1–3+ h).
• How painful
  • Evacuation: moderate visceral pain/cramping; CS/abdominal source control: severe postoperative pain.
  • Analgesia: multimodal (paracetamol ± NSAID if renal function/bleeding risk acceptable), neuraxial opioid if neuraxial used, consider TAP/QL blocks for laparotomy/CS; cautious opioids in shock/respiratory compromise.
• Intraoperative priorities
  • Resuscitate before induction where possible: oxygen, left uterine displacement, large-bore IV access, early vasopressors, treat hypoglycaemia, correct hypocalcaemia if massive transfusion/citrate.
  • A-line early if unstable; consider CVC if vasopressor infusion/poor access; strict fluid balance and urine output monitoring.
  • Sepsis + pregnancy: higher risk of rapid desaturation, aspiration, difficult airway; plan for failed intubation and early senior help.

Definition and epidemiology

• Sepsis = life-threatening organ dysfunction caused by dysregulated host response to infection (Sepsis-3). In pregnancy, physiological changes can mask early severity; use clinical judgement and obstetric early warning scores.
• Maternal sepsis is a leading cause of maternal morbidity/mortality in the UK; common around labour, postpartum, and after invasive procedures.

Physiological changes in pregnancy relevant to sepsis recognition

• Cardiovascular: ↑HR, ↓SVR, ↑CO; mild hypotension may be “normal” → shock may be missed until late.
• Respiratory: ↓FRC, ↑O2 consumption → rapid desaturation; mild respiratory alkalosis is common; tachypnoea can be physiological but is also an early sign of sepsis.
• Haematology: pregnancy is hypercoagulable; WCC may be elevated physiologically; platelets may be lower (gestational thrombocytopenia) but falling platelets in sepsis suggests DIC/HELLP overlap.
• Renal: ↑GFR → lower baseline creatinine; “normal” creatinine may represent renal dysfunction in pregnancy.

Common sources and organisms in pregnancy

• Genital tract: chorioamnionitis, endometritis, septic miscarriage/retained products, wound infection post-CS.
• Urinary tract: pyelonephritis (risk ↑ with ureteric dilatation/urinary stasis), obstructed infected system.
• Respiratory: influenza, pneumonia (including aspiration).
• Skin/soft tissue: necrotising fasciitis, perineal infections, IV line infections.
• Key pathogens: Group A Strep (GAS) and Group B Strep, E. coli, anaerobes (genital tract), Staph aureus; consider listeria in pregnancy (food-borne).

Recognition: clinical features and investigations

• Symptoms/signs: fever or hypothermia, rigors, tachycardia, tachypnoea, hypotension, altered mental state, oliguria, abdominal/pelvic pain, uterine tenderness, foul lochia, reduced fetal movements.
• Red flags for severe sepsis/shock: persistent hypotension, lactate elevation, mottling, new oxygen requirement, confusion, platelets falling, coagulopathy, creatinine rise, bilirubin rise.
• Investigations (do not delay antibiotics): blood cultures x2, FBC, U&E/creatinine, LFT, coagulation, fibrinogen, CRP, VBG/ABG with lactate, glucose, group & save/crossmatch, urinalysis/culture, relevant swabs (high vaginal/cervical), CXR, ultrasound/CT/MRI as needed (maternal benefit first).

Immediate management (first hour priorities)

• Escalate early: call obstetric consultant + anaesthetic consultant + critical care outreach/ICU; treat as time-critical emergency.
• A-E approach with pregnancy modifications: high-flow oxygen, left uterine displacement, consider early intubation if tiring/hypoxic/altered consciousness.
• Antibiotics: give within 1 hour of recognition after cultures if possible; choose broad-spectrum covering likely source + local policy; add clindamycin for toxin suppression if suspected GAS/staph toxic shock; involve microbiology early.
  • Consider early antivirals if influenza suspected; do not delay for test results in severe disease.
• Fluids: cautious balanced crystalloid boluses (e.g., 250–500 mL) with frequent reassessment; pregnancy/postpartum increases risk of pulmonary oedema (capillary leak + reduced oncotic pressure).
• Vasopressors: start early if hypotension persists after limited fluids; noradrenaline first-line (via central line ideally, but can start peripherally with a good cannula while obtaining central access). Aim MAP ≥65 mmHg (individualise).
• Source control: urgent senior obstetric/surgical review; plan imaging and intervention; do not delay theatre if clear surgical source and patient deteriorating.
• Monitoring: continuous ECG, SpO2, NIBP (consider arterial line), temperature, hourly urine output (catheter), serial lactate, strict fluid balance.
• Thromboprophylaxis: sepsis increases VTE risk; balance against bleeding/DIC and neuraxial plans; follow local obstetric thromboprophylaxis guidance.

Obstetric and fetal considerations

• Maternal resuscitation is the best fetal resuscitation; prioritise maternal oxygenation, perfusion, and source control.
• Fetal monitoring: CTG if viable gestation and resources allow, but do not delay maternal stabilisation/transfer to theatre/ICU.
• Delivery decisions: based on gestation, fetal status, and whether delivery is required for source control or obstetric indication; involve neonatology early if preterm delivery likely.
• Perimortem Caesarean (resuscitative hysterotomy): if maternal cardiac arrest and uterus at/above umbilicus (~≥20 weeks), aim to start within 4 minutes to improve maternal venous return and fetal outcome.

Anaesthetic implications (perioperative/ICU)

• Pre-op: treat as full stomach; aspiration prophylaxis if time; optimise haemodynamics before induction; check Hb, platelets, coagulation, fibrinogen; anticipate DIC and major haemorrhage if obstetric source.
• Induction: haemodynamically stable RSI technique; consider ketamine or etomidate (where available) in shock; reduce induction doses; have vasopressor boluses/infusion ready.
• Ventilation: lung-protective strategy; beware ARDS; maintain maternal oxygenation and normocapnia (avoid severe hypocapnia reducing uterine blood flow).
• Fluids and blood: dynamic assessment (echo, stroke volume variation where appropriate); early blood products if DIC/haemorrhage; consider fibrinogen replacement guided by labs/TEG/ROTEM.
• Analgesia: avoid NSAIDs if AKI; consider regional blocks if coagulation safe; epidural infusions may cause hypotension—titrate carefully.
• Post-op: likely ICU/HDU; ongoing vasopressors, ventilation, renal support; glycaemic control; early enteral nutrition; daily review for de-escalation of antibiotics and line removal.

Differentials and overlaps (important in viva)

• HELLP/pre-eclampsia: hypertension, proteinuria, RUQ pain, haemolysis, elevated LFTs, low platelets; can coexist with sepsis.
• Obstetric haemorrhage: hypovolaemic shock vs septic shock; may coexist (e.g., retained products + bleeding).
• Pulmonary embolism: sudden hypoxia, chest pain, RV strain; sepsis can cause hypoxia too—use imaging if needed.
• Anaphylaxis: abrupt onset, bronchospasm/urticaria; can mimic septic shock perioperatively.