ACUTE MATERNAL DECOMPENSATION

(AMNIOTIC FLUID EMBOLISM, SEPTIC SHOCK) 

INTRODUCTION RARE – BUT SERIOUS (LIFE THREATENING)

Maternal decompensation is a rare but life-threatening event,

with a wide ranging etiology.
The outcome primarily for the mother, but also the fetus,
depends on prompt and effective resuscitation
DIFFERENTIAL DIAGNOSIS

• HEMORRHAGE
• ANAPHYLAXIS
• SEPSIS
• AFE
• UTERINE INVERSION
• CARDIAC ARRHYTHMIA
• ACUTE HEART FAILURE
• CEREBRAL POST ICTAL (EPILEPSY)
• ECLAMPSIA CEREBROVASCULAR ACCIDENT
AMNIOTIC FLUID EMBOLISM (AFE)

• CATASTROPHIC CONDITION THAT APPEARS TO INVOLVE THE INITIATION OF A

"CYTOKINE STORM" AS A RESULT OF EXPOSURE TO AN UNKNOWN INCITING
ANTIGEN, POSSIBLY RELATED TO AMNIOTIC FLUID CONTENTS, THAT
TYPICALLY OCCURS DURING LABOR OR DELIVERY.
• PROMPT RECOGNITION FACILITATES RAPID INITIATION OF POTENTIALLY
LIFE-SAVING THERAPIES.
INCIDENCE
AFE IS RARE, RANGING FROM 1.9 TO 6.1 CASES PER 100,000 DELIVERIES IN A
REVIEW OF REPORTS FROM AUSTRALIA, CANADA, THE NETHERLANDS, THE
UNITED KINGDOM, AND THE UNITED STATES THAT USED VARIOUS CRITERIA
FOR DIAGNOSIS .

EPIDEMIOLOGIC DATA MAY OVERESTIMATE THE TRUE INCIDENCE OF AFE

SINCE MANY SUCH STUDIES INCLUDE PATIENTS MISDIAGNOSED AS HAVING
AFE USING NONSPECIFIC FINDINGS
 PATHOGENESIS

THE PATHOGENESIS OF AFE IS NOT CLEAR.

IT IS HYPOTHESIZED THAT ENTRY OF AMNIOTIC FLUID INTO THE MATERNAL SYSTEMIC

CIRCULATION VIA A BREACH IN MATERNAL/FETAL INTERFACE LEADS TO RELEASE OF
VASOACTIVE AND PROCOAGULANT SUBSTANCES, SIMILAR TO THE SYSTEMIC
INFLAMMATORY RESPONSE SYNDROME .

BACTERIAL ANTIGENS MAY PLAY A ROLE INSTEAD OF, OR IN ADDITION TO, FETAL
ANTIGENIC MATERIAL. ABNORMAL ACTIVATION OF HUMORAL AND IMMUNOLOGICAL
PROCESSES AND RELEASE OF VASOACTIVE AND PROCOAGULANT SUBSTANCES, SIMILAR TO
THE SYSTEMIC INFLAMMATORY RESPONSE SYND. BACTERIAL ANTIGENS MAY PLAY A ROLE
INSTEAD OF, O IN ADDITION TO, FETAL ANTIGENIC MATERIAL
PATHOGENESIS
• AS A RESULT, PULMONARY PRESSURES USUALLY BECOME ACUTELY
ELEVATED, THE RIGHT VENTRICLE (RV) PRESSURE INCREASES, AND THE RV
BEGINS TO FAIL.
• MECHANICAL OBSTRUCTION OF PULMONARY ARTERIES FROM CELLULAR
COMPONENTS OF AND DEBRIS IN AMNIOTIC FLUID PLAYS NO ROLE IN THIS
RV FAILURE .
• RV FAILURE MAY SUBSEQUENTLY LEAD TO LEFT VENTRICLE (LV) FAILURE
AND SYSTEMIC HYPOTENSION.
• LV FAILURE MAY ALSO BE A DIRECT EFFECT OF HYPOXIC INJURY TO THE
LEFT VENTRICLE, RELEASE OF MATERNAL INFLAMMATORY MEDIATORS, OR
A DIRECT DEPRESSANT EFFECT OF AMNIOTIC FLUID ON THE MYOCARDIUM
PATHOGENESIS
• ACUTE PULMONARY HYPERTENSION ALSO RESULTS IN SEVERE
VENTILATION/PERFUSION MISMATCHING, CARDIOGENIC PULMONARY
EDEMA, AND HYPOXEMIC RESPIRATORY FAILURE LATER,
NONCARDIOGENIC PULMONARY EDEMA CAN OCCUR IN SOME
PATIENTS.
• ACTIVATION OF FACTOR VII AND PLATELETS AND RELEASE OF
INFLAMMATORY MEDIATORS LIKELY ACTIVATES THE COAGULATION
CASCADE, RESULTING IN (DIC) AND, IN TURN, ISCHEMIC DISTAL
ORGAN DYSFUNCTION AND MULTI-ORGAN FAILURE.
• HEMORRHAGE FROM DIC FURTHER CONTRIBUTES TO HEMODYNAMIC
INSTABILITY FLUID AND AMNIOTIC FLUID DEBRIS IN THE SPUTUM AND
ALVEOLAR SPACES OF THESE PATIENTS
RISK FACTORS

• ALTHOUGH NO RISK FACTORS FOR AFE HAVE BEEN FIRMLY ESTABLISHED,

CESAREAN DELIVERY, INSTRUMENTAL VAGINAL DELIVERY, PLACENTAL
ABNORMALITIES (PREVIA, ABRUPTION, ACCRETA), AND
PREECLAMPSIA/ECLAMPSIA HAVE BEEN CITED AS POTENTIAL RISK FACTORS
DIAGNOSIS
• CLINICAL DIAGNOSIS 
AFE IS A CLINICAL DIAGNOSIS BASED UPON THE PRESENCE OF THE
CHARACTERISTIC CLINICAL FINDINGS AND EXCLUSION OF OTHER POTENTIAL
CAUSES OF THESE FINDINGS. THE DIAGNOSIS SHOULD BE SUSPECTED IN
PREGNANT OR RECENTLY POSTPARTUM WOMEN WHO EXPERIENCE SUDDEN
CARDIOVASCULAR COLLAPSE, SEVERE RESPIRATORY DIFFICULTY AND
HYPOXIA, AND/OR SEIZURES, PARTICULARLY WHEN FOLLOWED BY
DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC). HOWEVER, ALL OF
THESE CLASSIC CLINICAL FINDINGS ARE NOT PRESENT IN ALL PATIENTS WITH
AFE.
THE CONDITION GENERALLY ARISES DURING LABOR OR SOON AFTER
DELIVERY, IN THE ABSENCE OF OTHER EXPLANATIONS FOR THESE FINDINGS.
IN MANY CASES, THE DIAGNOSIS IS MADE RETROSPECTIVELY, AFTER ALL
INVESTIGATIVE DATA, INCLUDING AUTOPSY DATA, HAVE BEEN COLLECTED.
ATYPICAL CASES, REPRESENTING APPROXIMATELY ONE-FOURTH OF ALL CASES
OF AFE, MAY PRESENT WITH ONLY ACUTE RESPIRATORY FAILURE AND
HYPOTENSION. UNCOMMONLY, DIC MAY BE THE INITIAL PRESENTING FEATURE
OR MAY BE ABSENT.
CONTRARY TO POPULAR BELIEF, THE IDENTIFICATION OF AMNIOTIC FLUID
DEBRIS (SQUAMOUS CELLS, TROPHOBLASTIC CELLS, MUCIN, AND LANUGO) IN
BLOOD DRAWN FROM THE DISTAL END OF A PULMONARY ARTERY CATHETER
OR ON HISTOPATHOLOGY OF LUNG TISSUE IS NOT DIAGNOSTIC OF AFE SINCE
THESE FINDINGS CAN BE FOUND IN THE MATERNAL CIRCULATION AND LUNGS
OF WOMEN WITHOUT AFE
DIAGNOSTIC CRITERIA

• PLATELET COUNT >100,000/ML = 0 POINTS, <100,000 = 1 POINT, <50,000 = 2 POINTS

• PROLONGED PROTHROMBIN TIME OR INTERNATIONAL NORMALIZED RATIO <25
PERCENT INCREASE = 0 POINTS, 25 TO 50 PERCENT INCREASE = 1 POINT, >50
PERCENT INCREASE = 2 POINTS
• FIBRINOGEN LEVEL >200 MG/L = 0 POINTS, <200 MG/L = 1 POINT
• A SCORE ≥3 IS COMPATIBLE WITH OVERT DIC. COAGULOPATHY MUST BE DETECTED
BEFORE HEMORRHAGE ITSELF CAN ACCOUNT FOR DILUTIONAL OR SHOCK-
RELATED CONSUMPTIVE COAGULOPATHY.
• CLINICAL ONSET DURING LABOR OR WITHIN 30 MINUTES OF PLACENTAL DELIVERY.
DIAGNOSTIC CRITERIA
• SUDDEN ONSET OF CARDIORESPIRATORY ARREST OR HYPOTENSION (SYSTOLIC
BLOOD PRESSURE <90 MMHG) WITH EVIDENCE OF RESPIRATORY COMPROMISE
(EG, DYSPNEA, CYANOSIS, OR PERIPHERAL OXYGEN SATURATION <90 PERCENT).

• DOCUMENTATION OF OVERT DIC USING THE SCORING SYSTEM OF THE SCIENTIFIC

AND STANDARDIZATION COMMITTEE ON DIC OF THE INTERNATIONAL SOCIETY
ON THROMBOSIS AND HAEMOSTASIS (ISTH), MODIFIED FOR PREGNANCY
• ABSENCE OF FEVER (≥38°C) DURING LABOR.
MOST EXPERTS AGREE THAT THE USE OF THESE CRITERIA WOULD CLEARLY
EXCLUDE ANY PATIENTS WHO DO NOT HAVE AFE BUT MAY NOT CAPTURE THOSE
WITH TYPICAL AFE
 INITIAL EMERGENCY MANAGEMENT FOR
UNSTABLE PATIENTS

• A MULTIDISCIPLINARY, TEAM-BASED APPROACH INVOLVING MATERNAL-FETAL

MEDICINE, ANESTHESIA, CRITICAL CARE, RESPIRATORY, AND NURSING IS
DESIRABLE TO INCREASE THE CHANCES OF STABILIZATION AND AVOID
FURTHER DETERIORATION, GIVEN THAT MOST PATIENTS PRESENT WITH ACUTE
CARDIORESPIRATORY COMPROMISE, HYPOXEMIA, AND HEMORRHAGE FROM
DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
 INITIAL EMERGENCY MANAGEMENT FOR
UNSTABLE PATIENTS

• PERFORM CARDIOPULMONARY RESUSCITATION (CPR) – MOST EXPERTS

RECOMMEND "HIGH QUALITY CPR" (EG, RAPID [100/MINUTE] FORCEFUL [2 INCH
DEPTH] CHEST COMPRESSIONS WITH TIME FOR ADEQUATE RECOIL AND WITH
MINIMAL [NO MORE THAN 5 TO 10 SECONDS] INTERRUPTION) . WHEN REAL CPR
EVENTS ARE VIDEOTAPED AND REVIEWED, MANY TIMES CLINICIANS PERFORM
"LOW QUALITY CPR."
 INITIAL EMERGENCY MANAGEMENT FOR
UNSTABLE PATIENTS

• CONTROL HEMORRHAGE AND REVERSE COAGULOPATHY – WE RECOMMEND

ADMINISTERING TRANEXAMIC ACID (TXA) AND ACTIVATING A MASSIVE
TRANSFUSION PROTOCOL.
• CONFIRM THE PRESUMPTIVE DIAGNOSIS OF AFE BY EXCLUDING OTHER
DIAGNOSES.
• DELIVER THE FETUS IF THE FETUS IS ALIVE OR IF DELIVERY WILL AID IN
MATERNAL RESUSCITATION
 INITIAL EMERGENCY MANAGEMENT FOR
UNSTABLE PATIENTS

• HEMODYNAMIC SUPPORT (FLUIDS AND VASOPRESSORS) — INITIAL

RESUSCITATION INVOLVES THE RAPID ADMINISTRATION OF IV FLUIDS TO
RESTORE TISSUE PERFUSION
• RESPIRATORY SUPPORT — THE MANAGEMENT OF RESPIRATORY FAILURE IS
SUPPORTIVE AND INCLUDES THE ADMINISTRATION OF SUPPLEMENTAL
OXYGEN, AND, IN MOST CASES, INTUBATION AND MECHANICAL VENTILATION
THERE IS NO EVIDENCE TO SUPPORT PROPHYLACTIC ANTICOAGULATION
FOR DIC IN THE ABSENCE OF THROMBUS
 MANAGEMENT OF STABLE PATIENTS

• SUPPORTIVE CARE AND MONITORING — ONCE PATIENTS ARE

DELIVERED AND STABILIZED, THEY SHOULD BE TRANSFERRED TO
THE INTENSIVE CARE UNIT AND, IF INDICATED, UNDERGO
MEASURES TO ELIMINATE COMPETING ETIOLOGIES.
PROGNOSIS
• PROGNOSISAFE IS ONE OF THE LEADING CAUSES OF MATERNAL MORTALITY
AND IS REPORTED TO CAUSE 10 PERCENT OF ALL MATERNAL DEATHS IN
DEVELOPED COUNTRIES MATERNAL MORTALITY RATES ARE HIGH AND
PROGNOSIS IN THOSE WHO SURVIVE IS POOR
• THE MATERNAL MORTALITY RATE HAS BEEN REPORTED TO RANGE FROM 10
TO 90 PERCENT
• HYPOXEMIA, WHICH IS OFTEN PROFOUND, CAUSES ABOUT 50 PERCENT
OF THE DEATHS THAT OCCUR WITHIN THE FIRST HOUR
• THOSE WHO SURVIVE TYPICALLY HAVE A POOR OUTCOME, WITH AS MANY
AS 85 PERCENT SUFFERING SIGNIFICANT NEUROLOGIC INJURY DUE TO
CEREBRAL HYPOXIA, ALTHOUGH PATIENTS WITH MILDER PRESENTATIONS
LIKELY HAVE BETTER OUTCOMES .
 NEONATAL OUTCOMES

• THE MORTALITY RATE IS ESTIMATED TO BE BETWEEN 20 AND 60

PERCENT AND ONLY UP TO 50 PERCENT OF SURVIVORS ARE
NEUROLOGICALLY INTAC. OUTCOME IS RELATED TO THE TIME
BETWEEN MATERNAL CARDIOPULMONARY COLLAPSE AND
DELIVERY, WHICH IDEALLY SHOULD BE NO MORE THAN FOUR
MINUTES
 MATERNAL SEPSIS

IS A LIFE-THREATENING CONDITION WITH ORGAN DYSFUNCTION RESULTING FROM

INFECTION DURING PREGNANCY ,CHILDBIRTH, POST-ABORTION, OR IN THE
POSTPARTUM PERIOD.

THE WHO ESTIMATED THAT THE GLOBAL PREVALENCE OF MATERNAL SEPSIS IS 4.4%
AMONG LIVE BIRTHS, WITH AN INCIDENCE OF 9–49 PER 100 000 DELIVERIES IN HIGH
INCOME COUNTRIES DEPENDING ON THE DEFINITION USED AND POPULATION STUDIED.

SEVERAL STUDIES FROM DEVELOPED COUNTRIES HAVE SHOWN THAT THE RATE OF
MATERNAL SEPSIS HAS BEEN INCREASING IN THE LAST DECADE, WITH HIGH
MORTALITY RATES.
THE DEFINITION OF SEPSIS

FURTHER SUBSETS OF PATIENTS WHO HAVE “SEPTIC SHOCK” INCLUDE THOSE WHO
REQUIRE VASOPRESSORS TO MAINTAIN A MEAN ARTERIAL PRESSURE OF AT LEAST 65 MM
HG AND WHO HAVE A SERUM LACTATE LEVEL OF AT LEAST 2 MMOL/L.
PATIENTS WHO MET THESE CRITERIA AND HAD ORGAN DYSFUNCTION WERE CLASSED
AS HAVING “SEVERE SEPSIS”, AND PATIENTS WHO HAD HYPOTENSION WHICH DID NOT
RESPOND TO FLUID RESUSCITATION WERE CLASSED AS HAVING “SEPTIC SHOCK”.
“SEPSIS ONSET IN PREGNANCY CAN BE INSIDIOUS, AND PATIENTS MAY APPEAR
DECEPTIVELY WELL BEFORE RAPIDLY DETERIORATING WITH THE
DEVELOPMENT OF SEPTIC SHOCK, MULTIPLE ORGAN DYSFUNCTION SYNDROME,
OR DEATH .THE OUTCOME AND SURVIVABILITY IN SEVERE SEPSIS AND SEPTIC
SHOCK IN PREGNANCY ARE IMPROVED WITH EARLY DETECTION, PROMPT
RECOGNITION OF THE SOURCE OF INFECTION, AND TARGETED THERAPY.”
- BARTON & SIBAI, 2012
 MATERNAL SEPSIS

MATERNAL SEPSIS IS THE MAIN CAUSE OF MATERNAL DEATH AND A MAJOR CONTRIBUTOR
TO SEVERE MATERNAL MORBIDITY WORLDWIDE, ACCOUNTING FOR 11% OF MATERNAL
DEATHS
WORLDWIDE AND IS THE THIRD MOST COMMON DIRECT CAUSE OF MATERNAL DEATH.
MATERNAL SEPSIS IS CURRENTLY THE THIRD OR FOURTH LEADING CAUSE OF MATERNAL
MORTALITY IN THE USA,
ACCOUNTING FOR 13% OF ALL MATERNAL DEATHS WITH A CAUSE SPECIFIC MATERNAL
MORTALITY RATIO OF 2.2 DEATHS PER 100 000LIVE BIRTHS
 MATERNAL SEPSIS

IN LOW- AND MIDDLE-INCOME COUNTRIES, RATES OF FATALITY AFTER PUERPERAL

INFECTION CAN BE AS HIGH AS 50%.
UNDER NEW SEPSIS DEFINITIONS, SOME REPRESENTATIVE REPORTS GAVE RANGES
ON THE MORTALITY OF SEPSIS IN THE GENERAL POPULATION OF 25%–30%.

THE MORTALITY RANGE FOR SEPTIC SHOCK WAS 40%–70%

Pregnancy-Related Mortality in the US (1987-2013)

Source: Creanga et al., 2017

 Causes of Pregnancy-Related Death in
the US (2011-2016)

Infection
was the third leading cause of pregnancy-
related death between 2011-2016.
Source: CDC, 2019
 PATHOPHYSIOLOGY
THE PATHOPHYSIOLOGY CORE ISSUE IS A MULTIFACETED HOST RESPONSE TO AN
INFECTING PATHOGEN THAT MAY BE SIGNIFICANTLY AMPLIFIED BY
ENDOGENOUS FACTORS.
THE “SEPSIS 1” AND “SEPSIS 2” FOCUSED SOLELY ON INFLAMMATORY EXCESS.
SEPSIS IS NOW RECOGNIZED TO INVOLVE EARLY ACTIVATION OF BOTH PRO/AND
ANTI-INFLAMMATORY RESPONSES, ALONG WITH MAJOR MODIFICATIONS IN
NONIMMUNOLOGIC PATHWAYS SUCH AS CARDIOVASCULAR, NEURONAL,
AUTONOMIC, HORMONAL, BIOENERGETIC, METABOLIC, AND COAGULATION, ALL
OF WHICH HAVE PROGNOSTIC SIGNIFICANCE.
PATIENTS WITH SEPSIS CAN HAVE CLINICAL PRESENTATIONS IN VARIOUS
SYSTEMS, INCLUDING RESPIRATORY, CARDIOVASCULAR, HEPATIC AND
GASTROINTESTINAL, RENAL, HEMATOLOGICAL, ENDOCRINOLOGICAL, AND
CENTRAL NERVOUSSYSTEMS.25 MATERNAL SEPSIS MAY CAUSE INTRA-
AMNIOTIC INFECTION, WHICH RESULTS IN
(1) PREMATURE RUPTURE OF MEMBRANES OR PRETERM LABOR OR BIRTH;
(2) CEREBRAL WHITE MATTER DAMAGE OR CEREBRAL PALSY OR
NEURODEVELOPMENT ALDELAY
(3) STILLBIRTH
(4) EARLY- OR LATE-ONSET SEPSIS
(5) PERINATAL DEATH.
CAUSES, RISK FACTORS, AND MICROORGANISMS
CAUSES AND RISK FACTORS
CHANGES IN MATERNAL IMMUNE RESPONSES OCCUR DURING PREGNANCY TO
PROTECT THE UNBORN FETUS FROM REJECTION.
THESE CHANGES MAY PREDISPOSE PREGNANT PATIENTS TO THE DEVELOPMENT
OF INFECTIONS. SEPSIS MAY BE DUE TO OBSTETRIC OR NON-OBSTETRIC CAUSES.
THE OBSTETRIC CAUSES INCLUDE UTERINE INFECTION, SUCH AS
CHORIOAMNIONITIS AND ENDOMYOMETRITIS, SEPTIC ABORTION, AND WOUND
INFECTION. SEPSIS MAY FOLLOW INVASIVE PROCEDURES SUCH AS
AMNIOCENTESIS, CHORIONICVILLUS SAMPLING, CERVICAL CERCLAGE, OR
PERCUTANEOUS UMBILICAL BLOOD SAMPLING.
IN A FRENCH STUDY, THE MOST COMMON SOURCE OF BACTEREMIA WAS
CHORIOAMNIONITIS(47%). THE NON-OBSTETRIC CAUSES OF SEPSIS INCLUDE
PYELONEPHRITIS AND PNEUMONIA
RISK FACTORS ASSOCIATED WITH MATERNAL
SEPSIS

• PATIENT FACTORS OBSTETRIC FACTORS

•   OBESITY •   CESAREAN DELIVERY
•   IMPAIRED IMMUNITY OR IMMUNOSUPPRESSANT
THERAPY •   RETAINED PRODUCTS OF CONCEPTION
•   ANEMIA •   PROLONGED RUPTURE OF
•   IMPAIRED GLUCOSE TOLERANCE MEMBRANES
•   VAGINAL DISCHARGE
•   MULTIPLE GESTATION
•   HISTORY OF PELVIC INFECTION
•   HISTORY OF GROUP B STREPTOCOCCAL INFECTION •   CERVICAL CERCLAGE
•   GROUP A STREPTOCOCCAL INFECTION IN CLOSE
CONTACTS
•   AMNIOCENTESIS OR OTHER INVASIVE
•   AGE OLDER THAN 35 Y PROCEDURE
•   DISADVANTAGED SOCIOECONOMIC BACKGROUND •   COMPLEX PERINEAL LACERATIONS
•   CONGESTIVE HEART FAILURE
•   WOUND HEMATOMA
•   CHRONIC RENAL FAILURE
•   CHRONIC LIVER FAILURE
•   SYSTEMIC LUPUS ERYTHEMATOUS
 SEPTIC SHOCK

SEPTIC SHOCK IS SEVERE SEPSIS WITH HYPOTENSION

AND/OR HYPOPERFUSION
MATERNAL SAFETY BUNDLE FOR
SEPSIS IN PREGNANCY

Updated April 2020

 Safe Motherhood Initiative:
Bundle Development

• Founded in evidence-based best practices

• Delineation of standard of care

R EADINESS
• Minimization of variability
R ECOGNITION
• Decreased reliance on memory
R ESPONSE
• Emphasized patient safety
R EPORTING
• Reduction in redundant efforts
Maternal Sepsis

World Health Organization

Maternal sepsis definition:

A life-threatening condition defined as organ

dysfunction resulting from infection during
pregnancy, childbirth, post-abortion, or
postpartum period.

Statement on Maternal Sepsis, WHO, 2017

Safe Motherhood Initiative: Maternal Sepsis Bundle
Elements

Readiness & Recognition* Response & Reporting

• Utilization of maternal early • Standardized sepsis

warning system management algorithm
• Education of patient & • Consultation
provider • Consideration of obtaining
• Standardized sepsis work-up higher level care
criteria • Case debriefing
• Standardized sepsis diagnostic • Multidisciplinary reviews
tool
* For the purposes of this bundle, “readiness” includes the development of preparedness tools & “recognition” is
loosely defined as the use of these tools in the evaluation and diagnosis of maternal sepsis.
UTILIZATION OF A MATERNAL EARLY WARNING SYSTEM
 Safe Motherhood Initiative: Maternal Early Warning
System

• Definition: Set of specific vital sign and physical exam findings that prompt a bedside
evaluation and/or work-up

• Action: Positive MEWS screen  Prompt provider bedside evaluation  clinical

judgement, differential diagnosis leads provider to implement appropriate bundle(s)

• Goal: Prompt and timely identification and treatment of women developing critical illness

“An effective early-warning system should facilitate timely diagnosis and treatment, and thereby limit
the severity of any morbidity.”
– Mhyre et al., 2014
 EXAMPLE

Safe Motherhood Initiative:

Maternal Early Warning System (MEWS)

• An early warning system is a screening test designed to identify (at an

early stage) significant medical and surgical complications. The
qualities of the ideal screening test are:

1. Simplicity
2. Balance between sensitivity and specificity
 EXAMPLE

Safe Motherhood Initiative:

Clinical Significance of Sensitivity & Specificity

Higher Sensitivity Lower Sensitivity

Identifies most relevant cases Misses some relevant cases

- Many cases to be evaluated - Fewer cases to be evaluated

- Costly; difficult to maintain - Easier to maintain
- Alert fatigue
 EXAMPLE

Safe Motherhood Initiative:

Maternal Early Warning System

Recommended MEWS Option: Modified MEWC

(MEWC = Maternal Early Warning Criteria*)

Systolic BP (mmHg) <90 or >160 Positive screen

Diastolic BP >100
(mmHg) Heart <50 or >120
Rate Respiratory <10 or >24 1 abnormal
Rate criteria,
O2 Sat on room air; % <95 sustained for >20
Oliguria, mL/hr x 2hrs <35 minutes
Temperature <36 C or >38 C
WBC <4,000 or
>15,000

Maternal agitation, confusion, or unresponsiveness; patient with hypertension reporting a

non-remitting headache or shortness of breath requires immediate attention
*Mhyre et al., 2014, National Partnership for Maternal Safety
MATERNAL EARLY WARNING SYSTEM
POSITIVE SCREEN
Prompt Bedside Evaluation

Specific MEWS abnormality:

Abnormal temperature, tachycardia
Clinical presentation: Sepsis
Signs of respiratory/urinary infections, etc. most likely
Uterine tenderness/foul smelling vaginal discharge diagnosis
Risk factors present*:
Prolonged labor
• 1st stage: >12-15 hours
• 2nd stage: >3hrs for nulliparous women
>2hrs for multiparous women
Prolonged rupture of membranes (ROM) SMI Sepsis
Fetal tachycardia Bundle
Examination-indicated cerclage (also know as rescue cerclage)
History of UTIs
Additional tests:
Abnormal U/A  WBCs, bacteria
*this is NOT an exclusive list
Safe Motherhood Initiative:
Maternal Sepsis

The Infection to Sepsis Spectrum

Infection Sepsis Shock

Detection period

Maternal Early Warning System - Positive Screen

(ie, abnormal vital signs, abnormal maternal mental status, etc.)
Refer to SMI MEWS* Bundle
* ’MEWS’ used here as a generic term
 EXAMPLE

MATERNAL SEPSIS
STANDARDIZED SEPSIS WORK-UP CRITERIA
 EXAMPLE

Standardized Sepsis Work-Up Algorithm

Sepsis Work-Up: Initiate as soon as possible (with therapy

commencing within 1 hour of suspected sepsis diagnosis):
Physical Assessment: Lab Assessment:
• Mental status • Cultures x 2 – blood, urine,
• Temperature sputum, placental, etc., as
• Respiratory rate clinically indicated
• Oxygen saturation • CBC
• Blood pressure • CMP
• Heart rate • Coagulation profile
• Urine output • Lactate

Targeted imaging studies to aid in

diagnosis

 Work-up to be done ASAP by any

appropriately credentialed
multidisciplinary provider
Assessment & Monitoring Recommendations
(excerpted from CMQCC Maternal Sepsis Toolkit)

MONITORING TIMEFRAME ADDITIONAL CONSIDERATIONS

Fetal monitoring Continuous Antepartum/intrapartum

Pulse oximetry Continuous Until vital signs are normalized
Until lactate less than 2.0 mmol/L, then Q2 h for
Blood pressure (MAP) Q 30 minutes from ‘Time non-laboring patients*
Zero’

Until lactate less than 2.0 mmol/L, then Q2 h for

Temperature 30 minutes from ‘Time non-laboring patients*
Zero’

Q 1 hour from ‘Time

Urine output Zero’ Foley catheter with urometer

Note: agitation, confusion or

Mental status Continuous unresponsiveness

The ongoing assessment recommendations are based on ‘Time Zero.’ Once the patient triggers a positive Initial Sepsis Screen, ‘Time Zero’ will start. A review of
nursing technique for collecting a urine sample from a Foley catheter is provided in Appendix E of the Toolkit.
Source: Adapted from Gibbs et al., 2020, CMQCC Maternal Sepsis Toolkit
 EXAMPLE

MATERNAL SEPSIS: STANDARDIZED SEPSIS

DIAGNOSTIC TOOL
 Maternal Sepsis Diagnosis
ANY 1 ABNORMALITY
RR >30/min O2 sat
Pulmonary <90%

MAP <65mm Hg SBP

Cardiovascular <85mm Hg
>40mm Hg decrease in SBP

Platelets <100 x 109/L INR >1.5

Coagulation PTT >60 sec

Liver Bilirubin >2.0mg/dL

Cr >0.9mg/dL or doubling of Cr Oliguria
Renal (<35cc/hr x 2 hours)
Mental Status Agitation, confusion, unresponsive
Lactate >2 mmol/L
 EXAMPLE

Maternal Sepsis Diagnosis

In addition, a subgroup of patients at increased risk that requires

closer surveillance, and may require a higher level of care can be
identified using these criteria:

Any 2 abnormalities:
• Maternal temperature > 38.9o C or < 34o C

• Maternal HR ≥ 130 bpm

• WBC ≥ 25,000 or < 3,000

• Bands ≥10%

56
 Maternal Septic Shock Diagnosis

Diagnosis of Septic Shock

• Hypotension with need for vasopressor support

to maintain MAP > 65
AND
• Elevated serum lactate ≥ 4 mmol/L

Infection Sepsis Shock

Sources: Barton & Sibai, 2012; Rhodes et al., 2017; Sepsis Alliance, 2019
Maternal Sepsis: Standardized Sepsis
Management Algorithm
 Maternal Sepsis Management

• Initial Sepsis Management Triad:

1. Antibiotics
2. Fluid management
3. Call appropriate consultants as per institutional protocol
• Consults may include OB/MFM/Medicine/Anesthesia/Critical Care/Surgery
• Followed by:
• Consider transfer to higher level care
• Source control
• Vasopressors as needed
• Consider antenatal steroids as appropriate for fetal lung maturity
• Consider magnesium sulfate for neuroprotection
• VTE prophylaxis
• Evaluate need for delivery

Sources: ACOG Committee Opinion #455; SMI VTE Bundle

 EXAMPLE

Maternal Sepsis Management

Antibiotics:

• Start within 1 hour of sepsis suspicion

• Broad spectrum
• Narrow and focus antibiotics once pathogen and sensitivities are identified

Delayed antibiotics > 1 hour = increased mortality

Sources: Bauer et al., 2018; Padilla & Palanisamy, 2017; Rhodes et al., 2017
 Antibiotic Regimens by Source of Infection
(excerpted from CMQCC Maternal Sepsis Toolkit)

SOURCE INFECTION RECOMMENDED ANTIBIOTICS

Abdominal infections Ceftriaxone, cefotaxime, ceftazidime, or cefepime plus metronidazole;

Complicated case may require monotherapy with a carbapenem or piperacillin-tazobactam

Ampicillin plus gentamicin. Add anaerobic coverage with clindamycin or
Chorioamnionitis metronidazole if cesarean delivery required
Cefotaxime, ceftriaxone, ertapenem, or ampicillin plus azithromycin,
Community-acquired pneumonia clarithromycin, or erythromicin
Ampicillin, gentamicin, and metronidazole (or clindamycin); Alternatively,
Endomyometritis may use cefotaxime or ceftriaxone plus metronidazole.
Low risk patients: piperacillin-tazobactam, meropenem, imipenem, or cefepime

Hospital-acquired pneumonia High mortality risk patients: double coverage for pseudomonas (beta lactam
plus an aminoglycoside or a quinolone) and MRSA coverage with vancomycin
or linezolid

Vancomycin plus piperacillin-tazobactam

Skin and soft tissues (necrotizing) If Streptococcus Group A or Clostridium perfringens are present, use penicillin G
plus clindamycin

Gentamycin with ampicillin; Alternatlvely, may use monotherapy with a

Urinary tract infections carbapenem or piperacillin-tazobactam

Consult your hospital antibiogram

Source: SMFM, 2019; Gibbs et al., 2020, CMQCC Maternal Sepsis Toolkit
 Maternal Sepsis Management

Fluid Management:
For sepsis-induced hypoperfusion:
• Administer initial 30cc/kg bolus of IV crystalloids (1-2L minimum) within 3 hours of
diagnosis
• Fluid approach requires clinical judgement & may require adjustment based on clinical situation
• Highest risk for fluid overload in patients with preeclampsia, cardiovascular disease
• Close monitoring of the patient with obesity
• Reevaluate patient’s status after IV bolus
• Failure to respond  higher level care/ICU

Sources: Plante, 2016; Rhodes et al., 2017; SMFM, 2019; Adams et al., 2017; Taylor et al., 2018
Maternal Septic Shock Management

Septic Shock Management:

• Critical care consult recommended

INFECTION SEPSIS SHOCK

 Maternal Sepsis Management

Source Control:
• After cultures obtained and antibiotics started
• Drainage, evacuation, removal, or other clinically appropriate
procedure

Identify/exclude as rapidly as possible

Sources: Plante, 2016; Rhodes et al., 2017; SMFM, 2019

 Maternal Sepsis Management

Source Control: Non-Responders

For patients with no response to antibiotics (over 2-3 days)
• Consider and address some of these rare complications:
• Intra-abdominal abscess  Surgical drainage
• Septic pelvic thrombophlebitis  Add anticoagulation (in addition to
continuing antibiotics)
• Bowel injury during initial surgery (Timely re-exploration)
• Endomyometritis with myometrial abscesses (can only be seen on
nuclear scan)  May require TAH
 Maternal Sepsis Management
(adapted from CMQCC Maternal Sepsis Toolkit

Consider transfer to a higher level of care for any of the following:

• Medically complex patient; patient with significant comorbidities

• Hypotension (MAP below 65 mm Hg) despite fluid resuscitation or need for

administration of vasopressors
• Persistent hypoxia (SpO2 <92% on room air)
• Altered mental status (combativeness, confusion, disorientation)

Source: SMFM, 2019; Gibbs et al., 2020, CMQCC Maternal Sepsis Toolkit
 Maternal Sepsis Management

Fetal Considerations:
• Antenatal steroids are considered safe in sepsis
• Consider per usual guidelines for fetal lung maturity
• “…in the context of maternal critical care, antenatal
corticosteroids are not contraindicated, even in the
setting of sepsis.”

• Consider magnesium sulfate for neuroprotection if EGA < 32

weeks

• Evaluate need for delivery

Sources: ACOG Committee Opinions #455, #713

 Maternal Sepsis Management

VTE Prophylaxis:
• Provision of pharmacologic prophylaxis may be with
unfractionated heparin (UFH) or low-molecular weight
heparin (LMWH)

• For women undergoing cesarean delivery, recommend

sequential compression devices (SCDs) perioperatively and
postpartum

Source: ACOG DII SMI VTE Bundle

Maternal Sepsis Management

Continued Management
(for patients not requiring ICU admission):
• Antibiotics – narrow spectrum once sensitivities available
• Fluids – after correction of hypoperfusion, give maintenance fluids only:
≈100-150 cc/hr (include PO fluids)
• Check labs every 6-8 hrs for first 24 hrs after diagnosis
• Continuous pulse oximeter for first 24 hrs after diagnosis
• Strict I/Os – hourly for first 12 hrs, and then q 2 hrs if normal
• Monitor vital signs per unit protocol
• Delivery timing based on routine obstetric indications
 Maternal Sepsis Management

Higher level care considerations:

• Individual institutions should evaluate existing policies and/or
create new ones that are certain to align with their available
resources to safely manage a critically ill pregnant or
postpartum woman.
Delivery Planning:
• Obstetric indications should be used to direct delivery in most
instances
• “Optimal fetal status is generally predicated on optimizing the
maternal condition as much as possible.”

Sources: ACOG Practice Bulletin #211; SMFM, 2019

Maternal Sepsis: Education of Patient & Provider
Case Debriefing Multidisciplinary Review
Maternal Sepsis Case Debriefing & Multidisciplinary
Review

• Conduct a multidisciplinary
review of all cases of
septic shock and/or
admission to higher level
of care
• Monitor process metrics
and outcomes in a
standardized fashion
• Debrief all cases of
maternal sepsis for systems
issues and compliance
with protocols
 Conclusions & Clinical Pearls

• Early recognition, action, & targeted management are key to

risk reduction and successful clinical outcomes in maternal
sepsis
• Advance preparation for a multidisciplinary, team-based
approach to care helps to ensure availability of resources
when the need arises
• Evaluation & diagnostic criteria need to account for alterations
in maternal hemodynamics, respiratory function, and renal
function due to pregnancy physiology
• Increasing evidence indicates that standardization of care
improves patient outcomes
 Conclusions & Clinical Pearls

• All team members should feel empowered to speak up, and maintain a
high index of suspicion for maternal sepsis
• Timing is critical  cultures should be taken and antibiotics started
within 1 hour of suspicion of sepsis
• Antenatal steroids are NOT contraindicated
• Follow-up on interventions is critical  escalate care if there is no
response
Move fast during the golden hour to save lives: fluid resuscitation should be
initiated rapidly for patients with a blood lactate level greater than 4
mmol/L or mean arterial pressure less than 65 mm Hg.

Adapted from Gibbs et al., 2020, CMQCC Maternal Sepsis Toolkit

BEYOND THE GOLDEN HOUR

• ESCALATION OF CARE IS CRITICAL TO SURVIVAL

• ANTICIPATE AND PREVENT ADVERSE PREGNANCY OUTCOMES
• ONCE THE PATIENT IS STABILIZED, GET TO THE SOURCE OF THE PROBLEM!
 REFERERNCE
• SMFM CONSULT SERIES #47: SEPSIS DURING PREGNANCY AND THE
PUERPERIUM,2019
• UPTODATE 2022
• MATERNAL COLLAPSE IN PREGNANCY AND THE PUERPERIUM GREEN-TOP
GUIDELINE NO. 56 DECEMBER 201
• ACOG SAFE MOTHERHOOD INITIATIVE: BUNDLE DEVELOPMENT , 2021
• CLINICAL EXPERT SERIES ,TOP 10 PEARLS FOR THE RECOGNITION, EVALUATION,
AND MANAGEMENT OF MATERNAL, SEPSIS ,FEB 2021