OB GYN Board Review Course

A 20-year-old gravida 1 para 0 woman presents to you at 20 weeks of gestation with complaints of fever, dysuria, and right flank pain since yesterday. She is having shaking chills and her extremities are cool and clammy.

Her temperature is 38.5 °C, heart rate is 120 beats/minute, blood pressure is 80/50 mm Hg (mean arterial pressure [MAP] 60 mm Hg), respiration rate is 24 breaths/minute, and her oxygen saturation is 99% on room air.

Her physical examination is notable for moderate right costovertebral angle tenderness. Fetal heart tracing (FHT) is in the 170s on Doppler ultrasonography. White blood cell count is 24,000/mm³.

Which of the following is the most appropriate initial step in this patient’s care?

 volume resuscitation with blood products
 volume resuscitation with crystalloids
 intravenous ampicillin 2 g every 6 hours
 norepinephrine infusion

Correct Answer:

volume resuscitation with crystalloids

Educational Objective:

Characterize the initial management of suspected sepsis.

Key Point:

Early recognition of suspected sepsis or suspected septic shock along with prompt, early, goal-directed treatments can reduce mortality and improve outcomes in the general population; these recommendations have also been applied to obstetric patients. Goals of therapy for sepsis are the initiation of broad-spectrum antibiotics within 1 hour of presentation, initial volume resuscitation of 30 mL/kg within 3 hours, source identification, and source control.

Explanation:

This patient’s clinical scenario is suspicious for sepsis. Her symptoms are most consistent with acute pyelonephritis, which is one of the most common causes for sepsis during pregnancy. She is hypotensive, which indicates her illness is significant enough to provoke a decrease in systemic vascular resistance. Preload is decreased due to increased fluid loss from fever, vasodilation, and increased vascular permeability. The most appropriate initial step to treat her hypovolemia and hypotension is intravenous fluid resuscitation with either lactated Ringer solution or 0.9% normal saline.

The intravascular volume depletion associated with sepsis is due to fever and free-spacing, not blood loss, so transfusion is inappropriate at this time. Blood component replacement would be appropriate if significant coagulopathy with bleeding or anticipated bleeding is found.

Empiric, broad-spectrum antibiotics should be started within 1 hour of presentation of suspected sepsis. Ideally, blood cultures should be obtained prior to the initiation of antibiotics, but they should not delay administration of therapy beyond 1 hour. For obstetric patients, gram-positive, gram-negative, and anaerobic coverage is needed. One recommended regimen is penicillin 5 million units every 6 hours (or ampicillin 2 g every 6 hours) plus clindamycin 900 mg every 8 hours (or metronidazole 500 mg every 12 hours) plus gentamycin 7 mg/kg every 24 hours.

Ampicillin alone is inadequate for empiric treatment. Historically ampicillin was used as a sole agent to treat acute pyelonephritis, but increasing Escherichia coli resistance has necessitated the use of combination treatment with ampicillin and gentamycin. Although pyelonephritis is the suspected source, results of urine and other cultures are necessary for actual source identification.

Vasopressors may be needed to maintain MAP of at least 65 mm Hg in adequately volume-resuscitated patients with sepsis. This patient has hypotension but has not begun intravenous fluids. Therefore, norepinephrine infusion, the first-line vasopressor used in cases of septic shock, is not appropriate at this time.

References:

Barton JR, Sibai BM. Severe sepsis and septic shock in pregnancy. Obstet Gynecol. 2012;120:689-706.

Resnik R, et al. Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. 8th ed., 2019.

Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43:304-377.

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