Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

Septic shock in a pregnant or recently pregnant woman Denis Cavanagh MD To cite this article: Denis Cavanagh MD (1977) Septic shock in a pregnant or recently pregnant woman, Postgraduate Medicine, 62:4, 62-68, DOI: 10.1080/00325481.1977.11714636 To link to this article: http://dx.doi.org/10.1080/00325481.1977.11714636

Published online: 07 Jul 2016.

Submit your article to this journal

View related articles

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [FU Berlin]

Date: 07 January 2017, At: 04:10

topics in • pr1mary care septic shock in a pregnant or recently pregnant woman Denis Cavanagh, MD University of South Florida College of Medicine Tampa

Success in management of septic shock depends in large measure on early recognition. Obstetric patients at high risk should receive vigorous antibiotic therapy and should be watched closely for signs of impending shock.

• The term ''shock'' refers to a condition in which the circulating blood volume is less than the capacity of the vascular bed. This disparity results in hypotension, reduced tissue perfusion of vital organs, cellular hypoxia, and if allowed to continue, cellular death. "Septic shock" is shock associated with infection (most commonly caused by Gram-negative bacilli) and is also called Gram-negative or endotoxic shock. The prevalence of Gram-negative sepsis among hospitalized patients bas increased more than tenfold in the past 20 years. 1 The mortality of septic shock in reported series bas ranged from 11% to 82%2 •3 and bas averaged 50%. Pathophysiologic aspects of septic shock have been considered in detail in a recent publication. 4 Obstetric patients at particular risk for septic shock include those with infected abortion, chorioamnionitis, or pyelonephritis.

Preventive Measures A patient with infected abortion should receive vigorous therapy with antibiotics administered by the intravenous (IV) route, and the foc us of infection should be removed earl y. Large doses of aqueous penicillin G (30 million to 60 million units/day in IV fluid) and gentamicin ( 1 mg/kg of body weight every eight hours) or of ampicillin (1 gm every four hours) and gentamicin usually are adequate. I believe that uterine curettage should be done within six hours after antibiotic therapy begins, or no later than 12 hours afterward. Oxytocin, 20 units/liter of IV fluid, may be administered to aid in removal of the conceptus. A temperature higher than 39 C ( 102 F) is common with infected abortion and should prompt close observation of the patient for the development of endotoxic shock. Chorioamnionitis can be prevented in many patients by induction of labor with oxytocin following spontaneous premature rupture of the fetal membranes. Labor should be induced even in an afebrile patient if there is no contraindication and if the estimated fetal age is more than 36 weeks. If the estimated age is 32 to 36 weeks, induction of labor still may be indicated, because the hazard of infection may exceed the risk associated with prematurity. Management must be individualized, and the comparatively high incidence of chorioamnionitis among patients in low socioeconomic groups should be kept in mind.

62

POSTGRADUATE MEDICINE • October 1977 • Vol. 62 • No. 4

Photomicrograph: Courtesy of Minnesota Department of Heahh, Section of Microbiology

Pyelonephritis occurring during pregnancy is mainly the result of urinary stasis from uterine pressure on the ureters. Intracaliceal pressure can be reduced by having the patient lie on ber side. Although the disease is bilateral, usually it is worse on the right side and the patient is more comfortable lying on ber left. Antibiotic therapy with adequate dosage is essential in this situation. Choosing antibiotics to use is difficult because sorne reportedly affect the fetus adversely (tetracycline, sulfisoxazole, nitrofurantoins). It is my policy to hospitalize the patient and give ampicillin, l gm every four hours by the IV route, unless urinary culture yields an ampicillinresistant organism such as Pseudomonas, in which case gentamicin is the drug of choice.

Careful interrogation of patients at risk for septic shock is essential. A patient who bas bad an illegal abortion (or even, in sorne instances, a legal abortion) is likely to give a vague or even contradictory his tory. Often the menstrual history is falsified. Patients with chorioamnionitis should be asked about the time of rupture of the fetal membranes and the ons et of symptoms. Important historical items in cases of pyelonephritis are the ti me of onset of flank pain, dysuria, and chills and the estimated date of confinement. Postpartum endometritis is commonly associated with manual exploration of the uterus or, even more commonly, intrapartum chorioammionitis . ..,.

Vol. 62 • No. 4 • October 1977 • POSTGRADUATE MEDICINE

63

Important Historical Items

septic shock---------------------1 have found penicillin (or ampicillin) and chloramphenicol to be generally the most useful antibiotics in septic shock.-Dr Cavanagh

Findings on Physical Examination A patient with infected abortion is likely to have a temperature of more than 39 C. A normal or subnormal temperature associated with the clinical picture of shock is a grave prognostic sign and warrants earl y aggressive management. Local findings depend on the site of infection. Suprapubic tendemess is present with infected abortion, and local or general rebound tendemess is frequent. On inspection with a vaginal speculum, the cervix is bluish and soft and may show tenaculum marks. A malodorous discharge may be coming from the extemal os. Products of conception may be found in the cervical canal or vagina. Bleeding may be minimal if the conceptus has been expelled or removed. Foreign bodies (eg, gauze, catheter) may be found. Bimanual examination elicits marked tendemess. The internai os may admit one finger. The uterus is enlarged and soft, and manipulation of the cervix or uterine body elicits excruciating pain. Broad-ligament tendemess is evidence of parametritis and pel vic cellulitis. Rarely, thrombosed veins are palpable. In patients with chorioamnionitis the findings are similar, with evidence of local or general peritonitis and marked uterine tenderness. Fetal heart tones are absent in sorne instances. In patients with pyelonephritis, loin tendemess is elicited, usually in the absence of evidence of peritoneal or pelvic infection. Postpartum endometritis usually is associated with uterine subinvolution and tendemess and with signs of peritonitis.

Clinical Classification When shock supervenes, certain aspects of the patient's appearance serve as a useful guide to the type of treatment required. Septic shock may be classified clinically as follows: 1. Primary (reversible) septic shock a. Early ("warm-hypotensive") phase b. Late ("cold-hypotensive") phase 2. Secondary (irreversible) shock In the early, or warm-hypotensive, phase of primary septic shock, the patient is alert and apprehensive. Her face is flushed and her skin is warm. Usually her temperature is be-

64

tween 38.4 and 40.6 C (101 and 105 F). Profuse sweating is not uncommon. A shaking chill may coïncide with a temperature peak. Most patients have moderate tachycardia ( 100 to 11 0/min) but in my experience about 20% have a pulse rate of less than 72/ min. The pulse pressure remains satisfactory in this phase, and urinary output is good. In the late, or cold-hypotensive, phase, the patient is pale and her skin is clammy. A subnormal temperature is common. Gradually she becomes less alert and less apprehensive. As pulse pressure drops, oliguria may ensue. The triad of hypotension, tachycardia, and oliguria is typical of this phase of septic shock. In secondary, irreversible septic shock, prolonged cellular hypoxia and anaerobie metabolism are manifested by metabolic acidosis and excess blood lactate levels. Elevated arterial blood lactate levels should arouse strong suspicion of irreversible shock. Anuria, cardiac or respiratory distress, and coma are grave signs.

Laboratory Investigations and Clinical Monitoring Septic shock necessitates careful laboratory workup and close monitoring of the patient. Laboratory studies should include the following, as a minimum: Complete blood count Urinalysis Gram-stained smear, culture, and antibiotic sensitivity testing of urine obtained at time of insertion of indwelling catheter Gram-stained smear, culture, and antibiotic sensitivity testing of cervical secretions Culture of blood samples drawn at ti me of admission and at times of shaking chills or temperature peaks Serum electrolyte, blood urea nitrogen, and serum urie acid determinations ECG X-ray examination of chest If septic abortion is suspected, a plain film of the abdomen and lower part of the chest, taken with the patient upright, should be obtained to rule out the presence of free air und er the diaphragm, which would suggest uterine

POSTGRADUATE MEDICINE • October 1977 • Vol. 62 • No. 4

perforation, and to rule out the presence of a foreign body (eg, a catheter) in the peritoneal cavity. Other studies are made according to special requirements and available facilities. Ideally, in se verel y hypotensive patients a coagulation profile, arterial blood lactate determinations, and measurements of blood gases and blood volume would be obtained immediately and repeated as often as necessary. Th at blood volume determinations are unreliable late in endotoxic shock should be kept in mind. The clinical determinations that 1 have found most useful for monitoring are listed in table 1.

table 1. monitoring of patients with septic shock Determination

Frequency

Pulse rate Blood and pulse pressures Central venous (or pulmonary artery wedge) pressure Blood volume Urinary output

15 min 15 min 30-60 min (early) 60 min

table 2. outline of medical management of patients with septic shock 1. 2. 3. 4. 5. 6. 7.

Adequate airway Fluid and blood replacement Antibiotics Glucocorticoid Vasomotor drug Digitalis (central venous pressure > 15 cm H 2 0) Heparin (sorne cases)

Essentials of Management The essentials of management of septic shock in a pregnant or recently pregnant woman are outlined in table 2. 1. Make sure that the patient has an adequate airway. If necessary, insert an endotracheal tube or perform tracheostomy. 2. Replace fluid and blood loss, using as guides the central venous pressure (or, better, pulmonary artery wedge pressure), urinary output, and blood volume estimation. Give blood, plasma, serum albumin, or 5% dextrose in saline solution as indicated. Dextran of low molecular weight is probably useful in this situation because it affords volume replacement and reduces sludging in the microcirculation. Metabolic acidosis is common in patients with septic shock and is progressive if not corrected; 0.45% saline solution with 1 or 2 ampules of sodium bicarbonate added is useful. Lactate should not be used to correct acidosis because conversion to bicarbonate requires aerobic metabolism. Sodium bicarbonate acts rapidly and provides good buffering action. 3. Select antibiotics according to results of tests of urine and cervical secretions, keeping in mind also the known antibiotic sensitivities of similar organisms isolated in the hospital. Give the appropriate agents in massive doses by the IV route. 1 have found penicillin (or ampicillin) and chloramphenicol to be generally the most useful antibiotics in septic shock. Penicillin is given as crystalline penicillin G in a dosage of 10 million units every four hours in IV fluid. If ampicillin is

used (as an alternative to penicillin), the dosage is 1 gm every four hours. Chloramphenicol is given every six hours as an IV bolus of 1 gm in 100 ml of saline solution. If Pseudomonas infection is suspected, gentamicin, l mg/kg every eight hours by the IV route, also is given. A void the use of nephrotoxic drugs in the presence of oliguria. If renal damage is present, the interval (in hours) between doses of gentamicin may be determined by multiplying the serum creatinine value (mg/dl) by 8. Bear in mind that most crystalline penicillin is supplied in the form of the potassium salt. The large amount of potassium in a 60million unit dosage of potassium penicillin G (90 mEq) would create a hazard in the presence of renal failure. The sodium salt, or ampicillin, should be used when possible. 4. Administer glucocorticoid in pharmacologie doses. 5 There is sorne evidence that the synthetic corticosteroids are more effective in these cases than hydrocortisone. Dexamethasone, 6 mg/kg/day, or methylprednisolone sodium succinate, 30 mg/kg/ day, should be given by continuous IV infusion after IV injection of a loading dose of20 mg of dexamethasone or 125 mg of methylprednisolone. According to Sladen, 6 amounts four times greater than these may be required in shock lung syndrome . ..,.

Vol. 62 • No. 4 • October 1977 • POSTGRADUATE MEDICINE

65

----------------------septic shock The corticosteroids probably exert a beneficiai effect in at least four ways: lysosomal stabilization at the cellular level, inotropic effect on the heart, improved renal perfusion, and volume conservation in the vascular space. Abrupt discontinuance of the agents after periods up to 72 hours does not produce ill effects, in my experience, and a regimen of graduai withdrawal is therefore unnecessary. ln 61 patients with septic shock seen at Jackson Memorial Hospital, Miami, and St. Louis University Hospitals between July 1, 1969, and June 30, 1976, glucocorticoids apparently played a part in reducing mortality (table 3). 5. Give vasomotor drugs as indicated by the patient' s clinical condition. In sep tic shock the primary aim of therapy is improved tissue perfusion rather than normal blood pressure. To talk of alpha and beta mimetic agents or alpha and beta blockers may seem highly knowledgeable, but the fact is that each of the se has been used successfully in the management of endotoxic shock in experimental animais. Each acts on the myocardium and the peripheral vascular bed. The choice depends largely on the patient's appearance, and talking about vasopressors and vasodilators is therefore more practical. Further, des pite what has been written to the contrary, it is my conviction that in the warmhypotensive phase of septic shock, use of vasopressor rather than a vasodilator is indicated. 1 have found metaraminol to be the most useful vasopressor in this situation. 1 give only enough of the agent to maintain the systolic pressure at the lower limit of the range that assures adequate urinary output. In the cold-hypotensive phase of septic shock, marked by general vasoconstriction, an element of hypovolemia usually is also present. Volume replacement together with administration of vasodilator in small doses is indicated. The agent that 1 have found to be best is chlorpromazine, 5 to 10 mg every half hour by the IV route. If the central venous pressure is elevated and the pulse rate is in the normal range, isoproterenol may be used for inotropic and vasodilator (beta-receptor) effects. A patient with a pulse rate exceeding 120/min should not be given isoproterenol because it tends to produce arrhythmia.

Vol. 62 • No. 4 • October 19n • POSTGRADUATE MEDICINE

table 3. mortality of septic shock in 61 cases Subgroup

Deaths

Patients not receiving glucocorticoid Patients receiving glucocorticoid

3 (of 6) 4 (of 55)

6. Digitalize patients who have tachycardia and whose central venous pressure exceeds 15 cm H 2 0. 7. Con si der gi ving heparin if clotting studies indicate consumption coagulopathy (thrombocytopenia, hypofibrinogenemia, fall in levels of factors V, VIII, and XIII, presence offibrin split products). If a full coagulation profile is unavailable and the patient is not responding to standard treatment, try heparin. Heparin should not be used routinely in cases of septic shock, in my opinion. There is no evidence that hypothermia or hyperbaric oxygen is of value in treatment of endotoxic shock. Administration of dopamine, 200 mg in 500 ml of 5% dextrose in water as an infusion at a rate adjusted according to the blood pressure, bas been advised. This drug is useful but must be given with great care because different dosages may have opposite effects in the same patient.

Surgical Treatment If the nidus of infection can be extirpated surgie ally, this is the keystone oftreatment of septic shock. In septic abortion, the nidus preferably should be removed within six hours after antibiotic (and adequate supportive) therapy begins. Usually, dilation of the cervix and evacuation of uterine contents with ring forceps, followed by suction and sharp curettage, are adequate. If the disease has advanced to myometrial microabscess formation, hysterectomy is the only logical surgical treatment. Hysterectomy should be considered if shock persists following curettage and adequate supportive therapy, if the uterus is larger than a 16-week gestation, if the uterus is perforated, if the patient is oligurie, if intrauterine infection with Clostridium welchii is diagnosed, or if a corrosive or toxic douche bas been used . ..,..

67

septic shock-------------------------Denis Cavanagh

Dr Cavanagh is professor of obstetrics and gynecology, University of South Florida College of Medicine, Tampa.

The technique of hysterectomy should be individualized. For example, in the presence of clostridial infection the pedicles should be kept small so a minimum of devitalized tissue is left behind. Septic pelvic thrombophlebitis with involvement of both ovarian and hypogastric vessels is not uncommon in patients with long-standing infected abortion, postpartum endometritis, or chorioamnionitis. Septic pulmonary embolization and fatal Jung abscesses may ensue. Sorne observers have suggested that this condition can be treated successfully with heparin, but in the cases described the diagnosis has been presumptive. 7 Inasmuch as the underlying problem is septic rather than thrombotic, I fee! that the use of anticoagulant is contraindicated unless the diagnosis of septic pelvic thrombophlebitis is in doubt or unless the patient is un fit for surgery. The treatment of choice is ligation of the inferior vena cava and ovarian veins with postoperative heparin therapy. The surgical approach must be transperitoneal to gain access to the ovarian veins. Collins8 has reviewed the use of this procedure in suppurative pelvic thrombophlebitis.

In the presence of chorioamnionitis, abdominal delivery (best accomplished by low transverse cesarean section) should be considered seriously if vaginal delivery is not effected within 12 hours. If severe infection or endotoxic shock is present, cesarean hysterectomy should be performed, with ligation of the inferior vena cava and ovarian veins if indicated. Persistence of oliguria or anuria may necessitate dialysis and is an indication for consultation with a nephrologist. Acute tubular necrosis and acute cortical necrosis carry mortality rates of 50% and 90%,9 respectively. Anuria in a normovolemic patient suggests the possibility of acute bilateral cortical necrosis.

Summary Septic shock may be classified clinically as primary (reversible) or secondary (irreversible). Primary shock is further distinguished as early ("warm-hypotensive") or late ("coldhypotensive' '). Infected abortion, chorioamnionitis, or pyelonephritis of pregnancy calls for appropriate measures directed toward preventing septic shock, including administration of huge doses of antibiotics. If septic shock ensues, extirpation of the nidus of infection becomes a primary consideration. Surgical extirpation should be carried out if possible, and as soon as possible. Besides antibiotics, patients with septic shock may require glucocorticoids, vasomotor drugs, digitalis, and heparin. Careful monitoring is essential. • Address reprint requests to Denis Cavanagh, MD, Department of Obstetrics and Gynecology, University of South Florida College of Medicine, Tampa, FL 33612.

References 1. Petersdorf RG: Septic shock. In Thom GW, Adams RD,

2. 3. 4.

5.

68

Braun wald E, et al (Editors): Harrison 's Princip les of Internai Medicine. Ed 8. New York, McGraw-Hill Book Co, 1977, p 771 Coleman BD: Septic shock in pregnancy. Obstet Gynecol 24:895-902, 1964 Shubin H, Weil MH: Bacterial shock: A serious complication in urological practice. 1AMA !85:850-853, 1963 Cavanagh D, Rao PS, Comas MR: Septic Shock in Obstetrics and Gynecology. Major Problems in Obstetrics and Gynecology, Vol Il. Philadelphia, WB Saunders Co, 1977 Schumer W: Steroids in the treatment of clinical septic

shock. Ann Surg 184:333-341, 1976 6. Sladen A: Methylprednisolone: Pharmacologie doses in shock Jung syndrome. 1 Thorac Cardiovasc Surg 71:800806, 1976 7. Gibbs RS: Treatment of refractory postpartum fever. Clin Obstet Gynecol 19:83-95, 1976 8. Collins CG: Suppurative pel vic thrombophlebitis: A study of202 cases in which the disease was treated by ligation of the vena cava and ovarian vein. Am 1 Obstet Gynecol 108:681-687, 1970 9. Chugh KS, Singhal PC, Sharma BK, et al: Acute renal failure of obstetric origin. Obstet Gynecol 48:642-646, 1976

POSTGRADUATE MEDICINE • October 1977 • Vol. 62 • No. 4

Septic shock in a pregnant or recently pregnant woman.

Postgraduate Medicine ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20 Septic shock in a pregnant...
3MB Sizes 0 Downloads 0 Views