Objective To explore the clinical manifestations, diagnosis, treatment and prognosis of patients with obstetric sepsis due to reproductive tract infection (RTI) during pregnancy combined with amniotic fluid embolism (AFE), and review relevant literature.
Methods A patient who was clinically diagnosed as obstetric sepsis due to RTI during pregnancy combined with AFE and hospitalized and delivered in Chengdu Fifth People′s Hospital in September 2021 was selected as research subject. Clinical data of this patient were collected by retrospective study method, and her clinical manifestations, diagnosis and treatment were analyzed. Literature about obstetric sepsis due to RTI during pregnancy combined with AFE were retrieved with key words of " reproductive tract infection during pregnancy" " obstetric sepsis" and " amniotic fluid embolism" both in Chinese and English, based on China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), VIP, Wanfang Data Service Platform, PubMed and Ovid Medline database. Literature retrieval time was set from the establishment of above databases to October 2021. Clinical manifestations, diagnosis and treatment of obstetric sepsis due to RTI during pregnancy combined with AFE were summarized. The procedures followed in this study were in line with the requirements of World Medical Association Declaration of Helsinki revised in 2013.
Results ①This patient was 38 year old at childbirth who admitted to case collected hospital due to " menopause 31+ 1 week, recurrent vaginal bleeding 12+ h, aggravation 2 h" at 7: 20 am on September 8, 2021. On admission, results of fetal ultrasonography indicated that intrauterine single live fetus with head presentation, and placenta previa; maternal blood routine examination indicated that white blood cell count and percentage of neutrophils both were increased, which were 11.6×109/L and 94.5%, respectively; vaginal secretion culture and identification results indicated that the patient was infected with Candida glabrata. At 9: 40 am on the day of admission, the patient′s body temperature was 37.9 ℃, and cefuroxime was given for anti-infective therapy, magnesium sulfate was used to protect fetal central nervous system, and dexamethasone was used to promote fetal lung maturity. On the second day after admission, when chest CT was planned to be performed under continuous mask oxygen inhalation to further clarify the source of infection, the patient had sudden dyspnea and a large amount of vaginal amniotic fluid flowed out, and 10 minutes later, she developed cyanosis all over the body with cold limbs, paralysis, lockjaw and loss of consciousness. Endotracheal intubation was immediately performed, and ECG monitoring suggested that pulse was 120 times/min, blood pressure was 74 mmHg/42 mmHg (1 mmHg=0.133 kPa), pulse oxygen saturation (SpO2) was 70%, fetal heart was 57 times/min, and emergency cesarean section was performed immediately. Intraoperative blood routine examination showed that hemoglobin was normal with 116 g/L and platelet count was 35×109/L, which was lower than the normal reference value; prothrombin time was 19.9 s, international standardized ratio was 1.72, partial thromboplastin time was>180.0 s, thrombin time was>180.0 s, fibrinogen degradation product was 189.65 μg/mL, which all were lower than the normal reference values, and fibrinogen was 0.49 g/L, which was higher than the normal reference value. Results of pleural fluid culture and blood culture showed positive of gram-negative bacilli, and septic shock was considered. Total hysterectomy and left salpingectomy were performed for the diagnosis of septic shock caused by sepsis, AFE and disseminated intravascular coagulation (DIC). After operation, she was transferred to intensive care unit. With cooperation of a multidisciplinary team, she was treated by continuous renal replacement therapy (CRRT) to stabilize internal environment, blood transfusion for supplement of blood components, management of blood volume, and increase blood pressure, and glucocorticoids for anti-inflammatory and anti-immune treatment. She was also treated by treprostinil to reduce pulmonary arterial pressure, imipenem and cilastatin for anti-infective treatment, suppression of gastric acid secretion, continuous blood purification to reduce inflammation reaction, and extracorporeal membrane oxygenation (ECMO) to improve oxygen supply and hypothermia treatment, and so on. Because the patient was complicated with septic shock and AFE, and the disease progressed rapidly and was very critical, she died 23 days after delivery due to ineffective rescue. ②According to literature retrieval strategy developed in this study, literature retrieval results showed that there was not a single case of obstetric sepsis due to RTI during pregnancy combined with AFE, so there was no diagnosis and treatment report of related cases so far.
Conclusions Incidence of RTI during pregnancy is high, but case reports of AFE after RTI are rare. Clinical treatment for patients with RTI during pregnancy should be identified as soon as possible, and actively standardized anti-infection treatment should be taken to reduce the occurrence of obstetric sepsis and AFE. For the treatment of patients with obstetric sepsis due to RTI during pregnancy combined with AFE, a multidisciplinary team is needed to effectively improve patients′ prognosis for patients′ multiple organ failure (MOF).