Infection, Diabetes, Analgesia, and Airway Medications

Learning objectives

After completing this chapter, you should be able to plan time-critical antimicrobial therapy for maternal sepsis; distinguish GBS prophylaxis from treatment of established infection; manage the medication sequence of diabetic ketoacidosis; select analgesia and antiemetic therapy with pregnancy-specific considerations; anticipate opioid and sedative effects on the fetus and newborn; prepare hemodynamically appropriate rapid-sequence induction; explain why paralysis is not sedation; choose vasopressor support based on physiology; and understand transport implications of neonatal surfactant therapy.

Opening transport scenario

A 28-year-old patient at 31 weeks is transferred with fever, ruptured membranes, uterine tenderness, tachycardia, and a lactate of 3.2 mmol/L. She also has type 1 diabetes, glucose 286 mg/dL, bicarbonate 15 mEq/L, positive ketones, and potassium 3.1 mEq/L. During preparation, respiratory effort worsens. The team must coordinate antibiotics, cultures, fluids, potassium, insulin timing, airway medications, vasopressor readiness, and fetal monitoring without allowing one problem to obscure another.

1. Maternal sepsis medications

Maternal sepsis is a medical emergency. Treatment should begin when sepsis is suspected rather than waiting for fever, culture confirmation, or a complete diagnostic picture. Obtain appropriate cultures before antibiotics when this can be accomplished promptly, but do not delay antimicrobial therapy in a deteriorating patient. Current maternal-sepsis guidance supports broad-spectrum antibiotics ideally within one hour when sepsis or septic shock is recognized.

Intra-amniotic infection often requires broad coverage and obstetric delivery planning. Antibiotics should not be presented as a reason to suppress indicated labor or delay source control.

2. Group B Streptococcus prophylaxis

GBS prophylaxis is intended to reduce early-onset neonatal GBS disease during labor. It is not the same as broad-spectrum treatment of chorioamnionitis or maternal sepsis. Penicillin G is commonly preferred; ampicillin is an alternative. Cefazolin, clindamycin, or vancomycin may be selected based on the allergy history and susceptibility information.

• Document the GBS result, source, date, allergy history, susceptibility if relevant, antibiotic selected, loading dose, and administration time.
• Do not delay medically necessary birth solely to complete four hours of prophylaxis.
• If intra-amniotic infection is suspected, use the treatment regimen ordered for infection rather than assuming prophylaxis alone is adequate.

3. Diabetic ketoacidosis in pregnancy

Pregnancy increases susceptibility to ketoacidosis, and DKA may occur at lower glucose concentrations than in nonpregnant adults. Diagnosis depends on ketonemia, metabolic acidosis, and the clinical context—not glucose alone. Common triggers include infection, insulin interruption, vomiting, corticosteroids, beta-agonists, and pump failure.

1. Restore circulation with carefully reassessed isotonic or balanced crystalloid.
2. Check potassium before insulin. If potassium is severely low, replace potassium and delay insulin until the level is safe according to protocol.
3. Start regular insulin infusion once potassium permits; avoid an unplanned interruption in basal insulin for insulin-pump users.
4. Add dextrose when glucose falls but ketoacidosis has not resolved so insulin can continue clearing ketones.
5. Replace potassium, magnesium, and phosphate according to serial results and clinical indications.
6. Identify and treat the precipitating cause, such as infection or medication exposure.
7. Continue fetal assessment, but recognize that definitive fetal improvement often follows correction of maternal acidosis and perfusion.

4. Analgesia and antipyretic therapy

Untreated severe pain, fever, and agitation can worsen catecholamine release, oxygen demand, uterine activity, and cooperation with care. Medication decisions should balance maternal benefit, gestational age, hemodynamics, fetal exposure, and proximity to birth.

Recent professional guidance continues to support acetaminophen when medically indicated during pregnancy. Medication counseling should avoid absolute statements and should compare the risk of treatment with the risk of untreated fever or pain.

5. Antiemetics and aspiration-risk reduction

Nausea and vomiting can worsen dehydration, DKA, aspiration risk, and medication intolerance. Antiemetic selection depends on rhythm risk, sedation, prior response, and the underlying cause. Metoclopramide, ondansetron, promethazine, and other agents may be used according to order. Monitor for QT prolongation, dystonia, sedation, hypotension, and additive effects with opioids or airway medications.

6. Airway medication strategy

Pregnancy reduces oxygen reserve, increases aspiration risk, and may make laryngoscopy more difficult. The medication plan should therefore be part of a comprehensive airway strategy—not a disconnected dose list.

Common induction agents include etomidate and ketamine; propofol may cause major hypotension in a volume-depleted patient. Succinylcholine provides rapid short-duration paralysis but is contraindicated in important hyperkalemic and neuromuscular states. Rocuronium provides longer paralysis and requires an explicit postintubation sedation plan.

7. Vasopressors

Vasopressors are selected according to the cause of hypotension. Norepinephrine is commonly first-line in septic shock. Phenylephrine may be used for vasodilatory hypotension when tachycardia is problematic, and ephedrine may be used in selected obstetric-anesthesia settings. Epinephrine is required for anaphylaxis and cardiac arrest. The transport clinician should treat the underlying physiology rather than choosing a pressor simply because it is familiar.

• Correct aortocaval compression before escalating medication when applicable.
• Confirm concentration, central versus peripheral access plan, pump programming, and extravasation response.
• Trend maternal perfusion and fetal response; uterine blood flow depends on maternal pressure and cardiac output.
• Reassess whether hemorrhage, pulmonary embolism, cardiomyopathy, or medication effect requires a different strategy.

8. Surfactant principles

Exogenous surfactant is a neonatal therapy for respiratory distress syndrome and selected neonatal respiratory conditions. It reduces alveolar surface tension and improves lung compliance. Administration typically occurs through an endotracheal tube or specialized less-invasive technique by trained neonatal clinicians. Transport teams should understand the timing, route, ventilation changes, oxygen response, potential transient bradycardia or desaturation, and the need to avoid accidental extubation or tube obstruction.

9. Medication transport checklist

• Reconcile indication, agent, concentration, dose, route, start time, next dose, allergies, renal/hepatic function, and response.
• Carry enough medication, fluid, oxygen, battery, and rescue therapy for the planned route plus delay or diversion.
• Trace each line and identify compatibility, dedicated access, and pressure-bag or pump requirements.
• Identify medications likely to alter fetal tracing, neonatal tone, respiration, glucose, or blood pressure.
• Communicate trigger points for stopping, escalating, or changing destination.

10. Evolving case study

Phase 1

Blood cultures and urine are obtained without delaying antibiotics. Broad-spectrum therapy begins, and balanced crystalloid is given in reassessed aliquots. Potassium is 3.1 mEq/L, so potassium replacement begins before insulin.

Phase 2

After potassium improves, insulin starts. Dextrose is added later while the anion gap remains open. Fetal tachycardia persists but begins improving as maternal temperature, perfusion, and acidosis improve.

Phase 3

Respiratory failure progresses. The team preoxygenates, prepares suction and a backup airway, selects induction based on septic hemodynamics, prepares norepinephrine, uses rapid paralysis, and immediately begins postintubation analgesia and sedation. The patient is diverted to a center with critical care, obstetric source-control, and neonatal capability.

11. High-yield summary

• Maternal sepsis requires prompt broad-spectrum antibiotics and source-control planning.
• GBS prophylaxis is not treatment for maternal sepsis or chorioamnionitis.
• Pregnancy DKA can occur at lower glucose levels; potassium determines when insulin can safely begin.
• Add dextrose when necessary so insulin can continue until ketoacidosis resolves.
• Acetaminophen remains a common first-line analgesic/antipyretic when indicated.
• Routine NSAID use after about 20 weeks requires caution and medical direction.
• Opioids and sedatives can affect maternal ventilation, fetal tracing, and neonatal respiration.
• Paralysis is not sedation.
• Norepinephrine is commonly first-line in septic shock, but pressor choice must match physiology.
• Surfactant is a neonatal therapy requiring airway and ventilation preparation.

References

1. Society for Maternal-Fetal Medicine. Consult Series #67: Maternal Sepsis. Reaffirmed 2025.
2. American Diabetes Association. Standards of Care in Diabetes—2026: Management of Diabetes in Pregnancy.
3. Centers for Disease Control and Prevention. Group B Streptococcus and Pregnancy.
4. U.S. Food and Drug Administration. Avoid NSAIDs in pregnancy at 20 weeks or later because they may result in low amniotic fluid.
5. Society for Maternal-Fetal Medicine. Acetaminophen use in pregnancy. 2026.
6. International Board of Specialty Certification. Maternal Fetal Transport Microcredential Candidate Handbook. Updated April 2026.