Identification and Management of Maternal Sepsis
Definition and Scope
Maternal sepsis is defined (WHO, 2017; adopted from Sepsis-3) as "a life-threatening condition resulting from organ dysfunction, resulting from infection during pregnancy, childbirth, post-abortion, or the postpartum period" — formally, a rise in SOFA score of ≥2 points. Septic shock is sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mmHg, plus a persistent serum lactate >2 mmol/l despite adequate fluid resuscitation; associated hospital mortality exceeds 40%. Scope covers antenatal, intrapartum and postpartum sepsis (including post-abortion), genital-tract and non-genital sources, and influenza; primary viral (excluding influenza/HSV) and parasitic infections are excluded. UK data (MBRRACE 2019–21): 78 maternal deaths from sepsis (2.50/100,000 maternities); sepsis causes ~11% of maternal deaths globally.
Recognition — Red and Amber Flags
Monitoring should use an obstetric-modified early warning score (MEOWS/SBAR escalation). Red flags (high risk — initiate sepsis bundle or urgent hospital referral): GCS <15 or "not alert" on AVPU; respiratory rate ≥25/min; SpO₂ <94% on air; heart rate >130 bpm; systolic BP <90 mmHg; no urine passed in >12 hours, or <0.5 ml/kg/hr if catheterised. Amber flags (moderate risk — senior review within 1 hour): respiratory rate 21–24/min; heart rate 100–130 bpm or new dysrhythmia; systolic BP 91–100 mmHg; temperature <36°C or >38°C; reduced urine output; recent invasive procedure; prolonged rupture of membranes; behavioural/functional change.
Investigations
Two sets of blood cultures (sequential, before antibiotics, without delaying treatment), venous blood gas for lactate/glucose, FBC, coagulation, U&E, creatinine, LFTs, CRP, and prompt imaging (pelvic ultrasound/CT if abscess suspected, CXR if respiratory). Serum lactate ≥4 mmol/l should trigger immediate escalation and consideration of critical care.
Bundle of Care and Antibiotics
A sepsis bundle (Surviving Sepsis Campaign Hour-1 bundle, or local Sepsis Six equivalent) improves compliance: (1) measure lactate; (2) take blood cultures before antibiotics; (3) give broad-spectrum IV antibiotics; (4) give a 30 ml/kg crystalloid bolus for hypotension or lactate ≥4 mmol/l; (5) start vasopressors if hypotension persists after fluids, to keep MAP ≥65 mmHg; remeasure lactate within 1 hour if initially elevated. IV broad-spectrum antibiotics are recommended within 1 hour in women at high risk of sepsis, with or without septic shock [Grade C]. For life-threatening sepsis of unknown source: piperacillin-tazobactam OR meropenem, PLUS clindamycin (anti-exotoxin effect); add vancomycin if MRSA risk. Review and narrow-spectrum antibiotics once cultures return.
Source Control
Source control is a priority — e.g. surgical drainage of pus, expedited birth where the source is intrauterine. Suspected infected retained products of conception should receive antibiotics and prompt surgical evacuation. Necrotising fasciitis (most often GAS) presents with pain disproportionate to clinical signs and needs urgent surgical debridement plus piperacillin-tazobactam/meropenem + clindamycin ± IVIG.
Birth and Fetal Considerations
Timing/mode of birth in a critically unwell woman is individualised and led by a senior obstetrician; birth may be expedited if beneficial to mother or fetus. Continuous electronic fetal monitoring is recommended intrapartum; caution is advised with fetal blood sampling as results can be falsely reassuring.
High-Yield Exam Points
- Septic shock = vasopressor-requiring hypotension (MAP ≥65 mmHg target) + lactate >2 mmol/l despite fluids; mortality >40%.
- Red flag thresholds: RR ≥25, SpO₂ <94%, HR >130, systolic BP <90, GCS <15/not alert, oliguria (<0.5 ml/kg/hr).
- Lactate ≥4 mmol/l = urgent escalation/critical care discussion trigger.
- IV broad-spectrum antibiotics within 1 hour in high-risk women [Grade C].
- Empirical severe-sepsis regimen: piperacillin-tazobactam or meropenem + clindamycin (± vancomycin for MRSA).
- Pregnancy raises invasive Group A Streptococcus (GAS) risk ~20-fold; up to 80-fold in the first 28 days postpartum.
- Source control (drainage/evacuation of infected products/expedited birth) is as important as antibiotics.
Source: RCOG Green-top Guideline No. 64 (2nd edition, published online 18 December 2024 (BJOG 2025;132:e61–e85). Replaces the 2012 GTG 64a (*Bacterial Sepsis in Pregnancy*) and 64b (*Bacterial Sepsis Following Pregnancy*). Scheduled for update review 3 years post-publication.)
Read the original on rcog.org.uk
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