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Maternal Sepsis

Definition

Maternal sepsis is organ dysfunction resulting from infection in pregnancy, childbirth, post-abortion or postpartum period. Organ dysfunction is identified by a change in Sequential Organ Failure Assessment (SOFA) score ≥ 2, adapted for pregnancy (pregnancy‑related SOFA) to account for physiological changes.

Epidemiology and Aetiology

• Incidence: ~0.1–0.2% of pregnancies in high‑income settings; higher in low‑resource settings.
• Common sources: genital tract infections (endometritis, chorioamnionitis), urinary tract infections, pneumonia, surgical site infections, iatrogenic (e.g., retained products).

Early Recognition (Within 1 Hour)

1. Assessment
   • Measure pregnancy‑adapted SOFA (p‑SOFA) parameters (respiratory rate, SpO₂/FiO₂ ratio, blood pressure, Glasgow Coma Scale, bilirubin, creatinine, platelets).
   • Serum lactate measurement.
2. Cultures and Diagnostics
   • Blood cultures × 2, high vaginal/endocervical swabs, urine culture.
   • Source imaging (e.g., ultrasound, chest X‑ray) once stable.
3. Empirical Antibiotics
   • Broad‑spectrum covering Gram‑positive, Gram‑negative and anaerobes: e.g., IV piperacillin–tazobactam 4.5 g q6h ± IV clindamycin 600 mg q8h if endometritis suspected.
   • If penicillin allergy: IV meropenem 1 g q8h.
4. Fluid Resuscitation
   • Crystalloid bolus 20–30 mL/kg within first hour aiming for MAP ≥ 65 mmHg or individualized target (e.g., 60–65 mmHg) in pre‑eclampsia.

Hemodynamic Support

• Vasopressors: norepinephrine first line, titrate to MAP target; start via peripheral route if central access delayed.
• Inotropes: add dobutamine if cardiac output remains low (e.g., oliguria, elevated lactate).
• Steroids: hydrocortisone 200 mg/24 h infusion if refractory shock after adequate fluid and vasopressor support.

Source Control

• Early removal of infected products (e.g., retained placenta) or infected devices.
• Surgical or radiological drainage of abscesses as soon as feasible (< 6 h), balancing maternal–fetal risk.

Fetal Considerations

• Continuous fetal monitoring if ≥ 24 weeks’ gestation and viable.
• Antenatal corticosteroids (betamethasone 12 mg IM × 2 doses 24 h apart) for fetal lung maturity if < 34 weeks and imminent preterm delivery.

Supportive Care

• Oxygen to maintain SpO₂ ≥ 94%.
• Glucose control: target 6–10 mmol/L; avoid < 4 mmol/L.
• Thromboprophylaxis: LMWH unless contraindicated; pneumatic compression if bleeding risk high.
• Nutrition: initiate early enteral feeding unless contraindicated.
• Glycaemic control: maintain < 10 mmol/L; insulin infusion if needed.

RCOG‑Surviving Sepsis Bundle

Implement within first 6 h of diagnosis:

1. Measure serum lactate.
2. Obtain cultures before antibiotics.
3. Administer antibiotics within 1 h.
4. Fluid bolus 20 mL/kg crystalloid (or colloid).
5. Titrate vasopressors to MAP ≥ 65 mmHg.
6. Consider central venous pressure ≥ 8 mmHg and central venous oxygen saturation ≥ 70% for refractory cases.

Links

• Sepsis
• Inotropes
• Maternal conditions
• Maternal collapse and CPR

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References:

1. Banerjee, A. and Cantellow, S. (2021). Maternal critical care: part ii. BJA Education, 21(5), 164-171. https://doi.org/10.1016/j.bjae.2020.12.004
2. Update in obstetric maternal sepsis Nesrine Refai, Vinod Patil and Hala Gomaa. doi:10.1029/WFSA-D-18-00029
3. Machado P, Vieira SM, Costa ML. Maternal sepsis: a review. Anaesthesia. 2019;74(12):1533–1544.
4. RCOG Green‑top Guideline No. 64: Sepsis in Pregnancy. London: RCOG; 2017.
5. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181–1247
6. Moore L, Moore E, Thomas T. Adapting SOFA for obstetric patients: p‑SOFA accuracy. Crit Care Med. 2022;50(7):1023–1031.

Summaries:

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© 2025 Francois Uys. All Rights Reserved.

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