Maternal Sepsis (pregnancy and postpartum)

1 · Think sepsis

• Any woman pregnant or within 6 weeks of the end of pregnancy, with suspected infection and deteriorating
• Repeated presentation is itself a red flag (MBRRACE) — repeat GP, midwife or triage contact needs a full assessment, not more reassurance
• Pain after birth not settling with simple analgesia — face-to-face review. After-pains do not start after discharge
• Black, Asian and minority ethnic women are at higher risk; rashes may look different on darker skin

2 · Red flags — high risk

• GCS <15, or not alert on AVPU
• RR ≥25
• SpO₂ <94% on air
• HR >130
• SBP <90
• No urine >12h, or <0.5ml/kg/hr catheterised

Any one: start the bundle, or blue-light in from the community. Score with MEOWS, not NEWS2.

3 · Amber flags — senior review within 1 hour

• RR 21–24 · HR 100–130 or new dysrhythmia · SBP 91–100
• Temp <36°C or >38°C — hypothermia counts
• Behavioural change, or acute loss of function
• No urine 12h, or 0.5–1ml/kg/hr catheterised
• Invasive procedure in 6 weeks — caesarean, assisted birth, ERPC, cerclage, CVS, amniocentesis, termination
• Impaired immunity, including oral steroids
• Diabetes or gestational diabetes
• Close GAS contact in the last 7 days
• ROM 18–24h
• Prolonged bleeding with abdominal pain after birth
• Offensive vaginal discharge

4 · Investigations

• Two sets of blood cultures before antibiotics — but do not delay them
• Lactate urgently. ≥2: senior review, fluids, repeat. ≥4: escalate, discuss critical care
• FBC, coag, U&E, creatinine, LFTs, CRP, venous gas
• Throat swab if tonsillitis or pharyngitis — GAS
• Nasal swab for MRSA if status unknown
• Consider HSV PCR
• Do not defer imaging because she is pregnant

Labour and bleeding both raise lactate. Use it, but do not explain a high one away.

5 · Antibiotics within 1 hour

• IV broad-spectrum within 1 hour if high risk, with or without shock
• Unknown organism: piperacillin-tazobactam or meropenem + clindamycin — clindamycin switches off exotoxin production
• Add vancomycin with any MRSA history
• Penicillin anaphylaxis: avoid all cephalosporins and carbapenems
• Pyrexia ≥38°C in labour: cover GBS, continuous fetal monitoring
• Not clindamycin for GBS unless known sensitive — 31% resistance
• Follow local antimicrobial policy

6 · Fluids — 500ml boluses

• 500ml crystalloid if hypotensive or lactate >4. Repeat to response
• Critical care input if >2L without the blood pressure improving
• Catheter and hourly urometer
• Pre-eclampsia changes this — high pulmonary oedema risk, individualise with anaesthetics or critical care

7 · Source control

• Drain pus surgically
• Infected retained products — antibiotics and prompt surgery
• Expedite birth where it helps mother, baby or both
• Genital tract sepsis: think GAS and E. coli. GAS discharge is often watery, not offensive — so it gets dismissed

8 · The baby, and the birth

• Continuous electronic fetal monitoring. Caution with fetal blood sampling
• Senior obstetrician decides timing and mode of birth
• Senior anaesthetist assesses anaesthesia and invasive monitoring
• Babies treated in labour, or 24h either side of birth, need assessment for neonatal infection
• Invasive GAS postpartum: treat mother AND baby, barrier nurse

9 · Not settling? Widen the differential

• Herpes simplex — often no rash. Not responding? Add IV aciclovir 500mg 8-hourly with the antibiotic change, not after it. ALT >10x with a normal bilirubin gets misread as HELLP
• Necrotising fasciitis — pain out of proportion, escalating to opioids, often no early skin change. Bruising means something deeper. Plastics, ITU and infection specialist now
• Masquerades: pre-eclampsia · acute fatty liver · TTP · HLH · transfusion reaction · epidural fever · misoprostol · occult bleeding
• Reassess thromboprophylaxis — infection is a VTE risk in its own right