Maternal Sepsis

WHO Definition (2017)

“A life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period.”

Pregnancy Physiology Relevant to Sepsis

Cardiovascular Changes

• Increased cardiac output
• Increased heart rate
• Reduced SVR
• Physiological mild hypotension

Thus:

• Tachycardia may be underestimated
• Shock may present late

Respiratory Changes

• Increased minute ventilation
• Mild respiratory alkalosis normal

Thus:

• Tachypnea may be early sign
• Rapid desaturation occurs

Hematological Changes

• Physiological leukocytosis
• WBC may normally be 12,000–16,000
• Hypercoagulable state

Thus:

• WBC alone unreliable
• High risk of DIC

Renal Changes

• Increased GFR
• Lower baseline creatinine

Thus:Creatinine 1 mg/dL may indicate AKI in pregnancy

Common Sources of Infection

Risk Factors

Microbiology

Maternal sepsis is often polymicrobial.

Gram-positive

• Group A Streptococcus (GAS),Group B Streptococcus,Staphylococcus aureus,Enterococcus

Gram-negative

• E. coli,Klebsiella,Pseudomonas

Anaerobes

• Bacteroides,Clostridium

Others

• Listeria,Influenza,COVID-19,Malaria (in endemic areas)

Clinical Features

General Symptoms

• Fever or hypothermia
• Malaise
• Chills
• Weakness

Early Signs

• Tachycardia
• Tachypnea
• Altered mental state

Obstetric Clues

• Uterine tenderness
• Foul-smelling lochia
• Abdominal pain
• Perineal pain
• Wound discharge
• Breast tenderness

Severe Disease Features

• Hypotension
• Oliguria
• Cyanosis
• Respiratory distress
• Confusion
• Lactate elevation

Diagnosis

Maternal sepsis is primarily a clinical diagnosis.

Do not delay antibiotics awaiting confirmation.

Investigations

Basic Labs

• CBC
• CRP
• Procalcitonin
• Renal function
• LFT
• Coagulation profile
• ABG
• Lactate

Cultures

Obtain before antibiotics if possible:

• Blood cultures ×2
• Urine culture
• High vaginal/cervical swab
• Wound cultures
• Sputum culture if indicated

Imaging

Ultrasound

Useful for:

• Retained products
• Pelvic abscess
• Septic pelvic thrombophlebitis

Chest X-ray

For:Pneumonia/ARDS/Pulmonary edema

CT/MRI

If source unclear:

• Pelvic abscess
• Necrotizing infection
• Septic thrombophlebitis

Lactate

Important marker of:

• Tissue hypoperfusion
• Severity
• Response to treatment

Lactate >2 mmol/L suggests severe disease.

Sepsis Scoring in Pregnancy

Traditional scores may fail due to pregnancy physiology.

qSOFA Limitations

Less sensitive in pregnancy.

Modified Obstetric Early Warning Score (MEOWS)

Management

Fluid Therapy

Initial:Balanced crystalloids preferred

Usually:30 mL/kg for hypotension/lactate elevation

But pregnancy requires caution:

• Increased pulmonary edema risk

Frequent reassessment essential.

Empirical Antibiotics

Depends on source.

Antibiotic Principles in Pregnancy

Choose drugs considering:

• Placental transfer
• Fetal safety
• Breastfeeding compatibility

Postpartum Endometritis

Common regimen:Clindamycin + gentamicin

Alternative:Piperacillin-tazobactam

Severe Maternal Sepsis / Septic Shock

Broad-spectrum options:

• Piperacillin-tazobactam
• Meropenem
• Cefepime + metronidazole
• Add:Vancomycin if MRSA risk

Suspected GAS Toxic Shock

Add:Clindamycin

Reason:Suppresses toxin production

Source Control

One of the most important aspects.

Role of Delivery

Sometimes fetus/placenta is infection source.

Indications may include:

• Chorioamnionitis
• Fetal distress
• Maternal deterioration

Decision individualized.