Obstetric critical care

Sepsis in pregnancy and the puerperium

Reviewed Nov 2026·1 references
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Recognise sepsis despite physiological changes, give antibiotics within 1 h, find and control the source, and protect both patients.

Definition
Maternal sepsis: organ dysfunction from infection during pregnancy, childbirth, post-abortion or postpartum period (up to 42 days). Common sources: genital tract (chorioamnionitis, endometritis, septic abortion), urinary tract, pneumonia, wound/breast infection; in India also malaria, dengue, leptospirosis.

At the bedside

  1. 1

    Recognise

    Use an obstetric early warning score; normal pregnancy raises HR and lowers BP and PaCO2, so persistent HR > 110, RR > 24, temperature > 38 °C or < 36 °C, lactate > 2 mmol/L and altered mentation are concerning. Do not use qSOFA alone.

  2. 2

    Antibiotics within 1 h

    ≤ 1 h

    Blood cultures, then broad-spectrum: piperacillin-tazobactam 4.5 g q6h (or meropenem if ESBL risk); add clindamycin 900 mg q8h for suspected group A streptococcal or toxic shock; add azithromycin/doxycycline per source (doxycycline after delivery).

  3. 3

    Resuscitate

    Left uterine displacement (> 20 weeks); 1-2 L crystalloid in boluses with reassessment (pulmonary oedema risk); noradrenaline for MAP ≥ 65 mmHg.

  4. 4

    Source control

    Evacuation of retained products, delivery for chorioamnionitis, drainage of abscess, hysterectomy for necrotising myometritis.

  5. 5

    Fetal considerations

    Fetal monitoring when viable; maternal stabilisation is the best fetal resuscitation; delivery is not indicated for maternal sepsis alone unless intrauterine source.

  6. 6

    Other

    VTE prophylaxis, glucose control, steroids for fetal lung maturity if preterm delivery likely; avoid ACE inhibitors and tetracyclines before delivery.

Empirical maternal sepsis

Piperacillin-tazobactam

IV
Dose
4.5 g q6h

Suspected toxic shock / GAS

Clindamycin

IV
Dose
900 mg q8h
Red flag · call your senior now
Severe abdominal pain, diarrhoea, rash and shock postpartum: group A streptococcal sepsis - very rapid progression; clindamycin plus beta-lactam and surgical review.
Pitfall
Attributing tachycardia and low BP to normal pregnancy.
Pitfall
Supine positioning causing aortocaval compression and worsening hypotension.
Pearl
Lactate is not increased by normal pregnancy, but can rise during labour.

References

  1. 1

    Society for Maternal-Fetal Medicine; Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. Am J Obstet Gynecol 2019;220:B2-10.

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