Sepsis in Pregnancy

Also known as Maternal sepsis · Puerperal sepsis · Chorioamnionitis · Maternal early warning score · MEOWS

Maternal sepsis is a leading cause of maternal mortality and is under-recognised because the physiological changes of pregnancy mask the signs. The commonest sources are pyelonephritis, chorioamnionitis, puerperal endometritis, wound infection, and mastitis; the key organisms are Group B Streptococcus, E. coli, anaerobes, and Group A Streptococcus. Management follows the pregnancy-adapted sepsis bundle: broad-spectrum antimicrobials within one hour, volume-limited balanced crystalloid resuscitation (1 to 2 L over the first 3 hours), norepinephrine as first-line vasopressor, source control (including delivery when the uterus is the source), and maternity early-warning scores for recognition.

high9 referencesUpdated 19 Aug 20268 min readVerification in progress

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8 MCQs

The one-line answer

Maternal sepsis is a leading cause of maternal mortality, and it kills because it is under-recognised — the physiologic changes of pregnancy (a raised heart rate and white cell response, a lower blood pressure) mask the very signs the sepsis screen depends on. Treat sepsis and septic shock in pregnancy as a medical emergency with immediate resuscitation: broad-spectrum antimicrobials ideally within one hour of recognition, cautious fluids — 1 to 2 L of balanced crystalloid over the first 3 hours with dynamic reassessment (pulmonary oedema is the iatrogenic killer), norepinephrine as the first-line vasopressor, source control (prompt delivery or uterine evacuation when the uterus is the source, regardless of gestational age), and a maternity early-warning score for recognition. Resuscitate the mother to resuscitate the foetus — there is no foetal fix that bypasses the mother.^[1]^[2]^[3]^[5]

Meet the patient

A 31-year-old woman, gravida 2 para 2, BMI 33, is admitted to ICU on day three after an emergency lower-segment caesarean section for failure to progress. She had prolonged rupture of membranes (24 hours) and manual removal of the placenta. Her temperature is 39.2, heart rate 138, blood pressure 78 over 46 (MAP 57) on noradrenaline despite 2 L of balanced crystalloid, respiratory rate 30, SpO2 94 percent, lactate 4.8. Her lochia is foul-smelling and the uterus is tender.^[1]^[2]^[3]

The first question that frames every maternal sepsis stem is where is the source? — because source control differs fundamentally for each. This woman has puerperal endometritis with septic shock: the source is the uterus, and the source control is gynaecological. The trap is treating her as "just septic" without identifying and controlling the source, and over-loading her with fluid into pulmonary oedema.^[1]^[2]

References9Show

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[2]Shields A, de Assis V, Halscott T Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis Obstet Gynecol, 2021.PMID 34237760
[3]Shields AD, Plante LA, Pacheco LD, et al. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis Am J Obstet Gynecol, 2023.PMID 37236495
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[9]Nair S, Spring A, Dockrell L, Mac Colgain S Irish Maternal Early Warning Score Ir J Med Sci, 2020.PMID 31254160