O&G · Postpartum care — infection and sepsis
Puerperal sepsis and endometritis
Also known as Puerperal sepsis · Maternal sepsis · Postpartum endometritis · Endomyometritis · Childbed fever · Puerperal pyrexia
Exam-exhaustive FRANZCOG fellowship reference on puerperal sepsis and endometritis — the organisms including group A Streptococcus and its speed, recognition against physiological postnatal change, the first-hour sepsis bundle with antibiotic names and doses, source control, and the maternal-death lesson from the UKOSS case-control analysis. SOMANZ- and RANZCOG-anchored, globally tagged.
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Target exams
Red flags
- Pain out of all proportion to the findings — the earliest sign of invasive group A streptococcal infection, and the one that is dismissed
- A postnatal woman with diarrhoea and vomiting labelled gastroenteritis — group A Streptococcus presents this way and kills within hours
- Respiratory rate over 20 in a postnatal woman — the vital sign least often recorded and most predictive of deterioration
- Antibiotics still not given while imaging is arranged — never receiving antibiotics carried an adjusted odds ratio of 22.7 for death
- Persistent fever on adequate antibiotics — you have a collection to drain or a septic pelvic vein, not the wrong drug
- An unwell child at home with a sore throat, and a septic mother — ask the question, notify public health, and check the baby
It is day 3. She had a normal birth, went home, and is back with abdominal pain, a temperature of 38.4 degrees Celsius and vomiting. The triage note says gastroenteritis. Four hours later she is hypotensive and no one has given an antibiotic. This is the case the Confidential Enquiries describe over and over, and the whole topic exists so that you are not the person who wrote that triage note.[1][7]
Overview and definition
Maternal sepsis has a modern definition and you should quote it, not the old fever-based one. [3]
- WHO consensus definition (2017): a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or the postpartum period.[3]
- The key shift: sepsis is infection plus organ dysfunction, not infection plus fever. Fever is neither necessary nor sufficient.[3][6]
- Puerperal pyrexia — the older definition of a temperature of 38 degrees Celsius or above on two occasions at least 24 hours apart in the first 10 days — is a screening trigger, not a diagnosis.[14]
- Endometritis is infection of the decidua and myometrium and is the commonest genital-tract source; endomyometritis, parametritis, pelvic abscess and septic pelvic thrombophlebitis are the escalating extensions of it.[11][16]
References19ShowHide
- [1]Mohamed-Ahmed O, Nair M, Acosta C, et al. Progression from severe sepsis in pregnancy to death: a UK population-based case-control analysis. BJOG, 2015.PMID 26213333
- [2]Bowyer L, Cutts BA, Barrett HL, et al. SOMANZ position statement for the investigation and management of sepsis in pregnancy 2023. Aust N Z J Obstet Gynaecol, 2025.PMID 38922822
- [3]Bonet M, Nogueira Pileggi V, Rijken MJ, et al. Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation. Reprod Health, 2017.PMID 28558733
- [4]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med, 2021.PMID 34599691
- [5]Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med, 2017.PMID 28528569
- [6]Shields A, de Assis V, Halscott T Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis. Obstet Gynecol, 2021.PMID 34237760
- [7]Anderson BL Puerperal group A streptococcal infection: beyond Semmelweis. Obstet Gynecol, 2014.PMID 24785617
- [8]Harris K, Proctor LK, Shinar S, et al. Outcomes and management of pregnancy and puerperal group A streptococcal infections: A systematic review. Acta Obstet Gynecol Scand, 2023.PMID 36636775
- [9]Donders G, Greenhouse P, Donders F, et al. Genital Tract GAS Infection ISIDOG Guidelines. J Clin Med, 2021.PMID 34068785
- [10]Reicher L, Attali E, Dominski O, et al. Estimating predictors of severity of group A Streptococcus infection in pregnancy. J Matern Fetal Neonatal Med, 2023.PMID 36997169
- [11]Mackeen AD, Packard RE, Ota E, et al. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev, 2015.PMID 25922861
- [12]Conde-Agudelo A, Romero R, Jung EJ, et al. Management of clinical chorioamnionitis: an evidence-based approach. Am J Obstet Gynecol, 2020.PMID 33007269
- [13]Tita AT, Szychowski JM, Boggess K, et al. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med, 2016.PMID 27682034
- [14]Arulkumaran N, Singer M Puerperal sepsis. Best Pract Res Clin Obstet Gynaecol, 2013.PMID 23993724
- [15]Sriskandan S Severe peripartum sepsis. J R Coll Physicians Edinb, 2011.PMID 22184573
- [16]Foeller ME, Gibbs RS Maternal sepsis: new concepts, new practices. Curr Opin Obstet Gynecol, 2019.PMID 30789841
- [17]Edwards W, Dore S, van Schalkwyk J, et al. Prioritizing Maternal Sepsis: National Adoption of an Obstetric Early Warning System to Prevent Morbidity and Mortality. J Obstet Gynaecol Can, 2020.PMID 32171506
- [18]Wheaton N, Al-Abdullah A, Haertlein T Postdelivery Emergencies. Emerg Med Clin North Am, 2019.PMID 30940373
- [19]Mitchell KB, Johnson HM, Rodríguez JM, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med, 2022.PMID 35576513