Bacterial infections during childbirth can lead to sepsis, a life-threatening condition caused by the body's response to an infection. Sepsis is a global leading cause of maternal mortality, accounting for 1 in 10 maternal deaths worldwide. The diagnostic criteria for sepsis include symptoms like fever, increased heart rate, respiratory rate and blood markers of infection. Early goal-directed treatment within 3-6 hours including antibiotics, fluid resuscitation and source control can improve outcomes. Ongoing monitoring and organ support is often needed. Risk factors like obesity, diabetes and preterm rupture of membranes increase the risk of sepsis in pregnancy.

1. SEPSIS IN PREGNANCY

2.  Bacterial infections during labour and the puerperium are
among the leading causes of maternal mortality
worldwide, accounting for about 1/10 of the global
burden of maternal deaths
 Leading cause of maternal deaths in the UK between
2006-2008
 Long term disabilities e.g. chronic pelvic pain, fallopian
tube blockage, secondary infertility
 Newborn mortality – estimated 1 million newborn deaths
are associated with such infections annually

3.  SEPSIS
 Life threatening organ dysfunction due to a dysregulated host response to
infection
 SEPTIC SHOCK
 Persistent hypoperfusion despite adequate fluid replacement therapy
 MATERNAL PERIPARTUM INFECTION (WHO recommendations for
prevention and treatment of maternal peripartum infections, 2015)
 infection of the genital tract occurring at any time between the onset of rupture
of membranes or labour and the 42nd day postpartum in which two or more of
the following are present: pelvic pain, fever, abnormal vaginal discharge,
abnormal smell/foul odour discharge or delay in uterine involution
 Common terms : maternal sepsis, puerperal sepsis, genital tract sepsis

4. Diagnostic criteria in suspected/confirmed
infection
General Core temperature >38.3oC or <36oC
HR >90bpm
Tachypnea
Altered mental status
Significant edema or positive fluid balance ( >20ml/kg over
24hrs)
Hyperglycemia ( plasma glucose >110mg/dl or 7.7mmol/l )
Inflammatory TWC >12,000/uL or <4,000/uL
Normal white cell count with >10% immature forms
Plasma CRP >2SD obove normal value
Plasma procalcitonin >2SD above normal value
Hemodynamic SBP <90mmHg, MAP <70 or SBP decrease >40mmHg in adults or
<2SD below normal for age
SCVO2 >70%
Cardiac index >3.5l/min/m2

5. Organ dysfunction PaCO2/FiO2 <300
Urine output <0.5ml/kg/h
Creatinine increase >0.5mg/dl
INR >1.5 or APTT >60s
Platelet count <100,000/uL
Ileus
Plasma total bilirubin >4mg/dL or >70mmol/L
Tissue perfusion Lactate >3mmol/L
Decrease capillary refill or mottling
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, SCCM/ESICM/ACCP/ATS/SIS 2001
SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31(4):1250–1256. Review.

6. RISK FACTORS
 OBESITY
 GDM/DM
 ANAEMIA
 VAGINAL DISCHARGE
 H/O PELVIC INFECTION
 H/O GBS INFECTION
 AMNIOCENTESIS AND OTHER INVASIVE PROCEDURES
 CERVICAL CERCLAGE
 PROLONGED RUPTURED OF MEMBRANES
 CLOSE CONTACT WITH PEOPLE WITH GAS INFECTION
 IMPAIRED IMMUNE SYSTEMS BECAUSE OF ILLNESS OR DRUGS
 CHEMOTHERAPY, LONG TERM STEROID, IMMUNOSUPPRESSANT
 POST SPLENECTOMY, SICKLE CELL DISEASE

9. Stratifying risks
Sepsis : recognition, diagnosis and early management. NICE guideline (NG51) July 2016

13. SURVIVING SEPSIS CAMPAIGN CARE
BUNDLES
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate >4mmol/L
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION
1. Apply vasopressors (for hypotension that does not respond to initial fluid
resuscitation) to maintain a mean arterial pressure (MAP) >65mmHg
2. In the event of persistent hypotension (MAP <65mmHg) or if initial lactate was
>4mmol/L, reassess volume status and tissue perfusion and document findings
3. Remeasure lactate if initial lactate elevated

14. DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH :
EITHER
 Repeat focused exam (after initial fluid resuscitation) by licensed independent
practitioner including vital signs, cardiopulmonary, capillary refill, pulse and skin
findings
OR TWO OF THE FOLLOWING
 Measure CVP
 Measure ScvO2 (>70%)
 Bedside cardiovascular ultrasound
 Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

15. MANAGEMENT
 MEDICAL EMERGENCIES !!!
 Sepsis induced hypoperfusion
 IV crystalloid > 30ml/kg to be given within the first 3hr
 Additional fluid be guided by frequent reassessment of
hemodynamic status
 Target MAP – 65mmHg
 To normalize lactate in patients with elevated lactate levels as a
marker of tissue hypoperfusion

16.  Diagnosis
 Microbiologic culture, including blood, to be taken before antimicrobial therapy
 Antimicrobial therapy
 IV antimicrobial, ASAP, within 1 hr of recognition of sepsis and septic shock
 Broad-spectrum, one or more antimicrobial, to cover all likely pathogen. To narrow
down once pathogen is identified and/or adequate clinical improvement is noted
 How to choose? Consider anatomic site, prevalence within community & hospital;
resistant patterns; specific immune defects; age & comordities
 De-escalation with discontinuation of combination therapy within the first few days
in response to clinical improvement and/or evidence of infection resolution.
 Duration – 7 to 10 days.
 Longer course for those who have slower clinical response, undrainable foci of
infection, S. aureus, some fungal & viral infections, immunologic deficiencies
 Shorter course with rapid clinical resolution, following effective source control

17.  Source control
 Fluid therapy
 Crystalloid
 Albumin, if require substantial amount of crystalloids
 Vasoactive medications
 Norepinephrine
 Add vasopressin or epinephrine to increase MAP
 Dopamine as alternative only in selected patients (i.e. low risk of
tachyarrhythmias, absolute or relative bradycardia)
 Dobutamine – persistent hypoperfusion despite adequate fluid loading
and vasopressor agents

18.  Corticosteroids – not recommended
 Blood & blood products transfusion
 Hb <7.0g/dL
 Platelet
 <10x109/L in the absence of bleeding
 <20x109/L if significant bleeding risk
 <50x109/L for active bleeding, surgery or invasive procedures
 Immunoglobulins – not recommended, weak recommendation with low
quality of evidence. Require further evaluation.
 GTG RCOG – IVIG is recommended for severe invasive streptococcal or
staphylococcal infection if other therapies have failed
 Glucose control
 Insulin when 2 consecutive blood glucose levels >180mg/L

19.  VTE prophylaxis
 LMWH or UFH
 Combination of mechanical and pharmacologic whenever possible
 Mechanical, when pharmacologic is contraindicated
 Stress ulcer prophylaxis
 Proton pump inhibitor, histamine-2 receptor antagonist
 Renal replacement therapy
 Sedation, analgesia
 Mechanical ventilation
 Nutrition
 Bicarbonate therapy

20. MEOWS
CHART

23. Indications for transfer to ICU
SYSTEM INDICATION
CVS
Respiratory
Renal
Neurological
Miscellaneous
Hypotension/raised serum lactate despite fluid
resuscitation, suggesting the need for inotrope support
Pulmonary oedema
Mechanical ventilation
Airway protection
Renal dialysis
Significantly decreased conscious level
Multi organ failure
Uncorrected acidosis
Hypothermia

24. Antimicrobials
Antimicrobials Limitations
Co-amoxiclav
Metronidazole
Clindamycin
Piperacilin-tazobactam
and carbapenems
Gentamicin
X MRSA, Pseudomonas
Increase risk of NEC in neonates exposed in utero
Anaerobes
Most streptococci and staphylococci, including MRSA
Not nephrotoxic
Covers all except MRSA
Renal sparing
No problem in normal renal function but if given
regularly, serum levels must be monitored

25. Fetus
 Increased perinatal morbidity and mortality
 Risk of neonatal infection, encephalopathy and CP
 Consider delivery
 Decision on timing and mode of delivery should be made by senior obstetrician
 Antenatal steroid if preterm delivery
 Continuous electronic fetal monitoring intrapartum
 Avoid epidural/spinal anaesthesia

26. Infection control
 Local infection control guideline
 Hand hygiene
 Isolation
 Informed neonatologist
 Educate family members and healthcare workers to seek medical attention
should any symptoms develop
 Antibiotic prophylaxis for healthcare workers who have been exposed

27. Guidelines & recommendations
1. Surviving Sepsis Campaign : International Guidelines for management of
Sepsis and Septic Shock : 2016
2. Sepsis : recognition, diagnosis and early management. NICE guideline (NG51),
July 2016.
3. WHO recommendations for prevention and treatment of maternal peripartum
infections. 2015.
4. The UK Sepsis Trust 2016.
5. Bacterial Sepsis in Pregnancy, Green-top Guideline No. 64a, April 2012.