Infection, sepsis, severe sepsis and septic shock in pregnancy and pueperium

• Endometritis- Genital tract sepsis is the commonest site in postnatal women
• Mastitis
• Urinary tract infection / pyelonephritis
• Pneumonia & URTI
• Skin and soft-tissue infection
• Gastroenteritis
• DVT and Pulmonary embolism
• Septic pelvic thrombosis
• Rarer causes-bacterial meningitis, appendicitis, spinal abscess
• Check contact history- family members with known streptococcal infections (pharyngitis, impetigo, cellulitis)
• Consider COVID-19 in all women with pyrexia and/ or sepsis

Investigations and management

• Full MEOWS and repeat every ½ hour or earlier if required
• After a full clinical examination (including breasts, respiratory examination legs, perineum and  abdominal  palpation of the uterus) send an MSU and endocervical ± wound swab for culture
• If chest infection is suspected, also send sputum for culture, nasal and throat
  swabs and organise chest X-ray
• If COVID-19 suspected isolate and swab
• Sepsis 6 pathway if the patient is systemically unwell (see table below). Send blood cultures, FBC, U&Es, lactate, throat swabs and glucose/BM.
• If site of infection clear, treat with appropriate antibiotics.
• If the source of infection is not clear, and high suspicion of COVID-19, patient should be isolated until confirmatory test results are negative.
• Treat patients postnatally with either :

Co-amoxiclav 625mg/ PO TID (or 1.2g / IV / TID)
Add Gentamicin in severe Infection 5mg/Kg / IV / OD (daily dose)

If Allergic to Penicillin , treat with:
Clindamycin 450 mg / PO / QID ( or 600mg / IVI / QID ; up to 4.8mg daily in 2-4 divided dose if severe infection) + Ciprofloxacin 500mg / PO / BD (or 400mg / IV / BD)
Add Gentamicin in severe Infection 5mg / Kg / IV / OD (daily dose)

Sepsis - definition

Sepsis is an infection, suspected or proven, plus 2 or more SIRS criteria (see below).

Patients with uncomplicated sepsis need to be observed and monitored to detect early possible organ dysfunction and complications.

Systemic Inflammatory Response Syndrome (SIRS)

This can be triggered by infectious and non-infectious causes such as trauma. It is characterised by any 2 or more of the following features:

• Temperature >38 or <36
• Tachypnoea >20
• Tachycardia >90
• WCC <4 or >14
• Blood glucose > 7.7mmols/l

Severe Sepsis - definition

Severe sepsis is defined as sepsis complicated by organ dysfunction

Criteria for organ dysfunction:

Respiratory: new or increased O2 requirement to maintain SpO2>90%

Renal: urine output <0.5 ml/kg/hr for 2 hrs or newly raised creatinine (>176 μmol/l)

Hepatic: newly raised bilirubin (>34 μmol/l)

Coagulation: platelets <100, INR>1.5 or APTT>60s

Neurology: altered mental state/ GCS

Criteria for tissue hypoperfusion - organ dysfunction:

Systolic BP <90 or MAP <65 mmHg (Mean Arterial Pressure)

Lactate >4 mmol/l. Recheck lactate after 1-2 hours if initially >2mmol/l

Septic Shock -definition

Septic shock can only be diagnosed only if initial fluid resuscitation of patients suffering from severe sepsis has failed to improve tissue perfusion.

If Systolic BP <90, MAP < 65 or a repeated lactate > 4mmol/l, then septic shock is present. 

Look for potential source of infection (as above). Involve senor colleagues, anaesthetics and microbiology at an early stage

For all women with sepsis
• BM, Urine dip stick
• Venous blood – FBC, U&E, LFT, Glucose, Clotting profile, Lactate and Group & Save
• Arterial blood gas (ABG)
• Microbiology specimen:
• Blood cultures
• Urine (MSU or CSU)
• Throat swab
• Oro and nasopharyngeal swab (COVID-19)
• Vaginal swab

As clinically indicated according to suspected source of infection:
• Wound swab including perineum if vaginal delivery
• Placental swab
• Sputum
• Faeces (including C.difficile toxin)
• Herpes and Epstein Barr Virus

Imaging, according to source of infection:
• Chest X ray
• Abdominal X-ray
• Pelvic & abdominal ultrasound
• CT abdomen/pelvis
• Electrocardiograph (ECG)
• Echocardiogram

Management of sepsis, severe sepsis and septic shock
Multidisciplinary approach under a senior obstetrician in consultation with an
anaesthetist and microbiologist.
1. Antibiotics
Should be started within 1 hour (‘Golden hour’) after obtaining culture specimens
Where the organism is unknown in Sepsis, and the woman has delivered:
• Co-amoxiclav 1.2g / 8 hourly IV + Clindamycin 1.2g/ IVI / QID if GAS suspected
In cases of allergy to penicillin and cephalosporins:
• Clindamycin 1.2g / IVI / QID + Ciprofloxacin 400mg / IV / BD
In severe sepsis or septic shock add Gentamicin 5 - 7mg/Kg / IV / OD
Seek advice from consultant microbiologist as soon as possible regarding initial empirical
intravenous antibiotic therapy.
2. Commence high flow O2 to maintain SpO2> 94%
3. Fluid Resuscitation
If hypotensive give bolus of Hartmann’s 20ml/kg up to a max of 60ml/kg.
Aim for MAP >65
If BP does not improve inform ITU anaesthetist- vasopressors may be required
4. Monitoring
Monitoring should take place on labour ward or ITU as appropriate after consultation with
anaesthetist. Hourly observations- temperature, pulse rate, blood pressure and respiratory rate)
should be recorded on a modified early obstetric warning score (MEOWS) chart. The patient
should be catheterised and hourly urine output should be measured.
More intensive monitoring may be required for patients with severe sepsis/shock.
5. Analgesia
Paracetamol or opioid analgesia is appropriate.
NSAIDs should be avoided for pain relief in cases of sepsis as they impede the ability of
polymorphs to fight GAS infection, and may impair renal function.
6. VTE prophylaxis
TED stockings and prophylactic dalteparin (with caution if coagulopathic) as per guidline
7. Surgical management
Surgical management should be considered in the following patients:
Wound /Pelvic abscesses may need surgical drainage.
ERPC if sepsis thought to be due to retained products- if clinically appropriate should have
antibiotics for 24 hours before procedure to reduce complication rate.
Wide debridement for necrotising fasciitis may be considered after liaison with surgical team.

Patients requiring ongoing fluid support above 60ml/kg may require central venous
monitoring on ITU
• Evidence of > 1 organ dysfunction
• Hypotension or raised serum lactate persisting despite fluid resuscitation – may
require inotropic support
• Respiratory compromise
• Renal failure
• Significantly decreased conscious level
• Condition not improving despite treatment
The decision for transfer to ITU will be taken after discussion with the anaesthetist.
If there are concerns about the patient’s condition outwith the above criteria the on call
anaesthetist should be consulted.

SSC Hour-1 Bundle of Care Elements:
•Measure lactate level*
•Obtain blood cultures before administering antibiotics.
•Administer broad-spectrum antibiotics.
•Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4
mmol/L.
•Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP
≥ 65 mm Hg- involve anaesthetist for this
* Re-measure lactate if initial lactate is elevated (> 2 mmol/L)

Antenatal

Pyrexia

• If site of infection clear, treating with appropriate antibiotics as seen below.
• If the source of infection is not clear, and suspicion of COVID-19, patient should be isolated until confirmatory test results are negative. See COVID guidance.
• Microbiology input to discuss management and treatment options.

UTI

• Mild: Cephalexin 250mg QDS PO 7 days
• Unwell or pylonephritis: cefuroxime 750mg TDS IV +/- gentamicin 5mg/kg/day

Intrapartum

Chorioamnionitis

• Cefuroxime 750mg TDS IV and metronidazole 500mg TDS IV
• Consider addition of clindamycin IVI if Group A strep suspected
• If penicillin allergic: Clindamycin 900mg IVI loading then 600mg 6 hourly
• Consider urgent delivery if chorioamnionitis suspected and delivery is not imminent

GBS (Group B Streptococcus)
• Benzyl Penicillin 3g IV loading then 1.5g 4hourly until delivery
• Penicillin allergic: Clindamycin 900mg IVI loading then 600mg 6 hourly

For more details see Obstetric Guidelines / Antenatal and LW / Group B Strep Endocarditis prophylaxis

• Labour: amoxicillin 1g 6 hourly until delivery + gentamicin 1.5mg/kg (max 120mg) over 2mins
• If penicillin allergic: vancomycin (see antimicrobial policy for dose) + gentamicin 1.5mg/kg (max 120mg) over 2mins

For more details see Obstetric Guidelines / Antenatal and LW / Endocarditis

Post Natal

Caesarean Section or Forceps Delivery in Theatre

• Cefuroxime 1.5g and metronidazole 500mg IV, both given at start of procedure
• If penicillin allergic: clindamycin 600mg IVI

For more details see Obstetric Guidelines / General / Theatre

Manual Removal Of Placenta

• Co-amoxiclav 1.2g IV one off dose only in theatre, no further PO doses
• If penicillin allergic: Clindamycin 600mg IVI one off dose only in theatre, no further PO doses

For more details see Obstetric Guidelines / Postnatal / Third Stage of Labour 3rd degree tear

• Co-amoxiclav 1.2g IV in theatre followed by 5/7 co-amoxiclav 625mg TDS PO
• Penicillin allergic: Clindamycin 300mg PO QID