Maternal Sepsis Management (RCOG 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Maternal Sepsis

   Pregnant or recently delivered patient with signs of infection

   1. ●

      Action

      Recognize Sepsis - MEOWS

      Use modified early warning score for obstetrics

      • Temp >38°C or <36°C
      • HR >100-120 bpm (higher in pregnancy)
      • RR >20-25/min
      • SBP <90 mmHg or MAP <65
      • Altered mental status
      • Fetal tachycardia (if pregnant)
      • Uterine tenderness, foul lochia
      1. ⚠

         Warning

         SEPSIS 6 - Within 1 Hour

         Time-critical interventions

         • 1. HIGH-FLOW OXYGEN (target SpO2 >94%)
         • 2. BLOOD CULTURES before antibiotics
         • 3. IV ANTIBIOTICS within 1 hour
         • 4. IV FLUIDS - 30mL/kg crystalloid
         • 5. LACTATE measurement
         • 6. URINE OUTPUT monitoring (Foley)
         1. ●

            Action

            Empiric Antibiotics

            Broad spectrum, cover likely sources

            • CHORIOAMNIONITIS: Ampicillin 2g IV q6h + Gentamicin
            • ENDOMETRITIS: Clindamycin + Gentamicin (or Amp-Gent)
            • UNKNOWN SOURCE: Pip-Tazo 4.5g IV q6h
            • ADD Clindamycin if GAS suspected (toxin suppression)
            • If penicillin allergy: Vanc + Aztreonam or Meropenem
            1. ◆

               Decision

               Source Control Needed?

               May require procedural intervention

               1. ●

                  Action

                  Source Control Procedures

                  Remove/drain infectious focus

                  • D&C for retained products
                  • Delivery if chorioamnionitis (often indicated)
                  • Wound debridement
                  • Abscess drainage (breast, pelvic)
                  • Hysterectomy if refractory endometritis (rare)
                  • Laparotomy for peritonitis
                  1. ●

                     Action

                     Fetal Considerations (If Undelivered)

                     Continuous monitoring, delivery decisions

                     • Continuous fetal monitoring
                     • Maternal stabilization priority
                     • Delivery may be source control
                     • Consider GA at time of delivery decision
                     • Steroids if preterm and time permits
                     1. ✓

                        Outcome

                        Outcome

                        Recovery with appropriate treatment

                        • Most patients recover with prompt treatment
                        • Complete antibiotic course (typically 7-14 days)
                        • Debrief and document
                        • Counsel on signs of recurrence
               2. ◆

                  Decision

                  Septic Shock?

                  Hypotension despite fluids, elevated lactate

                  • MAP <65 despite fluid resuscitation
                  • Lactate >2 mmol/L
                  • Need for vasopressors
                  1. ●

                     Action

                     ICU/Critical Care Management

                     For septic shock or organ dysfunction

                     • Vasopressors: Norepinephrine first-line
                     • Central venous access
                     • Arterial line for BP monitoring
                     • Consider stress-dose steroids if refractory shock
                     • Mechanical ventilation if needed
                     • VTE prophylaxis when stable
                  2. ●

                     Action

                     Ongoing Monitoring

                     Track response to treatment

                     • Vitals q1-2h initially
                     • Serial lactate (target clearance)
                     • Urine output >0.5 mL/kg/hr
                     • Daily CBC, CRP, procalcitonin
                     • Reassess antibiotics at 48-72h (culture results)
         2. ●

            Action

            Identify Source

            Common sources in obstetric sepsis

            • GENITAL TRACT: Chorioamnionitis, endometritis, wound infection
            • URINARY: Pyelonephritis, UTI
            • BREAST: Mastitis, breast abscess
            • RESPIRATORY: Pneumonia
            • Consider: retained products, septic pelvic thrombophlebitis
      2. ⚠

         Warning

         ⚠️ Group A Strep (GAS)

         Can be rapidly fatal - high vigilance

         • Can progress to death in hours
         • Presents with sore throat, rash, diarrhea
         • Early shock disproportionate to signs
         • ADD CLINDAMYCIN (suppresses toxin)
         • Consider IVIG in refractory cases