See also: [[Chorioamnionitis]], [[Endometritis]] > [!references]- > - [RWH - Maternal Sepsis Guideline](x-devonthink-item://2D701108-291C-4A64-B4A2-446705787914) > - [Safer Care Victoria - Maternal Sepsis](https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/maternity/maternal-sepsis) > - [RCOG - Bacterial Sepsis in Pregnancy (2012)](x-devonthink-item://458EE655-81F8-4642-B2FF-FCAD33531094) > - [ACOG - intraamniotic infection 2017](https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/intrapartum-management-of-intraamniotic-infection) > - [RANZCOG - prophylactic antibiotics in obstetrics and gynaecology](https://ranzcog.edu.au/wp-content/uploads/Prophylactic-Antibiotics-Obstetrics-Gynaecology.pdf) # Recognition > in general, there is a lower threshold for identifying sepsis in obstetrics than in other adults. This is endorsed by the [CMQCC](https://www.cmqcc.org/toolkits-quality-improvement/sepsis) and the [RWH](x-devonthink-item://2D701108-291C-4A64-B4A2-446705787914) Maternal Sepsis Guideline. ***Step 1: Sepsis Screen***: 2 more more warning signs may be sepsis - Temp <36 or >38? - RR >24/min sustained for 15 min - HR >110 sustained for 15 min - WCC >15 or <4 or >10% immature neutrophils (bands) **Start doing all the usual "septic screen" stuff**, give abx and fluid resus if SBP <90 if not in labour (and consider maternal cardioplegia/cardiomyopathy as well!) unique sepsis screen in obstetrics: - high vaginal , low vagina, endocervical swab for mcs +/- STI PCR - breast milk m/c/s ***Step 2: Confirmation of Sepsis*** > Confirmation if 1 more more are met: | Measure | Criteria | | ------------ | --------------------------------------------------------------------------------------- | | Respiratory | - Acute resp failure <br>- PaO2/FiO2 <300 | | Coagulation | - Plt <100<br>- INR > 1.5<br>- PTT > 60s | | Liver | Bili > 30 | | Cardio | - Persistent hypotension after fluids<br>- SBP < 85<br>- MAP <65<br>- >40 mmHG ↓ in SBP | | Renal | - Cr > 100<br>- doubling of Cr<br>- urine output < 0.5mL/kg/h x2 hours | | Mental state | agitation, confusion, or obtundation | | Lactic acid | >2 mmol/L in the absence of labour | ## DDx *pretty much any cause of sepsis, with specific emphasis on obstetric causes:* - septic abortion / retained products of conception - [[Chorioamnionitis]] / [[Endometritis]] - mastitis Other: - pneumonia/influeza - pyelonephritis - [[Sepsis#Toxic Shock syndrome|Toxic Shock Syndrome]] - appendicitis - wound infection > E coli most common cause of maternal bacterial infections and need coverage for [[Chorioamnionitis]] with aminoglycocide . Invasive Group A strep infection is the most frequent cause of maternal *death* from sepsis. ## Management ### Emperic Antibiotic recommendations maternity / Post-Partum | Indication | No penicillin allergy | Non-Severe <br>penicillin hypersensitivity | Severe Penicillin allergy | | ------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------ | ----------------------------------------------- | ----------------------------------------- | | Community-acquired sepsis <br>(source NOT apparent) | - gentamicin, then<br>- amoxicillin 2g Q6H, then<br>- metronidazole 500mg Q12H | - gent<br>- cefazolin 2g Q6H<br>- metronidazole | - gent, then<br>- clindamycin 600mg Q8H | | hospital-acquired sepsis<br>(source not known) | - pip-taz 4.5g Q6H | - gent<br>- cefazolin<br>- metronidazole | - gent<br>- vancomycin<br>- metronidazole | | [puerperal](https://www.ncbi.nlm.nih.gov/books/NBK560804/) (antenatal and post-natal resulting from genitourinary tract) sepsis | - gent<br>- amoxicillin 2g <br>- metronidazole | - ceftriaxone 1g<br>- metronidazole | - gent<br>- clinda | ***Additional Abx considerations*** - Risk of group a strep/ toxic shock → Add clinda and consider **IVIG** 1-2g/kg IV for up to 2 doses during first 72 hours - Septic shock → consider adding vanc if at risk of MRSA, clinda - suspected neisseria meningitidis → ceftriaxone 2g - pt with prior multi-resistant gram negative eg carbapenem-resistant organisms, ESBL, multi-resistant organsmss or contact with an overseas healthcare facility in prior 12 months → replace all emperic abx with single meropenem IV 2g Q8H