Obstetrics & Gynaecology
Maternal Sepsis: Red Flags, omSOFA, Hour-1 Bundle & Antibiotics
Contents
Maternal sepsis in one place: how to recognise it when pregnancy hides the early signs, what to do in the first hour, and which antibiotics cover what. Based on the OLSS (Obstetric Life Saving Skills) lecture on maternal sepsis at Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, which draws on the RCOG Green-top Guideline No. 64 and the OGSM Handbook of Obstetric Emergencies.
Definitions
- Maternal sepsis (WHO): a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or the postpartum period. Infection alone is not sepsis: sepsis = infection + organ dysfunction.
- Septic shock: sepsis with persisting hypotension needing vasopressors to keep MAP ≥65 mmHg, plus a persistent serum lactate (venous or arterial) >2 mmol/L despite adequate volume resuscitation.
- Puerperal sepsis: infection of the genital tract at any time between the onset of labour (or rupture of membranes) and the 42nd day postpartum.
Why it matters
- Sepsis and septic shock are medical emergencies, and sepsis is a leading preventable cause of maternal death, with a mortality of about 11%.
- About 50% of maternal sepsis is puerperal sepsis.
- It is the 6th leading cause of maternal death in the UK; in Malaysia, 13 mothers died of it in 2015-2017.
Pregnancy masks the early signs
| Normal pregnancy | May mimic or mask sepsis |
|---|---|
| Heart rate increased | Tachycardia |
| Respiratory rate increased | Tachypnoea |
| White cell count increased | Leucocytosis |
| BP slightly reduced | Hypotension may appear late |
| Mild respiratory alkalosis | Alters blood gas interpretation |
Always ask: could this be sepsis?
Sources of infection
| Period | Examples |
|---|---|
| Antenatal | Pyelonephritis / UTI, chorioamnionitis, influenza, COVID |
| Intrapartum | Chorioamnionitis, PROM |
| Postpartum | Endometritis, caesarean wound or other surgical site infection, mastitis, UTI |
Sites outside the genital tract to remember:
| Site | Infection |
|---|---|
| Head | Meningitis, meningoencephalitis |
| Ear, nose, throat | Otitis media, sinusitis, pharyngitis / laryngitis |
| Chest | Pneumonia |
| Cardiac | Infective endocarditis |
| Hepatobiliary | Cholecystitis / cholangitis |
| Abdomen | Gastroenteritis, appendicitis |
| Breast | Mastitis |
| Urinary tract | UTI, pyelonephritis |
| Regional anaesthesia | Meningitis, spinal abscess |
| Wounds | Cannula thrombophlebitis, caesarean or episiotomy wound |
| Soft tissue | Early necrotising fasciitis |
Common organisms: group B streptococcus (GBS), group A streptococcus (GAS), E. coli, Streptococcus pneumoniae, MRSA, Acinetobacter, Pseudomonas aeruginosa, Clostridium and Morganella.
Remark: UTI = urinary tract infection; PROM = prelabour rupture of membranes; MRSA = methicillin-resistant Staphylococcus aureus.
Risk factors
| Before pregnancy | In pregnancy |
|---|---|
| Obesity | Unsafe abortion |
| Diabetes | Pelvic infection or vaginal discharge |
| Immunosuppression | Group B streptococcus infection |
| Anaemia | Genital tract trauma |
| Immigrants | Amniocentesis or chorionic villus sampling |
| Low socio-economic status | Cervical cerclage |
| Caesarean section | |
| Retained products of conception | |
| Premature rupture of membranes |
Clinical features
- General: fever, rigors, rash, dehydration, lethargy, loss of appetite.
- Respiratory: productive cough.
- Abdominal: abdominal pain, diarrhoea, vomiting.
- Urinary: dysuria, frequency, loin tenderness.
- Pelvic: pelvic pain and tenderness, delayed involution of the uterus, vaginal discharge or heavy lochia.
Red flags
| Sepsis | Severe sepsis |
|---|---|
| Temperature >38°C or <36°C | Altered mental status |
| Heart rate >120 bpm | Systolic BP <90 mmHg |
| Respiratory rate >22/min | SpO₂ <90% |
| Leucocytosis or leucopenia | Urine output <0.5 mL/kg/h |
| CRP >7 mg/L | Decreased capillary refill |
| Lactate >4 mmol/L | Creatinine >178 µmol/L |
| Procalcitonin >0.25 ng/mL may suggest bacterial infection | INR >1.5 |
| Bilirubin >34 µmol/L |
The lecture also lists the high-risk features that call for immediate management (start the sepsis bundle in hospital, or blue-light transfer from the community): GCS <15, respiratory rate >25, SpO₂ <94%, systolic BP <90, heart rate >130, and anuria or urine output <0.5 mL/kg/h.
Remark: CRP = C-reactive protein; INR = international normalised ratio; GCS = Glasgow Coma Scale.
Scoring: MEOWS and omSOFA
- MEOWS (Modified Early Obstetric Warning Score) chart: use it for every obstetric patient to pick up deterioration early.
- omSOFA (obstetrically modified SOFA): six organ systems scored 0-2. An acute rise of 2 or more points with documented or suspected infection confirms obstetric sepsis.
| Parameter | 0 | 1 | 2 |
|---|---|---|---|
| Respiration: PaO₂/FiO₂ | ≥400 | 300-400 | <300 |
| Coagulation: platelets ×10⁹/L | ≥150 | 100-150 | <100 |
| Liver: bilirubin (µmol/L) | ≤20 | 20-32 | >32 |
| Cardiovascular: MAP (mmHg) | ≥70 | <70 | Vasopressors required |
| Central nervous system | Alert | Rousable by voice | Rousable by pain |
| Renal: creatinine (µmol/L) | ≤90 | 90-120 | >120 |
Use the omSOFA calculator, and the obstetric shock index for haemodynamics.
Remark: MAP = mean arterial pressure; PaO₂/FiO₂ in mmHg.
Who needs ICU
- Cardiovascular: hypotension or a raised lactate despite fluid resuscitation, suggesting the need for inotropes.
- Respiratory: pulmonary oedema, mechanical ventilation, airway protection.
- Renal: needing dialysis.
- Neurological: decreased conscious level.
- Others: multi-organ failure, uncorrected acidosis, hypothermia.
Management: hour-1 bundle
Start with ABCDE: airway; breathing (oxygen); circulation (IV access, bloods, fluids); disability (GCS, glucose); exposure (look for the source). Treat while you investigate.
Surviving Sepsis Campaign hour-1 bundle:
- Measure lactate; re-measure (within 1 hour) if the first level is >2 mmol/L.
- Take blood cultures before antibiotics, but do not delay the antibiotics.
- Give broad-spectrum antibiotics.
- Give 30 mL/kg crystalloid rapidly for hypotension or lactate ≥4 mmol/L.
- Start vasopressors (norepinephrine) if she is hypotensive during or after fluid resuscitation, to keep MAP ≥65 mmHg.
Antibiotic choices
| Antibiotic | Coverage and limitations |
|---|---|
| Co-amoxiclav (e.g. Augmentin) | Does not cover MRSA, Pseudomonas or ESBL producers. Risk of NEC |
| Metronidazole | Anaerobes only. Can be combined with a cephalosporin if chorioamnionitis is suspected |
| Cefuroxime (cephalosporin) | Covers beta-haemolytic streptococci including GAS and GBS (not enterococci). Associated with C. difficile infection |
| Clindamycin | Covers most streptococci and staphylococci, including MRSA, and switches off exotoxin production. Not nephrotoxic. Increased risk of C. difficile superinfection |
| Piperacillin-tazobactam (Tazocin) | Covers most organisms except MRSA. Renal sparing (unlike aminoglycosides). Does not cover ESBL producers |
| Gentamicin, single dose 3-5 mg/kg | Mainly Gram-negative cover, including most Pseudomonas. No streptococcal or anaerobic cover. Needs level monitoring if given regularly. Nephrotoxic and ototoxic |
| Carbapenem | Very broad: most Gram-negatives (including most ESBL producers) and anaerobes, and most Gram-positives except MRSA. CPE are resistant |
| Vancomycin | Covers MRSA; GBS prophylaxis if allergic to penicillin. No Gram-negative cover. IV only (except for C. difficile). Nephrotoxic and ototoxic: monitor levels. Rapid infusion causes "red man syndrome" |
Remark: ESBL = extended-spectrum beta-lactamase; NEC = necrotising enterocolitis; CPE = carbapenemase-producing Enterobacteriaceae; C. difficile = Clostridioides difficile.
Supportive care
- Fetus: CTG monitoring; antenatal corticosteroids for lung maturity if delivery is anticipated (unless in septic shock).
- Find and control the source, with imaging as indicated, and take appropriate cultures.
- Sepsis by itself is not an indication for delivery, except with chorioamnionitis.
- Feed early; give VTE prophylaxis (TED stockings, LMWH); control glucose.
- Use prognostic tools (modified SOFA, NEWS, SIRS) and MEOWS, and manage with a multidisciplinary team.
- Consider low-dose steroids (hydrocortisone 200 mg/day as a continuous infusion) if there is no response to norepinephrine.
- Consider packed cell transfusion if Hb <7 g/dL.
- Consider de-escalating antibiotics after 48 hours if cultures are negative and she is clinically well.
- Infection prophylaxis for the neonate and for healthcare staff.
Remark: CTG = cardiotocography; VTE = venous thromboembolism; TED = thromboembolic deterrent; LMWH = low-molecular-weight heparin; NEWS = National Early Warning Score; SIRS = systemic inflammatory response syndrome.
Prevention
- Antenatal screening for asymptomatic bacteriuria, and STD screening in women at risk.
- Antibiotics for surgical management of miscarriage and termination of pregnancy.
- Vaginal examinations and delivery in sterile conditions, with antiseptic for vaginal examinations and skin preparation before surgery.
- Active management of PROM / SROM, and GBS screening in PPROM.
- IV broad-spectrum antibiotics within 30 minutes before caesarean section, and within 3 hours of operative childbirth.
Remark: STD = sexually transmitted disease; SROM = spontaneous rupture of membranes; PPROM = preterm prelabour rupture of membranes.
Sources
- Obstetric Life Saving Skills (OLSS) lecture: Maternal Sepsis. Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, 2026.
- Royal College of Obstetricians and Gynaecologists. Identification and management of maternal sepsis during and following pregnancy. Green-top Guideline No. 64, as cited in the lecture.
- Obstetrical and Gynaecological Society of Malaysia (OGSM). Handbook of Obstetric Emergencies (ICOE), as cited in the lecture.