Maternal Sepsis

Learning objectives

After completing this chapter, you should be able to recognize maternal sepsis even without fever; identify common obstetric and nonobstetric sources; detect organ dysfunction; implement the first-hour response; use dynamic assessment for fluids and vasopressors; understand fetal effects; prioritize source control; and determine the safest transport destination.

Opening transport scenario

A 28-year-old patient at 35 weeks presents with flank pain, vomiting, and progressive weakness. Temperature is 37.7°C, heart rate 132/min, BP 88/52 mm Hg, respiratory rate 30/min, and lactate 4.1 mmol/L. She has right costovertebral-angle tenderness and fetal tachycardia. Because she is not febrile, a team member suggests dehydration alone. The transport clinician must recognize suspected infection with organ dysfunction and begin sepsis care without waiting for fever.

1. What maternal sepsis means

Maternal sepsis is infection with organ dysfunction during pregnancy, childbirth, the postabortion period, or postpartum. Fever may be absent, particularly in early infection, immunosuppression, antipyretic use, or advanced shock. A normal pregnancy-associated increase in heart rate or leukocytes should not be used to dismiss a dangerous trend.

2. Common infection sources

3. The first-hour response

SMFM recommends treating maternal sepsis as an emergency. In septic shock or a high likelihood of sepsis, broad-spectrum antimicrobials should begin promptly—ideally within one hour. Obtain cultures before antibiotics when doing so does not create a meaningful delay.

1. Recognize and mobilize: activate obstetric, critical-care, pharmacy, laboratory, and source-control resources.
2. Airway and oxygenation: support ventilation, correct hypoxemia, and anticipate rapid deterioration.
3. Access and tests: obtain blood cultures, source cultures, CBC, metabolic panel, coagulation studies, lactate, blood gas, and other source-directed tests without delaying therapy.
4. Antibiotics: administer an empiric regimen covering likely organisms and source, allergies, prior cultures, and local resistance patterns.
5. Perfusion support: give balanced crystalloid for hypotension or hypoperfusion and reassess dynamically.
6. Source control: drain, debride, evacuate, remove infected material, or deliver when the uterus is the source and obstetric criteria are met.

4. Fluids and dynamic reassessment

SMFM supports an initial 1–2 L of balanced crystalloid during the first three hours for sepsis complicated by hypotension or suspected hypoperfusion, with individualized reassessment. Pregnancy, preeclampsia, renal disease, and cardiac dysfunction increase the risk of pulmonary edema.

• Use small reassessed increments rather than an automatic unlimited volume.
• Trend BP, pulse pressure, capillary refill, mental status, urine output, lactate, lung sounds, oxygen requirement, and bedside cardiac/lung ultrasound when available.
• Consider passive leg raise or other dynamic measures when feasible; static CVP alone is unreliable.
• Stop escalating crystalloid when pulmonary congestion increases or perfusion fails to respond.

5. Vasopressors and refractory shock

Norepinephrine is commonly recommended as the first-line vasopressor in maternal septic shock when hypotension persists after appropriate fluid assessment. Start vasoactive therapy promptly when perfusion remains inadequate; it is not necessary to wait for a large arbitrary fluid volume. Use the best available vascular access while arranging secure central access when needed.

Persistent vasopressor requirement may prompt corticosteroid therapy under critical-care guidance. Refractory shock requires reassessment for hemorrhage, cardiogenic dysfunction, pulmonary embolism, adrenal crisis, medication effect, uncontrolled source, abdominal catastrophe, or mixed shock.

6. Antimicrobial transport principles

• Record the suspected source, exact drugs, doses, infusion start and completion times, allergies, and cultures obtained.
• Verify renal and hepatic function, pregnancy-specific considerations, line compatibility, and the next scheduled dose.
• Carry enough medication and pump power for delay or diversion.
• Do not narrow therapy solely because one early test is negative; de-escalation follows clinical and microbiologic reassessment.
• Communicate any prior multidrug-resistant organism, recent hospitalization, invasive device, or antibiotic exposure.

7. Source control and delivery

Source control is a time-dependent component of sepsis care. When the uterus is the source—such as intra-amniotic infection, infected retained products, or septic abortion—prompt delivery or evacuation may be required. Delivery is not performed merely because sepsis exists; the decision depends on source, gestational age, fetal status, labor, and maternal stability.

8. Fetal assessment

Fetal tachycardia may reflect maternal fever, catecholamines, dehydration, medication, or infection. Minimal variability and decelerations may reflect reduced oxygen delivery. Reposition the mother, correct hypoxemia and hypotension, treat fever and infection, and continuously reassess when gestational age and resources allow.

9. Transport implementation

• Confirm that antibiotics have started and the next dose is known.
• Carry vasopressor, fluids, airway equipment, warming/cooling resources, and laboratory trend data.
• Define hemodynamic targets and escalation triggers with medical direction.
• Choose a receiving center with obstetric surgery, blood bank, critical care, neonatal capability, and source-control resources.
• Provide an en-route update for vasopressor changes, new hypoxemia, rising lactate, oliguria, altered mental status, fetal deterioration, or suspected need for delivery.

10. Evolving case study

Phase 1: Sepsis recognized

Despite temperature below 38°C, the patient has suspected pyelonephritis, hypotension, elevated lactate, tachypnea, and fetal tachycardia. Blood and urine cultures are obtained without delaying broad-spectrum antibiotics.

Phase 2: Shock support

After reassessed balanced crystalloid, BP remains low and crackles begin to develop. Norepinephrine is started rather than continuing unbounded fluid administration.

Phase 3: Destination

Ultrasound suggests obstructed infected hydronephrosis. The receiving plan changes to a center with obstetrics, critical care, and urgent urologic drainage capability.

11. High-yield chapter summary

1. Maternal sepsis is infection with organ dysfunction; fever is not required.
2. Pregnancy physiology can mask or mimic early sepsis.
3. Give broad-spectrum antibiotics promptly—ideally within one hour in shock or high-likelihood sepsis.
4. Obtain cultures first only when they do not meaningfully delay antibiotics.
5. Use lactate and organ-function trends, not one screening score alone.
6. Balanced crystalloid is reassessed dynamically; avoid fluid overload.
7. Norepinephrine is a common first-line vasopressor for persistent septic hypotension.
8. Source control is time dependent.
9. Maternal stabilization is the first fetal intervention.
10. Destination must match source-control and critical-care needs.

References

1. International Board of Specialty Certification. Maternal Fetal Transport Microcredential Candidate Handbook. Updated April 2026.
2. Society for Maternal-Fetal Medicine. Consult Series #67: Maternal Sepsis. Reaffirmed 2025; ACOG endorsed.
3. Alliance for Innovation on Maternal Health. Sepsis in Obstetric Care Patient Safety Bundle.
4. Surviving Sepsis Campaign. International guidelines for management of sepsis and septic shock.