Identification and Management of Maternal Sepsis During and Following Pregnancy

Abstract

The need for such a guideline was originally identified by the 2007 Confidential Enquiry into Maternal Deaths [1]. The scope of this guideline covers the recognition and management of sepsis in the antenatal, intrapartum and postpartum periods, including post-abortion sepsis. The scope includes bacterial infections arising in the genital tract or elsewhere and influenza and their management in secondary care. Sepsis arising due to primary viral (other than influenza and HSV) or parasitic infection is outside the scope of this guideline. There is separate specific guidance available on Coronavirus (COVID-19) infection in pregnancy [2].

This guideline is for healthcare professionals who care for women, non-binary and trans people suspected of, or diagnosed with, sepsis in primary or secondary healthcare. This guideline excludes mild to moderate illness in primary care.

Within this document we use the terms woman and women's health. However, it is important to acknowledge that it is not only women for whom it is necessary to access women's health and reproductive services in order to maintain their gynaecological health and reproductive wellbeing. Gynaecological and obstetric services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth.

Sepsis during and following pregnancy remains an important cause of maternal death globally, accounting for 11% of all maternal deaths [3]. Between 2019–21, 241 of 2 066 997 women giving birth in the UK died. Of these, 78 women died of sepsis, either direct or indirect. Despite a statistically non-significant increase in the overall maternal death rate due to sepsis in the UK between 2016–18 and 2019–21, most of this was accounted for by SARS-COV-2 viral infections in unvaccinated women.

In the UK and Ireland, during or up to six weeks after the end of pregnancy and defined “in the broadest sense as death from a primary infective cause” the overall mortality rate for sepsis was 2.50 per 100 000 maternities (95% CI 1.89–3.25 per 100 000) [1, 4].

Between 2019–21, 10% of all maternal deaths were due to sepsis and 14% of deaths were due to COVID-19 infection [4]. Overall, 47 of the 78 deaths (60%) were attributable to viral infections, 43 due to COVID-19, one varicella zoster virus, one viral myocarditis of unknown cause and two following influenza A [4]. Deaths attributable to influenza A were significantly lower than in the years 2010–12 when 13 women died, reflecting the importance of vaccination. Only one of the 43 women who died from SARS-CoV-2 had been vaccinated, and had only had one dose of COVID-19 vaccine [4].

The number of bacterial sepsis related deaths was significantly higher than in the previous MBRRACE report (2015–2017), [5] where a breakdown of responsible agents was given as 27 deaths overall, 16 classified as ‘direct’ maternal deaths from sepsis and ten due to genital tract sepsis [5]. Excluding SARS-COV-2 deaths, the dramatic decline from an overall figure of 2.04 deaths due to sepsis per 100 000 maternities (data from the 2009–12 MBRRACE report) [6] likely reflects the combination of increasing influenza vaccine uptake, mandatory education of healthcare staff to recognise sepsis and implementation of various sepsis-related guidelines, including the previous edition of this RCOG Green-top Guideline. The National Maternity and Perinatal Audit (NMPA) report examining maternity admissions to intensive care in 2015/2016 highlighted the importance of infection as the second most common cause for admission, after haemorrhage. The most common infections were pneumonia (44%), urinary tract (20.4%) and genital tract infections (18.5%) [7].

Suboptimal care continues to be identified in many cases where women die from sepsis [1, 3, 4]. To reduce maternal death from sepsis requires high levels of vigilance and to “Think Sepsis” at an early stage with any unwell, pregnant or recently pregnant woman. Key actions are the importance of early diagnosis, the rapid initiation of broad spectrum antibiotics and the need for review by senior doctors and midwives and early involvement of relevant experts such as infection specialists and critical care, where appropriate. To avoid preventable deaths the importance of maternal vaccination for influenza and COVID-19 must be continually promoted [2, 4, 5].

Not included in the 2023 MBRRACE report are two women who died of disseminated Herpes Simplex virus (HSV) infection following birth by caesarean section, a very rare cause of sepsis. These cases prompted calls for HSV and other viral infections to be considered when evaluating the cause of postpartum infection, [8] as specified by the Coroner's prevention of future death report on the cases [9].

This RCOG guideline was developed in accordance with standard methodology for producing RCOG Green-top Guidelines [10]. The Cochrane Library and electronic databases (DARE, EMBASE, Trip, MEDLINE and PubMed) were searched using the relevant Medical Subject Headings (MeSH) terms, including all subheadings and synonyms, and this was combined with a keyword search. Search terms included ‘sepsis and pregnancy’, ‘bacterial infection and pregnancy’, ‘antenatal bacterial infection’, ‘bacterial sepsis’, ‘intrapartum septic shock’, ‘intrapartum infection’ and ‘maternal pyrexia’ and the search was limited to humans and English language. The search was restricted to articles published between September 2011 to October 2023.

Where possible, recommendations are based on available evidence. In the absence of published evidence, these have been annotated as ‘good practice points’. Further information about the assessment of evidence and the grading of recommendations may be found in Appendix 1.

The UK Sepsis Trust: support and eduction for the public, patients and their families affected by sepsis and for health care professionals https://sepsistrust.org

Group B Strep Support: offer information and support to families affected by Group B Strep (and their health professionals), during pregnancy and after birth www.gbss.org.uk

The Lee Spark NF Foundation: support and education for those patients and their families with NF or severe streptococcal infections https://nfsuk.org.uk/

The World Health Organisation “STOP SEPSIS” campaign. Resources for health care providers and links to WHO materials on the prevention and management of maternal sepsis. https://srhr.org/sepsis/

D.L. has received Salary support through NIHR Global Health Professorship personal award; grants from the Medical Research Council for the LACTATE study, exploring the diagnostic accuracy of lactate measurement for diagnosis of maternal sepsis in low resource settings and the APT-Sepsis study, a clinical trial to examine clinical and cost effectiveness of APT-Sepsis intervention in Malawi and Uganda. A.B. has declared no conflicts of interest. M.M. has declared no conflicts of interest. D.P. is the Deputy Chair Committee of Infections in Pregnancy, International Federation of Gynaecology and Obstetrics and Chair Elect (2025) Committee of Infections in Pregnancy, International Federation of Gynaecology and Obstetrics. F.P. has received payment for regular reports as expert witness in obstetric anaesthesia for Solicitors, coroners and is a council member of the Royal College of Anaesthetists.