M8Fever, maternal sepsis, antimicrobials and source control

Clinical overview

Maternal sepsis is life-threatening organ dysfunction caused by infection during pregnancy, after abortion, intrapartum or postpartum. Fever supports the diagnosis but is not required. Hypothermia, confusion, tachypnoea, oliguria, hypoxaemia, hypotension, thrombocytopenia, coagulopathy, AKI or rising lactate may be the presenting signal. Treat sepsis and septic shock as medical emergencies: resuscitation, antimicrobials and source control begin together.

South African practice must consider genital-tract and surgical infection alongside pneumonia, pyelonephritis, malaria or other travel/exposure disease, HIV-associated infection and TB. The likely organisms, resistance and available medicines vary by facility; a fixed international antibiotic table is unsafe. Use the current NDoH STG/EML, local antibiogram and microbiology advice, with pregnancy, renal/hepatic function, allergy and recent exposure considered.

Core knowledge

Infection, inflammation and organ dysfunction

Inflammation is not synonymous with infection. Fever may follow transfusion, medicines, thromboembolism, tissue injury, pancreatitis, thyroid storm or intracranial disease. Conversely, severe infection may present without fever, especially after antipyretics, with immune compromise or late shock. Obtain a focused history and examination while treating a high-probability life threat.

Treat fever for comfort, extreme temperature and excessive metabolic demand, while treating the cause. Paracetamol can be used within safe total dosing when hepatic function allows; physical cooling is appropriate for severe hyperthermia. Routine aggressive antipyresis has not been shown to reverse septic organ dysfunction, and a lower temperature after medicine does not confirm a benign illness or adequate source control. Avoid NSAIDs when renal injury, bleeding, hypertensive disease, gestational risk or another contraindication is present.

Pregnancy’s higher heart rate, lower PaCO₂ and physiological leucocytosis reduce the specificity of traditional SIRS criteria. Do not use SIRS or qSOFA as a sole screen. An obstetric early-warning system and clinician concern should trigger evaluation; suspected/confirmed infection plus otherwise unexplained organ dysfunction should trigger sepsis management.

Sepsis causes vasodilatation, endothelial dysfunction, capillary leak, altered microcirculatory flow and sometimes myocardial depression. The patient may be intravascularly underfilled yet prone to pulmonary oedema. Fluid must be titrated dynamically and vasopressors started early when tone remains inadequate.

Tap to enlarge

Figure M8.1 — Maternal sepsis couples infection-driven endothelial activation with vasodilatation, capillary leak, maldistributed microflow and myocardial depression; organ dysfunction may occur without fever, while intravascular underfilling and pulmonary congestion can coexist.

Find the source

Common sources and required source-control questions include:

• Septic abortion/retained infected tissue: is urgent uterine evacuation required?
• Chorioamnionitis/intra-amniotic infection: is delivery required for maternal source control, and what is the safest route?
• Postpartum endometritis or retained products: is evacuation, imaging or drainage needed?
• Caesarean/perineal wound infection: is there collection, dehiscence or necrotising infection requiring surgery?
• Pyelonephritis/infected obstruction: is ultrasound/imaging needed and does an obstructed system require urgent drainage?
• Pneumonia/aspiration: is respiratory support, pleural drainage or TB/influenza/COVID-directed care needed?
• Intra-abdominal infection: is there perforation, appendicitis, cholecystitis, bowel injury or collection requiring operation/drainage?
• Line/device infection: can the device be removed or exchanged safely?