Introduction

The World Health Organization defines puerperal sepsis as ‘infection of the genital tract occurring at any time between the onset of the rupture of membranes or labor and the 42nd day postpartum’.

Sepsis in the puerperium is still an important cause of maternal morbidity and mortality.

In the UK, according to the 2012–14 maternal mortality report, it accounts for 10 deaths per year.¹

Globally, puerperal sepsis is a major cause of maternal death and accounts for 15 per cent of all maternal deaths in developing countries. It is also a major cause of morbidity (long-term health problems, e.g. chronic pelvic pain, chronic pelvic inflammatory disease (PID) and infertility.²

Severe sepsis with acute organ dysfunction has a mortality rate of 20–40 per cent, rising to around 60 per cent if septicaemic shock develops.

In the UK, 2012–14 maternal mortality report, direct sepsis (genital tract sepsis and other pregnancy-related infections) and indirect sepsis (influenza, pneumonia, others) accounted for seven maternal deaths, being the second cause of maternal mortality after cardiac disease.

Definitions

SEPSIS:

infection plus systemic manifestations of infection.

SEVERE SEPSIS:

sepsis plus sepsis-induced organ dysfunction or tissue hypo perfusion.

SEPTIC SHOCK:

the persistence of hypoperfusion despite adequate fluid replacement therapy.³

Risk Factors

Signs and Symptoms

• 
  

  Fever (temperature of 38°C or more), rigours

  
  
• 
  

  Chills

  
  
• 
  

  General malaise

  
  
• 
  

  Lower abdominal pain, pelvic tenderness

  
  
• 
  

  Tender sub-involuted uterus

  
  
• 
  

  Purulent, foul-smellinglochia

  
  
• 
  

  Light vaginal bleeding

  
  
• 
  

  Diarrhoea or vomiting – may indicate exotoxin production (early toxic shock)

  
  
• 
  

  Wound infection – spreading cellulitis or discharge

  
  
• 
  

  General – non-specific signs such as lethargy

  
  
• 
  

  Reduced appetite

  
  
• 
  

  Shock

Differential Diagnosis

• 
  

  Urinary tract infection (acute pyelonephritis)

  
  
• 
  

  Surgical site infection

  
  
• 
  

  Mastitis or breast abscess

  
  
• 
  

  Thromboembolic disorders, e.g. thrombophlebitis or deep vein thrombosis

  
  
• 
  

  Respiratory tract infections (pneumonia)

  
  
• 
  

  Extragenital infections: gastroenteritis, pharyngitis, bacterial meningitis

  
  
• 
  

  Other infections, such as malaria and typhoid

  
  
• 
  

  HIV-related infections

Infecting Organisms

• 
  

  Streptococci

  
  
• 
  

  Staphylococci

  
  
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  Escherichia coli (E. coli)

  
  
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  Clostridium tetani

  
  
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  Clostridium welchii

  
  
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  Chlamydia

  
  
• 
  

  Gonococci

  
  
• 
  

  Tetanus

Warning Signs and Symptoms of Puerperal Sepsis

Warning signs and symptoms should prompt need for early medical attention and urgent referral for hospital assessment:

1. 
   

   1. Woman appears seriously unwell, by emergency ambulance

   
   
2. 
   

   2. Pyrexia more than 38°C

   
   
3. 
   

   3. Sustained tachycardia more than 90 beats/minute

   
   
4. 
   

   4. Breathlessness (respiratory rate more than 20 breaths/minute; a serious symptom)

   
   
5. 
   

   5. Abdominal or chest pain

   
   
6. 
   

   6. Diarrhoea and/or vomiting

   
   
7. 
   

   7. Uterine pain and tenderness

   
   
8. 
   

   8. Woman is generally unwell or seems unduly anxious or distressed

Indications for Intensive Care Unit (ICU) Admissions⁴

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  Cardiovascular: hypotension or raised serum lactate persisting despite fluid resuscitation, suggesting the need for inotrope (agents to increase the strength of muscular contraction) support

  
  
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  Respiratory: pulmonary oedema

  
  
• 
  

  Neurological: significantly decreased conscious level

  
  
• 
  

  Miscellaneous multiple organ failure

  
  
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  Uncorrected acidosis

  
  
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  Hypothermia

Diagnosis and Investigations

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