⚡ Maternal Sepsis
1 RECOGNIZE
- Suspected infection with new organ dysfunction: hypotension, altered mental state, oliguria, hypoxaemia, lactate elevation or coagulopathy. Fever can be absent.
- Examine for uterine tenderness/foul lochia or retained tissue, urinary infection, pneumonia, wound infection or another source; obstetric early-warning tools support but do not replace assessment.
2 CALL FOR HELP
- Activate maternal-sepsis response, senior obstetrician, anaesthesia/critical care and infection/microbiology support; state whether shock is present.
- Identify an urgent source-control need and prepare theatre/imaging/intervention in parallel.
3 IMMEDIATE ACTION
- Measure lactate, obtain appropriate cultures and bloods BEFORE antibiotics only if doing so causes no substantial delay. Give empiric broad-spectrum IV antibiotics ideally within 1 h for septic shock/high-likelihood sepsis.
- Select treatment for the suspected source, allergies, renal function and local resistance. The complete cards below show named obstetric-infection combinations, not a claim that one antibiotic treats every maternal sepsis source: chorioamnionitis uses ampicillin PLUS gentamicin; postpartum endometritis may use clindamycin PLUS gentamicin; septic miscarriage needs broad anaerobic cover and evacuation.
- For hypotension/hypoperfusion, give balanced crystalloid with frequent response/tolerance checks. SMFM recommends 1–2 L in the first 3 h; NICE NG255 uses 500 mL boluses over <15 min with reassessment and consultant review if two boluses fail. Do not apply an automatic unmonitored 30 mL/kg prescription in pregnancy.
- If shock persists or fluids are poorly tolerated, start norepinephrine with critical-care supervision, using the explicit salt/concentration/pump calculation below. Catheterise and track hourly urine output; assess oxygenation and perfusion continuously.
Drug doses & preparation
Choose the regimen for the stated indication. Alternatives are not instructions to give every medicine. Check prior doses, contraindications, concentration and the response before repeating.
Ampicillin — chorioamnionitis componentMinistry of Health Malaysiachecked
Dose2 g
RouteIV infusion
FrequencyEvery 6 hours
DurationContinue through birth with postpartum review; the cited Malaysian NAG continues until afebrile/asymptomatic ≥48 h. Other national protocols shorten postpartum treatment after clinical recovery
PreparationReconstitute the actual vial per label; dilute each adult dose in 100 mL sodium chloride 0.9% or glucose 5% and infuse over 30 min. Use a separate line/flush from gentamicin
Max dose8 g/day in this 2 g every-6-h regimen; renal impairment requires adjustment
- Indication: Intra-amniotic infection, in combination with gentamicin; add anaerobic cover for caesarean according to the chosen guideline
- This is not GBS prophylaxis and is not ampicillin monotherapy. The postpartum duration differs between guidelines; record the local choice explicitly.
Monitoring
- Temperature, pulse, BP, uterine tenderness, fetal heart rate, cultures and renal function
Contraindications: Penicillin anaphylaxis; check severe delayed beta-lactam reactions
Gentamicin — obstetric infection componentMSFchecked
Dose5 mg/kg using the approved aminoglycoside dosing weight
RouteIV infusion
FrequencyEvery 24 h initially if renal function allows; subsequent interval depends on drug levels and renal function
DurationDaily review; limit unnecessary exposure, stop or narrow after source control and clinical recovery. Duration follows the infection, not a universal 48–72 h rule
Preparation40 mg/mL stock: volume in mL = prescribed mg ÷40. Dilute the adult dose in 100 mL sodium chloride 0.9%/glucose 5%; infuse over 30 min. Use a separate line/flush from beta-lactams
Max doseWeight-based; do not apply total body weight uncritically in obesity. Withhold/review further doses for accumulating levels or renal deterioration
- Indication: Combination therapy for chorioamnionitis, postpartum endometritis or septic miscarriage
- Renal / hepatic: Adjust interval/dose to renal function and measured levels; do not keep automatic daily dosing in AKI
Monitoring
- Baseline and serial creatinine/urine output; drug-level monitoring using the hospital once-daily schedule
- Ask about tinnitus, hearing change or vertigo; stop and review suspected ototoxicity
Contraindications: Aminoglycoside allergy; myasthenia gravis, AKI, prior auditory/vestibular toxicity require specialist assessment
Metronidazole — obstetric anaerobic coverMSFchecked
Dose500 mg
RouteIV infusion
FrequencyEvery 8 hours
DurationReview daily and switch to oral when feasible; duration is source-specific: uncomplicated infection recovery versus septic miscarriage (10–14 days in Malaysian NAG)
PreparationReady-to-use 500 mg/100 mL (5 mg/mL) bag infused over 30 min; do not add other drugs to the bag
Max dose1.5 g/day in this regimen; severe hepatic impairment requires reduction
- Indication: Combination treatment of selected septic miscarriage/endometritis or caesarean chorioamnionitis
- Renal / hepatic: In severe hepatic impairment the cited MSF monograph reduces the daily dose to one third
Monitoring
- Clinical response, LFTs in prolonged treatment, interacting anticoagulants and neuropathy with prolonged exposure
Contraindications: Nitroimidazole allergy; severe hepatic impairment requires a reduced regimen
Clindamycin — endometritis componentMinistry of Health Malaysiachecked
Dose900 mg
RouteIV infusion
FrequencyEvery 8 hours
DurationContinue until clinical improvement and afebrile for 24–48 h in the cited NAG regimen; persistent fever needs source reassessment
Preparation150 mg/mL concentrate: 900 mg =6 mL; dilute in compatible IV fluid and infuse over at least 30 min (not IV push)
Max dose2700 mg/day in this regimen
- Indication: Postpartum endometritis, in combination with gentamicin when appropriate
Monitoring
- Temperature, uterine tenderness, renal function/gentamicin levels for the partner drug; diarrhoea/C. difficile risk
Contraindications: Clindamycin allergy; previous severe antibiotic-associated colitis requires assessment
Norepinephrine (noradrenaline) — MSF peripheral protocolMSFchecked
DoseStart 0.1 microgram/kg/min of NOREPINEPHRINE TARTRATE; increase by 0.05 microgram/kg/min as required
RouteIV infusion pump through a suitable monitored large vein
FrequencyContinuous infusion; MSF reassessment/titration every 10 min initially
DurationUntil perfusion and BP recover; taper gradually, do not stop abruptly
PreparationFor the cited stock 8 mg TARTRATE/4 mL (=4 mg BASE/4 mL): 2 mL contains 4 mg tartrate. Add 38 mL compatible fluid for FINAL 40 mL =100 micrograms TARTRATE/mL. Rate = dose × kg ×60 ÷100 mL/h; at 70 kg and 0.1, rate=4.2 mL/h
Max doseMSF peripheral protocol ceiling 1 microgram/kg/min TARTRATE; persistent/escalating shock requires ICU and central/arterial access planning
- Indication: Persistent shock while fluid responsiveness/source control are addressed; first-line vasopressor in maternal septic shock
Monitoring
- Continuous ECG, frequent BP (arterial when possible), perfusion and urine output; inspect peripheral site frequently for extravasation
- Clearly label SALT versus BASE: this MSF tartrate dose is twice the numerical BASE dose; NEVER copy its pump rate into a base-labelled concentration
Contraindications: Correct hypovolaemia in parallel; vasopressors do not replace haemorrhage control/blood replacement · Extravasation threatens tissue; use a dedicated monitored line, not an unobserved small distal cannula
4 INVESTIGATIONS (never delaying treatment)
- Blood cultures, lactate, CBC/platelets, renal/electrolytes, LFTs, coagulation and blood gas; repeat lactate to assess trajectory.
- Urine, genital/wound or respiratory samples as appropriate; ultrasound/CT/MRI according to the suspected source and clinical urgency.
5 DEFINITIVE MANAGEMENT
- Rapidly remove/control the source: evacuate infected retained tissue, drain an abscess, debride an infected wound or relieve urinary obstruction when indicated.
- If the uterus is the suspected/confirmed source, prompt delivery/evacuation may be needed regardless of gestation (SMFM); sepsis alone from another source is not an automatic indication for delivery.
- Review antibiotics when microbiology and the clinical response are available, usually within 24–48 h: narrow, adjust renal dosing, stop unnecessary partners and record the total course for the actual infection. Persistent fever/shock requires a search for uncontrolled source or resistant organisms.
6 ESCALATION
- Persistent hypotension, escalating vasopressor need, respiratory failure, altered consciousness, rising lactate or organ dysfunction: ICU immediately.
- Assess need for ventilation, renal support and obstetric surgery without waiting for a complete test panel.
7 POST-EVENT CARE
- Follow organ recovery, glycaemia, fluid balance and medication toxicity; reassess thromboprophylaxis when bleeding/neuraxial constraints permit.
- Document a specific antibiotic stop/review date and provide post-sepsis physical/psychological follow-up and counselling.
Admission & discharge after the acute event
Care setting: Emergency hospital admission; organ dysfunction may require critical care
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit suspected sepsis, hypotension, respiratory compromise, altered mental state, oliguria or inability to maintain intake. Arrange urgent source control and appropriate organ support.
When clinic, day care or home care may be suitable
- Suspected maternal sepsis with systemic illness is not a routine outpatient antibiotic prescription. A localised infection without sepsis may follow its own outpatient pathway after assessment.
Before going home
- The source has been controlled or has a definitive plan; haemodynamics/respiratory function and organ trends support care outside hospital.
- No unresolved vasopressor/acute organ-support need; an effective oral regimen or a formally supported outpatient IV service is arranged if antibiotics remain necessary. Persistent fever or deterioration needs reassessment.
Discharge medicines and treatment changes
- Reconcile cultures with the actual infection diagnosis; give the selected antibiotic’s dose, route, remaining duration and stop/review date. Do not prescribe every sepsis example combination together.
Tests, pending results and their reviewer
- Assign a named reviewer and action plan for pending cultures, susceptibilities, pathology and abnormal renal/liver/blood results; ensure a patient callback route.
Home care and counselling
- Explain the source, treatment, risk of recurrence and post-sepsis physical/emotional effects. Provide written warning symptoms, 24-hour access and support for infant care if relevant.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before discharge | Book the early clinical/antimicrobial review required by the source and organ injury, with the responsible team. |
At the documented postnatal/post-sepsis review | Review recovery, medicines, outstanding results and any specialist rehabilitation needs. |
Return urgently
- Recurrent fever/rigors, confusion, faintness, breathlessness, reduced urine, worsening abdominal/wound pain or offensive lochia requires immediate reassessment.
Sources
SMFMcheckedNICE · NG255checkedMinistry of Health MalaysiacheckedMSFcheckedMSFcheckedMSFcheckedNICE · CG50, recommendationscheckedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedRCOG · Current public recovery informationchecked