Postpartum Sepsis

Postpartum sepsis is life-threatening organ dysfunction caused by infection within 6 weeks of birth, from any source: the uterus, wound, perineum, urinary tract, breast, lung, IV line or a blood parasite such as malaria. It affects 1 to 2 percent of women after birth and far more after caesarean section. It matters because the source is not always the genital tract, and treatment depends on finding it early.

• Risk factors: caesarean section, prolonged labour, instrumental delivery, anaemia, HIV, diabetes, obesity, postpartum haemorrhage, long hospital stay, IV cannulae and catheters.
• Malaria and pneumonia are common non genital causes in Kenya.
• Delay of 1 hour in antibiotics raises the risk of death.

Women have fever or low temperature, rigors, fast pulse and breathing, malaise and reduced urine, with signs pointing to the source such as a hot wound, painful breast, cough or loin pain. Severe cases have low blood pressure, confusion and mottled skin.

• Respiratory rate of 22 per minute or more, altered mental state and systolic blood pressure of 100 mmHg or less together suggest high risk.
• Source may be unclear for the first day.
• Differential diagnosis: severe malaria, pneumonia, pyelonephritis, endometritis, wound or perineal infection, mastitis with abscess, septic pelvic thrombophlebitis, pulmonary embolism, thyroid storm.
• Complications: septic shock, acute kidney injury, acute respiratory distress syndrome, disseminated intravascular coagulation, abscess formation, necrotising infection, hysterectomy, prolonged hospital stay, maternal death.

The approach is to recognise sepsis quickly and then search for the source.

• Vital signs every 15 to 30 minutes at first; level of consciousness; hourly urine output.
• Blood cultures (2 sets), urine culture, wound and high vaginal swabs, sputum culture, malaria rapid test and film, HIV test, full blood count, C-reactive protein, lactate, urea, creatinine, liver enzymes, clotting screen.
• Chest X-ray, pelvic and abdominal ultrasound, breast ultrasound, and CT where abscess or thrombophlebitis is suspected.
• Examination of every wound, the breasts, the calves, IV sites and the lungs.

The principle is broad spectrum antibiotics within 1 hour, fluids, and control of the source once it is found.

• Supportive: oxygen to keep saturation at 94 percent or above; two large-bore cannulae; Ringer's lactate 30 mL/kg IV over the first 3 hours; urinary catheter with hourly output; high dependency care; remove infected lines; breastfeeding continues unless there is a breast abscess on that side.
• Pharmacological: ceftriaxone 2 g IV once daily plus metronidazole 500 mg IV 8-hourly, or clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily; meropenem 1 g IV 8-hourly for septic shock or hospital-acquired infection; add flucloxacillin 2 g IV 6-hourly for wound or breast infection; severe malaria: artesunate 2.4 mg/kg IV at 0, 12 and 24 hours then once daily until able to take oral therapy, then artemether-lumefantrine 4 tablets (each 20 mg and 120 mg) oral at 0, 8, 24, 36, 48 and 60 hours; noradrenaline 0.05 micrograms/kg/minute IV titrated to a mean arterial pressure of 65 mmHg or more if shock persists after fluids; paracetamol 1 g oral or IV 6-hourly (maximum 4 g in 24 hours); enoxaparin 40 mg subcutaneous once daily until mobile.
• Procedures: drainage of abscess; evacuation of retained products; debridement of wounds; laparotomy for peritonitis or necrotising infection; hysterectomy for uncontrolled uterine sepsis.
• Special groups: renal impairment replaces gentamicin with ceftriaxone; severe penicillin allergy uses clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily and replaces flucloxacillin with clindamycin.
• Red flags: systolic blood pressure below 90 mmHg, lactate above 2 mmol/L, respiratory rate above 30 per minute, confusion, urine below 30 mL per hour, bleeding or purpura.
• Follow-up: vital signs 4-hourly; reassess at 48 hours with culture results and narrow antibiotics; discharge when afebrile for 48 hours and eating; review at 1 week and 6 weeks.