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SMFM Guidance: Diagnosis and Management of Maternal Sepsis


Sepsis accounts for about 14% of all pregnancy-related deaths despite occurring in only 4 per 10,000 live births, and the rate of maternal sepsis appears to be increasing. More than 50% of pregnant patients who die from sepsis have at least one chronic comorbidity, such as congestive heart failure or chronic renal disease. The diagnosis of sepsis in the early postpartum period can be difficult due to the rapid physiologic changes that occur postpartum, such as large fluid shifts, postpartum hemorrhage, and heart rate and blood pressure alterations. This consult series document refers to sepsis in individuals who are either pregnant or in the postpartum period. 

Sepsis Definition 

  • Is not a defined illness, but a life-threatening organ disruption with a dysregulated host response to infection
  • Septic Shock
    • Is a subset of sepsis in which persistent hypotension requiring the use of vasopressors despite adequate fluid resuscitation
  • Fever is not necessary or sufficient to identify sepsis
  • Consider the diagnosis if
    • Unexplained end organ damage if suspected infectious process
    • End organ damage in a previously healthy individual

Potential Sources of Infection

  • Obstetric
    • Antepartum: Septic abortion | Chorioamnionitis
    • Postpartum: Endometritis | Wound infection
  • Non-obstetric
    • Antepartum: UTI | Pneumonia | Appendicitis
    • Postpartum: UTI | Pneumonia | GI

Note: No source identified in 30% of cases  

Sepsis During Pregnancy

  • Normal physiologic changes in pregnancy can delay the identification and diagnosis
    • Examples: Expanded blood volume | Increased cardiac output | Peripheral vasodilation
    • More complex immediately postpartum due to fluid shifts 
  • Early recognition essential
  • Associated with
    • Preterm birth
    • Prolonged recovery
    • Stillbirth
    • Maternal death

Tools for Recognizing Sepsis in Pregnancy

  • No single, reliable screening test validated for pregnancy
  • Quick Sequential Organ Failure Assessment (qSOFA) score
    • Bedside rapid assessment tool: 3 Clinical criteria
      • Systolic blood pressure ≤100 mmHg
      • Respiratory Rate ≥22
      • Altered mental status
    • If any two are present start therapy and consider ICU transfer

Note: Low sensitivity and has not been validated in pregnancy


Initial Management: within the first hour of suspected diagnosis

  • Perform cultures
  • Send serum lactate
  • Use broad spectrum antibiotics
    • Choice of antibiotics: Possible infection source | Likely microorganisms | Antibiotic resistance patterns
    • Cover anaerobic and aerobic Gram-positive and Gram-negative bacteria
  • Fluids: 1 to 2 liters of crystalloid (or more as needed) in the first three hours

Proposed Antibiotic Coverage Based on Source

  • Community-acquired pneumonia
    • Cefotaxime | Ceftriaxone | Ertapenem | Ampicillin plus azithromycin | Clarithromycin | Erythromycin
  • Hospital-acquired pneumonia: Low risk
    • Ceftriaxone | Ampicillin-Sulbactam | Ertapenem | Meropenem | Imipenem | Cefepime
  • Hospital-acquired pneumonia: High risk or mortality
    • Double coverage for Pseudomonas
      • Beta lactam plus an aminoglycoside or quinolone
      • MRSA coverage: Vancomycin or linezolid
    • Chorioamnionitis
      • Ampicillin plus gentamicin
      • Cesarean: Add clindamycin or metronidazole for anerobic coverage
    • Endomyometritis
      • Ampicillin, gentamicin, and metronidazole (or clindamycin) or
      • Cefotaxime or
      • Ceftriaxone plus metronidazole
    • UTI
      • Gentamicin plus ampicillin or
      • Carbapenem or
      • Piperacillin-tazobactam
    • Abdominal infections: Uncomplicated
      • Ceftriaxone | Cefotaxime | Ceftazidime | cefepime plus metronidazole
    • Abdominal infections: Complicated
      • Carbapenem | Piperacillin-tazobactam
    • Skin and soft tissues (necrotizing)
      • Vancomycin plus piperacillin-tazobactam
      • If Streptococcus Group A or Clostridium perfringens are present: Penicillin G plus clindamycin

Fluid Management

  • Maintain fluids to keep mean arterial pressure (MAP) >65 mmHg

Vasopressors and Inotropes

  • Hypoperfusion: Start norepinephrine through central line
    • 0.25 mcg/kg/min
    • MAP of >65 mmHg target
  • Cardiac dysfunction and hypoperfusion with adequate fluid resuscitation
    • Dobutatmine or epinephrine
    • If no response: Add vasopressin

Additional Management

  • Hydrocortisone 50 mgs q6 hours IV infusion
    • Use if no response to norepiphrine
    • Betamethasone if fetal lung maturity indicated for management
  • Electronic fetal monitoring if viable
  • Imaging to identify source
  • DVT prophylaxis
  • Maintain glycemic control with insulin: Keep serum glucose <180
  • Potential surgical debridement
  • Comprehensive family support

When to Deliver

  • Diagnosis of sepsis is not an indication for delivery
  • If the uterus is the source
    • Delivery is indicated regardless of gestational age
  • Delivery otherwise guided by obstetric indications


  • Whether or not a fever is present, sepsis should be considered If unexplained end organ damage with a suspected or confirmed infection
  • A serum lactate level should be sent if sepsis is suspected 
  • Appropriate microbiologic cultures should be obtained as long as there are no delays in initiating antibiotics
    • If septic shock or a high suspicion of sepsis,   empiric broad spectrum antibiotics should be instituted 
  • Within 1 to 3 hours, 1 to 2 liters of a balanced crystalloid solution should be given if hypoperfusion or hypotension is present
  • Norepinephrine should be the first line vasopressor
    • If vasopressors are necessary, IV corticosteroids should be given 
  • VTE prophylaxis should be instituted
  • If glucose is ≥180, insulin should be initiated 
  • If the uterus is the source of sepsis, prompt evacuation should occur regardless of gestational age
  • Hospital systems should develop metrics and protocols for sepsis management 

Learn More – Primary Sources:  

Society for Maternal-Fetal Medicine Consult Series #67: Maternal Sepsis 

Alliance for Innovation on Maternal Health: Consensus Bundle

CMQCC Guidelines: Management of Sepsis in Pregnancy


Sepsis during pregnancy remains a significant and potentially preventable cause of maternal morbidity and mortality. The importance of heightened vigilance and early initiation of therapy is a key feature of the CMQCC guideline and mirrored across multiple medical organizations. 

Clinical Actions

  • Order
    • Cultures: Blood | Sputum | Urine and other samples as indicated
      • CMQCC recommends cultures be drawn upon diagnosis even if antibiotic therapy has already been initiated
    • Serum lactate levels
  • Begin
    • Antibiotics within 1 hour (see ‘Key Points’ below)
    • Broad Spectrum (anaerobic and aerobic gram-positive and gram negative bacteria)
  • Determine source as early as possible following initiation of resuscitation and initiation of antibiotics
    • Imaging as necessary
    • Manage depending on findings (e.g. abscess drainage as required)
    • Use the least invasive approach possible (e.g. percutaneous best when appropriate) except in case where more invasive approach is desirable (e.g., debridement if indicated)


  • CMQCC states

We recommend that resuscitation from sepsis-induced hypoperfusion include at least 30 mL/kg of intravenous crystalloid fluid within three hours of recognition of sepsis

Surviving Sepsis Campaign does not recommend one crystalloid over another

  • Do not use CVP or pulmonary artery occlusion pressure to guide fluid resuscitation
  • Determine if patient is fluid responsive
    • Pulse pressure variation using arterial line wave form
      • Reliable with [1] sedation [2] positive pressure controlled mechanical ventilation and [3] in sinus rhythm
      • Pulse pressure should vary ≥13% with the respiratory cycle
    • Passive leg raise to 30 to 45 degrees (spontaneous breathing or not in sinus)
      • Auto transfusion results in increased cardiac output
      • May not be a good test in third trimester: Use 250 to 500cc cardiac bolus rather than leg raise

Vasopressors and Inotropes

  • Use vasopressors in hypotensive patients if
    • Not fluid responsive or
    • Further fluid therapy is contraindicated (e.g. pulmonary edema)
  • First line: Norepinephrine
    • Target MAP: >65 mmHg
    • Norepinephrine appears to be safe in pregnancy although high-quality data is limited
  • Other vassopressors
    • Data on other vasopressors more limited
  • Consider dobutamine (inotrope) to increase cardiac output if
      • Patient remains hypotensive following fluids and vasopressors
      • Myocardial dysfunction is present
  • Start hydrocortisone 200 mg/day (continuous infusion) if no response to norepinephrine

Note: Initiate DVT prophylaxis


Antibiotic Therapy

  • Consider the following when beginning antimicrobial therapy
    • Initially, choice of antibiotic will likely be empiric
    • Choice of antibiotic will be dependent on
      • Source | Local resistance | Hospital protocols
    • Start with broad spectrum coverage, including anaerobic and aerobic gram-positive and gram-negative bacteria
    • Consultation with infectious disease may be appropriate

CMQCC Antibiotic Recommendations if Source Unknown (at least
one antibiotic for Gram-negative and anaerobic coverage PLUS one for Gram-positive coverage)

7 to 10 day duration usually adequate

  • Gram-negative plus anaerobic coverage
    • Piperacillin/tazobactam 3.375 g IV q8h (extended infusion) or 4.5 g IV q6h or
    • Meropenem 1 g IV q8h (if recent hospitalization or concern for multi-drug resistant organisms) or
    • Cefepime 1-2g IV q8h plus metronidazole 500 mg IV q8h or
    • Aztreonam 2 g IV q8h (for women with severe penicillin allergy) plus metronidazole 500 mg IV q8h or
    • Aztreonam 2g IV q8h plus clindamycin 900 mg IV q8h


  • Gram-positive coverage
    • Vancomycin 15-20 mg/kg q8h-q12h (goal trough 15-20 mcg/mL) or
    • Linezolid 600 mg IV/PO q12h (for women with severe vancomycin allergy)

Fetal Assessment and Delivery

  • Fetal assessment: Consider the following
    • Electronic fetal monitoring ≥24 weeks
    • Corticosteroids for fetal lung maturity >23 to 24 weeks of pregnancy
  • Delivery (Grade 1B recommendations)
    • SMFM recommends against delivery for sepsis if this is the sole indication
    • Delivery should be dictated based on obstetric indications

Learn More – Primary Sources:

The Surviving Sepsis Campaign Bundle 2018 Update

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016

CMQCC Toolkit: Improving Diagnosis and Treatment of Maternal Sepsis

CMQCC Guidelines: Making the Diagnosis of Sepsis in Pregnancy


Sepsis remains a major cause of maternal morbidity and mortality. Sepsis is considered a preventable cause of maternal mortality. Because vital signs are altered in pregnancy (and may mimic infection such as increased maternal heart rate), both professional organizations emphasize the importance of recognizing that sepsis screening tools may need modification during pregnancy.  CMQCC has developed its own algorithm (see details below)

Risk Factors

  • Nulliparity
  • Black race
  • Insurance: public or none
  • Cesarean delivery
  • ART
  • Multiple gestation

Note: Presence of co-morbidities increases maternal mortality risk

Definitions and Clinical Criteria

The Third Internal Consensus Definitions for Sepsis and Septic Shock (2016)


  • Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection
  • Septic shock: Sepsis with circulatory and cellular/metabolic abnormalities profound enough to substantially increase mortality

Clinical Criteria

  • Sepsis
    • Suspected or documented infection and an acute increase of ≥2 SOFA (Sequential Organ Failure Assessment) points (see ‘Key Points’ below)
      • Proxy for organ dysfunction
  • Septic Shock
    • Sepsis and vasopressor therapy needed to
      • Elevate MAP ≥ 65 mmHg and lactate > 2 mmol/L (18 mg/dL) after adequate fluid resuscitation

CMQCC 2-Step System for Maternal Sepsis Screening and Diagnosis

Step 1 – Sepsis Screen: ≥2 elements considered positive 

  • Oral temperature: < 36°C (98.6°F) or ≥ 38°C (100.4°F)
  • HR: > 110 beats per minute and sustained for 15
  • RR: > 24 breaths per minute and sustained for
    15 minutes
  • WBC: > 15,000/mm3 or < 4,000/mm3 or >
    10% immature neutrophils (bands)

Note: Verify abnormal values | Obtain a complete set of vital signs (i.e., include 02 sat) and repeat in 15 minutes | Do not wait for fever if there are other suspicious clinical signs that infection is present | Corticosteroids will elevate WBCs but peak expected within 24 hours and should be baseline again after 96 hours

If Step 1 Positive – Obtain the following 

  • Laboratory values: CBC
    • Coags: Prothrombin time | INR | PTT
    • Comprehensive metabolic panel
    • Venous lactic acid
  • Bedside assessment
    • Urine output (Foley catheter with urometer
    • Pulse oximetry
    • Mental status assessment

Step 2 Confirmation: CMQCC Sepsis Diagnosis Algorithm (only 1 criteria required for sepsis diagnosis) 

  • Respiratory function
    • Need for invasive or non-invasive mechanical
      ventilation or
    • PaO2/FiO2 < 300
  • Coag studies
    • Platelets < 100 x 109/L or
    • INR: > 1.5 or
    • PTT: > 60 seconds
  • Liver function
    • Bilirubin > 2 mg/dL
  • Cardiovascular function (persistent hypotension)
    • SBP < 85 mm Hg or
    • MAP < 65 mm Hg or
    • > 40 mm Hg decrease in SBP
  • Renal function
    • Creatinine > 1.2 mg/dL or
    • Doubling of creatinine or
    • Urine output < 0.5 mL/kg/hour (for 2 hours)
  • Mental status
    • Agitation | Confusion | Unresponsiveness
  • Lactic acid
    • 2 mmol/L
    • Can be used for diagnosis in the absence of labor | For women in labor with an elevated lactic acid and positive step 1 screen but negative step 2 confirmation, CMQCC recommends close surveillance with repeated bedside evaluation and repeated lactic acid levels over time

Note: CMQCC has not evaluated its algorithm in a research setting, but based on clinical practice data sets, the anticipated performance is estimated to be 97% for sensitivity and 99% for specificity


  • Sepsis and Septic Shock are Medical Emergencies
  • Resuscitation and treatment should begin immediately
  • Consider sepsis in pregnant women “otherwise unexplained end-organ damage in the presence of an infectious process”
  • Treat regardless of whether or not fever is present
  • Multiple organ systems aside from cardiovascular, pulmonary and CNS may be affected including
    • GI (ileus) | Hepatic injury or failure | Renal injury or failure | Coagulation (low platelets or DIC) | Endocrine system (adrenal / insulin resistance)
  • CMQCC emphasizes that a MAP of <65 mm Hg that persists after a 30ml/kg fluid load in the setting of infection “directly defines septic shock”

Learn More – Primary Sources:

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA: Consensus Definitions for Sepsis and Septic Shock

CMQCC: Improving Diagnosis and Treatment of Maternal Sepsis