Skip to main content Accessibility help




Sepsis is associated with high morbidity and mortality worldwide. Although, it is not the major reason for intensive care unit admissions during pregnancy, several physiological changes that occur during pregnancy limit the ability of the pregnant woman to compensate for the derangements produced by severe sepsis, often resulting in severe organ dysfunction. Moreover, there are several disorders peculiar to the pregnant state, including preeclampsia, placental abruption, amniotic fluid embolism and postpartum haemorrhage, all of which can produce potentially life-threatening organ failure and may be present concurrently with sepsis contributing to maternal mortality. Evidence-based guidelines advocate assessment and monitoring aimed at early recognition and treatment of sepsis. Early goal-directed therapy, adequate blood glucose control, and corticosteroid replacement when indicated are improving outcomes in patients with severe sepsis, although most of these have not been validated in pregnancy.


Corresponding author

Eileen Sung, Obstetric Physician, King Edward Memorial Hospital, Subiaco, Western Australia. Email:


Hide All
1.Dellinger, RP, Levy, MM, Carlet, JM, Bion, J, Parker, MM, Jaeschke, R, et al: Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2008; 36: 296327.
2.Ronsmans, C, Graham, WJ. Lancet maternal survival steering group. Maternal mortality: who, when, where, and why. Lancet 2006; 368: 1189–200.
3.Khan, P, Wojdyla, D, Say, L, Gulmezoglu, M, Look, PV. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367: 1066–74.
4.Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118(Suppl. 1): 1203.
5.The Prevention And Management of Puerperal Infections: Report of a Technical Working Group, Geneva, 20–22 May 1992. Geneva: World Health Organization, Division of Family Health, 1995.
6.Maharaj, D. Puerperal Pyrexia: A Review Part 1. Obstet Gynecol Surv 2007; 62: 393–99.
7.Bone, RC, Balk, RA, Cerra, FB, Dellinger, RP, Fein, AM, Knaus, WA, et al. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20: 864–74.
8.Levy, MM, Fink, MP, Marshall, JC, Abraham, E, Angus, D, Cook, D et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Critical Care Med 2003; 31: 1250–56.
9.Alberti, C, Brun-Buisson, C, Goodman, SV, Guidici, D, Granton, J, Moreno, R, et al. Influence of systemic inflammatory response syndrome and sepsis on outcome of critically ill infected patients. Am J Respir Crit Care Med 2003; 168: 7784.
10.Sprung, CL, Sakr, Y, Vincent, JL, Le Gall, JR, Reinhart, K, Ranieri, VM, et al. An evaluation of systemic inflammatory response syndrome signs in the sepsis occurrence in acutely ill patients (SOAP) study. Intensive Care Med 2006; 32: 421–27.
11.Afessa, B, Green, B, Delke, I, Koch, K. Systemic inflammatory response syndrome, organ failure, and outcome in critically ill obstetric patients treated in an ICU. Chest 2001; 120: 1271–77.
12.Duvekot, JJ, Peeters, LLH. Very early changes in cardiovascular physiology. In: Chamberlain G, Pipkin FB (eds). Clinical physiology in obstetrics. Blackwell Scientific, Oxford, 1998; 332.
13.Cunningham, FG, Leveno, KJ, Bloom, SL, Hauth, JC, Rouse, DJ, Spong, CY, et al: Maternal physiology. In: Williams Obstetrics. Twenty third Edition. New York, McGraw-Hill, 107–35.
14.Andrew, ML. Pregnancy and Critical Care Medicine Part 1: Normal Physiologic Changes in Pregnancy. Critical Care (Alert) 2011; 18: 8993.
15.Falagas, ME, Kompoti, M. Obesity and infection. Lancet Infect Dis 2006; 6: 438–46.
16.Tsoi, E, Shaikh, H, Teoh, TG. Obesity in pregnancy: a major healthcare issue. Post Grad Med J 2010; 86: 617–23.
17.Heslehurst, N, Simpson, H, Ells, LJ, Rankin, J, Wilkinson, J, Lang, R, et al. The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis. Obes Rev 2008; 9: 635–83.
18.Edward, R, Yeomans, Larry C. Gilstrap III. Physiologic changes in pregnancy and their impact on critical care. Crit Care Med 2005 33: S256258.
19.Lewinsohn, G, Herman, A, Leonov, Y, Klinowski, E. Critically ill obstetrical patients: Outcomes and predictability. Crit Care Med 1994; 22: 1412–14.
20.El-Solh, AA, Grant, BJ. A comparison of severity of illness scoring systems for critically ill obstetric patients. Chest 1996; 110: 1299–304.
21.Vasquez, DN, Estenssoro, E, Canales, HS, Reina, R, Saenz, MG, Das Neves, AV et al. Clinical characteristics and outcomes of obstetric patients requiring ICU admission. Chest 2007; 131: 718–24.
23.Somerset, DA, Zheng, Y, Kilby, MD, Sansom, DM, Drayson, MT. Normal human pregnancy is associated with an elevation in the immune suppressive CD25+ CD4+ regulatory T-cell subset. Immunology 2004; 112: 3843.
24.Aagard-Tillery, KA. Immunology of normal pregnancy. Semin Fetal Neonat Med 2006; 11: 279–95.
25.Lamont, RF, Sobel, J, Mazaki-Tovi, S, Kusanovic, JP, Vaisbuch, E, Kim, SK, et al. Listeriosis in human pregnancy: a systematic review. J Perinat Med 2011; 39: 227–36.
26.Blanco, JD. Bacteremia in obstetrics: clinical course. Obstet Gynecol 1981; 58: 621–25.
27.Van Beneden, CA, Hicks, LA, Riley, LE, Schulkin, J. Provider knowledge, attitudes and practices regarding obstetric and postsurgical gynaecologic infections due to Group A Streptococcus and other infectious agents. Infect Dis Obstet Gynecol 2007; 2007: 90189.
28.Paruk, F.Infections in obstetric critical care. Best Prac Res Clin Obst Gyn 2008; 22: 865–83.
29.Joseph, J, Sinha, A, Paech, M, Walters, BNJ. Sepsis in pregnancy and early goal-directed therapy. Obstet Med 2009; 2: 9399
30.Bernard, GR, Vincent, JL, Laterre, PF, LaRosa, SP, Dhainaut, JF, Lopez-Rodriguez, A, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699709.
31.Martí-Carvajal, AJ, Solà, I, Lathyris, D, Cardona, AF. Human recombinant activated protein C for severe sepsis. Cochrane Database Syst Rev 2011; (4): CD004388.
32.Al-Rawi, S, Woodward, LJ, Knight, J. Puerperal streptococcal toxic shock syndrome treated with recombinant human activated protein C and intravenous immunoglobulin. Int J Obstet Anesth 2009; 18: 169–72.
33.Medve, L, Csitári, IK, Molnár, Z, László, A. Recombinant human activated protein C treatment of septic shock syndrome in a patient at 18th week of gestation: a case report. Am J Obstet Gynecol 2005; 193: 864–65.
34.FDA (US Food and Drug Administration) 25/10/11.
35.Garcia, J, Aboujaoude, R, Apuzzio, J, Alvarez, JR. Septic pelvic thrombophlebitis: diagnosis and management. Infect Dis Obstet Gynecol 2006; 2006:15614.
36.Maharaj, D. Puerperal Pyrexia: A Review. Part II. Obstet Gynaecol Surv 2007; 62: 400406.
37.Faro, S. Postpartum Endometritis. Clin Perinatol 2005; 32: 803–14.
38.Viscomi, CM, Manullang, T. Maternal fever, neonatal sepsis evaluation and epidural labour analgesia. Reg Anesth Pain Med 2000; 25: 549–53.
39.Kaitz, AL. Urinary concentrating ability in pregnant women with asymptomatic bacteriuria. J Clin Invest 1961; 40: 1331–338.
40.Sweet, RL. Bacteriuria and pyelonephritis during pregnancy. Semin Perinatol 1977; 1: 2540.
41.Naeye, RL. Causes of the excessive rates of perinatal mortality and prematurity in pregnancies complicated by maternal urinary-tract infections. N Engl J Med 1979; 300: 819–23.
42.Mittendorf, R, Williams, MA, Kass, EH. Prevention of preterm delivery and low birth weight associated with asymptomatic bacteriuria. Clin Infect Dis 1992; 14: 927–32.
43.Nicolle, LE, Bradley, S, Colgan, R, Rice, JC, Schaeffer, A, Hooton, TM et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005; 40: 643–54.
44.Patterson, TF, Andriole, VT. Detection, significance, and therapy of bacteriuria in pregnancy. Update in the managed health care era. Infect Dis Clin North Am 1997; 11: 593608.
45.Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited; 2010.
46.Dubois, V, De Barbeyrac, B, Rogues, AM, Arpin, C, Coulange, L, Andre, C et al. CTX-M-producing Eschericia coli in a maternity ward: a likely community importation and evidence of mother to neonate transmission. J Antimicrob Chemother 2010; 65: 1368–371.
47.Gorgas, DL. Infections Related To Pregnancy. Emerg Med Clin N Am 2008: 26: 345–66.
48.Centre for Maternal and Childhood Enquiries (CMACE). Review of Maternal Deaths in the United Kingdom related to A/H1N1 2009 Influenza. 2010 Department of Health.
49.French, L, Smaill, FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev 2004: CD001067.
50.Patai, K, Szilágyi, G, Hubay, M, Szenttmáriay, Paulin F. Severe endometritis caused by genital mycoplamas after Caesarean section. J Med Microbiol 2005; 54: 1249–50.
51.Hollier, LM, Scott, LL, Murphree, SS, Wendal, GD JR. Postpartum endometritis caused by herpes simplex virus. Obstet Gynecol 1997; 89: 836–38.
52.Anteby, EY, Yagel, S, Hanoch, J, Shapiro, M, Moses, AE. Puerperal and intrapartum group A streptococcal infection. Infect Dis Obstet Gynecol 1999; 7: 276–82.
53.Stevens, D. Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis and new concepts in treatment. Emerg Infect Dis 1995: 1: 6978.
54.Health Protection Agency. Group A Streptococcus Working Group. Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease. Commun Dis Public Health 2004; 7: 354–61.
55.Vandanesh, F, Naimi, T, Enright, MC, Lina, G, Nimmo, GR, Hefferman, H et al. Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine Leukocidin genes: worldwide emergence. Emerg Infect Dis 2003; 9: 978–84.
56.Faro, S. Postpartum Endometritis. Clin Perinatol 2005; 32: 803–14.
57.Foxman, B, D'Arcy, H, Gillespie, BG, Bobo, JK, Schwartz, K. Lactation mastitis: Occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol 2002; 15: 103–14.
58.Baskettv, TF, Sternadel, J. Maternal intensive care and near-miss mortality in obstetrics. Br J Obstet Gynecol 1998; 105: 981–84.
59.Fernández-Pérez, ER, Salman, S, Pendem, S, Farmer, C. Sepsis in Pregnancy. Crit Care Med 2005; 33: S286293.
60.Sheffield, JS. Sepsis and septic shock in pregnancy. Crit Care Clin 2004; 20: 651–60.
61.Seale, AC, Mwaniki, M, Newton, CR, Berkley, JA. Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-saharan Africa. Lancet 2009; 9: 428–38.
62.Fischer, M, Bhatnagar, J, Guarner, J, Reagan, S, Hacker, JK, Van Meter, SH et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med 2005; 353: 2352–360.
63.Meis, JF, Muytjens, HL, van den Berg, PP, Voss, A, Melchers, WJ. Analysis of an outbreak of Puerperal fever due to Group A Streptococci by random amplified polymorphic DNA fingerprinting. Infect Dis In Obstet Gynecol 1997; 5: 232–36.
64.Aldape, MJ, Bryant, AE, Stevens, DL. Clostridium sordelli infection: epidemiology, clinical findings and current perspectives on diagnosis and treatment. Clin Infect Dis 2006; 43: 1436–446.
65.Cohen, AL, Bhatnagar, J, Reagan, S, Zane, SB, D'Angeli, MA, Fischer, M et al. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol 2007; 110: 1027–33.
66.Workowski, KA, Berman, S; Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR Recomm Rep 2010; 59: 1110.
67.Meyers, D, Wolff, T, Gregory, K, Marion, L, Moyer, V, Nelson, H et al. USPSTF recommendations for STI screening. Am Fam Physician 2008; 77: 819–24.
68.`National Institute for Health and Clinical Excellence: Guidance. Antenatal Care: Routine care for the healthy pregnant woman. March 2008 (Guideline 62).
69.Smaill, FM, Gyte, GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev 2010; CD007482.
70.Gray, J, Patwardhan, SC, Martin, W. Methicillin-resistant Staphylococcus aureus screening in obstetrics: a review. J Hosp Infect 2010; 75: 8992.
71.Lamont, R, Sobel, J, Kusanovic, J, Vaisbuch, E, Mazaki-Tovi, S, Kim, S et al. Current debate on the use of antibiotic prophylaxis for caesarean section. BJOG 2011; 118: 193201.
72.Kenyon, S, Boulvain, M, Neilson, J. Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev 2003; CD001058.
73.Hutzal, CE, Boyle, EM, Kenyon, SL, Nash, JV, Winsor, S, Taylor, DJ et al. Use of antibiotics for the treatment of preterm parturition and prevention of neonatal morbidity: a metanalysis. Am J Obstet Gynecol 2008; 199: 620. e18.
74.Thinkhamrop, J, Hofmeyr, GJ, Adetoro, O, Lumbiganon, P. Prophylactic antibiotic administration during second and third trimester in pregnancy for preventing infectious morbidity and mortality. Cochrane Database Syst Rev 2002; CD002250.
75.Wilson, W, Taubert, KA, Gewitz, M, Lockhart, PB, Baddour, LM, Levison, M et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116: 1736–54.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Fetal and Maternal Medicine Review
  • ISSN: 0965-5395
  • EISSN: 1469-5065
  • URL: /core/journals/fetal-and-maternal-medicine-review
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed