Maternal sepsis (Puerperal fever) due to Group A Streptococcus – Information for clinicians

Sepsis associated with pregnancy, delivery, and post partum is often insidious in onset but can progress very rapidly.
Early recognition of the signs and symptoms of maternal sepsis, urgent transfer to hospital and prompt, aggressive treatment of sepsis will save lives.
Educate your postnatal patients about good personal and perineal hygiene to minimise the risk of maternal sepsis.

Last updated: 25 June 2012

What is group A streptococcal maternal sepsis?

The leading cause of severe, life-threatening maternal sepsis is group A Streptococcus (GAS).
A wide range of other organisms including group B,C and G Streptococcus, Staphylococcus aureus, Escherichia coli, Enterobacter spp, and Chlamydia trachomatis may also cause maternal sepsis. Over recent decades a resurgence of invasive GAS has been observed in industrialised countries around the world. In NSW, clusters of maternal sepsis have been associated with GAS.
Maternal sepsis can occur antenatally; however most morbidity and mortality is experienced in the postpartum period (when it is known as puerperal sepsis).
5-30% of the community are asymptomatic carriers of group A streptococci, usually on the skin or in the throat.¹Cases of maternal sepsis are often preceded by a sore throat or an upper respiratory infection..²
Group A Streptococcus (GAS) is typically acquired in the community, although it may be hospital acquired. In hospitals, invasive GAS outbreaks have been linked to asymptomatic health care workers..³
While most postpartum deaths associated with GAS occur after operative delivery, healthy women with uncomplicated pregnancy and delivery are still at risk of sepsis.

What are the clinical features of GAS maternal sepsis?

Fever of more than 380C
Tender, sub-involuted uterus (has not returned to its normal size following childbirth)
Chills and general malaise
Lower abdominal pain
Diarrhoea (can indicate pelvic sepsis)
Purulent and foul-smelling lochia (vaginal discharge after delivery)
Vaginal bleeding

Features of severe sepsis include:

Hypothermia, tachypnoea, and neutropenia
Signs of shock such as hypotension and sustained tachycardia (>100 bpm).

Who is at risk of GAS maternal sepsis?

Risk factors related to childbirth include:
- Caesarean section
- Protracted labour and/or prolonged rupture of membranes
- Frequent vaginal examinations in labour
- Traumatic delivery
- Retained placental products
A sore throat or upper respiratory tract infection in the woman or close contacts, including health care workers
Poor personal or perineal hygiene in the early post-natal period
Australian Aboriginal women have higher rates of GAS maternal sepsis
Other risk factors include:
- Chronic disease
- Immunosuppression
- Injecting drug use

How is GAS maternal sepsis diagnosed?

Early involvement of microbiologists and infectious disease specialists in the management of suspected GAS maternal sepsis is recommended.
Diagnostic tests may include:
- Perineal, high vaginal, endocervical swabs for culture and sensitivity
- Blood cultures( at least 2 sets)
- Mid stream urine
- Typing (M [emm]type) should be requested on GAS isolates associated with a maternal sepsis cluster

How is GAS maternal sepsis treated?

Sepsis in pregnancy is often insidious in onset but can progress very rapidly. Regular monitoring of pulse, blood pressure, respiratory rate may assist with early identification
If sepsis is suspected in a patient in the community, urgent referral to hospital is indicated.
In hospital, high-dose intravenous broad spectrum antibiotics should be started immediately after obtaining appropriate cultures; septicaemia can develop rapidly and has a high mortality rate. Treatment should not be delayed unduly by collection of clinical samples and can be adjusted after results of investigations become available.
For treatment options refer to Therapeutic Guidelines: antibiotic or seek advice from a microbiologist or infectious disease specialist. (Note: if GAS is isolated IV penicillin is the treatment of choice).
Aggressive fluid resuscitation and close monitoring of fluid balance may be required; early involvement of critical care staff may be necessary.

How is GAS maternal sepsis prevented?

Inform pregnant and post-natal patients about the risks and signs and symptoms of genital tract infection, and the need to seek advice early if concerned or unwell.
Educate women about the importance of good personal hygiene in the peri-natal period, including the importance of washing hands (for at least 15 seconds with soap and running water) before and after using the toilet or changing sanitary pads.
Good hygiene is particularly important if the woman, her family or close contacts have a sore throat or upper respiratory infection.
Antibiotic prophylaxis is recommended for the following clinical scenarios:.²
- Peri-abortion(including termination of pregnancy)
- Preterm and/or prolonged rupture of membranes
- Caesarean section operations (pre-incision)
- Anal sphincter tear repair( intra operative and post operative)
A throat swab should be taken when a pregnant woman presents with a sore throat and there should be a lower threshold for antibiotic treatment..⁴
Invasive GAS outbreaks have been linked to asymptomatic health care workers. All health care professionals who care for pregnant and recently delivered women must adhere to infection control guidelines.⁵, and comply with the 5 moments of hand hygiene iniative.⁶.

What is the public health response?

Puerperal sepsis and invasive group A streptococcus are not notifiable in NSW; however, the public health unit should be contacted if a potential outbreak or cluster of infections is identified. A cluster may be considered as two or more cases occurring in a defined group linked by time and place.

References

Health Protection Agency. Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease, Group A Streptococcus Working Group. Commun Dis Public Health. 2004; 7: 354-361.
Centre for Maternal and Child Enquiries. CMACE Emergent Theme Briefing #1: Genital Tract Sepsis. September 2010.
Health Protection Agency. Guidelines for the investigation, control and prevention of spread of group A streptococcal (GAS) infection in acute healthcare settings in the United Kingdom.
Centre for Maternal and Child Enquiries. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011; 118(supp 1): 1-203
NHMRC (2010) Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia.

Clinical Excellence Commission, NSW Health. Hand hygiene program can be accessed at: http://www.cec.health.nsw.gov.au/programs/hand-hygiene.

Further information - Public Health Units in NSW
For more information please contact your doctor, local public health unit or community health centre - look under NSW Government at the front of the White Pages
Metropolitan Areas	Location	Number	Rural Areas	Location	Number
Northern Sydney	Hornsby	02 9477 9400	Greater Southern	Goulburn	02 4824 1837
Central Coast	Gosford	02 4349 4845		Albury	02 6080 8900
South Eastern Sydney	Randwick	02 9382 8333	Greater Western	Broken Hill	08 8080 1499
Illawarra Shoalhaven	Wollongong	02 4221 6700		Dubbo	02 6841 5569
Sydney South West	Camperdown	02 9515 9420		Bathurst	02 6339 5601
Sydney West	Penrith	02 4734 2022	Hunter/New England	Newcastle	02 4924 6477
	Parramatta	02 9840 3603		Tamworth	02 6764 8000
Justice Health Service	Matraville	02 9311 2707	North Coast	Port Macquarie	02 6588 2750
				Lismore	02 6620 7585

See full Contact details for Public Health Units.