Sepsis in Pregnancy and the Puerperium: A Comparative Review of Major Guidelines
Authors: Giouleka Sonia , Boureka Eirini , Tsakiridis Ioannis , Lallas Konstantinos , Papazisis Georgios , Mamopoulos Apostolos , Kalogiannidis Ioannis , Athanasiadis Apostolos , Dagklis Themistoklis 
Published: April 2023

ABSTRACT

Introduction
Sepsis is one of the leading causes of maternal morbidity and mortality worldwide and a major public health concern, often associated with delayed diagnosis, suboptimal management, and poor perinatal outcomes.

Objectives
The aim of this study was to review and compare the most recently published influential guidelines on the prevention, diagnosis, and management of this complication during antenatal, intrapartum, and postpartum periods.

Evidence Acquisition
A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Society for Maternal-Fetal Medicine (SMFM), the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ), the World Health Organization (WHO), and the Society of Obstetricians and Gynecologists of Canada (SOGC) on maternal and puerperal sepsis was carried out.

Results
RCOG, SMFM, and SOMANZ provide guidance on the diagnosis and management of sepsis in pregnancy and the puerperium, whereas the WHO and the SOGC refer only to the prevention of peripartum infections. There is a consensus among the reviewed guidelines that a detailed personal history, along with physical examination, cultures, laboratory tests, and appropriate imaging, is the mainstay in sepsis diagnosis; however, there are several discrepancies regarding the diagnostic criteria. On management, the necessity of broad-spectrum antibiotics administration, within the first hour from recognition, and early source control are underlined by RCOG, SMFM, and SOMANZ. Furthermore, adequate fluid resuscitation with crystalloids is required, targeting for a mean arterial pressure (MAP) >65 mm Hg, whereas persistent hypotension or tissue hypoperfusion should be managed with vasopressors. In addition, RCOG, SMFM, and SOMANZ agree that increased fetal surveillance is warranted in case of maternal sepsis and point out that the decision regarding the optimal time of delivery should be guided according to maternal and fetal condition. In case of preterm labor, the use of corticosteroids should be considered. Moreover, SOMANZ and SMFM recommend thromboprophylaxis for septic women. With regards to prevention of peripartum infections, the WHO recommends prophylactic antibiotic administration in case of cesarean delivery, group B Streptococcus colonization, manual placenta removal, third/fourth-degree perineal tears, and preterm premature rupture of membranes, while discouraging antibiotics in case of preterm labor with intact membranes, prelabor rupture of membranes at term, meconium-stained amniotic fluid, uncomplicated vaginal birth, episiotomy, and operative vaginal delivery. Finally, SOGC, although supporting antibiotic prophylaxis for cesarean delivery and third/fourth-degree perineal injury, does not recommend this intervention in case of manual placenta removal, postpartum dilatation, and curettage for retained products of conception, operative vaginal delivery, and cervical cerclage.

Conclusions
Sepsis remains a significant contributor of maternal morbidity and mortality with a constantly rising global incidence, despite the advances in diagnostic and therapeutic techniques. Thus, the development of consistent international practice protocols for the prevention, timely recognition, and effective management of this complication both in pregnancy and in the puerperium seems of paramount importance to safely guide clinical practice and subsequently improve perinatal outcomes.

Target Audience
Obstetricians and gynecologists, family physicians

Learning Objectives
After participating in this activity, the learner should be better able to identify the risk factors associated with maternal sepsis; evaluate the diagnostic and management procedures for sepsis in pregnancy and puerperium; and propose strategies for the prevention of peripartum infections.