Postpartum Sepsis: Diagnosis and Management
Most Likely Diagnosis
This clinical presentation—high-grade fever, tachycardia (150 bpm), normal blood pressure, and marked leukocytosis (24,000/µL) in the postpartum period—is most consistent with postpartum endometritis with evolving sepsis. 1
Immediate Assessment and Screening
Initiate the 3-hour sepsis bundle immediately as this patient meets criteria for sepsis screening based on the obstetrically modified SIRS (omSIRS) criteria: fever, tachycardia >100 bpm, and WBC >20,000/µL in the postpartum period. 1
Critical Initial Actions (Within 3 Hours):
- Obtain blood cultures (two sets from different sites) before antibiotics 1
- Measure serum lactate level immediately—this is crucial for risk stratification, though note that lactate elevations can occur from non-septic causes in the immediate postpartum period 1
- Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 1
- Begin aggressive IV fluid resuscitation with crystalloids (30 mL/kg bolus if hypotension develops or lactate ≥4 mmol/L) 1
Antibiotic Therapy
The gold standard treatment for postpartum endometritis is IV clindamycin plus gentamicin, which provides excellent coverage for the polymicrobial flora including gram-positive anaerobes like Bacteroides fragilis, E. coli, and Group A/B Streptococcus—the most common causative organisms. 2, 3
Specific Regimen:
- Clindamycin 900 mg IV every 8 hours PLUS Gentamicin 5-7 mg/kg IV once daily 2
- Continue antibiotics until the patient has been afebrile for 24-48 hours; oral antibiotics after IV therapy are not necessary 2
Important Caveat:
- Monitor gentamicin levels carefully to avoid nephrotoxicity and ototoxicity, especially if renal function is compromised 1
Monitoring for Septic Shock
Watch closely for progression to septic shock, which would be indicated by: 1
- Persistent hypotension (SBP <90 mmHg or MAP <65 mmHg) despite fluid resuscitation
- Lactate >2 mmol/L (>4 mmol/L indicates severe shock)
- Signs of end-organ dysfunction (altered mental status, oliguria <0.5 mL/kg/hr, elevated creatinine >1.2 mg/dL, platelets <100,000/µL)
If Septic Shock Develops:
- Start norepinephrine as first-line vasopressor (0.02 µg/kg/min, titrate to MAP ≥65 mmHg) 1
- Repeat lactate within 6 hours to assess response 1
- Consider low-dose hydrocortisone (200 mg/day) if requiring norepinephrine ≥0.25 µg/kg/min for ≥4 hours 1
Evaluation for Complications
If fever persists beyond 72 hours of appropriate antibiotic therapy (occurs in ~10% of cases), investigate for:
- Pelvic abscess (most common complication) 2, 4
- Retained placental tissue 4
- Pelvic hematoma (especially after operative delivery) 4
- Ovarian vein thrombosis 4
- Wound infection (if cesarean delivery) 3
Obtain pelvic ultrasound or CT imaging to identify these complications, as imaging leads to definitive diagnosis in >90% of refractory cases. 4
Critical Pitfalls to Avoid
- Do not delay antibiotics waiting for culture results—early administration (within 1 hour) significantly reduces mortality 1
- Do not use NSAIDs for postpartum analgesia in septic patients, as they increase risk of acute kidney injury, especially with concurrent sepsis 1, 5
- Do not assume normal blood pressure excludes sepsis—this patient has compensated sepsis without shock, but can deteriorate rapidly 1
- Do not overlook Group A Streptococcus—though less common, it causes severe invasive disease with rapid progression and high mortality if untreated 3, 6
Differential Considerations
While postpartum endometritis is most likely, briefly consider:
- Urinary tract infection/pyelonephritis—obtain urinalysis and urine culture 3
- Chorioamnionitis (if intrapartum fever was present) 3
- Peripartum cardiomyopathy—unlikely given normal BP and absence of respiratory symptoms, but would present 2-62 days postpartum with heart failure symptoms 7
- Preeclampsia with severe features—excluded by normal blood pressure 1