›Ceftriaxone 1 to 2 g intravenously every 24 hours; use a carbapenem if extended-spectrum beta-lactamase organisms are likely
›Listeriosis suspected
›High-dose ampicillin 2 g intravenously every 4 hours, with gentamicin 5 mg/kg intravenously every 24 hours for synergy
›If penicillin-allergic, trimethoprim-sulfamethoxazole 8 to 10 mg/kg per day of the trimethoprim component intravenously in divided doses, avoiding it near term
›Necrotizing soft tissue infection
›Piperacillin-tazobactam 4.5 g intravenously every 6 hours or a carbapenem, plus clindamycin 900 mg intravenously every 8 hours, plus vancomycin, alongside immediate surgical debridement
›Influenza or viral pneumonia
›Oseltamivir 75 mg by mouth twice daily for 5 days, started empirically in pregnancy without waiting for testing
›Add azithromycin 500 mg intravenously or by mouth once daily for atypical cover; prefer it over clarithromycin 500 mg twice daily in pregnancy
›Disseminated herpes simplex or varicella
›Aciclovir 10 mg/kg intravenously every 8 hours, adjusted for renal function, with adequate hydration
Antimicrobial safety in pregnancy and lactation
›Generally acceptable in pregnancy
›Penicillins, cephalosporins, carbapenems, clindamycin, metronidazole, azithromycin, and vancomycin
›Aminoglycosides for short courses with a specific indication — gentamicin 5 mg/kg intravenously every 24 hours; prolonged or repeated courses carry a fetal eighth-nerve toxicity risk, so limit duration and monitor levels
›Use only when no safer alternative
›Fluoroquinolones — ciprofloxacin 400 mg intravenously every 8 to 12 hours; an animal arthropathy signal, not first line
›Tetracyclines — doxycycline 100 mg intravenously or by mouth every 12 hours; dental staining and skeletal effects after roughly 20 weeks, though short courses under 21 days for rickettsial disease are considered acceptable when there is no alternative
›Linezolid 600 mg intravenously every 12 hours — limited human pregnancy data; reserve
›Trimester- and term-specific cautions
›Trimethoprim — 200 mg by mouth twice daily; a folate antagonist, avoid in the first trimester and give folic acid 5 mg daily if unavoidable
›Sulfonamides — avoid after 32 weeks and near term for theoretical kernicterus and hemolysis in glucose-6-phosphate dehydrogenase deficiency
›Nitrofurantoin 100 mg by mouth twice daily — acceptable for lower urinary tract infection in the second trimester, but avoid at term and in glucose-6-phosphate dehydrogenase deficiency for neonatal hemolysis
›Lactation
›Penicillins, cephalosporins, macrolides, clindamycin, and metronidazole are compatible with breastfeeding
›Continue feeding or expressing from an affected breast during treatment for mastitis
›Fluid choice
›Balanced crystalloid such as lactated Ringer's or a balanced electrolyte solution, preferred over 0.9% saline to avoid hyperchloremic acidosis
›Do not use hydroxyethyl starch — it causes renal replacement and mortality harm
›Consider 5% albumin when large crystalloid volumes are already required; it is not first line
›Titrated approach
›Give an initial bolus of 30 ml/kg within the first 3 hours for sepsis-induced hypoperfusion or lactate at or above 4 mmol/l, delivered in 250 to 500 ml aliquots with reassessment after each
›Reassess with lung auscultation, SpO2, lung ultrasound B-lines, and a dynamic measure such as passive leg raise; note that inferior vena cava and pulse-pressure variation are less reliable in the gravid abdomen
›Why the pregnant patient tolerates over-resuscitation poorly
›Plasma colloid oncotic pressure is lower and pulmonary capillary permeability is higher, so a cumulative positive balance drives pulmonary edema faster than in the non-pregnant patient
›Preeclampsia, tocolytic use (nifedipine 10 to 20 mg orally, terbutaline 0.25 mg subcutaneously, or magnesium sulfate), and twin gestation raise the risk further
›In these patients use 250 ml aliquots and start a vasopressor earlier rather than chasing a fixed volume
›Blood products
›Transfuse red cells for hemoglobin below 70 g/l, or at a higher threshold with active hemorrhage, disseminated intravascular coagulation, or ongoing ischemia
›Replace fibrinogen and platelets per disseminated intravascular coagulation and hemorrhage protocols
Vasopressors, inotropes, and refractory shock
›Norepinephrine is first line
›Start at 0.05 mcg/kg/min, or 5 mcg/min, through a good peripheral line if central access is not yet in place
›Titrate every 5 to 10 minutes by 0.02 to 0.05 mcg/kg/min to a MAP of at least 65 mmHg; the usual effective range is 0.05 to 0.5 mcg/kg/min
›Switch to smaller increments as MAP approaches 65 mmHg to avoid overshoot and excessive uteroplacental vasoconstriction
›If borderline hypotension only, start at the low end rather than bolusing
›Add-on agents
›Vasopressin 0.03 units/min as a fixed, non-titrated dose when norepinephrine exceeds roughly 0.25 to 0.5 mcg/kg/min
›Phenylephrine 40 to 100 mcg intravenous bolus or 0.5 to 1.4 mcg/kg/min infusion — familiar to obstetric anesthesia and useful as a bridge; expect reflex bradycardia
›Epinephrine 0.05 to 0.5 mcg/kg/min as a second-line add-on; it raises lactate, which is an interpretation trap during clearance monitoring
›Dobutamine 2 to 20 mcg/kg/min if there is myocardial dysfunction with persistent hypoperfusion despite an adequate MAP and preload, considering sepsis cardiomyopathy and peripartum cardiomyopathy overlap
›Monitoring cadence for titrated infusions
›Continuous arterial pressure, with reassessment of the dose response every 5 to 10 minutes during titration
›Hourly urine output, mental status, and peripheral perfusion; lactate every 2 to 4 hours until it is clearing
›Continuous ECG — watch for peaked T waves and QRS widening if acute kidney injury raises potassium, QT prolongation when azithromycin or a fluoroquinolone is combined with electrolyte derangement, and PR or QRS prolongation with magnesium infusion
›Corticosteroid for pressor-dependent shock
›Hydrocortisone 200 mg intravenously per day, as 50 mg every 6 hours or a continuous infusion, when vasopressors are still required 4 or more hours after adequate resuscitation
›Wean when vasopressors are stopped
›When therapy is not working
›Re-image or re-examine for an undrained or undelivered source, including the uterus, a wound, and a pelvic collection
›Reconsider the organism — resistant gram-negative, group A Streptococcus, Staphylococcus aureus, listeria — and whether cover and dosing are adequate
›Reconsider a non-infectious or additional diagnosis — pulmonary embolism, amniotic fluid embolism, HELLP, diabetic ketoacidosis, adrenal crisis, hemorrhage
›Check for evolving necrotizing infection and involve surgery
›Confirm the vasopressor is actually infusing and the line is patent
›Aim to achieve source control within 6 to 12 hours of recognition
›Give the first antibiotic dose and begin resuscitation first, but do not wait for a "perfect" resuscitation
›Delay in source control is a leading modifiable contributor to maternal sepsis death
›Uterine sources
›Retained products of conception or septic abortion — suction curettage or uterine evacuation
›Chorioamnionitis with a viable fetus — deliver; route follows obstetric indication, with vaginal delivery preferred and cesarean reserved for standard obstetric indications, since infection alone is not an indication for cesarean
›An undelivered septic uterus not responding to antibiotics and resuscitation — deliver regardless of gestational age
›Hysterectomy if the uterus is the unsalvageable source, such as clostridial myonecrosis or refractory infection
›Remove an infected cervical cerclage or an intrauterine device
›Non-uterine sources
›Tubo-ovarian or pelvic abscess — image-guided drainage or surgery
›Necrotizing soft tissue infection of a wound, perineum, or abdominal wall — immediate surgical debridement without waiting for imaging, as mortality rises with every hour of delay
›Remove and culture any infected intravascular catheter
Fetal monitoring and delivery decisions
›Monitoring
›Continuous electronic fetal monitoring once the fetus is viable, per the local gestational threshold
›Most fetal heart rate abnormalities — tachycardia, reduced variability, recurrent late decelerations — improve as the mother is stabilized
›Timing decisions
›Do not rush to cesarean for a non-reassuring tracing during active maternal resuscitation unless the tracing stays persistently abnormal after maternal parameters are corrected, or there is a separate obstetric emergency such as abruption, cord prolapse, or uterine rupture
›Maternal instability is a contraindication to elective delivery until it is corrected, unless the uterus is the sepsis source
›Supportive fetal measures
›Treat maternal fever with paracetamol 1 g intravenously or by mouth every 6 hours to a maximum of 4 g in 24 hours, because maternal hyperthermia independently causes fetal tachycardia and worsens neurologic outcome
›Left lateral tilt or manual left uterine displacement for any patient beyond 20 weeks
›Optimize maternal oxygenation and MAP as the primary fetal interventions
›Antenatal corticosteroid and neuroprotection
›Betamethasone 12 mg intramuscularly every 24 hours for 2 doses, or dexamethasone 6 mg intramuscularly every 12 hours for 4 doses, at 24 0/7 to 33 6/7 weeks when delivery is anticipated within 7 days; give a single course even with suspected intra-amniotic infection, but do not delay delivery or source control to complete it
›Verify against current obstetric guideline before use
›Magnesium sulfate 4 to 6 g intravenously over 20 to 30 minutes then 1 to 2 g/hour for fetal neuroprotection when under 32 weeks and delivery is expected within 24 hours, and for eclampsia prophylaxis if preeclampsia coexists
›Reduce the dose and monitor levels, reflexes, and respiratory rate in renal impairment, as magnesium is renally cleared and sepsis-associated acute kidney injury raises toxicity risk
›Calcium gluconate 1 g intravenously over 3 minutes is the antidote for magnesium toxicity
›Verify against current obstetric guideline before use
›Delivery logistics
›Neonatology present at delivery; anticipate early-onset neonatal sepsis and send placental histopathology and neonatal cultures
›If maternal cardiac arrest occurs with a fundus at or above the umbilicus, start resuscitative hysterotomy by 4 minutes to aid maternal resuscitation
›Verify against current resuscitation guideline before use
Airway management and rapid sequence intubation
›Anticipate a difficult airway
›Mucosal edema, weight gain, large breasts, and Mallampati progression in labor and preeclampsia
›Use a smaller tube of 6.0 to 7.0 mm, a ramped position, video laryngoscopy, and the most experienced operator
›Pre-oxygenation and positioning
›Reduced functional residual capacity with raised oxygen consumption causes rapid desaturation, so pre-oxygenate for 3 to 5 minutes with a tight seal
›Apneic oxygenation by nasal cannula at 15 l/min, 20 to 30 degrees head-up, with left uterine displacement
›Drugs
›Aspiration risk is high from reduced lower esophageal sphincter tone and delayed gastric emptying, so perform a true rapid sequence with cricoid pressure at operator discretion
›Induction with ketamine 1 to 2 mg/kg intravenously, which supports blood pressure and is preferred in shock
›Verify against current pediatric guideline before use if the patient is an adolescent dosed by weight
›Etomidate 0.3 mg/kg intravenously is an alternative, but a single dose still causes measurable adrenal suppression in sepsis, so have a low threshold for stress-dose hydrocortisone
›Propofol 1 to 2 mg/kg intravenously, reduced to 0.5 to 1 mg/kg in shock, can drop an already low systemic vascular resistance
›Paralysis with rocuronium 1.2 mg/kg intravenously or succinylcholine 1.5 mg/kg intravenously
›Ventilation targets
›Match the patient's pregnancy-appropriate PaCO2 of about 28 to 32 mmHg; a measured PaCO2 of 40 mmHg signals impending respiratory failure
›Lung-protective ventilation at 6 ml/kg predicted body weight
›Permissive hypercapnia is less well tolerated because of fetal acidosis; keep PaCO2 below 45 to 50 mmHg and maternal pH above 7.30 where possible, and SpO2 at least 95%
›Neuraxial anesthesia is contraindicated in untreated bacteremia or coagulopathy — epidural abscess and meningitis risk; defer until antibiotics are given, the patient is improving, and platelets and coagulation are acceptable