In the late evening, a call was received from the emergency department (ED) regarding an unwell postnatal patient. The patient had been triaged presenting with a complaint of severe abdominal pain, as well as pain, tenderness, and swelling in the right arm and was noted to be pale and diaphoretic. She was seven days post vaginal birth. The ED recognised the presentation as potential sepsis. Blood cultures were collected, and fluid resuscitation and antibiotics (piperacillin and tazobactam) were initiated according to local protocols. The on-call sonographer was requested to attend, and the patient referred to obstetrics and gynaecology.

On review by the gynaecology team, the patient was found to be extremely unwell. She was drowsy and struggled to provide a history. Collateral history provided by family members reported multiple days of severe abdominal pain, pain and swelling in the right arm, and a sore throat. She denied excessive vaginal bleeding. On examination she was found to have a fluctuating GCS (rousable to voice), an exquisitely tender abdomen, malodorous vaginal discharge without excessive bleeding, and a swollen, tender right arm. No other localising symptoms were noted. She had an intermittent oxygen requirement with tachypnoea and was hypotensive and tachycardic, despite appropriate fluid resuscitation.

Preliminary investigations revealed raised inflammatory markers (WCC 23.4, CRP 290), acute liver function derangement, an evolving acute kidney injury, and a lactate of 1.1. Pelvic ultrasound showed a 700cc uterus, with no myometrial definition and a 42x23x27mm distended cavity with vascularity concerning for retained products of conception. She continued to test positive for influenza B (she was known to be positive from 35 weeks).

The patient was admitted under Obstetrics and Gynaecology. She was identified as high risk of Group A Streptococcus (GAS) sepsis, and antibiotics were extended to include clindamycin. The septic screen was extended to include repeat lactate, chest x-ray, urine MCS, and upper limb ultrasound. She was transferred to the ward, and ICU review was requested given concern for clinical deterioration.

On review of her pregnancy, the patient was complex with a high-risk pregnancy history. She was 36 years old, G5P2 with risk factors including smoking and marijuana use, a long inter-pregnancy interval, and mental health concerns for which she was known to a perinatal mental health service. Her pregnancy was complicated by admissions for cannabinoid-induced hyperemesis, gestational hypertension developing into pre-eclampsia from 33 weeks (requiring oral labetalol), and influenza B at 35 weeks.

On the background of influenza B, she was admitted for an abnormal CTG at 36+3 and underwent an induction at 36+4 for the same reason. Following an ARM (which revealed thick meconium) she had a precipitous vaginal birth. Active management of third stage led to delivery of placenta after 10 minutes, with a total blood loss of 320ml and a placenta documented as complete/complete. She was afebrile throughout her labour and postpartum admission, and was documented to have expected postpartum pain and bleeding. She remained an inpatient for blood pressure monitoring and was discharged on day three postpartum.

Following her re-presentation one-week postpartum, she was admitted to the obstetrics ward and care was escalated immediately via a MET call for clinical deterioration and hypotension non-responsive to fluid resuscitation. Despite being given two litres of CSL and 500ml 5% albumin, she remained hypotensive and thus was admitted to the ICU requiring vasopressor support. Her clinical progress is detailed below.

Day 1 ICU:

Following stabilisation in the ICU, she was noted to have an intermittent vasopressor requirement, fluctuating delirium and liver derangement, secondary to toxic shock. The patient underwent a suction, dilatation, and curette for source control and under ultrasound guidance, a large volume of malodorous products of conception were removed, later confirmed on histopathology. The procedure was complicated by secondary postpartum haemorrhage (1.2L blood loss), requiring full medical management.

Day 2 ICU:

Preliminary blood culture results revealed a gram-positive cocci, likely group A streptococcus (GAS). The infectious diseases service was consulted, GAS public health notification was made, contact tracing was commenced, and the antibiotic regime was extended to include high dose benzylpenicillin, ceftriaxone, clindamycin, and vancomycin. All of the patient’s household contacts were treated with cephalexin and the newborn was reviewed by paediatrics.

Intravenous immunoglobulin (IVIG) was administered, and a cephalic/subclavian deep venous thrombosis of the right arm was identified. Therapeutic clexane was commenced.

Day 3 ICU:

Due to anaemia (Hb 59), the patient was transfused two units PRBCs and given a second dose of IVIG due to limited clinical improvement from sepsis.

Day 4 ICU:

Symptoms concerning for heart failure prompted an echocardiogram which revealed new onset cardiac dysfunction, including mild left ventricular dilatation with moderate global systolic dysfunction. This picture was concerning for potential transfusion-related lung injury, versus septic or postpartum cardiomyopathy. Cardiology was consulted and felt the presentation was in keeping with an acute or chronic insult precipitating decompensation and initiated diuresis. The patient was clinically improving but was understandably suffering from deterioration in mental health due to the burden of her illness preventing her from bonding with her baby. The patient’s ability to breastfeed was also limited due to the severity of her illness and support was sought from the hospital’s lactation consultant service.

Day 5 ICU:

With clinical improvement, the patient was discharged from the ICU.

The patient had a prolonged stay on a general ward under multidisciplinary team care, including input from medical, infectious disease, haematology, cardiology, and O&G teams. Psychiatry assisted in supporting the patient with the extreme toll this experience took on her mental health. A repeat echocardiogram prior to discharge revealed resolution of the abnormal findings, and cardiology felt this was in keeping with either takotsubo or peripartum cardiomyopathy, with complete resolution. Antibiotics were slowly down-titrated and the patient was eventually discharged two weeks following her initial readmission, with ongoing follow up from the teams detailed above. At a debrief review facilitated by the O&G and ICU departments, the patient expressed how traumatic and distressing this experience was for both herself and her family.

This case highlights the severity of postpartum sepsis and septic shock, and the significant toll that it can take on a patient’s physical but also mental wellbeing. Sepsis can be lethal and is recognised as an event which can be “life-changing” and critically impacts the “woman’s passage to motherhood, the establishment of breastfeeding and her ongoing connection to her baby.”¹ While E.Coli is the most common cause of maternal bacterial infection, the most frequent case of maternal death from sepsis is infection with Group A beta-haemolytic streptococcus (GAS), also known as streptococcus pyogenes, species¹ – the notable culprit in this case.

Although considered rare, GAS is described by SOMANZ as a “devastating disease”² and a 20-fold increase in incidence is seen in pregnant and postpartum women, compared with non-pregnant women,³ the reason for which is not clear.⁴ It is carried asymptomatically amongst the community and is spread from person to person via contact or droplet,² hence the need for contact tracing. The clinical presentation can be extremely varied, and thus a high index of suspicion is required for early diagnosis. However, classically concerning symptoms include a sore throat, diarrhoea, and/or abdominal pain, antenatally or postnatally.²

Treatment of suspected sepsis must be aggressive, and rapid recognition, early antimicrobial initiation, and involvement of senior staff remain essential factors to improving outcomes.² An interesting practice point in this case was the use of intravenous immunoglobulin (IVIG). IVIG has an immunomodulatory effect and in streptococcal sepsis neutralises the super-antigen effect of exotoxins and inhibits production of tumour necrosis factor and interleukins.⁵

To conclude, this case illustrates the rapid progression and profound morbidity of puerperal sepsis due to GAS. Early recognition, aggressive multidisciplinary management, and supportive care were vital to the patient’s survival. Beyond physical sequelae, the psychological impact was significant, underscoring the importance of holistic follow-up in maternal critical illness.