01:03am Sunday 23 February 2020

TOG release: Group A streptococcal has few symptoms but can rapidly lead to severe maternal morbidity

Genital tract sepsis has been identified as the leading cause of direct maternal deaths in the UK in the Saving Mothers’ Lives report published in 2011. Most cases were associated with community acquired GAS infection. The report mentions 26 direct deaths from maternal sepsis during the 2006–8 triennium, 13 of which were due to GAS infection, 6 of these were GAS puerperal sepsis.

The Health Protection Agency has reported an increase in the number of severe cases of GAS infection in the UK in December 2008, and again in December 2010.

Women often have few or no clinical symptoms initially for GAS. However, the infection has the potential to progress rapidly to a life-threatening invasive infection.  Early recognition and prompt intervention are, therefore, essential to prevent severe morbidity and maternal mortality, states the review.

Over the last century cases of GAS have declined through better hygiene such as hand washing and the introduction of penicillin. The number of GAS infections is now estimated to be about 3–4 cases per 100,000 population every year in developed countries. However, despite the low numbers GAS carries a relatively high mortality rate.

GAS infections cause varying degrees of symptoms from mild respiratory, skin and soft tissue infections to serious invasive infections.

GAS puerperal sepsis also has diverse symptoms. Early symptoms can present within the first 48 hours of delivery and are like those of influenza including fever, rigours and a fast heart rate. However women can develop symptoms up to 7 days postpartum.

Other symptoms include sudden severe limb or chest pain and lower abdominal pain. Also early symptoms can include an altered mental state, prior to rapidly deteriorating and developing streptococcal toxic shock syndrome.

The review states that women presenting postnatally with puerperal sepsis should be promptly investigated. Antibiotics need to be commenced immediately. If treatment is delayed the risk of death is increased.

Following initial treatment, if the woman shows signs of deterioration it is essential to look for signs of deep infection and radical surgical intervention may be necessary such as a hysterectomy.

About 5–12% of all severe GAS infections are found to be associated with health care. Transmission is usually through direct contact with droplets of saliva, nasal secretions or infected lesions of people with the condition. Women need to be made aware of the importance of personal hygiene. Moreover, healthcare workers are possible sources or carriers of the infection says the review.

Nithiya Palaniappan, Specialty Trainee in Obstetrics and Gynaecology, Royal Infirmary of Edinburgh and co-author of the review said:

“With Group A streptococcal infection, the patient’s condition can deteriorate very rapidly, even within hours with little warning. It is vital that healthcare workers are alert to suspect the infection and intervene even with non-specific symptoms.

“Personal hygiene is the most important factor in preventing the infection. Managing the healthcare environment and close community contacts is the key to effective containment of the infection.”

TOG’s Editor–in-Chief, Jason Waugh added:

“This review highlights the seriousness of Group A streptococcal infection. Early recognition is necessary in order to prevent severe morbidity. This infection can progress rapidly and have devastating effects.” 


For more information please contact Naomi Weston on 020 7772 6357 or nweston@rcog.org.uk 


The Health Protection Agency’s GAS Guideline Development Working Group has drafted a set of guidelines for the investigation, control and prevention of spread of group A streptococcal (GAS) infection in acute healthcare settings in the United Kingdom. For more information please click here.

The Obstetrician & Gynaecologist (TOG) is published quarterly and is the Royal College of Obstetricians and Gynaecologists’ (RCOG) medical journal for continuing professional development. TOG is an editorially independent, peer reviewed journal aimed at providing health professions with updated information about scientific, medical and clinical developments in the specialty of obstetrics and gynaecology.


Palaniappan N, Menezes M,Willson P. Group A streptococcal puerperal sepsis: management and prevention. The Obstetrician & Gynaecologist 2012;14:9–16

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