Atypical Presentation of Group A Streptococcal Puerperal Sepsis and Toxic Shock Syndrome: A Case Report

Sepsis remains a significant cause of maternal mortality, and is responsible for approximately 11% of maternal deaths worldwide. Group A β-haemolytic Streptococcus (GAS) is one of the pathogens linked to maternal sepsis. It is notable for its virulence, rapidly progressing to invasive group A streptococcal (iGAS) infections with a high mortality rate of 20–40%. The authors report a case of puerperal sepsis due to GAS in a postpartum woman who initially presented with limb swelling following an uneventful vaginal delivery. Within hours, she rapidly deteriorated into septic shock, despite early initiation of the Sepsis Six pathway. GAS was isolated from both the genital tract and blood, even though classic symptoms of endometritis were absent. Intensive treatment, including broad-spectrum antibiotics, fluid resuscitation, intravenous Ig, intensive care support, and surgical debridement successfully saved her life. However, she experienced prolonged morbidity due to extensive tissue loss from wound debridement. Although iGAS is rare in the UK, pregnant and postpartum women have a significantly increased risk, particularly within the first 28 days postpartum. Puerperal GAS infections often present atypically, with non-specific symptoms rather than classical signs of endometritis. Given the high mortality associated with iGAS, a high index of clinical suspicion, early recognition, and aggressive management are critical to improve the outcome.