Sepsis in Obstetrics

Sepsis in Obstetrics

Dr Lay-Kok Tan

MBBS FRCOG MMED(OG) FAMS

Senior Consultant, Department of OBGYN

Singapore General Hospital

Adjunct Associate Professor, Duke-NUS Graduate School of Medicine

Overview

Size of the problem

Risk factors

Concept of the continuum of sepsis

Pitfalls in diagnosis

Management of sepsis in obstetrics

Why this interest in sepsis?

Why this interest? Sepsis as cause of maternal mortality is a problem of THE PAST and stastistics show its DRAMATIC decline over last DECADES

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Why this interest in sepsis?

18th and 19th centuries, puerperal fever >50% of maternal deaths in Europe

Today accounts for up to 15% of maternal deaths worldwide

Global burden of maternal sepsis >6.9 million / year (WHO)

75k maternal deaths /year in low income countries

Health disparity: low versus high income countries >3:1

But sepsis CONCERNS the developed world

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Why this interest in sepsis?

UK: sepsis leading cause of direct maternal deaths

29 cases: rate up from 0.85 to 1.13/100,000 maternities

From EARLY 2000s, leading cause was sepsis

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Why this interest in Sepsis?

Increase in maternal deaths in UK

Tripled in last 25 years

CEMD: lack of recognition of signs, lack of guidelines on management

Urgent need for national clinical guideline to cover identification & management of sepsis in pregnancy, labour and postnatal period

RCOG issued two guidelines for sepsi IN and AFTER pregnancy

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In USA, sepsis is NOT a small player and shares same freq as hypertnsive disorders

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Maternal Sepsis in USA

4th leading case of maternal mortality (USA), 13%

MMWR Surveillance Summ 2003

5% of maternal admissions to ICU

Pollock W et al. Intensive Care Med 2010

Frequency increasing 1:15,385 (1998) to 1:7246 (2008)

10% increase sepsis-related maternal death

Bauer MET et al Anesth Analg 2013

BURDEN is particuarly CONCENTRATED in Asia, Africa, Central and South America,

SIGNIFICANT missing data

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Over 6.9 million / year (WHO)

75k maternal deaths /year in low income countries

High income countries: 0.1-0.6 / 1000 deliveries (2.1% of all maternal deaths)

Low income 11.6% of maternal deaths

Over 6.9 million / year (WHO)

75k maternal deaths /year in low income countries

Maternal deaths from Sepsis are largely

PREVENTABLE

The CONSTANT REFRAIN we hear is that

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A NZ study looking at PREVENTABILITY of severe maternal morbidity

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That the most common causes of preventable morbidiy was HAEMORRHAGE which all obstetric units are fully aware of and significant RESOURCES dedicated for this, and SEPTICAEMIA, which arguably has not received the same ATTENTION

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Low incidence of bacteremia (0.2%) (54/37584)

No maternal deaths

Sepsis occurs at all gestational ages

URINARY TRACT most common route for Prenatal bacteraemia

GENITAL TRACT most common route for Intrapartum & Postpartum bacteraemia

E coli the most common organism

38% pre and intrapartum bacteraemia & 79% postpartum bacteraemia had raised WBC

Obstetric settlings abortion, miscarriage, PPROM, stillbirth

AN Irish study reviewing maternal bactermia found LOW incidence of SEPSIS occuts at ALL gestation ages, the URINARY trach for PRENATAL and GENITAL TRACT for intraprtum and postpartum, E coli

Not all baecteremia elicited a leucocytosis, and the commonest obstetric settings were

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The same centre studied maternal and fetal outcomes

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Sepsis rate of 1.8 per k, E coli and GBS commonest, Strep A postpartum sepsis,, preterm lidevery, increased perinatal MR

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Fetal Outcome & Maternal Sepsis

Pregnancy looses significant in 1st and second trimester

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Obstetric interventions & Sepsis

They found BOTH CS and INSTRUMENTAL were INTERVENTIONS a/w sepsis

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So causes can be divided into obstetric, genital and non genital, and non obstetric causes, which obstetricians in particular should not forget

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Among the risk factors identified, the PREVALENT ones include obesity, diabeteswary of those who have stitches inesrted, and ROM

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These can be perhaps better organised, divided into obsetric and patient factors

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The single most important risk factor for post-partum infection is caesarean section

van Dillen J, Zwart J, Schutte J, et al. Maternal sepsis: epidemiology, etiology and outcome.

Current Opinion in Infectious Diseases 2010;23(3):24954.

CS carries 5-20 fold increase in infectious morbidity compared with vaginal birth

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Sepsis

Syndrome reflecting patients systemic response to infection

=SIRS + Infection

Satisfies 2 or more

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Challenges in Obstetrics

Overlap between physiological changes in vital signs and inflammatory response

Immune modulation leading to differential response to infection

By these criteria Pregnancy associated immune modulation leads to

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Other challenges

decreased vigiliance and complaisance

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Other problems

Source of infection was not apparent in 44% of their patients with septic shock.

Mabie WC, Barton JR, Sibai B. Septic shock in pregnancy. Obstet Gynecol. 1997;90:55361.

Time from the first symptom of infection to full-blown sepsis was