Puerperal sepsis of a new mother

Puerperal sepsis is a certain or suspected infection associated with organ damage that occurs from the rupture of the amniotic sac to the 42nd day after delivery. It occurs mainly after discharge, in the first 24 hours after delivery.

After obstetric hemorrhage, puerperal sepsis is the second leading cause of direct maternal mortality in our country. Globally, it is the sixth leading cause of disease among women aged 15-44; Every year there are 5.2 million new cases of maternal sepsis and it is estimated that 62,000 of these cases are fatal (10.7% of maternal deaths globally).

Sepsis is also among the preventable conditions and it has been widely demonstrated that the implementation of prevention measures is effective in reducing the incidence of infection. It has also demonstrated the importance that these infections are recognized, prevented and managed promptly to facilitate an effective therapeutic pathway.

Definition

In 2016, at the end of a year of work, on the occasion of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) sepsis was defined as “a life-threatening organ dysfunction caused by an unregulated response of the body to an infection“. From this definition it is clear that the two key words of sepsis are: infection (organ) and damage (organ).

Apparatuses involved in the infection

In the obstetric population, the systems most frequently involved in infections are:

  • the genital apparatus;
  • the urinary tract;
  • udders;
  • the respiratory system;
  • the cardiovascular system;
  • the central nervous system;
  • The digestive system;
  • the integumentary apparatus.

Diagnosis of maternal sepsis

To make the diagnosis of maternal sepsis:

  • in case of suspected or certain infection it is necessary to look for signs and symptoms of organ damage;
  • in case of organ damage not otherwise explained, it is necessary to look for signs and symptoms of a suspected or certain infection;
  • in case of alteration of vital signs it is necessary to look for signs and symptoms of infection and organ damage to exclude or confirm the diagnosis of sepsis;

Pending the development of internationally validated diagnostic criteria for maternal sepsis at national level, the ItOSS project has adopted the following diagnostic criteria for the clinical diagnosis of infection and organ damage.

Criteria for clinical diagnosis of infection

The clinical diagnosis of infection is based on the detection of at least one of the following signs/symptoms:

  • fever ≥38°C;
  • headache and/or neck stiffness;
  • respiratory symptoms (productive cough, pharyngodynia, etc);
  • respiratory distress (respiratory rate ≥20 breaths/min and/or use of muscles
  • accessory and/or hypoxemia with SpO2 <95%);
  • urinary symptoms (dysuria etc);
  • abdominopelvic pain and tension;
  • diarrhea or vomiting;
  • skin rash;
  • foul-smelling vaginal discharge;
  • preterm contractions and/or premature rupture of membranes in preterm pregnancies (PPROM);
  • malodorous and/or puruloid amniotic fluid in case of PPROM;
  • signs of fetal or neonatal infection.

Criteria for diagnosis of organ damage

The diagnosis of organ damage is based on the finding of at least one of the following parameters:

  • cardiovascular: PAS <90 mmHg or PAM <65 mmHg;
  • respiratory: need for oxygen to maintain SpO2 >95%;
  • Renal: creatinine level >1.2 mg/dl;
  • hepatic: bilirubinemia value >1.2 mg/dl;
  • central nervous system: alterations in the state of consciousness;
  • haematological: platelet value <100,000/mm3 or 50% decrease compared to usual values in pregnancy.

These parameters have been extrapolated from those of the SOFA (Sequential sepsis related Organ Failure Assessment score) and adapted to the diagnostic needs of health professionals who assist women in pregnancy, childbirth or puerperium.

Risk factors

Risk factors contributing to infections are caused by repeated handling of patients during delivery, prolongation of labor or rupture of the amniotic sac, as well as poor sanitary conditions before and after delivery, and poor services within facilities sanitary.

Among the main independent risk factors for sepsis, obesity and cesarean section should also be mentioned.

Improved care practice

From an observational, prospective population-based study carried out in 9 regions (75% of those bornin Italy) in the years 2018-2020 it emerged that the aspects susceptible to improvement of care practice are:

  • timeliness of diagnosis and early start of the sepsis six bundle;
  • choice of evidence-based antibiotic therapy schemes;
  • reduction in the number of vaginal explorations in labour;
  • asepsis in invasive care procedures.

In the literature, the lethality of sepsis in obstetrics is often associated with substandard care, most often due to a late diagnosis of the condition.

Prevention

According to the Istituto Superiore della Sanità dossier, the key messages to improve infection prevention are:

  1. if a pregnant or postpartum woman reports a malaise “think early about the infection/sepsis” among the possible differential diagnoses;
  2. if a pregnant or postpartum woman repeatedly goes to the general practitioner, local services or emergency room, consider this behavior as an alarm bell and carefully look for possible signs of infection/sepsis;
  3. during the seasonal influenza epidemic, promote the active offer of influenza vaccination;
  4. inform women, within 24 hours of childbirth, about the signs and symptoms indicative of risky clinical conditions, including infection/sepsis, to invite them to seek immediate health care; identify and report infection/sepsis risk factors in health records to aid in the suspicion/diagnosis of complications.

Puerperal sepsis, conclusions

All healthcare professionals should be familiar with the signs and symptoms of puerperal sepsis and be aware of the rapid and life-threatening course of this condition particularly as it progresses to septic shock. It is important to remember that the clinical signs/symptoms of infection and organ damage vary according to the site and are often subtle due to the physiological alterations of pregnancy.

Katherine Johnson, M.D., is a board-certified obstetrician-gynecologist with clinical expertise in general obstetrics and gynecology, family planning, women’s health, and gynecology.

She is affiliated with the Obstetrics and Gynecology division at an undisclosed healthcare institution and the online platform, Maternicity.com.

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