By Jeanine Mikek, MSN, RN, CEN, RNC-NIC
Maternal Child Health Educator, IU Arnett Hospital, Lafayette, IN
Ms. Mikek reports no financial relationships relevant to this field of study.
SYNOPSIS: In this analysis of California deliveries between 2008 and 2011, risk factors for maternal readmission for sepsis were found to include preterm birth, hemorrhage, obesity, and a primary cesarean delivery.
SOURCE: Foeller ME, Sie L, Foeller TM, et al. Risk factors for maternal readmission with sepsis. Am J Perinatol 2020;37:453-460.
Data from the California Department of Public Health were collected from birth certificates and hospital discharge records to better understand what factors may precipitate maternal readmission for sepsis up to nine months after delivery. In alignment with the World Health Organization definition of sepsis from 2017, the presence of organ dysfunction was required for those cases to be included in the study. More than 1.88 million deliveries over the gestational age of 20 weeks were reviewed, and a total of 494 (0.03%) women were readmitted. Out of the 494 readmissions, 192 patients (39%) were hospitalized with sepsis less than six weeks after delivery (early sepsis) and the remaining 61% (n = 302) were readmitted between six weeks and nine months post-delivery (late sepsis. Multiple variables were investigated, including sociodemographic differences such as maternal age, ethnicity, comorbidities, body mass index (BMI), and mode of delivery. In addition, specific complications related to pregnancy also were reviewed, such as infection or sepsis during delivery admission, unplanned cesarean deliveries, or postpartum hemorrhage.
Women who were readmitted for sepsis were more likely to have an increased BMI and a younger gestational age at delivery (P < 0.001). Readmission with sepsis was found more commonly in those who had government-issued insurance and underwent a primary cesarean delivery (P < 0.001). Surprisingly, the statistical significance reflecting chorioamnionitis as a potential risk factor is not profound (P = 0.047). In fact, hemorrhage and preeclampsia were found to be of greater risk and had higher incidences in the readmission group (P = 0.038 and P < 0.001, respectively).
More than three-fourths of the readmissions within nine months post-delivery had infectious processes identified, primarily a urinary tract infection, pyelonephritis, or pneumonia. The majority of infecting organisms were found to be Escherichia coli (10%), Staphylococcus (8%), and Streptococcus (5%).
COMMENTARY
There are many factors that can place a postpartum patient at increased risk for sepsis. Interestingly, women in the study who experienced a birth with a gestational age less than 28 weeks demonstrated a sevenfold increase in risk for sepsis readmission within six weeks postpartum. Several factors may contribute to this, including underlying infection that could precipitate the preterm birth, maternal immune dysregulation, or variants of tumor necrosis factor. However, the direct reasoning behind the correlation remains unclear.
With nearly 49 million cases worldwide and 11 million associated deaths, sepsis is a leading cause of mortality for all patients and should not be taken lightly.1 Because of the high mortality rate, healthcare providers must be observant and suspicious for sepsis when the patient reports feeling ill or has vague complaints. At the six-week postpartum visit, providers should be cognizant of questioning patients about any physical symptoms that could reflect a potential infection and overall physical health.
Although the majority of pregnant patients who are readmitted for sepsis do so within the first nine months postpartum, infection also can be present during pregnancy/labor and may be difficult to identify. Typically, vital signs that raise suspicion for sepsis include an elevated temperature, increased heart rate, and/or increased respiratory rate.2 However, pathophysiological changes of pregnancy can mimic signs of an infection and can hinder recognition, testing, and treatment. For example, an elevated heart rate caused by increased cardiac output, as well as shallow breaths and decreased functional residual capacity of the lungs, can be justified by either labor progression or a potential infectious process.3
Screening tools exist to help guide provider questions and assessments with an emphasis on feelings of fatigue or pain, elevated temperature, increased heart rate or weakness, and shortness of breath. Such examples include the quick Sequential Organ Failure Assessment (qSOFA) score, Modified Early Warning Score (MEWS), and Systemic Inflammatory Response Syndrome (SIRS) criteria.4 Although the screening tools can increase knowledge, awareness, and prompt treatment, the majority of mothers do not present as septic while in labor or in the immediate postpartum period of two to three days.5 Therefore, patients need to be well educated to watch for these symptoms at home and to call their provider when feeling ill.
Sepsis is a topic discussed much more commonly in the emergency department when compared to labor and delivery or postpartum units in the hospital setting. Best practices related to decreasing infection rates are used in the labor and delivery process, including sterile insertion of a urinary catheter and proper application of a surgical skin cleanser prior to a cesarean delivery. However, infectious processes can begin at any time, and the study found that most mothers present with sepsis weeks to months after delivery, not in the day or two they still are hospitalized. Discharge education related to sepsis should be discussed on the postpartum unit, and instructions on when to call a provider (such as presence of a fever, body aches, fast heart rate, dizziness, etc.) should be provided for all deliveries, not just cesarean deliveries. At the postpartum visit in the office or clinic, providers should question any new symptoms the mother has experienced, and patients should not hesitate to call telephone triage for medical advice if they are feeling ill.
REFERENCES
- World Health Organization. Sepsis. Aug. 26, 2020. https://www.who.int/news-room/fact-sheets/detail/sepsis
- California Maternal Quality Care Collaborative. Improving diagnosis and treatment of maternal sepsis. https://www.cmqcc.org/resources-toolkits/toolkits/improving-diagnosis-and-treatment-maternal-sepsis
- Greer O, Shah NM, Johnson MR. Maternal sepsis update: Current management and controversies. The Obstetrician & Gynaecologist 2020;22:45-55.
- Niehaus MT, Baldisseri MR. Sepsis in Pregnancy. In: Hyzy RC, McSparron J, eds. Evidence-Based Critical Care: A Case Study Approach. Springer;2020:767-770.
- Shields LE, Wiesner S, Klein C, et al. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol 2016;214:527.e1-527.e6.
