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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