Overview:
Maternal Sepsis
Background
Maternal sepsis, also called “puerperal sepsis”, is defined by WHO as “infection of the genital tract occurring at any time between the onset of rupture of membranes or labor and the 42nd day postpartum, in which fever and one or more of the following are present: pelvic pain, abnormal vaginal discharge, abnormal smell/foul odor of discharge and delay in the rate of reduction of the size of the uterus”.[1] This includes chorioamnionitis and endometritis. In the absence of treatment, maternal sepsis may lead to death and serious long-term morbidity such as chronic pelvic pain, pelvic inflammatory disease and secondary infertility.[2]
Epidemiology
- Maternal sepsis causes at least 75,000 maternal deaths every year, mostly in low-income countries,[3] and accounts for 14% of maternal mortality in Asia and Africa.[4]
- For every death there are a number of women who suffer acute and/or long-term morbidity, although data for a precise estimate are lacking.
- There are multiple risk factors associated with maternal sepsis including home birth in unhygienic conditions, low socioeconomic status, poor nutrition, and caesarean sections.[5]
The intervention assessments below summarize the information presented in the
"Key Findings" table.
Prevention: What Works?
There are three major categories of prevention interventions that have been assessed for maternal sepsis: antibiotics, labor management, and supplemental therapies. Health care worker hand washing is considered standard of practice, as in medicine generally, and thus not reviewed here.
-
Antibiotics.
Strong evidence suggests that for women with premature rupture of membranes and other high risks, preventive antibiotics reduce sepsis by 52-90%.[6] Antibiotics before c-section reduce both sepsis (46 – 61%) and mortality (50-72%), based on very strong evidence.
-
Labor management.
Drugs to induce labor after 37 weeks gestation or if pre-labor rupture of membranes reduce sepsis by 25-70%, based on strong evidence, and potentially c-sections by 6-9%. Active management does not have a statistically significant effect on sepsis, however very strong evidence indicates that it reduces C-sections by 12-23%. Training traditional birth attendants (TBAs) can reduce the risk of sepsis by 83% (one study, moderately strong evidence).
-
Supplemental therapies.
Nutritional supplements and chlorhexidine vaginal wash have been examined, but not found to provide statistically significant benefit.
Treatment: What Works?
Antibiotics reduce the incidence and severity of the serious sequelae of maternal sepsis, and are considered standard of care. Thus, evidence comparing antibiotics to no therapy or placebo is generally unavailable. Instead, we focused on differences among antibiotic regimens. We found one study in progress of antibiotics vs. none for a milder form of sepsis, chorioamnionitis (amniotic fluid infection).[7]
-
Clindamycin plus aminoglycoside
for endometritis (a severe type of sepsis) has been shown to reduce treatment failures by 30% (very strong evidence) and other complications and wound infection by 22-48% (moderate evidence), compared with multiple other antibiotic regimens. Similar studies for chorioamnionitis have shown no significant differences among antibiotic regimens.
Summary / Future Directions
Prevention. Antibiotics and labor-inducing drugs can prevent most maternal sepsis. Training of traditional birth attendants appears to reduce sepsis, independent of these drugs.
Treatment. Antibiotics are the mainstay of treatment. For women with endometritis, clindamycin plus aminoglycoside is significantly more effective than other antibiotic regimens.
Reduction of maternal mortality by 75% between 1990 and 2015 is the first target of the fifth United Nations Millennium Development Goals (MDGs). However, according to WHO this target is critically off track, and the short-fall is particularly acute in sub-Saharan Africa.[8],[9] With regard to maternal sepsis, there is a stark disjunction between the technical means to reduce mortality and severe morbidity and the increased attention to improved emergency obstetric care that will be needed if the MDG is to be achieved. The main barrier to success appears to be the insufficient application of available interventions.
References
1. van Dillen, J., J. Zwart, et al. Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis. 2010; 23(3): 249-254.
2. Abouzahr C, Aaahman E, Guidotti R. Puerperal sepsis and other puerperal infections. In: Health dimensions of sex and reproduction: the global burden of sexually transmitted diseases, maternal conditions, perinatal disorders, and congenital anomalies, eds. CJL Murray and AD Lopez, WHO 1998.
3. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007; 62:393–399.
4. Khan KS, Wojdyla D, Say L, et al. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006; 367:1066–1074.
5. van Dillen, J., J. Zwart, et al. Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis. 2010; 23(3): 249-254.
6. This is an interquartile range – from 25th to 75th percentile of studies.
7. NIH. Treatment of chorioamnionitis after delivery – clinical trial. Available from: http://clinicaltrials.gov/ct2/show/NCT00814905.
8. Cross, S., J. S. Bell, et al. What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries. Bull World Health Organ. 2010; 88(2): 147-153.
9. WHO. Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. 2007. Available from: http://www.who.int/whosis/mme_2005.pdf
-- Updated June 2011