Pregnancy-Related Sepsis Deaths Linked to Delays in Care

Neil Osterweil

September 09, 2015

Maternal deaths from pregnancy-related sepsis are uncommon in the United States, but the few that do occur may be preventable with better recognition of early sepsis, prompt administration of appropriate antibiotics, and care escalation when necessary, a research team advises.

A review of maternal deaths from sepsis in Michigan during an 8-year period showed that sepsis was identified as the cause of death in 22 of 151 women who died from pregnancy-related causes. The available hospital records for 15 cases showed that for 11 patients, there was a delay in starting antibiotics, and in eight cases, there was a delay in escalation of care, report Melissa E Bauer, DO, assistant professor of anesthesiology at the University of Michigan Medical Center in Ann Arbor, and colleagues.

"If further studies reveal a similar rate of maternal deaths at home due to sepsis and postpartum deaths after discharge, there may be a role for improving patient education concerning when to seek medical attention, timing of postpartum visits, and use of home visits," the investigators write in an article published in the October issue of Obstetrics & Gynecology.

Dr Bauer and colleagues combed through surveillance data on maternal deaths from the Michigan Department of Community Health. The deaths occurred from 1999 through 2006 and included deaths during pregnancy and up to 42 days postpartum.

They defined maternal death from sepsis as sepsis listed on the death certificate as the cause of death, determination of sepsis as the cause of death by consensus of the Maternal Mortality Medical Surveillance Committee, or identification of a specific source of infection leading to organ failure according to American College of Chest Physicians and Society of Critical Care Medicine's definitions of severe sepsis.

The rate of maternal deaths resulting from sepsis was 2.1 per 100,000 live births. When the researchers added in sepsis-contributing deaths (deaths from other causes but with sepsis regarded as a contributing factor), the rate increased to 2.9 per 100,000.

Among 12 women who presented to the hospital with sepsis, nine had one or more vital sign abnormalities, including a heart rate higher than 120 beats per minute, respiratory rate greater than 30 breaths per minute, systolic blood pressure below 90 mm Hg, and peripheral capillary oxygen saturation less than 95% on room air. However, only two of 11 women with sepsis had a fever on presentation, and three of 12 never developed a fever during their hospitalizations.

The authors suggest that documented respiratory rates may have been inaccurate in some cases. Of 11 women with documented respiratory rates, eight had measurements of 18, 20, or 24 breaths per minute. "On review, the pH and lactate levels taken shortly after decompensation and respiratory rate documentation depicted a state of metabolic acidosis so severe that a normal respiratory rate would not likely have been possible," the authors write. "Although respiratory rate is poorly documented in clinical settings, it has been shown to correlate with severity of sepsis in the general population."

In 15 of the cases in which the patients received hospital care for sepsis, 11 women were treated initially with antibiotics that did not provide adequate coverage based on their clinical situation. In addition, for two of the 15 patients, it was not possible to determine from the record whether adequate antibiotics had been used. The remaining two patients received the appropriate initial antibiotic, the authors found.

Of the 15 women who were treated for sepsis in hospital, eight had a delay in escalation of care, five had appropriate escalation of care, and two had indeterminate evidence of the timing of care.

The seven patients with sepsis not treated in the hospital either died at home or were dead on arrival. The investigators could not determine whether these women had sought treatment before their deaths.

"Observations from this study lead to the following suggestions: 1) consider maternal sepsis in critically ill women even in the absence of fever; 2) administer early appropriate antibiotic therapy and use consultation (maternal–fetal medicine, infectious disease, critical care) early if there is marked derangement in vital signs or an inadequate response; 3) vital sign derangement should be investigated, closely monitored, and, if severe, should prompt escalation of care; and 4) vital signs should be accurately taken at appropriate intervals consistent with the maternal condition," the investigators recommend.

The study was funded by the University of Michigan Department of Anesthesiology and grants to coauthors.

Obstet Gynecol. 2015;126:747-752.


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