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Sepsis Redefined
Vol. 21 No 4 | Summer 2019
Feature
Maternal care: public health interventions
Dr Alexandra Bonner
MBBS, MPHTM, FRANZCOG

Public health interventions are essential in preventing maternal sepsis. Maternal sepsis, during and after pregnancy, may arise from many sources and is not limited to infections arising from the genital tract. Given the diversity of sepsis causation pathways, it is essential that targeted evidence-based interventions are identified.1

Management of sepsis is no longer limited to the acute care of individual patients. Prevention and treatment of sepsis is now recognised as a public health challenge requiring population- and systems-based solutions. This article aims to frame maternal sepsis as a public health issue and provides an overview of the primary, secondary and tertiary prevention approaches available using Kempker’s conceptual model of prevention (Table 1).2

Kempker’s model can be used to reframe maternal sepsis from a prevention perspective and identify systematic evidence-based interventions that are relevant to the antenatal, intrapartum and postnatal periods.

In this context, primary prevention refers to the prevention of infection or the sepsis event. Secondary prevention refers to the early recognition and treatment of sepsis. Tertiary prevention refers to in-hospital and post-hospital treatment to reduce the long-term consequences of sepsis.

Table 1. Primary, secondary and tertiary prevention approaches to sepsis.

Traditional model of prevention

Maternal sepsis

PRIMARY PREVENTION: Prevention of infections and onset of sepsis
Hygiene Infection control

  • Hand-hygiene and barrier protection
  • Surgical and perineal wound care
Public awareness Antenatal education

  • Interpreters and translated health information
Antibiotic prophylaxis Use of prophylactic antibiotics

  • Asymptomatic bacteriuria
  • Caesarean delivery
  • Operative vaginal delivery
  • PPROM and PROM
Risk factor management Quality of care

  • Health Infrastructure
  • Health worker standards in antenatal, intrapartum and postnatal care

Quality surgical services

  • Access to caesarean section
  • Access to abortion care
  • Vaginal application of antiseptics
Immunisation
  • Vaccination for influenza and varicella
SECONDARY PREVENTION: Early detection and treatment of acute sepsis
Provider awareness and triage
  • PROMPT training
Sepsis care bundles
  • ‘Sepsis 6’
  • In-hospital guidelines
Sepsis alert and in-hospital response
  • Choice of antibiotic
  • Identifying cause
  • Mode and timing of delivery
TERTIARY PREVENTION: Limit consequences of sepsis
ICU care
  • Established referral criteria and local escalation pathways
Rehabilitation
Post-sepsis follow up

 

Primary prevention

Evidence-based interventions that have been shown to prevent infection and subsequently reduce maternal morbidity and mortality include:

Infection control

Measures such as handwashing with soap or other cleansing agents, and the use of barrier protection, are widely acceptable practices for limiting the spread of micro-organisms, particularly within hospital environments.

Pathogen Group A Streptococcus (GAS) is the most common cause of severe maternal sepsis, identified as directly responsible for 13 of the 29 maternal deaths from infection in the UK during 2006–08. Patient hand hygiene, and careful perineal wound care are fundamental in preventing infection with GAS in the puerperium.3

Antenatal education

Recognition of the severity of an infection by pregnant or postpartum women, family members and healthcare providers has been identified as a key barrier to reducing sepsis-related deaths. Sociodemographic disparities on maternal severe outcomes related to infection have been shown in high-income countries, particularly for ethnic minorities, as well as low- and middle-income countries.4 Inclusion of education of infection prevention and recognition is an integral component of standard antenatal care in Australia for patients and their families and it is essential that this be provided with the use of interpreters and translated health information.

Antibiotic prophylaxis

  • Screening for asymptomatic bacteriuria, which occurs in 2–10 per cent of all pregnancies, is recommended because if untreated, women may develop acute cystitis and subsequent pyelonephritis, with can lead to maternal urosepsis, preterm labour and delivery.5 Urosepsis accounts for one third of antenatal sepsis events.
  • Caesarean delivery is the single most important risk factor for postpartum maternal infection. Prophylactic antibiotics at the time of caesarean section reduces the risk of wound infection, endometritis and serious maternal infectious morbidity.6
  • Operative vaginal delivery is also a risk factor in which antibiotic prophylaxis is considered in the literature and clinical practice. The evidence from available Cochrane reviews is insufficient to determine whether prophylactic antibiotics given with operative delivery or following third- or fourth-degree perineal tears reduces infectious postpartum morbidities.7 8 Even so, the use of antibiotics among women with a third- or fourth-degree perineal tear is recommended by the WHO for prevention of wound complications.9
  • Preterm (PPROM) and term prelabour rupture of membranes (PROM) carries a risk of chorioamnionitis and severe maternal sepsis. Evidence for prophylactic antibiotics with PPROM demonstrated a significant reduction in chorioamnionitis and markers of neonatal morbidity.10 There is no convincing evidence to support the use of prophylactic antibiotics for PROM11, though active management with induction of labour at term has been shown to reduce infectious maternal morbidity.12 In the context of prolonged rupture of membranes (more than 18 hours) the use of antibiotics is common clinical practice due to a presumed increased risk of maternal and neonatal infection.

Quality of care

Maternal deaths from sepsis highlight and expose broader health determinants and other underlying issues related to substandard quality of care. Factors relevant to the global context include: infrastructure challenges; overcrowding; limited access to water and sanitation; constraints to safe births by skilled birth attendants; lack or inconsistent use of infection prevention and control measures; inaccurate or delayed diagnosis and poor or late management of infection and complications.13

Identification of well-recognised risk factors for maternal sepsis, including the presence of pre-existing medical conditions such as anaemia, febrile illness in the two weeks prior to diagnosis of sepsis, and, most notably, mode of delivery, can make a difference in identifying sepsis and subsequent prompt management, which ultimately affects the outcome.

Quality surgical services

  • Access to safe abortion care, which includes access to safe, quality operating services with the use of prophylactic antibiotics, reduces morbidity. Maternal mortality for unsafe abortion is largely due to sepsis from endometritis.14
  • Access to caesarean section, and operative vaginal delivery, is central to the management of obstructed labour. Obstructed labour accounts for an estimated 4 per cent of maternal deaths, which are caused by ruptured uterus, haemorrhage and sepsis.15
  • Vaginal application of antiseptics for caesarean delivery has been demonstrated to reduce the risk of postoperative endometritis, but no clear difference was detected in postoperative fever or any wound complications, although the beneficial effects might be greater for women with ruptured membranes.16 There has been no difference in incidence of chorioamnionitis and postpartum endometritis in women who had vaginal application of antiseptic (chlorhexidine douche) for vaginal delivery.17

Vaccination

Pregnant women are at high risk for influenza-related and varicella-related morbidity and mortality, including higher rates of hospitalisation, cardiopulmonary complications and death, compared to the general public, hence, influenza vaccination is a component of standard antenatal care and varicella vaccination can be offered pre- or post-pregnancy.18

Secondary prevention

Provider awareness and triage facilitates early recognition and treatment of maternal sepsis. Failure to recognise the severity of an infection is known to be a key barrier in reducing sepsis-related deaths.19 The most common site of sepsis in the puerperium is the genital tract and, in particular, the uterus; however, more broadly other sites of sepsis to be considered include mastitis, pyelonephritis, pneumonia, skin and soft-tissue infection, gastroenteritis and pharyngitis. The timing of infection correlates with particular sites: antenatally, urinary tract infections cause one third of all cases of maternal sepsis, whereas postnatally, genital tract infections cause one third of sepsis cases.20 Overall, infections due to E. coli are most numerous, although infections with GAS are associated with greater severity of sepsis, morbidity and mortality.21 Pregnant women are also at higher risk of complications of certain specific infections, such as influenza, varicella zoster and listeria.

Practical Obstetric Multi-Professional Training (PROMPT), developed in the UK, is widely used throughout Australia and New Zealand in training of midwifery, nursing, obstetric and anaesthetic staff, to encourage early recognition and algorithm-led appropriate responses to obstetric emergencies, including maternal sepsis.

Sepsis 6, which is promoted by PROMPT training, aims to identify sepsis and enact the following six steps within 60 minutes:

  1. Blood cultures
  2. Full blood count and lactate
  3. IV fluid challenge
  4. IV antibiotics
  5. Monitoring of urine output
  6. Oxygen administration22

Choice of antibiotic is dependent on the likely source of infection, while considering known hospital and individual factors, such as prevalence of antibiotic resistant organisms and mode of delivery, patient response and subsequent culture results.

However, it is also important to consider that broad adoption of early, empiric antibiotic treatment may have consequences that are negating to emerging principles in infection control, such as: the inappropriate use of antibiotics leading to depletion of a limited resource; an increase in adverse drug toxicities; and developing emergence of antimicrobial resistance.

Identifying the cause of the infection and ‘source control’ is essential in the timely management of maternal sepsis. This may require caesarean delivery, hysterotomy or hysterectomy in women with genital tract sepsis.23 The UK and Ireland Confidential Enquiry into Maternal Deaths identified several women who subsequently died from maternal sepsis following delayed delivery.24 In several women, delivery was delayed because the fetus had already died and there was a perceived need to ensure the woman delivered vaginally. Failure to deliver the fetus and placenta early in the setting of chorioamnionitis will lead to a persisting source of infection and progression of sepsis despite adequate resuscitation and antibiotic treatment.25

Tertiary prevention

Sepsis is among the leading cause of maternal ICU admission. ICU is a largely centralised resource and often not immediately available. Hence, clear referral criteria and recognition of the need for treatment escalation by maternity staff is essential. ICU involvement is indicated when there is cardiorespiratory compromise, evidence of organ dysfunction or other serious clinical concern.

As described in the SOMANZ Sepsis Guideline26 management of maternal sepsis in ICU is similar in principle to the non-obstetric patient. Limited evidence regarding ICU management of obstetric patients exists, with pregnant patients typically being excluded from clinical ICU trials. Management focuses on maintenance of physiological parameters, organ support and targeted care. General management includes thromboprophylaxis, analgesia, skin protection, bowel care and nutrition. In the postpartum period, perineal care, breast care and lactation issues need to be attended to, in addition to facilitating contact between mother and baby when possible.

Tertiary prevention focuses on efforts to limit the consequences of sepsis, optimising post-sepsis recovery. Maternal infection around childbirth has been shown to have a significant effect on newborn wellbeing.27 In addition, infection-related morbidities and prolonged hospitalisation can interfere with mother–infant bonding in the first days after birth. Long-term disabilities, such as chronic pelvic pain, fallopian tube occlusion and secondary infertility, can also occur because of maternal sepsis.

As with sepsis in the general population, the complexity of maternal sepsis precludes an all-encompassing targeted public health policy. Sepsis is not a clearly defined disease entity, rather it’s a nonspecific, clinical syndrome resulting from many combinations of pathogens, host responses and organ dysfunction. It is challenging to diagnose and manage, and uniform strategies do not apply. These challenges are compounded in resource-poor settings where the exact sepsis burden is unknown, but estimated to be substantial. Framing maternal sepsis in a population framework, with primary, secondary and tertiary care principles, can assist in ultimately preventing maternal sepsis and limiting its consequences.

References

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