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  • Journal of Mind and Medical Sciences is published by MDPI from Volume 12 Issue 1 (2025). Previous articles were published by another publisher in Open Access under a CC-BY (or CC-BY-NC-ND) licence, and they are hosted by MDPI on mdpi.com as a courtesy and upon agreement with Valparaiso University (ValpoScholar).
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25 October 2023

Best Therapeutic Practices in the Management of Obstetric Sepsis

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and
1
Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
2
CF2 Clinical Hospital, Department of Anesthesia and Intensive Care, Bucharest, Romania
3
Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
4
St. Ioan Hospital, Bucur Maternity, Bucharest, Romania
J. Mind Med. Sci.2023, 10(2), 304-311;https://doi.org/10.22543/2392-7674.1436
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Abstract

Background. Physiological changes that occur during pregnancy make maternal sepsis a difficult condition to diagnose and treat, still having a fairly high mortality rate. Consequently, an early diagnosis and prompt therapeutic management of sepsis can significantly decrease mortality. The purpose of this study is to review literature data that present current practices in the management of obstetric sepsis. Methods. To collect the data required for the study, we performed a search of published articles in the PubMed and Google Scholar databases related to obstetric sepsis. Research paper articles from the period 2012–2022 were included in the analysis. In addition, 145 articles from the period 2012–2022 were evaluated, with the aim of finding out in which situations the risk of maternal death is higher. Thus, the analysis included a total number of 151 articles, which were divided into two distinct stages. Results. The risk of maternal death is higher among patients with the human immunodeficiency virus (HIV), followed by Escherichia coli, genital tract infection, cancer, drug users and in the case of patients with chronic liver disease. Conclusions. After analyzing the data, we found that prompt and focused antibiotic therapy as well as fluid resuscitation are essential to increase the chances of survival of these patients.

Introduction

Worldwide, between 20-40% of maternal deaths are caused by sepsis during the peripartum period [1,2,3]. Due to the physiological changes that occur during pregnancy, maternal sepsis is a condition with a high mortality rate, which becomes quite difficult to diagnose, thus leading to delays in the application of therapeutic protocols aimed at reducing mortality [4,5,6].
Post-abortion sepsis can occur following a miscarriage, a surgical abortion or even the consequence of an illegal abortion. It is usually caused by an ascending infection that leads to endometritis or parametritis, and which later progresses to sepsis [7,8,9].
Validated diagnostic criteria for maternal sepsis and septic shock may reduce their impact on maternal health globally. Unfortunately, the overlapping manifestations of the physiological adaptations that occur during pregnancy and the signs and symptoms of infection and sepsis can cause delays in both diagnosis and treatment [10,11].
When signs of sepsis are not recognized and treated promptly, they can progress rapidly in pregnant women or women who have recently given birth, leading to life- threatening pathophysiological imbalances [12].
Infertility, fetal death, chronic pelvic inflammatory disease, organ failure, bilateral tubal blockage, chronic pelvic pain are major morbidities associated with obstetric sepsis. Therefore, early detection and prompt therapeutic action are essential for a successful outcome.
For the identification and prognosis of patients with sepsis, machine learning prediction models outperformed already used sepsis scoring systems, including SOFA, SIRS, qSOFA, and MEWS. Using machine learning algorithms to predict patients with sepsis could help doctors actively monitor and take preventive measures to improve patients’ conditions [13].

Materials and Methods

The aim of this study is to review the studies that present the practices used in the management of obstetric sepsis. The Google Scholar database was used, and for obstetric sepsis we obtained 224,000 articles. To facilitate the analysis, we decided to investigate the articles from the period 2012-2022, obtaining a number of 17,900 articles. The PubMed database was also queried, thus generating 261 articles for obstetric sepsis (period 2012–2022). In the end, we had to study a total of 18,161 articles.
We proposed to analyze in the first stage 20 articles according to the following criteria: full paper articles, not be duplicated, research paper type, a large number of citations, publication period starting with 2012. From the 20 articles we managed to extract only 6 that corresponded to the topic of analysis. In the second stage, we set out to analyze 250 articles from the period 2012-2022 in which we wanted to find out in which situations the risk of maternal death is higher. The selection of articles was made on the same principle as in the first stage. We were able to retrieve 145 articles from the Google Scholar. In total, we analyzed 151 articles from the PubMed database and from the Google Scholar search engine, by Prisma Model, as presented in Figure 1.
Figure 1. Identification and selection of studies analyzed

Results

We propose to present 6 articles following the analysis process: authors and year of publication, purpose, results, conclusions and limitations. Thus, we obtained the following results from the review process, which are presented in the Table 1, Table 2, Table 3, Table 4, Table 5 and Table 6.
Table 1. Results obtained by Albright et al. (2014) [14].
Table 2. Results obtained by Aarvold et al. (2017) [15].
Table 3. Results obtained by Leisman et al. (2017) [16].
Table 4. Results obtained by Ferrer et al. (2014) [17].
Table 5. Results obtained by Holanda et al. (2020) [18].
Table 6. Results obtained by Al-Ostad et al. (2015) [19].
The study by Albright et al. (2014) showed that until that time, no scoring system had been developed that took into account the normal physiological changes of pregnancy. This is also the reason why morbidity and mortality in a pregnant population has been accurately predicted. So S.O.S. became a modified sepsis scoring system for pregnancy-specific physiologic changes that was able to identify pregnant and postpartum patients at risk for sepsis intensive care unit admission within 48 hours of emergency department presentation [14].
The study by Aarvold et al. (2017) contradicts the study by Albright et al. (2014) who say that the best predictor of mortality in the obstetric population is the MODS score. This score was significantly better than the physiology- based SAPS II (Simplified Acute Physiology Score) and APACHE II (Acute Physiology and Chronic Health Evaluation) scores and the obstetric-specific SOS score. On the other hand, MODS and SOFA scores performed better in the obstetric population, suggesting that perhaps an organ-based system is more accurate. This is because of poorer outcomes in patients with multiple organ dysfunction than those in whom organ function is preserved [15].
The study by Leisman et al. (2017) showed that adherence to the 3-hour bundle is sufficient to improve clinical outcomes for patients without relying on invasive monitoring or complex physiological endpoints. We intend to carry out further analysis for the following studies [16].
The study by Ferrer et al. (2014) showed that for the increased risk associated with delay there was a linear increase in the risk of mortality for each hour of delay in antibiotic administration from the first to the sixth hour after patient identification. In other words, sepsis is a time- dependent condition and must be recognized as an urgent situation that requires an immediate response [17].
In the study conducted by Holanda et al. (2020) provided a better understanding of the factors associated with death resulting from sepsis in obstetric patients with the aim of identifying prognostic factors and optimizing management [18].
The study by Al-Ostad et al. (2015) showed that black women, older than 35 years, and smokers were more likely to experience maternal sepsis. An association has also been found between maternal sepsis and diabetes mellitus, cardiovascular disease, eclampsia, hysterectomy, puerperal infection, preterm birth, postpartum hemorrhage, transfusion, and chorioamnionitis [19].

Discussions

The analysis of this study included a sample of 29,952 patients, 3 cohorts, and a database of 5 million births from 6 specialty studies.
The analyzed studies recommended the following therapeutic practices for the management of obstetric sepsis. The S.O.S. sepsis scoring system (Obstetric Sepsis Score) was able to identify pregnant and postpartum patients at risk of admission to the intensive care unit for sepsis within 48 hours of presentation to the emergency department.
Disease severity scores based on organ failure, such as the MODS (Multiple Organ Dysfunction Score), have been shown to be equally effective in obstetric and nonobstetric (age- and sex-equivalent) populations.
Adherence to the 3-hour protocol was associated with improved survival and significant cost savings.
The administration of antibiotics must be done as soon as possible to avoid the death of the patient.
The selection of articles was made according to the following criteria: complete articles, not to be duplicated, the type of research paper, a large number of citations, and the publication period starting from 2012.
For patients with suspected sepsis, prompt and focused antibiotic therapy and fluid resuscitation are essential for the survival of these cases [20,21].
The study by Bowyer et al. (2017) presents a series of diagnostic and therapeutic indications related to general anesthesia. Thus, the study claims that the septic obstetric patient frequently exhibits hemodynamic instability and has a higher-than-normal pregnancy-related metabolic oxygen requirement. For the administration of general anesthesia, practical considerations include for the airways avoiding delayed gastric emptying, and thus avoiding an increased risk of gastric reflux followed by aspiration. It is recommended that women be premedicated with combined prophylaxis with antacid antihistamines (effervescent ranitidine, 150 mg). A rapid induction sequence is also recommended. For the pulmonary ventilation process, it would be advisable to provide patients with adequate pre- oxygenation before induction of anesthesia. In these patients there is a reduced residual functional capacity, which implies a limitation of the interrelationship between ventilation and perfusion. Consequently, the use of therapeutic ventilation strategies is recommended to maintain adequate oxygenation to minimize possible subsequent lung injury [22].
Regarding the circulatory system, consideration should be given to avoiding aortocaval compression by lateral tilting of the uterus, ensuring adequate fluid resuscitation, including appropriate use of blood products and, if necessary, inotropic support. Alpha adrenergic agonists (especially noradrenaline) are the agents of choice for maintaining uteroplacental flow.
Rapid and effective fluid resuscitation is essential to stabilize septic shock or sepsis-induced tissue hypoperfusion. Given the critical status of this medical emergency, early fluid resuscitation should begin as soon as the patient is diagnosed with sepsis, hypotension, or elevated lactate, and be completed within three hours of diagnosis. The minimum recommended amount of intravenous crystalloid for such therapy is 30 ml/kg according to current guidelines [23].
Effective treatment of sepsis was found to require aggressive resuscitation protocols involving adequate control of the source of sepsis, appropriate antibiotic drugs, and adequate support for failing organs. Therefore, delay in starting appropriate antibiotic treatment increases the risk of death in obstetric patients with sepsis [24,25].
We also aimed to analyze which studies are at risk of bias. Thus, 145 articles from 2012-2022 were analyzed, in which we intended to identify in which situations the risk of maternal death is higher.
Thus, the largest proportion of this maternal risk (24%) is found in patients with the human immunodeficiency virus (HIV), 29% in patients with Escherichia coli, 17% in patients with genital tract infection, 14% in patients with cancer, 14 % in the case of drug users, and 12% in the case of patients with chronic liver disease (Figure 2).
Figure 2. The risk of maternal death.
HIV infection may contribute to an increased risk of postpartum infection and infection-related mortality [26].
About 13% of cases require admission to intensive care, so there is a 2.9-fold risk of preterm birth and a 5.8- fold risk of perinatal mortality. In the case of infection of the genital tract for the first and second trimester, fetal loss occurs. The most prevalent organisms are E. coli and group B streptococcus, although the most virulent organisms are E. coli associated with preterm sepsis and group A streptococcus associated with postpartum sepsis [27,28,29].
Women who give birth by caesarean section are more prone to severe sepsis, while women who give birth vaginally are more prone to infection with group A streptococcus. On the other hand, women already infected with group A streptococcus have a higher risk of progression to septic shock, in contrast to women infected with another infectious agent [30,31,32].
The study by Balki et al. (2022) also included among the risks: stillbirths, artificial rupture of membranes, retained products of conception, as well as surgical procedures (hysterectomy, cervical cerclage, dilatation and curettage) and obstetric conditions (postpartum hemorrhage, preeclampsia/eclampsia, and placental abruption) [33].
The study by Shields et al. (2023) presents a series of recommendations on how to manage sepsis during pregnancy and in the postpartum period. Thus, if sepsis and septic shock are medical emergencies, treatment and resuscitation should begin as soon as possible. In the case of severe organ damage in pregnant patients due to an infectious process, the diagnosis of sepsis must be made as quickly as possible, while broad-spectrum antibiotics must be administered (to any pregnant woman suspected of having sepsis) within a maximum of 1 hour. Also, requirements include obtaining cultures (blood, urine, respiratory, etc.) and serum lactate levels in pregnant or postpartum women with suspected or identified sepsis, and early control of the source of sepsis should be completed as soon as possible. Early administration of 1-2 L of crystalloid solutions is also recommended in sepsis complicated by arterial hypotension or suspected organ hypoperfusion [34,35,36,37,38,39]. Another recommendation concerns the use of norepinephrine as a first-line vasopressor during pregnancy and the postpartum period in sepsis with persistent hypotension and/or hypoperfusion, in addition to fluid resuscitation [36,37,38,39,40]. Therefore, protocols to improve early diagnosis and effective therapeutic management may help reduce the incidence and consequences of maternal sepsis during labor and delivery.

Conclusions

Maternal deaths due to severe sepsis are generally caused by late presentation to the doctor, which further leads to delay in diagnosis and treatment.
The obstetric-specific S.O.S. score has been shown to have a poor predictive value for the assessment of mortality in obstetric septic shock.
Establishing an early diagnosis and rapid multidisciplinary therapeutic management (obstetrician, neonatologist and intensive care physician and anesthetist) are essential for the patient’s prognosis.
Transfer to intensive care is necessary if the patient is hemodynamically unstable and requires vasopressor support, requires mechanical ventilation or presents an altered level of consciousness, hemodialysis, multiple organ failure, or hypothermia.

Compliance with ethical standards

Any aspect of the work covered in this manuscript has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. Informed consent was obtained from all subjects involved in the study.

Conflict of interest disclosure

There are no known conflicts of interest in the publication of this article. The manuscript was read and approved by all authors.

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