Puerperal sepsis and maternal outcome in developing countries: an observational study

INTRODUCTION

Puerperal sepsis is one of the leading causes of maternal morbidity and mortality worldwide. The world health organization (WHO) has defined puerperal sepsis as bacterial infection of female genital tract occurring at any time from rupture of membranes or onset of labor till the 42nd day postpartum with presence of two or more of the following clinical symptoms: fever (oral temperature 38.5°C/101.3°F or higher on any occasion), pelvic pain, abnormal vaginal discharge (pus-like), abnormal smell/foul-smelling lochial discharge or delay in rate of uterine involution.¹ Recently a new definition of maternal sepsis was given by WHO according to which, maternal sepsis is a serious condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or post-partum period.²

Worldwide, puerperal sepsis is the third most common direct cause of maternal mortality after hemorrhage and hypertensive disorders of pregnancy, accounting for approximately 11% of all maternal deaths annually.³ It was reported that the burden of maternal sepsis ranges from 15 to 19 million cases annually all over the world, accounting for an estimated 75,000 maternal deaths, especially in low-income countries.^4,5 The incidence of maternal mortality is comparatively very low in developed countries, ranging from 0.1 to 0.6 per 1000 births.^5,6 Furthermore, the majority of cases of maternal deaths due to sepsis come from Southern Asia (13.7%) and sub-saharan Africa (10.3%), as compared to very fewer cases from developed countries (4.7%).^3,7 Moreover, when abortions and intra-uterine fetal demises are also included, the overall incidence of severe puerperal sepsis further increased from 11 per 10,000 pregnancies in 2001 to 26 per 10,000 in 2010, resulting in a 9.1% annual increment in sepsis-associated maternal deaths.⁸

Immunosuppressed state during pregnancy, makes women prone to the risk of grabbing various infections.8 Puerperal sepsis is polymicrobial in origin, with following organisms accounting for most of the cases: Escherichia coli, Streptococcus pyogenes, Staphylococcus aureus, Streptococcus pneumonia, Clostridium tetani, Clostridium welchii, Methicillin-resistant, S. aureus (MRSA), Gonococci or Chlamydia. The predisposing factors include anemia, malnutrition, obesity, immunosuppressed state or medications, poor hygiene, diabetes, prolonged spontaneous rupture of membranes, retained products of conception, pelvic infection, vaginal trauma, cesarean section or wound hematoma, amniocentesis or other invasive procedures, etc.^6,9 Severe puerperal sepsis is characterized by septic shock or systemic inflammatory response syndrome secondary to an infectious process with resultant organ dysfunction or failure.⁸ Hence, the present observational study was conducted to know the burden of severe puerperal sepsis, its risk factors and overall maternal outcome associated with puerperal sepsis in a rural tertiary care center of Northern India.

METHODS

Study design

Observational cohort study.

Study setting and duration

The present study was conducted in the department of Obstetrics and Gynecology of a rural tertiary care center of Northern India over eight months (1st January to 31st July 2018).

Participants

A cohort of women with features of severe puerperal sepsis presenting within 42 days of delivery or abortion admitted in the Obstetrics department were enrolled as study participants.

Inclusion criteria

All the women who had delivered or aborted in the institution or those who were referred from outside within 42 days of delivery or abortion having clinical features and investigations suggestive of puerperal sepsis including fever (38.5°C/101.3°F), foul-smelling vaginal discharge, bleeding per vaginum, uterine tenderness, abdominal pain, abdominal distention, signs of peritonitis, pelvic abscess, shock or multi-organ failure were enrolled as study participants.

Exclusion criteria

Women presenting with fever during antenatal period or after 42 days of delivery or abortion, women with fever due to other medical conditions like thrombophlebitis, urinary tract infection, viral fever, breast inflammation or infection, etc. and those not willing to be a part of the study were excluded

Method of selection

Consecutive sampling of all the cases was done till the desired duration of study.

Variables

Exposures

Institutional/home delivery, mode of delivery, delivery or abortion by trained or untrained personnel, comorbidities like Anemia, Hypertensive disorders of pregnancy, heart disease, intra-uterine fetal demise.

Predictors

Age, parity, booked/un-booked status, complications at the time of presentation like peritonitis, septic shock, end organ failure, multi-organ dysfunction syndrome, conservative or surgical management.

Outcomes

Maternal morbidity and mortality.

Data sources

The present study was conducted as per the strengthening the reporting of observational studies in epidemiology (STROBE) statement. After proper institutional ethical committee approval and informed written consent in their language from participants fulfilling inclusion criteria, various socio-demographic features like age, parity, antecedent pregnancy/abortion details, mode of delivery, post-delivery or post-abortion day at the time of presentation, any predisposing factors, booked/un-booked status, delivery/abortion conducted by trained or untrained person, place of delivery, co-morbidities were recorded on a preformed data collection sheet by a trained nursing staff. The presenting clinical features including fever, abdominal pain, foul-smelling vaginal discharge or bleeding, etc. were recorded on the datasheet followed by a thorough general and physical examination for features of peritonitis, abdominal distention, organ injuries, single or multiple organ failure or shock. Detailed medical and family history of all the participants along with their vitals and routine investigations were also recorded.

The data thus obtained was analyzed to know the overall maternal outcome including maternal morbidity and mortality and various risk factors predisposing to the poor maternal outcome.

Study size

A total of sixty-six (66) women with features of severe puerperal sepsis were enrolled in the study. This study size was achieved by consecutive sampling of all cases for a duration of eight months enrolling all the cases with severe puerperal sepsis from 1st January to 31st July 2018.

Statistical analysis

The data was statistically analyzed by statistical package for the social sciences (SPSS) software version 22.0. The numerical data were presented as mean±standard deviation (SD) and categorical variables as frequencies or rates where ever needed. ANOVA/kruskal wallis test was used for comparison of more than two groups and the Chi-Square test was for a comparison of qualitative variables. A p-value of<0.05 was considered statistically significant.

RESULTS

Participants

Out of total 2,596 admissions in the department of Obstetrics and Gynecology, 66 had severe puerperal sepsis, which is 2.5%.

Descriptive data

Most (86.4%) of these cases belonged to 21-30 years age group with average (±SD) age of all the cases 25.42±4.004 years and were multiparous (62.1%). The majority of them had vaginal delivery 28 (42.4%), followed by cesarean section 22 (33.3%) and one (1.5%) case of instrumental delivery. There was a total of 15 (22.7%) cases of abortions, eight (53.3%) first trimester and seven (46.7%) second-trimester abortions respectively. The average (±SD) days after which the cases presented was 8.53±5.27 with the majority of cases (39.4%) presenting between 0-5 days after delivery or abortion. The various socio-demographic features are depicted in (Table 1).

Outcome data

All the patients (100%) presented with high-grade fever (101.3°F), tachycardia, breathlessness, and foul-smelling vaginal discharge at the time of admission. Of total 66 cases, 35(53.0%) presented with abdominal distention, 11 (16.7%) with scar site infection, 11 (16.7%) had vaginal or per rectal bleeding, 18(27.3%) presented with features of peritonitis (abdominal pain with distention, guarding and rigidity on palpation) and eight (12.1%) had septic shock at the time of presentation. Of all the cases, 10 (15.2%) patients developed end-organ failure due to sepsis, seven (10.6%) developed multi-organ dysfunction syndrome (MODS), 16 (24.2%) had organ injuries [ten (62.5%) had single organ and six (37.5%) multiple organ injuries (uterus, bowel and or ureteric)]. Eighteen (27.2%) patients required intubation and ventilatory support at the time of admission. The correlation of need for ventilatory support in women with severe puerperal sepsis and various risk factors and maternal outcome is depicted in (Table 2).

*HDU: High Dependency Unit

There were 15 (22.7%) women who could not be revived after all efforts and succumbed to death due to complications of severe puerperal sepsis. The most common predisposing factor observed was anemia (95.5%) followed by unsafe delivery practices (36.4%). Surgical management was required in 57.6% of cases. The overall maternal outcome and its correlation with various risk factors are depicted in (Table 3).

Main results

The multivariate analysis of need for ventilatory support in women with severe puerperal sepsis with various risk factors and overall maternal outcome revealed that women presenting with features of septic shock were 12.8 times more prone for high dependency unit (HDU) admission and need for ventilation (p=0.03, 95%, CI:1.2-136.79). Furthermore, women on ventilatory support were 46.8 times more at risk of dying as compared to those not requiring ventilatory support (p=0.00, 95% CI:6.35-345.28). Other risk factors were not found to be significantly correlated with maternal death on multivariate analysis of maternal death with various risk factors.

DISCUSSION

Puerperal sepsis is one of the common and preventable causes of maternal morbidity and mortality all over the world, especially in developing countries like India. In the present study, we observed that 2.5% of all the admissions in the Obstetric ward had severe puerperal sepsis. Most of the patients (86.4%) belonged to 21-30 years of age group and 62.1% were multiparous. The most common mode of delivery in antecedent pregnancy was vaginal delivery (42.4%) followed by cesarean section (33.3%). The majority (83.3%) of these cases were referred from outside and delivered either at home or peripheral hospitals and most of them (39.4%) presented between 0-5 days post-delivery or abortion. This was similar to the results of a recent study which also observed that the overall incidence of puerperal sepsis in their institution was 2.5% and most of the women with sepsis belonged to 20-30 years of age group and were multigravidas. Most of the cases (94%) were referred from outside after delivery at home or from peripheral centers. In their study, the most common mode of delivery from antecedent pregnancy was cesarean section and the majority of them presented within first 72 hours of delivery, with chief complaints of fever (100%), abdominal pain (70%), foul-smelling vaginal discharge and abdominal distension (64%). This was similar to our observations. Another similar study also reported that most of the women with puerperal sepsis (65.11%) were 31 years of age and multiparous (78.29%). Around 75.96% were un-booked and referred from outside. The most common mode of delivery was vaginal (60.46%).10 A recent study also reported the same findings that puerperal sepsis was more common in un-booked patients (76%), women between 21-30 years of age (66%), multiparous (78%) and was associated with anemia (68%).11 Similar results were reported by another study conducted in Ethiopia which also found that maximum cases of puerperal sepsis belonged to 25-29 years of age group, were multiparous, referred from outside and had a spontaneous vaginal delivery.¹²

In our study the most common presenting features were fever (100%), tachycardia (100%), breathlessness (100%), foul-smelling vaginal discharge (100%), abdominal distention (53.0%), scar site infection (16.7%), vaginal or per rectal bleeding (16.7%), features of peritonitis (27.3%), septic shock (12.1%). Around 15.2% patients developed end-organ failure, 10.6% MODS, 27.3% uterine perforation, 3.0% bowel injuries and 1.5% had ureteric injury. A similar study also reported that the chief presenting symptoms were fever (90.69%), wound infection (39.53%), and abdominal distention (21.70%). Serious complications including septicemia (27.13%) disseminated intravascular coagulation (17.82%) were observed and 11 (8.52%) women died of puerperal sepsis, indicating very high morbidity and mortality associated with this condition.¹⁰

The most common risk factor associated with severe puerperal sepsis in this study was anemia. It was associated with 95.5% of all cases, furthermore, it was significantly associated with increased risk of maternal morbidity and mortality. Around 60.3% had moderate anemia, 31.7% severe and 7.9% very severe anemia at the time of presentation. This was similar to the results of a study which also reported that anemia was one of the most common risk factors associated with puerperal sepsis.¹⁰ Centre for maternal and child enquiries (CMACE) conducted a study to know the causes for maternal death in the United Kingdom also reported that anemia is one of the common risk factors for puerperal sepsis in addition to obesity, impaired immunity, diabetes.9 Another similar study also reported that the common predisposing factors for puerperal sepsis include un-booked status, cesarean section, anemia, repeated vaginal examination and prolonged rupture of membranes.13 Similar results were reported by other studies also.¹⁴

In the present study majority (57.6%) of the patients were managed surgically with 6.1% requiring hysterectomy alone, 9.1% hysterectomy with bowel repair, 3.0% uterine repair, 6.1% underwent removal of mop from abdominal cavity, 13.6% abdominal wash only, etc. Similar results were reported by another study also where majority of puerperal cases were managed surgically (75%).¹⁴

In the present study out of a total of 66 patients with severe puerperal sepsis 27.3% required ventilatory support and 22.7% could not be revived and succumbed to death, leading to the very high maternal mortality rate from puerperal sepsis. Similar results were reported by another study which also observed that puerperal sepsis was associated with a high incidence of Intensive care unit admission (73%), intubation and maternal mortality. Around 85% of women succumbed to death due to multi-organ failure (24%) and pulmonary edema (36%) resulting from sepsis.¹⁴ Another study also reported that puerperal sepsis was associated with increased risk of mortality (78%), mechanical ventilation (54%) and need for intensive care unit admission and advanced life support (7%).¹⁵ Another recent study has reported that puerperal sepsis (30.9 %) is the most common cause of maternal mortality followed by obstetric hemorrhage (21.6 %) and hypertensive disorders in pregnancy (14.4 %).¹⁶ A systematic analysis carried out between 2003 and 2009 by WHO also reported that hemorrhage, hypertensive disorders, and sepsis were major causes of maternal mortality and responsible for more than half of maternal deaths worldwide.³

Limitations

The present study was conducted for a shorter duration and included only those patients who had features of severe puerperal sepsis. Also, we didn’t include all those cases which were managed at private hospitals. In the future we can plan to conduct the study over a longer duration including all cases of puerperal sepsis and a multicentric study, covering all nearby hospitals. We can also try to find out other reasons like the impact of socio-economic status, regular antenatal check-up, literacy, etc. on the incidence of puerperal sepsis. Furthermore, we will try to follow these patients for any long-term complications.

CONCLUSION

Hence, puerperal sepsis is one of the preventable causes of high maternal morbidity and mortality especially in developing countries like India. It can be prevented to a large extent by creating awareness amongst people about the need for regular antenatal check-ups throughout pregnancy, adequate dietary intake, regular Iron supplementation, to prevent the development of anemia, hospital deliveries, and proper hygiene during the puerperal period and training of midwives and trained birth attendants for proper sterilization techniques. All antenatal women should be made aware of the warning signs and symptoms in the puerperal period, so that they can report early to the hospital for better intervention, thereby reducing maternal morbidity and mortality.

ACKNOWLEDGEMENTS

I thank Dr. Namit Kant Singh, Adhvan Singh and Nutty Singh for their constant support.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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