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Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case–Control Study

Bauer, Melissa E. DO*; Housey, Michelle MPH*; Bauer, Samuel T. MD; Behrmann, Sydney BS*; Chau, Anthony MD, MMSc; Clancy, Caitlin BA, BSN, RN§; Clark, Erin A. S. MD; Einav, Sharon MSc, MD; Langen, Elizabeth MD#; Leffert, Lisa MD§; Lin, Stephanie MD; Madapu, Manokanth MBBS§; Maile, Michael D. MD, MS*; McQuaid-Hanson, Emily MD§; Priessnitz, Kristina BS*; Sela, Hen Y. MD**; Shah, Anuj MD††; Sobolewski, Paul MD; Toledo, Paloma MD, MPH‡‡,§§; Tsen, Lawrence C. MD; Bateman, Brian T. MD, MSc

doi: 10.1213/ANE.0000000000003709
Obstetric Anesthesiology: Original Clinical Research Report
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BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis.

METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls.

RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour.

CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.

From the *Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan

Department of Obstetrics and Gynecology, Beaumont Health, Royal Oak, Michigan

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts

§Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts

Department of Obstetrics and Gynecology, University of Utah School of Medicine and Intermountain Healthcare, Salt Lake City, Utah

Intensive Care Unit, Shaare Zedek Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel

#Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan

**Department of Obstetrics and Gynecology, Shaare Zedek Medical Centre, Jerusalem, Israel

††Feinberg School of Medicine, Northwestern University, Evanston, Illinois

‡‡Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois

§§Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Published ahead of print 29 August 2018.

Accepted for publication July 3, 2018.

S. Behrmann is currently affiliated with the University of Michigan Medical School, Ann Arbor, Michigan. A. Chau is currently affiliated with the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia. C. Clancy is currently affiliated with the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York. S. Lin is currently affiliated with the Department of Perinatal Medicine, Marian Regional Medical Center, Santa Maria, California. K. Priessnitz is currently affiliated with the Michigan State College of Human Medicine, East Lansing, Michigan. A. Shah is currently affiliated with the Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan.

Funding: This work was supported by the University of Michigan Health System Department of Anesthesiology. Support for REDCap (Research Electronic Data Capture) reported in this publication was provided by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000433. E.A.S.C. is supported by a grant from the Burroughs Wellcome Foundation. P.T. was supported by a grant from the Robert Wood Johnson Foundation (Princeton, NJ), Harold Amos Medical Faculty Development Program (award 69779). B.T.B. is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Bethesda, MD) under Award Number K08HD075831. No source of funding had a role in any stage of the study, analysis, or writing of this manuscript.

Conflicts of Interest: See Disclosures at the end of the article.

This work was presented, in part, at the 48th Society for Obstetric Anesthesia and Perinatology Annual Meeting, Boston, MA, May 18–22, 2016.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Reprints will not be available from the authors.

Address correspondence to Melissa E. Bauer, DO, Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to mbalun@med.umich.edu.

Copyright © 2018 International Anesthesia Research Society
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