As the WHO says “One of the greatest tragedies of the thousands of deaths caused by sepsis is that many of them could have been prevented”.
“Today we grow concerned about birth not being natural enough, having become too medical. Historically, it was thoroughly natural, wholly unmedical and gravely dangerous”. Did you know that women can die during one of the most joyous events in of their lives? Losing a young fit healthy wife, mother, daughter, sister during pregnancy and childbirth can be devastating. The maternal mortality rate (MMR) in India is 130 maternal deaths per 100,000 live births. In the western world, it varies between 3 – 18/100000.
Why do women die?
The main killers of women in this country are:
- Haemorrhage – excessive bleeding after the delivery of the baby (or in pregnancy) can be life-threatening. If this is not recognised and treated promptly it can lead to severe maternal complications and death.
- Sepsis– Sepsis refers to an infection which enters the blood and can happen during pregnancy or post-delivery. Sepsis is very insidious and can kill very quickly unless it is recognised early and treated aggressively.
- Anaemia – refers to the haemoglobin or blood count being low. After delivery, a woman loses a certain amount of blood naturally. If the woman is anaemic even this normal blood loss is not well tolerated. And especially if she bleeds excessively, she is at grave risk of succumbing to the blood loss.
- Pre-eclampsia and Eclampsia – these are conditions which are associated with high BP, fits, damage to the kidneys, brain and death.
- Abortion – performed by untrained personnel can give rise to infection and bleeding and death.
If not recognised early and treated aggressively it can rapidly progress to multiple organ failure and death. Amongst those who survive many are left with chronic pain and fatigue, post-traumatic stress disorder and organ dysfunction.
The Indian Scenario explained by Dr Prathima Reddy
- Maternal sepsis is common in the developing world but is also a significant cause of maternal death in the developed world.
- It is estimated that Maternal Sepsis accounts for 11-16% of maternal deaths in India.
- A study in rural Maharashtra put it down as the second largest cause of maternal mortality after haemorrhage.
- Studies conducted in referral hospitals in Andhra Pradesh concluded that it was the main cause of maternal deaths in their series.
- In the UK it accounts for about 10% of maternal deaths and in the USA it complicates about 4-10 per 10,000 live births.
What are the Risk Factors for Maternal Sepsis?
Miscarriages especially if performed under unsterile conditions outside a healthcare facility
- Cervical cerclage or “stitch”
- Prolonged rupture of membranes
- Prolonged or obstructed labour
- Complications of Caesarean Section
- Infection following vaginal deliveries, especially if conducted in unhygienic conditions outside a health care facility, possibly due to repeated unhygienic vaginal examinations
- Assisted vaginal deliveries eg. Forceps, vacuum
- Manual removal of placenta/retained bits of placenta after delivery or abortion
- Poor standards of handwashing and general hygiene in the days following delivery
- Urinary Tract Infection
- Viral or Bacterial Illnesses
What are the Warning Signs of Sepsis?
- Chills and shivering
- High temperature (over 38.3°C)
- Very low temperature (less than 36°C)
- Fast breathing or breathlessness
- Severe abdominal pain
- Excessive bleeding or foul-smelling discharge
- Productive cough
- Urinary symptoms – such frequent urination, pain during passing urine, blood in the urine
- Extreme sleepiness
- Dizziness and collapse
Case Study by Dr Prathima Reddy
- Ms BM a 30-year-old lady, pregnant for the 3 rd time was first seen in our outpatient clinic at 10 weeks of pregnancy. The previous two pregnancies had ended in a spontaneous miscarriage at 18 weeks of gestation. A diagnosis of cervical incompetence (a condition in which the mouth of the womb – cervix- shortens and opens early, leading to miscarriages) was made and she underwent a cervical stitch at 16 weeks.
- At about 26 weeks of pregnancy, she complained of pain abdomen and she was admitted to hospital as there was a risk of preterm labour. She was monitored closely and the pains settled.
- At 27 weeks, routine bedside examination revealed an abnormally fast heart rate and a low blood pressure. She was also breathing faster than normal and her oxygen level was suboptimal. Her temperature, however, remained normal and she did not complain of any alarming symptoms. A working diagnosis of Sepsis was made and relevant investigations were performed. The blood tests confirmed sepsis. Appropriate medical treatment was started immediately and aggressively.
- She was later delivered by a caesarean section. She was monitored in the Intensive Care Unit by a multi-disciplinary team and after 4 days made a full recovery. The baby stayed in the Neonatal Intensive Care Unit for 6 weeks and was discharged home in good health.
- The above case illustrates how insidious sepsis can be. Here the patient did not have any obvious complaints but close monitoring and a low threshold for diagnosing Sepsis helped make the diagnosis early and avert a poor outcome. The cause of sepsis, in this case, was most probably the cervical stitch.
It is clear from several studies that in the majority of women that died from sepsis there was a delay in diagnosis and treatment and the escalation of treatment. Most women did not have a fever, possibly delaying the recognition of the presence of sepsis.
The WHO recommends the following measures to prevent sepsis:
- access to clean water and sanitation
- access to quality care during pregnancy and birth
- responsible and timely access to the right medicines
- proper infection prevention and control in hospitals and clinics
- Health workers need to be adequately trained and skilled to be able to recognise the signs of sepsis and to treat the condition effectively
In addition to the above, the following will also help reduce the incidence of sepsis - good personal hygiene, regular changing of sanitary napkins, not using tampons until advised to do so and washing hands before and after going to the toilet
(Inputs by Dr Prathima Reddy MBBS, MRCOG (London), FRCOG (London), FACOG (USA) Director, Senior Obstetrician and Gynaecologist - Fortis La Femme Hospital, Richmond Road Bangalore)
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