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Sepsis is a condition in which the body reacts to an infection in such an extreme way that it threatens the life of the person and will very likely lead to death if doctors do not intervene aggressively. Sepsis is rare in young, healthy people, but when it happens during pregnancy, and in the hours and days following delivery, common reasons are chorioamnionitis and urinary tract infections. Chorioamnionitis is an infection of the membranes that enclose the fetus and of the amniotic fluid in which the fetus floats. Often, chorioamnionitis is identified by a type of bacteria called E. coli or another type of bacteria called Group B Streptococcus. A common reason for chorioamnionitis is that the woman is in labor for many hours after the membranes rupture (the ‘water breaks’).
Typically, chorioamnionitis is treated with antibiotics and the condition resolves without further complications, but sepsis represents a rare, severe complication that can begin with chorioamnionitis or with other types of infection. Urinary tract infections, which can be lower (affecting the bladder and urethra) or upper (has advanced to the ureters and kidneys), but it’s typically an upper urinary tract infection that can be severe enough to cause sepsis. Nevertheless, treatment with antibiotics can solve the problem before it leads to sepsis. Other infections that can lead to maternal sepsis include endometritis (infected endometrial layer of the uterus), retention of products of conception in the uterus (after spontaneous abortion or stillbirth or after delivery of an infant), and postpartum infections due to entry of bacteria through the birth canal or through a cesarean incision site.
Humanity’s journey to understand maternal sepsis began in the 1840s, in Vienna, where obstetrics was a new specialty of medicine and obstetricians and midwives faced large number of cases of what doctors called “childbirth fever”. At one major hospital, deliveries were managed on certain days of the week by midwives and their students, whereas other days care for women in labor fell upon physicians, who also taught students. A Hungarian Jewish physician, Ignaz Semmelweis, noticed that death rates from childbirth were dramatically higher in patients tended by physicians and medical students (13-18%) as compared with women tended only by midwives (2%). Initially, this was puzzling, but then another doctor, who worked as a pathologist, cut his hand during an autopsy, developed all the manifestations of childbirth fever, and consequently died.
Whereas midwives and midwifery students worked only with pregnant women, medical students were required to participate in autopsies prior to arriving at the maternity ward. Most of the autopsies were on victims of childbirth fever and nobody was washing hands after working in the autopsy lab. Semmelweis didn’t know that bacteria were killing the women, causing infections leading to sepsis and a further complication, septic shock. But he reasoned that the students were carrying some agent from the deceased women that was causing women in labor to develop the same condition. By instituting a policy in which everybody –physicians, midwives, and students of both professions– had to wash their hands thoroughly with chlorinated lime water before working with each live patient, he decreased the rate of childbirth fever and maternal mortality dramatically, both in the obstetric and midwifery wards. From that point until the mid-1860s, Semmelweis battled with much of the medical community that dismissed his findings and thought it ridiculous to wash their hands. Given the Jewish tradition of washing hands before meals, some even ridiculed Semmelweis for bringing a ‘Jewish superstition’ to the clinics. Tragically, after suffering what was described as a nervous breakdown, Semmelweis was committed to an asylum, where he was beaten by guards and died of his injuries in 1865 at the age of 47.
Over the course of the next decade, work of the French scientist Louis Pasteur, the German scientist Robert Koch, and the British surgeon Joseph Lister led to the acceptance of the germ theory of disease and establishment of hand washing with antiseptic agents prior to invasive procedures. This led to a drop in the incidence of postpartum sepsis, followed by another drop with the advent of sulfa antibiotics in the 1940s. Today, maternal sepsis is much less common in develop countries than in undeveloped countries, but it can still happen and when it does, this is a life-threatening situation for the mother and, if it happens prior to delivery, for the fetus as well.
The main categories of medication for managing sepsis consist of antibiotics to combat the infection, medications to increase blood pressure (vasopressors) when there is septic shock, and intravenous fluids. Antibiotic regimens that are compatible with pregnancy can be chosen, but sepsis is a life-threatening condition in which the woman is treated in an intensive care setting. This means that medications, including drugs affecting the cardiovascular system, must be chosen first for their ability to save the mother’s life.