Sepsis in Pregnancy

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Recently, we discussed the topic of sepsis in the neonate  –the newborn infant—so now let’s turn our attention to sepsis occurring in the mother. As explained in the neonatal post, the term sepsis refers to an infection throughout the body. The technical definition of sepsis actually is very complex and changes every few years as critical care doctors learn more and adjust sepsis categories. Doing this makes it easier to study different treatments and their effects on the rates of recovery and death. But you need only remember that there is an infection by pathogenic (disease-causing) microorganisms in the blood (septicemia), or in other tissues throughout the body, and the body is responding in ways that cause organs to malfunction. It is possible to develop sepsis from a viral infection or a fungal infection, but most cases of sepsis are due to bacteria.

Sepsis can result as a complication a variety of infective conditions, such as abdominal infections (appendicitis, cholecystitis [gallbladder infection], peritonitis), pneumonia, kidney and other urinary tract infections, and central nervous system (brain and spinal cord) infections. You also can develop sepsis through the skin, including from skin infections (cellulitis), from wounds, and through intravenous catheters, including central lines (catheter into a large, deep vein).

Sepsis also can develop from infections particular to pregnancy, such as chorioamnionitis (infection of the fetal membranes), 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 post-partum infections due to entry of bacteria through the birth canal or though a caesarian incision site (this includes endometritis, but also other obstetric infections).

Known as puerperal fever, or “childbed fever”, post-partum sepsis (maternal sepsis) triggered by a peripartum infection, such as chorioamnionitis or endometritis, is a condition whose incidence peaked in the developed world during the 19th century. The peak was due an increasing number of women giving birth in hospitals, rather than at home in an era when the understanding the role of microorganisms in disease was still a few decades away. The crisis came to a head in Vienna of the 1840s, when the Hungarian physician Ignaz Semmelweis realized that a higher death rate in women tended by physicians with medical students compared with women tended only by midwives (13-18% versus 2%) had to do with cadavers in a pathology lab. This happened when a colleague, who worked as a pathologist, cut his hand during an autopsy and developed the same disease that was killing the pregnant women. Unlike the midwifery students who worked only with pregnant women, the medical students also participated in autopsies prior to arriving at the maternity ward, without washing their hands in between. Semmelweis didn’t know that bacteria were killing the women; he hypothesized the culprit to be some kind of particles that were not necessarily alive. However, by instituting a policy in which everybody –physicians, midwives, and students of both professions– had to wash their hands thoroughly before working with each 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. 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, the work of Louis Pasteur and Joseph Lister led to the acceptance of the germ theory of disease and establishment of hand washing and other sanitation procedures. This led to a drop in the incidence of post-partum 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), 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.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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