Sepsis remains one of the foremost cause of preventable maternal death worldwide even decades after the advent of effective low cost novel antimicrobials . It is one vital member of the deadly triad, along with haemorrhage and hypertensive disorders, that contributes greatly to maternal morbidity and mortality . Chiefly in settings like India, where the paramount impediment to intervention is poverty, maternal mortality due to sepsis is a continuing representation of maternal health inequality. According to reports of WHO, puerperal sepsis has been stated to be the second leading cause of maternal mortality in developing countries .
Puerperal sepsis is the septicaemia contracted by women during or soon after child birth or miscarriage . It is constituted by a conglomeration of symptoms of fever and supplementary symptoms of pelvic pain, foul smelling vaginal discharge and subinvolution of uterus during the period. Sepsis is described as infection coupled with its systemic manifestations. Severe sepsis is summarized as a possibly perilous malady typified by systemic inflammatory response syndrome along with infection, organ dysfunction, hypoperfusion or hypotension [5,6].
Most conjectures of maternal sepsis, especially from low income countries, come from small cohorts which have focused on either postabortal sepsis (or its sequelae) or on postdelivery sepsis [7-14]; amongst them, very few have amalgamated the causes through a holistic approach. Keeping in view this backdrop, the present study was proposed to analyse the patients presenting with puerperal sepsis (postabortal and postdelivery) in a tertiary level hospital, to determine the magnitude of the problem. This would help to formulate institutional protocols, which would be, in turn, instrumental in planning preventive strategies at higher levels. This would go a long way in fostering maternal health.
Materials and Methods
This retrospective study was carried out in VMMC and Safdarjung Hospital, New Delhi from January 2016 to June 2016 in Obstetrics and Gynaecology department. During this period, 366 women with puerperal sepsis admitted in the hospital were enrolled into the study. Ethical approval was taken by Institutional Ethical Commitee.
Inclusion criteria were any patient presenting: a) either immediately after or within 42 days of vaginal delivery, caesarean section (LSCS) or miscarriage; b) associated with pain abdomen, malodorous lochia, abdominal distention, uterine tenderness, pelvic abscess, peritonitis, mechanical or foreign body injury, any system/organ failure and shock.
Exclusion criteria consisted of: a) fever during pregnancy or more than 42 days after delivery, LSCS or miscarriage; b) fever due to medical causes; c) wound/surgical site infection; d) mastitis; e) UTI; and f) thrombophlebitis.
A total of 33 women with severe maternal sepsis were finally enrolled for the study and their case records were reviewed.
The primary outcome was frequency of severe puerperal sepsis, while secondary outcomes included demographic variables, booking status, predisposing risk factors, antecedent pregnancy event and the interval between it and presentation, clinical presentation at admission, complications, need for ICU admission and/or surgical management, duration and course of hospital stay and mortality with cause of death.
Data analysis was performed using SPSS version 21.0 for windows and applying chi-square test, keeping null hypothesis value of 10% for risk factors, clinical profile and possible modifiable factors. In all cases, p-value < 0.05 was considered significant.
During the study period, there were 14,550 admissions in Obstetrics and Gynaecology Department, out of which, 366 were due to puerperal sepsis, giving an incidence of 2.5%. Of these, 33 (9%) women fulfilling the inclusion and exclusion criteria for severe puerperal sepsis were finally enrolled into the study.
Young women aged less than 20 years constituted 9% of these patients and 12% of the patients were primiparas. Preponderance of women was seen between 20-30 years (p-value=0.001). Maximum women were multigravidas (p-value=0.002). Majority (94%) of the patients were unbooked (p-value=0.001), having delivered at home (p-value=0.007) or in other peripheral hospitals [Table/Fig-1].
Demographic variables and baseline maternal characteristics.
|Baseline characteristics||Cases n=33(%)||p-value|
|SE status (Modified Kuppuswami)|
|Lower middle||5 (15%)|
|Upper Lower||13 (39%)|
Antecedent pregnancy event was term delivery in 24 women and miscarriage in nine (two in first trimester and seven in second trimester) females. The most frequent mode of delivery in patients reaching term was LSCS (67%), making it statistically significant (p-value=0.001). Also, higher incidence was seen in second trimester unsafe abortions (p-value=0.009) [Table/Fig-2,3].
Antecedent pregnancy event in cases.
|Antecedant pregnancy event||Cases n =33 (100%)||p-valuea||p-valueb|
|Miscarriage 9 (27%)• Spontaneous• Induced||09 (27%)||-||<0.001|
|Delivery 2 (6%)• Vaginal• Instrumental||2(6%) 0||-|
|Caesarean 22 (67%)• Elective• Emergency||1 (3%)21 (64%)||<0.001|
p-value-gives the association of women with caesarean section as antecedent pregnancy event when compared to miscarriage and delivery
p-value-gives the comparison of emergency caesarean with elective cesearean indicating that maximum women had undergone emergency cesearean prior to developing sepsis, and this was significant with p <0.001.
Risk factors for puerperal sepsis.
|Body mass index <18.9||28 (85%)||<0.001|
|Comorbidities• Anaemia• Diabetes Mellitus• Tuberculosis||14 (42%)2 (6%)2 (6%)||<0.0010.44370.4437|
|Poor hygiene||7 (21%)||0.0352|
|Frequent vaginal examinations (>5)||10 (30%)||<0.001|
|Delivery/abortion by untrained persons||11 (33%)||<0.001|
|Prolonged labour||12 (36%)||<0.001|
|Prolonged rupture of membrane||14 (42%)||<0.001|
|Delivery / abortion place (n=11)• Home• Institutional||10 (30%)1 (3%)||<0.001|
|Postpartum haemorrhage||10 (30%)||<0.001|
|Period of gestation of induced abortion (n=9)• First trimester• second trimester||3 (9%)6 (18%)||0.009|
|Methods for induced abortion (n=9)• Curettage• Instillation of abortifacientalign="center"• Hysterotomy• Others/history not revealed by patient||5 (15%)2 (6%)0 2 (6%)||0.009|
Women were uniformly distributed with respect to puerperal day of presentation, with most of the patients presenting within first 72 hours/more than six days postpartum (p-value=0.845), with frequent complaints of fever (100%), pain abdomen (70%, p-value<0.001), malodorous discharge (p-value<0.001) and abdominal distension (64%, p-value<0.001) [Table/Fig-4].
Clinical profile of the patients.
|Clinical profile||Casesn (%)||p-value|
|Puerperal day of presentation• 1-3• 3-6• 6-9• ≥10||9 (27%)6(18%)9 (27%) 9 (27%)||0.845|
|Persistent fever >100.4 without chills||33 (100%)||-|
|Malodorous discharge||9 (27%)||<0.001|
|Pain abdomen/pelvic pain||23 (70%)||<0.001|
|Uterine tenderness||18 (55%)||<0.001|
|Abdominal distension||21 (64%)||<0.001|
|Systemic /end-organ failure||11 (33%)||<0.001|
|Multi Organ Dysfunction Syndrome (MODS)||5 (15%)||0.338|
Amongst the associated risk factors, malnourishment (67%, p-value <0.001 and pre-existing anaemia (42%, p-value<0.001) were the most common and significant, followed by prolonged rupture of membranes (30%, p-value<0.001) and frequent pelvic examinations (30%, p-value<0.001) [Table/Fig-3].
A total of 73% women required surgical exploration and further procedure for management which was statistically significant (p-value=0.009). A breakup of surgical procedures showed uniform distribution amongst all of these women (p-value=0.09) [Table/Fig-5].
Management protocol instituted.
|Management protocol||Cases n=33 (100%)||p- value||p-value for surgical correction* (1,2, 3)||p-value for a, b and c within 1 and 2|
|Conservative (non-surgical)||9 (27%)|
|Surgical (n=24)*Exploratory laparotomy followed by• Uterine rent repair along with# a.closure b.bladder repair c.gut resection and anastomosis• Subtotal hysterectomy along with# a.closure b.gut resection and anastomosis • Peritoneal lavage only • Colpotomy||24 (73%)8 (24%) 5 (15%) 2 (6%)1 (3%) 5 (15%) 3 (9%) 2 (6%) 8 (24%) 3 (9%)||0 .009||0.392||0.197 0.655|
Majority (73%) of patients were admitted in the ICU of the hospital; another 18% did not get ICU care even though required due to non availability of ICU beds.
Despite best efforts, 85% of women succumbed to their illness, most common cause of death being pulmonary oedema (36%) or multiorgan dysfunction syndrome (24%), though it was insignificant [Table/Fig-6].
|Course in the hospital||Cases n = 33 (100%)||p-value|
|ICU admission• Yes• No~Not needed~Needed but no availability*||• 24 (73%)• 9 (27%) ~3 (9%)~6 (18%)||0.009|
|Duration of hospital stay• <48 Hours• 48-96 hours• 96-168 hours• >168 hours||• 18 (55%)• 11 (33%)• 2 (6%)• 2 (6%)||<0.001|
|FATE IN HOSPITAL• Recovered• Died• LAMA• Re-laparotomy||• 3 (9%)• 28 (85%)• 0• 2 (6%)||<0.001|
|Cause of death• Pulmonary edema• DIC• Cardiac arrest• MODS||• 12 (36%)• 4 (12%)• 4 (12%)• 8 (24%)||0.098|
*=these patients though required ICU care, could not be sent to ICU due to non-availability of beds in ICU, owing to high patient load in this tertiary care government hospital.
MODS- Multiorgan dysfunction syndrome, DIS- Disseminated intravascular coagulation, LAMA-Leaving against medical advice
Amongst the preventable modifiable factors, considerable delay in diagnosis of by index physician (39%) was the chief amendable issues unveiled during the study that were significantly associated with severe sepsis [Table/Fig-7].
Possible modifiable factors.
|Modifiable Factors||Cases (n=33||p- value|
|1. Personal/Family• Delay in obtaining legal abortion• Delay in seeking timely help of doctor• Lack of awareness of available services• Lack of resources• Past adverse experience• Refusal of treatment/admission||• 9 (27%)• 6 (18%)• 3 (9%)• 14 (42%)• 3 (9%)• 1 (3%)||0.0010.1260.848<0.0010.8480.180|
|2. Logistics• Lack of transport from home to health care facility• Lack of transport between health facilities• Lack of communication network||• 9 (27%)• 3 (9%)• 5 (15%)||0.0010.8480.338|
|3. Other Lacunae at first referral units• Infrastructural issues• Inappropriate choice of antibiotics• Lack of safe instruments, equipments/consumables• Surgical complications• Lack of recognition of seriousness of condition by caregiver• Delay in referral of patient to tertiary care hospital• Lack of support services (anaesthesia, OT staff, blood bank services)||7 (21%)7 (21%)6 (18%)9 (27%)13 (39%)12 (36%)4 (12%)||0.0350.0350.1260.001<0.001<0.0010.702|
|4. Present Facility/facilities• Infrastructural issues like non availability of ICU beds due to patient load• Lack of medications, instruments, equipments/ consumables• Non utilization of available medications, instruments, equipments/ consumables||6 (18%)00||0.126|
Severe puerperal sepsis is a known source of severe maternal morbidity and mortality in developing nations like India . In the course of the study period, 2.5% of the total admissions in Obstetrics and Gynaecology Department were due to puerperal sepsis. Amongst these, 9% were anguished with severe puerperal sepsis.
[Table/Fig-8] displays a comparative evaluation of studies done by past pollsters on obstetric sepsis across the world, with the findings of the present study.
Comparative evaluation of observations of all researches on sepsis.
|Study||Type of study||Sample population/ duration||Criteria||Conclusion|
|Regmi C et al., ||Retrospective||70 cases/three year||Unsafe abortion||52% high grade sepsis; most recovered, eight maternal deaths.|
|Madhudas C et al., ||Retrospective||230 patients/ two years||Puerperal sepsis following delivery/LSCS only, not included post abortion cases||Puerperal sepsis= 6.28% of 3656 admissions; risk factors =anemia, unbooked status, frequent vaginal examination, home delivery and prolonged rupture of membranes; Mortality=21.68%.|
|Acosta CD and Knight M ||Case control study||13 years||Pregnant, intrapartum and postpartum women with sepsis or severe sepsis||Obesity, operative vaginal delivery and age <25 years are significant risk factors for sepsis and should be considered in clinical obstetric care.|
|Rocca CH et al., ||Cross-sectional study||527 women presenting with complications from induced abortion/ 10 years, four hospitals||Septic abortion||Majority had undergone medically induced abortions using unknown substances acquired from uncertified sources.|
|Ahmed MI et al., ||Prospective cohort||170 women/One year||Sepsis during labor or in puerperal period; not included abortions||Out the 124 pathogen positive cases, aerobes were the predominant ;Higher rate of infections followed vaginal delivery compared to Cesarean section 121 (97.6%), 3 (2.5%) respectively.|
|Al-Ostad G et al., ||Retrospective||study cohort consisted of 5338 995 women/ 10 years||Sepsis during labour, postdelivery and post abortion sepsis||Incidence of maternal sepsis=29.4 per 100, 000 births black women >35years and who smoke were high risk; association found with diabetes mellitus, cardiovascular disease, eclampsia, preterm birth, hysterectomy, puerperal infection, post-partum hemorrhage, transfusion and chorioamnionitis.|
|Present study 2016||366 cases/six months||six months study duration||Only severe puerperal= postdelivery /LSCS and postabortal cases||2.5% sepsis, 9% severe sepsis. Unsafe abortion, anaemia, prolonged labour, delivery by untrained person risk factors. 70 % mortality, mostly due to Multiorgan dysfunction syndrome.|
In contrast with previous research studies, a relatively younger women in the present study reflects an early age at marriage and conception in India [1,3,4,7-12,14]. On further analysis, most of them were unbooked with no prior antenatal supervision, having delivered at home or in outside hospitals; hailing mostly from lower socioeconomic background. Maximum females thus came as referral cases from peripheral centres following unnecessary labour induction and substandard sterilization practices by less skilled practitioners. In under-resourced settings like India, there is a vital need to segregate unbooked/referred cases coming to hospitals from those who develop the ailment in the hospital setting; since the former indicates a lack of basic infrastructural facilities, or failure in access to the facilities in the peripheral hospitals and/or to the referral chain, indicating that such first referral units should be made equipped with ample resources and organization to be able to manage such emergent predicaments .
These aforesaid observations were in consonance with the available reviews in literature from both developing and developed countries, which emphasizes that this consortium of women endures most of the infectious morbidities [3,4,15,16]. It may be further attributed to poverty, illiteracy, malnutrition, early age at marriage and subsequently first conception. This cohort of women is ignorant about availability of family planning services, concept of high risk pregnancy, hygiene and safe health care practices. Moreover, as such, they are clinically malnourished and may have associated comorbidities like tuberculosis and anaemia; the present study also observed anaemia in 42% of cases.
There was a high incidence of sepsis following LSCS done at peripheral hospitals (22/24 term deliveries) in the current study. This is a relatively novel observation when equated with work in literature [1,3,4,7-12,14]; highlighting the fact that increasing number of obstetric surgeries, in developing countries like India, are still being done by untrained personnel’s for extraneous reasons, who fail to follow the accredited norms of disinfection during surgeries, unaware of safe surgical practices. Similarly, lack of awareness among women at the grass-root level about contraception leads to unwanted pregnancies; compelling them to resort to unsafe abortions in absence of widespread cheap safe abortion services.
Akin to observations of the earlier investigators, most common presenting complaints in our patients were fever followed by pain in abdomen and abdominal distension [7,8,11-18]. Hence, a prompt and thorough evaluation for impending sepsis is warranted which would go a long way in preventing end organ damage and minimizing sepsis related morbidity and mortality in the country.
The breakup of risk factors for sepsis is comparable to various surveys in the preceding times with malnourishment and pre-existing anaemia emerging as the leading factors among all cases [11-14]. This reflects poor maternal health services in the region, including shortage of awareness, accessibility, availability and ignorance on the part of the patients.
The extant study also witnessed high incidence of prolonged rupture of membranes, frequent pelvic examinations and poor hygiene as the plausible causative factors instrumental in generating sepsis in women. These conclusions were analogous to those of previous canvassers, from developing countries [15-17]. It advocates maintenance of hygiene and asepsis during examination in parturient women by both doctors and dais, besides judicious use of antibiotics. It further mandates upgrading of their knowledge of midwifery abreast with innovative and new fangled protocols in infection control.
The above observations also necessitate provision of safe and accessible abortion services in the country in order to minimize postabortion infection rate. Additionally, women presenting with signs and symptoms of infection after abortion procedures require prompt evaluation and management to avoid septic complications. Besides, the latest infection control guidelines should be strictly adhered to in all the health facilities across the nation to decrease the incidence of sepsis and nosocomial infections [19,20]. Recently, utilization of antiseptic washes to the vaginal area during labour has also gained interest of many clinicians, though the evidence of establishing their role in preventing maternal infection is still inconclusive [19,20].
Parallel to erstwhile reports on puerperal sepsis, a large proportion of women in the current research required surgical exploration for management [11-18]. However, all of these women had already been treated by many clinicians outside, before being referred to our tertiary hospital. These annotations re-emphasize that deficient surgical expertise in peripheral smaller hospitals (first referral units) needs to be parted with, by audacious efforts at both the state and national level to boost the maternal health in the long run.
Majority of these patients were admitted in ICU of the hospital while another 18%, though requiring intubation, could not get the same due to non availability of ICU beds. This reflected the severity and gravity of women at the time of admission and the burden on the health care facilities, especially in government sector. Hence, all healthcare infirmaries should have regular internal audits to assess the magnitude of patients requiring critical care, to upgrade their support services from time to time.
The high rate of morbidity and mortality in our study could be attributed to surgical complications (27%), considerable delay in diagnosis of same by index physician (39%), lack of recognition of gravity of ailment by the caregiver (36%) and deferment in referral of patient to tertiary care hospital (33%). This elevated rate of mortality, in contrast to former explorations, stems from the fact that Safdarjung Hospital, being one of the largest tertiary care hospitals of India, caters to a sizeable chunk of critically ill referred cases from neighbouring states in Northern India. Characteristic problems related to infection control including wrong antibiotics prescribing practices, poorly functioning laboratory services at the smaller peripheral hospitals were also instrumental. In general, most serious postabortion infectious complications can be avoided by improving health education, imparting awareness among general public and equipping the smaller hospitals with best facilities to handle emergency and essential obstetric care besides, augmenting the first referral units.
Our conclusions having been drawn from a relatively smaller study population cannot be an actual and precise representative of the disease entity at the national level. It being a retrospective study, research is limited by the accuracy and completeness of data that had been entered in the case files. Also, this being a single centred hospital based study; it cannot reflect data at national level completely.
Under-reporting of cases of severe puerperal sepsis, especially those following unsafe abortion, leads to underestimation of its contribution to maternal death. An early diagnosis along with intensive care resourcing influences the efficacy of goal directed therapy. There is a need to enlighten the populace on the need for safe abortion practices, regular antenatal supervision, trained and skilled birth attendant, and preferably institutional delivery under aseptic conditions. Modification of risk factors and prevention of unplanned and unwanted pregnancies (by sex education and access to safe and sustainable family planning methods) and penetration of health services to the lowest echelons, including awareness building and health education would be crucial in tackling this menace.ap-value-gives the association of women with caesarean section as antecedent pregnancy event when compared to miscarriage and deliverybp-value-gives the comparison of emergency caesarean with elective cesearean indicating that maximum women had undergone emergency cesearean prior to developing sepsis, and this was significant with p <0.001.*=these patients though required ICU care, could not be sent to ICU due to non-availability of beds in ICU, owing to high patient load in this tertiary care government hospital.MODS- Multiorgan dysfunction syndrome, DIS- Disseminated intravascular coagulation, LAMA-Leaving against medical advice