Page 43 Complete Your CE Test Online - Click Here Incidence Maternal sepsis (sepsis that develops during pregnancy) and postpartum sepsis are more common in developing countries where women do not have access to quality medical care or may live in unsanitary conditions than women in developed countries (Sepsis Alliance, n.d.). While maternal and postpartum sepsis is considered to be rare in the more developed countries, incidence and maternal deaths from sepsis are rising, and attention to this specific population should be considered in the discussion of the adult patient with sepsis. Data from the mid-1990s showed sepsis as the cause of 7.6% of maternal deaths in the United States, and this number continues to rise (Bauer et al., 2013; Sepsis Alliance, n.d.). Sepsis is the leading cause of maternal deaths in the United Kingdom (Bauer et al., 2013). The incidence of medical and surgical emergencies in the pregnant and postpartum patient leading to sepsis is rising and is expected to continue to rise in the future (Barton & Sibai, 2012). The reasons for this rise include an increased maternal age, multiple gestations, and obesity (Barton & Sibai, 2012), along with the following reasons. Increasing maternal age: Pregnancy in women over age 40 is much more common than it was in the past, carrying with it an increase in the incidence of obesity, diabetes, placenta previa, and abruptio placentae (Barton & Sibai, 2012; Montan, 2007). Multiple gestations: Multiple gestations that carry increased maternal risk are on the rise with the availability of reproductive technologies. Multiple gestations require more invasive and diagnostic procedures, such as cervical cerclage, serial amnioreduction, and fetal or placental surgery (Barton & Sibai, 2012; Hoffman & Sciscione, 2004; Plachouras, Sotiriadis, Dalkalitsis, Kontostolis, Xiropotamos, & Paraskevaidis, 2004). Obesity: The incidence of pregnant women who are obese or morbidly obese has risen over the past decade causing an increase in obesity- related complications, such as increased hypertensive disorders, type 2 diabetes, caesarean section, and cardiopulmonary complications (Barton & Sibai, 2012; Gunatilake & Perlow, 2011). Etiology Urinary tract infections during pregnancy are responsible for one-third of sepsis in pregnant patients, whereas in the postpartum period, one- third of sepsis is caused by genital tract infections, with E. coli the most frequent causative pathogen, and group A. streptococci causing a more severe sepsis (Acosta et al., 2014). Causes of maternal sepsis and postpartum sepsis include the following (Barton & Sibai, 2012): ● ● Acute pyelonephritis. ● ● Retained products of conception. ● ● Septic abortion: An infection that occurs after an incomplete miscarriage or an incomplete medically performed abortion. Infection can extend into parametritis or peritonitis. ● ● Placenta accreta: When all or part of the placenta attaches to the myometrium, the middle layer of the uterus. ● ● Placenta percreta: The most severe form of placenta accretes that involves the attachment of placenta to the urinary bladder. ● ● Chorioamnionitis or endomyometritis: Bacteria can migrate from the lower genital tract into the lower uterine segment during labor or rupture of membrane causing infection of the chorion, amnion, and fetus. ● ● Necrotizing myometritis: An infection of the middle layer of the uterine wall. ● ● Gas gangrene: A very rare occurrence that is an infection caused by the anaerobic organism Clostridium perfringens. ● ● Pelvic abscess: An infection that usually occurs after acute appendicitis or gynecological infection. ● ● Pneumonia: Bacterial causes – Staphylococcus, Pneumococcus, Mycoplasma, Legionella; viral causes – influenza, H1N1, herpes, varicella. ● ● Poorly treated or undiagnosed necrotizing fasciitis: Necrotizing fasciitis is an infection of soft tissue with extensive necrosis of tissue and deep fascia that spreads rapidly. ● ● Necrotizing vulvitis: Necrotizing fasciitis of the vulva that can arise from a perineal laceration or episiotomy site. ● ● Abdominal incision: An infection can occur at the site of a cesarean section. ● ● Episiotomy: A surgical incision of the perineum performed to enlarge vaginal opening and to prevent tears during birth. ● ● Perineal laceration: A cut or tear in the perineum. ● ● Nonobstetric causes: Ruptured appendix or acute appendicitis, bowel infarction, acute cholecystitis, necrotizing pancreatitis. As with the general population, comorbidities in pregnant women increase the risk for the development of sepsis. Comorbidities that increase risk for sepsis in pregnant women include the following (Bauer et al., 2013): ● ● Obesity. ● ● Urinary tract infections. ● ● Congestive heart failure. ● ● Chronic liver or kidney disease. ● ● Systemic lupus erythematous (SLE). Sepsis also occurs in pregnant patients with no risk factors, emphasizing the need for screening and early detection and management to avoid progression of sepsis (Bauer et al., 2013). Key points ● ● Maternal sepsis is more common in developing countries than in the developed countries, but incidence and mortality is rising in developed countries because of such factors as increased maternal age, multiple gestation, and obesity. ● ● Urinary tract infections are responsible for one-third of sepsis cases in pregnant women, and genital tract infections are responsible for one-third of sepsis case in the postpartum period. ● ● Women who have comorbidities are more likely to develop sepsis than women with a single condition. Self-evaluation: Question 8 Mary is a 34-year-old woman who is pregnant with triplets as a result of in vitro fertilization. Previous to pregnancy, she was an active and healthy adult with no preexisting health conditions. Which statement is true regarding the risk Mary has for developing sepsis? a. Mary is not an increased risk for developing sepsis because she was a healthy adult before pregnancy and had no preexisting medical conditions. b. Mary is more at risk for developing a urinary tract infection during pregnancy because she is carrying triplets. c. Mary is at risk for developing sepsis as a result of more invasive and diagnostic procedures that may be needed during a multiple pregnancy. d. Mary’s age is a risk factor for developing sepsis during pregnancy or the postpartum period. RECOMMENDATIONS ON THE CARE OF PATIENTS WITH SEPSIS The Surviving Sepsis Campaign (SSC) originally published guidelines for the treatment of sepsis in 2004, with updates in 2008 and 2012. The newest updates are now available for 2017. All clinicians should be aware of these recommendations, using the latest research in an effort to combat the cascade of events that start with infection and increase quickly in the progression of sepsis. Nursing consideration: The 2015 SSC bundle recommendations are currently undergoing revision consideration in response to the SSC guideline updates of 2017. All clinicians, including nurses, should check for the latest bundle recommendations!