Maternal Sepsis and patient safety
Aleksandra Szycman UCD School of Medicine and Medical Science, University College Dublin, Belfield, Dublin 4, Ireland
Sepsis is a serious issue both in the general clinical and maternity setting, though the consequences of maternal sepsis are often more detrimental. Not only are high morbidity and mortality rates associated with sepsis, but the infection also incurs high costs. Patient safety is a priority in maternal sepsis cases in Ireland and worldwide. In order to enhance safety, healthcare professionals should have sufficient knowledge of pathophysiology, aetiology, and risk factors related to maternal sepsis. One of the most effective and common methods in assessing pregnant women’s well-being is through the use of Irish Maternity Early Warning System (IMEWS), which allows for early recognition of signs of deterioration that accompany a sepsis diagnosis. This facilitates quick and effective treatment, thus improving patient outcomes and safety. Healthcare providers caring for pregnant women, particularly those at higher risk of sepsis, must possess the necessary skills and training, as possible consequences of insufficient care, as in the case of Savita Halappanavar, can be disastrous. Furthermore, neonates that are born to mothers with sepsis are at risk of acquiring sepsis from the mother, while the same risk factors putting mothers at threat of sepsis put neonates at increased risk of developing early onset neonatal sepsis (EONS), with antibiotic prophylaxis being crucial in both cases. To conclude, maternal sepsis must be treated as emergency and healthcare providers should be familiar with prevention strategies and the importance of early recognition and treatment.
Traditionally, instruction in human anatomy has involved learning from both cadaveric dissection and formal lectures. The aim of this project was to introduce another dimension to learning anatomy using the medium of radiology. This integrated approach to anatomy learning was previously missing in the UCD's dissection lab. To fulfil this aim, the e-learning tool X-perience was created.
Cadaveric radiography as an anatomy teaching aid has been described in the literature as far back as 1983 by McNiesh  and 1985 by Pantoja . More recent reports on medical student and anatomy faculty impressions of supplementing cadaver dissection with radiological images have been extremely positive . Pantoja commended this approach to anatomy as an effective, easily implemented learning aid. While both McNiesh and Pantoja commented on increased student enthusiasm and interest in anatomy and radiology [1, 2]. Sugand et al. state that multimodal teaching is the basis of future learning and helps combat the issue of limited dissection time . While some medical schools have “abandoned dissection for user friendly multimedia”, it has been concluded that the beneficial values of orthodox dissection should not be replaced, but rather enhanced by hybrid teaching modalities . A large body of research suggests that multimedia teaching is most useful in combination with dissection.
Sepsis can be defined as lethal organ dysfunction, which results from dysregulated immune response to infection . It may also cause Systemic Inflammatory Response Syndrome (SIRS) and Multiple Organ Dysfunction Syndrome (MODS). When not immediately diagnosed and treated, it may progress into septic shock and eventually be fatal . Hospitals are using more aggressive management strategies to improve its control and treatment , but the incidence within the healthcare setting is still high. Approximately 102,000 suffer and 37,000 die from sepsis every year in the UK. From an economic standpoint, each case of sepsis in the developed world costs around £20,000, which leads to approximately £2 billion (€2.3 billion) spent on sepsis by the UK healthcare system every year . In Ireland in 2015 alone there were 8,888 cases of sepsis, a 37% increase from 2011. The incidence of paediatric and maternal sepsis has increased from 737 paediatric and 190 maternal cases in 2011 to 766 paediatric and 308 maternal cases in 2015 . This demonstrates the scale of the issue and highlights the importance of prevention and effective treatment in order to decrease morbidity, mortality, and cost.
'in Ireland in 2011, sepsis was the cause of severe maternal morbidity in 25 cases; in 2012 this number increased to 41 cases'
sepsis and pregnancy
The exact pathogenesis of sepsis is not fully understood, though ongoing research continues to further our knowledge. It is thought that sepsis is the body’s inflammatory response to infections of microbial origin . In some cases, sepsis can be diagnosed clinically without a positive culture for pathogens . Diagnosis of severe sepsis occurs when organ dysfunction or failure is present. Septic shock is the addition of another clinical sign such as hypotension .
Normal physiological changes during pregnancy tend to mask the clinical and laboratory symptoms of sepsis, making it a challenge for healthcare professionals to effectively diagnose and treat . During pregnancy, blood pressure changes due to vasodilation induced by pregnancy hormones. There is a significant drop in diastolic blood pressure and, to a lesser extent, systolic blood pressure. This usually settles towards the end of pregnancy . White cell count (WCC) rises due to stress, leading to leukocytosis. This is particularly evident just prior to delivery, when the WCC can fluctuate between 9,000 to 25,000 mcL . Normal values range between 4,000 and 11,000 mcL . This demonstrates how the normal physiological changes during pregnancy can cause abnormal readings or laboratory results when compared with the non-pregnant population, potentially leading to a missed diagnosis of sepsis.
It is evident that maternal sepsis is a massive patient safety issue, affecting maternity units and hospitals worldwide, with drastic consequences that must be addressed. The MBRRACE  report states that overall maternal deaths are decreasing in the UK and Ireland (from 11 to 10 per 100,000). However, in Ireland in 2011, sepsis was the cause of severe maternal morbidity in 25 cases; in 2012 this number increased to 41 cases . Furthermore, sepsis was responsible for 25% of maternal deaths between 2009 and 2012, in Ireland and the UK. In the USA, maternal sepsis was the leading cause of maternal death (20.6%) between 2003 and 2011 . However, a study of pregnant women between 1993 and 2006 in the Netherlands showed the maternal mortality rate caused by sepsis to be only 0.73 per 100,000 , indicating that the Irish and British health services have significant room for improvement, which was also supported by an Irish study by Knowles et al., . Despite the significant impact of sepsis on patients, many symptoms continue to go unnoticed and cases are not detected quickly enough for efficient treatment. If symptoms of sepsis are detected early and managed immediately, patient outcomes could improve dramatically .
Group A streptococcus is the main bacterial cause of sepsis, implicated in over half of maternal deaths , consequently majority of guidelines regarding identification and treatment are related to this pathogen . However, Abir et al., , stated that Escherichia coli bacteria was responsible for the majority of cases in their study, showing there are inconsistencies in bacteriological origin. Other organisms related to maternal sepsis comprise of: Listeria monocytogenes, anaerobic bacteria, Staphylococcus aureus and Group B Streptococcus (GBS) , which is also associated with sepsis and meningitis in new-borns, that can usually be prevented by treating GBS positive mothers during intranatal period with antibiotics . Approximately 1 in 5 women carry GBS, however there is no universal screening for it during pregnancy either in Ireland or the UK [19,18].
The rapid onset of sepsis leaves very little time for error. Thus, all potential risk factors, such as repetitive vaginal examinations without rationale or prolonged rupture of membranes , should be considered when assessing patients. Acosta et al., , stated that factors such as obesity, operative vaginal delivery, and age above 25 years can also increase this risk. Sriskandan  compared the different risk factors for women in developed and developing countries. In developed countries, risks for maternal death from sepsis were: emergency caesarean section, prolonged rupture of membranes, retained products of conception, premature labour, history of infection, excessive vaginal examinations, low income, diabetes, anaemia, recent upper respiratory tract infections in family, and giving birth during the winter months. Similar to Acosta et al.,  obesity was mentioned as risk factor. Each woman should be individually assessed antenatally, during labour, and postnatally, to ensure that the risks are adequately controlled and managed.
One of most common ways to assess health status during pregnancy, labour, and throughout the postnatal period (42 days after birth) is by checking vital signs. The Irish Maternity Early Warning System (IMEWS) is widely used in maternity services in Ireland where routine vitals such as pulse, respiration rate, oxygen saturation, temperature, blood pressure, neurological state and pain score are noted . Similarly, The Modified Early Obstetric Warning System (MEOWS) is used in the UK, which was recommended by the CEMACH 2003-2005 report. Singh et al.,  wrote that MEOWS is “cost effective, safe, and validated”. In their study, 676 cases involving the use of MEOWS were assessed and no deaths were reported . However it’s suggested that use of MEOWS is limited in the cases of chorioamnionitis, an infection of the amniotic fluid acquired through introduction of bacteria into the uterus through the birth canal and severe infections . Measurement of a woman’s blood pressure prior to 10 weeks’ gestation, upon her first antenatal check-up, provides a baseline for the remainder of her pregnancy . This baseline allows healthcare professionals to more accurately judge abnormally high or low blood pressure readings for the individual patient. If IMEWS is triggered, it indicates that the underlying cause of the change in blood pressure needs immediate attention. As well as recording vitals, it aids in the identification of abnormalities, assists in further assessment and referral .
Furthermore, 82% of sepsis, 100% of severe sepsis, and 86% of septic shock cases are diagnosed postnatally, with the most common point of origin being the genital tract . In most hospitals, women are discharged within 24 hours of giving birth. However, an increasing number of women choose the ‘Early Transfer Home’ option available in Ireland, and return home as soon as 12 hours after delivery . This quick turnover of patients provides midwives only a short window of opportunity to recognise sepsis and implement appropriate treatment.
Certain symptoms of sepsis cause abnormal vital signs. When this occurs, IMEWS or MEOWS automatically highlights the issue and alerts the healthcare provider. This allows for rapid action and referral of the patient for appropriate further screenings [23, 22]. Such warning systems simplify this process by providing a clear escalation protocol for deteriorating patients. This early detection is especially crucial due to the rapid spread of maternal sepsis.
Despite IMEWS and MEOWS providing a great guiding tool for healthcare providers, they themselves must be able to take and interpret vital signs, consequently follow appropriate actions. Also healthcare providers need to follow certain guidelines, which are strict and evidence-based providing a reference when dealing with patients with maternal sepsis, such as NICE  guideline on recognition, diagnosis and management of sepsis, RCOG  guideline on bacterial sepsis in pregnancy and their own local hospital policies. Such guidelines aim to ensure patient receive the best care possible. In 2013, The Health Information Quality Authority (HIQA) published the report of their investigation into a maternal sepsis death in an Irish hospital in 2012. The investigation identified a failure in the provision of basic elements of patient care and a failure to recognize and act upon signs of clinical deterioration in a timely and appropriate manner . The report made several recommendations, including the development and implementation of a national clinical guideline on the management of sepsis which has been made to aid healthcare professionals in detection, recognition and treatment of sepsis . National clinical guideline on IMEWS has also been created and implemented after HIQA report , to assist clinicians in identifying deteriorating pregnant patients as opposed to National Early Warning Score (NEWS) which focuses on deterioration of a non-pregnant adult patient. Also another aim of this guideline was to standardized care and provide consistency among all maternity units in Ireland . Since the introduction if IMEWS in 2013, an enhancement has been noted in consistency and documenting of vital signs particularly the respiratory rate  which is considered as the first warning sign of deterioration . However, further evaluation is recommended in relation to, is IMEWS improving patient outcomes, as study by Maguire et al.,  comprised of quite a small sample. Lastly, the biggest change involved the development of National Maternity Strategy 2016-2026, which is meant to improve and standardize both maternity and neonatal care, ensure that all pregnant women in Ireland can make an informed choice regarding their mode of care that’s evidence based and also have access and support regarding such care . However more time is needed to be able to see full potential and effects of this strategy being implemented in Ireland.
Cross transmission of infection is another important patient safety issue contributing to maternal sepsis. Infections can easily spread between patients, thus special care must be taken when treating women with maternal sepsis. To prevent cross transmission of infection, when conducting certain procedures such as administration of intravenous fluids, aseptic techniques should be used correctly . All staff involved in the care of a patient with maternal sepsis should be made aware of such cross transmission issues and take the necessary precautions. Infection prevention and control is crucial and WHO five moments of hand hygiene should be followed. Further, isolation of patients with multidrug resistant organisms is recommended where possible . Prophylactic antibiotics are recommended for neonates born to mothers with severe sepsis, though transmission of sepsis from mother to baby is rare . There is evidence that the risk factors for the mother also put the neonate at increased risk of early-onset neonatal sepsis (EONS), which develops in first 72hrs of life. The two highest risk factors being repetitive vaginal examinations and chorioamnionitis, while not using prophylactic antibiotics when indicated was a significant risk factor associated with EONS .
Maternal sepsis must be regarded as a major obstetric emergency  with which all hospital staff should be trained to handle. Healthcare professionals should be aware that maternal deaths caused by sepsis, although low, are increasing. Methods of prevention include minimizing invasive interventions, early diagnosis with tools such as IMEWS/MEOWS, adequate interpretation of vital signs, appropriate referral, and adherence to infection prevention and control precautions. If healthcare practitioners, from midwives to obstetricians, take appropriate steps in recognising the early signs of maternal sepsis and take the correct actions and precautions thereafter, patient outcomes should improve. Wider education and research regarding maternal sepsis is recommended, focusing on its cause, transmission, and development of best practice guidelines for prevention and treatment.
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