Puerperal sepsis in the 21st century: progress, new challenges and the situation worldwide

Abstract

Puerperal sepsis is one of the five leading causes of maternal mortality worldwide, and accounts for 15% of all maternal deaths. The WHO defined puerperal sepsis in 1992 as an infection of the genital tract occurring at any time between the rupture of membranes or labour and the 42nd day post partum; in which, two or more of the following are present: pelvic pain, fever, abnormal vaginal discharge and delay in the reduction of the size of the uterus. At the same time, the WHO introduced the term puerperal infections, which also include non-genital infections in the obstetric population. Recent epidemiological data shows that puerperal sepsis and non-genital tract infections are a major area of concern. In puerperal sepsis, group A streptococcus (GAS) is the most feared pathogen. Up to 30% of the population are asymptomatic carriers of GAS. GAS commonly causes throat infections. Women who died from GAS-positive sepsis all had signs of a throat infection themselves or one of their family members suffered from a throat infection. The pathway of infection is from the hands of the pregnant women or the mother to her perineum. In non-genital tract infections, influenza viruses and the HIV pandemic in the developing part of the world are responsible for many maternal deaths, and demand our attention. The physiological changes of pregnancy and the puerperium can obscure the signs and symptoms of sepsis in the obstetric population. A high level of suspicion is, therefore, needed in the care for the sick pregnant patient. If sepsis is suspected, timely administration of antibiotics, sepsis care bundles, multidisciplinary discussion and early involvement of senior staff members are important to improve outcome.

Prolonged activation of innate antiviral gene signature after childbirth is determined byIFNL3genotype

“…Puerperal sepsis, a bacterial infection originating in the uterus following delivery, is the leading infectious cause of maternal death worldwide (26). Type I IFN signaling has been associated with increased severity of infection with a number of relevant pathogens, including staphylococcal and Pseudomonas species (27,28).…”

Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation

“…A total of 78 were selected for full-text evaluation. After screening, 26 studies [2, 4, 5, 8, 10, 12, 20–39], 9 guidelines [13, 40–47] and 3 WHO documents [48–50] matched the inclusion criteria (Fig. 1).…”

“…The majority of reviews and guidelines cover all stages of pregnancy, intrapartum, postpartum and post-abortion periods. However some studies [2, 4, 8, 20, 22, 30, 37] and guidelines [40, 48, 49] were limited to certain stages (e.g. postpartum) or conditions (abortion) [2, 20, 24, 31].…”

“…Other preferred to differentiate those infections from nosocomial infections, or to classify infections into those related to the genital-tract infections and non-genital-tract infections. Furthermore, four documents (2 reviews [4, 30], 2 WHO documents [48, 49]) limited to postpartum genital tract infections. Three reviews focused on Group A Streptococcus (GAS) infections [8, 28, 38].…”

“…Furthermore, physiological adaptations to pregnancy (e.g. hyperdynamic circulation, tachycardia, diminished oxygen reserve, hypercoagulability), maternal efforts during second stage of labour, interventions during labour, or blood loss, may obscure signs and symptoms of infection and sepsis [3, 4]. This may result in delays in the recognition and treatment of sepsis [5].…”