Sepsis & maternal mortality

According to the World Health Organization (WHO), nearly 800 women died every day in 2020 from preventable causes related to pregnancy and childbirth (1). Approximately 95% of these maternal deaths occurred in low and middle income countries. 

Worldwide, sepsis is one of the most frequent causes of maternal death (2,3). Sepsis is a state where the body responds in an unregulated way to infection. More specifically, the NIH defines sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection” (4).

Sepsis is commonly considered to be a consequence of infection in the genitourinary system, however, respiratory and gastrointestinal infections are also frequent. It is  particularly dangerous for new and expecting mothers as it can be hard to detect due to existing physiologic changes associated with pregnancy and childbirth. Time also plays a crucial role in the detection and treatment of sepsis in expecting mothers. Thus, early intervention can be difficult to initiate, specifically in LMICs, where mothers are often birthing at home and are not educated or aware of the symptoms which are indicative of early sepsis. It is also very challenging to treat sepsis among the pregnant population in general because of the presence of the fetus. Therefore, certain antibiotics that would normally be provided to an individual experiencing sepsis cannot be used.

Several factors may increase the risk of peripartum maternal infections, which could result in the development of sepsis. These factors include pre-existing health problems (such as malnutrition, diabetes, obesity, severe anemia, bacterial vaginosis, and group B streptococcal infections), as well as spontaneous conditions or interventions by healthcare professionals during labor and delivery (such as prolonged rupture of membranes, repeated vaginal examinations, manual removal of the placenta, and cesarean delivery) (3).

Prevention of sepsis in expectant mothers via antibiotics

Steps have been taken to reduce maternal mortality resulting from sepsis, among them, creating strategies that allow for the early identification of sepsis followed by early initiation of treatment. Prophylaxis is limited to correcting modifiable risk factors such as anemia and obesity. However, the administration of antibiotics prior to cesarean delivery has been studied and has quite marked beneficial effects.

Azithromycin, an antibiotic that has a known ability to defend against a wide spectrum of bacteria, was recently tested for its capability of preventing sepsis in mothers in labor. The study found that a single dose considerably reduced the rate of sepsis and maternal mortality (5).

An important factor that contributes to the increase in bacterial resistance is the irrational use of antibiotics. However,  over the short period of time azithromycin has been tested in pregnant mothers, it has not been shown that a single dose of azithromycin is associated with an increase in bacterial resistance. Of course, additional studies are needed to assess the long-term effects of this practice, although for now it seems promising.  

1. World Health Organization. Maternal mortality. February 22, 2023. Available at: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
2. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-e333. doi:10.1016/S2214-109X(14)70227-X
3. Shields A, de Assis V, Halscott T. Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis. Obstet Gynecol. 2021;138(2):289-304. doi:10.1097/AOG.0000000000004471
4. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
5. Tita ATN, Carlo WA, McClure EM, et al. Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal Birth. N Engl J Med. 2023;388(13):1161-1170. doi:10.1056/NEJMoa221211

Written by Dr. Nestor Ferrer