Dr. Niranjan Chavan presented on an obstetrics sepsis bundle approach. Maternal sepsis is a leading cause of maternal mortality worldwide. Early screening and treatment is key to managing sepsis. The sepsis bundle approach involves completing 6 tasks within 1 hour of diagnosis: administering oxygen, collecting cultures, giving antibiotics, fluid resuscitation, measuring lactate levels, and monitoring urine output. Additional treatment may include source control, vasopressors, corticosteroids, DVT prophylaxis, and determining whether delivery is necessary based on maternal and fetal status. With rapid identification and treatment, the sepsis bundle approach can help reduce mortality from this life-threatening condition.

1. OBSTETRICS SEPSIS – BUNDLE
APPROACH
FOGSI-FIGO International Conference on Women's Health
International Convention Centre, Hyderabad
15th July 2023

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
67 publications in International and National Journals with 166 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2022)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS)
at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)

3. • Maternal sepsis, the third most common
direct cause of maternal mortality,
accounting for 11% of maternal deaths
worldwide.
• Undetected or poorly managed maternal
infections can lead to sepsis, death or
disability for the mother.
• Increased likelihood of early neonatal
infection and other adverse outcomes.
Haemorrhage
27%
Sepsis11%
Hypertensive
disorders14%
Obstructed
labour 9%
Abortion8%
Others 31%
Source- WHO 2014
INTRODUCTION

4. • In low- and middle-income countries, rates of fatality
after puerperal infection can be as high as 50%.
• Under new sepsis definitions some representative reports
gave ranges on the mortality of sepsis in the general
population of 25%–30%.
• The mortality range for septic shock was 40%–70%.

5. SEPSIS - CONTROVERSIES AND
LIMITATIONS
• There are inherent challenges in defining sepsis and septic shock.
• First is a broad term applied to a ill understood process.
• There are yet no simple clinical criteria or biological, imaging or laboratory features that
can identify a septic patient.

6. • Maternal sepsis is a life-threatening condition defined as organ dysfunction
resulting from infection during pregnancy, childbirth, post-abortion, or
postpartum period (WHO).
DEFINITION

8. Dr Komal N. Chavan, Mumbai

9. CAUSES OF SEPSIS
Obstetric causes
• Retained product of conception (septic
abortion, retained placenta)
• Chorioamnionitis
• Endometritis pelvic abscess and
• Wound infection
Non Obstetric causes
• Pyelonephritis
• Appendicitis
• Bowel infarction
• Pancreatitis and pneumonia (bacterial as
staphylococcus or pneumococcus) or
• Viral (H1 N1,influenza, Herpes)

10. WHAT ARE THE RISK FACTORS
FOR MATERNAL SEPSIS?
• Obesity
• Advanced age
• Diabetes
• Impaired immunity,
• Anaemia , vaginal infections
• History of pelvic infection,
• History of group B streptococcal
infection
• Caesarean birth
• Amniocentesis
• cervical cerclage
• Prolonged ROM
• Group A streptococcal (GAS)infection
in close contacts
• Retained products of conception
Dr Komal N. Chavan, Mumbai

11. THE MOST COMMON INFECTIOUS
ETIOLOGIES OF SEPSIS
Source of
infection
Pelvic
intrapartum postpartum
Non pelvic
antepartum
• The causative microorganism can be
identified in 64%
• The source of infection can be
identified in 74%
• In 16%, neither the inciting organism
nor the source of sepsis can be
identified.
• Escherichia coli and group A and
group B Streptococcus
• Staphylococci, gram-negative and
anaerobic bacteria
• Mixed infections are also possible
• 15% of maternal sepsis deaths in
which organisms could be
identified, the infection was
polymicrobial.

12. TYPES OF INFECTION
Infection Features
1. Infected wound (perineal or abdominal) Discharge from wound, pain, erythema and swelling around
wound, wound dehiscence, burst abdomen
2. Endometritis/septic abortion Abdominal pain, vaginal bleeding, offensive cervical discharge,
uterine tenderness, delayed uterine involution, fever
3. Chorioamnionitis Abdominal pain, vaginal bleeding, offensive vaginal discharge
or lochia, uterine tenderness, delayed uterine involution, fetal
tachycardia >160 beats per minute, fever
4. Respiratory tract infection Productive cough, sore throat, shortness of breath/difficulty
breathing, chest pain and fever
5. Breast abscess/mastitis Breast pain and tenderness, erythema, painful induration, nipple
discharge

13. 6. Urinary tract infection Dysuria, increased frequency, urgency, abdominal/flank/back
pain, rigors, fever, nausea and vomiting
7. Malaria Fever, headache, muscle/joint pain, jaundice, anemia
8. Meningitis Headache, rash, photophobia, neck stiffness, confusion, fever,
nausea and vomiting
9. Toxic shock syndrome (streptococcal and staphylococcal) Nausea, vomiting, diarrhea, watery vaginal discharge,
generalized maculopapular rash, conjunctival suffusion
10.Non-specific features of infection Lethargy, reduced appetite, fever, nausea, vomiting

14. Pathophysiology of Sepsis
Infection
Inflammatory
response
Extravasation
of albumin and
fluid
Organ
dysfunction
Cytokines
Decreased
SVR&
increased COP
Dysregulated host
response
hypovolemia
Septic cardiomyopathy Pulmonary oedema and
hypotension

15. Dr Komal N. Chavan, Mumbai

16. SECOND STAGE - ORGAN
DYSFUNCTION

17. CLINICAL AND LABORATORY
DIAGNOSIS OF SEPSIS
Signs and Symptoms
• Fever or Temperature instability(>380 C or
110 beats/min)
• Tachypnea (>24 breaths/min)
• Diaphoresis
• Clammy or mottled skin
• Nausea or vomiting
• Hypotension or shock
• Oliguria or anuria
• Pain (location based on site of infection)
• Altered mental state (confusion, decreased
alertness)
Laboratory Findings
• Leukocytosis or leukopenia
• Positive culture from infection site and/or blood
• Hypoxemia
• Thrombocytopenia
• Metabolic acidosis: serum lactate, low arterial
pH, base deficit
• Elevated serum creatinine
• Elevated liver enzymes
• Hyperglycemia in the absence of diabetes
• Disseminated intravascular coagulation

18. INVESTIGATIONS
• Complete blood count
• Electrolytes
• Blood cultures, if sepsis is suspected
• Urinalysis, with cultures and sensitivity tests
• Cervical or uterine cultures
• Wound cultures
• Lactate
• Coagulation studies, if pelvic thrombosis, deep vein thrombosis, pulmonary embolism,
or invasive treatment (eg, surgical procedure) is being considered.
• Pelvic USG- retained products of conception, pelvic abscess, or infected hematoma.
• CT or MRI - septic pelvic thrombosis.

19. DIFFERENT SCORING SYSTEMS
FOR OBSTETRIC SEPSIS

20. Dr Komal N. Chavan, Mumbai
Adv Excellent NPV
98.6%
Rapidly rules out need for
ICU
Does not use altered
mental status in criteria
Disadv Complex scoring
system with multiple
variables
Requires laboratory data,
which can delay
diagnosis

21. OBSTETRICALLY MODIFIED QUICK
SEQUENTIAL ORGAN FAILURE
ASSESSMENT (OM QSOFA)
• Presence of 3 clinical criteria:
Systolic<90mm of hg
RR≥25
Altered mental status
(≥ 2 of these associated with ↑ risk poor outcome)
Advantage: Simple bedside screening tool Uses only clinical data, allowing for rapid
diagnosis.
Disadvantage: Altered mental status in criteria may have nonseptic causes in obstetric
patients may need for secondary testing.

22. • RCOG –has recommended modified early obstetric warning score (MEOWS) to detect signs
of sepsis
Dr Komal N. Chavan, Mumbai
Advantage:
Simple bedside
screening tool
Disadvantage:
Marked variation of
thresholds and
formats
Validated for
chorioamnionitis
Over detects severe
sepsis
Need for secondary
testing to identify true-
positives
Low specificity.

26. • The best tool for identifying infection or predicting mortality in pregnant or postpartum
patients remains unknown.
• But simple bedside screening tool such as the MEOWS or OMQSOFA.
• Followed by further evaluation for evidence of end-organ damage are used for early
recognition of sepsis.

27. ROLE OF BIOMARKERS
• Currently no one biomarker has been identified as the gold standard.
• Commonly used markers such as white cell count and C-reactive protein are neither
specific nor sensitive.
• Procalcitonin - guiding antibiotic therapy -shows promise, NICE guidelines- there is
currently insufficient evidence. Surviving Sepsis Campaign (SSC) Guidelines- low-
quality evidence to support its use. There is absence of an accepted normal range during
pregnancy.
• Serum lactate - is a useful biomarker, elevated lactate levels associated with poor
outcomes in maternal sepsis. Repeat measurement required if initial lactate is greater
than 2 mmol/L.

28. Dr Komal N. Chavan, Mumbai

29. EARLY SCREENING AND
MANAGEMENT

30. 1. Screening and Management of Infection: The first step - cultures and blood samples
followed by administering appropriate antibiotics.
2. Screening for Organ Dysfunction and Management of Sepsis : identified by the organ
dysfunction criteria; omqSOFA.
3. Identification and Management of Initial Hypotension: Patients with infection and
hypotension or a lactate level >4mmol/L, are given 30mL/kg crystalloid with reassessment
of volume responsiveness and tissue perfusion.
In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate
>4mmol/l vasopressors are used.
a. Achieve a central venous pressure (CVP) of ≥8mmHg
b. Achieve a central venous oxygen saturation (ScvO2 ) ≥ 70% or mixed venous oxygen
saturation (ScvO2 ) ≥ 65%.

31. Sepsis Six (Bundle Approach)' – a set of
six tasks including
• Oxygen,
• Cultures,
• Antibiotics,
• Fluids,
• Lactate measurement and
• Urine output monitoring
to be instituted within one hour.

34. ROLE OF CORTICOSTEROIDS
• Corticosteroids in septic patients is subject of controversy.
• Hydrocortisone – reserved for septic patients with refractory shock (those who remain
hypotensive following initial fluid resuscitation and vasopressors).
• IV infusion of hydrocortisone at a dose of 200mg per day.
• Monitored for hyperglycemia and hypernatremia.
• Must be given within the first 7 days of treatment and should be interrupted as soon as the
patient shows signs of clinical improvement.
• Another benefit is the need for corticoids to accelerate fetal lung maturation.

35. SOURCE CONTROL
• Once a source of sepsis is identified, source
control is a priority and may involve abscess
drainage or the delivery of the fetus if the uterus
is found to be the source of the infection.

36. DEEP VENOUS THROMBOSIS
PROPHYLAXIS
• Prevention of DVT is essential in septic pregnant patients
as both pregnancy and sepsis are associated with
hypercoagulability.
• Methods of prophylaxis are the use of compression
stockings, intermittent lower limb compression, and
LMWH or unfractionated heparin.
• The role of intravenous immunoglobulin (IVIG):
• IVIG is recommended for severe invasive streptococcal or
staphylococcal infection if other therapies have failed
because of its immunomodulatory effect.

37. DELIVERY DECISION
• Influenced by patient’s condition, gestational age, fetal status, presence of
chorioamnionitis, and labour.
• In a critically ill woman, delivery is considered if it would be beneficial to the mother
or the baby or to both.
• Attempting delivery of unstable mother increases the maternal and fetal mortality rates
unless the source of infection is intrauterine.
• Indicators of delivery are Intrauterine infection, DIC, hepatic/ renal problems,
heart failure, compartmental syndrome, multifetal gestation and ARDS. While
foetal factors include foetal demise and a gestationally viable fetus
• During the intrapartum period, continuous electronic fetal monitoring is recommended.
• Epidural/spinal anaesthesia should be avoided in women with sepsis and a general
anaesthetic will usually be required for caesarean section.

38. EXTRACORPOREAL MEMBRANE
OXYGENATION (ECMO)
• Respiratory failure in patients in the intensive care
unit, ECMO has been used increasingly during
pregnancy and the puerperium,
• ECMO may be a choice for the treatment of
refractory sepsis.

39. SUMMARY LIST OF WHO
RECOMMENDATIONS FOR PREVENTION AND
TREATMENT OF MATERNAL PERIPARTUM
INFECTIONS CONTEXT RECOMMENDATION
• Routine perineal/pubic shaving prior to giving vaginal birth is not recommended.
• Digital vaginal examination at intervals of four hours is recommended for routine assessment of
active first stage of labour in low-risk women.
• Routine vaginal cleansing with chlorhexidine during labour for the purpose of preventing
infectious morbidities is not recommended.
• Routine vaginal cleansing with chlorhexidine during labour in women with group B
Streptococcus (GBS) colonization is not recommended for prevention of early neonatal GBS
infection.
• Vaginal cleansing with povidone-iodine immediately before caesarean section is recommended.

40. MATERNAL AND PERINATAL
COMPLICATIONS OF SEVERE
SEPSIS AND SEPTIC SHOCK
• Pulmonary oedema and adult respiratory distress syndrome.
• Myocardial ischemia and left ventricular dysfunction.
• Renal failure
• Disseminated intravascular coagulation.
• Multiple organ failure is associated with a high rate of
maternal mortality.
• Preterm labour result of release of endotoxins.
• Neonatal hypoxia, sepsis or death.

42. Recognition is key
Pearl 1. Always maintain a high index of suspicion for sepsis.
Pearl 2. Implement a rapid bedside tool for detection of maternal deterioration.
Move fast during the golden hour
Pearl 3. Implement sepsis bundles to facilitate rapid escalation of care.
Pearl 4. Laboratory and radiologic studies are keys to search for etiology and source control.
Pearl 5. Know microbes and likely origin, and that group A streptococcus can kill quickly.
Pearl 6. Choose antimicrobials tailored to the most likely diagnosis.
Pearl 7. Fluid resuscitation should be initiated rapidly for patients with a blood lactate greater
than 4 mmol/L or mean arterial pressure less than 65 mm Hg.
Beyond the golden hour
Pearl 8. Escalation of care is critical to survival.
Pearl 9. Once the patient is stabilized, get to the source of the problem.
Pearl 10. Anticipate and prevent adverse pregnancy outcomes.
Top 10 Pearls for Managing
Maternal Sepsis
Take Home Messages

43. Dr Komal N. Chavan, Mumbai