Population study of maternal mortality due to sepsis in Antioquia, Colombia, between 2004 and 2014: an overview of the challenge of timely identification and treatment
DOI:
https://doi.org/10.18597/rcog.1043Keywords:
Maternal mortality, sepsis, infectionAbstract
Objective: To describe the characteristics of women who died as a result of sepsis and to identify the care-associated factors contributing to those deaths in the Department of Antioquia, Colombia.
Materials and methods: Case series study of maternal deaths caused by infection between the years 2004 and 2014. Maternal deaths were analysed based on the recommendations of the “Surviving Sepsis Campaign” and on clinical practice guidelines for specific infections. Judgements were made by consensus. The variables evaluated were timeliness of the diagnosis of sepsis, antibiotic treatment, septic shock, culture sampling, pregnancy termination, performance of surgery for controlling the source of the infection, admission to the intensive care unit, referral to a higher complexity level, and overall quality of management. Descriptive analysis.
Results: Out of 476 maternal deaths in 11 years, 47 (9.87%) were non-obstetrical cases of sepsis and 11 (5.2%) were obstetrical. Pneumonia was the leading cause of death. All the cases were associated with at least one consideration of poor care quality. The main factors influencing the outcome were delays in symptom identification and antibiotic initiation; inadequate treatment of septic shock; care of women at levels with low resolution capacity; and failure to modify therapeutic measures, even in the face of patient decline.
Conclusion: Maternal deaths from sepsis were mainly associated with non-obstetric causes. There are critical factors that can be modified, such as delay identifying the syndrome and timely initiation of adequate antibiotic therapy.
Author Biographies
Jesús Arnulfo Velásquez-Penagos, Universidad de Antioquia Hospital Universitario San Vicente Fundación
Ginecoobstetra; Cuidado intensivo obstétrico. Docente Universidad de Antioquia, Hospital Universitario San Vicente Fundación. Investigador centro NACER, Universidad de Antioquia, Medellín (Colombia). jesus.velasquez@udea.edu.co
Gladis Adriana Vélez-Álvarez
Joaquín Guillermo Gómez-Dávila
Sandra Milena Escobar-Osorio
Heillen Karina Garay-Vásquez
John Jairo Zuleta-Tobón
References
Sheffield JS. Sepsis and septic shock in pregnancy. Crit Care Clin. 2004; 20:651-60; viii. https://doi.org/10.1016/j.ccc.2004.05.012
Royal College of Obstetricians and Gynaecologists. Bacterial Sepsis in Pregnancy. Green–top Guideline No. 64a. London; 2012.
Khan KS, Wojdyla D, Say L, Gülmezoglu AM, van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367:1066-74. https://doi.org/10.1016/S0140-6736(06)68397-9
Center for Disease Control and prevention. Pregnancy Mortality Surveillance System [visitado Sept 2017]. Disponible en: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
Pollock W, Rose L, Dennis C-L. Pregnant and postpartum admissions to the intensive care unit: a systematic review. Intensive Care Med. 2010;36:1465-74. https://doi.org/10.1007/s00134-010-1951-0
Equipo Maternidad Segura. Subdirección de Prevención Vigilancia y Control en Salud Pública. Instituto Nacional de Salud. Protocolo de vigilancia en salud pública Mortalidad Materna. Bogotá; 2016 [visitado 2017 Sept 11]. Disponible en: http://www.ins.gov.co/lineas-de-accion/Subdireccion-Vigilancia/sivigila/Protocolos %20SIVIGILA/PRO%20Mortalidad %20materna.pdf.
Barton JR, Sibai BM. Severe sepsis and septic shock in pregnancy. Obstet Gynecol. 2012;120:689-706. https://doi.org/10.1097/AOG.0b013e318263a52d
Borloz MP, Hamden KE. Sepsis in Special Populations. Emerg Med Clin North Am. 2017;35:139-58. https://doi.org/10.1016/j.emc.2016.08.006
Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ. 2001;322:1089-93-4.
Royal College of Obstetricians and Gynaecologists. Bacterial Sepsis following Pregnancy. Green–top Guideline No. 64b. London; 2012.
Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32:858-73. https://doi.org/10.1097/01.CCM.0000117317.18092.E4
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. 2008;34:17-60. https://doi.org/10.1007/s00134-007-0934-2
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637. https://doi.org/10.1097/CCM.0b013e31827e83af
World health Organization. Health statistics and information systems [visitado 2017 Sept 11]. Disponible en: http://www.who.int/healthinfo/statistics/indmaternalmortality/en/
Asociación Colombiana de Neumología y Cirugía de Tórax (ACNCT), Asociación Colombiana de Medicina Crítica y Cuidado Intensivo (AMCI), Asociación Colombiana de Medicina Interna (ACMI), Asociación Colombiana de Infectología (ACIN). Recomendaciones para el diagnóstico, tratamiento y prevención de la neumonía adquirida en la comunidad en adultos inmunocompetentes. Infectio. 2013;17(suplemento 1):1-38.
Mandell LA, Bartlett JG, Dowell SF, File TM, Musher DM, Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003;37:1405-33.
Martinez E, Osorio J, Delgado J, Esparza GE, Motoa G, Blanco VM, et al. Infecciones del tracto urinario bajo en adultos y embarazadas: consenso para el manejo empírico. Infectio. 2013;17:122-35. https://doi.org/10.1016/S0123-9392(13)70719-7
Lapinsky SE. Obstetric infections. Crit Care Clin. 2013;29:509-20. https://doi.org/10.1016/j.ccc. 2013.03.006
Morgan J, Roberts S. Maternal Sepsis. Obstet Gynecol Clin North Am. 2013;40:69-87. https://doi.org/10.1016/j.ogc.2012.11.007
Sniderman AD, LaChapelle KJ, Rachon NA, Furberg CD. The necessity for clinical reasoning in the era of evidence-based medicine. Mayo Clin Proc. 2013;88:1108-14. https://doi.org/10.1016/j.mayocp.2013.07.012
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27-72. https://doi.org/10.1086/511159
Lipman S, Cohen S, Einav S, Jeejeebhoy F, Mhyre JM, Morrison LJ, et al. The Society for Obstetric Anesthesia and Perinatology consensus statement on the management of cardiac arrest in pregnancy. Anesth Analg. 2014;118:1003-16. https://doi.org/10.1213/ANE.0000000000000171
Lapinsky SE. Acute respirator y failure in pregnancy. Obstet Med. 2015;8:126-32. https://doi.org/10.1177/1753495X15589223
Jimenez MF, Marshall JC, International Sepsis Forum. Source control in the management of sepsis. Intensive Care Med. 2001;27(Suppl 1):S49-62. https://doi.org/10.1007/PL00003797
Rojas-Suárez JA, González MV, Monsalve G, Escobar-Vidarte MF, Vasco-Ramírez M. Consenso colombiano para la definición de los criterios de ingreso a unidades de cuidados intensivos en la paciente embarazada críticamente enferma. Rev Colomb Obstet Ginecol. 2014;65:47-74. https://doi.org/10.18597/rcog.79
Velásquez J, Vélez G, Zuleta J, Franco F, Gómez J. H1N1 influenza pandemic and maternal mortality in Antioquia, Colombia. Int J Gynaecol Obstet. 2011;115:144-7. https://doi.org/10.1016/j.ijgo.2011.05.022
Bauer ME, Bateman BT, Bauer ST, Shanks AM, Mhyre JM. Maternal sepsis mortality and morbidity during hospitalization for delivery: Temporal trends and independent associations for severe sepsis. Anesth Analg. 2013;117:944-50. https://doi.org/10.1213/ANE.0b013e3182a009c3
Rivers EP. Point: Adherence to early goal-directed therapy: Does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest. 2010;138:476-80. https://doi.org/10.1378/chest.10-1405
van der Velden LBJ, Tromp M, Bleeker-Rovers CP, Hulscher M, Kullberg BJ, Mouton JW, et al. Non adherence to antimicrobial treatment guidelines results in more broad-spectrum but not more appropriate therapy. Eur J Clin Microbiol Infect Dis. 2012;31:1561-8. https://doi.org/10.1007/s10096-011-1478-5
Levy MM, Artigas A, Phillips GS, Rhodes A, Beale R, Osborn T, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis. 2012;12:919-24. https://doi.org/10.1016/S1473-3099(12)70239-6
Castellanos-Ortega Á, Suberviola B, García-Astudillo LA, Ortiz F, Llorca J, Delgado-Rodríguez M. Late compliance with the sepsis resuscitation bundle: impact on mortality. Shock. 2011;36:542-7. https://doi.org/10.1097/SHK.0b013e3182360f7c
Lefrant JY, Muller L, Raillard A, Jung B, Beaudroit L, Favier L, et al. Reduction of the severe sepsis or septic shock associated mortality by reinforcement of the recommendations bundle: a multicenter study. Ann Fr Anesth Reanim. 2010;29:621-8. https://doi.org/10.1016/j.annfar.2010.04.007
Wang Z, Xiong Y, Schorr C, Dellinger RP. Impact of sepsis bundle strategy on outcomes of patients suffering from severe sepsis and septic shock in china. J Emerg Med. 2013;44:735-41. https://doi.org/10.1016/j.jemermed.2012.07.084
Albright CM, Ali TN, Lopes V, Rouse DJ, Anderson BL. The Sepsis in Obstetrics Score: A model to identify risk of morbidity from sepsis in pregnancy. Am J Obstet Gynecol. 2014;211:39.e1-8. https://doi.org/10.1016/j.ajog.2014.03.010
Rubulotta F, Marshall JC, Ramsay G, Nelson D, Levy M, Williams M. Predisposition, insult/infection, response, and organ dysfunction: A new model for staging severe sepsis. Crit Care Med. 2009;37:1329-35. ttps://doi.org/10.1097/CCM.0b013e31819d5db1
Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-96. https://doi.org/10.1097/01.CCM.0000217961.75225.E9
Organización Mundial de la Salud. Plan de acción mundial sobre la resistencia a los antimicrobianos. Ginebra; 2016.
Maldonado NA, Múnera MI, López JA, Sierra P, Robledo CG, Robledo J, et al. Tendencias de la resistencia a antibióticos en Medellín y municipios del Área Metropolitana entre 2007-2012: resultados de seis años de vigilancia. Biomédica. 2014;34:433-46. https://doi.org/10.7705/biomedica.v34i3.1658
Quintero RA, Martinez CA, Gamba JD, Ortiz I, Jaimes F. Adherence to international guidelines on early management in severe sepsis and septic shock. Biomedica. 2012;32:449-56.
Plante LA. Management of sepsis and septic shock for the obstetrician–gynecologist. Obs Gynecol Clin North Am. 2016;43:659-78. https://doi.org/10.1016/j.ogc.2016.07.010
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