CHAPTER 1

INTRODUCTION

In countries with developed healthcare systems, sepsis remains a leading cause of

preventable maternal morbidity and mortality and the number one cause of death in the
intensive care unit, with a mortality rate of up to 29%. The reported incidence is
approximately 240300 cases per 100,000 population, with over 750,000 cases per year and
an expected increase by1.5% each year.
The WHO estimates that puerperal sepsis accounts for 15 per cent of maternal
mortality globally. In highincome settings, maternal death rates are so low that morbidity
data may yield more useful information, such as case-fatality rates for maternal sepsis.
Incidence of serious acute maternal morbidity (SAMM) from sepsis in such countries is 0.1
0.6 per 1000 deliveries. However, uniformity of definitions, management protocols and data
collection across countries and regions are necessary to enable meaningful comparisons.
Sepsis may be defined as infection plus systemic manifestations of infection; severe
sepsis may be defined as sepsis plus sepsis-induced organ dysfunction or tissue
hypoperfusion. Septic shock is defined as the persistence of hypoperfusion despite adequate
fluid replacement therapy. If untreated, sepsis can rapidly progress along a continuum of
severity to septicaemic shock and eventually death. Pregnant and postpartum women
represent a particularly vulnerable population for developing severe sepsis because of
changing physiology, biochemistry and immune response, as well as heightened susceptibility
to wound infection during delivery.
There are several well-established risk factors for maternal sepsis including caesarean
section and anemia. Pregnancies complicated by severe sepsis and septic shock are associated
with increased rates of preterm labor, fetal infection, and preterm delivery. Sepsis onset in
pregnancy can be insidious, and patients may appear deceptively well before rapidly
deteriorating with the development of septic shock, multiple organ dysfunction syndrome, or
death. An increase in maternal deaths owing to sepsis and, in particular, a resurgence of beta
haemolytic Group A streptococcus (GAS) as a cause. In the report, several organisms were
identified and many infections were polymicrobial, but GAS was responsible for 13 of the 29

deaths described, followed by E.coli and Staphylococcus aureus. Deaths occurred from early
pregnancy through to the postnatal period.
The outcome and survivability in severe sepsis and septic shock in pregnancy are
improved with early detection, prompt recognition of the source of infection, and targeted
therapy.

CHAPTER II
LITERATURE REVIEW
I. Definitions
1Systemic Inflammatory Response Syndrome (SIRS). The systemic inflammatory
response to a wide variety of severe clinical insults, manifested by 2 or more of the following
conditions:
Temperature > 38C or < 36C
Heart rate > 90 bpm
Respiratory rate > 20 breaths/min or Paco2 < 32 mm Hg
White blood cell count > 12 103/L or < 4 103/L, or > 10% immature (band)
forms
Sepsis. The systemic inflammatory response to infection. In association with
infection, manifestations of sepsis are the same as those previously defined for SIRS. It
should be determined whether they are a direct systemic response to the presence of an
infectious process and represent an acute alteration from baseline in the absence of other
known causes for such abnormalities.The clinical manifesta- tions would include 2 or more of
the following conditions as a result of a documented infection:
Temperature > 38C or < 36C
Heart rate > 90 bpm
Respiratory rate > 20 breaths/min or Paco2 < 32 mm Hg
White blood cell count > 12 103/L or < 4 103/L or > 10% immature (band)
forms
Severe sepsis/SIRS. Sepsis (SIRS) associated with organ dysfunction, hypoperfusion,
or hypotension. Hypoperfusion and perfusion abnormalities may include, but are not limited
to, lactic acidosis, oliguria, or an acute alteration in mental status.
Sepsis (SIRS)-induced hypotension. A systolic blood pressure < 90 mm Hg or a
reduction of 40 mm Hg from baseline in the absence of other causes of hypotension.
Septic shock/SIRS shock. A subset of severe sepsis (SIRS) and defined as sepsis
(SIRS)induced hypotension despite adequate fluid resuscitation along with presence of
perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an
acute alteration in mental status. Patients receiving inotropic or vasopressor agents may no
longer be hypotensive by the time they manifest hypoperfusion abnormalities or organ
dysfunction, yet they would still be considered to have septic (SIRS) shock.

Multiple organ dysfunction syndrome (MODS). Presence of altered organ function in

an acutely ill patient such that homeostasis cannot be maintained without intervention.