Risk factors for postpartum sepsis: a nested case-control study

Determinants of puerperal sepsis among postpartum women: a case-control study in East Shoa Zone public hospitals, Central Ethiopia

OBJECTIVE

To identify determinants of puerperal sepsis among postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023.

DESIGN AND SETTING

An institutional-based, unmatched case-control study was conducted from 19 June 2023 to 4 September 2023, in East Shoa Zone public hospitals.

PARTICIPANTS

495 postpartum women (100 cases and 395 controls) were selected using systematic sampling techniques. Data were collected through face-to-face interviews and from medical charts using a pretested, structured questionnaire. The AOR with its corresponding 95% CI was used to identify determinant variables. Findings were presented in texts and tables.

OUTCOME MEASURES

The medical charts of participants were reviewed to identify those who had developed puerperal sepsis.

RESULTS

Anaemia (AOR 6.05; 95% CI 2.57 to 14.26), undernourishment (AOR 4.43; 95% CI 1.96 to 10.01), gestational diabetes mellitus (AOR 3.26; 95% CI 1.22 to 8.74), postpartum haemorrhage (AOR 3.17; 95% CI 1.28 to 7.87), obstructed labour (AOR 2.76; 95% CI 1.17 to 6.52), multiparity (AOR 2.54; 95% CI 1.17 to 5.50), placenta previa (AOR 2.27; 95% CI 1.11 to 4.67) and vaginal examination ≥5 times (AOR 2.19; 95% CI 1.05 to 4.54) were the independent determinants of puerperal sepsis in this study.

CONCLUSION

This study found that gestational diabetes mellitus, anaemia, undernourishment, placenta previa, obstructed labour, postpartum haemorrhage and five or more per-vaginal examinations during labour were the determinants of puerperal sepsis. Therefore, it is recommended that obstetric care providers strictly adhere to guidelines on the number of vaginal exams that should be performed throughout labour and that they perform these exams using the appropriate infection-prevention techniques. In addition, they should provide comprehensive health education on nutrition during pregnancy and postnatal periods and the importance of iron supplements.

Determinants of puerperal sepsis among post-partum mothers in Mekelle city public hospitals, Tigray, Ethiopia, 2021: a case control study

BACKGROUND

Puerperal sepsis is among the leading causes of preventable maternal death not only in developing countries but also in developed countries which is usually reported as the third or fourth common direct cause of maternal death. Although the prevalence of puerperal sepsis is low, it is the significant cause of maternal mortality, morbidities and other long-term complications like secondary infertility. The aim of this study was to assess the determinants of puerperal sepsis among post-partum mothers at Mekelle city public hospitals.

METHOD

Institution based unmatched case control study was conducted among 444 total sample size (111 cases and 333 controls) in Mekelle city public hospitals from March 21, 2021 to April 20, 2021. Consecutive sampling for the cases and systematic sampling for the controls was used. Pretested structured questionnaire was used to collect data and the data was entered into Epi data version 4.1 then cleaned, coded and edited and exported to SPSS version 23 statistical software for analysis. Logistic regression was done and variables with a P-value of < 0.25 on Binary logistic regression were taken to multiple logistic regression analysis. At 95% confidence interval, a P-value of < 0.05 was used as cut-off point to declare the association with the dependent variable.

RESULTS

Multiple logistic regression analysis revealed that rural residence (AOR: 3, 95% CI: 1.50-5.90), no ANC follow up (AOR: 2.7, 95% CI: 1.08-6.71), duration of rupture of membrane > 24 h (AOR: 4.1, 95% CI: 1.60-10.58), duration of labor > 24 h (AOR: 4.3, 95% CI: 1.86-9.92), number of vaginal examination >  = 5 (AOR: 2.8, 95% CI: 1.26-6.26), cesarean section mode of delivery (AOR: 2.8, 95% CI: 1.48-5.20) and no PNC follow up (AOR: 3.9, 95% CI: 1.60-9.36) were the determinant factors of puerperal sepsis in this study.

CONCLUSION

The determinants of puerperal sepsis in this study were rural residence, not having antenatal care, prolonged duration of rupture of membrane, prolonged duration of labor, frequent number of vaginal examination, cesarean section and not having postnatal care. It is recommended that strengthening provision of health education on danger signs of pregnancy, parthograph utilization and avoiding of frequent vaginal examinations.

A Matter of the Heart: Why It Is Time to Change How We Talk About Maternal Mortality

As the global burden of disease shifts from "diseases of poverty" such as diarrhea to "diseases of affluence" like diabetes and heart disease, a parallel shift is underway in maternal health. Maternal death from hemorrhage is decreasing, while deaths resulting from exacerbation of underlying chronic disease are on the rise.

Explainable ensemble machine learning model for prediction of 28-day mortality risk in patients with sepsis-associated acute kidney injury

Background

Sepsis-associated acute kidney injury (S-AKI) is a major contributor to mortality in intensive care units (ICU). Early prediction of mortality risk is crucial to enhance prognosis and optimize clinical decisions. This study aims to develop a 28-day mortality risk prediction model for S-AKI utilizing an explainable ensemble machine learning (ML) algorithm.

Methods

This study utilized data from the Medical Information Mart for Intensive Care IV (MIMIC-IV 2.0) database to gather information on patients with S-AKI. Univariate regression, correlation analysis and Boruta were combined for feature selection. To construct the four ML models, hyperparameters were tuned via random search and five-fold cross-validation. To evaluate the performance of all models, ROC, K-S, and LIFT curves were used. The discrimination of ML models and traditional scoring systems was compared using area under the receiver operating characteristic curve (AUC). Additionally, the SHapley Additive exPlanation (SHAP) was utilized to interpret the ML model and identify essential variables. To investigate the relationship between the top nine continuous variables and the risk of 28-day mortality. COX regression-restricted cubic splines were utilized while controlling for age and comorbidities.

Results

The study analyzed data from 9,158 patients with S-AKI, dividing them into a 28-day mortality group of 1,940 and a survival group of 7,578. The results showed that XGBoost was the best performing model of the four ML models with AUC of 0.873. All models outperformed APS-III 0.713 and SAPS-II 0.681. The K-S and LIFT curves indicated XGBoost as the most effective predictor for 28-day mortality risk. The model's performance was evaluated using ROCpr curves, calibration curves, accuracy, precision, and F1 scores. SHAP force plots were utilized to interpret and visualize the personalized predictive power of the 28-day mortality risk model. Additionally, COX regression restricted cubic splines revealed an interesting non-linear relationship between the top nine variables and 28-day mortality.

Conclusion

The use of ensemble ML models has shown to be more effective than the LR model and conventional scoring systems in predicting 28-day mortality risk in S-AKI patients. By visualizing the XGBoost model with the best predictive performance, clinicians are able to identify high-risk patients early on and improve prognosis.

Postpartum septic shock presenting as symmetrical peripheral gangrene: A rare entity

Symmetric peripheral gangrene (SPG) is a rare clinical entity defined as ischemia of peripheral parts of the body without underlying vaso-occlusive disease. Its pathogenesis is unknown, but it is seen from previous reports that SPG is a sequel of underlying Disseminated Intravascular Coagulation (DIC). We report a case of a middle-aged woman who developed high-grade fever followed by painful black discoloration of the digits of four limbs, few days after spontaneous vaginal delivery at home. The patient developed septic shock. However, peripheral pulses were palpable and radiologic and laboratory investigations did not show any evidence of vessel occlusion. The patient had neutrophilic leukocytosis and a deranged clotting profile. Blood culture revealed growth of Staphylococcus Aureus and Pseudomonas Aeruginosa. The patient was diagnosed with SPG due to postpartum sepsis and DIC. She was managed with fluids, antibiotics, aspirin, and heparin but unfortunately, the patient underwent amputation of limbs due to irreversible ischemia. Therefore, prompt diagnosis and management of SPG are crucial to prevent mortality and morbidity.

Determinants of puerperal sepsis among postpartum women at public hospitals of Hawassa city, Southern Ethiopia: Institution-based unmatched case-control study

Background

World health organization reported that from 358,000 maternal deaths occurring during labor and childbirth about 15% were attributed to puerperal sepsis. In Ethiopia, puerperal sepsis is the fourth leading direct cause of maternal death next to hemorrhage, obstructed labor, and pregnancy-induced hypertension. Early recognition and management of the contributing factors would help to modify the problem. Therefore, this study was aimed to identify the determinants of puerperal sepsis among postpartum women at Hawassa city public hospitals in South Ethiopia.

Methods

& materials: Institution-based unmatched case-control study was conducted among 305 postpartum women (61 cases & 242 controls; with a ratio of 1:4) at Hawassa city public hospitals from June 17 to August 20/2021. Cases were all postpartum women admitted with puerperal sepsis and controls were randomly selected postpartum women admitted with other cases. A pre-tested interviewer-administered questionnaire was used to collect the data. Data were entered into Epi data version 4.6 and then exported to STATA version 14 for analysis. Bivariable analysis was performed and variables having a p-value <0.25 made candidates for the multivariable logistic regression model. Adjusted Odds ratio (AOR) with 95% confidence interval was computed to identify the presence and strength of association and statistical significance was declared at p-value <0.05.

Result

In this study, a total of 61 cases & 242 controls were included. Cesarean section delivery (AOR = 2.85; 95% CI; 1.36-5.98), manual removal of placenta (AOR = 6.0; 95% CI = ; 0.39-26.26), ≥5 times Per-vaginal Examination during labor (AOR = 4.53; 95% CI; 2.10-9.80), presence Gestational Diabetes Mellitus (AOR = 8.50; 95% CI; 1.99-36.33) & prolonged labor (AOR = 3.43; 95% CI; 1.20-9.76) were identified as determinants of puerperal sepsis.

Conclusion

In this study, cesarean delivery, Per-vaginal Examination ≥5 times during labor, manual removal of placenta, Gestational Diabetes Mellitus & prolonged labor were factors that significantly increased the odds of developing puerperal sepsis among postpartum women. So, labor & delivery procedures should be conducted as per labor & delivery management protocols.

Epidemiology and clinical features of maternal sepsis: A retrospective study of whole pregnancy period

Maternal sepsis results in poor outcomes such as fetal or maternal death. The incidence and mortality rates of maternal sepsis vary in different places because of differences in economic development, race and medical conditions. Identifying the clinical features and determining possible mechanisms for avoiding morbidity and preventing poor outcomes would benefit committed patients. Therefore, this was an epidemiological study at a maternity transfer center in Southeast China that aimed to identify local disease features of maternal sepsis. To investigate the incidence and risk factors associated with maternal sepsis and its progression to severe sepsis in a large population-based birth cohort. This local epidemiological study was conducted in at a tertiary care center in Guangzhou, China, from 2015 to 2019. A total of 74,969 pregnant women experiencing childbirth were included in this study; Of these, 74 patients with maternal sepsis were diagnosed according to the sepsis criterion, and 118 patients without sepsis in the same period were selected randomly as the control group to study possible reasons for postpartum sepsis. This retrospective analysis covered the entire period from the first trimester to puerperium. Clinical data were collected using the hospital's electronic medical record system. Multivariate logistic regression was used to analyze risk factors for maternal sepsis. The incidences of maternal sepsis, the maternal mortality, and the fetal mortality were 0.099%, 0.004%, and 0.007%, respectively. Septic shock was associated with a higher severity of illness. All poor outcomes (maternal or fetal death) occurred during pregnancy. Postpartum sepsis had the longest onset period, and was associated with premature rupture of fetal membranes and preeclampsia. Sepsis is an important cause of both maternal and fetal mortality. Herein, we describe an epidemiological study that evaluated the incidence, development, and prognosis of local maternal sepsis. Furthermore, the characteristics of maternal sepsis are likely due to unknown pathological mechanisms, and patients would benefit from identifying more effective treatments for maternal sepsis.

The risk factors and nursing countermeasures of sepsis after cesarean section: a retrospective analysis

Background

Sepsis is a very serious complication of cesarean section, understanding the influencing factors is important to the prevention and management of sepsis. We aimed to analyze the associated risk factors of sepsis of cesarean section, to provide evidences into the clinical management and nursing care of cesarean section.

Methods

Patients who underwent cesarean section surgery from January 1, 2017 to June 30, 2021 in our hospital were included. The characteristics of patients were collected and analyzed. Logistic regression analyses were conducted to analyze the influencing factors of sepsis of cesarean section.

Results

A total of 3819 patients undergoing cesarean section were included, the incidence of sepsis in patients undergoing cesarean section was 0.84%. There were significant differences in the age, vaginal delivery attempt, premature rupture of membranes, preoperative hemoglobin, estimated blood loss during surgery and postoperative urinary tube implacement between sepsis and no sepsis patients (all p < 0.05). Logistic regression analyses found that age ≥ 35y(OR3.22, 95%CI1.20 ~ 5.15), gestational diabetes(OR2.64, 95%CI1.91 ~ 4.15), vaginal delivery attempt(OR2.05, 95%CI1.70 ~ 4.42), premature rupture of membranes(OR2.42, 95%CI1.02 ~ 4.20), preoperative hemoglobin ≤ 105 g/L(OR4.39, 95%CI1.02 ~ 7.88), estimated blood loss during surgery ≥ 400 ml(OR1.81, 95%CI1.35 ~ 3.01), postoperative urinary tube implacement(OR2.19, 95%CI1.27 ~ 2.50) were the risk factors of sepsis in patients undergoing cesarean section(all p < 0.05). Escherichia Coli(46.15%), Enterococcus faecalis(17.95%) and Pseudomonas aeruginosa(12.83%) were the most commonly-seen bacteria in sepsis patients.

Conclusion

In clinical practice, medical workers should carry out strict management and early prevention of related risk factors during the perioperative period of pregnant women, to effectively reduce the occurrence of sepsis after cesarean section.

Effect of a tailored sepsis treatment protocol on patient outcomes in the Tikur Anbessa Specialized Hospital, Ethiopia: results of an interrupted time series analysis

BACKGROUND

Despite improvement, sepsis mortality rates remain high, with an estimated 11 million sepsis-related deaths globally in 2017 (Rudd et. al, Lancet 395:200-211, 2020). Low- and middle-income countries (LMICs) are estimated to account for 85% of global sepsis mortality; however, evidence for improved sepsis mortality in LMICs is lacking. We aimed to improve sepsis care and outcomes through development and evaluation of a sepsis treatment protocol tailored to the Tikur Anbessa Specialized Hospital Emergency Department, Ethiopia, context.

METHODS

We employed a mixed methods design, including an interrupted times series study, pre-post knowledge testing, and process evaluation. The primary outcome was the proportion of patients receiving appropriate sepsis care (blood culture collection before antibiotics and initiation of appropriate antibiotics within 1 h of assessment). Secondary outcomes included time to antibiotic administration, 72-h sepsis mortality, and 90-day all-cause mortality. Due to poor documentation, we were unable to assess our primary outcome and time to antibiotic administration. We used segmented regression with outcomes as binomial proportions to assess the impact of the intervention on mortality. Pre-post knowledge test scores were analyzed using the Student's t-test to compare group means for percentage of scenarios with correct diagnosis.

RESULTS

A total of 113 and 300 patients were enrolled in the pre-implementation and post-implementation phases respectively. While age and gender were similar across the phases, a higher proportion (31 vs. 57%) of patients had malignancies in the post-implementation phase. We found a significant change in trend between the phases, with a trend for increasing odds of survival in the pre-implementation phase (OR 1.24, 95% CI 0.98-1.56), and a shift down, with odds of survival virtually flat (OR 0.95, 95% CI. 0.88-1.03) in the post-implementation phases for 72-h mortality, and trends for survival pre- and post-implementation are virtually flat for 90-day mortality. We found no significant difference in pre-post knowledge test scores, with interpretation limited by response rate. Implementation quality was negatively impacted by resource challenges.

CONCLUSION

We found no improvement in sepsis outcomes, with a trend for increasing odds of survival lost post-implementation and no significant change in knowledge pre- and post-implementation. Variable availability of resources was the principal barrier to implementation.

TRIAL REGISTRATION

Open Science Framework osf.io/ju4ga . Registered June 28, 2017.

Determinants of birthplace among middle-to lower-class women in Indonesia: A study using the Indonesian Demographic and Health Survey

Background

One of the factors contributing to a high maternal mortality rate is the utilization of non-healthcare facilities as a birthplace for women. This study analyzed determinants affecting birthplace in middle-to lower-class women in Indonesia.

Methods

This study analyzed the 2017 Indonesian Demographic and Health Survey (IDHS) data. The total national sample size was 49,627 eligible women. Our sample included 11,104 women, aged 15–49, who had delivered babies and were of low-to-middle economic status. The type of survey dataset was individual record dataset. Data were analyzed with chi-square and multivariate logistic regression tests using Stata 16 software.

Results

About 64.99% middle to lower class women in Indonesia delivered in healthcare facilities. Women aged 45–49 (OR = 2.103; 95% CI = 1.13–3.93), who graduated from higher schools (OR = 2.885; 95% CI = 1.76–4.73), whose husbands had higher education (OR = 2.826; 95% CI = 1.69–4.74) and were employed (OR = 2.523; 95% CI = 1.23–5.17), who considered access to healthcare facilities was not a problem (OR = 1.528; 95% CI = 1.28–1.82), who had a single child (OR = 2.349; 95% CI = 1.97–2.80), and who lived in urban areas (OR = 2.930; 95% CI = 2.40–3.57) were determinants that significantly correlated with women giving birth in healthcare facilities.

Conclusion

This study provides insights for policymakers and healthcare centers in the community to strengthen access to healthcare services and devise health promotion strategies for pregnant mothers. Policy interventions designed for middle- to lower-class women should be implemented to support vulnerable groups.