This study used to develop a model based on risk factors and clinical sign and symptoms of sepsis among postpartum women. Internationally validated SIRS criteria were used as the gold standard for identification of women with sepsis. Previous studies identified sepsis among obstetric population based on sophisticated laboratory investigation.
Clinical and community settings both are different in terms of practice, feasibility and resource availability. As a result, models that are developed in hospital setting may have high sensitivity and specificity but needs to be adapted accordingly to make it feasible, available and applicable for community setting. The model proposed in the current study used risk factors, clinical sign and symptoms and only random blood sugar test instead of any advanced laboratory investigation. This would enable lay health workers in timely identification of postpartum sepsis in woman and help in early referral to tertiary care facility for management. One of the studies conducted at King Edward Hospital Lahore also provide evidence for using Score for Neonatal Acute Physiology II (SNAP II) for prediction of mortality among neonates with sepsis. The study assessed diagnostic accuracy of SNAP II tool which includes lowest mean arterial pressure, worst PaO2/FiO2 ratio, lowest temperature, lowest serum, urine output less than 1 ml/Kg/hr and presence of seizures. Based on mentioned indicators severity of illness categorized into mild ()1–20), moderate (21–40) and severe (> 40). SNAP II helps to identify neonates who were at high risk of mortality. (12).
Previous literature highlights that hemorrhage, lacerations, multiple vaginal examination, mode of delivery are major contributors to sepsis that may develop within few hours of giving birth (13, 14). This study also reinforced the risk factors mentioned in previous studies and antenatal care is one of them. Antenatal Care (ANC) helps women to promote healthy home practices, health seeking behaviors and identifies complications related to pregnancy (15, 16). Women are more likely to give birth with a skilled birth attendant if they have had at least one ANC visit (17). This study also depicts that not seeking antenatal care put women at a higher risk to develop sepsis. The results of this study are similar to that reported by Joseph et al who identified that the odds of maternal deaths was 3.6 (95% CI, 1.8-7.0) times higher among those who had received no antenatal care visit (18).
Multiple vaginal examinations is a contributor to infectious morbidities associated with prolonged labor. Kenyan study reported that women who had vaginal examination from 2–4 times and > 5 times were 2.28 and 3.8 times at higher risk of developing sepsis as compared to those women who have vaginal examination < 2 times (19). These findings are coherent with our study as more than four hourly vaginal examinations could potentially increase the risk of sepsis due to the prolonged state of an open cervix which impairs normal mechanical barrier to infections (20).
Home delivery was a significant contributor to postpartum sepsis (aOR = 9.0; 95% CI = 1.72–50.02) in this study. A study in Pakistan reported that the odds of puerperal infection was 2.7 (95% CI; 1.1–6.2) times among women who delivered in unhygienic conditions at homes as compared to deliveries conducted at health facilities (21). The report by State of World Children (2009) identifies that the regions with high maternal deaths have 60% of home deliveries where lack of practice of aseptic measures like hand washing, use of antiseptic materials and perinatal hygiene by unskilled birth attendants were key features for developing sepsis (22, 23). Similar to home delivery Preterm delivery was also reported to increase chance of sepsis by 2–3 folds (24, 25) which was also reported in this study.
Lower abdominal pain is a well-recognized non-specific symptom of puerperal sepsis. After delivery, invasion of bacteria may infect the uterus and cause pelvic inflammation which presents with lower abdominal pain (26, 27). In this study, women with sepsis reported lower abdominal pain and vaginal discharge more commonly as compared to women without sepsis. Moreover, the odds of foul smell vaginal discharge was 3.2 times higher among women with sepsis as compared to those without.
Blood glucose level and diabetes during pregnancy were significant risk factors for sepsis in this study. In sepsis, the activation of pro inflammatory indicators may lead to pathological changes that include hyperglycemia (28). Acousta et al explained that diabetic women had 47% greater adjusted odds of developing severe sepsis compared to septic women without diabetes (7). All these pathological changes also effect blood oxygen saturation. Pulse oximetry is a non-invasive method to determine oxygen level in the blood. In the adult population, SpO2 (> 95%) has been shown to have 90% sensitivity to detect probability of having pulmonary embolism (29, 30). In SOS scoring, SpO2 had a low discriminative ability in identifying sepsis (10). However, in this study, contribution of SpO2 was high as evident by adjusted odds ratio of 13.0 (95% CI 4.80–37.10). One of the reasons for this discrepancy may be that for SOS scoring, missing values were considered as normal so subjects with missing SpO2 values was considered as having oxygen saturation (> 95%) which ultimately make remarkable difference in results.
Strength of this study was representative sample. Study was conducted at a tertiary level public health facility such as JPMC where women belonged to a wide range of ethnicities and socio-demographic backgrounds. This makes our study generalizable to a wider population of postpartum women. Secondly, we have used calibrated instruments for collecting information on clinical signs to reduce bias introduced by instruments. One limitation of this study was using standard SIRS criteria for identification of cases of sepsis which itself has low sensitivity. Michael et al, found 52% (95% CI 46%– 58%) sensitivity of SIRS criteria for critical illness (31). Despite this limitation, we used this diagnostic criteria as others such as SOS criteria, SOFA require sensitive laboratory investigations which are not routinely done in our study setting.