February 2019 | Feabhra 2019

A Novel Bedside Index for the Early Identification of Maternal Sepsis

Wed, 20 February 19 16:48

International consensus reports have recently recommended that the Systemic Inflammatory Response Syndrome (SIRS) criteria for the diagnosis of sepsis should cease and that new bedside criteria need to be developed to improve prevention, early diagnosis and treatment.

Researchers at the UCD Centre for Human Reproduction at the Coombe Women and Infants University Hospital describe the development of a novel bedside index for the early identification of severe maternal infection.  The group conducted a retrospective audit evaluating a suite of four bedside clinical criteria, called the Early Maternal Infection Prompts (EMIP), to help identify women with a suspected severe infection who were admitted to a High Dependency Unit (HDU) in a large tertiary referral stand-alone maternity hospital.

The four EMIP criteria were selected based on existing national obstetric guidelines and a review of the recent literature on maternal critical illnesses. The parameters align with the existing Irish Maternity Early Warning System (IMEWS) currently in operation across the country’s maternity hospitals.

In this audit, cases were identified from the HDU registry for the three years 2015-2017. Individual charts were retrieved, and the four EMIP parameters were measured at the time of the clinical assessment that led to the HDU admission. Clinical and sociodemographic details were computerised for analysis.

Of 73 women admitted with suspected severe maternal infection, the handwritten records were available in 69 cases. The mean age of the mothers was 31.3 years, 71% were multiparous and 26.1% were obese. Three quarters of cases were antenatal admissions. Infection was confirmed microbiologically in 56 (81.1%) of cases.  There were no maternal deaths among the cases studied.

There was no case of organ dysfunction diagnosed but two women required vasopressors to maintain blood pressure. Recordings of the maternal vital signs were not always fully completed before admission. In 69.1% (n = 47) of cases the temperature was elevated 37.5oC, in 81.2% (n = 56) of cases the heart rate was increased 100 bpm, in 51.9% (n = 27) cases the respiratory rate was increased  20 bpm, and in 25.4% (n = 17) cases the systolic blood pressure was 100 mmHg. At least one of the four EMIP criteria was abnormal in 91.3% (n = 63) of cases of suspected severe infection.

The audit confirmed that this bedside index has potential in helping to identify maternal infection early before sepsis develops. Prospective studies are required to evaluate the index in different settings, for different infections and at the different stages of maternal infection.  Prospective studies are required to evaluate the index in different settings, for different infections and at the different stages of maternal infections.

The research, published in the European Journal of Obstetrics & Gynaecology and Reproductive Biology, was led by Prof Michael Turner, UCD Professor of Obstetrics & Gynaecology and the National Clinical Programme in Obstetrics & Gynaecology at the Coombe Women and Infants University Hospital.

Sepsis is defined as infection plus life-threatening organ dysfunction, which is characterised by an acute change greater than 1 point in the Sequential Organ Failure Assessment (SOFA) score.  The SOFA assessment is generally not suitable outside of a high-resource environment and hence a new bedside test is required to identify those patients with suspected infection who are at risk of a poor outcome outside of intensive care units.  Such tests need sufficient sensitivity and specificity to accurately detect otherwise healthy women who may be in a ‘pre-sepsis’ and should not require progression to significant organ dysfunction before alerting the clinical team.

Reference

Development of a novel bedside index for the early identification of severe maternal infection.  Catherine O’Regan, Eimer G. O’Malley, Karen A. Power, Ciara M.E. Reynolds, Sharon R. Sheehan, Michael J. Turner European Journal of Obstetrics & Gynecology and Reproductive Biology 235 (2019) 26–29 [Link]