Maternal Sepsis — One Scientist’s Simple Solutions

How life-threating, post-partum infections happen and how mothers can survive them.

Patricia Ryan, PhD is a microbiologist/molecular geneticist at Rockefeller University in New York where she studies group A streptococci, one of the leading causes of postpartum sepsis and maternal mortality around the world. Ryan explains how quick action and simple solutions could prevent mothers from dying around the world.

Every Mother Counts: We know that sepsis is an overwhelming infection and a leading cause of maternal death. How do mothers get infections in maternal health settings?

Dr. Ryan: A great number of infections that cause maternal sepsis are actually caused by a woman’s own bacteria going somewhere in the body it’s not supposed to go. For example, when a mother’s amniotic membranes rupture and vaginal bacteria travel up into the uterus. Other times, sepsis is the result of nosocomial infections (infections that start inside a healthcare setting). They’re caused by medical interventions that introduce foreign bacteria into the body, for example, on a scalpel during a cesarean birth or contaminated urinary catheters.

Every Mother Counts: How does the body avoid getting infected?

Ryan: Lots of bacteria occupy different parts of our bodies and most do good and healthy things for us. The immune system becomes sensitized to recognize these bacteria as part of its’ self. Throughout the day, as we take in organisms from all over the place, the body does surveillance on itself. It constantly samples through phagocytes as the immune system tries to decide, ‘is this organism foreign or not foreign?’ If it’s not foreign, it’s ignored. If it’s something you’ve never seen before though, then your body mounts primary and secondary immune responses to fight off a potential pathogen (organism that makes you sick). These immune responses can be overwhelming though, as we see in cases of sepsis. Often times, it is not the foreign invader or bacteria that actually kills you. It’s the body’s overwhelming immune response that does it.

Every Mother Counts: Are we seeing more cases of sepsis?

Ryan: We estimate about 75,000 maternal deaths per year are caused by sepsis within the first six weeks after birth and that number is declining globally as healthcare providers have become more aware of infection risks during birth. There are still pockets where numbers are high though and rates aren’t going down the way they should in places like the U.S. With all our resources, we shouldn’t be seeing any cases at all. The worst overall statistics in the U.S. come primarily from African American communities, where women have nearly three and four times higher mortality rates compared to white or Hispanic women, respectively. That highlights the confounding inequities in women’s health that exist in nations like the U.S.

Every Mother Counts: What role does antibacterial resistance play in maternal sepsis?

Ryan: The problem isn’t that we’re giving antibiotics that don’t work. We know that the same organisms, like E. coli, Staphylococcus aureus, and group A streptococci cause most cases of maternal sepsis around the world and we know what antibiotics work. Mothers often die because providers fail to identify symptoms and start treatment fast enough.

Every Mother Counts: What are the symptoms and why don’t people recognize them?

Ryan: There’s this myth in the medical world that infections don’t happen before 24 hours and that there’s a predictable set of symptoms. A lot of clinicians won’t treat them unless they fit the mold. But some infections can happen within six to eight hours of birth. Not every organism has the same symptoms and sepsis doesn’t always come with fever.

If your temperature is 38 degree Centigrade (100.4 Fahrenheit) or above –there’s a good chance something infectious is going on. But sometimes with sepsis/septic shock, your temperature actually drops to below 36 C (96.8 F). Low body temperature is a major symptom of sepsis. We also see increased respiration (above 20 breaths per minute) and heart rate (over 90 beats per minute). Sometimes the white blood cell count is elevated, but not always. Pain, or lack there of, is another important diagnostic tool, because certain organisms can destroy tissues and nerve cells rapidly.

Every Mother Counts: What are the solutions?

Ryan: We have to do a better job at training healthcare providers, mothers and families to recognize three or four simple warning signs. Maybe we could have moms watch a short video while they’re still in the hospital or give them a refrigerator magnet that reminds them to watch for warning signs when they get home. Whatever we do, we have to impress upon families that this is as important as feeding the baby. Treatment of sepsis must never be delayed.

Every Mother Counts: What about women who don’t deliver in healthcare facilities?

Ryan: We need to make sure that every mother is seen by a doula, nurse or other healthcare professional within 24 hours of birth and at regular intervals thereafter. Simplicity is key. You don’t need advanced medical equipment. You don’t have to do lab work. You simply need to look at these mothers and ask, ‘Are you too hot or too cold, are you breathing too fast and is your heart racing?” Whether or not they have access to antibiotics beyond that point is another question; but…they might and they deserve a chance.

Every Mother Counts: What else could we do?

Ryan: I’d like to see existing screening tests being utilized during pregnancy to identify more cases of group A strep. Currently, all pregnant women in the US are screened for group B strep. If their screen is positive, they’re given antibiotics during labor to prevent deadly newborn infections. Group A and group B strep look very similar on those tests. If you get a positive result, you immediately know whether you have one or the other, but group A strep is rarely reported to the doctor. If we treated every woman who screens positive for group A strep with antibiotics in advance of her birth, we could drop the rate of group A sepsis, the # 1 cause of sepsis in women during the post partum period, to nothing. We’re already doing the test. All we have to do is mandate that group A results get reported. Women just don’t have to die from this.