Original Research
Obstetrics
Delivery-associated sepsis: trends in prevalence and mortality

Presented as an oral presentation at the 39th annual pregnancy meeting of the Society of Maternal-Fetal Medicine. Las Vegas, NV, Feb. 11–16, 2019.
https://doi.org/10.1016/j.ajog.2019.02.002Get rights and content

Background

Sepsis is a leading cause of pregnancy-related mortality. Previous studies have reported an increased prevalence of sepsis during pregnancy. Despite national campaigns to increase sepsis awareness, there is a lack of pregnancy-specific guidelines.

Objective

We aimed to provide updated national estimates of the prevalence and trends of sepsis, sepsis-related in-hospital mortality, and factors associated with in-hospital mortality among women with sepsis at delivery.

Study Design

We conducted a serial, cross-sectional analysis using data from the 2002–2015 National Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. We used International Classification of Diseases, ninth edition, Clinical Modification diagnosis and procedure codes to identify the study sample of delivery-associated hospitalizations and to capture diagnoses of sepsis (defined as infection with associated end-organ dysfunction). The primary outcome was in-hospital mortality. Obstetric comorbidities and pregnancy-related outcomes were also analyzed. Logistic regression was used to explore factors associated with sepsis during pregnancy and, among those with sepsis, to identify predictors of in-hospital mortality. Joinpoint regression was used to estimate the temporal trends in both sepsis and in-hospital mortality.

Results

Of the more than 55 million delivery-associated hospitalizations, 13,129 women met criteria for sepsis, corresponding to a rate of 2.4 per 10,000 deliveries. This rate increased from 1.2 to 3.7 per 10,000 over the study period, representing an annual increase of 6.6% (95% confidence interval, 4.2–9.1). The highest crude rates of sepsis (per 10,000) were among deliveries paid for by Medicare (14.8), deliveries to women aged 40 years or older (8.0), and deliveries to non-Hispanic black women (4.6). Compared with women without sepsis, women with sepsis had a greater than 10-fold increased prevalence of most selected obstetric comorbidities. One in 11 women with sepsis died prior to discharge, compared with 1 death in every 15,411 deliveries without sepsis. The sepsis-related mortality rate decreased 21.8% each year from 2010 through 2015. Maternal age greater than 40 years and nonprivate insurance demonstrated the highest odds of sepsis-related in-hospital mortality.

Conclusion

While rates of delivery-associated sepsis have increased, case fatality has decreased.

Section snippets

Design, data source, and study sample

We conducted a serial cross-sectional analysis of delivery hospitalizations in the United States among women 15–49 years of age from Jan. 1, 2002, through Sept. 30, 2015, using data from the National Inpatient Sample (NIS).

The NIS, a product of the Healthcare Cost and Utilization Project developed through a federal-state-industry partnership, is the largest publicly available all-payer inpatient database in the United States. Forty-seven states and the District of Columbia currently contribute

Rate and temporal trends of delivery-associated sepsis

Of the more than 55 million delivery hospitalizations during the 14-year study period, 13,124 women met the criteria for sepsis, corresponding to 1 case of sepsis in every 4196 deliveries, or a rate of 2.4 per 10,000 delivery hospitalizations. The temporal trend in the prevalence of sepsis during pregnancy is displayed in Figure 1. The rate increased from 1.2 per 10,000 (95% CI, 1.0–1.5) to 3.7 per 10,000 (95% CI, 3.2–4.2) between 2002 and 2015. Joinpoint regression analyses estimated a

Comment

In an analysis of more than 55 million delivery-associated hospitalizations, we observed an increase in the rate of delivery-associated sepsis over a 14 year study period. However, the rate of sepsis-related in-hospital maternal mortality declined significantly during the last 6 years of the study. Patients older than age 40 years, insured by Medicaid, or with comorbidities were more likely to die prior to discharge.

The increase in maternal mortality rates in the United States, at a time when

References (32)

  • S.S. Kadri et al.

    Estimating ten-year trends in septic shock incidence and mortality in United States academic medical centers using clinical data

    Chest

    (2017)
  • A. Hirshberg et al.

    Epidemiology of maternal morbidity and mortality

    Semin Perinatol

    (2017)
  • Aoyama K, Ray JG, Pinto R, et al. Temporal variations in incidence and outcomes of critical illness among pregnant and...
  • A.A. Creanga et al.

    Pregnancy-related mortality in the United States, 2011–2013

    Obstet Gynecol

    (2017)
  • B.A. Lawton et al.

    Preventability review of severe maternal morbidity

    Acta Obstet Gynecol Scand

    (2019)
  • L. Oud et al.

    Evolving trends in the epidemiology, resource utilization, and outcomes of pregnancy-associated severe sepsis: a population-based cohort study

    J Clin Med Res

    (2015)
  • G. Al-Ostad et al.

    Incidence and risk factors of sepsis mortality in labor, delivery and after birth: population-based study in the USA

    J Obstet Gynaecol Res

    (2015)
  • A. Rhodes et al.

    Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

    Intens Care Med

    (2017)
  • C.W. Seymour et al.

    Time to treatment and mortality during mandated emergency care for sepsis

    N Engl J Med

    (2017)
  • R.P. Dellinger et al.

    Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012

    Intens Care Med

    (2013)
  • P.A. Prasad et al.

    Relationship between a sepsis intervention bundle and in-hospital mortality among hospitalized patients: a retrospective analysis of real-world data

    Anesth Analg

    (2017)
  • E.K. Stevenson et al.

    Two decades of mortality trends among patients with severe sepsis: a comparative meta-analysis

    Crit Care Med

    (2014)
  • A.M. Kendle et al.

    Recognition and treatment of sepsis in pregnancy

    J Midwif Womens Health

    (2018)
  • R.R.D. Houchens et al.

    Final report on calculating National Inpatient Sample (NIS) variances for data years 2012 and later

    (2015)
  • R.R.D. Houchens et al.

    Using the HCUP Nationwide Inpatient Sample to estimate trends

    (2016)
  • E.V. Kuklina et al.

    An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity

    Matern Child Health J

    (2008)
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    Cite this article as: Kendle AM, Salemi JL, Tanner JP, Louis JM. Delivery-associated sepsis: trends in prevalence and mortality. Am J Obstet Gynecol. 2019;220:391.e1-16.

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