A retrospective audit of post-caesarean sepsis at Tygerberg Hospital

Coetzer, Marsel (2017-12)

Thesis (MMed)--Stellenbosch University, 2017.

Thesis

ENGLISH SUMMARY: INTRODUCTION: Caesarean section (CS) is one of the most common surgical procedures performed worldwide and remains the most important individual risk factor for developing pregnancy related sepsis. Pregnancy related sepsis leads to an estimated 75 000 maternal deaths worldwide each year, with most of these deaths occurring in low and middle-income countries. According to the 2015 Saving Mothers Annual Report, pregnancy related sepsis remained the 3rd leading cause of direct maternal deaths in South Africa. In the USA, the attributable costs (per case) of post CS surgical site infection and post CS endometritis were estimated around $3500 and $3900 respectively in 2010. AIM & METHOD: To audit post-CS sepsis at Tygerberg Hospital in order to determine the incidence, as well as to describe the risk-factor profile and determine the outcome of women who develop post-CS sepsis. A retrospective audit of patient records of all women who delivered by CS in a three-month period between 1 February 2014 and 30 April 2014 was undertaken. All records were followed up for thirty days after delivery, in order to identify cases with post-CS sepsis. The CDC diagnostic criteria for surgical site infection (both superficial and deep) and endometritis were used. RESULTS: During the 3-month study period a total of 1 834 deliveries were managed at Tygerberg Hospital. Eight hundred and forty eight CS were performed, with a hospital-based CS rate of 46.24%. A total of 811 patient records were audited and 38 women with post-CS sepsis were identified. The cumulative incidence for post-CS sepsis was therefore 4.69%. Patient characteristics illustrated the high-risk nature of the patient population served by Tygerberg Hospital, with a high incidence of known risk factors for post-CS sepsis such as obesity, hypertension and HIV. Risk factors associated with post CS sepsis included: HIV infection without antiretroviral therapy (Risk Ratio 5.83, 95% Confidence Interval 1.72 – 19.77, p=0.005) and prolonged surgical duration (Risk Ratio 3.01, 95% Confidence Interval 1.10 – 8.19, p=0.03). Thirty-three women had severe post-CS sepsis and were treated as inpatients. Of these women, 12 required repeat surgery or admission to a high care or intensive care unit. CONCLUSION: Despite a post-CS sepsis incidence that compares well with high-income countries (4.69% vs. 3.5 – 8.11%) post-CS sepsis remains a significant contributor to maternal morbidity in the South African setting. Risk factors for post-CS sepsis remain multifactorial and in the setting of a referral hospital, all women should be treated as potentially at risk. Optimization of chronic medical conditions, vigilant intra-partum care, meticulous surgical technique and recognition of early signs of post-CS sepsis are essential in order to prevent maternal morbidity.

AFRIKAANS OPSOMMING: INLEIDING Die keisersnit is een van die mees algemene chirurgiese prosedures wêreldwyd en is steeds die belangrikste risiko faktor vir swangerskaps-verwante sepsis. Swangerskapsverwante sepsis is jaarliks verantwoordelik vir ongeveer 75 000 moederlike sterftes wêreldwyd, met die meerderheid van sterftes in lae- en middelinkomste lande. Volgens die 2015 “Saving Mothers Annual Report”, is swangerskapsverwante sepsis steeds die derde belangrikste direkte oorsaak van moederlike sterfte in Suid-Afrika. Die beraamde koste vir die behandeling van wond infeksie of endometritis, na ‘n keisersnit, beloop $3500 en $3900, per geval, in die VSA. DOEL & METODE: ‘n Retrospektiewe oudit van keisersnitte by Tygerberg Hospitaal vir die tydperk 1 Februarie 2014 tot 30 April 2014 is onderneem. Pasiëntrekords is nagegaan met die doel om die insidensie van sepsis na keisersnit te bepaal, die risikoprofiel van vroue te ondersoek, asook om die uitkoms van vroue met sepsis te evalueer. Pasiëntnotas is opgevolg vir ‘n totaal van dertig dae na keisersnit, met die doel om ook vroue wat na ontslag presenteer, te identifiseer. Die CDC se diagnostiese kriteria vir wond infeksie en endometritis is gebruik. RESULTATE: ‘n Totaal van 1 834 verlossings is tydens die 3 maande studie periode by Tygerberg Hospitaal hanteer. Agt honderd, agt en veertig vroue (46.24%) is verlos deur middel van keisersnitte. Agt honderd en elf vroue is by die oudit ingesluit en 38 vroue met sepsis na keisersnit is geïdentifiseer. Die kumulatiewe insidensie van sepsis na keisersnit is dus 4.69%. ‘n Hoë insidensie van bekende risiko faktore vir sepsis, onder andere obesiteit, hipertensie en MIV-infeksie is gevind, wat die hoë-risiko profiel van die populasie bevestig. Beide MIV infeksie sonder antiretrovirale behandeling (p=0.005), asook verlengde duur van chirugie (p=0.03) is geidentifiseer as risiko faktore vir sepsis na keisersnitte. Drie en dertig vroue is gediagnoseer met erge sepsis en het binne-pasiënt behandeling ontvang. Van die bogenoemde vroue het 12 vroue verdere chirurgie, of opname in ‘n hoësorg of intensiewe sorg eenheid benodig. GEVOLGTREKKING Selfs al is die insidensie van sepsis vergelykbaar met hoë-inkomste areas (4.69% vs. 3.5 – 8.11%), is sepsis na keisersnitte steeds ‘n noemenswaardige oorsaak van moederlike morbiditeit in Suid-Afrika. Die oorsprong van sepsis na keisersnitte is multifaktorieël en dus moet alle vroue in Tygerberg Hospitaal as hoë-risiko behandel word. Stappe on risiko te verlaag, insluitende optimalisering van mediese siektes, waaksame kraamsorg, noukeurige chirurgiese tegniek en vroeë herkenning van tekens van sepsis, is noodsaaklik om verdere moederlike morbiditeit te vermy. Verdere, prospektiewe studies word benodig.

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