PUERPERAL SEPSIS AT UNIVERSITY COLLEGE HOSPITAL, IBADAN: A 10-YEAR REVIEW

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A.S. Olutoye¹, A.D. Agboola¹, O.O. Bello^1,2

1. Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria.
2. Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Abstract

Background: Puerperal sepsis is one of the leading causes of pregnancy-related maternal morbidity and mortality in developing countries. This study explored the complications, treatment modalities, and management outcomes of puerperal
sepsis.

Methods: A 10-year retrospective review of women managed for puerperal sepsis at University College Hospital, Ibadan, Nigeria between January 2009 and December 2018. Information on their socio-demographic and obstetrics characteristics, presenting complaints, treatment modalities, complications, and outcomes were obtained from the medical records. Data was analyzed with SPSS version 20. Descriptive statistics was done and results were presented in tables and chart.

Results: The prevalence of puerperal sepsis during the period reviewed was 0.83%. The mean age of the women was 29.0±6.7 years. The primiparous women 53(33.5%) were mostly affected. Klebsiella spp 25(15.8%) was the most common organism isolated and most sensitive to the third generation of Cephalosporin and Quinolones. Anaemia 90(56.8%) was the most common complication and all the women had intravenous antibiotics while about half (46.5%) of those with abdominopelvic collections were managed surgically via laparotomy. The case fatality rate was 16.5%.

Conclusion: Despite the low prevalence of puerperal sepsis within the period reviewed, a high case fatality was recorded. Cephalosporin and Quinolones should be considered in managing puerperal sepsis in our facility but more importantly prevention of maternal sepsis is essential.

Keywords: Puerperal sepsis, Management, Complications, Ibadan

Introduction

It is a known fact that childbirth is a life-changing event associated with joy however, it can be a difficult period, bringing with it new problems like puerperal sepsis.¹ The World Health Organization (WHO) defined puerperal sepsis as an infection of the genital tract occurring at any time between rupture of a membrane or labour and 42nd day postpartum in which two or more of the following are present; pelvic pain, fever (temperature >38.5oC on any occasion), abnormal vaginal discharge, delay in the rate of uterine involution (< 2cm/day in first 8 days postpartum).²

Puerperal sepsis has historically been a common pregnancy-related complication associated with obstetric shock and maternal death.^3,4 With the current maternal mortality ratio of 512 maternal deaths per 100,000 live births, Nigeria still has one of the highest ratios of maternal mortality in the world.5 It was reported by the WHO that Nigeria did not achieve the MDG goal-⁵ that sought to reduce maternal mortality by 75% by 2015, on the contrary, there was a substantial increase in maternal death.2,6 Along with pre-eclampsia and obstetric hemorrhage, puerperal sepsis had formed the lethal triad of causes for maternal morbidity and mortality.^7,8

Annually, over 5 million cases of puerperal sepsis occur globally, with an estimated 75,000 maternal deaths and mortality rates attributable to sepsis estimated at 33%in low-income countries.⁹ It is difficult to establish the exact incidence in developing countries largely due to under-reporting and discrepancies in diagnostic criteria. Studies from Sokoto, North West Nigeria, and PortHarcourt, South-South Nigeria reported incidences of 0.9% and 9.34% respectively.^1,10 In Jos, North-Central Nigeria, puerperal sepsis accounted for 16.7% of postpartum morbidities.¹¹ Puerperal sepsis also contributed to 1.3% of maternal mortality in Ogbomosho and 0.9% of maternal complications in Ibadan, Southwestern Nigeria.^12,13

An unhygienic home delivery which is a common practice in Nigeria increases the incidence of puerperal sepsis.¹⁴ Other risk factors include diabetes mellitus, anaemia, retained placenta, human immunodeficiency virus, low socioeconomic status, frequent vaginal examinations, and prolonged rupture of membranes.¹⁵ Meanwhile, puerperal sepsis is a preventable condition with the standard practice of good antenatal care, aseptic delivery practices, and proper postpartum care.¹⁴ Once diagnosed, delay or inadequate treatment will result in a rapid progression to endotoxic shock, peritonitis, abscess formation, generalized sepsis, and death. Long-term complications of secondary infertility and chronic disabilities are also associated with this condition. It is thus imperative that health facilities identify the specific causative organisms causing puerperal sepsis in their locality and determine their microbiologic pattern to eliminate the prescription of antibiotics to which the organisms are not sensitive to, to avoid prolonged recovery time, and high cost of therapy. Therefore, our study’s outcome will guide the management of puerperal sepsis and the development of the local protocol.