Maternal Sepsis in Italy: A Prospective, Population-Based Cohort and Nested Case-Control Study

Global incidence of maternal sepsis: A systematic review and meta-analysis

OBJECTIVE

This study investigates the global incidence of maternal sepsis, a life-threatening condition and major cause of maternal mortality. Through a systematic review and meta-analysis, we aim to provide a more precise estimation of its incidence, identify regional variations, and examine associated risk factors to inform improved prevention and management strategies.

METHODS

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of PubMed/MEDLINE, Scopus, Google Scholar, EMBASE, and the Web of Science was performed for studies published from inception to January 10, 2025. The methodological quality of the included studies was rigorously assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. The pooled incidence rate per 10,000 pregnancies was estimated using a random-effects meta-analysis model to account for study heterogeneity. Furthermore, the analysis also explored the risk factors that contribute to the development of maternal sepsis.

RESULTS

A total of 44 studies, encompassing 141,200,302 pregnant women from 24 countries, were included in the analysis. The global cumulative incidence of maternal sepsis was found to be 13.16 per 10,000 pregnant women (95 % CI: 9.91-17.47). Regional variations were significant, with the highest crude incidence observed in the African region (129.17 per 10,000; 95 % CI: 67.05-248.85), while the lowest was recorded in the Region of the Americas (6.31 per 10,000; 95 % CI: 4.36-9.12). These findings were based on six studies from the African region and 17 from the Americas. Additionally, the study identified several factors, such as age ≥ 35, multiple pregnancies, gestational diabetes, preeclampsia/eclampsia, hypertension, diabetes mellitus, obesity, and cesarean delivery, that were linked to an increased risk of maternal sepsis.

CONCLUSION

This study provides global and regional estimates of maternal sepsis, with a cumulative incidence of 13.16 per 10,000 pregnancies, highlighting regional disparities. Key risk factors include multiple pregnancies, preeclampsia, hypertension, obesity, and cesarean delivery. The findings emphasize the need for improved healthcare access, better data collection, and early intervention to reduce maternal sepsis worldwide.

Maternal Sepsis and associated factors: A multi-central study from two tertiary care hospitals of South Punjab, Pakistan

Objective

To determine the risk factors and outcomes of maternal sepsis.

Methods

This case-control study was performed at the departments of Obstetrics & Gynecology, Nishtar Hospital, Multan, and Ghazi Khan Hospital, Dera Ghazi Khan, Pakistan, from June 2023 to May 2024. Cases were comprised of females aged 18-45 years diagnosed with maternal sepsis, and admitted during the study period. Controls were randomly selected females reporting during the study period and undergoing delivery. Sepsis was labeled on the basis of positive blood culture report. Crude and adjusted odds ratio with 95% confidence interval were reported regarding various risk factors of maternal sepsis as well as maternal and fetal outcomes taking p<0.05 as significant. Mortality was noted from the onset of labor until seven days postpartum.

Results

In a total of 74 women (37 in each group), the mean age and, gestational age were 30.64±5.12 years, and 36.19±1.84 weeks, respectively. Multivariate binary logistic regression showed that gestational age below 37 weeks (AOR: 5.22; 95% CI: 1.35-19.67; p=0.015), unbooked cases (AOR: 5.34; 95% CI: 1.19-24.2; p=0.029), and anemia (AOR: 8.13; 95% CI: 1.05-63.10; p=0.045) were significant predictors of maternal sepsis. E. coli was the most common etiological agent among cases, affecting 14 (37.8%) cases. Mortality was significantly high among females with maternal sepsis versus those without maternal sepsis (32.4% vs. 2.7%, p=0.008).

Conclusion

Gestational age below 37 weeks, lack of antenatal booking, and anemia were found to be significant predictors of maternal sepsis. E. coli was the most common pathogen identified. High mortality rate in maternal sepsis highlights the need for early identification, effective management, and close monitoring to reduce maternal mortality from sepsis.

Maternal mortality in Italy estimated by the Italian Obstetric Surveillance System

This study aimed to calculate Italy's first national maternal mortality ratio (MMR) through an innovative record-linkage approach within the enhanced Italian Obstetric Surveillance System (ItOSS). A record-linkage retrospective cohort study was conducted nationwide, encompassing all women aged 11-59 years with one or more hospitalizations related to pregnancy or pregnancy outcomes from 2011 to 2019. Maternal deaths were identified by integrating data from the Death Registry and national and regional Hospital Discharge Databases supported by the integration of findings from confidential enquiries conducted through active surveillance. Maternal Mortality Ratio (MMR), direct MMR (DMMR), and causes of maternal death are the study main outcomes. The MMR was found to be 8.4 per 100,000 live births (95% CI 7.5-9.3), significantly higher than the 3.9 per 100,000 (95% CI 3.3-4.5) calculated solely from the Death Registry, with a notable declining trend over the study period. Causes of death have been classified according to the 10th International Classification of Diseases. Within 42 days from pregnancy outcome, leading causes were obstetric haemorrhage, sepsis, and cardiovascular diseases. Late maternal deaths were primarily attributed to suicide, malignancies, and cardiovascular diseases. This integrated methodology provides a comprehensive understanding of maternal mortality trends and causes in Italy, offering valuable insights for countries utilizing or planning enhanced surveillance systems.

Clinical characteristics associated with peripartum maternal bloodstream infection

Objective

Bloodstream infection (BSI) during the peripartum period is a major cause of maternal morbidity and mortality. However, data on maternal BSI during hospitalization for delivery are limited. This study aimed to investigate the incidence, clinical characteristics, risk factors, microbiological features, and antibiotic resistance patterns of maternal peripartum BSI, with a focus on understanding the role of premature rupture of membranes (PROM), fever, and other risk factors in its development.

Methods

We investigated the clinical characteristics associated with maternal BSI during the peripartum period. This study included febrile women with blood cultures obtained during hospitalization for delivery. We analyzed the clinical characteristics, pathogenic microorganisms, antibiotic resistance, and maternal and neonatal outcomes of these patients. Participants were divided into BSI (n = 85) and non-BSI (n = 361) groups.

Results

Spontaneous rupture of membranes, PROM, PROM >24 h before labor, vaginal examinations >5 times, and cesarean sections during labor were more common in the BSI group. Escherichia coli (51.8%; 44/85) was the predominant causative pathogen, followed by Enterococcus faecalis (7.1%, 6/85). Approximately 31.2% of E. coli were resistant to levofloxacin, and 38.6% were extended-spectrum β-lactamase-producing bacteria. The BSI group had higher rates of maternal sepsis and Apgar scores ≤ 7 at 1 min than the non-BSI group. Furthermore, PROM, fever ≥38.9°C (102°F), and fever within 24 h after delivery were risk factors for postpartum BSI in the adjusted analysis.

Conclusion

Maternal BSI is a potentially life-threatening disease associated with PROM and the timing and severity of fever. Early identification and surveillance of pathogen composition and antimicrobial resistance can help prevent adverse outcomes.

Evaluation of microbiological epidemiology and clinical characteristics of maternal bloodstream infection: a 10 years retrospective study

Objective

Although the incidence of bloodstream infection (BSI) during pregnancy is relatively low, it can lead to unfavorable outcomes. The aim of our study was to analyze the clinical and microbiological characteristics of maternal bacteremia and to assess maternal and fetal outcomes.

Methods

Our study was a retrospective study conducted in a tertiary women and children's hospital in Guangzhou, China, from 2013 to 2022. Data were extracted from medical records and the laboratory information system. The participants were divided into groups, and the difference between the groups was analyzed.

Results

The incidence of maternal BSI during the 10 years study period was 10.2 cases/10,000 maternities, with a peak found from 2014 to 2016. Escherichia coli (48%) was the predominant causative pathogen, followed by Streptococcus agalactiae (13%). Gestational diabetes mellitus (GDM) (15%) was the most common underlying condition among maternal BSI episodes. Urinary tract (13%) and genital tract (28%) were the predominant source of BSI. About 14% of neonates were infected, and BSI was the most common type of infection. E. coli was the predominant pathogen in mother-neonate pairs with concurrent BSI. Premature rupture of membranes (PROM, OR:4.68) and preterm birth (OR:3.98) were the risk factors predicting neonatal infection. More than 85% of the E. coli were resistant to ampicillin (AMP) and 50% of the E. coli were extended-spectrum β-lactamase (ESBL)-producing bacteria.

Conclusion

Maternal BSI is a rare event, but continuous monitoring on the aspects of pathogen composition, antimicrobial resistance characteristics, and risk factors for adverse outcomes remains necessary to further reduce poor outcomes and mitigate bacterial resistance.