The golden hour of sepsis: An in-depth analysis of sepsis-related maternal mortality in middle-income country Suriname

<div><p>Background</p><p>Sepsis was the main cause of maternal mortality in Suriname, a middle-income country. Objective of this study was to perform a qualitative analysis of the clinical and management aspects of sepsis-related maternal deaths with a focus on the ‘golden hour’ principle of antibiotic therapy.</p><p>Methods</p><p>A nationwide reproductive age mortality survey was performed from 2010 to 2014 to identify and audit all maternal deaths in Suriname. All sepsis-related deaths were reviewed by a local expert committee to assess socio-demographic characteristics, clinical aspects and substandard care.</p><p>Results</p><p>Of all 65 maternal deaths in Suriname 29 (45%) were sepsis-related. These women were mostly of low socio-economic class (n = 23, 82%), of Maroon ethnicity (n = 14, 48%) and most deaths occurred postpartum (n = 21, 72%). Underlying causes were pneumonia (n = 14, 48%), wound infections (n = 3, 10%) and endometritis (n = 3, 10%). Bacterial growth was detected in 10 (50%) of the 20 available blood cultures. None of the women with sepsis as underlying cause of death received antibiotic treatment within the first hour, although most women fulfilled the diagnostic criteria of sepsis upon admission. In 27 (93%) of the 29 women from which sufficient information was available, substandard care factors were identified: delay in monitoring in 16 (59%) women, in diagnosis in 17 (63%) and in treatment in 21 (78%).</p><p>Conclusion</p><p>In Suriname, a middle-income country, maternal mortality could be reduced by improving early recognition and timely diagnosis of sepsis, vital signs monitoring and immediate antibiotic infusion (within the golden hour).</p></div

Clinical signs when sepsis was diagnosed in the sepsis-related maternal deaths in Suriname between 2010 and 2014 (n = 27).

<p>Clinical signs when sepsis was diagnosed in the sepsis-related maternal deaths in Suriname between 2010 and 2014 (n = 27).</p

Number of sepsis-related maternal deaths showing different organ system dysfunctions (n = 27).

<p>Number of sepsis-related maternal deaths showing different organ system dysfunctions (n = 27).</p

Overview of the time between admission, first signs of sepsis, first vital signs after admission, the initiation of antibiotic treatment and death per patient with sepsis as the underlying cause of death (n = 17).

<p>Legend: initial signs of sepsis designated with a gray triangle, use of antibiotics designated with grey rhombus, death designated with a black cross, vital signs recorded after initial signs of sepsis designated with a grey circle.</p

Overview of the sepsis-related maternal deaths between 2010 and 2014 in Suriname.

<p>Overview of the sepsis-related maternal deaths between 2010 and 2014 in Suriname.</p

Characteristics of the sepsis-related maternal deaths in Suriname 2010–2014.

<p>Characteristics of the sepsis-related maternal deaths in Suriname 2010–2014.</p

Case description of direct maternal deaths between 2010 and 2014 in Suriname with sepsis as underlying cause.

<p>Case description of direct maternal deaths between 2010 and 2014 in Suriname with sepsis as underlying cause.</p

Micro-organisms isolated from the cultures performed in the sepsis-related maternal deaths in Suriname.

<p>Micro-organisms isolated from the cultures performed in the sepsis-related maternal deaths in Suriname.</p

Substandard care analysis of sepsis-related maternal deaths in Suriname between 2010 and 2014.

<p>Substandard care analysis of sepsis-related maternal deaths in Suriname between 2010 and 2014.</p

Geographical setting of the antenatal clinics of the Shoklo Malaria Research Unit.

<p>Location of the Shoklo Malaria Research Unit antenatal clinics and Mae Sot, the main town in the Thai province of Tak, bordering Burma. The locations of the antenatal clinics are represented by squares.</p