Maternal deaths due to Pregnancy-Related Sepsis arising from bowel injury: A retrospective folder review from the NCCEMD triennium 2020-2022

Background: Maternal deaths due to pregnancy-related sepsis, specifically those emanating from bowel injury during caesarean delivery (CD), remains a concern in South Africa. Aim: In this review, we describe the profile of women who died of pregnancy-related sepsis (PRS) due to bowel injuries during caesarean section, with the aim of providing insight into the contributing and/or avoidable factors. Methods: Data on PRS deaths were retrieved from the Maternal Morbidity and Mortality Audit System (MaMMAS) database of the National Committee for Confidential Enquiry into Maternal Deaths (NCCEMD). An analysis was performed after reviewing the hard copy fi les of PRS maternal deaths which contained the clinical notes, maternal death notification forms, and assessors forms. Results: Between 2020 and 2022, 172 women died due to PRS and 16 (9.3%) were as a result of bowel injuries sustained during caesarean section. Of the 16 cases, 14 (88%) fi les had sufficient information to enable analysis. The majority of the women who died were in the age group 25-34 years, 10 (71.4%) were HIV positive, and 10 (71.4%) had increased BMI. Eight maternal deaths (57.1%) occurred in regional and tertiary hospitals combined. None of the bowel injuries were diagnosed intra-operatively. All the women who died were discharged on day three post caesarean section and readmitted at least on day seven. Tachycardia was present in 13 (92.9%) cases at least on the third day post caesarean section. There was overall poor compliance towards the sepsis bundles’ implementation as evidenced by delayed and inadequate treatment following diagnosis. Only two women (14%) had at least fi ve out of six (83%) components of the sepsis bundle implemented. Conclusion: Maternal sepsis remains one of the leading causes of maternal mortality, and while the rate of PRS deaths has shown a slow but steady decline in recent years, the high proportion of avoidable deaths is still of great concern. Caesarean section in the background of previous caesarean section is associated with increased risk for bowel injury and high mortality. Identification of risk factors, meticulous surgical techniques, a high level of vigilance following a caesarean section, and compliance with septic bundles during resuscitation are critical.