Episode #277 Transforming Maternal Care: Faster Sepsis Recognition, Smarter Hemorrhage Response, and Safer VTE Prevention

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. This is the second episode in our Stoelting Conference series, and we are continuing the conversation about transforming maternal care. We hope that you checked out last week’s show for PART 1, and we are glad that you are back with us today for part 2. Don’t forget, you can also check out recordings from the conference on our website and YouTube channel. Thank you to our industry sponsors for supporting the 2025 APSF Stoelting Conference: BD, Medtronic, Solventum, and Intelliguard. Check out the show notes for more information.

Before we dive further into the episode today, we’d like to recognize Blink, a major corporate supporter of APSF. Blink has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink – we wouldn’t be able to do all that we do without you!”

Our next Stoelting Conference speaker is Emily Naoum, an obstetric anesthesiologist and critical care physician at Massachusetts General Hospital to talk about Maternal Sepsis. Let’s start with a definition. The world health organization defines maternal sepsis as a life-threatening condition characterized by the presence of organ dysfunction resulting from infection during pregnancy, childbirth, or the postpartum period. It is difficult to determine exactly how common maternal sepsis is since the definitions of sepsis, severe sepsis, and septic shock have changed over the past 30 years. It is estimated to occur in about 0.1% of all deliveries in the United States and contributes up to 25% of ICU admissions. This is a significant contributor to maternal morbidity and about 10-15% of maternal deaths. There has been no improvement in the maternal mortality rate over the past decade despite treatment changes. The etiology for maternal sepsis often involves respiratory or urogenital systems with pneumonia and urinary tract infections common during pregnancy and genital tract or surgical site infections more common during the postpartum period. In about one third of cases, no pathogen is detected. We also see that group A strep is particularly virulent and viral infections have increased severity in pregnancy. Obstetric risk factors include the following:

• Multiple gestation
• Preterm delivery
• Premature rupture of membranes
• Induction of labor
• Assisted vaginal delivery
• Cesarean delivery
• Stillbirth
• Retained products of conception
• And postpartum hemorrhage.

Additional risk factors include anemia, congestive heart failure, chronic liver disease, chronic kidney disease, obesity, African American race, and public health insurance in the United States.  Keep in mind that it is difficult to identify maternal sepsis. Many of the SIRS criteria may not be useful due to pregnancy physiology. Only about 18% of patients will present with fever and 25% of patients who died from maternal sepsis never had a fever. So, what can we use? There are several screening tools and early warning systems that can be used and even integrated into electronic medical records to aid detection and allow for early action with antibiotics, source control and ICU admission. Some of these tools include the Obstetric Early Warning Score, the Modified Early Obstetric Warning System, Sepsis in Obstetrics Score, and Maternal Early Warning Criteria. There is no perfect system at this time, but it is important to have a high index of suspicion and use the screening tools early. Remember, patients may look really good even in early septic shock. Treatment considerations for maternal sepsis are similar to management for non-pregnant patients with timely antibiotic administration ideally within 1 hour of diagnosis along with fluid resuscitation, source control, and vasopressors if needed. This is an area where we can and need to do better. We need better recognition of maternal sepsis and faster response. This means escalating care when needed, prescribing antibiotics sooner, and getting them into the patients faster. Emily provides some examples for how our systems can do better with multidisciplinary reviews, process mapping to identify gaps and measure improvements, and collaboration. Other opportunities include the use of simulation cognitive aids, and patient education so that patients are empowered to know what is and what is not normal for them. Here are the big takeaways:

• Maternal morbidity and mortality due to sepsis remains high.
• Maternal sepsis can be difficult to diagnose
• A high index of suspicion, the use of an early warning system with a standardized treatment algorithm, and efficient delivery of care is necessary.
• And multidisciplinary care and review are essential.

What early warning system are using at your institution?

Next up, we have Beth Clayton, a certified registered nurse anaesthetist at the University of Cincinnati Medical Centre to talk about maternal haemorrhage. This is the leading cause of maternal morbidity and mortality and there is room for improvement due to gaps in diagnosis and management. Delays in recognition of haemorrhage lead to worse outcomes. Often, clinicians may just use visual detection to make the diagnosis, but using calibrated drapes and observation allows for real-time estimated blood loss and facilitates early recognition. Beth reminds us that checking a haemoglobin level can be used for confirmation but not detection and the shock index may be used to detect deterioration, but not early recognition. WE hope that you will check out the 2023 article in the New England Journal of Medicine, “Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage” by Gallos and colleagues that evaluated the use of calibrated drapes for determination of postpartum hemorrhage followed by using a treatment bundle which led to a lower risk of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding. You can find the citation in the show notes.

Now, what about the role for administration of tranexamic acid? There may be a no benefit for prophylactic administration to patients who are low risk while high risk patients undergoing c-section will benefit from prophylactic administration. For high-risk patients, it makes sense to give TXA at skin incision without waiting to give later. We still need more research when it comes to blood and product transfusion for patients with postpartum hemorrhage as the 2025 Cochrane database of systemic reviews concluded that the current evidence is uncertain for the effects of blood and blood product transfusion on maternal outcomes. There is also not a lot of evidence related to intraoperative cell salvage at this time, but this might be best to use for patients who refuse blood transfusion. There is an intervention that does move the needle on morbidity and mortality following postpartum hemorrhage. These involve multiple coordinated interventions and promote earlier intervention by clinicians. The California Maternal Quality Care Collaborative has toolkits available including the “Improving Health Care Response to Obstetric Hemorrhage Toolkit, Version 3.0.” We hope that you will check out it. I will include a link in the show notes as well. You can download the toolkit and there is a lot of information and tools available.

Another important consideration related to maternal hemorrhage is placenta accrete spectrum. There is an increased incidence due to the increase in c-section delivery. Patients with placenta accreta have a higher risk for hemorrhage and worse outcomes. There are hospitals that are placenta accreta centers with multidisciplinary teams and plans in place to treat patients and keep them safe. For anaesthesia professionals, it is important to have a role on the multidisciplinary team, but at this time the optimal anaesthesia for delivery remains unclear.

We are moving on to our next speaker, Lisa Leffert, who is a professor and chair of Anesthesiology at Yale Medical School, to talk about maternal venous thromboembolism. Let’s start with the scope of the problem. Venous thromboembolism is a leading cause of maternal mortality and patients have a 5-6-fold overall risk with the greatest risk occurring in the weeks after delivery. Risk factors include high BMI, immobility, preeclampsia, and infection. Keep in mind that patients’ risk assessment should not be static. All patients should be assessed for VTE risk multiple times in pregnancy including upon presentation for prenatal care, during hospitalization for an antepartum indication, at delivery hospitalization, and prior to discharge from delivery hospitalization.   So, what can we do to keep patient’s safe? This is where prophylactic treatment with anticoagulants can help. The choice for anticoagulant may be heparin which has a short half-life and may be reversed with protamine or with low molecular heparin which is easy to administer with better bioavailability and safety profile, more predictable dosing, lower incidence of HIT, fewer bleeding episodes, and lower incidence of osteoporosis. What are you using at your institution? There are many different protocols which makes it hard to determine what is working and what isn’t working. Unfortunately, the mortality rate has gone up again between 2020 and 2022, and we still have insufficient evidence or sample size to base recommendations for thromboprophylaxis during pregnancy, so more work is needed in this area.

Another consideration for patients receiving anticoagulants is the risk for bleeding complications and spinal or epidural hematoma. The good news is that OB patients are at incredibly low risk for this complication of about 1:200,000 to 1:250:000. If you review the literature, there are no cases of spinal epidural hematoma following neuraxial anaesthesia in OB patients receiving thromboprophylaxis. There is likely underreporting, and it is important to consider ASRA guidelines when it comes to timing for neuraxial anaesthesia procedures and anticoagulant administration. Lisa provides several strategies to help facilitate neuraxial anaesthesia for patients at risk for VTE including the following:

• Advanced planning and structured communication.
• Clear understanding of unit-based protocols
• System-wide alert systems
• Pre-delivery anaesthesia consultation
• Prompt communication of changes in pregnant status
• Trigger to hold anticoagulant
• Pre-procedure huddles
• And Timeouts.

There is a call to action to address the knowledge gaps in this area with validation  of clinical prediction tools for evaluating the absolute risk for patients, the optimal risk threshold, the optimal dose, optimal duration, and the absolute bleeding risks.

What a great first morning at the Stoelting Conference. We had some wonderful questions and comments from members of the audience including some additional considerations for patients with heart failure. Here is a mini algorithm that may be useful.

• For women who present with oxygen saturation less than 95%, it is important to rule out heart failure. Once patients start desaturating or if they require supplemental oxygen, immediate action is necessary.
• Consider checking a BNP. If this is normal, then it can rule out heart failure.
• Can your patient lie flat? If not, consider diuresis until they can lie flat. For patients who are unable to lie flat and require a c-section, this is when a general anaesthetic may be needed.

There is a wellness bias for pregnant patients. Many people including healthcare professionals still think that all pregnant patients are young and healthy, but it is so important to understand the physiologic changes of pregnancy, important vital signs, and what is abnormal for pregnant patients so that we don’t miss these early signs.

We still have more to talk about when it comes to the 2025 APSF Stoelting Conference and we hope that you will continue to tune in for this podcast series. Mark your calendars for PART 3 next week.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Have you checked out the other APSF Patient Safety Resource initiatives? Head over to ASPF.org and click on the Patient Safety Resources heading. The first one down, right above this podcast, is Initiatives. From here, you can check out the following:

• Look Alike Drug Vials
• Continuous Blood Pressure Monitoring
• Surgical Fires – A Preventable Problem
• Workplace Violence Prevention
• Drug-Drug Interactions
• And the Covid perioperative resource center.

So many great initiatives to help improve anesthesia patient safety.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2025, The Anesthesia Patient Safety Foundation