Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case-Control Study
Open accessAbstract
BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.
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The most common sites of infection in pregnant and postpartum women are the urinary system (5.2%), reproductive system (such as chorioamnionitis, 27.6%) and respiratory system (13.8%). Other common infections include surgical incision infections and skin and soft tissue infections (3.5%).
“The most common sites of infection in pregnant and postpartum women are the urinary system (accounting for 5.2%), reproductive system (such as chorioamnionitis, accounting for 27.6%) and respiratory system (accounting for 13.8%).35,36 Other common infections include surgical incision infections and skin and soft tissue infections (accounting for 3.5%).37,38”
From Clinical and Pathogenic Characteristics of 45 Cases of Bloodstream Infection in Obstetrics: A Clinical Analysis (2026) · cites this paper as [37]
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Self-citationCurrent Key Challenges in Managing Maternal Sepsis
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InfluentialAntibiotic Considerations in the Treatment of Maternal Sepsis
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“Time of sepsis diagnosis was defined by the earliest time that any one of the following criteria was met: (1) time of initiation of broad-spectrum antibiotics or broadening of existing antibiotic regimen; (2) time of documentation of sepsis in the chart; or (3) time of transfer to the intensive care unit for sepsis.”
MethodSelf-citationInitial septic shock therapy in obstetrics (clinical guidelines)
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“example, may support the known literature that endometritis is more common after cesarean than vaginal birth [25].”
Result(2020) · Anesthesia and Analgesia · doi:10.1213/ane.0000000000004699 · Cited by 1 · see citing works
Maternal Sepsis: Recognition, Treatment, and Escalation of Care
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Naoum, E., Walsh, E., Smith, M. R., Mueller, A. L., Freret, T. S., Duzyj, C., Zachek, C., Minehart, R. D., & Shelton, K. T. (2026) · Journal of clinical anesthesia · doi:10.1016/j.jclinane.2026.112333
Senn, L., Stephens-Hennessy, B. M., & Olvera, L. (2026) · Nursing for Women s Health · doi:10.1016/j.nwh.2026.06.003
Lyu, X., Chen, S.-Y.-Y.-W.-H., Shi, H.-T., Hong, S.-B., Jiang, M., Liu, C., Wang, C., & Zhang, N. (2026) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-026-09381-x
“…as these instruments were designed for different purposes and time points. qSOFA and SOS primarily serve as screening tools for infection-related deterioration and rely on vital signs and subjective criteria and have demonstrated suboptimal sensitivity in obstetric populations [10, 12, 24].”
Shields, L. E., & Lin, S. N. (2025) · Obstetrics and Gynecology Clinics of North America · doi:10.1016/j.ogc.2025.09.004
Self-citationThompson, K., Yan, S., Low, G., & Henry, A. (2025) · Frontiers in Global Women's Health · doi:10.3389/fgwh.2025.1532500
Sepsis and Septic Shock in Pregnancy
Islamy, N., Aziz, M. A., Yonata, A., Lumentut, A. M., Maelissa, M., Maya Khaerunnisa, P., & Wirawan, W. (2025) · Journal La Medihealtico · doi:10.37899/journallamedihealtico.v6i2.1863
“A recent meta-analysis found that SIRS has better sensitivity, while qSOFA is more specific (Bauer et al., 2019).”
InfluentialDiagnosis and Management of Maternal Sepsis
Clifford, C. C., Behnia, F., & Pacheco, L. D. (2025) · Topics in Obstetrics & Gynecology · doi:10.1097/01.pgo.0001097472.73472.f8
Reanimación de la mujer embarazada
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Surviving maternal sepsis: Clinical, laboratory, and treatment features
Ribeiro-do-Valle, C. C., Luz, A., Pacagnella, R., & Cecatti, J. G. (2024) · International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics · doi:10.1002/ijgo.15440
“Bauer et al. 12 found that 8% of women admitted for childbirth with sepsis who received antibiotics in the first hour after diagnosis died, whereas those who received it later, had a 20% mortality.”
Réanimation de la femme enceinte
Muller, M., Chamaraux-Tran, T., & Pottecher, J. (2024) · EMC - Obstétrique · doi:10.1016/s0246-0335(23)45945-5
Kulikov, A. V., Shifman, E. M., Николаевич, П. Д., Ovezov, A. M., Ronenson, A. M., Raspopin, Y. S., Артымук, Н. В., Belokrinitskaya, T. E., Николаевич, З. К., Щеголев, А. В., et al. (2023) · Annals of critical care · doi:10.21320/1818-474x-2023-2-7-44 · Cited by 1 · see citing works
Sela, H., Seri, V., Zimmerman, F. S., Levin, P., Smueloff, A., & Einav, S. (2020) · Research Square · doi:10.21203/rs.3.rs-61687/v1
“As in other studies [21, 22], relevant maternal parameters (particularly respiratory rate and mental status) were not documented.”
ResultSelf-citationOtkjær, A. M., Jørgensen, H. L., Clausen, T. D., & Krebs, L. (2020) · Obstetric Anesthesia Digest · doi:10.1097/01.aoa.0000661336.05316.78
Tong, D., Zhou, Y., & Wang, S.-D. (2020) · doi:10.21203/rs.3.rs-16897/v1
“Moreover, the SIRS ≥2 have been used to screen infection events by previous studies[5,17,18].”
MethodObstetric Anesthesia: Origins and Current Practice
Leffert, L., & Toledano, R. (2020) · ASA Monitor · doi:10.1097/01.asm.0001079308.40759.db
Self-citation
- Authors
- Bauer, M. E., Housey, M., Bauer, S. T., Behrmann, S., Chau, A., Clancy, C., Clark, E. A. S., Einav, S., Langen, E., Leffert, L., Lin, S., Madapu, M., Maile, M. D., McQuaid-Hanson, E., Priessnitz, K., Sela, H. Y., Shah, A., Sobolewski, P., Toledo, P., Tsen, L. C., & Bateman, B. T.
- Affiliations
- University of Michigan (US)
- Beaumont Health (US)
- Brigham and Women's Hospital (US)
- Massachusetts General Hospital (US)
- Intermountain Healthcare (US)
- Hebrew University of Jerusalem (IL)
- Shaare Zedek Medical Center (IL)
- Northwestern University (US)
- Corresponding author
- Bauer, Melissa E.
- Housey, Michelle
- Behrmann, Sydney
- Maile, Michael D.
- Priessnitz, Kristina
- Sela, Hen Y.
- ORCID
- Venue
- Anesthesia & Analgesia
- Published
- 2019-12
- Volume
- 129
- Issue
- 6
- Pages
- 1613-1620
- ISSN
- 0003-2999 (ISSN-L)
- PMC
- PMC7543988
- OpenAlex
- W2922814492
- Cited by
- 89
- References
- 21
- Citations by year
- 2026: 11 · 2025: 6 · 2024: 28 · 2023: 17 · 2022: 3 · 2021: 12 · 2020: 8 · 2019: 4
- FWCI
- 4.68
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Anesthesia & Analgesia (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (KL2TR002241, UL1TR000433)
- National Center for Advancing Translational Sciences
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (K08HD075831)
- Topics
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Neonatal and Maternal Infections
- Life Sciences › Immunology and Microbiology › Immunology › Inflammation biomarkers and pathways
- Keywords
- maternal sepsis, pregnancy, sepsis screening, qSOFA, systemic inflammatory response syndrome, chorioamnionitis, endometritis, sepsis etiology, risk factors, timing of antibiotic administration, sepsis mortality, parturients, Escherichia coli, Streptococcus pyogenes, Gram-negative bacteria, pneumonia in pregnancy
- MeSH terms
- Adult, Chorioamnionitis, Endometritis, Female, Humans, Mass Screening, Pregnancy, Pregnancy Complications, Infectious, Retrospective Studies, Risk Factors, Cohort Studies, Case-Control Studies, Sepsis, Young Adult
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