AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 19 ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Maternal deaths due to Pregnancy-Related Sepsis arising from bowel injury: A retrospective folder review from the NCCEMD triennium 2020-2022 ABSTRACT 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 files 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%) files 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 five 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. INTRODUCTION In South Africa, a National Committee of Confidential Enquiries into Maternal Deaths (NCCEMD) was established to review all maternal deaths. The NCCEMD aim to identify challenges in the health system and make recommendations for improvement. The World Health Organisation (WHO) defines maternal sepsis as the “life-threatening organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or postpartum”. 1 Maternal sepsis has always been among the leading causes of maternal mortality. In South Africa, according to the 2020-2022 NCCEMD saving mothers report, 172 women died due to pregnancy related sepsis (PRS). Of these, 71 women had sepsis following vaginal delivery, and 71 women after caesarean section. Thirteen deaths were caused by chorioamnionitis, and 17 women suffered bowel trauma during caesarean section. 2 Caesarean sections (CS) are among the most frequently performed major obstetric surgical procedures across the world, and it is not without complications. 3 The caesarean section rate in South Africa is higher than the WHO recommended rate of 10-15%, and the proportion of deaths in South Africa after caesarean section due to PRS varies from 43.8 % (2011-2013), 49.3 % (2014-2016), 47.2% (2017-2019) and 41.3% for this triennium (2020- 2022). 2 The SA caesarean delivery rate (CDR) was, 25.7%, 28.1%, and 28.28% between 2014-2016, 2017-2019, and 2020-2022 respectively. The overall case fatality rates (CFR) per 100 000 CD were 167, 132, and 155.9 over the same three trienniums respectively. For PRS, the CFR was 14.12, 10.02, and 12.0 for 2014-2016, 2017-2019, and 2020-2022 respectively. 2,4,5 Bowel trauma contributed 10% of all PRS deaths, with a CFR of 2.5 per 100000 CD for the 2020-2022 triennium. There is a great concern regarding deaths from bowel injury at caesarean section and this may indicate a trend of increasing numbers of difficult repeat caesarean sections. The purpose of this review is to perform an in- depth analysis of deaths from PRS during 2020-2022 with a special focus on those that were due to bowel injury. The review aims to determine the risk factors associated with bowel injury, assess any difficulties associated with caesarean deliveries, the time of detection of injuries and interventions, and assess the implementation of interventions such as the sepsis bundles of care. METHODS Data on PRS deaths were retrieved from the Maternal Morbidity and Mortality Audit System (MaMMAS) of the S N Cebekhulu 1 ; L Chauke 2 1 Department of Obstetrics and Gynaecology, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Science University, Department of Health and National Committee on Confidential Enquiries into Maternal Deaths, Gauteng, South Africa. 2 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand and National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD), Gauteng, South Africa. CORRESPONDENCE: SN Cebekhulu | Email: syl.cebekhulu@gmail.com Maternal deaths due to Pregnancy-Related Sepsis arising from bowel injury: A retrospective folder review from the NCCEMD triennium 2020-2022