Association of Pregnancy-Adjusted Sepsis Screening Criteria with Risk of Maternal Infectious Morbidity in the Setting of Intrapartum Intraamniotic Infection

Abstract

Objective

The California Maternal Quality Care Collaborative (CMQCC) developed a pregnancy-adjusted sepsis screen that includes temperature ≥100.4°F, heart rate > 110 bpm, respiratory rate > 24 bpm, and white blood cell count > 15,000/mm³. This tool was not validated in the intrapartum state. We aim to evaluate the performance of the first part of the CMQCC sepsis screen to identify infection-related morbidity in patients diagnosed with intraamniotic infection.

Study Design

A retrospective cohort study was performed of 541 patients diagnosed with suspected intraamniotic infection prior to delivery at a single center from July 2017 to June 2021. The primary outcome was composite maternal infectious morbidity (end-organ injury, bacteremia, intensive care unit admission, postpartum endometritis, postpartum readmission for infection, or maternal death) in birthing people who screened positive (two or more CMQCC sepsis screen criteria) compared with those who screened negative. Binary logistic multivariable regression was performed with backward selection including overall sepsis screen results as well as individual screening criteria. Data presented as odds ratio (OR) with a two-sided p-value of 0.05 was used for significance.

Results

Of the 541 reviewed cases, 336 (62%) screened positive while 205 (38%) screened negative. Birthing people with a positive sepsis screen in labor had a higher rate of composite maternal infectious morbidity compared with those with a negative screen, although this did not reach statistical significance (17.6% vs. 11.7%; p = 0.07; OR: 1.6 [0.96–2.68]). In evaluating individual criteria, heart rate > 110 bpm (p = 0.003; OR: 2.1 [1.3–3.4]) and respiratory rate > 24 bpm (p = 0.039; 5.7 [1.09–29.8]) were significantly associated with composite maternal infectious morbidity.

Conclusion

Most birthing people with intraamniotic infection screen positive prior to delivery using the CMQCC sepsis screen. When looking at the sepsis screen's individual components, elevated heart rate and respiratory rate may be useful in identifying those at increased risk of infectious morbidity.

Key Points

• Most patients with intraamniotic infection screen positive prior to delivery using the CMQCC screen.

• The overall CMQCC sepsis screen was not associated with infectious morbidity.

• Elevated heart rate and respiratory rate may identify those at increased risk of morbidity.

Keywords

sepsis - intraamniotic infection - CMQCC

Publication History

Received: 09 March 2025

Accepted: 02 May 2025

Article published online:
23 May 2025

• References

• 1 Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol 2017; 130 (02) 366-373
• 2 Acosta CD, Kurinczuk JJ, Lucas DN, Tuffnell DJ, Sellers S, Knight M. United Kingdom Obstetric Surveillance System. Severe maternal sepsis in the UK, 2011-2012: a national case-control study. PLoS Med 2014; 11 (07) e1001672
• 3 Rouse DJ, Landon M, Leveno KJ. et al; National Institute of Child Health And Human Development, Maternal-Fetal Medicine Units Network. The maternal-fetal medicine units cesarean registry: chorioamnionitis at term and its duration-relationship to outcomes. Am J Obstet Gynecol 2004; 191 (01) 211-216
• 4 Hauth JC, Gilstrap III LC, Hankins GD, Connor KD. Term maternal and neonatal complications of acute chorioamnionitis. Obstet Gynecol 1985; 66 (01) 59-62
• 5 The California Pregnancy-Associated Mortality Review. Report from 2002–2007 Maternal Death Reviews. Sacramento: California Department of Public Health, Maternal, Child and Adolescent Health Division
• 6 Bauer ME, Lorenz RP, Bauer ST, Rao K, Anderson FWJ. Maternal deaths due to sepsis in the state of Michigan, 1999–2006. Obstet Gynecol 2015; 126 (04) 747-752
• 7 Evans L, Rhodes A, Alhazzani W. et al. Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49 (11) e1063-e1143
• 8 Singer M, Deutschman CS, Seymour CW. et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016; 315 (08) 801-810
• 9 Bauer ME, Bauer ST, Rajala B. et al. Maternal physiologic parameters in relationship to systemic inflammatory response syndrome criteria: a systematic review and meta-analysis. Obstet Gynecol 2014; 124 (03) 535-541
• 10 Bauer ME, Fuller M, Kovacheva V. et al. Performance characteristics of sepsis screening tools during antepartum and postpartum admissions. Obstet Gynecol 2024; 143 (03) 336-345
• 11 Main EK, Fuller M, Kovacheva VP. et al. Performance characteristics of sepsis screening tools during delivery admissions. Obstet Gynecol 2024; 143 (03) 326-335
• 12 Gibbs R, Bauer M, Olvera L, Sakowski C, Cape V, Main E. Improving Diagnosis and Treatment of Maternal Sepsis: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative;
• 13 Committee Opinion No. Committee opinion no. 712: intrapartum management of intraamniotic infection. Obstet Gynecol 2017; 130 (02) e95-e101
• 14 Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996; 49 (12) 1373-1379