HIV Infection and risk of postpartum infection, complications and mortality in rural Uganda

Maternal high-care and intensive care units in low- and middle-income countries

Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment. Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.

Risk factors for postpartum maternal mortality and hospital readmission in low- and middle-income countries: a systematic review

BACKGROUND

In low- and middle-income countries, approximately two thirds of maternal deaths occur in the postpartum period. Yet, care for women beyond 24 h after discharge is limited. The objective of this systematic review is to summarize current evidence on socio-demographic and clinical risk factors for (1) postpartum mortality and (2) postpartum hospital readmission.

METHODS

A combination of keywords and subject headings (i.e. MeSH terms) for postpartum maternal mortality or readmission were searched. Articles published up to January 9, 2021 were identified in MEDLINE, EMBASE, and CINAHL databases, without language restrictions. Studies reporting socio-demographic or clinical risk factors for postpartum mortality or readmission within six weeks of delivery among women who delivered a livebirth in a low- or middle-income country were included. Data were extracted independently by two reviewers based on study characteristics, population, and outcomes. Included studies were assessed for quality and risk of bias using the Downs and Black checklist for ratings of randomized and non-randomized studies.

RESULTS

Of 8783 abstracts screened, seven studies were included (total N = 387,786). Risk factors for postpartum mortality included Caesarean mode of delivery, nulliparity, low or very low birthweight, and shock upon admission. Risk factors for postpartum readmission included Caesarean mode of delivery, HIV positive serostatus, and abnormal body temperature.

CONCLUSIONS

Few studies reported individual socio-demographic or clinical risk factors for mortality or readmission after delivery in low- and middle-income countries; only Caesarean delivery was consistently reported. Further research is needed to identify factors that put women at greatest risk of post-discharge complications and mortality. Understanding post-discharge risk would facilitate targeted postpartum care and reduce adverse outcomes in women after delivery.

TRIAL REGISTRATION

PROSPERO registration number: CRD42018103955.

The interaction between antenatal care and abnormal temperature during delivery and its relationship with postpartum care: a prospective study of 1,538 women in semi-rural Uganda

BACKGROUND

Postnatal care (PNC) is an important tool for reducing maternal and neonatal morbidity and mortality. However, what predicts receipt and maintenance in PNC, particularly events during pregnancy and the peripartum period, is not well understood. We hypothesized that fever or hypothermia during delivery would engender greater health consciousness among those attending antenatal care, leading to greater PNC engagement after hospital discharge and our objective was to evaluate this relationship.

METHODS

Women were prospectively enrolled immediately postpartum at Mbarara Regional Referral Hospital (MRRH). We collected postpartum vital signs and surveyed women by telephone about PNC receipt, fever, and infection at two and six weeks postpartum. Our outcome of interest was receipt of PNC post-discharge, defined as whether a participant visited a health facility and/or was hospitalized in the postpartum period. Our explanatory variables were whether a participant was ever febrile (> 38.0˚C) or hypothermic (< 36.0˚C) during delivery stay and whether a participant attended at least 4 antenatal care (ANC) visits. We used logistic regressions to estimate the association between ANC and fever/hypothermia with PNC, including an interaction term between ANC and fever/hypothermia to determine whether there was a modifying relationship between variables on PNC. Regression models were adjusted for age, marital status, parity, HIV serostatus, Mbarara residency, and whether the participant was referred to MRRH, RESULTS: Of the 1,541 women, 86 (5.6%) reported visiting a health facility and/or hospitalization and 186 (12.0%) had an abnormal temperature recorded during delivery stay. Of those who reported at least one visit, 59/86 (68.6%) delivered by cesarean, 37/86 (43.0%) reported post-discharge fever, and 44/86 (51.2%) reported post-discharge infection. Neither ANC attendance, abnormal temperature after delivery, nor their interaction term, were significantly associated with post-discharge PNC. The included covariates were not significantly associated with the outcome.

CONCLUSIONS

While the overall proportion of women reporting post-discharge PNC was low, those who reported visiting a health facility and/or hospitalization had high proportions of post-discharge fever, post-discharge infection, and cesarean delivery, which suggests that these visits may have been related to problem-focused care. No significant associations between ANC and PNC were observed in this cohort. Further research assessing ANC quality and PNC visit focus is needed to ensure ANC and PNC are optimized to reduce morbidity and mortality.

Changes in Immune Activation During Pregnancy and the Postpartum Period in Treated HIV Infection

Background

Pregnant women with HIV (PWWH) have high postpartum morbidity and mortality from infections like tuberculosis. Immunologic changes during pregnancy and postpartum periods may contribute to these risks, particularly the immunoregulatory kynurenine pathway of tryptophan catabolism, which contributes to both HIV and tuberculosis pathogenesis and increases in the early postpartum period.

Methods

Women with HIV initiating antiretroviral therapy (ART) in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort who were pregnant at enrollment or became pregnant during observation were studied (n = 54). Plasma kynurenine/tryptophan (KT) ratio, soluble CD14 (sCD14), sCD163, sCD27, interferon-inducible protein 10 (IP-10), D-dimer, interleukin-6, and intestinal fatty-acid binding protein levels were assessed through the first year of ART and at 3-month intervals throughout pregnancy and 1 year postpartum. Biomarker changes were assessed with linear mixed models adjusted for ART duration. Hemoglobin concentration changes were used to estimate pregnancy-related changes in plasma volume.

Results

The median pre-ART CD4 count was 134. D-dimer increased through the third trimester before returning to baseline postpartum, while most other biomarkers declined significantly during pregnancy, beyond what would be expected from pregnancy-associated plasma volume expansion. IP-10 and sCD14 remained suppressed for at least 12 months postpartum. KT ratio was the only biomarker that increased above prepregnancy baseline postpartum (mean + 30%; P < .001) and remained higher than baseline for ≥9 months (P ≤ .045 for all time points).

Conclusions

Several immune activation markers decline during pregnancy and remain suppressed postpartum, but the kynurenine pathway of tryptophan catabolism increases above baseline for ≥9 months postpartum. The mechanisms underlying postpartum kynurenine pathway activity are incompletely understood but may contribute to increased tuberculosis risk in this setting.

Determinants and aetiologies of postpartum pyrexia; a retrospective analysis in a tertiary health facility in the Littoral Region of Cameroon

BACKGROUND

Postpartum febrile morbidity is relatively common, occurring in approximately 5-7% of births. Differentiating between potentially serious and benign causes of postpartum pyrexia (PP) is fundamental in curbing the mortality rate from sinister causes such as sepsis. The paucity of data on PP in Cameroon makes it difficult to access its actual burden. This study was aimed at determining the prevalence, risk factors and aetiologies of PP at a tertiary hospital in Douala, Cameroon.

METHODS

This was a 2 - year hospital - based retrospective cohort study carried out at the Douala General Hospital (DGH), during which medical records of all postpartum admissions between January 1st 2017 and December 31st 2018 were reviewed. The review consisted of collecting data on socio-demographic characteristics, clinical profile, investigations and final diagnoses. The collected data was analysed in SPSS 23.0. Chi-squared test was used to test the association between variables and a logistic regression analysis was fitted to identify risk factors associated to PP.

RESULTS

A total of 1520 postpartum files were reviewed. The prevalence of PP was 8.82%. The most frequent causes of PP were: malaria (46.7%), urinary tract infections (18.7%), puerperal sepsis (17.9%) and pneumonia (8.7%). E. coli was the most (49.3%) cultured germ isolated in positive cultures. Onset of PP was more common (85%) within the first 3 days postpartum and malaria (60%) was the leading aetiology within this period. Five or more vaginal examinations prior to delivery (OR 59.151, 95% CI: 21.463-163.019; p < 0.001), perineal tears (OR 45.157, 95% CI: 2.266-899.722; p < 0.001), and duration of labour > 18 h (OR 26.760, 95% CI: 7.100-100.862; p < 0.001) were the most significant risk factors associated with PP.

CONCLUSION

Approximately 1 in every 12 postpartum cases in the DGH presents with PP. Malaria was the leading cause of PP at DGH especially for cases registered within 3 days postpartum. The risk factors identified were mostly associated to perinatal events, such as frequent vaginal examinations, perineal tears and prolonged labour. Efforts towards preventing identified risk factors thus becomes paramount in order to curb this high rate of PP in the DGH.

Risk Factors for Vaginal Colonization and Relationship between Bacterial Vaginal Colonization and In-Hospital Outcomes in Women with Obstructed Labor in a Ugandan Regional Referral Hospital

Introduction

The proportion of women with severe maternal morbidity from obstructed labor is between 2 and 12% in resource-limited settings. Maternal vaginal colonization with group B streptococcus (GBS), Escherichia coli, and Enterococcus spp. is associated with maternal and neonatal morbidity. It is unknown if vaginal colonization with these organisms in obstructed labor women is associated with poor outcomes.

Objectives

To determine whether vaginal colonization with GBS, E. coli, or Enterococcus is associated with increased morbidity among women with obstructed labor and to determine the risk factors for colonization and antibiotic susceptibility patterns.

Methods

We screened all women presenting in labor to Uganda's Mbarara Regional Referral Hospital maternity ward from April to October 2015 for obstructed labor. Those meeting criteria had vaginal swabs collected prior to Cesarean delivery and surgical antibiotic prophylaxis. Swabs were inoculated onto sterile media for routine bacterial culture and antimicrobial susceptibility testing.

Results

Overall, 2,168 women were screened and 276 (13%) women met criteria for obstructed labor. Vaginal swabs were collected from 272 women (99%), and 170 (64%) were colonized with a potential pathogen: 49% with E. coli, 5% with GBS, and 8% with Enterococcus. There was no difference in maternal and fetal clinical outcomes between those colonized and not colonized. The number of hours in labor was a significant independent risk factor for vaginal colonization (aOR 1.02, 95% CI 1.00–1.03, P=0.04). Overall, 38% of GBS was resistant to penicillin; 61% of E. coli was resistant to ampicillin, 4% to gentamicin, and 5% to ceftriaxone and cefepime. All enterococci were ampicillin and vancomycin susceptible.

Conclusion

There was no difference in maternal or neonatal morbidity between women with vaginal colonization with E. coli, GBS, and Enterococcus and those who were not colonized. Duration of labor was associated with increased risk of vaginal colonization in women with obstructed labor.

Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda

Background

There is a paucity of recent prospective data on the incidence of postpartum infections and associated risk factors in sub-Saharan Africa. Retrospective studies estimate that puerperal sepsis causes approximately 10% of maternal deaths in Africa.

Methods

We enrolled 4231 women presenting to a Ugandan regional referral hospital for delivery or postpartum care into a prospective cohort and measured vital signs postpartum. Women developing fever (> 38.0 °C) or hypothermia (< 36.0 °C) underwent symptom questionnaire, structured physical exam, malaria testing, blood, and urine cultures. Demographic, treatment, and post-discharge outcomes data were collected from febrile/hypothermic women and a random sample of 1708 normothermic women. The primary outcome was in-hospital postpartum infection. Multivariable logistic regression was used to determine factors independently associated with postpartum fever/hypothermia and with confirmed infection.

Results

Overall, 4176/4231 (99%) had ≥1 temperature measured and 205/4231 (5%) were febrile or hypothermic. An additional 1708 normothermic women were randomly selected for additional data collection, for a total sample size of 1913 participants, 1730 (90%) of whom had complete data. The mean age was 25 years, 214 (12%) were HIV-infected, 874 (51%) delivered by cesarean and 662 (38%) were primigravidae. Among febrile/hypothermic participants, 174/205 (85%) underwent full clinical and microbiological evaluation for infection, and an additional 24 (12%) had a partial evaluation. Overall, 84/4231 (2%) of participants met criteria for one or more in-hospital postpartum infections. Endometritis was the most common, identified in 76/193 (39%) of women evaluated clinically. Twenty-five of 175 (14%) participants with urinalysis and urine culture results met criteria for urinary tract infection. Bloodstream infection was diagnosed in 5/185 (3%) participants with blood culture results. Another 5/186 (3%) tested positive for malaria. Cesarean delivery was independently associated with incident, in-hospital postpartum infection (aOR 3.9, 95% CI 1.5–10.3, P = 0.006), while antenatal clinic attendance was associated with reduced odds (aOR 0.4, 95% CI 0.2–0.9, P = 0.02). There was no difference in in-hospital maternal deaths between the febrile/hypothermic (1, 0.5%) and normothermic groups (0, P = 0.11).

Conclusions

Among rural Ugandan women, postpartum infection incidence was low overall, and cesarean delivery was independently associated with postpartum infection while antenatal clinic attendance was protective.