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Nieuwoudt C, White SE, Heine RP, Widelock TM. Maternal Sepsis. Clin Obstet Gynecol 2024; 67:589-604. [PMID: 38967478 DOI: 10.1097/grf.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
Sepsis is the second leading cause of pregnancy-related mortality in the United States. Early recognition, treatment, and escalation of care for the obstetric patient affected by sepsis mitigate the risk of mortality and improve patient outcomes. In this article, we provide an overview of maternal sepsis and address topics of maternal pathophysiology, early warning signs, diagnostic criteria, early goal-directed therapy, and contemporary critical care practices. We also present an overview of common etiologies of maternal sepsis and suggested treatment approaches.
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Affiliation(s)
- Claudia Nieuwoudt
- Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Salmanov AG, Shchedrov AO, Prishchepa AP, Artyomenko V, Korniyenko SM, Rud VO, Kolesnik AV. Postpartum infections and antimicrobial resistance of responsible pathogens in Ukraine: results a multicenter study (2020-2022). WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:375-382. [PMID: 38691775 DOI: 10.36740/wlek202403101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Aim: To determine the current prevalence of postpartum infections and antimicrobial resistance and antimicrobial resistance of responsible pathogens in Ukraine. PATIENTS AND METHODS Materials and Methods: Multicenter prospective cohort study was conducted from January 2020 to December 2022 in fifteen hospitals from twelve regions of Ukraine. Definitions of healthcare- associated postpartum infection were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Antibiotic susceptibility was done by the disc diffusion test as recommended by EUCAST. RESULTS Results: Among 21,968 women, 6,175 (28.1%) postpartum infections were observed. Of all postpartum infection cases, 83.1% were detected after hospital discharge. The postpartum infection rates were 17.3% after cesarean section and 10.8% after vaginal delivery. The most common postpartum infection types were endometritis (17.3%), followed by urinary tract Infection (3.5%), mastitis (3.4%), surgical site infection (excluding endometritis) (2.4%), and episiotomy site infection (1.5%). The predominant postpartum infection pathogens in Ukraine were: Escherichia coli (10.4%), Enterococcus spp. (9.6%), Staphylococcus aureus (6.7%), Pseudomonas aeruginosa (5.8%), Enterobacter spp. (5.8%). In our study pathogens of postpartum infection had differently levels of resistance to antibiotics. CONCLUSION Conclusions: Our results indicate that postpartum infections requiring medical attention are common in Ukraine and that most postpartum infections occur after hospital discharge, so that use of routine inpatient surveillance methods alone will lead to underestimation of postpartum infection rates. Optimizing the antibiotic prophylaxis may reduce the burden of postpartum infection, but prevention is the key element.
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Affiliation(s)
- Aidyn G Salmanov
- SHUPYK NATIONAL HEALTHCARE UNIVERSITY OF UKRAINE, KYIV, UKRAINE; INSTITUTE OF PEDIATRICS, OBSTETRICS AND GYNECOLOGY OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE, KYIV, UKRAINE
| | - Andrii O Shchedrov
- SCHOOL OF MEDICINE OF V. N. KARAZIN KHARKIV NATIONAL UNIVERSITY, KHARKIV, UKRAINE
| | | | | | | | - Victor O Rud
- NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
| | - Anna V Kolesnik
- LUTSK ACADEMY OF RECREATION TECHNOLOGIES AND LAW, LUTSK, UKRAINE
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Axelsson D, Brynhildsen J, Blomberg M. Maternal obesity and the risk of postpartum infections according to mode of delivery. J Matern Fetal Neonatal Med 2023; 36:2245102. [PMID: 37574213 DOI: 10.1080/14767058.2023.2245102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE The aim of the present study was to assess the impact of different maternal Body Mass Index (BMI) classes on the risk of postpartum endometritis, wound infection, and breast abscess after different modes of delivery. Secondly to estimate how the risk of postpartum infection varies with different maternal BMI groups after induction of labor and after obstetric anal sphincter injuries. METHODS A population-based observational study including women who gave birth during eight years (N = 841,780). Data were collected from three Swedish Medical Health Registers, the Swedish Medical Birth Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. Outcomes were defined by ICD-10 codes given within eight weeks postpartum. The reference population was uninfected women. Odds ratios were determined using Mantel-Haenszel technique. Year of delivery, maternal age, parity and smoking in early pregnancy were considered as confounders. RESULTS There was a dose-dependent relationship between an increasing maternal BMI and a higher risk for postpartum infections. Women in obesity class II and III had an increased risk for endometritis after normal vaginal delivery aOR 1.45 (95% CI: 1.29-1.63) and for wound infections after cesarean section aOR 3.83 (95% CI: 3.39-4.32). There was no difference in how maternal BMI affected the association between cesarean section and wound infection, regardless of whether it was planned or emergent. Women in obesity class II and III had a lower risk of breast abscess compared with normal-weight women, aOR 0.47 (95% CI: 0.38-0.58). The risk of endometritis after labor induction decreased with increasing maternal BMI. The risk of wound infection among women with an obstetrical sphincter injury decreased with increasing BMI. CONCLUSION This study provides new knowledge about the impact of maternal BMI on the risk of postpartum infections after different modes of delivery. There was no difference in how BMI affected the association between cesarean section and wound infections, regardless of whether it was a planned cesarean section or an emergency cesarean section.
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Affiliation(s)
- Daniel Axelsson
- Department of Obstetrics and Gynecology, Ryhov County Hospital, Jönköping, Sweden, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Jan Brynhildsen
- Department of Obstetrics and Gynecology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Lambert KA, Honart AW, Hughes BL, Kuller JA, Dotters-Katz SK. Antibiotic Recommendations After Postpartum Uterine Exploration or Instrumentation. Obstet Gynecol Surv 2023; 78:438-444. [PMID: 37480294 DOI: 10.1097/ogx.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Importance Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on the use of antibiotics in these scenarios is limited, resulting in few guidelines and divergent care. Objective To describe postpartum scenarios requiring uterine exploration and/or instrumentation, review data on antibiotic prophylaxis, and delineate antibiotic recommendations for each scenario. Evidence Acquisition Original articles were obtained from literature search in PubMed, MEDLINE, and OVID; pertinent articles were reviewed. Results These recommendations are based on published evidence and professional society guidelines. Antibiotic prophylaxis following manual placenta removal should include 1-time combination of ampicillin 2 g intravenously (IV) or cefazolin 1 g IV, plus metronidazole 500 mg IV. Antibiotic prophylaxis before postpartum dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade should include 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. If the patient in any of the above scenarios has received group B Streptococcus prophylaxis, then only metronidazole is recommended. Further randomized clinical trials are needed to optimize these regimens. Conclusions Uterine exploration or instrumentation increases the risk of postpartum endometritis and requires antibiotic prophylaxis. For manual placenta removal, we recommend 1-time combination of ampicillin 2 g IV or cefazolin 1 g IV, plus metronidazole 500 mg IV. For dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade, we recommend 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. For patients who already received antibiotic prophylaxis for group B Streptococcus, we recommend 1-time dose of metronidazole 500 mg IV. Relevance Providers can utilize our guidelines to prevent postpartum endometritis in these scenarios requiring postpartum uterine exploration and/or instrumentation.
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Affiliation(s)
| | | | | | - Jeffrey A Kuller
- Professor, Department of Obstetrics and Gynecology, Duke University, Durham, NC
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San-Juan R, Sanz-Prieto A, Contreras-Mora J, Fojo-Suárez I, Caso-Laviana JM, Fernández-Ruiz M, López-Medrano F, Rodríguez-Goncer I, Fayos M, Brañas P, Casado PB, García-Burguillo A, Aguado JM. Comprehensive analysis of current epidemiology, clinical features and Prognostic Factors of puerperal endometritis: A retrospective cohort analysis. Eur J Obstet Gynecol Reprod Biol X 2023; 18:100199. [PMID: 37234795 PMCID: PMC10206829 DOI: 10.1016/j.eurox.2023.100199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/06/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Background Puerperal endometritis has not been recently investigated. We aimed to describe the current dimension of the endometritis in the context of other causes of puerperal fever and investigate the microbiology and need for curettage in these patients. Methods A retrospective cohort study was conducted based on a prospectively maintained database of patients with puerperal fever, (2014-2020) in which cases fulfilling criteria for endometritis were selected for further analysis. Description of clinical and microbiological features was performed and determination of the factors related with puerperal curettage requirement were studied using univariate and multivariate analysis through binary logistic regression. Results From 428 patients with puerperal fever, endometritis was the main cause of puerperal fever (233 patients, 52.7 %). Curettage was required in 96 of them (41.2 %). Culture of endometrial samples were performed in 62 (64.5 %), of which 32 (51.6 %) yielded bacterial growth. Escherichia coli was the most common microorganism in curettage cultures (46.9 %). Multivariate analysis identified the following predictive factors for curettage: the presence of pattern compatible with retained products of conception (RPOC) in transvaginal ultrasonography (odds ratio [OR]: 17.6 [95 % confidence interval [CI]: 8.4-36.6]; P-value < 0.0001), fever during the first 14 days after delivery (OR:5.1; [95 % CI: 1.57-16.5]; P-value 0.007), abdominal pain (OR: 2.9; [95 % CI: 1.36-6.1]; P-value 0.012) and malodorous lochia (OR:3.5; [95 % CI: 1.25-9.9]; P-value 0.017). Scheduled cesarean delivery was protective (OR: 0.11 [95 % CI 0.01-1.2]; P-value 0.08). Conclusions Endometritis is still the main cause of puerperal fever. Women requiring curettage typically presented with abdominal pain and foul-smelling lochia, an ultrasound image compatible with RPOC and fever in the first 14 days postpartum. Curettage culture is useful for the microbiological affiliation mostly yielding gram-negative enteric flora.
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Affiliation(s)
- Rafael San-Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Alba Sanz-Prieto
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Javier Contreras-Mora
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Iván Fojo-Suárez
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - José María Caso-Laviana
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Marina Fayos
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Patricia Brañas
- Department of Microbiology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Patricia Barbero Casado
- Unit of Perinatal Medicine, Obstetrics and Gynaecology Department, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Antonio García-Burguillo
- Unit of Perinatal Medicine, Obstetrics and Gynaecology Department, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain. Complutense University of Madrid, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Ziogou A, Ziogos E, Giannakodimos I, Giannakodimos A, Sifakis S, Ioannou P, Tsiodras S. Bacterial Vaginosis and Post-Operative Pelvic Infections. Healthcare (Basel) 2023; 11:healthcare11091218. [PMID: 37174760 PMCID: PMC10178576 DOI: 10.3390/healthcare11091218] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/18/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Bacterial vaginosis (BV) represents a condition in which the normal protective Lactobacilli, especially those that produce H2O2, are replaced by high quantities of facultative anaerobes, leading to gynecologic and obstetric post-operative complications. BV is an important cause of obstetric and gynecological adverse sequelae and it could lead to an increased risk of contracting sexually transmitted infections such as gonorrhea, genital herpes, Chlamydia, Trichomonas, and human immunodeficiency virus. Herein, we reviewed bacterial vaginosis and its association with post-operative pelvic infections. In Obstetrics, BV has been associated with increased risk of preterm delivery, first-trimester miscarriage in women undergoing in vitro fertilization, preterm premature rupture of membranes, chorioamnionitis, amniotic fluid infections, postpartum and postabortal endomyometritis as well as postabortal pelvic inflammatory disease (PID). In gynecology, BV increases the risk of post-hysterectomy infections such as vaginal cuff cellulitis, pelvic cellulitis, pelvic abscess, and PID. BV is often asymptomatic, can resolve spontaneously, and often relapses with or without treatment. The American College of Obstetricians and Gynecologists recommends testing for BV in women having an increased risk for preterm delivery. Women with symptoms should be evaluated and treated. Women with BV undergoing gynecological surgeries must be treated to reduce the frequency of post-operative pelvic infections. Metronidazole and clindamycin are the mainstays of therapy. Currently, there is no consensus on pre-surgery screening for BV; decisions are made on a case-by-case basis.
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Affiliation(s)
- Afroditi Ziogou
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Eleftherios Ziogos
- Department of Gynecology and Obstetrics, University Hospital of Heraklion, 71110 Heraklion, Greece
| | - Ilias Giannakodimos
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Alexios Giannakodimos
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Petros Ioannou
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Sotirios Tsiodras
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Fourth Department of Internal Medicine, Attikon General Hospital, 12462 Athens, Greece
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Yuan H, Zhang C, Maung ENT, Fan S, Shi Z, Liao F, Wang S, Jin Y, Chen L, Wang L. Epidemiological characteristics and risk factors of obstetric infection after the Universal Two-Child Policy in North China: a 5-year retrospective study based on 268,311 cases. BMC Infect Dis 2022; 22:878. [PMID: 36418982 PMCID: PMC9682668 DOI: 10.1186/s12879-022-07714-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/30/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Obstetrical infection is one of the causes of maternal death and a difficult problem for many clinicians. Changes in the demographic and obstetric background of pregnant women following the Universal Two-Child Policy may have an impact on some fertility phenomena. And with the increase in the number of deliveries, the limited medical resources become more scarce. How will China's health system quickly adapt to the growing needs and expectations for maternal health and ensure the provision of qualified and accessible medical services? In addition, what social support measures should be provided to reduce preventable obstetric complications? Given the relatively low per capita share of medical resources in China, how should China deal with the impact of the Universal Two-Child Policy? Therefore, more studies based on the change of fertility policy are needed. We try to analyze the epidemiological characteristics and risk factors of obstetric infection before and after the Universal Two-Child Policy, with a view to providing reference for the prevention and control of obstetric infection in regions after the change of fertility policy, and also hope to make corresponding contributions to the solution of the above problems through relevant studies. METHODS The subjects of the survey were 268,311 pregnant women from Hebei Province Maternal Near Miss Surveillance System (HBMNMSS) of Hebei Women and Children's Health Center from January 1, 2013 to December 31, 2017. We analyzed the region, time and population distribution characteristics of obstetric infection, compared the epidemiological factors of obstetric infection before and after the Universal Two-Child Policy, and analyzed the relevant risk factors of obstetric infection. RESULTS The incidence of obstetric infection increased nearly twice after the Universal Two-Child Policy. The incidence of obstetric infection was highest in Chengde (1.9%), a city with a northward geographical distribution, Baoding (1.6%), Cangzhou (1.5%) followed; The higher the hospital grade, the higher the incidence; The incidence of obstetric infections in hospitals at all levels has increased; The age of onset before the Universal Two-Child Policy was (27.82 ± 5.047) years old, and the age after the Universal Two-Child Policy was (28.97 ± 4.880) years old; The incidence of obstetric infections is higher in winter. The rate of abortion-related infection (increased from 0.61 to 1.65%) and the rate of pregnant women with high school education (increased from 0.35 to 0.74%) increased significantly. The results of multivariate Logistic regression analysis after the Universal Two-Child Policy showed that anemia (OR = 1.249, 95%CI: 1.071-1.458), chronic hypertension (OR = 1.934, 95%CI: 1.375-2.722), mild preeclampsia (OR = 2.103, 95%CI: 1.323-3.344) and severe preeclampsia (OR = 2.228, 95%CI: 1.703-2.916) were independent risk factors for obstetric infection. Gestational age ≥ 37 weeks was a protective factor. CONCLUSION After the Universal Two-Child Policy, the prevention and control of obstetric infections should be strengthened, especially for abortion-related infections and elderly maternal with obstetric complications and complication in high-grade hospitals in winter. Educational background is also one of the factors that should be considered in the prevention of obstetric sensation. Prolonging gestational age is helpful to reduce the incidence of obstetric infection.
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Affiliation(s)
- Huiqing Yuan
- grid.440208.a0000 0004 1757 9805Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, 050051 China ,grid.256883.20000 0004 1760 8442Graduate School of Hebei Medical University, Shijiazhuang, 050071 China
| | - Cui Zhang
- grid.440208.a0000 0004 1757 9805Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, 050051 China
| | - Ei Ni Tar Maung
- grid.452859.70000 0004 6006 3273Department of Obstetrics and Gynecology, The Fifth Affiliated Hospital of Sun Yat-Sen University, No. 52 Meihua East Road, Zhuhai, 519000 Guangdong China
| | - Songli Fan
- Hebei Women and Children’s Health Center, Shijiazhuang, 050000 China
| | - Zijia Shi
- grid.440208.a0000 0004 1757 9805Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, 050051 China ,grid.256883.20000 0004 1760 8442Graduate School of Hebei Medical University, Shijiazhuang, 050071 China
| | - Fang Liao
- grid.440208.a0000 0004 1757 9805Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, 050051 China ,Graduate School of North China University of Technology, Tangshan, 063000 China
| | - Shuo Wang
- grid.440208.a0000 0004 1757 9805Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, 050051 China ,Graduate School of North China University of Technology, Tangshan, 063000 China
| | - Ying Jin
- grid.440208.a0000 0004 1757 9805Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, 050051 China
| | - Le Chen
- grid.452859.70000 0004 6006 3273Department of Obstetrics and Gynecology, The Fifth Affiliated Hospital of Sun Yat-Sen University, No. 52 Meihua East Road, Zhuhai, 519000 Guangdong China
| | - Li Wang
- grid.452859.70000 0004 6006 3273Department of Obstetrics and Gynecology, The Fifth Affiliated Hospital of Sun Yat-Sen University, No. 52 Meihua East Road, Zhuhai, 519000 Guangdong China
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Yousuf F, Malik A, Saba A, Sheikh S. Risk factors and Compliance of surviving sepsis campaign: A retrospective cohort study at tertiary care hospital. Pak J Med Sci 2022; 38:90-94. [PMID: 35035406 PMCID: PMC8713188 DOI: 10.12669/pjms.38.1.3992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/16/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Sepsis is one of the leading causes of direct maternal mortality in Pakistan. It is recommended that the first three hours after the presentation are crucial. During this time implementation of surviving sepsis campaign resuscitation bundles reduces maternal mortality. Our objective was to assess the factors contributing to puerperal sepsis and the compliance of "surviving sepsis campaign resuscitation bundles in puerperal sepsis" for the management of puerperal sepsis. METHODS This was a retrospective record review for five years from January 2011-December 2015. All women who fulfilled the inclusion criteria of puerperal sepsis were included and data from their files were collected and entered in SPSS version 19.0. Mean and standard deviations were calculated for continuous variables while for categorical variable proportion and percentages were used. RESULTS This retrospective record review in five years showed the 396 patients had P-sepsis, among them 44 patients had severe sepsis with organ dysfunction. The culture was positive in 26(59%) with trend of E-coli in 9(20%) Among them 12(27%) had serum lactate more than ≥4mmol/L. Central venous pressure monitoring with fluid resuscitation was done as per protocol of survival bundle given to all 12(100%), Vasopressin was needed in half of these patients 6(50%). Amid 44 patients of severe sepsis 29(66%) were admitted to special care, while 15(34%) required intensive care admissions. Our 7(16%) patients failed to survive. All of them had multi-organ failure. CONCLUSION There was moderate adherence of modified surviving sepsis campaign resuscitation bundles. Further improvement in compliance is warranted.
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Affiliation(s)
- Farheen Yousuf
- Dr. Farheen Yousuf, FRCOG, MCPS(HPE), FCPS. Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan
| | - Ayesha Malik
- Dr. Ayesha Malik, MRCOG, FCPS. Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan
| | - Ayesha Saba
- Dr. Ayesha Saba, FCPS. Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan
| | - Sana Sheikh
- Dr. Sana Sheikh, Masters in Epidemiology and Biostatics Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan
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Anim T, Na’Allah R, Griebel C. Postpartum Care. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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LeFevre AE, Mir F, Mitra DK, Ariff S, Mohan D, Ahmed I, Sultana S, Winch PJ, Shakoor S, Connor NE, Islam MS, El-Arifeen S, Quaiyum MA, Baqui AH, Gravett MG, Santosham M, Bhutta ZA, Zaidi A, Saha SK, Ahmed S, Soofi S, Bartlett LA. Validation of community health worker identification of maternal puerperal sepsis using a clinical diagnostic algorithm in Bangladesh and Pakistan. J Glob Health 2021; 11:04039. [PMID: 34912547 PMCID: PMC8645220 DOI: 10.7189/jogh.11.04039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Puerperal sepsis (PP sepsis) is a leading cause of maternal mortality globally. The majority of maternal sepsis cases and deaths occur at home and remain undiagnosed and under-reported. In this paper, we present findings from a nested case-control study in Bangladesh and Pakistan which sought to assess the validity of community health worker (CHW) identification of PP sepsis using a clinical diagnostic algorithm with physician assessment and classification used as the gold standard. Methods Up to 300 postpartum women were enrolled in each of the 3 sites 1) Sylhet, Bangladesh (n = 278), 2) Karachi, Pakistan (n = 278) and 3) Matiari, Pakistan (n = 300). Index cases were women with suspected PP Sepsis as diagnosed by CHWs clinical assessment of one or more of the following signs and symptoms: temperature (recorded fever ≥38.1°C, reported history of fever, lower abdominal or pelvic pain, and abnormal or foul-smelling discharge. Each case was matched with 3 control women who were diagnosed by CHWs to have no infection. Cases and controls were assessed by trained physicians using the same algorithm implemented by the CHWs. Using physician assessment as the gold standard, Kappa statistics for reliability and diagnostic validity (sensitivity and specificity) are presented with 95% CI. Sensitivity and specificity were adjusted for verification bias. Results The adjusted sensitivity and specificity of CHW identification of PP sepsis across all sites was 82% (Karachi: 78%, Matiari: 78%, Sylhet: 95%) and 90% (Karachi: 95%, Matiari: 85%, Sylhet: 90%) respectively. CHW-Physician agreement was highest for moderate and high fever (range across sites: K = 0.84-0.97) and lowest for lower abdominal pain (K = 0.30-0.34). The clinical signs and symptoms for other conditions were reported infrequently, however, the CHW-physician agreement was high for all symptoms except severe headache/ blurred vision (K = 0.13-0.38) and reported "lower abdominal pain without fever" (K = 0.39-0.57). Conclusion In all sites, CHWs with limited training were able to identify signs and symptoms and to classify cases of PP sepsis with high validity. Integrating postpartum infection screening into existing community-based platforms and post-natal visits is a promising strategy to monitor women for PP sepsis - improving delivery of cohesive maternal and child health care in low resource settings.
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Affiliation(s)
- Amnesty E LeFevre
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Fatima Mir
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Dipak K Mitra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Public Health, North South University, Dhaka, Bangladesh
| | - Shabina Ariff
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Imran Ahmed
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Shazia Sultana
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sadia Shakoor
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Nicholas E Connor
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mohammad Shahidul Islam
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Shams El-Arifeen
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - M A Quaiyum
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michael G Gravett
- University of Washington, Departments of Obstetrics & Gynecology and of Global Health, Seattle, Washington, USA
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Anita Zaidi
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Samir K Saha
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sajid Soofi
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Linda A Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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11
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Ariff S, Mir F, Aftab W, Raza F, Zaidi S, Memon S, LeFevre A, Bartlett LA, Winch P, Soofi SB, Bhutta ZA. Impact of local terminology on the design of a community-based diagnostic and management algorithm for postpartum sepsis: findings of formative research. Int Health 2021; 14:189-194. [PMID: 34043788 PMCID: PMC8890804 DOI: 10.1093/inthealth/ihab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/30/2021] [Accepted: 05/13/2021] [Indexed: 11/24/2022] Open
Abstract
Background Postpartum sepsis is one of the leading causes of maternal mortality and morbidity in developing countries. This formative research elicits local terms used for postpartum illnesses and symptoms of postpartum sepsis with the aim of improving postpartum diagnosis and management in Pakistan. Methods We conducted 34 in-depth interviews with recently delivered women (RDW), traditional birth attendants (TBAs), healthcare providers and family members of RDW from rural Sindh to explore local Sindhi terms used to describe postpartum sepsis and related symptoms. During interviews, all participants were asked to orally free list common symptoms of postpartum illnesses; those who were aware of the concept were asked to free list possible symptoms of postpartum sepsis. The responses were recorded by the interviewer. Free listing data were analyzed for frequency and salience. Results Most participants, including TBAs, were not familiar with the concept of postpartum sepsis as a distinct disease or of a local term denoting the concept. Almost all could identify and report symptoms related to postpartum sepsis in the local language. Only physicians were able to recognize the term postpartum sepsis and related symptoms. Multiple local terms were used for a particular symptom; still others were used to denote gradations of severity. ‘Bukhar’ (fever) was the most commonly named symptom although it was often considered a normal part of puerperium. Many postpartum illnesses were related to the highly non-specific local term ‘kamzori’ (weakness). Conclusions Better awareness about local terminology used in rural areas related to postpartum sepsis could improve communication, care-seeking patterns, diagnosis and management.
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Affiliation(s)
- Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fatima Mir
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Wafa Aftab
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Farrukh Raza
- Center of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Shujaat Zaidi
- Center of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Memon
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Amnesty LeFevre
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linda A Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peter Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sajid Bashir Soofi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Center of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Center of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
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12
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Donders G, Greenhouse P, Donders F, Engel U, Paavonen J, Mendling W. Genital Tract GAS Infection ISIDOG Guidelines. J Clin Med 2021; 10:jcm10092043. [PMID: 34068785 PMCID: PMC8126195 DOI: 10.3390/jcm10092043] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/18/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023] Open
Abstract
There has been an increasing worldwide incidence of invasive group A streptococcal (GAS) disease in pregnancy and in the puerperal period over the past 30 years. Postpartum Group A streptococci infection, and in particular streptococcal toxic shock syndrome (TSS) and necrotizing fasciitis, can be life threatening and difficult to treat. Despite antibiotics and supportive therapy, and in some cases advanced extensive surgery, mortality associated with invasive group A streptococcal postpartum endometritis, necrotizing fasciitis, and toxic shock syndrome remains high, up to 40% of postpartum septic deaths. It now accounts for more than 75,000 deaths worldwide every year. Postpartum women have a 20-fold increased incidence of GAS disease compared to non-pregnant women. Despite the high incidence, many invasive GAS infections are not diagnosed in a timely manner, resulting in potentially preventable maternal and neonatal deaths. In this paper the specific characteristics of GAS infection in the field of Ob/Gyn are brought to our attention, resulting in guidelines to improve our awareness, early recognition and timely treatment of the disease. New European prevalence data of vaginal GAS colonization are presented, alongside two original case histories. Additionally, aerobic vaginitis is proposed as a supplementary risk factor for invasive GAS diseases.
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Affiliation(s)
- Gilbert Donders
- Femicare, Clinical Research for Women, 3300 Tienen, Belgium;
- Department of Obstetrics and Gynecology, University Hospital Antwerp, 2000 Antwerp, Belgium
- Regional Hospital H Hart, 3300 Tienen, Belgium
- Correspondence: ; Tel.: +32-38-214413
| | | | | | - Ulrike Engel
- Department of Ob/Gyn Maternité, Centre Hospitalier, 1210 Luxembourg, Luxembourg;
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, 00260 Helsinki, Finland;
| | - Werner Mendling
- German Centre for Infections in Gynaecology and Obstetrics, St. Anna Hospital, 42109 Wuppertal, Germany;
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13
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Postpartum Care. Fam Med 2021. [DOI: 10.1007/978-1-4939-0779-3_15-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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García Prieto J, Alonso Sánchez J, Martínez Chamorro E, Ibáñez Sanz L, Borruel Nacenta S. Puerperal complications: Pathophysiological mechanisms and main imaging findings. RADIOLOGIA 2021. [DOI: 10.1016/j.rxeng.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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Gonzalo-Carballes M, Ríos-Vives MÁ, Fierro EC, Azogue XG, Herrero SG, Rodríguez AE, Rus MN, Planes-Conangla M, Escudero-Fernandez JM, Coscojuela P. A Pictorial Review of Postpartum Complications. Radiographics 2020; 40:2117-2141. [PMID: 33095681 DOI: 10.1148/rg.2020200031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Marta Gonzalo-Carballes
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Miguel Ángel Ríos-Vives
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Eva Castellà Fierro
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Xavier Gurí Azogue
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Susana Gispert Herrero
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Alberto Escudero Rodríguez
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - María Neus Rus
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Marina Planes-Conangla
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Jose Miguel Escudero-Fernandez
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Pilar Coscojuela
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
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16
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Solt I, Frank Wolf M, Michlin R, Farajun Y, Ophir E, Bornstein J. Intrauterine bacterial growth in elective and non-elective caesarean sections. J OBSTET GYNAECOL 2020; 41:733-738. [PMID: 33045855 DOI: 10.1080/01443615.2020.1789959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We assessed intrauterine bacterial growth for elective and non-elective caesarean sections (CSs). Aerobic uterine cultures were obtained from the uterine cavity immediately following placental removal from 1376 patients who underwent CS in one center during one year. About 13.8% (115/832) of elective CS were positive vs. 55.9% (304/544) of non-elective CS (p < .001). Of non-elective CSs, 28.6% (56/196) of those without ruptured membranes (ROM) were positive vs. 71.3% (248/348) with ROM (p < .001). Mean birth weight and 1-minute Apgar scores were significantly lower in women with positive cultures, elective and non-elective, than negative cultures. A higher percentage of women with positive uterine cultures presented with postpartum endometritis (p < .05). Intrauterine bacteria in elective CSs demonstrate that the uterine cavity is not sterile. Non-elective CS, particularly after membrane rupture, is a significant risk factor for positive uterine culture. Positive uterine culture is associated with lower birth weight, lower one-minute Apgar score and postpartum endometritis.Impact statementWhat is already known on this subject? Postpartum endometritis is a leading cause of postpartum febrile morbidity. Caesarean sections, in particular non-elective cesareans, are an important risk factor for the development of postpartum endometritis. Controversy exists concerning the sterility of the placenta and uterus. The diagnosis of endometritis is based mainly on clinical findings and does not necessitate bacterial isolation from the uterine cavity. Positive culture at caesarean section has been associated with positive postoperative culture and yet, currently, professional organisations do not recommend the routine sampling of intrauterine cultures during caesarean section.What do the results of this study add? Since positive uterine culture rate was higher in non-elective CSs and associated with lower birth weight and 1-minute Apgar score and postoperative endometritis, obtaining uterine culture in those cases might be of clinical value.What are the implications of these findings for clinical practice and/or further research? Obtaining routine intrauterine cultures during non-elective caesarean sections might be useful for detecting significant pathogens and tailoring antibiotic treatment in postpartum endometritis. Further studies are necessary in order to determine the impact of obtaining intrauterine cultures during caesarean sections, particularly non-elective cesareans.
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Affiliation(s)
- Ido Solt
- Division of Maternal-Fetal Medicine Service, Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Maya Frank Wolf
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Rosa Michlin
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
| | - Yaniv Farajun
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
| | - Ella Ophir
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Jacob Bornstein
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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17
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García Prieto J, Alonso Sánchez J, Martínez Chamorro E, Ibáñez Sanz L, Borruel Nacenta S. Puerperal complications: pathophysiological mechanisms and main imaging findings. RADIOLOGIA 2020; 63:22-31. [PMID: 33008619 DOI: 10.1016/j.rx.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/26/2020] [Accepted: 08/24/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Puerperium is the period during which the physiological changes that have taken place during pregnancy revert and the uterus involutes until it reaches its normal size. This is a period of intense systemic changes, and diagnosing complications in this period is a challenge for both gynecologists and radiologists. This paper reviews the complications that can occur during puerperium, classifying them according to the pathophysiological mechanisms involved: the prothrombotic state, hemodynamic and hormonal changes, rapid uterine growth, changes associated with endothelial damage (preeclampsia, eclampsia, and HELLP syndrome), and postoperative complications in patients undergoing cesarean sections. CONCLUSION Puerperal complications represent a diagnostic challenge. Understanding the pathophysiological mechanisms underlying these complications is fundamental for choosing the most appropriate imaging technique to ensure the correct diagnosis in each case.
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Affiliation(s)
| | | | | | - L Ibáñez Sanz
- Hospital Universitario 12 de Octubre, Madrid, España
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18
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Trell K, Jörgensen J, Rasmussen M, Senneby E. Management of an outbreak of postpartum Streptococcus pyogenes emm75 infections. J Hosp Infect 2020; 105:752-756. [PMID: 32497649 DOI: 10.1016/j.jhin.2020.05.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Streptococcus pyogenes is a well-known cause of postpartum infections and is causing significant morbidity and mortality. AIM To describe measures taken to control an outbreak of postpartum infections caused by S. pyogenes emm75 on a maternity ward. METHODS Patients presenting postpartum with signs and symptoms of infection were cultured for β-haemolytic streptococci with cervical swabs and blood cultures, and bacterial isolates were species-determined with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and emm-typed. Pharyngeal swabs were taken from healthcare workers (HCWs) at the ward. Bacterial isolates were subjected to whole-genome sequencing (WGS). The multi-locus sequence type and the number of single nucleotide polymorphisms (SNPs) compared to an index genome were determined. FINDINGS During a three-month period, six cases of postpartum infection with S. pyogenes emm75 were identified on the maternity ward. By comparing delivery dates with duty rotas, one HCW was identified as a possible source of infection in five cases. After repeated pharyngeal swabs from this individual, an S. pyogenes emm75 was isolated. The five isolates from patients epidemiologically linked to the HCW and the two isolates of the family members had an identical sequence type (ST49) and 0-2 SNPs difference compared to the HCW isolate, whereas the sixth patient had an unrelated isolate. Eradication antibiotic therapy with clindamycin and rifampicin was given to the carrier. All patients received intravenous antibiotic treatment and recovered. CONCLUSION A three-month outbreak was stopped when a carrier was identified and treated. Source identification and WGS proved vital for outbreak control.
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Affiliation(s)
- K Trell
- Division of Infection Medicine, Lund University, Lund, Sweden
| | - J Jörgensen
- Department of Translational Medicine, Infectious Disease Research Unit, Lund University, Malmö, Sweden
| | - M Rasmussen
- Division of Infection Medicine, Lund University, Lund, Sweden
| | - E Senneby
- Division of Infection Medicine, Lund University, Lund, Sweden.
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19
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Jain I, Sarkar P, Danger JL, Medicielo J, Roshika R, Calfee G, Ramalinga A, Burgess C, Sumby P. A Mobile Genetic Element Promotes the Association Between Serotype M28 Group A Streptococcus Isolates and Cases of Puerperal Sepsis. J Infect Dis 2020; 220:882-891. [PMID: 31107945 DOI: 10.1093/infdis/jiz195] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 04/18/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Bacterial infections following childbirth-so-called puerperal infections-cause morbidity in 5%-10% of all new mothers. At low frequency, the infection can spread to the blood, resulting in life-threatening sepsis known as puerperal sepsis. Pathogens causing puerperal sepsis include group A Streptococcus (GAS), and epidemiological analyses have identified isolates of a single serotype, M28, as being nonrandomly associated with cases of puerperal sepsis. The genomes of serotype M28 GAS isolates harbor a 36.3-kb mobile genetic element of apparent group B Streptococcus origin, termed region of difference 2 (RD2). METHODS The phenotypic (determined via tissue culture and a vaginal colonization model) and regulatory (determined via RNA sequencing analysis) contributions of RD2 were assessed by comparing parental, RD2 deletion mutant, and complemented mutant serotype M28 GAS strains. RESULTS RD2 affords serotype M28 isolates an enhanced ability to adhere to human vaginal epithelial cells and to colonize the female reproductive tract in a mouse model of infection. In addition, RD2 influences the abundance of messenger RNAs from >100 core chromosomal GAS genes. CONCLUSIONS The data are consistent with RD2 directly, via encoded virulence factors, and indirectly, via encoded regulatory proteins, modifying the virulence potential of GAS and contributing to the decades-old association of serotype M28 isolates with cases of puerperal sepsis.
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Affiliation(s)
- Ira Jain
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Poulomee Sarkar
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Jessica L Danger
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Josette Medicielo
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Roshika Roshika
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Gregory Calfee
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Anupama Ramalinga
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Cameron Burgess
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
| | - Paul Sumby
- Department of Microbiology and Immunology, University of Nevada-Reno School of Medicine
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20
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Admas A, Gelaw B, BelayTessema, Worku A, Melese A. Proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a referral Hospital in Bahir Dar, Northwest Ethiopia. Antimicrob Resist Infect Control 2020; 9:14. [PMID: 31956403 PMCID: PMC6958633 DOI: 10.1186/s13756-019-0676-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/29/2019] [Indexed: 01/10/2023] Open
Abstract
Background Puerperal sepsis is any bacterial infection of the genital tract that occurs after childbirth. It is among the leading causes of maternal morbidity and mortality especially in low-income countries including Ethiopia. The aim of this study was to determine the proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a Referral Hospital in Bahir Dar, Northwest Ethiopia. Methods A cross sectional study was conducted from January to May 2017 among 166 post-partum/aborted women admitted to Felege Hiwot Referral Hospital for medical services and suspected for puerperal sepsis.. Socio-demographic data and associated factors were collected using structured questionnaire. Bacteria were isolated and identified from blood samples on Trypton soya broth, blood, Chocolate and MacConkey agars following standard bacteriological procedures. The VITEK 2 identification and susceptibility testing system was used to determine the antimicrobial susceptibility profiles of bacterial isolates. Data were entered and analyzed using SPSS version 20. Factors associated with puerperal sepsis were considered statistically significant at P-value < 0.05. Results The overall proportion of bacterial isolates among post-partum/aborted women was 33.7% (56/166); of which 55.4% was caused by Gram-negative and 44.6% was by Gram-positive bacteria. The most frequently isolated bacteria were Escherichia coli (32.1%) from Gram-negatives and Staphylococcus aureus (33.9%) from Gram-positives. The proportion of other isolates was (7.2%) for Coagulase Negative Staphylococci (CoNS), (12.5%) for Klebsiella pneumoniae, (10.7%) for Acinetobacter baumanni and (3.6%) for Raoultella ornithinolytica. All isolates of Gram-positive and Gram-negative bacteria were resistant to tetracycline (100%). The gram negatives show resistance to Cefazolin (72.7%), Tetracycline (93.9%) and Ampicillin (100%). The overall prevalence of multidrug resistance (MDR) was 84%. Women having multiparous parity were more likely to develop puerperal sepsis than primiparous parity (AOR 4.045; 95% CI: 1.479-11.061; P < 0.05). Other socio-demographic and clinical factors had no significant association with puerperal sepsis. Conclusion About one third of post-partum/aborted women suspected for puerperal sepsis were infected with one or more bacterial isolates. Significant proportion of bacterial isolates showed mono and multi-drug resistance for the commonly prescribed antibiotics. Women with multiparous parity were more likely to develop puerperal sepsis than primiparous parity.
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Affiliation(s)
- Alemale Admas
- 1Department of Medical Laboratory Science, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Baye Gelaw
- 2Department of Medical Microbiology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - BelayTessema
- 2Department of Medical Microbiology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amsalu Worku
- 3Department of Gynecology and Obstetrics, School of Medicine, Bahir Dar University, Bahir Dar, Ethiopia
| | - Addisu Melese
- 1Department of Medical Laboratory Science, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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21
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Axelsson D, Brynhildsen J, Blomberg M. Vitamin D deficiency at the time of delivery - Prevalence and risk of postpartum infections. PLoS One 2019; 14:e0226673. [PMID: 31856242 PMCID: PMC6922419 DOI: 10.1371/journal.pone.0226673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 12/02/2019] [Indexed: 11/18/2022] Open
Abstract
Background Postpartum infections are a common cause of morbidity after childbirth. Vitamin D deficiency has been shown to increase the risk for several infections in a non-pregnant population. Vitamin D deficiency has been described as common in pregnant women. Objective To investigate whether vitamin D deficiency in pregnant women in labor was associated with an increased risk of overall postpartum infectious morbidity within eight weeks of delivery. A secondary aim was to estimate the prevalence of vitamin D deficiency among pregnant women in Linköping, Sweden at the time of delivery. Material and methods Serum vitamin D levels in labor were analyzed for 1397 women. Vitamin D deficiency was defined as serum levels <50 nmol/L. All ICD-10 codes given to the women eight weeks postpartum were reviewed and postpartum infections were defined as the presence of an ICD-10 code suggestive of infection. The prevalence of postpartum infections among women with sufficient vitamin D levels was compared with women with vitamin D deficiency. Adjusted Odds Ratios and 95% confidence intervals for postpartum infections were calculated using multivariate logistic regression analysis. Results Fifty eight per cent of the women had serum vitamin D levels <50 nmol/L. The proportion of women with vitamin D deficiency varied, as expected, with season. No association between vitamin D deficiency and postpartum infections was found. For vitamin D 25–50 nmol/L the adjusted Odds Ratio was 0.85 (95% confidence interval 0.56–1.29) and for vitamin D <25 nmol/L the adjusted Odds Ratio was 1.15 (95% confidence interval 0.66–2.03). Women who smoked or who had a cesarean section had an increased risk of postpartum infections. Conclusions Vitamin D deficiency was more common than previously reported in Swedish pregnant women. No association between vitamin D deficiency and postpartum infections was found. Other well-known risk factors for postpartum infection were identified.
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Affiliation(s)
- Daniel Axelsson
- Department of Obstetrics and Gynecology, Ryhov County Hospital, Jönköping, Sweden and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- * E-mail:
| | - Jan Brynhildsen
- Department of Obstetrics and Gynecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Abstract
There are various complications that can occur in the postpartum period, including pain, bleeding, and infection. These include complications related to cesarean section, postpartum hemorrhage and hematomas, bladder injury, torsion and uterine dehiscence, and rupture. It is important the radiologist is aware of these entities and the associated imaging features to help guide timely and appropriate management.
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Affiliation(s)
- Sherry S Wang
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East # 1A71, Salt Lake City, UT 84132, USA.
| | - Dorothy Shum
- Department of Radiology, University of California San Francisco, 505 Parnassus Avenue, 3rd Floor Box #0628, San Francisco, CA 94143, USA
| | - Anne Kennedy
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East # 1A71, Salt Lake City, UT 84132, USA; Maternal Fetal Diagnostic Center, University of Utah, 30 North 1900 East # 1A71, Salt Lake City, UT 84132, USA
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23
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Use of Ceftolozane/Tazobactam in a Case of Septic Shock by Puerperal Sepsis. Case Rep Obstet Gynecol 2019; 2019:8463693. [PMID: 31275681 PMCID: PMC6560331 DOI: 10.1155/2019/8463693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/05/2019] [Accepted: 04/08/2019] [Indexed: 12/27/2022] Open
Abstract
Multiresistant bacteria infections cause widespread morbidity and mortality and lead to an increase in expenses for hospital stays and complications. We describe the case of a 27-year-old patient with puerperal sepsis after cesarean section due to Escherichia coli complicated by multiresistant Klebsiella ESBL-producing superinfection with septic shock and multiple organ dysfunction syndrome, successfully treated with ceftolozane/tazobactam.
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24
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Fishel Bartal M, Sibai BM, Ben-Mayor Bashi T, Dangot A, Schushan Eisen I, Dulitzki M, Inbar Y, Mazaki-Tovi S, Hendler I. Abdominal computed tomography (CT) scan in the evaluation of refractory puerperal fever: impact on management . J Matern Fetal Neonatal Med 2018; 33:577-582. [PMID: 29973085 DOI: 10.1080/14767058.2018.1497603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Computed tomography (CT) imaging should be employed judiciously, given its cost, use of intravenous contrast, and ionizing radiation. The aim of this study was to determine the clinical benefit of a CT scan in the evaluation of refractory puerperal fever and to identify the appropriate candidates for its use.Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2007 to April 2017. Indications for CT scan were refractory postpartum fever of ≥3 days and/or ultrasound findings suggesting complex abdominal fluid collection. Primary outcome was defined as a change in the mode of treatment due to the CT findings. In addition, a multivariate analysis of risk factors for puerperal fever was performed to identify patients who would benefit from the CT scan evaluation.Results: There were 520 women that underwent an abdominal and pelvic CT scan during the study period, 238 (45.7%) met inclusion criteria, 94 (39.5%) had a normal CT scan, and 144 (60.5%) had abnormal findings including 32 (13.4%) cases with pelvic thrombophlebitis and 112 (47%) cases with pelvic fluid collections. Results of the CT changed clinical management in 93 (39.0%) patients, including: switching antibiotics in 24 (10%) patients, adding low molecular weight heparin for 28 (11.8%) patients, and surgical intervention (laparotomy or drainage insertion) in 41 (17.2%) patients. In the regression model, we didn't find any significant risk factors associated with treatment change following the CT scan.Conclusions: Abdominal and pelvic CT scan in women with refractory puerperal fever has a high clinical yield and lead to a change in management in a substantial number of patients.
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Affiliation(s)
- Michal Fishel Bartal
- Department of Obstetrics, Gynecology and Reproductive sciences, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA
| | - Tali Ben-Mayor Bashi
- Department of Obstetrics, Gynecology and Reproductive sciences, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ayelet Dangot
- Department of Obstetrics, Gynecology and Reproductive sciences, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Irit Schushan Eisen
- Department of Neonatology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Mordechai Dulitzki
- Department of Obstetrics, Gynecology and Reproductive sciences, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yael Inbar
- Diagnostic Radiology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics, Gynecology and Reproductive sciences, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Israel Hendler
- Department of Obstetrics, Gynecology and Reproductive sciences, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Ngonzi J, Bebell LM, Fajardo Y, Boatin AA, Siedner MJ, Bassett IV, Jacquemyn Y, Van Geertruyden JP, Kabakyenga J, Wylie BJ, Bangsberg DR, Riley LE. Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda. BMC Pregnancy Childbirth 2018; 18:270. [PMID: 29954356 PMCID: PMC6022296 DOI: 10.1186/s12884-018-1891-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 06/11/2018] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.
| | - Lisa M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Yarine Fajardo
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Adeline A Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Mark J Siedner
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Yves Jacquemyn
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | | | - Jerome Kabakyenga
- Institute of Maternal Newborn and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Blair J Wylie
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Laura E Riley
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
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26
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Axelsson D, Brynhildsen J, Blomberg M. Postpartum infection in relation to maternal characteristics, obstetric interventions and complications. J Perinat Med 2018; 46:271-278. [PMID: 28672754 DOI: 10.1515/jpm-2016-0389] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/11/2017] [Indexed: 11/15/2022]
Abstract
The purpose was to evaluate the association between maternal characteristics, obstetrical interventions/complications and postpartum wound infections (WI), urinary tract infection (UTI) and endometritis. Furthermore, this study aimed to determine the time from delivery to onset of infections after discharge from the hospital. Three large Swedish Medical Health Registers were scrutinized for the period 2005-2012. A total of 582,576 women had 795,072 deliveries. Women with diagnosis codes for WIs, UTIs or endometritis, from delivery to 8 weeks postpartum, were compared to non-infected women. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Increasing age and body mass index (BMI) were both associated with increasing prevalence of postpartum infections. WIs were most strongly associated with cesarean section (CS) (OR 17.2; 95%CI 16.1-18.3), 3rd and 4th degree tears (OR 10.7%; 95%CI 9.80-11.9) and episiotomy (OR 10.2; 95%CI 8.94-11.5). Endometritis was associated with anemia (OR 3.16; 95%CI 3.01-3.31) and manual placental removal (OR 2.72; 95%CI 2.51-2.95). UTI was associated with emergency CS (OR 3.46; 95%CI 3.07-3.89) and instrumental delivery (OR 3.70; 95%CI 3.29-4.16). For women discharged from the delivery hospital the peak occurrence of UTI was 6 days postpartum, while for WIs and endometritis it was 7 days postpartum.
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Affiliation(s)
- Daniel Axelsson
- Department of Obstetrics and Gynecology, Ryhov County Hospital, Jönköping, Sweden.,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Jan Brynhildsen
- Department of Obstetrics and Gynecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Lepine S, Lawton B, Geller S, Abels P, MacDonald EJ. Severe maternal morbidity due to sepsis: The burden and preventability of disease in New Zealand. Aust N Z J Obstet Gynaecol 2018; 58:648-653. [PMID: 29460453 DOI: 10.1111/ajo.12787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/17/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Sepsis is a life-threatening systemic condition that appears to be increasing in the obstetric population. Clinical detection can be difficult and may result in increased morbidity via delays in the continuum of patient care. AIMS To describe the burden of severe maternal morbidity (SMM) caused by sepsis in New Zealand and investigate the potential preventability. METHODS A multidisciplinary expert review panel was established to review cases of obstetric sepsis admitted to intensive care or high-dependency units over an 18 month span in New Zealand. Cases were then analysed for the characteristics of infection and their preventability. RESULTS Fifty cases met the inclusion criteria, most commonly due to uterine, respiratory or kidney infection. Fifty per cent (25) of these cases were deemed potentially preventable, predominantly due to delays in diagnosis and treatment. CONCLUSIONS A high index of suspicion, development of early recognition systems and multi-disciplinary training are recommended to decrease preventable cases of maternal sepsis.
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Affiliation(s)
- Sam Lepine
- RANZCOG, Wellington Regional Hospital, Wellington, New Zealand
| | - Beverley Lawton
- Centre for Women's Health Research, Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | - Stacie Geller
- Center for Research on Women and Gender, University of Illinois, Chicago, USA
| | - Peter Abels
- Wellington Regional Hospital, University of Otago, Wellington, New Zealand
| | - Evelyn J MacDonald
- Centre for Women's Health Research, Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
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28
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Bebell LM, Ngonzi J, Siedner MJ, Muyindike WR, Bwana BM, Riley LE, Boum Y, Bangsberg DR, Bassett IV. HIV Infection and risk of postpartum infection, complications and mortality in rural Uganda. AIDS Care 2018; 30:943-953. [PMID: 29451005 DOI: 10.1080/09540121.2018.1434119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
HIV infection may increase risk of postpartum infection and infection-related mortality. We hypothesized that postpartum infection incidence and attributable mortality in Mbarara, Uganda would be higher in HIV-infected than HIV-uninfected women. We performed a prospective cohort study of 4231 women presenting to a regional referral hospital in 2015 for delivery or postpartum care. All febrile or hypothermic women, and a subset of randomly selected normothermic women were followed during hospitalization and with 6-week postpartum phone interviews. The primary outcome was in-hospital postpartum infection. Secondary outcomes included in-hospital complications (mortality, re-operation, intensive care unit transfer, need for imaging or blood transfusion) and 6-week mortality. We performed multivariable regression analyses to estimate adjusted differences in each outcome by HIV serostatus. Mean age was 25.2 years and 481 participants (11%) were HIV-infected. Median CD4+ count was 487 (IQR 325, 696) cells/mm3, and 90% of HIV-infected women (193/215 selected for in-depth survey) were on antiretroviral therapy. Overall, 5% (205/4231) of women developed fever or hypothermia. Cumulative in-hospital postpartum infection incidence was 2.0% and did not differ by HIV status (aOR 1.4, 95% CI 0.6-3.3, P = 0.49). However, more HIV-infected women developed postpartum complications (4.4% vs. 1.2%, P = 0.001). In-hospital mortality was rare (2/1768, 0.1%), and remained so at 6 weeks (4/1526, 0.3%), without differences by HIV serostatus (P = 1.0 and 0.31, respectively). For women in rural Uganda with high rates of antiretroviral therapy coverage, HIV infection did not predict postpartum infection or mortality, but was associated with increased risk of postpartum complications.
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Affiliation(s)
- Lisa M Bebell
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA
| | - Joseph Ngonzi
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Mark J Siedner
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA.,c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Winnie R Muyindike
- d Department of Medicine , Mbarara Regional Referral Hospital , Mbarara , Uganda
| | - Bosco M Bwana
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Laura E Riley
- e Division of Obstetrics and Gynecology , Massachusetts General Hospital , Boston , MA , USA
| | - Yap Boum
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda.,f Epicentre Mbarara Research Centre , Mbarara , Uganda
| | - David R Bangsberg
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA
| | - Ingrid V Bassett
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA
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29
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Wiafe YA, Whitehead B, Venables H, Odoi AT. Sonographic parameters for diagnosing fetal head engagement during labour. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2018; 26:16-21. [PMID: 29456578 DOI: 10.1177/1742271x18755080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/10/2017] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to investigate the diagnostic performance of the head-perineum distance, angle of progression, and the head-symphysis distance as intrapartum ultrasound parameters in the determination of an engaged fetal head. Two hundred and one women in labour underwent both ultrasound and digital vaginal examination in the estimation of fetal head station. The transperineal ultrasound measured head-perineum distance, angle of progression, and head-symphysis distance for values correlating with digital vaginal examination head station. Using station 0 as the minimum level of head engagement, correlating cut-off values for head-perineum distance, angle of progression, and head-symphysis distance were obtained. Receiver operating characteristics were used in determining the diagnostic performance of these cut-off values for the detection of fetal head engagement. With head-perineum distance of 3.6 cm the sensitivity and specificity of sonographic determination of engaged fetal head were 78.7 and 72.3%, respectively. A head-symphysis distance of 2.8 cm also had sensitivity and specificity of 74.5 and 70.8%, respectively, in determining engagement, whilst an angle of progression of 101° was consistent with engagement by digital vaginal examination with 68.1% sensitivity and 68.2% specificity. Ultrasound shows high diagnostic performance in determining engaged fetal head at a head-perineum distance of ≤3.6 cm, head-symphysis distance of ≤2.8 cm, and angle of progression of ≥ 101°.
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Affiliation(s)
- Yaw A Wiafe
- Department of Nursing, Radiography and Healthcare, University of Derby, Derby, UK.,Department of Sonography, Faculty of Allied Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Bill Whitehead
- Department of Nursing, Radiography and Healthcare, University of Derby, Derby, UK
| | - Heather Venables
- Department of Nursing, Radiography and Healthcare, University of Derby, Derby, UK
| | - Alexander T Odoi
- Department of Obstetrics and Gynaecology, School of Medical Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital, Kumasi, Ghana
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30
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Hall J, Adams NH, Bartlett L, Seale AC, Lamagni T, Bianchi-Jassir F, Lawn JE, Baker CJ, Cutland C, Heath PT, Ip M, Le Doare K, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-ter Meulen A, Vekemans J, Gravett MG. Maternal Disease With Group B Streptococcus and Serotype Distribution Worldwide: Systematic Review and Meta-analyses. Clin Infect Dis 2017; 65:S112-S124. [PMID: 29117328 PMCID: PMC5850000 DOI: 10.1093/cid/cix660] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Infections such as group B Streptococcus (GBS) are an important cause of maternal sepsis, yet limited data on epidemiology exist. This article, the third of 11, estimates the incidence of maternal GBS disease worldwide. METHODS We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data on invasive GBS disease in women pregnant or within 42 days postpartum. We undertook meta-analyses to derive pooled estimates of the incidence of maternal GBS disease. We examined maternal and perinatal outcomes and GBS serotypes. RESULTS Fifteen studies and 1 unpublished dataset were identified, all from United Nations-defined developed regions. From a single study with pregnancies as the denominator, the incidence of maternal GBS disease was 0.38 (95% confidence interval [CI], .28-.48) per 1000 pregnancies. From 3 studies reporting cases by the number of maternities (pregnancies resulting in live/still birth), the incidence was 0.23 (95% CI, .09-.37). Five studies reported serotypes, with Ia being the most common (31%). Most maternal GBS disease was detected at or after delivery. CONCLUSIONS Incidence data on maternal GBS disease in developing regions are lacking. In developed regions the incidence is low, as are the sequelae for the mother, but the risk to the fetus and newborn is substantial. The timing of GBS disease suggests that a maternal vaccine given in the late second or early third trimester of pregnancy would prevent most maternal cases.
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Affiliation(s)
- Jennifer Hall
- Department of Reproductive Health Research, University College London Institute for Women’s Health, United Kingdom
| | - Nadine Hack Adams
- School of Social and Community Medicine, University of Bristol, United Kingdom
| | - Linda Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Anna C Seale
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom
- College of Health and Medical Sciences, Haramaya University, Dire Dawa, Ethiopia
| | - Theresa Lamagni
- Healthcare-Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, London,United Kingdom
| | - Fiorella Bianchi-Jassir
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Carol J Baker
- Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - Clare Cutland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, and Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand,Johannesburg, South Africa
| | - Paul T Heath
- Vaccine Institute, Institute for Infection and Immunity, St George’s Hospital, University of London and St George’s University Hospitals NHS Foundation Trust, United Kingdom
| | - Margaret Ip
- Department of Microbiology, Faculty of Medicine, Chinese University of Hong Kong
| | - Kirsty Le Doare
- Vaccine Institute, Institute for Infection and Immunity, St George’s Hospital, University of London and St George’s University Hospitals NHS Foundation Trust, United Kingdom
- Centre for International Child Health, Imperial College London, United Kingdom
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, and Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand,Johannesburg, South Africa
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Craig E Rubens
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle, Washington
- Department of Global Health, University of Washington, Seattle
| | | | - Stephanie Schrag
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
| | | | | | - Michael G Gravett
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle, Washington
- Department of Obstetrics and Gynecology, University of Washington, Seattle
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31
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Group A Streptococcus Septic Shock after Surgical Abortion: A Case Report and Review of the Literature. Case Rep Obstet Gynecol 2017; 2017:6316739. [PMID: 29085686 PMCID: PMC5612605 DOI: 10.1155/2017/6316739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 11/23/2022] Open
Abstract
Group A Streptococcus (GAS) causing puerperal sepsis is a leading cause of maternal mortality worldwide. Although rare, GAS infection is a relatively significant public health concern because of its propensity to evolve rapidly into septic shock, streptococcal toxic shock syndrome, and death. We report the case of a 27-year-old patient who presented with GAS septic shock after undergoing a surgical termination of pregnancy and was treated successfully and recovered without sequelae. GAS septic shock should always be included in the differential diagnosis of any patient who develops sepsis after a surgical abortion. Patients with GAS septic shock have a rapid clinical decline and need aggressive fluid management, early initiation of broad-spectrum antibiotics, and rapid surgical intervention.
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Irani M, Kordi M, Esmaily H. Relationship between length and width of the purple line and foetal head descent in active phase of labour. J OBSTET GYNAECOL 2017. [PMID: 28641025 DOI: 10.1080/01443615.2017.1322044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Purple line is one of the non-invasive methods to assess the progress of labour. This longitudinal observational study was performed on 350 women during the active phase of labour. We assessed the relationship between length and width of the purple line and foetal head descent. Women were examined in the lateral position and researcher recorded the presence or absence of the line before each vaginal examination. Where present length and width of the line was measured using a disposable tape measure. The purple line appeared in 75.3% of 350 women during the active phase of labour. There was a positive correlation between length of the purple line and station of the foetal head (r = +0.29, p = .001). There was also a medium positive correlation between width of the purple line and the station of the foetal head (r = +0.71, p < -.001). There is a positive correlation between purple line and station of the foetal head. Where the purple line is present, measurement of it may reduce the number of vaginal examinations, especially when the single aim is to measure station of the foetal head. Further research is needed to confirm the current finding in other races. IMPACT STATEMENT Current knowledge on the subject: In the literature, purple line is one of the non-invasive methods to assess the progress of cervical dilatation and foetal head descent in labour. Failure of the foetal head is the second most common indication for performing surgical deliveries. Progression of labour has been evaluated by vaginal examination for the assessment of cervical dilatation and foetal head station. Vaginal examinations can be unpleasant, intrusive, embarrassing and so painful for women. Researchers suggested to explore whether the line is also present in women across other ethnic and racial groups and they also suggested further researches to examine the width of purple line. The contribution made by the results of this study: The results of this study add to the growing body of research on progression of labour that the purple line appeared in most of Iranian women during the active phase of labour. There was a positive correlation between length and width of the purple line and station of the foetal head. The implications are of these findings for clinical practice and further research: The results of this study can be used reduce the number of vaginal examinations, especially when the single aim is to measure station of the foetal head. Further research is needed to confirm the current finding in other races.
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Affiliation(s)
- Morvarid Irani
- a Department of Midwifery, Student Research Committee, Nursing and Midwifery School , Mashhad University of Medical Science , Mashhad , Iran
| | - Masoumeh Kordi
- b Department of Midwifery, School of Nursing and Midwifery , Mashhad University of Medical Sciences , Mashhad , IR Iran
| | - Habibollah Esmaily
- c Department of Biostatistics and Epidemiology, School of Health , Mashhad University of Medical Sciences , Mashhad , IR Iran
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Bebell LM, Ngonzi J, Bazira J, Fajardo Y, Boatin AA, Siedner MJ, Bassett IV, Nyehangane D, Nanjebe D, Jacquemyn Y, van Geertruyden JP, Mwanga-Amumpaire J, Bangsberg DR, Riley LE, Boum Y. Antimicrobial-resistant infections among postpartum women at a Ugandan referral hospital. PLoS One 2017; 12:e0175456. [PMID: 28406949 PMCID: PMC5391058 DOI: 10.1371/journal.pone.0175456] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/27/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. METHODS We performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care, measured vital signs after delivery, performed structured physical exam, symptom questionnaire, and microbiologic evaluation of febrile and hypothermic women. Malaria rapid diagnostic testing, blood and urine cultures were performed aseptically and processed at Epicentre Mbarara Research Centre. Antimicrobial susceptibility and breakpoints were determined using disk diffusion per EUCAST standards. Hospital diagnoses, treatments and outcomes were abstracted from patient charts. RESULTS Mean age was 25 years, 12% were HIV-infected, and 50% had cesarean deliveries. Approximately 5% (205/4176) with ≥1 temperature measurement recorded developed postpartum fever or hypothermia; blood and urine samples were collected from 174 (85%), and 17 others were evaluated clinically. Eighty-four (48%) had at least one confirmed source of infection: 39% (76/193) clinical postpartum endometritis, 14% (25/174) urinary tract infection (UTI), 3% (5/174) bloodstream infection. Another 3% (5/174) had malaria. Overall, 30/174 (17%) had positive blood or urine cultures, and Acinetobacter species were the most common bacteria isolated. Of 25 Gram-negatives isolated, 20 (80%) were multidrug-resistant and cefepime non-susceptible. CONCLUSIONS For women in rural Uganda with postpartum fever, we found a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. Increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities.
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Affiliation(s)
- Lisa M. Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, MA, United States of America
| | - Joseph Ngonzi
- Mbarara University of Science and Technology, Mbarara, Uganda
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Joel Bazira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Yarine Fajardo
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adeline A. Boatin
- Massachusetts General Hospital Center for Global Health, Boston, MA, United States of America
- Division of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Mark J. Siedner
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, MA, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ingrid V. Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
| | | | | | - Yves Jacquemyn
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | | | - Juliet Mwanga-Amumpaire
- Mbarara University of Science and Technology, Mbarara, Uganda
- Epicentre Mbarara Research Centre, Mbarara, Uganda
| | - David R. Bangsberg
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, MA, United States of America
| | - Laura E. Riley
- Division of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Yap Boum
- Mbarara University of Science and Technology, Mbarara, Uganda
- Epicentre Mbarara Research Centre, Mbarara, Uganda
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Abstract
Pain has been documented as a major concern for women in the postpartum period. Management of postpartum pain, however, is a relatively neglected area of clinical research. As a result, evidence to support interventions to alleviate the discomforts associated with childbirth is sparse. This paucity of research on postpartum pain management is particularly surprising given that in the United States alone nearly 4 million women give birth each year. Inadequate pain relief in the hours to months following childbirth can interfere with maternal-newborn bonding and feeding and, by impeding mobility, can increase the risk of postpartum complications. In addition, pain that is not adequately managed may increase the risk of chronic pain that lasts beyond the postpartum period. In this article, the more common causes of pain following childbirth are reviewed and recommendations for pain management based on available evidence are outlined. Considerations for pain management in lactating women and for hospital discharge are discussed.
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Postpartum Care. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Clinical Characteristics of and Preventative Strategies for Peripartum Group A Streptococcal Infections. Obstet Gynecol 2016; 127:227-32. [PMID: 26942347 DOI: 10.1097/aog.0000000000001238] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To describe clinical characteristics in parturients with group A streptococcal infection and suggest preventive strategies. METHODS We performed a retrospective review of all group A streptococci cultures from women presenting with peripartum fever or abdominal tenderness between January 2008 and May 2015 in a university hospital. Records and epidemiologic investigations of patients and staff were reviewed. RESULTS Thirty-seven patients with group A streptococci cultures were identified, with an incidence of one identified postpartum group A streptococcal infection per 2,837 deliveries. Eighty-nine percent of infections occurred postpartum with isolates obtained mainly from the genital tract. Symptoms for group A streptococcal puerperal sepsis were high fever and abdominal tenderness, mostly appearing within 48 hours postpartum. More than one fifth of patients (n=7) developed streptococcal toxic shock syndrome often complicated by multiorgan failure, hysterectomy, and hospitalization in the intensive care unit. There were no uniform risk factors before infection. Epidemiologic investigations suggested that only 23% of infections were nosocomially acquired and that 77% were community-acquired. CONCLUSION The high morbidity and the scarcity of distinct risk factors related to parturient group A streptococcal infections in the face of often community-acquired group A streptococci call for reassessing preventive strategies. These may include improved microbiological screening during pregnancy in high-prevalence areas or clinical and microbiological risk stratification in the immediate prepartum and peripartum period.
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Hughes BL, Clifton RG, Hauth JC, Leveno KJ, Myatt L, Reddy UM, Varner MW, Wapner RJ, Mercer BM, Peaceman AM, Ramin SM, Tolosa JE, Saade G, Sorokin Y. Is Mid-trimester Insulin Resistance Predictive of Subsequent Puerperal Infection? A Secondary Analysis of Randomized Trial Data. Am J Perinatol 2016; 33:983-90. [PMID: 27120478 PMCID: PMC5240039 DOI: 10.1055/s-0036-1583188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective The objective of this study was to examine whether there is an association between insulin resistance and subsequent development of puerperal infection by measuring insulin resistance in the mid-trimester using the homeostasis model assessment (HOMA:IR). Methods Secondary analysis of low-risk nulliparas enrolled in a multicenter preeclampsia prevention trial. HOMA:IR was measured on fasting plasma glucose and insulin concentrations among low-risk nulliparas between 22 and 26 weeks' gestation. Median HOMA:IR was compared between women who did and did not develop puerperal infection using Wilcoxon rank sum test. Logistic regression was used to control for potential confounders. Results Of 1,180 women with fasting glucose and insulin available, 121 (10.3%) had a puerperal infection. Median HOMA:IR was higher among those with subsequent puerperal infection (4.3 [interquartile, IQR: 2.2-20.5] vs. 2.6 [IQR: 1.5-6.7], p < 0.0001). After controlling for potentially confounding variables HOMA:IR was only marginally associated with an increased risk of development of puerperal infection, adjusted odds ratio: 1.01 (95% confidence interval: 1.00-1.02; p = 0.04) per unit increase. Elevated HOMA:IR performed poorly as a predictor of puerperal infection, with a positive predictive value of 15% and a negative predictive value of 92%. Conclusion Though associated with an increased risk of puerperal infection, insulin resistance, measured by HOMA:IR, is not a clinically useful predictor of puerperal infection.
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Affiliation(s)
- Brenna L. Hughes
- Department of Obstetrics and Gynecology, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Rebecca G. Clifton
- The George Washington University Biostatistics Center, Washington, District of Columbia
| | - John C. Hauth
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Leslie Myatt
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Uma M. Reddy
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Michael W. Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Brian M. Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alan M. Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Susan M. Ramin
- Department of Obstetrics and Gynecology, Children’s Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jorge E. Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
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Choe SA, Min HS, Cho SI. The income-based disparities in preeclampsia and postpartum hemorrhage: a study of the Korean National Health Insurance cohort data from 2002 to 2013. SPRINGERPLUS 2016; 5:895. [PMID: 27386343 PMCID: PMC4923012 DOI: 10.1186/s40064-016-2620-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 06/17/2016] [Indexed: 02/07/2023]
Abstract
There is limited evidence on the effects of relatively low socioeconomic status on maternal health. Additionally, the global economic recession that began in 2008 could have worsened disparities in maternal complications. To explore disparities in maternal health, we analyzed the occurrence of preeclampsia and postpartum hemorrhage according to level of household income. A population-based cohort data set from the Korean National Health Insurance was used to calculate the age-adjusted incidence, slope index of inequality, and Kunst and Mackenbach relative index of inequality (RIIKM) for preeclampsia and postpartum hemorrhage from 2002 to 2013. In the aggregated data of 65,479 live births, women with lower household income showed a higher risk of developing preeclampsia and postpartum hemorrhage than those with higherhigher incomes after adjusting for conventional risk factors. The absolute and relative inequalities for both complications showed no significant change over the period from 2002 to 2013. Considering the difference in the trends and risks of major obstetric complications according to level of household income, policies to monitor and reduce disparities in maternal health across different economic levels need to be implemented.
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Affiliation(s)
- Seung-Ah Choe
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Hye-Sook Min
- Department of Preventive Medicine, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Sung-Il Cho
- Department of Epidemiology, Graduate School of Public Health and Institute of Health and Environment, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742 Republic of Korea
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Nabhan AF, Allam NE, Hamed Abdel‐Aziz Salama M. Routes of administration of antibiotic prophylaxis for preventing infection after caesarean section. Cochrane Database Syst Rev 2016; 2016:CD011876. [PMID: 27314174 PMCID: PMC8572032 DOI: 10.1002/14651858.cd011876.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Post-caesarean section infection is a cause of maternal morbidity and mortality. Administration of antibiotic prophylaxis is recommended for preventing infection after caesarean delivery. The route of administration of antibiotic prophylaxis should be effective, safe and convenient. Currently, there is a lack of synthesised evidence regarding the benefits and harms of different routes of antibiotic prophylaxis for preventing infection after caesarean section. OBJECTIVES The aim of this review was to assess the benefits and harms of different routes of prophylactic antibiotics given for preventing infectious morbidity in women undergoing caesarean section. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (6 January 2016) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing at least two alternative routes of antibiotic prophylaxis for caesarean section (both elective and emergency). Cross-over trials and quasi-RCTs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data from the included studies. These steps were checked by a third review author. MAIN RESULTS We included 10 studies (1354 women). The risk of bias was unclear or high in most of the included studies.All of the included trials involved women undergoing caesarean section whether elective or non-elective. Intravenous antibiotics versus antibiotic irrigation (nine studies, 1274 women) Nine studies (1274 women) compared the administration of intravenous antibiotics with antibiotic irrigation. There were no clear differences between groups in terms of this review's maternal primary outcomes: endometritis (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.70 to 1.29; eight studies (966 women) (low-quality evidence)); wound infection (RR 0.49, 95% CI 0.17 to 1.43; seven studies (859 women) (very low-quality evidence)). The outcome of infant sepsis was not reported in the included studies.In terms of this review's maternal secondary outcomes, there were no clear differences between intravenous antibiotic or irrigation antibiotic groups in terms of postpartum febrile morbidity (RR 0.87, 95% CI 0.48 to 1.60; three studies (264 women) (very low-quality evidence)); or urinary tract infection (RR 0.74, 95% CI 0.25 to 2.15; five studies (660 women) (very low-quality evidence)). In terms of adverse effects of the treatment on the women, no drug allergic reactions were reported in three studies (284 women) (very low-quality evidence), and there were no cases of serious infectious complications reported (very low-quality evidence). There was no clear difference between groups in terms of maternal length of hospital stay (mean difference (MD) 0.28 days, 95% CI -0.22 to 0.79 days, (random-effects analysis), four studies (512 women). No data were reported for the number of women readmitted to hospital. For the baby, there were no data reported in relation to oral thrush, infant length of hospital stay or immediate adverse effects of the antibiotics on the infant. Intravenous antibiotic prophylaxis versus oral antibiotic prophylaxis (one study, 80 women) One study (80 women) compared an intravenous versus an oral route of administration of prophylactic antibiotics, but did not report any of this review's primary or secondary outcomes. AUTHORS' CONCLUSIONS There was no clear difference between irrigation and intravenous antibiotic prophylaxis in reducing the risk of post-caesarean endometritis. For other outcomes, there is insufficient evidence regarding which route of administration of prophylactic antibiotics is most effective at preventing post-caesarean infections. The quality of evidence was very low to low, mainly due to limitations in study design and imprecision. Furthermore, most of the included studies were underpowered (small sample sizes with few events). Therefore, we advise caution in the interpretation and generalisability of the results.For future research, there is a need for well-designed, properly-conducted, and clearly-reported RCTs. Such studies should evaluate the more recently available antibiotics, elaborating on the various available routes of administration, and exploring potential neonatal side effects of such interventions.
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Affiliation(s)
- Ashraf F Nabhan
- Ain Shams UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine16 Ali Fahmi Kamel StreetHeliopolisCairoEgypt11351
| | - Nahed E Allam
- Alazhar UniversityDepartment of Obstetrics and GynaecologyAlmostashfa Elyounainy StCairoEgypt
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Interleukin-17A Contributes to the Control of Streptococcus pyogenes Colonization and Inflammation of the Female Genital Tract. Sci Rep 2016; 6:26836. [PMID: 27241677 PMCID: PMC4886215 DOI: 10.1038/srep26836] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/09/2016] [Indexed: 12/20/2022] Open
Abstract
Postpartum women are at increased risk of developing puerperal sepsis caused by group A Streptococcus (GAS). Specific GAS serotypes, including M1 and M28, are more commonly associated with puerperal sepsis. However, the mechanisms of GAS genital tract infection are not well understood. We utilized a murine genital tract carriage model to demonstrate that M1 and M28 GAS colonization triggers TNF-α, IL-1β, and IL-17A production in the female genital tract. GAS-induced IL-17A significantly influences streptococcal carriage and alters local inflammatory responses in two genetically distinct inbred strains of mice. An absence of IL-17A or the IL-1 receptor was associated with reduced neutrophil recruitment to the site of infection; and clearance of GAS was significantly attenuated in IL-17A(-/-) mice and Rag1(-/-) mice (that lack mature lymphocytes) but not in mice deficient for the IL-1 receptor. Together, these findings support a role for IL-17A in contributing to the control of streptococcal mucosal colonization and provide new insight into the inflammatory mediators regulating host-pathogen interactions in the female genital tract.
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Galvão A, Braga AC, Gonçalves DR, Guimarães JM, Braga J. Sepsis during pregnancy or the postpartum period. J OBSTET GYNAECOL 2016; 36:735-743. [PMID: 27152968 DOI: 10.3109/01443615.2016.1148679] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Sepsis is an important cause of maternal morbidity and mortality worldwide. Early recognition and timely treatment are the key to ensuring a favourable outcome. This article reviews recent literature about definitions, pathophysiology, incidence, diagnosis, management, treatment, prevention and outcome of sepsis during pregnancy and the postpartum period.
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Affiliation(s)
- Ana Galvão
- a Centro Hospitalar Do Porto - Centro Materno Infantil Do Norte , Porto , Portugal
| | - António Costa Braga
- a Centro Hospitalar Do Porto - Centro Materno Infantil Do Norte , Porto , Portugal
| | | | | | - Jorge Braga
- a Centro Hospitalar Do Porto - Centro Materno Infantil Do Norte , Porto , Portugal
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Golińska E, van der Linden M, Więcek G, Mikołajczyk D, Machul A, Samet A, Piórkowska A, Dorycka M, Heczko PB, Strus M. Virulence factors of Streptococcus pyogenes strains from women in peri-labor with invasive infections. Eur J Clin Microbiol Infect Dis 2016; 35:747-54. [PMID: 26873375 PMCID: PMC4840219 DOI: 10.1007/s10096-016-2593-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 10/24/2022]
Abstract
Invasive group A streptococcal (GAS) infections constitute an important epidemiological problem. Many cases occur in women during the postnatal period. The objective of this study was to evaluate the presence of the genes responsible for production of iron-chelating protein (perR) and superantigens (speA, speB, speC, speF, speG, speH, speI, speJ, speK, speL, speM, smeZ, and ssa) in S. pyogenes strains isolated from invasive infections in women after delivery. Furthermore, this study sought to verify whether S. pyogenes strains show special phenotypic and genotypic (sla, spy1325) characteristics that may play a decisive role in adherence to the genital tract epithelium. Moreover, the emm-types and antibiotic susceptibility were determined. We tested 30 invasive S. pyogenes strains isolated from postpartum invasive infection and 37 GAS control strains isolated from the genital tracts of asymptomatic multiparous women. The majority of the tested strains were shown to express two types of emm genes (1 and 28), though emm -12, -28, -75 and -89 were uniquely expressed in the group of strains isolated from invasive infections. A significantly higher prevalence of perR in the strains from puerperal fever was shown. Significant differences were also found between the two groups with respect to the incidence of the genes related to adherence; GAS strains originating from women with sepsis/puerperal fever showed presence of these genes less frequently than those of the control group. Although differences in frequencies of the gene coding for various superantigens were noted between the compared groups of GAS strains, they were not significant.
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Affiliation(s)
- E Golińska
- Jagiellonian University Medical College, 18 Czysta Str., 31-121, Kracow, Poland
| | - M van der Linden
- Institute of Microbiology, RWTH Aachen University, Faculty of Medicine and University Hospital, Aachen, Germany
| | - G Więcek
- Jagiellonian University Medical College, 18 Czysta Str., 31-121, Kracow, Poland
| | - D Mikołajczyk
- Jagiellonian University Medical College, 18 Czysta Str., 31-121, Kracow, Poland
| | - A Machul
- Jagiellonian University Medical College, 18 Czysta Str., 31-121, Kracow, Poland
| | - A Samet
- Department of Clinical Microbiology, University Clinical Center in Gdansk, 7 Debinki Str., 80-952, Gdansk, Poland
| | - A Piórkowska
- Department of Clinical Microbiology, University Clinical Center in Gdansk, 7 Debinki Str., 80-952, Gdansk, Poland
| | - M Dorycka
- Microbiological Laboratory, Diagnostics Inc., Kracow Branch, Na Skarpie 66 axis, 31-913, Kracow, Poland
| | - P B Heczko
- Jagiellonian University Medical College, 18 Czysta Str., 31-121, Kracow, Poland
| | - M Strus
- Jagiellonian University Medical College, 18 Czysta Str., 31-121, Kracow, Poland.
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Bartlett LA, LeFevre AE, Mir F, Soofi S, Arif S, Mitra DK, Quaiyum MA, Shakoor S, Islam MS, Connor NE, Winch PJ, Reller ME, Shah R, El Arifeen S, Baqui AH, Bhutta ZA, Zaidi A, Saha S, Ahmed SA. The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan. Reprod Health 2016; 13:16. [PMID: 26916141 PMCID: PMC4766721 DOI: 10.1186/s12978-016-0124-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/25/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk. METHODS/DESIGN The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics. DISCUSSION This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.
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Affiliation(s)
- L A Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - A E LeFevre
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - F Mir
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - S Soofi
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - S Arif
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - D K Mitra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - M A Quaiyum
- Centre for Reproductive Health, icddr,b, Dhaka, Bangladesh.
| | - S Shakoor
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - M S Islam
- Department of Microbiology, The Child Health Research Foundation, Dhaka Shishu Hospital, Dhaka, Bangladesh.
| | - N E Connor
- Department of Microbiology, The Child Health Research Foundation, Dhaka Shishu Hospital, Dhaka, Bangladesh.
| | - P J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - M E Reller
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - R Shah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - S El Arifeen
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh.
| | - A H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Z A Bhutta
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - A Zaidi
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - S Saha
- Department of Microbiology, The Child Health Research Foundation, Dhaka Shishu Hospital, Dhaka, Bangladesh.
| | - S A Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Halder A, Vijayselvi R, Jose R. Changing perspectives of infectious causes of maternal mortality. J Turk Ger Gynecol Assoc 2015; 16:208-13. [PMID: 26692770 PMCID: PMC4664211 DOI: 10.5152/jtgga.2015.0134] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/14/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Infections significantly contribute to maternal mortality. There is a perceived change in the spectrum of such infections. This study aims to estimate the contribution of various types of infections to maternal mortality. MATERIAL AND METHODS We retrospectively reviewed records of maternal death cases that took place between 2003 and 2012 in the Christian Medical College, Vellore, India. The International Classification of Diseases-Maternal Mortality was used to classify the causes of deaths and World Health Organization near-miss criteria were used to identify organ dysfunction that occurred before death. Infections during pregnancy were divided into three groups, i.e., pregnancy-related infections, pregnancy-unrelated infections, and nosocomial infections. RESULTS In this study, 32.53% of maternal deaths were because of some type of infection as the primary cause. The contribution of pregnancy-related infections was comparable with that of pregnancy-unrelated infections (16.03% vs. 16.50%). Metritis with pelvic cellulitis, septic abortions, tuberculosis, malaria, scrub typhus, and H1N1 influenza (influenza A virus subtype) were among the most commonly encountered causes of maternal death due to infections. Another 7.07% of cases developed severe systemic infection during the course of illness as nosocomial infection. A significant majority of mothers were below 30 years of age, were primiparae, had advanced gestational age, and had operative delivery. Cardiovascular and respiratory system dysfunctions were the most common organ dysfunctions encountered. CONCLUSION The contribution of pregnancy-unrelated infections to maternal deaths is significant. Control of these diverse community-acquired infections holds the key to a reduction in maternal mortality along with the promotion of clean birthing practices. Nosocomial infections should not be underestimated as a contributor to maternal mortality.
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Affiliation(s)
- Ajay Halder
- Department of Obstetrics and Gynecology, Christian Medical College, Vellore, India
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhopal, India
| | - Reeta Vijayselvi
- Department of Obstetrics and Gynecology, Christian Medical College, Vellore, India
| | - Ruby Jose
- Department of Obstetrics and Gynecology, Christian Medical College, Vellore, India
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Nabhan AF, Allam NE, Hamed Abdel-Aziz Salama M. Routes of administration of antibiotic prophylaxis for preventing infection after caesarean section. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal. PLoS One 2015; 10:e0136152. [PMID: 26295838 PMCID: PMC4546655 DOI: 10.1371/journal.pone.0136152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 07/31/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Globally, puerperal sepsis accounts for an estimated 8-12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival. We used data from the control arms of four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal, to examine associations between clean delivery kit use and hand washing by the birth attendant with maternal mortality among home deliveries. METHODS We tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Cross-sectional data were analysed by fitting logistic regression models with and without multiple imputation, and confounders were selected a priori using causal directed acyclic graphs. The robustness of estimates was investigated through sensitivity analyses. RESULTS Hand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28-0.93). The sensitivity analysis testing the missing at random assumption for the multiple imputation, as well as the sensitivity analysis accounting for possible misclassification bias in the use of clean delivery practices, indicated that the association between hand washing and maternal death had been over estimated. Clean delivery kit use was not associated with a maternal death (AOR 1.26, 95% CI 0.62-2.56). CONCLUSIONS Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported.
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Oral and intramuscular treatment options for early postpartum endometritis in low-resource settings: a systematic review. Obstet Gynecol 2015; 125:789-800. [PMID: 25751198 DOI: 10.1097/aog.0000000000000732] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To suggest options for oral and intramuscular antibiotic treatment of early postpartum endometritis in low-resource community settings where intravenous antibiotics are unavailable. DATA SOURCES Studies were identified through MEDLINE from inception through December 2014. Search terms included [("anti-bacterial agents [MeSH]" or "anti-infective agents [MeSH]") and ("endometritis [MeSH]" or "puerperal infection [MeSH]")]. A second search using the terms [("endometritis or endomyometritis or puerperal infection) and ("antibiotics or antimicrobials or anti-bacterial agents or anti-infective agents)"] was also used. Additionally, all references from selected articles were reviewed, a hand-search of a subject matter expert library was conducted, and a search of ClinicalTrials.gov was performed. METHODS OF STUDY SELECTION We conducted a systematic review of the literature in two phases. Phase I provides a summary of clinical cure data from prospective studies of oral and intramuscular antimicrobial regimens as well as summarizes evidence from trials of intravenous antimicrobials. Phase II is a quantitative analysis of pathogens from intrauterine postpartum endometritis samples. Based on these results, and with consideration of existing recommendations for antibiotic use during breastfeeding, we suggest oral and intramuscular antimicrobial options for the treatment of early postpartum endometritis after vaginal delivery in low-resource settings. TABULATION, INTEGRATION, AND RESULTS Reports involving oral or intramuscular antimicrobial treatment of postpartum endometritis are rare and of generally poor quality. Antimicrobial trials of postpartum endometritis treatment and intrauterine microbiology studies suggest five antimicrobial regimens may be effective: oral clindamycin plus intramuscular gentamicin, oral amoxicillin-clavulanate, intramuscular cefotetan, intramuscular meropenem or imipenem-cilastatin, and oral amoxicillin in combination with oral metronidazole. CONCLUSION This review provides suggestions for oral, intramuscular, and combined antimicrobial regimens that may warrant additional study. Experimental trials should consider clinical effectiveness, safety and side effects profiles, and feasibility of community-based treatment.
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Al-Ostad G, Kezouh A, Spence AR, Abenhaim HA. Incidence and risk factors of sepsis mortality in labor, delivery and after birth: population-based study in the USA. J Obstet Gynaecol Res 2015; 41:1201-6. [PMID: 25976287 DOI: 10.1111/jog.12710] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 01/27/2015] [Accepted: 02/06/2015] [Indexed: 01/23/2023]
Abstract
AIM Maternal sepsis is one of the leading causes of maternal mortality around the world. The aim of this study was to estimate the incidence and mortality rate of sepsis, and the associated risk factors for their development during pregnancy, labor, delivery and the post-partum period. METHODS We conducted a population-based cohort study consisting of 5 million births that occurred in the USA. Data were obtained from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) database from 1998 to 2008. Logistic regression was used to calculate the adjusted odds ratio and corresponding 95% confidence intervals (95%CI) for sepsis development and sepsis-related death during admission for delivery. RESULTS The overall incidence of maternal sepsis was 29.4 per 100 000 births (95%CI: 28.0-30.9) with a sepsis case fatality rate of 4.4 per 100 births (95%CI: 3.5-5.6). Both the incidence of maternal sepsis and sepsis-related death rate have increased over the last decade. Women who are black, older than 35 years and who smoke were more likely to experience maternal sepsis. An association was also found between maternal sepsis and diabetes mellitus, cardiovascular disease, eclampsia, preterm birth, hysterectomy, puerperal infection, post-partum hemorrhage, transfusion and chorioamnionitis. CONCLUSIONS Mortality from maternal sepsis during labor and delivery is an increasing and important problem in westernized countries. Initiatives aimed at improving early recognition and effective management may help reduce the occurrence and outcomes of maternal sepsis at time of labor and delivery.
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Affiliation(s)
- Ghassan Al-Ostad
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University
| | - Abbas Kezouh
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| | - Andrea R Spence
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
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Postpartum Care. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_15-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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