Peripartum Infections and Associated Maternal Mortality in Rural Malawi

Risk factors for death in patients with sepsis admitted to an obstetric intensive care unit: A cohort study

Improving understanding of the prognostic factors associated with death resulting from sepsis in obstetric patients is essential to allow management to be optimized. This retrospective cohort study aimed to determine the risk factors for death in patients with sepsis admitted to the obstetric intensive care unit of a tertiary teaching hospital in northeastern Brazil between April 2012 and April 2016.The clinical, obstetric, and laboratory data of the sepsis patients, as well as data on their final outcome, were collected. A significance level of 5% was adopted. Risk factors for death in patients with sepsis were evaluated in a multivariate analysis.During the period analyzed, 155 patients with sepsis were identified and included in the study, representing 5.2% of all obstetric intensive care unit (ICU) admissions. Of these, 14.2% (n = 22) died. The risk factors for death were septic shock at the time of hospitalization (relative risk [RR] = 3.45; 95% confidence interval [CI]: 1.64-7.25), need for vasopressors during hospitalization (RR = 17.32; 95% CI: 4.20-71.36), lactate levels >2 mmol/L at the time of diagnosis (RR = 4.60; 95% CI: 1.05-20.07), and sequential organ failure assessment score >2 at the time of diagnosis (RR = 5.97; 95% CI: 1.82-19.94). Following multiple logistic regression analysis, only the need for vasopressors during hospitalization remained as a risk factor associated with death (odds ratio [OR] = 26.38; 95% CI: 5.87-118.51).The need for vasopressors during hospitalization is associated with death in obstetric patients with sepsis.

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

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.

Resource availability for the management of maternal sepsis in Malawi, other low-income countries, and lower-middle-income countries

OBJECTIVE

To assess the availability of key resources for the management of maternal sepsis and evaluate the feasibility of implementing the Surviving Sepsis Campaign (SSC) recommendations in Malawi and other low-resource settings.

METHODS

A cross-sectional study was conducted at health facilities in Malawi, other low-income countries, and lower-middle-income countries during January-March 2016. English-speaking healthcare professionals (e.g. doctors, nurses, midwives, and administrators) completed a questionnaire/online survey to assess the availability of resources for the management of maternal sepsis.

RESULTS

Healthcare centers (n=23) and hospitals (n=13) in Malawi showed shortages in the resources for basic monitoring (always available in 5 [21.7%] and 10 [76.9%] facilities, respectively) and basic infrastructure (2 [8.7%] and 7 [53.8%], respectively). The availability of antibiotics varied between Malawian healthcare centers (9 [39.1%]), Malawian hospitals (8 [61.5%]), hospitals in other low-income countries (10/17 [58.8%]), and hospitals in lower-middle-income countries (39/41 [95.1%]). The percentage of SSC recommendations that could be implemented was 33.3% at hospitals in Malawi, 30.3% at hospitals in other low-income countries, and 68.2% at hospitals in lower-middle-income countries.

CONCLUSION

The implementation of existing SSC recommendations is unrealistic in low-income countries because of resource limitations. New maternal sepsis care bundles must be developed that are applicable to low-resource settings.

Changes in body mass index and hemoglobin concentration in breastfeeding women living with HIV with a CD4 count over 350: Results from 4 African countries (The ANRS 12174 trial)

INTRODUCTION

Breastfeeding is recommended for infants born to HIV-infected women in low-income settings. Both breastfeeding and HIV-infection are energy demanding. Our objective was to explore how exclusive and predominant breastfeeding changes body mass index (BMI) among breastfeeding HIV1-positive women participating in the ANRS12174 trial (clinical trial no NCT0064026).

METHODS

HIV-positive women (n = 1 267) with CD4 count >350, intending to breastfeed HIV-negative infants were enrolled from Burkina Faso, South Africa, Uganda and Zambia and counselled on breastfeeding. N = 1 216 were included in the analysis. The trial compared Lamivudine and Lopinavir/Ritonavir as a peri-exposure prophylaxis. We ran a linear mixed-effect model with BMI as the dependent variable and exclusive or predominant breastfeeding duration as the key explanatory variable.

RESULTS

Any breastfeeding or exclusive/predominant) breastfeeding was initiated by 99.6% and 98.6% of the mothers respectively in the first week after birth. The median (interquartile range: IQR) duration of the group that did any breastfeeding or the group that did exclusive /predominant breastfeeding were 9.5 (7.5; 10.6) and 5.8 (5.6; 5.9)) months, respectively. The median (IQR) age, BMI, CD4 count, and HIV viral load at baseline (day 7) were 27 (23.3; 31) years, 23.7 (21.3; 27.0) kg/m2, 530 (432.5; 668.5) cells/μl and 0.1 (0.8; 13.7)1000 copies/mL, respectively. No major change in mean BMI was seen in this cohort over a 50-week period during lactation. The mean change between 26 and 50 weeks after birth was 0.7 kg/m2. Baseline mean BMI (measured on day 7 postpartum) and CD4 count were positively associated with maternal BMI change, with a mean increase of 1.0 kg/m2 (0.9; 1.0) per each additional baseline-BMI kilogram and 0.3 kg/m2 (0.2; 0.5) for each additional CD4 cell/μl, respectively.

CONCLUSION

Breastfeeding was not negatively correlated with the BMI of HIV-1 infected Sub-Saharan African mothers. However, a higher baseline BMI and a CD4 count >500 cells/μl were associated with maternal BMI during the exclusive/ predominant breastfeeding period. Considering the benefits of breast milk for the infants and the recurrent results from different studies that breastfeeding is not harmful to the HIV-1-infected mothers, this study also supports the WHO 2016 guidelines on infant feeding that mothers living with HIV should breastfeed where formula is not safe for at least 12 months and up to 24 months, given that the right treatment or prophylaxis for the infection is administered. These findings and conclusions cannot be extrapolated to women who are immune-compromised or have AIDS.

HIV and maternal mortality

The majority of the 17 million women globally that are estimated to be infected with HIV live in Sub-Saharan Africa. Worldwide, HIV-related causes contributed to 19 000-56 000 maternal deaths in 2011 (6%-20% of maternal deaths). HIV-infected pregnant women have two to 10 times the risk of dying during pregnancy and the postpartum period compared with uninfected pregnant women. Many of these deaths can be prevented with the implementation of high-quality obstetric care, prevention and treatment of common co-infections, and treatment of HIV with ART. The paper summarizes what is known about HIV disease progression in pregnancy, specific causes of HIV-related maternal deaths, and the potential impact of treatment with antiretroviral therapy on maternal mortality. Recommendations are proposed for improving maternal health and decreasing maternal mortality among HIV-infected women based on existing evidence.

Sepsis and maternal mortality

PURPOSE OF REVIEW

Despite global progress towards reducing maternal mortality, sepsis remains a leading cause of preventable maternal death. This review focuses on current measurement challenges, trends, causes and efforts to curb maternal death from sepsis in high and low-income countries.

RECENT FINDINGS

Under-reporting using routine registration data, compounded by misclassification and unreported deaths, results in significant underestimation of the burden of maternal death from sepsis. In the UK and the Netherlands the recent increase in maternal death from sepsis is mainly attributed to an increase in invasive group A streptococcal infections. Susceptibility to infection may be complicated by modulation of maternal immune response and increasing rates of risk factors such as caesarean section and obesity. Failure to recognize severity of infection is a major universal risk factor. Standardized Surviving Sepsis Campaign (SSC) recommendations for management of severe maternal sepsis are continuing to be implemented worldwide; however, outcomes differ according to models of intensive care resourcing and use.

SUMMARY

The need for robust data with subsequent analyses is apparent. This will significantly increase our understanding of risk factors and their causal pathways, which are critical to informing effective treatment strategies in consideration of resource availability.

The WHO maternal near miss approach: consequences at Malawian District level

INTRODUCTION

WHO proposes a set of organ-failure based criteria for maternal near miss. Our objective was to evaluate what implementation of these criteria would mean for the analysis of a cohort of 386 women in Thyolo District, Malawi, who sustained severe acute maternal morbidity according to disease-based criteria.

METHODS AND FINDINGS

A WHO Maternal Near Miss (MNM) Tool, created to compare disease-, intervention- and organ-failure based criteria for maternal near miss, was completed for each woman, based on a review of all available medical records. Using disease-based criteria developed for the local setting, 341 (88%) of the 386 women fulfilled the WHO disease-based criteria provided by the WHO MNM Tool, 179 (46%) fulfilled the intervention-based criteria, and only 85 (22%) the suggested organ-failure based criteria.

CONCLUSIONS

In this low-resource setting, application of these organ-failure based criteria that require relatively sophisticated laboratory and clinical monitoring underestimates the occurrence of maternal near miss. Therefore, these criteria and the suggested WHO approach may not be suited to compare maternal near miss across all settings.