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Ribeiro-do-Valle CC, Bonet M, Brizuela V, Abalos E, Baguiya A, Bellissimo-Rodrigues F, Budianu M, Puscasiu L, Knight M, Lissauer D, Dunlop C, Jacob ST, Shakoor S, Gadama L, Assarag B, Souza JP, Cecatti JG. Aetiology and use of antibiotics in pregnancy-related infections: results of the WHO Global Maternal Sepsis Study (GLOSS), 1-week inception cohort. Ann Clin Microbiol Antimicrob 2024; 23:21. [PMID: 38402175 PMCID: PMC10894467 DOI: 10.1186/s12941-024-00681-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/19/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Pregnancy-related infections are important contributors to maternal sepsis and mortality. We aimed to describe clinical, microbiological characteristics and use of antibiotics by source of infection and country income, among hospitalized women with suspected or confirmed pregnancy-related infections. METHODS We used data from WHO Global Maternal Sepsis Study (GLOSS) on maternal infections in hospitalized women, in 52 low-middle- and high-income countries conducted between November 28th and December 4th, 2017, to describe the frequencies and medians of maternal demographic, obstetric, and clinical characteristics and outcomes, methods of infection diagnosis and causative pathogens, of single source pregnancy-related infection, other than breast, and initial use of therapeutic antibiotics. We included 1456 women. RESULTS We found infections of the genital (n = 745/1456, 51.2%) and the urinary tracts (UTI) (n = 531/1456, 36.5%) to be the most frequent. UTI (n = 339/531, 63.8%) and post-caesarean skin and soft tissue infections (SSTI) (n = 99/180, 55.0%) were the sources with more culture samples taken and microbiological confirmations. Escherichia coli was the major uropathogen (n = 103/118, 87.3%) and Staphylococcus aureus (n = 21/44, 47.7%) was the commonest pathogen in SSTI. For 13.1% (n = 191) of women, antibiotics were not prescribed on the same day of infection suspicion. Cephalosporins (n = 283/531, 53.3%) were the commonest antibiotic class prescribed for UTI, while metronidazole (n = 303/925, 32.8%) was the most prescribed for all other sources. Ceftriaxone with metronidazole was the commonest combination for the genital tract (n = 98/745, 13.2%) and SSTI (n = 22/180, 12.2%). Metronidazole (n = 137/235, 58.3%) was the most prescribed antibiotic in low-income countries while cephalosporins and co-amoxiclav (n = 129/186, 69.4%) were more commonly prescribed in high-income countries. CONCLUSIONS Differences in antibiotics used across countries could be due to availability, local guidelines, prescribing culture, cost, and access to microbiology laboratory, despite having found similar sources and pathogens as previous studies. Better dissemination of recommendations in line with antimicrobial stewardship programmes might improve antibiotic prescription.
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Affiliation(s)
- Carolina C Ribeiro-do-Valle
- Department of Gynaecology and Obstetrics, Faculty of Medical Sciences, University of Campinas, R. Alexander Fleming, 101, Campinas, São Paulo, CEP 13083-888, Brazil
| | - Mercedes Bonet
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland
| | - Vanessa Brizuela
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland
| | - Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya-HDSS), Research Institute of Health Sciences (IRSS), Ouagadougou, Burkina Faso
| | | | - Mihaela Budianu
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Lucian Puscasiu
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
| | - David Lissauer
- University of Liverpool, Blantyre, Malawi
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | | | - Shevin T Jacob
- Walimu, Mbarara, Uganda
- Department of Clinical Services, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sadia Shakoor
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
- Department of Microbiology, Aga Khan University, Karachi, Pakistan
| | - Luis Gadama
- Department of Obstetrics and Gynaecology, University of Malawi, Zomba, Malawi
| | | | - João Paulo Souza
- Department of Social Medicine, Ribeirão Preto Medical School, Ribeirão Preto, Brazil
| | - Jose G Cecatti
- Department of Gynaecology and Obstetrics, Faculty of Medical Sciences, University of Campinas, R. Alexander Fleming, 101, Campinas, São Paulo, CEP 13083-888, Brazil.
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Bladon S, Ashiru-Oredope D, Cunningham N, Pate A, Martin GP, Zhong X, Gilham EL, Brown CS, Mirfenderesky M, Palin V, van Staa TP. Rapid systematic review on risks and outcomes of sepsis: the influence of risk factors associated with health inequalities. Int J Equity Health 2024; 23:34. [PMID: 38383380 PMCID: PMC10882893 DOI: 10.1186/s12939-024-02114-6] [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: 07/25/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND AND AIMS Sepsis is a serious and life-threatening condition caused by a dysregulated immune response to an infection. Recent guidance issued in the UK gave recommendations around recognition and antibiotic treatment of sepsis, but did not consider factors relating to health inequalities. The aim of this study was to summarise the literature investigating associations between health inequalities and sepsis. METHODS Searches were conducted in Embase for peer-reviewed articles published since 2010 that included sepsis in combination with one of the following five areas: socioeconomic status, race/ethnicity, community factors, medical needs and pregnancy/maternity. RESULTS Five searches identified 1,402 studies, with 50 unique studies included in the review after screening (13 sociodemographic, 14 race/ethnicity, 3 community, 3 care/medical needs and 20 pregnancy/maternity; 3 papers examined multiple health inequalities). Most of the studies were conducted in the USA (31/50), with only four studies using UK data (all pregnancy related). Socioeconomic factors associated with increased sepsis incidence included lower socioeconomic status, unemployment and lower education level, although findings were not consistent across studies. For ethnicity, mixed results were reported. Living in a medically underserved area or being resident in a nursing home increased risk of sepsis. Mortality rates after sepsis were found to be higher in people living in rural areas or in those discharged to skilled nursing facilities while associations with ethnicity were mixed. Complications during delivery, caesarean-section delivery, increased deprivation and black and other ethnic minority race were associated with post-partum sepsis. CONCLUSION There are clear correlations between sepsis morbidity and mortality and the presence of factors associated with health inequalities. To inform local guidance and drive public health measures, there is a need for studies conducted across more diverse setting and countries.
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Affiliation(s)
- Siân Bladon
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Neil Cunningham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Alexander Pate
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Glen P Martin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Xiaomin Zhong
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Ellie L Gilham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
- NIHR Health Protection Unit in Healthcare-Associated Infection & Antimicrobial Resistance, Imperial College London, London, UK
| | - Mariyam Mirfenderesky
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Victoria Palin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester, M13 9WL, UK
| | - Tjeerd P van Staa
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
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Maternal Sepsis in Italy: A Prospective, Population-Based Cohort and Nested Case-Control Study. Microorganisms 2022; 11:microorganisms11010105. [PMID: 36677397 PMCID: PMC9865500 DOI: 10.3390/microorganisms11010105] [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: 11/28/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
Maternal sepsis represents a leading cause of mortality and severe morbidity worldwide. In Italy, it is the second cause of direct maternal mortality. Delay in recognition and treatment initiation are the drivers of sepsis-associated adverse outcomes. Between November 2017 and October 2019, the Italian Obstetric Surveillance System coordinated a prospective population-based study on maternal sepsis occurring before or after childbirth from 22 weeks' gestation onward and up to 42 days following the end of pregnancy. A nested 1:2 matched case-control study on postpartum sepsis was also performed. Maternal sepsis was diagnosed for the presence of suspected or confirmed infection alongside signs or symptoms of organ failure. The aim of this study was to assess maternal sepsis incidence and its associated risk factors, management, and perinatal outcomes. Six Italian regions, covering 48.2% of the national births, participated in the project. We identified an incidence rate of 5.5 per 10,000 maternities (95% CI 4.80-6.28). Seventy percent of patients had a low education level and one third were foreigners with a language barrier. Genital, respiratory, and urinary tract infections were the predominant sources of infection; the majority of cases was caused by E. coli and polymicrobial infections. The presence of vascular and indwelling bladder catheters was associated with a nine-fold increased risk of postpartum sepsis. There were no maternal deaths, but one fourth of women experienced a serious adverse event and 28.3% required intensive care; 1.8% of newborns died. Targeted interventions to increase awareness of maternal sepsis and its risk factors and management should be promoted.
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Dockree S, O'Sullivan J, Shine B, James T, Vatish M. How should we interpret lactate in labour? A reference study. BJOG 2022; 129:2150-2156. [PMID: 35866444 PMCID: PMC9804290 DOI: 10.1111/1471-0528.17264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To investigate maternal lactate concentrations in labour and the puerperium. DESIGN Reference study. SETTING Tertiary obstetric unit. POPULATION 1279 pregnant women with good perinatal outcomes at term. METHODS Electronic patient records were searched for women who had lactate measured on the day of delivery or in the following 24 hours, but who were subsequently found to have a very low likelihood of sepsis, based on their outcomes. MAIN OUTCOME MEASURES The normative distribution of lactate and C-reactive protein (CRP), differences according to the mode of birth, and the proportion of results above the commonly used cut-offs (≥2 and ≥4 mmol/l). RESULTS Lactate varied between 0.4-5.4 mmol/l (median 1.8 mmol/l, interquartile range [IQR] 1.3-2.5). It was higher in women who had vaginal deliveries than caesarean sections (median 1.9 vs. 1.6 mmol/l, pdiff < 0.001), demonstrating the association with labour (particularly active pushing in the second stage). In contrast, CRP was more elevated in women who had caesarean sections (median 71.8 mg/l) than those who had vaginal deliveries (33.4 mg/l, pdiff < 0.001). In total, 40.8% had a lactate ≥2 mmol/l, but 95.3% were <4 mmol/l. CONCLUSIONS Lactate in labour and the puerperium is commonly elevated above the levels expected in healthy pregnant or non-pregnant women. There is a paucity of evidence to support using lactate or CRP to make decisions about antibiotics around the time of delivery but, as lactate is rarely higher than 4 mmol/l, this upper limit may still represent a useful severity marker for the investigation and management of sepsis in labour.
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Affiliation(s)
- Samuel Dockree
- Women's CentreJohn Radcliffe HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Joseph O'Sullivan
- Women's CentreJohn Radcliffe HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Brian Shine
- Department of Clinical BiochemistryJohn Radcliffe HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Tim James
- Department of Clinical BiochemistryJohn Radcliffe HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Manu Vatish
- Women's CentreJohn Radcliffe HospitalOxford University Hospitals NHS Foundation TrustOxfordUK,Women's CentreNuffield Department of Women's and Reproductive HealthJohn Radcliffe HospitalUniversity of OxfordOxfordUK
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Balki I, Baghirzada L, Walker A, Lapinsky S, Balki M. Incidence, morbidity, and associated factors for sepsis in women hospitalized for delivery: a nationwide retrospective observational population-based study in Canada. Can J Anaesth 2022; 69:298-310. [PMID: 34939139 PMCID: PMC8694197 DOI: 10.1007/s12630-021-02158-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/14/2021] [Accepted: 09/08/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The objective of this research was to examine the epidemiology of maternal sepsis in Canada. METHODS We conducted a population-based retrospective cohort study of women (≥ 20 weeks gestation) hospitalized for delivery in all Canadian hospitals (excluding Quebec) between 1 April 2004 and 31 March 2017. Data were obtained from the national Canadian Institute for Health Information database and sepsis cases were identified via International Classification of Diseases, Tenth Revision, Canada (ICD-10-CA) codes. Our primary outcome was the number of hospitalizations for delivery associated with maternal sepsis. We further explored associations between patient characteristics, obstetric procedures/conditions, medical conditions, and maternal sepsis. Associations were presented using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS There were 4,183 cases of sepsis in 3,653,783 hospitalizations for delivery during the study period, with an incidence of 114 (95% CI, 111 to 118) per 100,000 hospitalizations and a mortality rate of 0.5%. Annual sepsis rates per 100,000 hospitalizations ranged from a high of 160 (95% CI, 146 to 177) in 2004 to 94 (95% CI, 83 to 106) in 2011. Highest regional rates were observed in the Territories (224 per 100,000). Severe sepsis was seen in 14% (n = 568) of all patients with sepsis, which was one or more of septic shock (15%; n = 85), organ failure (61%; n = 345), intensive care unit admission (78%; n = 443), or mortality (3%; n = 19). Multivariable models showed that postpartum hemorrhage (OR, 2.9; 95% CI, 2.7 to 3.2), Cesarean delivery (OR, 3.2; 95% CI, 3.0 to 3.5), anemia (OR, 3.9; 95% CI, 3.5 to 4.3), hysterectomy (OR, 4.9; 95% CI, 3.6 to 6.6), chorioamnionitis (OR, 7.6; 95% CI, 6.9 to 8.3), as well as cardiorespiratory, renal and liver conditions were associated with maternal sepsis. CONCLUSION Maternal sepsis rates have been decreasing in Canada but remain higher than those in the UK and USA. Our study explored associations with maternal sepsis and shows that one in seven women with sepsis develop severe sepsis-related morbidity, which warrants risk stratification and health policy changes.
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Affiliation(s)
| | - Leyla Baghirzada
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew Walker
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen Lapinsky
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Mrinalini Balki
- Department of Anesthesiology and Pain Medicine, Department of Obstetrics & Gynaecology, and Department of Physiology, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 7-405, Toronto, ON, M5G 1X5, Canada.
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.
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Lin L, Ren LW, Li XY, Sun W, Chen YH, Chen JS, Chen DJ. Evaluation of the etiology and risk factors for maternal sepsis: A single center study in Guangzhou, China. World J Clin Cases 2021; 9:7704-7716. [PMID: 34621821 PMCID: PMC8462250 DOI: 10.12998/wjcc.v9.i26.7704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/19/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Maternal sepsis is a major cause of gestational morbidity and neonatal mortality worldwide and particularly in China.
AIM To evaluate the etiology of maternal sepsis and further identify its risk factors.
METHODS In this retrospective study, we evaluated 70698 obstetric patients who were admitted to the Third Affiliated Hospital of Guangzhou Medical University between January 1, 2009 and June 30, 2018. Subjects were divided into sepsis group and non-sepsis group based on the incidence of sepsis. Data about medical history (surgical and obstetric history) and demographic information were collected. The Mann-Whitney U test was used to compare patient age, gestational age and duration of hospitalization between the two groups. Univariate and multivariate logistic regression models were used to analyze the etiology and the risk factors for maternal sepsis. Unadjusted and adjusted odds ratios (OR) are reported.
RESULTS A total of 561 of 70698 obstetric patients were diagnosed with infection; of the infected patients, 492 had non-sepsis associated infection (87.7%), while 69 had sepsis (12.3%). The morbidity rate of maternal sepsis was 9.76/10000; the fatality rate in the sepsis group was 11.6% (8/69). Emergency admission (OR = 2.183) or transfer (OR = 2.870), irregular prenatal care (OR = 2.953), labor induction (OR = 4.665), cervical cerclage (OR = 14.214), first trimester (OR = 6.806) and second trimester (OR = 2.09) were significant risk factors for maternal sepsis.
CONCLUSION Mode of admission, poor prenatal care, labor induction, cervical cerclage, first trimester and second trimester pregnancy were risk factors for maternal sepsis. Escherichia coli was the most common causative organism for maternal sepsis, and the uterus was the most common site of infection.
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Affiliation(s)
- Lin Lin
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou 510150, Guangdong Province, China
| | - Lu-Wen Ren
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou 510150, Guangdong Province, China
| | - Xue-Yuan Li
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou 510150, Guangdong Province, China
| | - Wen Sun
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou 510150, Guangdong Province, China
| | - Yan-Hong Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou 510150, Guangdong Province, China
| | - Jing-Si Chen
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou 510150, Guangdong Province, China
- Department of Fetal Medicine and Prenatal Diagnosis, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Dun-Jin Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou 510150, Guangdong Province, China
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Holanda AMC, de Amorim MMR, Bezerra SMB, Aschoff LMS, Katz L. Risk factors for death in patients with sepsis admitted to an obstetric intensive care unit: A cohort study. Medicine (Baltimore) 2020; 99:e23566. [PMID: 33327314 PMCID: PMC7738152 DOI: 10.1097/md.0000000000023566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Leila Katz
- Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)
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8
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Verschueren KJ, Kodan LR, Paidin RR, Samijadi SM, Paidin RR, Rijken MJ, Browne JL, Bloemenkamp KW. Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname. J Glob Health 2020; 10:020429. [PMID: 33214899 PMCID: PMC7649043 DOI: 10.7189/jogh.10.020429] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools. METHODS A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group. RESULTS There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable. CONCLUSIONS The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.
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Affiliation(s)
- Kim Jc Verschueren
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Lachmi R Kodan
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Obstetrics, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - Raëz R Paidin
- Department of Obstetrics, Diakonessen Hospital Paramaribo, Paramaribo, Suriname
| | - Sarah M Samijadi
- Department of Obstetrics, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - Rubinah R Paidin
- Department of Obstetrics, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - Marcus J Rijken
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joyce L Browne
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kitty Wm Bloemenkamp
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Wali A, Ishtiaq A, Rahim A, Iftikhar S. The Impact of Evidence-Based Transformation on Healthcare Practices at a Teaching Hospital. Cureus 2020; 12:e11744. [PMID: 33403174 PMCID: PMC7773286 DOI: 10.7759/cureus.11744] [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] [Indexed: 11/26/2022] Open
Abstract
Objective In this study, we aimed to compare the frequency of anemia, blood transfusions, and the use of antimicrobial therapy (AMT) before the implementation of standard protocols in obstetrics and gynecology with the data after one year of implementation at a teaching hospital. Methods In this retrospective observational study, the pre-intervention data (group A) were compared to the data after the implementation of standard protocols (group B). Data were retrieved from hospital electronic medical records and were entered and analyzed on SPSS Statistics version 24 (IBM, Armonk, NY). Results In obstetrics (n=829), anemia was observed in 43.1% vs. 26.8% (p<0.001) and transfusion rate in 5.4% vs. 0.6% (p<0.001) in the groups A and B respectively. In vaginal deliveries (VD), the use of AMT for >24 hours was 98% in group A vs. 9% in group B, and in cesarean deliveries (CD), it was 100% in group A vs. 54.5% in group B (p<0.001). The cost of AMT decreased by 78.4% in VD and by 51.1% in CD. In gynecology (n=221), the prevalence of anemia was 22.6% in group A vs. 17.9% in group B (p=NS). In minor procedures, the use of AMT for >24 hours was 76.7% vs. 8.4% (p<0.001), and in major procedures, it was 86.5% vs. 38% (p<0.001) between the two groups. The cost of AMT decreased by 79.5% in minor procedures and 26.4% in major procedures. Conclusion The implementation of quality standards can bring about significant improvements in clinical outcomes in a short period of time.
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Affiliation(s)
- Aisha Wali
- Obstetrics and Gynecology, The Indus Hospital, Karachi, PAK
| | | | - Anum Rahim
- Epidemiology and Public Health, The Indus Hospital, Karachi, PAK
| | - Sundus Iftikhar
- Statistics, Indus Hospital Research Center, The Indus Hospital, Karachi, PAK
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An Observational Cohort Study Evaluating Antimicrobial Use in Peripartum Sepsis: A Tendency towards Overdiagnosis? PHARMACY 2020; 8:pharmacy8040211. [PMID: 33187105 PMCID: PMC7712400 DOI: 10.3390/pharmacy8040211] [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: 09/20/2020] [Revised: 11/05/2020] [Accepted: 11/10/2020] [Indexed: 12/04/2022] Open
Abstract
(1) Background: Sepsis is the leading cause of maternal death in 11–15% of women worldwide. This emphasises the importance of administrating timely and appropriate antibiotic therapy to women with sepsis. We aimed to evaluate the appropriateness of antimicrobial prescribing in women diagnosed with peripartum sepsis. (2) Method: A prospective observational cohort study in a single Scottish health region with 12,233 annual live births. Data were collected on women diagnosed with sepsis in the peripartum period using physical and electronic medical records, drug Kardex® (medication administration) and ward handover records. (3) Results: A sepsis diagnosis was concluded in 89 of the 2690 pregnancy cases reviewed, with a median hospital stay of four days. Good overall adherence to the local guidelines for the empiric antimicrobial treatment of sepsis was observed. Group B Streptococcus was associated with 20.8% of maternal sepsis cases, whilst in 60% of clinical specimens tested no causative pathogen was isolated. (4) Conclusion: The lack of specific and sensitive clinical markers for sepsis, coupled with their inconsistent clinical application to inform diagnosis, hindered effective antimicrobial stewardship. This was further exacerbated by the lack of positive culture isolates from clinical specimens, which meant that patients were often continued on broader-spectrum empiric treatment.
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Agarwal R, Goyal P, Mohta M, Kar R. Comparison of Sequential Organ Failure Assessment (SOFA) and Sepsis in Obstetrics Score (SOS) in Women with Pregnancy-Associated Sepsis with Respect to Critical Care Admission and Mortality: A Prospective Observational Study. J Obstet Gynaecol India 2020; 71:45-51. [PMID: 33814798 DOI: 10.1007/s13224-020-01375-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/02/2020] [Indexed: 11/27/2022] Open
Abstract
Objective We aimed to determine performance of sequential organ failure assessment (SOFA) and Sepsis in Obstetrics Score (SOS), in women with pregnancy-associated sepsis (PAS) with respect to critical care admission and mortality. Methods Obstetric patients with PAS fulfilling any 2 of the quick SOFA (qSOFA) criteria were enrolled as cases. The various parameters of SOFA and SOS were recorded at admission and compared for outcomes. Results Critical care was required in 32 (50.7%) patients and associated mortality was high (31.7%). For our study population, a threshold of SOFA ≥ 6 had the best combination of sensitivity (84.4%) and specificity (61.3%) for critical care admission. For SOS, a cut-off value of ≥ 6 gave best sensitivity (64%) and specificity (40%) for the same. Conclusions SOFA was far more predictive of patient's critical condition as well as mortality compared to SOS. SOFA was superior to SOS in determining critical care admission and mortality for PAS.
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Affiliation(s)
- Rachna Agarwal
- Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Penzy Goyal
- Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Medha Mohta
- Department of Anaesthesia, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Rajarshi Kar
- Department of Biochemistry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
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12
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Haith-Cooper M, Stacey T, Bailey F, Broadhead-Croft S. The Co-development and Feasibility-Testing of an Innovative Digital Animation Intervention (DAISI) to Reduce the Risk of Maternal Sepsis in the Postnatal Period. Matern Child Health J 2020; 24:837-844. [PMID: 32356131 PMCID: PMC7261264 DOI: 10.1007/s10995-020-02932-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Sepsis is one of the most common causes of mortality in postnatal women globally and many other women who develop sepsis are left with severe morbidity. Women's knowledge of postnatal sepsis and how it can be prevented by simple changes to behaviour is lacking. METHODS This paper describes the co-development and feasibility testing of a digital animation intervention called DAISI (digital animation in service improvement). This DAISI is designed to enhance postnatal women's awareness of sepsis and how to reduce their risk of developing the condition. We co-designed the digital animation over a six-month period underpinned by theory, best evidence and key stakeholders, translated it into Urdu then assessed its use, firstly in a focus group with women from different Black, Asian and Minority Ethnic (BAME) groups and secondly with 15 clinical midwives and 15 women (including BAME women). Following exposure to the intervention, midwives completed a questionnaire developed from the COM-B behaviour change model and women participated in individual and focus group interviews using similar questions. RESULTS The animation was considered acceptable, culturally sensitive and simple to implement and follow. DISCUSSION DAISI appears to be an innovative solution for use in maternity care to address difficulties with the postnatal hospital discharge process. We could find no evidence of digital animation being used in this context and recommend a study to test it in practice prior to adopting its use more widely. If effective, the DAISI principle could be used in other maternity contexts and other areas of the NHS to communicate health promotion information.
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Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. Am J Obstet Gynecol 2019; 220:B2-B10. [PMID: 30684460 DOI: 10.1016/j.ajog.2019.01.216] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality and is a preventable cause of maternal death. The purpose of this guideline is to summarize what is known about sepsis and to provide guidance for the management of sepsis in pregnancy and the postpartum period. The following are SMFM recommendations: (1) we recommend that sepsis and septic shock be considered medical emergencies and that treatment and resuscitation begin immediately (GRADE 1B); (2) we recommend that providers consider the diagnosis of sepsis in pregnant patients with otherwise unexplained end-organ damage in the presence of an infectious process, regardless of the presence of fever (GRADE 1B); (3) we recommend that empiric broad-spectrum antibiotics be administered as soon as possible, ideally within 1 hour, in any pregnant woman in whom sepsis is suspected (GRADE 1B); (4) we recommend obtaining cultures (blood, urine, respiratory, and others as indicated) and serum lactate levels in pregnant or postpartum women in whom sepsis is suspected or identified, and early source control should be completed as soon as possible (GRADE 1C); (5) we recommend early administration of 1-2 L of crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (6) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period in sepsis with persistent hypotension and/or hypoperfusion despite fluid resuscitation (GRADE 1C); (7) we recommend against immediate delivery for the sole indication of sepsis and that delivery should be dictated by obstetric indications (GRADE 1B).
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Mohamed-Ahmed O, Hinshaw K, Knight M. Operative vaginal delivery and post-partum infection. Best Pract Res Clin Obstet Gynaecol 2018; 56:93-106. [PMID: 30992125 DOI: 10.1016/j.bpobgyn.2018.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/17/2018] [Accepted: 09/23/2018] [Indexed: 10/28/2022]
Abstract
During the past decade, there has been an increase in the awareness of infections associated with pregnancy and delivery. The most significant cause of post-partum infection is caesarean section; 20-25% of operations are followed by wound infections, endometritis or urinary tract infections. Approximately 13% of women in the UK undergo operative vaginal delivery (OVD) with forceps or vacuum, which is also associated with an increased risk of infection, estimated at 0.7%-16% of these deliveries. Despite this, previous reviews have identified only one small trial of antibiotic prophylaxis in 393 women and concluded that there was insufficient evidence to support the routine use of prophylactic antibiotics after OVD. The ANODE trial, a multicentre, blinded, placebo-controlled trial from the UK, is due to report findings from more than 3400 women in 2019 and will be the largest study to date of antibiotic prophylaxis following OVD.
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Affiliation(s)
- Olaa Mohamed-Ahmed
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Kim Hinshaw
- City Hospitals Sunderland NHS Foundation Trust, Faculty of Health Sciences, University of Sunderland, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK.
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Kodan LR, Verschueren KJC, Kanhai HHH, van Roosmalen JJM, Bloemenkamp KWM, Rijken MJ. The golden hour of sepsis: An in-depth analysis of sepsis-related maternal mortality in middle-income country Suriname. PLoS One 2018; 13:e0200281. [PMID: 29990331 PMCID: PMC6039050 DOI: 10.1371/journal.pone.0200281] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 06/22/2018] [Indexed: 12/02/2022] Open
Abstract
Background Sepsis was the main cause of maternal mortality in Suriname, a middle-income country. Objective of this study was to perform a qualitative analysis of the clinical and management aspects of sepsis-related maternal deaths with a focus on the ‘golden hour’ principle of antibiotic therapy. Methods A nationwide reproductive age mortality survey was performed from 2010 to 2014 to identify and audit all maternal deaths in Suriname. All sepsis-related deaths were reviewed by a local expert committee to assess socio-demographic characteristics, clinical aspects and substandard care. Results Of all 65 maternal deaths in Suriname 29 (45%) were sepsis-related. These women were mostly of low socio-economic class (n = 23, 82%), of Maroon ethnicity (n = 14, 48%) and most deaths occurred postpartum (n = 21, 72%). Underlying causes were pneumonia (n = 14, 48%), wound infections (n = 3, 10%) and endometritis (n = 3, 10%). Bacterial growth was detected in 10 (50%) of the 20 available blood cultures. None of the women with sepsis as underlying cause of death received antibiotic treatment within the first hour, although most women fulfilled the diagnostic criteria of sepsis upon admission. In 27 (93%) of the 29 women from which sufficient information was available, substandard care factors were identified: delay in monitoring in 16 (59%) women, in diagnosis in 17 (63%) and in treatment in 21 (78%). Conclusion In Suriname, a middle-income country, maternal mortality could be reduced by improving early recognition and timely diagnosis of sepsis, vital signs monitoring and immediate antibiotic infusion (within the golden hour).
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Affiliation(s)
- Lachmi R. Kodan
- Department of Obstetrics and Gynaecology, Academical Hospital Paramaribo (AZP), Paramaribo, Suriname
- Department of Obstetrics, Division Women and Baby, Birth Centre, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Global Health, The Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - Kim J. C. Verschueren
- Department of Obstetrics, Division Women and Baby, Birth Centre, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Humphrey H. H. Kanhai
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
- Anton de Kom University, Paramaribo, Suriname
| | - Jos J. M. van Roosmalen
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
- Athena Institute, VU University Amsterdam, Amsterdam, the Netherlands
| | - Kitty W. M. Bloemenkamp
- Department of Obstetrics, Division Women and Baby, Birth Centre, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcus J. Rijken
- Department of Obstetrics, Division Women and Baby, Birth Centre, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Global Health, The Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing clinical conundrum. Am J Obstet Gynecol 2018; 219:52-61. [PMID: 29305251 DOI: 10.1016/j.ajog.2017.12.232] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/16/2017] [Accepted: 12/27/2017] [Indexed: 02/03/2023]
Abstract
While global maternal mortality has decreased in the last 25 years, the maternal mortality ratio in the United States has actually increased. Maternal mortality is a complex phenomenon involving multifaceted socioeconomic and clinical parameters including inequalities in access to health care, racial and ethnic disparities, maternal comorbidities, and epidemiologic ascertainment bias. Escalating maternal mortality underscores the importance of clinician preparedness to respond to maternal cardiac arrest that may occur in any maternal health care setting. Management of maternal cardiac arrest requires an interdisciplinary team familiar with the physiologic changes of pregnancy and the maternal resuscitation algorithm. Interventions intended to mitigate obstacles such as aortocaval compression, which may undermine the success of resuscitation interventions, must be performed concurrent to standard basic and advanced cardiac life support maneuvers. High-quality chest compressions and oxygenation must be performed along with manual left lateral uterine displacement when the uterine size is ≥20 weeks. While deciphering the etiology of maternal cardiac arrest, diagnoses unique to pregnancy and those of the nonpregnant state should be considered at the same time. If initial basic life support and advanced cardiac life support interventions fail to restore maternal circulation within 4 minutes of cardiac arrest, perimortem delivery is advised provided the uterus is ≥20 weeks' size. Preparations for perimortem delivery are best anticipated by the resuscitation team for the procedure to be executed opportunely. Following delivery, intraabdominal examination may reveal a vascular catastrophe, hematoma, or both. If return of spontaneous circulation has not been achieved, additional interventions may include cardiopulmonary bypass and/or extracorporeal membrane oxygenation. Simulation and team training enhance institution readiness for maternal cardiac arrest. Knowledge gaps are significant in the science of maternal resuscitation. Further research is required to fully optimize: relief of aortocaval compression during the resuscitation process, gestational age and timing of perimortem delivery, and other interventions that deviate from nonpregnant standard resuscitation protocol to achieve successful maternal resuscitation. A robust detailed national and international prospective database was recommended by the International Liaison Committee on Resuscitation in 2015 to facilitate further research unique to cardiac arrest during pregnancy that will produce optimal resuscitation techniques for maternal cardiac arrest.
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18
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Zöllner J, Howe LG, Edey LF, O'Dea KP, Takata M, Gordon F, Leiper J, Johnson MR. The response of the innate immune and cardiovascular systems to LPS in pregnant and nonpregnant mice. Biol Reprod 2018; 97:258-272. [PMID: 29044422 DOI: 10.1093/biolre/iox076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 07/13/2017] [Indexed: 11/14/2022] Open
Abstract
Sepsis is the leading cause of direct maternal mortality, but there are no data directly comparing the response to sepsis in pregnant and nonpregnant (NP) individuals. This study uses a mouse model of sepsis to test the hypothesis that the cardiovascular response to sepsis is more marked during pregnancy. Female CD1 mice had radiotelemetry probes implanted and were time mated. NP and day 16 pregnant CD-1 mice received intraperitoneal lipopolysaccharide (LPS; 10 μg, serotype 0111: B4). In a separate study, tissue and serum (for RNA, protein and flow cytometry studies), aorta and uterine vessels (for wire myography) were collected after LPS or vehicle control administration. Administration of LPS resulted in a greater fall in blood pressure in pregnant mice compared to NP mice. This occurred with similar changes in the circulating levels of cytokines, vasoactive factors, and circulating leukocytes, but with a greater monocyte and lesser neutrophil margination in the lungs of pregnant mice. Baseline markers of cardiac dysfunction and apoptosis as well as cytokine expression were higher in pregnant mice, but the response to LPS was similar in both groups as was the ex vivo assessment of vascular function. In pregnant mice, nonfatal sepsis is associated with a more marked hypotensive response but not a greater immune response. We conclude that endotoxemia induces a more marked hypotensive response in pregnant compared to NP mice. These changes were not associated with a more marked systemic inflammatory response in pregnant mice, although monocyte lung margination was greater. The more marked hypotensive response to LPS may explain the greater vulnerability to some infections exhibited by pregnant women.
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Affiliation(s)
- Julia Zöllner
- Imperial College Parturition Research Group, Chelsea and Westminster Hospital, 369 Fulham Road, London, UK.,Imperial College Parturition Research Group, Institute of Reproductive and Developmental Biology, Hammersmith Hospital Campus DuCane Road, London, UK.,MRC Clinical Sciences Centre, Hammersmith Hospital Campus, DuCane Road, London, UK
| | - Laura G Howe
- Imperial College Parturition Research Group, Chelsea and Westminster Hospital, 369 Fulham Road, London, UK.,Imperial College Parturition Research Group, Institute of Reproductive and Developmental Biology, Hammersmith Hospital Campus DuCane Road, London, UK.,MRC Clinical Sciences Centre, Hammersmith Hospital Campus, DuCane Road, London, UK
| | - Lydia F Edey
- Imperial College Parturition Research Group, Chelsea and Westminster Hospital, 369 Fulham Road, London, UK.,Imperial College Parturition Research Group, Institute of Reproductive and Developmental Biology, Hammersmith Hospital Campus DuCane Road, London, UK
| | - Kieran P O'Dea
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Faculty of Medicine, Chelsea and Westminster Hospital, London, UK
| | - Masao Takata
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Faculty of Medicine, Chelsea and Westminster Hospital, London, UK
| | - Fabiana Gordon
- Statistical Advisory Service, School Of Public Health, UG15, Ground Floor (Mezzanine), Medical School, St Mary's Campus, Norfolk Place, London, UK
| | - James Leiper
- MRC Clinical Sciences Centre, Hammersmith Hospital Campus, DuCane Road, London, UK
| | - Mark R Johnson
- Imperial College Parturition Research Group, Chelsea and Westminster Hospital, 369 Fulham Road, London, UK.,Imperial College Parturition Research Group, Institute of Reproductive and Developmental Biology, Hammersmith Hospital Campus DuCane Road, London, UK
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Abstract
PURPOSE OF REVIEW This review outlines the challenges in looking after pregnant women with thromboembolism and sepsis who either become or are at risk of becoming critically ill during pregnancy. RECENT FINDINGS The Pregnancy Mortality Surveillance systems in both the USA and UK record the most common causes of maternal death as thromboembolism and sepsis. Both of these conditions have improved outcomes with timely maternal critical care provided by a multidisciplinary team. SUMMARY In this review, we discuss the pathophysiology, diagnosis, and management of thromboembolism and sepsis, two very important conditions with high mortality requiring admission to intensive care.
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Bowyer L, Robinson HL, Barrett H, Crozier TM, Giles M, Idel I, Lowe S, Lust K, Marnoch CA, Morton MR, Said J, Wong M, Makris A. SOMANZ guidelines for the investigation and management sepsis in pregnancy. Aust N Z J Obstet Gynaecol 2017; 57:540-551. [PMID: 28670748 DOI: 10.1111/ajo.12646] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 04/24/2017] [Indexed: 12/14/2022]
Abstract
SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence-based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence-based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non-infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines.
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Affiliation(s)
- Lucy Bowyer
- Maternal Fetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Helen L Robinson
- Department of Medicine, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Helen Barrett
- Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Timothy M Crozier
- Intensive Care, Monash Medical Health, Melbourne, Victoria, Australia
| | - Michelle Giles
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Irena Idel
- Department of Nephrology, Eastern Health, Melbourne, Victoria, Australia
| | - Sandra Lowe
- Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Karin Lust
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Mark R Morton
- Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Joanne Said
- Department of Maternal Fetal Medicine, Sunshine Hospital, Melbourne, Victoria, Australia.,Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Maggie Wong
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Angela Makris
- Department of Nephrology, Liverpool Hospital, Liverpool, New South Wales, Australia.,Department of Medicine, Western Sydney University, Sydney, New South Wales, Australia
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23
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Abstract
PURPOSE OF REVIEW This article examines the contemporary knowledge and uncertainties about the burden of pregnancy-associated severe sepsis (PASS), and its manifestations, management, and outcomes. RECENT FINDINGS There are relatively sparse data on PASS, related in part to infrequent reports and varying use of terminology and case definitions. PASS remains rare, although its incidence appears to be rapidly rising in some high-resource countries, affecting especially women with limited resources, minorities, and those with chronic illness. High level of clinician vigilance and rapid initiation of appropriate antimicrobial therapy, coupled with effective systemic support for organ dysfunction and correction of occult and overt hypoperfusion are the keys to limit adverse outcomes. However, timely diagnosis and provision of effective care remain a challenge, with reported prevalent delay in recognition and delivery of time-sensitive care interventions among maternal decedents. The mortality rate of PASS has been rising and its case fatality, although relatively low, has remained unchanged, in contrast to the outcome gains in the general population. The long-term sequelae of PASS remain unknown. SUMMARY The relatively limited contemporary data on PASS suggest a rising public health hazard in the obstetric population in high-resource countries, with ongoing challenges in assuring consistent provision of time-sensitive care.
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Abstract
Sepsis accounts for up to 28% of all maternal deaths. Prompt, appropriate treatment improves maternal and fetal morbidity and mortality. To date, there are no validated tools for identification of sepsis in pregnant women, and tools used in the general population tend to overestimate mortality. Once identified, management of pregnancy-associated sepsis is goal-directed, but because of the lack of studies of sepsis management in pregnancy, it must be assumed that modifications need to be made on the basis of the physiologic changes of pregnancy. Key to management is early fluid resuscitation and early initiation of appropriate antimicrobial therapy directed toward the likely source of infection or, if the source is unknown, empiric broad-spectrum therapy. Efforts directed at identifying the source of infection and appropriate source control measures are critical. Development of an illness severity scoring system and treatment algorithms validated in pregnant women needs to be a research priority.
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Mohamed-Ahmed O, Nair M, Acosta C, Kurinczuk JJ, Knight M. Progression from severe sepsis in pregnancy to death: a UK population-based case-control analysis. BJOG 2015. [PMID: 26213333 PMCID: PMC5008196 DOI: 10.1111/1471-0528.13551] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective To identify factors associated with progression from pregnancy‐associated severe sepsis to death in the UK. Design A population‐based case‐control analysis using data from the UK Obstetric Surveillance System (UKOSS) and the UK Confidential Enquiry into Maternal Death (CEMD). Setting All pregnancy care and death settings in UK hospitals. Population All non‐influenza sepsis‐related maternal deaths (January 2009 to December 2012) were included as cases (n = 43), and all women who survived severe non‐influenza sepsis in pregnancy (June 2011 to May 2012) were included as controls (n = 358). Methods Cases and controls were identified using the CEMD and UKOSS. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals. Main outcome measures Odds ratios for socio‐demographic, medical, obstetric and management factors in women who died from sepsis, compared with those who survived. Results Four factors were included in the final regression model. Women who died were more likely to have never received antibiotics [aOR = 22.7, 95% confidence interval (CI) 3.64–141.6], to have medical comorbidities (aOR = 2.53, 95%CI 1.23–5.23) and to be multiparous (aOR = 3.57, 95%CI 1.62–7.89). Anaemia (aOR = 13.5, 95%CI 3.17–57.6) and immunosuppression (aOR = 15.0, 95%CI 1.93–116.9) were the two most important factors driving the association between medical comorbidities and progression to death. Conclusions There must be continued vigilance for the risks of infection in pregnant women with medical comorbidities. Improved adherence to national guidelines, alongside prompt recognition and treatment with antibiotics, may reduce the burden from sepsis‐related maternal deaths. Tweetable abstract Medical comorbidities, multiparity and antibiotic delays increase the risk of death from maternal sepsis.
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Affiliation(s)
- O Mohamed-Ahmed
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - M Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - C Acosta
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - J J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - M Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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