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Obstetrics and Gynecology Mar 2024To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions.
OBJECTIVE
To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions.
METHODS
This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion.
RESULTS
We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum.
CONCLUSION
For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.
Topics: Pregnancy; Female; Humans; Case-Control Studies; Postpartum Period; Hospitalization; Puerperal Infection; Sepsis; Systemic Inflammatory Response Syndrome; Retrospective Studies
PubMed: 38086052
DOI: 10.1097/AOG.0000000000005480 -
International Journal of Environmental... Mar 2024Fever is one of the most important signs of infection and can provide useful information for further assessment, diagnosis, and management. Early detection of postnatal...
Fever is one of the most important signs of infection and can provide useful information for further assessment, diagnosis, and management. Early detection of postnatal fever could reduce severe outcomes, such as maternal mortality due to puerperal sepsis. The purpose of this cross-sectional study was to determine the prevalence of and associated factors of postnatal fever among postnatal women at Kawempe National Referral Hospital. Three hundred postnatal women were recruited. Temperature measurements were conducted and a 29-item questionnaire was completed along with the extraction of health history from the medical records of the participants. The prevalence of maternal fever was 58/300 (19.3%). Multivariable analysis indicated that only four factors-HIV-positive status (AOR = 2.56; 95% CI = 1.02-6.37), labor complications (AOR = 6.53; 95% CI = 2.40-17.71), prolonged labor (AOR = 3.12; 95% CI = 1.11-8.87), and more than 24 h spent in postnatal care (AOR = 5.16; 95% CI = 2.19-12.16)-were found to be significantly associated with postnatal fever. The prevalence of postnatal maternal fever among postnatal women at Kawempe National Referral Hospital was higher than that in other reports in the literature. The factors significantly associated with maternal fever were HIV-positive status, complications during labor, prolonged labor, and more than 24 h spent in postnatal care. Health workers involved in the provision of labor and obstetric services must follow guidelines to assess fever and manage the underlying conditions causing it.
Topics: Pregnancy; Humans; Female; Uganda; Prevalence; Cross-Sectional Studies; Pregnancy Complications; Hospitals; HIV Infections; Referral and Consultation
PubMed: 38541315
DOI: 10.3390/ijerph21030316 -
Medicine Aug 2023Placental residue is a relatively common and sophisticated disease among obstetric delivery complications. A failure to detect placental residue in time may cause poor...
RATIONALE
Placental residue is a relatively common and sophisticated disease among obstetric delivery complications. A failure to detect placental residue in time may cause poor outcomes such as postpartum hemorrhage and puerperal infection.
PATIENT CONCERNS
We present the case of a 33-year-old full-term singleton parturient with placental residue. Upon precipitate labor and childbirth, the placenta and fetal membranes were examined to be intact. However, 1 day after discharge, she felt that there was discharge from the vagina and thus presented to our emergency department.
DIAGNOSES
The patient was diagnosed with residual membranes and readmitted to the hospital for uterine curettage.
INTERVENTION
Uterine curettage was performed under B-ultrasound guidance.
OUTCOME
The patient was discharged smoothly without any postoperative complications.
LESSONS
This paper can provide significant enlightenment for the prevention and early treatment of placental residue, including enhancing the risk awareness of high-risk patients, standardizing the process of clinical examination of the placenta, and early uterine contraction promotion to assist in the discharge of residual tissue, so as to reduce the occurrence of placental residue.
Topics: Pregnancy; Humans; Female; Adult; Patient Discharge; Placenta; Patient Readmission; Delivery, Obstetric; Extraembryonic Membranes
PubMed: 37565921
DOI: 10.1097/MD.0000000000034565 -
International Health Jan 2024Anaemia in pregnancy is one of the most frequent complications related to pregnancy and is a public health concern. This article examines the prevalence of anaemia in...
BACKGROUND
Anaemia in pregnancy is one of the most frequent complications related to pregnancy and is a public health concern. This article examines the prevalence of anaemia in the third trimester of pregnancy and the associations between anaemia and adverse perinatal outcomes in Hebei Province, China.
METHODS
We used SPSS software to describe the incidence of anaemia in the third trimester of pregnancy in Hebei Province and analysed the clinical characteristics in anaemic patients and the relationship between anaemia and adverse pregnancy outcomes.
RESULTS
The overall prevalence of anaemia in the third trimester of pregnancy was 35.0% in Hebei Province. The prevalence of anaemia in the population with a high education level was lower than that in the population with a low education level. The incidence rate in rural areas was higher than that in urban areas. After adjustment for confounding factors, anaemia in the third trimester of pregnancy is an independent risk factor in terms of placenta previa, placental abruption, uterine atony, pre-eclampsia, gestational diabetes mellitus, heart disease, postpartum haemorrhage, premature birth, laceration of birth canal, puerperal infection, caesarean section and large for gestational age.
CONCLUSIONS
The prevalence of anaemia in the third trimester of pregnancy is associated with an increased risk of adverse perinatal outcomes. A comprehensive approach to prevent anaemia is needed to improve maternal and child health outcomes.
Topics: Child; Pregnancy; Humans; Female; Pregnancy Trimester, Third; Cesarean Section; Prevalence; Placenta; Pregnancy Outcome; Anemia
PubMed: 37093789
DOI: 10.1093/inthealth/ihad028 -
American Journal of Obstetrics and... Jun 2024Intrapartum fever (>38°C) is associated with adverse maternal and neonatal outcomes. However, the correlation between low-grade fever (37.5°C-37.9°C) and adverse...
BACKGROUND
Intrapartum fever (>38°C) is associated with adverse maternal and neonatal outcomes. However, the correlation between low-grade fever (37.5°C-37.9°C) and adverse perinatal outcomes remains controversial.
OBJECTIVE
This study aimed to compare maternal and neonatal outcomes of women with prolonged rupture of membranes (≥12 hours) at term between those with low-grade fever and those with normal body temperature.
STUDY DESIGN
This retrospective study included women hospitalized in a tertiary university-affiliated hospital between July 2021 and May 2023 with singleton term and rupture of membranes ≥12 hours. Women were classified as having intrapartum low-grade fever (37.5°C-37.9°C) or normal body temperature (<37.5°C). The co-primary outcomes, postpartum endometritis and neonatal intensive care unit admission rates, were compared between these groups. The secondary maternal outcomes were intrapartum leukocytosis (>15,000/mm), cesarean delivery rate, postpartum hemorrhage, postpartum fever, surgical site infection, and postpartum length of stay. The secondary neonatal outcomes were early-onset sepsis, 5-minute Apgar score of <7, umbilical artery cord pH<7.2 and pH<7.05, neonatal intensive care unit admission length of stay, and respiratory distress. The data were analyzed according to rupture of membranes 12 to 18 hours and rupture of membranes ≥18 hours. In women with rupture of membranes ≥18 hours, intrapartum ampicillin was administered, and chorioamniotic membrane swabs were obtained. The likelihood ratios and 95% confidence intervals were calculated for the co-primary outcomes. A multivariate logistic regression model was used to predict puerperal endometritis controlled for rupture of membranes duration, low-grade fever (compared with normal body temperature), positive group B streptococcus status, mechanical cervical ripening, cervical ripening by prostaglandins, artificial rupture of membranes, meconium staining, epidural analgesia, and cesarean delivery. A multivariate logistic regression model was used to predict neonatal intensive care unit admission controlled for rupture of membranes duration, low-grade fever, positive group B streptococcus status, mechanical cervical ripening, artificial rupture of membranes, meconium staining, cesarean delivery, and neonatal weight of <2500 g.
RESULTS
This study included 687 women with rupture of membranes 12 to 18 hours and 1109 with rupture of membranes ≥18 hours. In both latency groups, the rates were higher for cesarean delivery, endometritis, surgical site infections, umbilical cord pH<7.2, neonatal intensive care unit admission, and sepsis workup among those with low-grade fever than among those with normal body temperature. Among women with low-grade fever, the positive likelihood ratios were 12.7 (95% confidence interval, 9.6-16.8) for puerperal endometritis and 3.2 (95% confidence interval, 2.0-5.3) for neonatal intensive care unit admission. Among women with rupture of membranes ≥18 hours, the rates were higher of Enterobacteriaceae isolates in chorioamniotic membrane cultures for those with low-grade fever than for those with normal intrapartum temperature (22.0% vs 11.0%, respectively; P=.006). Low-grade fever (odds ratio, 9.0; 95% confidence interval, 3.7-21.9; P<.001), artificial rupture of membranes (odds ratio, 4.2; 95% confidence interval, 1.5-11.7; P=.007), and cesarean delivery (odds ratio, 5.4; 95% confidence interval, 2.2-13.4; P<.001) were independently associated with puerperal endometritis. Low-grade fever (odds ratio, 3.2; 95% confidence interval, 1.7-6.0; P<.001) and cesarean delivery (odds ratio, 1.9; 95% confidence interval, 1.1-13.1; P=.023) were independently associated with neonatal intensive care unit admission.
CONCLUSION
In women with rupture of membranes ≥12 hours at term, higher maternal and neonatal morbidities were reported among those with low-grade fever than among those with normal body temperature. Low-grade fever was associated with a higher risk of Enterobacteriaceae isolates in chorioamniotic membrane cultures. Moreover, low-grade fever may be the initial presentation of peripartum infection.
PubMed: 38871240
DOI: 10.1016/j.ajog.2024.05.054 -
BMJ Case Reports Nov 2023Group A (GAS) in the setting of postpartum endometritis can have severe and life-threatening complications. We report a rare case of septic pulmonary emboli that we...
Group A (GAS) in the setting of postpartum endometritis can have severe and life-threatening complications. We report a rare case of septic pulmonary emboli that we surmised to have originated from septic pelvic thrombosis in the setting of GAS toxic shock syndrome (TSS) secondary to postpartum endometritis and intrauterine demise. Although the patient had source control with hysterectomy, she continued to have new septic emboli to the lungs seen on CT scans. CT scan of the pelvis demonstrated several filling defects in the renal and pelvic veins. The patient eventually responded well to anticoagulation in addition to antibiotics, which is similar to cases of Lemierre's syndrome. Additionally, we would like to bring attention to how important radiological findings can be missed if there is lack of interspecialty communication about the patient's clinical situation.
Topics: Female; Pregnancy; Humans; Shock, Septic; Endometritis; Thrombophlebitis; Sepsis; Streptococcus pyogenes; Puerperal Infection; Soft Tissue Infections; Pelvis
PubMed: 37996149
DOI: 10.1136/bcr-2023-255455 -
BJOG : An International Journal of... May 2024The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and...
OBJECTIVE
The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period.
DESIGN
A population-based cohort study.
SETTING
Regions of Stockholm and Gotland, Sweden, 2008-2020.
POPULATION
A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups.
METHODS
The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed.
MAIN OUTCOME MEASURES
Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures.
RESULTS
The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage.
CONCLUSIONS
Increasing active first stage duration is associated with maternal complications in the early postpartum period.
Topics: Pregnancy; Female; Humans; Lacerations; Delivery, Obstetric; Cohort Studies; Urinary Retention; Postpartum Period; Puerperal Infection; Perineum; Hematoma
PubMed: 37840230
DOI: 10.1111/1471-0528.17692 -
PloS One 2024The acute respiratory infection caused by severe acute respiratory syndrome coronavirus disease (COVID-19) has resulted in increased mortality among pregnant, puerperal,...
Impact of COVID-19 pandemic in the Brazilian maternal mortality ratio: A comparative analysis of Neural Networks Autoregression, Holt-Winters exponential smoothing, and Autoregressive Integrated Moving Average models.
BACKGROUND AND OBJECTIVES
The acute respiratory infection caused by severe acute respiratory syndrome coronavirus disease (COVID-19) has resulted in increased mortality among pregnant, puerperal, and neonates. Brazil has the highest number of maternal deaths and a distressing fatality rate of 7.2%, more than double the country's current mortality rate of 2.8%. This study investigates the impact of the COVID-19 pandemic on the Brazilian Maternal Mortality Ratio (BMMR) and forecasts the BMMR up to 2025.
METHODS
To assess the impact of the COVID-19 pandemic on the BMMR, we employed Holt-Winters, Autoregressive Integrated Moving Average (ARIMA), and Neural Networks Autoregression (NNA). We utilized a retrospective time series spanning twenty-five years (1996-2021) to forecast the BMMR under both a COVID-19 pandemic scenario and a controlled COVID-19 scenario.
RESULTS
Brazil consistently exhibited high maternal mortality values (mean BMMR [1996-2019] = 57.99 ±6.34/100,000 live births) according to World Health Organization criteria. The country experienced its highest mortality peak in the historical BMMR series in the second quarter of 2021 (197.75/100,000 live births), representing a more than 200% increase compared to the previous period. Holt-Winter and ARIMA models demonstrated better agreement with prediction results beyond the sample data, although NNA provided a better fit to previous data.
CONCLUSIONS
Our study revealed an increase in BMMR and its temporal correlation with COVID-19 incidence. Additionally, it showed that Holt-Winter and ARIMA models can be employed for BMMR forecasting with lower errors. This information can assist governments and public health agencies in making timely and informed decisions.
Topics: Humans; Infant, Newborn; Brazil; COVID-19; Forecasting; Maternal Mortality; Neural Networks, Computer; Pandemics; Retrospective Studies; Female; Pregnancy
PubMed: 38295029
DOI: 10.1371/journal.pone.0296064 -
Gynecologie, Obstetrique, Fertilite &... Apr 2024Over the 2016-2018 period, maternal mortality due to direct infectious causes accounted for 13% of maternal deaths by direct causes. The increasing trend in...
Over the 2016-2018 period, maternal mortality due to direct infectious causes accounted for 13% of maternal deaths by direct causes. The increasing trend in genital-tract infections related-deaths noted in the 2013-2015 report continues for the 2016-2018 period, but this 2010-2018 increase remains at the limit of statistical significance given the low number of cases (p 0.08). The 13 deaths from direct infectious causes for the 2016-2018 period were due to 4 cases of puerperal toxic shock syndrome (Streptococcus A beta hemolyticus or Clostridium group bacilli), 6 sepsis caused by intrauterine infection due to E. Coli and 3 cases of septic shock from intrauterine origin and no documented bacteria. In this 2016-2018 triennium, the quality of care concerning women who died of direct infections was considered non-optimal in 85% (11/13). Death was considered possibly or probably avoidable in 9/13 cases (69%), which made it one of the most avoidable causes of maternal mortality. Preventable factors related to the medical management were the most frequent (9/13), with in particular a diagnostic failure or delayed diagnosis leading to a delay in the introduction of medical treatment. The others contributory factors to these deaths were related to the organization of healthcare (delayed transfer, lack of communication between practitioners) as well as factors related to patient social and/or mental vulnerability.
Topics: Female; Humans; Maternal Mortality; Reproductive Tract Infections; Escherichia coli; Maternal Death; Delivery of Health Care; Shock, Septic; France
PubMed: 38382839
DOI: 10.1016/j.gofs.2024.02.014 -
American Journal of Perinatology Feb 2024As body mass index increases, the risk of postpartum infections has been shown to increase. However, most studies lump women with a body mass index (BMI) of above...
OBJECTIVE
As body mass index increases, the risk of postpartum infections has been shown to increase. However, most studies lump women with a body mass index (BMI) of above 40 kg/m together, making risk assessment for women in higher BMI categories challenging. The objective of this study was to evaluate the impact of extreme obesity on postpartum infectious morbidity and wound complications during the postpartum period.
STUDY DESIGN
The present study is a secondary analysis of women who underwent cesarean delivery and had BMI ≥ 40 kg/m in the Maternal-Fetal Medicine Units Cesarean Registry. The primary outcome was a composite of postpartum infectious morbidity including endometritis, wound infection, inpatient wound complication prior to discharge, and readmission due to wound complications. Appropriate statistics used to compare baseline demographics, pregnancy complications, and primary outcomes among women by increasing BMI groups (40-49.9, 50-59.9, 60-69.9, and >70 kg/m).
RESULTS
Rates of postpartum infectious morbidity increased with BMI category (11.7% BMI: 50-59.9 kg/m; 13.7% BMI: 60-69.9 kg/m; and 21.9% BMI >70+ kg/m; = 0.001). Readmission for wound complications also increased with BMI (3.1% for BMI: 50-59.9 kg/m; 6.2% for BMI: 60-69.9 kg/m; and 9.4% for BMI >70+ kg/m; = 0.001). After adjusting for confounders, increased BMI of 70+ kg/m category remained the most significant predictor of postpartum infectious complications compared with women with BMI of 40 to 49.9 kg/m (adjusted odds ratio [aOR] = 6.38; 95% confidence interval [CI]: 1.37-29.7). The adjusted odds of readmission also increased with BMI (aOR = 2.33, 95% CI: 1.35-4.02 for BMI 50-59.9 kg/m; aOR = 4.91, 95% CI: 2.07-11.7 for BMI of 60-69.9 kg/m; and aOR = 36.2, 95% CI: 7.45-176 for BMI >70 kg/m).
CONCLUSION
Women with BMI 50 to 70+ kg/m are at an increased risk of postpartum wound infections and complications compared with women with BMI 40 to 49.9 kg/m. These data provide increased guidance for counseling women with an extremely elevated BMI and highlight the importance of postpartum wound prevention bundles.
KEY POINTS
· Women with super obesity have higher rates of wound complications.. · Women at extremes of obesity experience worse postpartum infectious morbidity.. · More research is needed on effective strategies to minimize morbidity in this population..
Topics: Pregnancy; Female; Humans; Body Mass Index; Cesarean Section; Obesity; Postpartum Period; Puerperal Infection; Morbidity; Retrospective Studies
PubMed: 34710942
DOI: 10.1055/a-1682-2976