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Obstetrics and Gynecology Aug 2021Maternal sepsis is an obstetric emergency and a leading cause of maternal morbidity and mortality. Early recognition in a pregnant or postpartum patient can be a... (Review)
Review
Maternal sepsis is an obstetric emergency and a leading cause of maternal morbidity and mortality. Early recognition in a pregnant or postpartum patient can be a challenge as the normal physiologic changes of pregnancy may mask the signs and symptoms of sepsis. Bedside assessment tools may aid in the detection of maternal sepsis. Timely and targeted antibiotic therapy and fluid resuscitation are critical for survival in patients with suspected sepsis. Once diagnosed, a search for etiologies and early application of source control measures will further reduce harms. If the patient is in septic shock or not responding to initial treatment, multidisciplinary consultation and escalation of care is necessary. Health care professionals should be aware of the unique complications of sepsis in critically ill pregnant and postpartum patients, and measures to prevent poor outcomes in this population. Adverse pregnancy outcomes may occur in association with sepsis, and should be anticipated and prevented when possible, or managed appropriately when they occur. Using a standardized approach to the patient with suspected sepsis may reduce maternal morbidity and mortality.
Topics: Anti-Bacterial Agents; Critical Illness; Female; Humans; Maternal Mortality; Postpartum Period; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Shock, Septic; Streptococcal Infections; Streptococcus pyogenes; Time Factors
PubMed: 34237760
DOI: 10.1097/AOG.0000000000004471 -
The Western Journal of Emergency... Aug 2019The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant... (Review)
Review
The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant patients. This narrative review evaluates the presentation, scoring systems for risk stratification, diagnosis, and management of sepsis in pregnancy. Sepsis is potentially fatal, but literature for the evaluation and treatment of this condition in pregnancy is scarce. While the definition and considerations of sepsis have changed with large, randomized controlled trials, pregnancy has consistently been among the exclusion criteria. The two pregnancy-specific sepsis scoring systems, the modified obstetric early warning scoring system (MOEWS) and Sepsis in Obstetrics Score (SOS), present a number of limitations for application in the emergency department (ED) setting. Methods of generation and subsequently limited validation leave significant gaps in identification of septic pregnant patients. Management requires consideration of a variety of sources in the septic pregnant patient. The underlying physiologic nature of pregnancy also highlights the need to individualize resuscitation and critical care efforts in this unique patient population. Pregnant septic patients require specific considerations and treatment goals to provide optimal care for this particular population. Guidelines and scoring systems currently exist, but further studies are required.
Topics: Critical Care; Emergency Service, Hospital; Female; Humans; Pregnancy; Pregnancy Complications, Infectious; Resuscitation; Sepsis
PubMed: 31539341
DOI: 10.5811/westjem.2019.6.43369 -
Clinics in Perinatology Jun 2010Chorioamnionitis is a common complication of pregnancy associated with significant maternal, perinatal, and long-term adverse outcomes. Adverse maternal outcomes include... (Review)
Review
Chorioamnionitis is a common complication of pregnancy associated with significant maternal, perinatal, and long-term adverse outcomes. Adverse maternal outcomes include postpartum infections and sepsis whereas adverse infant outcomes include stillbirth, premature birth, neonatal sepsis, chronic lung disease, and brain injury leading to cerebral palsy and other neurodevelopmental disabilities. Research in the past 2 decades has expanded understanding of the mechanistic links between intra-amniotic infection and preterm delivery as well as morbidities of preterm and term infants. Recent and ongoing clinical research into better methods for diagnosing, treating, and preventing chorioamnionitis is likely to have a substantial impact on short and long-term outcomes in the neonate.
Topics: Chorioamnionitis; Diagnosis, Differential; Female; Humans; Infant, Newborn; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Risk Factors
PubMed: 20569811
DOI: 10.1016/j.clp.2010.02.003 -
The New England Journal of Medicine Mar 2023The use of azithromycin reduces maternal infection in women during unplanned cesarean delivery, but its effect on those with planned vaginal delivery is unknown. Data... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The use of azithromycin reduces maternal infection in women during unplanned cesarean delivery, but its effect on those with planned vaginal delivery is unknown. Data are needed on whether an intrapartum oral dose of azithromycin would reduce maternal and offspring sepsis or death.
METHODS
In this multicountry, placebo-controlled, randomized trial, we assigned women who were in labor at 28 weeks' gestation or more and who were planning a vaginal delivery to receive a single 2-g oral dose of azithromycin or placebo. The two primary outcomes were a composite of maternal sepsis or death and a composite of stillbirth or neonatal death or sepsis. During an interim analysis, the data and safety monitoring committee recommended stopping the trial for maternal benefit.
RESULTS
A total of 29,278 women underwent randomization. The incidence of maternal sepsis or death was lower in the azithromycin group than in the placebo group (1.6% vs. 2.4%), with a relative risk of 0.67 (95% confidence interval [CI], 0.56 to 0.79; P<0.001), but the incidence of stillbirth or neonatal death or sepsis was similar (10.5% vs. 10.3%), with a relative risk of 1.02 (95% CI, 0.95 to 1.09; P = 0.56). The difference in the maternal primary outcome appeared to be driven mainly by the incidence of sepsis (1.5% in the azithromycin group and 2.3% in the placebo group), with a relative risk of 0.65 (95% CI, 0.55 to 0.77); the incidence of death from any cause was 0.1% in the two groups (relative risk, 1.23; 95% CI, 0.51 to 2.97). Neonatal sepsis occurred in 9.8% and 9.6% of the infants, respectively (relative risk, 1.03; 95% CI, 0.96 to 1.10). The incidence of stillbirth was 0.4% in the two groups (relative risk, 1.06; 95% CI, 0.74 to 1.53); neonatal death within 4 weeks after birth occurred in 1.5% in both groups (relative risk, 1.03; 95% CI, 0.86 to 1.24). Azithromycin was not associated with a higher incidence in adverse events.
CONCLUSIONS
Among women planning a vaginal delivery, a single oral dose of azithromycin resulted in a significantly lower risk of maternal sepsis or death than placebo but had little effect on newborn sepsis or death. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; A-PLUS ClinicalTrials.gov number, NCT03871491.).
Topics: Female; Humans; Infant, Newborn; Pregnancy; Azithromycin; Perinatal Death; Pregnancy Complications, Infectious; Sepsis; Stillbirth; Anti-Bacterial Agents; Delivery, Obstetric; Neonatal Sepsis; Administration, Oral; Pregnancy Outcome; United States
PubMed: 36757318
DOI: 10.1056/NEJMoa2212111 -
F1000Research 2019Maternal sepsis accounts for 11% of all maternal deaths worldwide. It is the third most common direct cause of maternal death and is a major contributor to other common... (Review)
Review
Maternal sepsis accounts for 11% of all maternal deaths worldwide. It is the third most common direct cause of maternal death and is a major contributor to other common causes of maternal death, such as haemorrhage and thromboembolism. This review addresses important topics, including the epidemiology, risk factors, prevention, diagnosis, care bundles and management of maternal sepsis, including antibiotic treatment, and critical care interventions such as extracorporeal membrane oxygenation. Preventative measures that have had an impact on maternal sepsis as well as future research directions are also covered in this review. Case studies of maternal sepsis which highlight key learning points relevant to all clinicians involved in the management of obstetric patients will also be presented. Although, historically, maternal death from sepsis was considered to be a problem for low-income countries, severe obstetric morbidity and maternal death from sepsis are increasing in high-income countries. The global burden of maternal sepsis and the obstetric-related and patient-related risk factors and the likely sources are presented. Recent changes in definition and nomenclature are outlined, and challenges in diagnosis and identification are discussed. Following maternal sepsis, early diagnosis and early intervention are critical to save lives and prevent long-term adverse sequelae. Dogma surrounding critical care interventions in pregnancy is being challenged, and future research is warranted to maximise therapeutic options available for maternal septic shock.
Topics: Adult; Escherichia coli; Female; Humans; Infant, Newborn; Pregnancy; Pregnancy Complications, Infectious; Sepsis
PubMed: 31508205
DOI: 10.12688/f1000research.18736.1 -
Journal of Midwifery & Women's Health May 2021Congenital cytomegalovirus (cCMV) is the most common congenital infection in the United States, with 1 of 200 live births affected. It is the leading viral cause of... (Review)
Review
Congenital cytomegalovirus (cCMV) is the most common congenital infection in the United States, with 1 of 200 live births affected. It is the leading viral cause of intrauterine fetal demise and miscarriage. It is a common cause of neonatal hearing loss, second only to genetic factors. Yet, health care provider awareness remains low. The purpose of this article is to provide a brief overview of the epidemiology, presentation, diagnosis, and treatment of antenatal cytomegalovirus (CMV) infection and cCMV in the neonate. Maternal CMV infection in pregnancy often presents with mild cold-like symptoms or is asymptomatic. The virus can be vertically transmitted to a growing fetus, the risk of transmission and severity of fetal impact varying by timing of exposure during pregnancy. Most neonates born with cCMV show no signs at birth, yet 15% to 25% will have long-term adverse neurodevelopmental conditions. Misconceptions that cCMV cannot be prevented or that neonates born without signs of the disease will be unaffected are common. Evidence supporting antenatal education around behavioral change to lower a woman's risk of acquiring CMV during pregnancy is mounting. CMV infection during pregnancy should be co-managed with a maternal-fetal medicine specialist. There is early evidence for the use of antiviral medication in reducing risk of vertical transmission. Identification of cCMV during pregnancy may help ensure the neonate receives timely treatment after birth. Midwives can play an important role in providing antenatal education about cCMV risk reduction and in initiating a diagnostic evaluation when there is clinical suspicion.
Topics: Cytomegalovirus; Cytomegalovirus Infections; Female; Fetal Diseases; Humans; Infant, Newborn; Infectious Disease Transmission, Vertical; Pregnancy; Pregnancy Complications, Infectious
PubMed: 34031974
DOI: 10.1111/jmwh.13228 -
Seminars in Perinatology Feb 2018Sepsis is a leading cause of maternal morbidity and mortality in developed and developing nations. Obstetric practitioners should be familiar with guidelines that... (Review)
Review
Sepsis is a leading cause of maternal morbidity and mortality in developed and developing nations. Obstetric practitioners should be familiar with guidelines that promote the safe and expeditious recovery of those affected. This article will provide the reader with rational steps to aid in the recovery of such a patient.
Topics: Anti-Bacterial Agents; Female; Humans; Maternal Health Services; Obstetrics; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications, Infectious; Resuscitation
PubMed: 29463391
DOI: 10.1053/j.semperi.2017.11.003 -
MMWR. Recommendations and Reports :... Nov 2010Despite substantial progress in prevention of perinatal group B streptococcal (GBS) disease since the 1990s, GBS remains the leading cause of early-onset neonatal sepsis...
Despite substantial progress in prevention of perinatal group B streptococcal (GBS) disease since the 1990s, GBS remains the leading cause of early-onset neonatal sepsis in the United States. In 1996, CDC, in collaboration with relevant professional societies, published guidelines for the prevention of perinatal group B streptococcal disease (CDC. Prevention of perinatal group B streptococcal disease: a public health perspective. MMWR 1996;45[No. RR-7]); those guidelines were updated and republished in 2002 (CDC. Prevention of perinatal group B streptococcal disease: revised guidelines from CDC. MMWR 2002;51[No. RR-11]). In June 2009, a meeting of clinical and public health representatives was held to reevaluate prevention strategies on the basis of data collected after the issuance of the 2002 guidelines. This report presents CDC's updated guidelines, which have been endorsed by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American College of Nurse-Midwives, the American Academy of Family Physicians, and the American Society for Microbiology. The recommendations were made on the basis of available evidence when such evidence was sufficient and on expert opinion when available evidence was insufficient. The key changes in the 2010 guidelines include the following: • expanded recommendations on laboratory methods for the identification of GBS, • clarification of the colony-count threshold required for reporting GBS detected in the urine of pregnant women, • updated algorithms for GBS screening and intrapartum chemoprophylaxis for women with preterm labor or preterm premature rupture of membranes, • a change in the recommended dose of penicillin-G for chemoprophylaxis, • updated prophylaxis regimens for women with penicillin allergy, and • a revised algorithm for management of newborns with respect to risk for early-onset GBS disease. Universal screening at 35-37 weeks' gestation for maternal GBS colonization and use of intrapartum antibiotic prophylaxis has resulted in substantial reductions in the burden of early-onset GBS disease among newborns. Although early-onset GBS disease has become relatively uncommon in recent years, the rates of maternal GBS colonization (and therefore the risk for early-onset GBS disease in the absence of intrapartum antibiotic prophylaxis) remain unchanged since the 1970s. Continued efforts are needed to sustain and improve on the progress achieved in the prevention of GBS disease. There also is a need to monitor for potential adverse consequences of intrapartum antibiotic prophylaxis (e.g., emergence of bacterial antimicrobial resistance or increased incidence or severity of non-GBS neonatal pathogens). In the absence of a licensed GBS vaccine, universal screening and intrapartum antibiotic prophylaxis continue to be the cornerstones of early-onset GBS disease prevention.
Topics: Adult; Algorithms; Antibiotic Prophylaxis; Female; Humans; Infant, Newborn; Infant, Newborn, Diseases; Infectious Disease Transmission, Vertical; Mass Screening; Pregnancy; Pregnancy Complications, Infectious; Premature Birth; Prenatal Care; Risk Factors; Sepsis; Specimen Handling; Streptococcal Infections; Streptococcal Vaccines; Streptococcus agalactiae; United States
PubMed: 21088663
DOI: No ID Found -
Handbook of Clinical Neurology 2020Neurologic infections during pregnancy represent a significant cause of maternal and fetal morbidity and mortality. Immunologic alterations during pregnancy increase the... (Review)
Review
Neurologic infections during pregnancy represent a significant cause of maternal and fetal morbidity and mortality. Immunologic alterations during pregnancy increase the susceptibility of the premature brain to damage. This chapter summarizes the epidemiology, pathophysiology, and clinical manifestations in the pregnant woman and the infant, and the diagnosis, treatment, and prevention of the major viral, parasitic, and bacterial infections known to affect pregnancy. These organisms include herpes virus, parvovirus, cytomegalovirus, varicella, rubella, Zika virus, toxoplasmosis, malaria, group B streptococcus, listeriosis, syphilis, and tuberculosis. There is an emphasis on the important differences in diagnosis, treatment, and fetal outcome between trimesters. An additional overview is provided on the spectrum of neurologic sequelae of an affected infant, which ranges from developmental delay to hydrocephalus and seizures.
Topics: Communicable Diseases; Female; Humans; Infant; Pregnancy; Pregnancy Complications, Infectious; Rubella; Syphilis; Toxoplasmosis; Zika Virus; Zika Virus Infection
PubMed: 32768096
DOI: 10.1016/B978-0-444-64240-0.00005-2 -
Journal of Medicine and Life 2021Tuberculosis (TB) in pregnancy is not only a matter of the past; it is also a current problem. These days, TB appears through mass migration and tourism in countries... (Review)
Review
Tuberculosis (TB) in pregnancy is not only a matter of the past; it is also a current problem. These days, TB appears through mass migration and tourism in countries where it was believed that this condition is eradicated. Adequate knowledge about the medical history of patients, risk factors, diagnosis and treatment of tuberculosis should be part of the armamentarium of each physician involved in clinical practice. TB is mainly found in urban and socially deprived areas. Due to the length of the treatment, there is an increased risk of drug resistance in partially treated patients. Strong knowledge about the history, risk factors, diagnosis and treatment of TB should be part of the armamentarium of each physician. Many practitioners are reluctant to request a chest X-ray in pregnancy due to the fear of harming the fetus. Bypassing a diagnosis can have a devastating effect on the mother and fetus, as well as their family and medical staff. This article discusses the matters of diagnosis and treatment of asymptomatic infection and active TB in pregnancy.
Topics: Drug Resistance, Bacterial; Female; Humans; Mass Screening; Pregnancy; Pregnancy Complications, Infectious; Risk Factors; Tuberculosis
PubMed: 34104238
DOI: 10.25122/jml-2021-0001