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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 -
Viruses Oct 2023Human Cytomegalovirus (HCMV) is a ubiquitous member of the Herpesviridae family, responsible for the most common congenital viral infection-congenital Cytomegalovirus... (Review)
Review
Human Cytomegalovirus (HCMV) is a ubiquitous member of the Herpesviridae family, responsible for the most common congenital viral infection-congenital Cytomegalovirus (cCMV) infection. While a majority of HCMV infections in children and adults are asymptomatic, HCMV is well known to cause severe infections in the immunocompromised individual and maternal infections with variable long-term sequelae after maternal-fetal transmission with primary or nonprimary infections. HCMV seroprevalence and cCMV incidence vary by geographic area and demographic characteristics like race and socioeconomic status. While cCMV birth prevalence ranges from 0.2% to 6% in different parts of the world, it is influenced by regional HCMV seroprevalence rates. HCMV screening during pregnancy is not routinely offered due to lack of awareness, hurdles to accurate diagnosis, and lack of well-established effective treatment options during pregnancy. This review will focus on antiviral treatment options currently available for use during pregnancy and in the newborn period for the treatment of maternal and congenital HCMV infections.
Topics: Infant, Newborn; Pregnancy; Adult; Child; Female; Humans; Cytomegalovirus; Seroepidemiologic Studies; Cytomegalovirus Infections; Family; Infectious Disease Transmission, Vertical; Antiviral Agents; Pregnancy Complications, Infectious
PubMed: 37896892
DOI: 10.3390/v15102116 -
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 -
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 -
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 -
Ciencia & Saude Coletiva Aug 2022The aim of this article is to evaluate the conditions of Primary Care (PC) services in Brazil as regards the availability of quick tests (QTs) for early diagnoses and of...
The aim of this article is to evaluate the conditions of Primary Care (PC) services in Brazil as regards the availability of quick tests (QTs) for early diagnoses and of Benzylpenicillin (BZP) for the treatment of pregnant women with syphilis. This was a cross-sectional study, conducted with data from PC services that participated in the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB, in Portuguese). The services where QTs were not readily available or where BZP was not available in a sufficient quantity were categorized as "inadequate", while those where the QTs were readily available and BZP was found in sufficient quantities were categorized as "adequate". A bivariate analysis and Odds Ratio (OR) estimates, together with their respective 95% confidence intervals (CI), were performed. The sample included 20,286 PC services from regions throughout the country. The prevalence of services with inadequate conditions for the diagnosis and treatment of syphilis was 47.7%. The Midwest region and non-capital cities presented the highest prevalence rates for PC services with inadequate conditions for the diagnosis and treatment of syphilis in pregnant women (p<0.05). Differences in the regions and locations of the PC services impact the availability of QTs and BZP.
Topics: Cross-Sectional Studies; Female; Humans; Pregnancy; Pregnancy Complications, Infectious; Pregnant Women; Prenatal Care; Primary Health Care; Syphilis
PubMed: 35894342
DOI: 10.1590/1413-81232022278.05022022