Antenatal pyelonephritis hospitalisation trends, risk factors and associated adverse outcomes: A retrospective cohort study.

OBJECTIVE: To analyse trends, risk factors and adverse outcomes associated with antenatal pyelonephritis hospitalisations. DESIGN: Retrospective cohort. SETTING: A national sample of US delivery hospitalisations with associated antenatal hospitalisations. POPULATION: US delivery hospitalisations in the Nationwide Readmissions Database from 2010 to 2020. METHODS: Antenatal hospitalisations with a pyelonephritis diagnosis within the 9 months before delivery hospitalisation were analysed. Clinical, demographic and hospital risk factors associated with antenatal pyelonephritis hospitalisations were analysed with unadjusted and adjusted logistic regression models with unadjusted and adjusted odds ratios as measures of effect. Temporal trends in antenatal pyelonephritis hospitalisations were analysed with Joinpoint regression to determine the relative measure of average annual percent change (AAPC). Risk for severe maternal morbidity and sepsis during antenatal pyelonephritis hospitalisations was similarly analysed with Joinpoint regression. RESULTS: Of an estimated 10.2 million delivery hospitalisations, 49 140 (0.48%) had an associated antenatal pyelonephritis hospitalisation. The proportion of deliveries with a preceding antenatal pyelonephritis hospitalisation decreased by 29% from 0.56% in 2010 to 0.40% in 2020 (AAPC -2.9%, 95% CI -4.0% to -1.9%). Antenatal pyelonephritis decreased, but risk for sepsis diagnoses increased during these hospitalisations from 3.7% in 2010 to 18.0% in 2020 (AAPC 17.2%, 95% CI 14.2%-21.1%). Similarly, risk for severe morbidity increased from 2.6% in 2010 to 4.4% in 2020 (AAPC 5.5%, 95% CI 0.8%-10.7%). CONCLUSION: Antenatal pyelonephritis admissions appear to be decreasing in the USA. However, these hospitalisations are associated with a rising risk for sepsis and severe maternal morbidity.

Obstetric Sepsis: A Review Article.

Introduction: The World Health Organization defines obstetric (maternal) sepsis as organ failure caused by infection during pregnancy, childbirth, post-abortion or postpartum period. It is the third most prevalent reason for maternal death. According to statistics, sepsis caused 11 percent of maternal fatalities worldwide. Discussion: Physiological changes related to pregnancy may imitate the start of sepsis, which makes definitive diagnosis difficult. The definition of sepsis is gradually amended over decades. Various diagnostic tools and criteria are available. Conclusion: Prevention, early diagnosis, and appropriate management can reduce sepsis related maternal mortalities and morbidities. To reduce unnecessary maternal mortality, future policy development in the area of evaluation and care of obstetric sepsis is essential.

Determinants of Survival in obstetric Sepsis: Retrospective Observational Study.

Introduction: Sepsis is the dysregulated response of the body to the infection. Obstetric sepsis carries significantly greater morbidity and mortality as the condition is also augmented by the physiological adaptation of body during pregnancy. We conducted this study to determine the various epidemiological and clinical determinants of severity of sepsis which can help in prediction of survival in case of obstetric sepsis. Materials and Methods: This retrospective study was conducted in a tertiary care center and all cases admitted with the diagnosis of obstetric sepsis as per the defined criteria between January 1, 2016 and December 31, 2020 were included in the study. Patients were evaluated for their clinical presentation, SOFA score, biochemical and microbiological parameters and the treatment given during their course of stay. Variables were compared among survivor and non-survivor group using appropriate statistical tests. Parameters which have significant association were further taken for binary logistic regression analysis. Result: A total 46 patients of obstetric sepsis were admitted under defined criteria. Twelve out of 46 patients did not survive (26.09%). On statistical analysis, mean SOFA score (p = 0.005) as well as patients with SOFA score > 6 (p = 0.029), presence of multi organ failure (0.04) and septic shock (p = 0.012) were found to be significantly associated with mortality. Conclusion: The study suggests that these determinants of survival should always be evaluated while catering to a patient of obstetric sepsis in order to guide the treatment, prognostication and improving outcome of the patients.

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.

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.

Predictores de mortalidad en pacientes con sepsis obstétrica mediante uso de score de sepsis obstétrica y evaluación secuencial de falla orgánica-obstétrica / Predictors of mortality in patients with obstetric sepsis using sepsis obstetric score and sequential organ failure assessment-obstetrics / Preditores de mortalidade em pacientes com sepse obstétrica usando Escore de Sepse Obstétrica e Avaliação Seqüencial de Falha Orgânico-Obstétrica

Resumen: Objetivo: Determinar los predictores de mortalidad en pacientes con sepsis obstétrica mediante score de sepsis obstétrica (SOS) y evaluación secuencial de falla orgánica-obstétrica (SOFA-O). Material y métodos: Se realizó un estudio observacional, retrospectivo, descriptivo, donde se recabaron los datos de pacientes que ingresaron a una Unidad de Cuidados Intensivos de hospitales de segundo nivel, en el periodo 30 de junio de 2015 al 30 de junio de 2017 y que tuvieron diagnóstico de sepsis obstétrica, donde se aplicaron instrumentos mediante escala SOS y SOFA-O, correlacionándose las variables con mortalidad materna. Resultados: De un universo de 284 pacientes que ingresaron a UCI de Hospitales de segundo nivel se seleccionaron 51, quienes tenían criterios de inclusión para sepsis, correlacionándose con variables de escala de SOS y SOFA-O, encontrando como mayor factor de riesgo para el desarrollo de sepsis ser multigesta, tener preeclampsia, anemia, cesárea, mal control prenatal y tener procedimientos invasivos. Las variables cuantitativas relacionadas con muerte materna fueron creatinina, relación PaO2/FiO2, frecuencia cardiaca, lactato, saturación venosa, con un puntaje de SOS mínimo y máximo para muerte materna (7-22) y para SOFA-O (10-18) puntos. Hubo una mortalidad de 7.8% (cuatro pacientes) de la población estudiada. Conclusiones: La incidencia de sepsis obstétrica se encuentra en aumento, por lo que el reconocimiento rápido de ésta y la terapia adecuada impactarán en la supervivencia de la paciente.

Abstract: Objective: To determine the predictors of mortality in patients with obstetric sepsis using Sepsis Obsessional Score (SOS) and Sequential Organ Failure Assessment-Obstetric (SOFA-O). Material and methods: An observational, retrospective, descriptive study was carried out, where data were collected from patients who entered an intensive care unit of second level hospitals in the period June 30 2015, to June 30 2017, who had a diagnosis of sepsis Obstetric, where SOS and SOFA-O instruments were applied, correlating the variables with maternal mortality. Results: From a universe of 284 patients who entered the ICU of second level hospitals, 51 patients were selected who had inclusion criteria for sepsis, correlating with SOS and SOFA-O scale variables, finding it to be a major risk factor for development of sepsis being multigested, having preeclampsia, anemia, cesarean section, prenatal poor control and having invasive procedures, the quantitative variables related to maternal death were: creatinine, PaO2/FiO2 ratio, heart rate, lactate, venous saturation. With a minimum and maximum SOS score for maternal death (7-22) and SOFA-O (10-18) points. There was a mortality of 7.8% (four patients) of the study population. Conclusions: The incidence of obstetric sepsis is increasing, so rapid recognition and appropriate therapy will impact patient survival.

Resumo: Objetivo: Determinar os preditores de mortalidade em pacientes com sepse obstétrica pelo Escore de Sepse Obstétrica (S.O.S.) e Avaliação Seqüencial de Falha Orgânico-Obstétrica (SOFA-O). Material e métodos: Foi realizado um estudo observacional, retrospectivo, descritivo, onde foram coletados dados de pacientes internados em uma unidade de terapia intensiva no período de 30 de junho de 2015 a 30 de junho de 2017 com diagnóstico de sepse obstétrica, onde foram aplicados instrumentos utilizando escalas S.O.S e SOFA-O, correlacionando as variáveis com a mortalidade materna. Resultados: De um universo de 284 pacientes internados na UTI, foram selecionados 51 pacientes que possuíam critérios de inclusão para sepse, correlacionando com as variáveis S.O.S e SOFA-O, encontrando como um importante fator de risco para o desenvolvimento da sepse ser multigesta, apresentar pré-eclâmpsia, anemia, cesárea, controle pré-natal deficiente e procedimentos invasivos. As variáveis quantitativas relacionadas ao óbito materno foram creatinina, relação PaO2/FiO2, frequência cardíaca, lactato, saturação venosa. Com um escore de S.O.S mínimo e máximo para morte materna (7-22) e para SOFA-O (10-18). Houve uma mortalidade de 7.8% (4 pacientes) da população estudada. Conclusões: A incidência de sepse obstétrica está aumentando, portanto o reconhecimento rápido e a terapia adequada terão impacto na sobrevida do paciente.

Evaluation of a novel device for the management of high blood pressure and shock in pregnancy in low-resource settings: study protocol for a stepped-wedge cluster-randomised controlled trial (CRADLE-3 trial).

BACKGROUND: Obstetric haemorrhage, sepsis and pregnancy hypertension account for more than 50% of maternal deaths worldwide. Early detection and effective management of these conditions relies on vital signs. The Microlife® CRADLE Vital Sign Alert (VSA) is an easy-to-use, accurate device that measures blood pressure and pulse. It incorporates a traffic-light early warning system that alerts all levels of healthcare provider to the need for escalation of care in women with obstetric haemorrhage, sepsis or pregnancy hypertension, thereby aiding early recognition of haemodynamic instability and preventing maternal mortality and morbidity. The aim of the trial was to determine whether implementation of the CRADLE intervention (the Microlife® CRADLE VSA device and CRADLE training package) into routine maternity care in place of existing equipment will reduce a composite outcome of maternal mortality and morbidity in low- and middle-income country populations. METHODS: The CRADLE-3 trial was a stepped-wedge cluster-randomised controlled trial of the CRADLE intervention compared to routine maternity care. Each cluster crossed from routine maternity care to the intervention at 2-monthly intervals over the course of 20 months (April 2016 to November 2017). All women identified as pregnant or within 6 weeks postpartum, presenting for maternity care in cluster catchment areas were eligible to participate. Primary outcome data (composite of maternal death, eclampsia and emergency hysterectomy per 10,000 deliveries) were collected at 10 clusters (Gokak, Belgaum, India; Harare, Zimbabwe; Ndola, Zambia; Lusaka, Zambia; Free Town, Sierra Leone; Mbale, Uganda; Kampala, Uganda; Cap Haitien, Haiti; South West, Malawi; Addis Ababa, Ethiopia). This trial was informed by the Medical Research Council guidance for complex interventions. A process evaluation was undertaken to evaluate implementation in each site and a cost-effectiveness evaluation will be undertaken. DISCUSSION: All aspects of this protocol have been evaluated in a feasibility study, with subsequent optimisation of the intervention. This trial will demonstrate the potential impact of the CRADLE intervention on reducing maternal mortality and morbidity in low-resource settings. It is anticipated that the relatively low cost of the intervention and ease of integration into existing health systems will be of significant interest to local, national and international health policy-makers. TRIAL REGISTRATION: ISCRTN41244132. Registered on 2 February 2016. Prospective protocol modifications have been recorded and were communicated to the Ethics Committees and Trials Committees. The adapted Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Checklist and the SPIRIT Checklist are attached as Additional file 1.

Predictores de la mortalidad en pacientes con sepsis obstétrica mediante el uso de una puntuación de sepsis obstétrica y evaluación secuencial de falla orgánica-obstétrica / Predictors of mortality in patients with obstetric sepsis using the Sepsis in Obstetrics Score and Sequential Organ Failure Assessment-Obstetrics / Preditores da mortalidade em pacientes com sepse obstétrica usando escore de sepse obstétrica e evaluação sequencial da falha orgânica obstétrica

Resumen Objetivo Determinar los predictores de mortalidad en pacientes con sepsis obstétrica mediante puntuación de sepsis obstétrica (SOS) y evaluación secuencial de falla orgánica-obstétrica (SOFA-O). Material y métodos Se realizó un estudio observacional, retrospectivo, descriptivo, donde se recabaron los datos de las pacientes que ingresaron a unidades de cuidados intensivos de hospitales de segundo nivel con diagnóstico de sepsis obstétrica en el periodo del 30 de junio de 2015 al 30 de junio de 2017; se aplicaron los instrumentos SOS (sepsis en obstetricia) y SOFA-O (evaluación secuencial de falla orgánica-obstétrica), y se correlacionaron las variables con la mortalidad materna. Resultados De un universo de 284 pacientes que ingresaron a las UCI de hospitales de segundo nivel, se seleccionaron 51 que tenían criterios de inclusión para sepsis, correlacionándose con variables de las escalas SOS y SOFA-O. Se encontró como mayor factor de riesgo para el desarrollo de sepsis ser multigesta, tener preeclampsia, anemia, cesárea, mal control prenatal y haber sido sometida a procedimientos invasivos. Las variables cuantitativas relacionadas con muerte materna fueron creatinina, relación PaO2/FiO2, frecuencia cardiaca, lactato, saturación venosa. El puntaje de SOS mínimo y máximo para muerte materna fue 7-22 y de SOFA-O, 10-18 puntos. Hubo una mortalidad de 7.8% (cuatro pacientes) de la población estudiada. Conclusiones La incidencia de sepsis obstétrica se encuentra en aumento, por lo que su reconocimiento rápido y la terapia adecuada impactarán en la supervivencia de la paciente.

Abstract Objective To determine the predictors of mortality in patients with obstetric sepsis using the Sepsis in Obstetrics Score (SOS) and the Sequential Organ Failure Assessment-Obstetrics (SOFA-O). Material and methods An observational, retrospective, descriptive study was carried out, where data were collected from patients who entered intensive care units of second-level hospitals with a diagnosis of obstetric sepsis in the period from June 30, 2015 to June 30, 2017. The SOS and SOFA-O instruments were applied, correlating the variables with maternal mortality. Results From a universe of 284 patients who entered the ICU of second level hospitals, 51 were selected who had inclusion criteria for sepsis, correlating with SOS and SOFA-O variables. We found that major risk factors for the development of sepsis were multigestation, having preeclampsia, anemia, cesarean section, poor prenatal control and been subject of invasive procedures. The quantitative variables related to maternal death were creatinine, PaO2/FiO2 ratio, heart rate, lactate, venous saturation. The minimum and maximum SOS scores for maternal death were 7-22, and SOFA-O, 10-18 points. There was a mortality of 7.8% (four patients) of the study population. Conclusions The incidence of obstetric sepsis is increasing; therefore, rapid recognition and appropriate therapy will impact patient's survival.

Resumo Objetivo Determinar os preditores de mortalidade em pacientes com sepse obstétrica por meio do escore de sepse obstétrica (S.O.S) e Avaliação Sequencial da falha orgânica-obstétrica (SOFA-O). Material e métodos Foi realizado um estudo observacional, retrospectivo e descritivo, onde foram coletados dados de todas as pacientes que ingressaram na unidade de terapia intensiva, no período de 30 de junho de 2015 a 30 de junho de 2017, com diagnóstico de sepse obstétrica, onde foram aplicadas escalas S.O.S e SOFA-O, correlacionando as variáveis com a mortalidade materna. Resultados De um universo de 284 pacientes que ingressaram na UTI, selecionaram-se 51 pacientes que apresentaram critérios de inclusão para sepse, correlacionando-se com variáveis de escala S.O.S e SOFA-O, encontrando como maior fator de risco para desenvolvimento da sepse ser: multigesta, apresentar pré-eclâmpsia, anemia, cesariana, controle pré-natal deficiente e procedimentos invasivos. As variáveis quantitativas relacionadas à morte materna foram: creatinina, relação PaO2/FIO2, freqüência cardíaca, lactato, saturação venosa. Com um escore mínimo e máximo de S.O.S para morte materna 7-22 e SOFA-O 10-18 pontos. Houve uma mortalidade de 7.8% (4 pacientes) da população estudada. Conclusões A incidência de sepse obstétrica está aumentando, de modo que reconhecimento rápido e uma terapia apropriada afetará a sobrevivência do paciente.

Ante-partum necrotising myometritis due to Streptococcal toxic shock.

Group A streptococcus (GAS) causes severe infections in obstetric patients. A rare complication is rapidly progressive necrotising myometritis. Postpartum necrotising myometritis has been previously described; however, antenatal development of such a condition is extremely rare. We present a patient who developed antenatal necrotising myometritis and toxic shock syndrome (TSS) due to GAS during the first trimester of pregnancy, eventually requiring hysterectomy and bilateral oophorectomy. We discuss the rare complication of ante-partum necrotising myometritis, as well as the antibiotic therapy, and treatment of TSS associated with severe Group A Streptococcal infections.

[Obstetrical aspects of perioperative medicine]. / A perioperatív medicina szülészeti aspektusai.

Recently the most frequently applied surgical procedure worldwide has been Cesarean section. It is essential to perform the operation without any complication. In addition, a fast postoperative recovery must be provided, because all mothers must have the chance for being together with their newborn infant even on the first day. The maternal mortality rates of Cesarean section significantly decreased in the last decades due to the planned team work as well as the widely applied regional (spinal and epidural) anesthetic procedures. Apart from the obstetrician and neonatologist the anesthesiologist is the member of the perinatal team, too, who is responsible for the patient's perioperative care. To prevent complications and have an early successful treatment the anesthesiologist should be informed by the pregnant woman' s health status in time in order to be able to plan the perioperative management. The high-risk groups of pregnant women, the most common causes of maternal death and possibilities of prevention and treatment are discussed.