Analysis of the impact of maternal sepsis on pregnancy outcomes: a population-based retrospective study.

BACKGROUND: To investigate the association between maternal sepsis during pregnancy and poor pregnancy outcome and to identify risk factors for poor birth outcomes and adverse perinatal events. METHODS: We linked the Taiwan Birth Cohort Study (TBCS) database and the Taiwanese National Health Insurance Database (NHID) to conduct this population-based study. We analysed the data of pregnant women who met the criteria for sepsis-3 during pregnancy between 2005 and 2017 as the maternal sepsis cases and selected pregnant women without infection as the non-sepsis comparison cohort. Sepsis during pregnancy and fulfilled the sepsis-3 definition proposed in 2016. The primary outcome included low birth weight (LBW, < 2500 g) and preterm birth (< 34 weeks), and the secondary outcome was the occurrence of adverse perinatal events. RESULTS: We enrolled 2,732 women who met the criteria for sepsis-3 during pregnancy and 196,333 non-sepsis controls. We found that the development of maternal sepsis was highly associated with unfavourable pregnancy outcomes, including LBW (adjOR 9.51, 95% CI 8.73-10.36), preterm birth < 34 weeks (adjOR 11.69, 95%CI 10.64-12.84), and the adverse perinatal events (adjOR 3.09, 95% CI 2.83-3.36). We also identified that socio-economically disadvantaged status was slightly associated with an increased risk for low birth weight and preterm birth. CONCLUSION: We found that the development of maternal sepsis was highly associated with LBW, preterm birth and adverse perinatal events. Our findings highlight the prolonged impact of maternal sepsis on pregnancy outcomes and indicate the need for vigilance among pregnant women with sepsis.

Factors associated with infection-related severe maternal outcomes in pregnant and recently pregnant women: A secondary analysis of the WHO global maternal sepsis study.

OBJECTIVE: The aim of the present study was to identify the risk factors for severe maternal outcomes (SMO) of women with suspected or confirmed infections using the data from the WHO global maternal sepsis study (GLOSS). METHODS: We conducted a secondary analysis of the GLOSS cohort study, which involved pregnant or recently pregnant women with suspected or confirmed infection around 713 health facilities in 52 low- and middle-income countries, and high-income countries. A nested case-control study was conducted within the GLOSS cohort. Cases included infection-related maternal deaths or near misses, while controls represented non-SMO. Logistic mixed models, adjusting for country variations, were employed. Using univariate analysis, we calculated crude odds ratios (crude OR) and their 95% confidence interval (95% CI). Variables were identified with less than 16% missing data, and P values less than 0.20 were used to perform the multivariate logistic model multilevel. RESULTS: A total of 2558 women were included in the analysis. As for the cases, 134 patients were found in the pregnant in labor or not in labor group and 246 patients in the postpartum or postabortion group. Pregnant women with prior childbirths faced a 64% increased risk of SMO. Ante- or intrapartum hemorrhage increased risk by 4.45 times, while trauma during pregnancy increased it by 4.81 times. Pre-existing medical conditions elevated risk five-fold, while hospital-acquired infections increased it by 53%. Secondary infections raised risk six-fold. Postpartum/postabortion women with prior childbirths had a 45% elevated risk, and pre-existing medical conditions raised it by 2.84 times. Hospital-acquired infections increased risk by 93%. Postpartum hemorrhage increased risk approximately five-fold, while abortion-related bleeding doubled it. Previous cesarean, abortion, and stillbirth also elevated risk. CONCLUSIONS: Key risk factors for SMO include prior childbirths, hemorrhage, trauma, pre-existing conditions, and hospital-acquired or secondary infections. Implementing effective alert systems and targeted interventions is essential to mitigate these risks and improve maternal health outcomes, especially in resource-limited settings.

Surviving maternal sepsis: Clinical, laboratory, and treatment features.

OBJECTIVE: To describe clinical, laboratory, and antibiotic treatment characteristics in pregnant or recently pregnant women diagnosed with maternal sepsis. METHODS: A retrospective cohort study was conducted in a Brazilian tertiary hospital from March 2014 until February 2018. The hospital implemented a Sepsis Protocol, based on the Brazilian Ministry of Health recommendation. All women who were pregnant or recently pregnant (up to 42 days postpartum), and who presented with suspected sepsis were included. Unconfirmed infections were excluded. Three hundred sixty-five women were included and divided into three groups according to sepsis severity (SEPSIS-2): sepsis, severe sepsis, and septic shock. Clinical, laboratory, and management characteristics were described and compared. RESULTS: Pregnancy-related and respiratory tract infections were the greater causes of maternal sepsis, and the urinary tract was the major cause of septic shock. We found almost total compliance with blood culture sample collection, and samples were positive in 10.8% of the cases, and in 41% of septic shock patients. Escherichia coli was the most common pathogen found and it was resistant to third-generation cephalosporins in none of the blood cultures and 3.3% of the urine cultures. Using the AWaRe (Access, Watch and Reserve) classification groups of antibiotics, Access and Watch antibiotics were used in virtually all women. We did not find any fatal maternal outcomes. CONCLUSION: Maternal sepsis is seldom the result of resistant microorganisms in this setting and the use of Access group antibiotics is widely possible. Health professionals' awareness of and institutional policies for maternal sepsis are crucial to its adequate treatment and better outcomes.

Maternal sepsis and factors associated with poor maternal outcomes in a tertiary hospital in Tigray, Ethiopia: a retrospective chart review.

BACKGROUND: Maternal sepsis is the third leading cause of maternal death in the world. Women in resource-limited countries shoulder most of the burdens related to sepsis. Despite the growing risk associated with maternal sepsis, there are limited studies that have tried to assess the impact of maternal sepsis in resource-limited countries. The current study determined the outcomes of maternal sepsis and factors associated with having poor maternal outcomes. METHODS: A facility-based retrospective cross-sectional study design was employed to assess the clinical presentation, maternal outcomes, and factors associated with maternal sepsis. The study was conducted in Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia, from January 1, 2017, to December 31, 2021. Sociodemographic characteristics, clinical characteristics and outcomes of women with maternal sepsis were analyzed using a descriptive statistic. The association between dependent and independent variables was determined using multivariate logistic regression. RESULTS: Among 27,350 live births, 298 mothers developed sepsis, giving a rate of 109 maternal sepsis for every 10,000 live births. There were 22 maternal deaths, giving rise to a case fatality rate of 7.4% and a maternal mortality ratio of 75 per 100,000 live births. Admission to the intensive care unit and use of mechanical ventilator were observed in 23.5% and 14.1% of the study participants, respectively. A fourth (24.2%) of the mothers were complicated with septic shock. Overall, 24.2% of women with maternal sepsis had severe maternal outcomes (SMO). Prolonged hospital stay, having parity of two and above, having the lung as the focus of infection, switchof antibiotics, and developing septic shock were significantly associated with SMO. CONCLUSIONS: This study revealed that maternal sepsis continues to cause significant morbidity and mortality in resource-limited settings; with a significant number of women experiencing death, intensive care unit admission, and intubation attributable to sepsis. The unavailability of recommended diagnostic modalities and management options has led to the grave outcomes observed in this study. To ward off the effects of infection during pregnancy, labor and postpartum period and to prevent progression to sepsis and septic shock in low-income countries, we recommend that concerted and meticulous efforts should be applied to build the diagnostic capacity of health facilities, to have effective infection prevention and control practice, and to avail recommended diagnostic and management options.

Prevalence and factors associated with maternal and neonatal sepsis in sub-Saharan Africa: a systematic review and meta-analysis.

Objectives: This study aimed to determine the prevalence and factors associated with maternal and neonatal sepsis in sub-Saharan Africa. Methods: This systematic review and meta-analysis used the PRISMA guideline on sepsis data in sub-Saharan Africa. The bibliographic search was carried out on the following databases: Medline/PubMed, Cochrane Library, African Index Medicus, and Google Scholar. Additionally, the reference lists of the included studies were screened for potentially relevant studies. The last search was conducted on 15 October 2022. The Joanna Briggs Institute quality assessment checklist was applied for critical appraisal. Estimates of the prevalence of maternal and neonatal sepsis were pooled using a random-effects meta-analysis model. Heterogeneity between studies was estimated using the Q statistic and the I2 statistic. The funnel plot and Egger's regression test were used to assess the publication bias. Results: A total of 39 studies were included in our review: 32 studies on neonatal sepsis and 7 studies on maternal sepsis. The overall pooled prevalence of maternal and neonatal sepsis in Sub-Saharan Africa was 19.21% (95% CI, 11.46-26.97) and 36.02% (CI: 26.68-45.36), respectively. The meta-analyses revealed that Apgar score < 7 (OR: 2.4, 95% CI: 1.6-3.5), meconium in the amniotic fluid (OR: 2.9, 95% CI: 1.8-4.5), prolonged rupture of membranes >12 h (OR: 2.8, 95% CI: 1.9-4.1), male sex (OR: 1.2, 95% CI: 1.1-1.4), intrapartum fever (OR: 2.4, 95% CI: 1.5-3.7), and history of urinary tract infection in the mother (OR: 2.7, 95% CI: 1.4-5.2) are factors associated with neonatal sepsis. Rural residence (OR: 2.3, 95% CI: 1.01-10.9), parity (OR: 0.5, 95% CI: 0.3-0.7), prolonged labor (OR: 3.4, 95% CI: 1.6-6.9), and multiple digital vaginal examinations (OR: 4.4, 95% CI: 1.3-14.3) were significantly associated with maternal sepsis. Conclusion: The prevalence of maternal and neonatal sepsis was high in sub-Saharan Africa. Multiple factors associated with neonatal and maternal sepsis were identified. These factors could help in the prevention and development of strategies to combat maternal and neonatal sepsis. Given the high risk of bias and high heterogeneity, further high-quality research is needed in the sub-Saharan African context, including a meta-analysis of individual data.Systematic review registration: PROSPERO (ID: CRD42022382050).

Compliance with maternal sepsis guidelines in a tertiary hospital in the Netherlands.

OBJECTIVES: Sepsis is a common cause of maternal mortality and morbidity. Early detection and rapid management are essential. In this study, we evaluate the compliance with the implemented maternity-specific Early Warning Score (EWS), Rapid Response Team (RRT) protocol and the Surviving Sepsis Campaign (SSC) Hour-1 Bundle in a tertiary hospital in the Netherlands. METHODS: We performed a retrospective patient chart review from July 2019 to June 2020 at the Leiden University Medical Centre. We included women who received therapeutic antibiotics and were admitted for at least 24 hours. RESULTS: We included 240 women: ten were admitted twice and one woman three times, comprising 252 admissions. A clinical diagnosis of sepsis was made in 22 women. The EWS was used in 29% (n = 73/252) of admissions. Recommendations on the follow-up of the EWS were carried out in 53% (n = 46/87). Compliance with the RRT protocol was highest for assessment by a medical doctor within 30 minutes (n = 98/117, 84%) and lowest for RRT involvement (n = 7/23, 30%). In women with sepsis, compliance with the SSC Bundle was highest for acquiring blood cultures (n = 19/22, 85%), while only 64% (n = 14/22) received antibiotics within 60 minutes of the sepsis diagnosis. CONCLUSION: The adherence to the maternity-specific EWS and the SSC Hour-1 bundle was insufficient, even within this tertiary setting in a high-income country.

Aetiology and use of antibiotics in pregnancy-related infections: results of the WHO Global Maternal Sepsis Study (GLOSS), 1-week inception cohort.

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.

Maternal sepsis in pregnancy and the puerperal periods: a cross-sectional study.

Maternal sepsis is a life-threatening condition and ranks among the top five causes of maternal death in pregnancy and the postpartum period. Herein, we conducted a retrospective study on sepsis cases to explain the related risk factors by comparing them with bloodstream infection (BSI) and control maternities. In total, 76 sepsis cases were enrolled, and 31 BSI and 57 maternal cases of the same age but with neither sepsis nor BSI were set as controls. Genital tract infection (GTI) and pneumonia were the two most common infection sources in both sepsis (22 cases, 29% and 29 cases, 38%) and BSI cases (18 cases, 58% and 8 cases, 26%). Urinary tract infection (UTI)/pyelonephritis (9 cases, 12%) and digestive infection cases (11 cases, 14%) only existed in the sepsis group. Significantly different infection sources were discovered between the sepsis-death and sepsis-cure groups. A higher proportion of pneumonia and a lower proportion of GTI cases were present in the sepsis-death group (17 cases, 45% pneumonia and 9 cases, 24% GTI) than in the sepsis-cure group (12 cases, 32% pneumonia and 13 cases, 34% GTI). In addition, although gram-negative bacteria were the dominant infectious microorganisms as previously reported, lower proportion of gram-negative bacteria infectious cases in sepsis (30 cases, 50%) and even lower in sepsis-death group (14 cases, 41%) was shown in this study than previous studies. As expected, significantly greater adverse maternal and fetal outcomes, such as higher maternal mortality (26.3% vs. 0% vs. 0%), higher fetal mortality (42.2% vs. 20.8% vs. 0%), earlier gestational age at delivery (26.4 ± 9.5 vs. 32.3 ± 8.1 vs. 37.7 ± 4.0) and lower newborn weight (1,590 ± 1287.8 vs. 2859.2 ± 966.0 vs. 3214.2 ± 506.4), were observed in the sepsis group. This study offered some potential pathogenesis and mortality risk factors for sepsis, which may inspire the treatment of sepsis in the future.

Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis.

Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).

Group B Streptococcus and the risk of perinatal morbidity and mortality following term labor.

Streptococcus agalactiae (group B Streptococcus) colonizes the genital tract of approximately 20% of pregnant women. In the absence of intervention, approximately 1% of infants born to colonized mothers exhibit a clinical infection. This has led to implementation of screening and intervention in the form of intrapartum antibiotic prophylaxis in many countries, including the United States. However, screening has not been introduced in a substantial minority of other countries because of the absence of supportive level 1 evidence, the very large number needed to treat to prevent 1 case, and concerns about antimicrobial resistance. Optimal screening would involve rapid turnaround (to facilitate intrapartum testing) and report antibiotic sensitivity, but no such method exists. There is significant scope for a personalized medicine approach, targeting intrapartum antibiotic prophylaxis to cases at greatest risk, but the pathogen and host factors determining the risk of invasive disease are incompletely understood. Epidemiologic data have indicated the potential of prelabor invasion of the uterus by group B Streptococcus, and metagenomic analysis revealed the presence of group B Streptococcus in the placenta in approximately 5% of pregnant women at term before onset of labor and membrane rupture. However, the determinants and consequences of prelabor invasion of the uterus by group B Streptococcus remain to be established. The vast majority (98%) of invasive neonatal disease is caused by 6 serotypes, and hexavalent vaccines against these serotypes have completed phase 2 trials. However, an obstacle to phase 3 studies is conducting an adequately powered trial to demonstrate clinical effectiveness given that early-onset disease affects approximately 1 in 1000 births in the absence of vaccination.

Feto-Maternal Outcomes Of Maternal Sepsis: A Snapshot Of The Illness.

BACKGROUND: Maternal sepsis is a life-threatening condition with serious adverse feto-maternal outcomes. This descriptive cross-sectional study aimed to study the incidence of common feto-maternal outcomes of maternal sepsis in our hospital. METHODS: Pregnant females with singleton pregnancy as per inclusion/exclusion criteria were enrolled in the study. A detailed medical history was taken and physical and obstetrical examination was done. They were investigated for the cause of their febrile illness and managed as per department protocols. Data was recorded in a pre-designed pro forma. RESULTS: The most common cause of infection was UTI (32; 42.6%) followed by genital infections (20; 26.7%) and respiratory tract infections (15; 20%). In 8 (10.7%) patients, the cause couldn't be found. Only one patient developed sepsis and was admitted to the medical ICU. That pregnancy resulted in PROM and an infant with low birth weight was delivered. Both the mother and the child survived and were discharged from the hospital. There was no mortality in our study group. CONCLUSIONS: Though sepsis was associated with adverse feto-maternal outcomes in our study, the study design prevents us from drawing any conclusions from this study concerning maternal sepsis in our region. Further research is needed to determine the true magnitude of the problem.

Immune-metabolic adaptations in pregnancy: A potential stepping-stone to sepsis.

Physiological shifts during pregnancy predispose women to a higher risk of developing sepsis resulting from a maladapted host-response to infection. Insightful studies have delineated subtle point-changes to the immune system during pregnancy. Here, we present an overlay of these point-changes, asking what changes and when, at a physiological, cellular, and molecular systems-level in the context of sepsis. We identify distinct immune phases in pregnancy delineated by placental hormone-driven changes in homeostasis setpoints of the immune and metabolic systems that subtly mirrors changes observed in sepsis. We propose that pregnancy immune-metabolic setpoint changes impact feedback thresholds that increase risk for a maladapted host-response to infection and thus act as a stepping-stone to sepsis. Defining maternal immune-metabolic setpoint changes is not only vital for tailoring the right diagnostic tools for early management of maternal sepsis but will facilitate an unravelling of the pathophysiological pathways that predispose an individual to sepsis.

Maternal Mortality in Low and Middle-Income Countries.

Despite a 38% decrease in global maternal mortality during the last decade, rates remain unacceptably high with greater than 800 maternal deaths occurring each day. There exists significant regional variation among rates and causes of maternal mortality, and the vast majority occurs in low-income and middle-income countries. The leading causes of direct maternal mortality are hemorrhage, hypertensive disorders of pregnancy, sepsis, complications of abortion, and thromboembolism. Eliminating preventable maternal mortality hinges on improving clinical management of these life-threatening obstetric conditions, as well as addressing the complex social and economic barriers that pregnant women face to access quality care.

Incidence and determinants of maternal sepsis in Ghana in the midst of a pandemic.

BACKGROUND: Despite being preventable, maternal sepsis continues to be a significant cause of death and morbidity, killing one in every four pregnant women globally. In Ghana, clinicians have observed that maternal sepsis is increasingly becoming a major contributor to maternal mortality. The lack of a consensus definition for maternal sepsis before 2017 created a gap in determining global and country-specific burden of maternal sepsis and its risk factors. This study determined the incidence and risk factors of clinically proven maternal sepsis in Ghana. METHODS: We conducted a prospective cohort study among 1476 randomly selected pregnant women in six health facilities in Ghana, from January to September 2020. Data were collected using primary data collection tools and reviewing the client's charts. We estimated the incidence rate of maternal sepsis per 1,000 pregnant women per person-week. Poisson regression model and the cox-proportional hazard regression model estimators were used to assess risk factors associated with the incidence of maternal sepsis at a 5% significance level. RESULTS: The overall incidence rate of maternal sepsis was 1.52 [95% CI: 1.20-1.96] per 1000 person-weeks. The majority of the participants entered the study at 10-13 weeks of gestation. The study participants' median body mass index score was 26.4 kgm-2 [22.9-30.1 kgm-2]. The risk of maternal sepsis was 4 times higher among women who developed urinary tract infection after delivery compared to those who did not (aHR: 4.38, 95% CI: 1.58-12.18, p < 0.05). Among those who developed caesarean section wound infection after delivery, the risk of maternal sepsis was 3 times higher compared to their counterparts (aHR: 3.77, 95% CI: 0.92-15.54, p < 0.05). Among pregnant women who showed any symptoms 14 days prior to exit from the study, the risk was significantly higher among pregnant women with a single symptom (aHR: 6.1, 95% CI: 2.42-15.21, p < 0.001) and those with two or more symptoms (aHR: 17.0, 95% CI: 4.19-69.00, p < 0.001). CONCLUSIONS: Our findings show a low incidence of maternal sepsis in Ghana compared to most Low and Middle-Income Countries. Nonetheless, Maternal sepsis remains an important contributor to the overall maternal mortality burden. It is essential clinicians pay more attention to ensure early and prompt diagnosis. Factors significantly predicting maternal sepsis in Ghana were additional maternal morbidity, urinary tract infections, dysuria, and multiple symptoms. We recommend that Ghana Health Service should institute a surveillance system for maternal sepsis as a monthly reportable disease.

[Recommendations and evidence synthesis: guidelines on antibiotic prophylaxis and choice of antiseptics for women in instrumental vaginal delivery or cesarean sectionSíntese de evidências e recomendações: diretrizes para a profilaxia antibiótica e a escolha de antissépticos em mulheres submetidas a parto vaginal operatório ou cesariana]. / Síntesis de evidencia y recomendaciones: directrices para la profilaxis antibiótica y la elección de antisépticos en las mujeres con parto vaginal instrumentado o cesárea.

Introduction: Maternal sepsis and infections during or after childbirth increase maternal mortality, leading to a high burden of disease in the Region of the Americas. The risk of infection after a cesarean section or instrumental vaginal delivery can be reduced with the appropriate skin antiseptic agents and antibiotic prophylaxis. Objectives: To synthesize World Health Organization (WHO) recommendations to improve the quality of care and health outcomes related to routine antibiotic prophylaxis in women during instrumental vaginal delivery; routine use of antibiotic prophylaxis in women having a cesarean section; the choice of antiseptics and skin preparation methods before a cesarean; and vaginal irrigation with antiseptics in women undergoing a cesarean. Methods: The WHO guidelines were based on the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology as described in the WHO Handbook for Guideline Development. Recommendations contained in four WHO guidelines were synthesized and a systematic search for studies carried out in the Region of the Americas was conducted in PubMed, Lilacs, Health Systems Evidence, Epistemonikos, and gray literature to identify barriers, facilitators, and implementation strategies. Results: Five recommendations were made on the routine use of antibiotic prophylaxis in women undergoing instrumental vaginal delivery, routine use of antibiotic prophylaxis in women having a cesarean section, the choice of antiseptics and skin preparation prior to a cesarean section, and vaginal irrigation with antiseptics during a cesarean section. Implementation barriers and facilitators were identified, and indicators were created to assess adherence and outcomes. Conclusions: The formulated recommendations aim to provide guidance on how to improve quality of care and outcomes related to antibiotic prophylaxis and the choice of antiseptics in women undergoing instrumental vaginal delivery or a cesarean section.

Introdução: As infecções maternas e a sepse durante ou após o parto aumentam a mortalidade materna e causam uma alta carga de doenças na Região das Américas. O risco de infecção após a cesariana e o parto operatório pode ser reduzido com o uso apropriado de antissépticos cutâneos e profilaxia antibiótica. Objetivos: Sintetizar as recomendações desenvolvidas pela Organização Mundial da Saúde (OMS) para melhorar a qualidade da assistência e os desfechos de saúde relacionados à profilaxia antibiótica de rotina em mulheres submetidas a parto vaginal operatório, à profilaxia antibiótica de rotina em mulheres submetidas a parto cesáreo, à escolha de antissépticos e ao método de aplicação para a preparação da pele antes de uma cesariana e à ducha vaginal com antissépticos em mulheres submetidas à cesariana. Métodos: As diretrizes desenvolvidas pela OMS seguiram os métodos de desenvolvimento da diretriz GRADE (Grading of Recommendations Assessment Development and Evaluation), do Manual para o desenvolvimento de diretrizes da OMS. Foi realizada uma síntese das recomendações de quatro diretrizes da OMS. Além disso, foi realizada uma busca sistemática nas bases de dados PubMed, Lilacs, Health Systems Evidence e Epistemonikos e na literatura cinzenta de estudos realizados nas Américas para identificar barreiras, facilitadores e estratégias de implementação, e para estabelecer indicadores. Resultados: Foram formuladas cinco recomendações para a profilaxia antibiótica de rotina em mulheres submetidas a parto vaginal operatório, a profilaxia antibiótica de rotina em mulheres submetidas a parto cesáreo, a escolha de antissépticos e o método de aplicação para a preparação da pele antes de uma cesariana e a ducha vaginal com antissépticos em mulheres submetidas a cesariana. Foram identificadas barreiras e facilitadores para a implementação e foram criados indicadores de adesão e resultados. Conclusões: As recomendações formuladas fornecem orientações para melhorar a qualidade da assistência e os desfechos de saúde relacionados à profilaxia antibiótica e à escolha de antissépticos em mulheres submetidas a parto vaginal operatório ou cesariana.

Case report: An unusual presentation of puerperal sepsis.

Group A Streptococcus (GAS; Streptococcus pyogenes) is a facultative gram-positive coccus, uncommonly colonizing parturient genitalia, where its presence can potentially lead to a life-threatening invasive infection after delivery. GAS infection typically occurs within the first 4 days post-partum and is characterized by high fever, chills, flashing, abdominal pain, and uterine tenderness. Nonetheless, patients with GAS puerperal sepsis may have an unusual presentation, when fever is absent, and the symptoms and signs can be mild, non-specific, and not indicative of the severity of infection. This unusual presentation may lead to a delayed diagnosis and increase the risk for severe puerperal sepsis. Therefore, in these cases, a high index of suspicion and prompt early antibiotic and surgical treatment is crucial to saving the parturient's life.

Fetal Loss and Preterm Birth Caused by Intraamniotic Haemophilus influenzae Infection, New Zealand.

Invasive Haemophilus influenzae infection during pregnancy can cause preterm birth and fetal loss, but the mechanism is unclear. We investigated 54 cases of pregnancy-associated invasive H. influenzae disease in 52 unique pregnancies in the Auckland region of New Zealand during October 1, 2008‒September 30, 2018. Intraamniotic infection was identified in 36 (66.7%) of 54 cases. Outcome data were available for 48 pregnancies. Adverse pregnancy outcomes, defined as fetal loss, preterm birth, or the birth of an infant requiring intensive/special care unit admission, occurred in 45 (93.8%) of 48 (pregnancies. Fetal loss occurred in 17 (35.4%) of 48 pregnancies, before 24 weeks' gestation in 13 cases, and at >24 weeks' gestation in 4 cases. The overall incidence of pregnancy-associated invasive H. influenzae disease was 19.9 cases/100,000 births, which exceeded the reported incidence of pregnancy-associated listeriosis in New Zealand. We also observed higher rates in younger women and women of Maori ethnicity.

Maternal sepsis.

Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection that can arise during pregnancy, childbirth, postabortion, or in the postpartum period. Validated diagnostic criteria of maternal sepsis and septic shock may reduce the impact of this condition on maternal health worldwide, but the lack of consensus on adequate tools due to the overlap between physiological adaptations that occur during pregnancy and signs and symptoms of infection and sepsis can delay both diagnosis and treatment. In the absence of evidence-based guidelines for obstetric populations, the WHO recommends the use of the "Surviving Sepsis Campaign" sepsis protocols for maternal care adapted to the local obstetric population. Interventions within the first hour from diagnosis have been proposed in 2021 to emphasize the state of emergency of a maternal sepsis. This review will highlight the utility of standardized diagnostic criteria, the implemented approaches for the prevention and treatment of maternal infections, and the strategies for early management of critically ill parturients.

Evaluation of the feasibility of the FAST-M maternal sepsis intervention in Pakistan: a protocol.

BACKGROUND: Maternal sepsis is a life-threatening condition, defined by organ dysfunction caused by infection during pregnancy, childbirth, and the postpartum period. It is estimated to account for between one-tenth and half (4.7% to 13.7%) of all maternal deaths globally. An international stakeholder group, including the World Health Organization, developed a maternal sepsis management bundle called "FAST-M" for resource-limited settings through a synthesis of evidence and international consensus. The FAST-M treatment bundle consists of five components: Fluids, Antibiotics, Source identification and control, assessment of the need to Transport or Transfer to a higher level of care and ongoing Monitoring (of the mother and neonate). This study aims to adapt the FAST-M intervention and evaluate its feasibility in Pakistan. METHODS: The proposed study is a mixed method, with a before and after design. The study will be conducted in two phases at the Liaquat University of Medical and Health Sciences, Hyderabad. In the first phase (formative assessment), we will adapt the bundle care tools for the local context and assess in what circumstances different components of the intervention are likely to be effective, by conducting interviews and a focus group discussion. Qualitative data will be analyzed considering a framework method approach using NVivo version 10 (QSR International, Pty Ltd.) software. The qualitative results will guide the adaptation of FAST-M intervention in local context. In the second phase, we will evaluate the feasibility of the FAST-M intervention. Quantitative analyses will be done to assess numerous outcomes: process, organizational, clinical, structural, and adverse events with quantitative comparisons made before and after implementation of the bundle. Qualitative analysis will be done to evaluate the outcomes of intervention by conducting FGDs with HCPs involved during the implementation process. This will provide an understanding and validation of quantitative findings. DISCUSSION: The utilization of care bundles can facilitate recognition and timely management of maternal sepsis. There is a need to adapt, integrate, and optimize a bundled care approach in low-resource settings in Pakistan to minimize the burden of maternal morbidities and mortalities due to sepsis.

Individualized treatment of preterm premature rupture of membranes to prolong the latency period, reduce the rate of preterm birth, and improve neonatal outcomes.

BACKGROUND: Preterm premature rupture of membranes complicates approximately 3% of pregnancies. Currently, in the absence of chorioamnionitis or placental abruption, expectant management, including antenatal steroids for lung maturation and prophylactic antibiotic treatment, is recommended. The benefits of individualized management have not been adequately explored. OBJECTIVE: This study aimed to compare the impact of 2 different management strategies of preterm premature rupture of membranes in 2 tertiary obstetrical centers on latency of >7 days, latency to birth, chorioamnionitis, funisitis, and short-term adverse maternal and neonatal outcomes. STUDY DESIGN: This was a multicenter retrospective study of women with singleton pregnancies with preterm premature rupture of membranes from 23 0/7 to 33 6/7 weeks of gestation between 2014 and 2018 and undelivered within 24 hours after hospital admission managed at Sunnybrook Health Sciences Center, Toronto, Canada (standard management group), and BCNatal (Hospital Clínic of Barcelona and Hospital Sant Joan de Déu Barcelona), Barcelona, Spain (individualized management group), following local protocols. The standard management group received similar management for all patients, which included a standard antibiotic regimen and routine maternal and fetal surveillance, whereas the individualized management group received personalized management on the basis of amniocentesis at hospital admission (if possible), to rule out microbial invasion of the amniotic cavity and targeted treatment. The exclusion criteria were cervical dilatation >2 cm, active labor, contraindications to expectant management (acute chorioamnionitis, placental abruption, or abnormal fetal tracing), and major fetal anomalies. The primary outcome was latency of >7 days, and the secondary outcomes included latency to birth, chorioamnionitis, and short-term adverse maternal and neonatal outcomes. Statistical comparisons between groups were conducted with propensity score weighting. RESULTS: A total of 513 pregnancies with preterm premature rupture of membranes were included in this study: 324 patients received standard management, and 189 patients received individualized management, wherein amniocentesis was performed in 112 cases (59.3%). After propensity score weighting, patients receiving individualized management had a higher latency of >7 days (76.0% vs 41.6%; P<.001) and latency to birth (18.1±14.7 vs 9.7±9.7 days; P<.001). Although a higher rate of clinical chorioamnionitis was suspected in the individualized management group than the standard group (34.5% vs 22.0%; P<.01), there was no difference between the groups in terms of histologic chorioamnionitis (67.2% vs 73.4%; P=.16), funisitis (57.6% vs 58.1%; P=.92), or composite infectious maternal outcomes (9.1% vs 7.9%; P=.64). Prolonged latency in the individualized management group was associated with a significant reduction of preterm birth at <32 weeks of gestation (72.1% vs 90.5%; P<.001), neonatal intensive care unit admission (75.6% vs 83.0%; P=.046), and neonatal respiratory support at 28 days of life (16.1% vs 26.1%; P<.01) compared with that in the standard management group. Moreover, prolonged latency was not associated with neonatal severe morbidity at discharge (survival without severe morbidity, 80.4% vs 73.5%; P=.09). CONCLUSION: Individualized management of preterm premature rupture of membranes may prolong pregnancy and reduce preterm birth at <32 weeks of gestation, the need for neonatal support, and neonatal intensive care unit admissions, without an increase in histologic chorioamnionitis, funisitis, neonatal infection-related morbidity, and short-term adverse maternal and neonatal outcomes.