Cefoxitin for Intra-amniotic Infections and Endometritis: A Retrospective Comparison to Traditional Antimicrobial Therapy Regimens Within a Healthcare System.

BACKGROUND: Local institutional guidelines and order sets were updated in June 2023 to recommend first-line cefoxitin monotherapy for the treatment of intra-amniotic infections (IAIs) and endometritis. This study evaluated the clinical impact of this change. METHODS: This was a retrospective, observational cohort study in an 11-campus health system comparing clinical outcomes of patients with chorioamnionitis, endometritis, or septic abortion receiving intravenous antimicrobial therapy before and after implementation of first-line cefoxitin monotherapy recommendations for the treatment of these infections. Primary outcome was a composite of serious clinical events postdelivery (ie, intensive care unit admission, death, hospital readmission related to IAI or endometritis within 30 days, additional surgery or procedures, or deep surgical site infection). Baseline characteristics between the pre- and post-cefoxitin groups were compared via Student's t tests for continuous variables and chi-square tests for categorical variables. Outcomes were evaluated via generalized linear modeling. RESULTS: A total of 472 patients were enrolled, 350 (74%) in the pre-cefoxitin group and 122 (26%) in the post-cefoxitin group. Groups were significantly different by race, healthcare payor, and hospital campus. Cefoxitin was rarely used in the pre-cefoxitin group (n = 2, <0.1%) and commonly used in the post-cefoxitin group (n = 112, 91.8%). After controlling for group differences, odds of experiencing serious clinical event postdelivery in the post-cefoxitin group were noninferior to those in the pre-cefoxitin group (adjusted odds ratio, .37; 95% CI, .17-.76; P = .010). CONCLUSIONS: Local institutional guidelines with predominant use of cefoxitin therapy were noninferior to traditional antimicrobial therapy regimens for the treatment of IAI.

Clinical Conundrum: Neisseria meningitidis Septic Abortion.

Septic shock after abortion is an important cause of global maternal mortality but is rarely encountered in developed countries. We describe a case of septic abortion with a novel associated pathogen: Neisseria meningitidis. A 30-year-old multiparous woman presented in septic shock after an incomplete spontaneous abortion. She received empiric antibiotics and vasopressors, underwent an urgent dilatation and curettage, and was admitted to the intensive care unit. Her blood cultures and endometrial tissue were positive for N. meningitidis. Antibiotics were adjusted based on culture, and the patient recovered. Septic shock requires prompt identification, antibiotic administration, and source control. Here, we identify an uncommon pathogen associated with septic abortion and highlight the importance of broad empiric and subsequent culture-guided antibiotic choice to ensure coverage.

Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions.

INTRODUCTION: Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions. METHODS: A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results. RESULTS: Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ±â€¯5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%. CONCLUSIONS: A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.

Actin from the apicomplexan Neospora caninum (NcACT) has different isoforms in 2D electrophoresis.

Apicomplexan parasites have unconventional actins that play a central role in important cellular processes such as apicoplast replication, motility of dense granules, endocytic trafficking and force generation for motility and host cell invasion. In this study, we investigated the actin of the apicomplexan Neospora caninum - a parasite associated with infectious abortion and neonatal mortality in livestock. Neospora caninum actin was detected and identified in two bands by one-dimensional (1D) western blot and in nine spots by the 2D technique. The mass spectrometry data indicated that N. caninum has at least nine different actin isoforms, possibly caused by post-translational modifications. In addition, the C4 pan-actin antibody detected specifically actin in N. caninum cellular extract. Extracellular N. caninum tachyzoites were treated with toxins that act on actin, jasplakinolide and cytochalasin D. Both substances altered the peripheric cytoplasmic localization of actin on tachyzoites. Our findings add complexity to the study of the apicomplexan actin in cellular processes, since the multiple functions of this important protein might be regulated by mechanisms involving post-translational modifications.

Molecular and serological data supporting the role of Q fever in abortions of sheep and goats in northern Egypt.

Q fever is a worldwide zoonotic disease, caused by Coxiella burnetii (C. burnetii), an obligate intracellular bacterium. The epidemiological data about the Q fever situation in Egypt is limited. The present study investigated the seroprevalence of Q fever among small ruminants in some localities in the northern Egypt and reported the shedders using specific real-time PCR (Rt-PCR). A total of 190 sera and vaginal swabs (110 sheep and 80 goats) were collected from aborted cases. Indirect ELISA was used to detect specific antibodies against C. burnetii, and Rt-PCR was used to detect DNA in the shedder animals. The study revealed that infection was significantly higher in sheep (22.7%) than in goats (12.5%) (p < 0.05). The Menoufia and Gharbia governorates had 20% seropositive animals while Qalubia and Alexandria had 15% and 17.5% seropositive animals, respectively. Using a Rt - PCR assay, C. burnetii was detected in 33.6% and 16.3% of sheep and goats, respectively. The findings of the study demonstrate that Q fever may be enzootic among small ruminants and distributed in the northern Egyptian Governorates. Further studies are needed in different regions to gain better understanding of the epidemiology of Q fever all over the country and to develop an appropriate preventive strategy for human and animals.

New approach to differentiate primary from latent Toxoplasma gondii abortion through immunoglobulin and DNA interpretation.

BACKGROUND: Toxoplasma gondii is an acute or latent zoonotic abortifacient human protozoan. Women may be aborted due to recent or latent infection during pregnancy or order to flare up of the dormant bradyzoites to acute tachyzoites (latent opportunistic relapse). AIMS: 1) to validate the interpretation of IgM and IgG immunoglobulins seromonotoring with DNA comparative results in differentiating recent from latent T. gondii abortion. METHOD: Blood with the corresponding placental or uterine wash samples were collected from 73 aborted Egyptian women from Cairo and Giza labour wards. Patients aborted in any of the phases (Ph-1, Ph-2, Ph-3 and Ph-4 were corresponding to abortion at the 1st, 2nd and 3rd trimesters plus females who gave birth with congenital anomalies), respectively. All aborted patients were assayed serologically by Enzyme Linked Immunosorbent Assay (ELISA) for IgM and IgG titers and the compatible DNA from placenta and uterine wash tissues by conventional Polymerase Chain Reaction (PCR) specific for T. gondii. RESULTS: Sero-positive aborted women were 50.7% by ELISA versus 37% by PCR. Not all T. gondii sero-positive aborted women were having T. gondii DNA or harboring compatible placental T. gondii cysts. This denotes that immunoglobulins alone are insufficient criteria for confirming toxoplasma abortion. CONCLUSION: Immunoglobulins with DNA comparative results can possibly differentiate recent from latent T. gondii abortion at higher precision. We recommend the need for routine monitoring of T. gondii i.e. (pre-, during and post-delivery).

The protective effect of berberine against lipopolysaccharide-induced abortion by modulation of inflammatory/immune responses.

OBJECTIVE: Berberine is an isoquinoline derivative alkaloid with anti-inflammatory activity. In this study, we investigated the protective effects of berberine in prevention of LPS-induced abortion. MATERIALS AND METHODS: On the gestation day (GD) 9.5, the pregnant mice were injected with low, medium, and high doses of berberine or with PBS. After 4 h, berberine or PBS-pretreated mice were injected with LPS. On GD 11.5, blood samples and uterine tissues were collected from treated mice and percentage of abortion and serum levels of NO, TNF-α, IL-10, and IL12p70 were measured by macroscopic examination and sandwich ELISA, respectively. RESULTS: Our findings show that mice injected with berberine were resistant to LPS-induced abortion. We also found that this treatment prevents the reduction of IL-10 and the enhancement of NO, TNF-α, and IL-12p70 in LPS-treated pregnant mice. CONCLUSIONS: Taken together, our results suggest that berberine as an anti-inflammatory agent has protective effects on LPS-induced abortion by modulation of inflammatory/immune responses.

Pharmacokinetics of chlortetracycline in maternal plasma and in fetal tissues following oral administration to pregnant ewes.

The purpose of this study was to determine if concentrations of chlortetracycline could be detected in fetal plasma or tissues after administering an oral dose of chlortetracycline (CTC; 500 mg/head/day) reported to be effective in controlling Campylobacter spp. abortions. Five pregnant ewes were administered 250 mg/head twice a day (total dose 500 mg/hd/d) for 7 days. On the beginning of day 7, intravenous catheters were surgically implanted or inserted into the fetus and dam. Plasma samples were collected from the ewe and fetus at various time points before and up to 36 hr after the last dose of CTC. All ewes were then sacrificed, and tissues were harvested from the fetus for drug analysis. Concentrations of CTC in maternal plasma were consistent with our previous study and below the minimum inhibitory concentration of Campylobacter abortion isolates. Concentrations of CTC were below the limit of detection in three of five fetal plasma samples and all of the placenta, amniotic fluid, and fetal stomach contents. Low concentrations were detectable in fetal kidney and liver, suggesting that CTC reaches the fetus, although at a variable and low ratio when compared to maternal concentrations.

CCR5 Is Involved in Interruption of Pregnancy in Mice Infected with Toxoplasma gondii during Early Pregnancy.

Toxoplasmosis can cause abortion in pregnant humans and other animals; however, the mechanism of abortion remains unknown. C-C chemokine receptor type 5 (CCR5) is essential for host defense against Toxoplasma gondii infection. To investigate the relationship between CCR5 and abortion in toxoplasmosis, we inoculated wild-type and CCR5-deficient (CCR5-/-) mice with T. gondii tachyzoites intraperitoneally on day 3 of pregnancy (embryonic day 3 [E3]). The pregnancy rate decreased as pregnancy progressed in infected wild-type mice. Histopathologically, no inflammatory lesions were observed in the fetoplacental tissues. Although wild-type mice showed a higher parasite burden at the implantation sites than did CCR5-/- mice at E6 (3 days postinfection [dpi]), T. gondii antigen was detected only in the uterine tissue and not in the fetoplacental tissues. At E8 (5 dpi), the embryos in infected wild-type mice showed poor development compared with those of infected CCR5-/- mice, and apoptosis was observed in poorly developed embryos. Compared to uninfected mice, infected wild-type mice showed increased CCR5 expression at the implantation site at E6 and E8. Furthermore, analyses of mRNA expression in the uterus of nonpregnant and pregnant mice suggested that a lack of the CCR5 gene and the downregulation of tumor necrosis factor alpha (TNF-α) and CCL3 expression at E6 (3 dpi) are important factors for the maintenance of pregnancy following T. gondii infection. These results suggested that CCR5 signaling is involved in embryo loss in T. gondii infection during early pregnancy and that apoptosis is associated with embryo loss rather than direct damage to the fetoplacental tissues.

Key Role of Capsular Polysaccharide in the Induction of Systemic Infection and Abortion by Hypervirulent Campylobacter jejuni.

Campylobacter jejuni is a zoonotic pathogen, and a hypervirulent clone, named clone SA, has recently emerged as the predominant cause of ovine abortion in the United States. To induce abortion, orally ingested Campylobacter must translocate across the intestinal epithelium, spread systemically in the circulation, and reach the fetoplacental tissue. Bacterial factors involved in these steps are not well understood. C. jejuni is known to produce capsular polysaccharide (CPS), but the specific role that CPS plays in systemic infection and particularly abortion in animals remains to be determined. In this study, we evaluated the role of CPS in bacteremia using a mouse model and in abortion using a pregnant guinea pig model following oral challenge. Compared with C. jejuni NCTC 11168 and 81-176, a clone SA isolate (IA3902) resulted in significantly higher bacterial counts and a significantly longer duration of bacteremia in mice. The loss of capsule production via gene-specific mutagenesis in IA3902 led to the complete abolishment of bacteremia in mice and abortion in pregnant guinea pigs, while complementation of capsule expression almost fully restored these phenotypes. The capsule mutant strain was also impaired for survival in guinea pig sera and sheep blood. Sequence-based analyses revealed that clone SA possesses a unique CPS locus with a mosaic structure, which has been stably maintained in all clone SA isolates derived from various hosts and times. These findings establish CPS as a key virulence factor for the induction of systemic infection and abortion in pregnant animals and provide a viable candidate for the development of vaccines against hypervirulent C. jejuni.

Chlamydia trachomatis and chlamydia-like bacteria: new enemies of human pregnancies.

PURPOSE OF REVIEW: This review provides an update on the roles of Chlamydia trachomatis and the related Waddlia chondrophila and Parachlamydia acanthamoebae in miscarriage, stillbirths and preterm labour in humans. A broad audience, including microbiologist, infectiologists, obstetricians and gynaecologists, should be aware of the potential threat of these Chlamydiales for human reproduction. RECENT FINDINGS: Despite increasing laboratory techniques and possibilities to perform diagnostic tests, the cause of miscarriage is only identified in 50% of the cases. Intracellular bacteria, such as C. trachomatis and Chlamydia-related bacteria, are difficult to detect in routine clinical samples and could represent possible agents of miscarriages. C. trachomatis is considered the world largest sexual transmitted bacterial agent and is associated with adverse pregnancy outcome in human. In the last decade Chlamydia-like organisms, such as W. chondrophila and P. acanthamoebae, have also been associated with adverse pregnancy outcomes in human and/or animals. SUMMARY: We review here the current evidences for a pathogenic role in humans, the diagnostic approaches and possible treatment options of C. trachomatis, W. chondrophila and P. acanthamoebae.

Induced abortion.

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Streptococcus G leading to septic abortion and multiple organ failure.

The authors report a patient admitted at 12 weeks of pregnancy with an acute infectious syndrome, leading to abortion, sepsis, and multiple organ failure. Admission to intensive care unit (ICU) was needed after curettage for incomplete abortion complicated by uterine atony, hemorrhage, and septic shock. The patient had multiple organ failure and required non-invasive ventilation. Hemoculture showed streptococcus G bacteremia. She had no evidence of concurrent infection, mainly genital or urinary, except amygdalitis few days before. Hematogenous spread to the gestational sac could have possibly been the cause of her sepsis. Streptococcus G infection during pregnancy can lead to severe consequences.

Septic miscarriage with toxic shock syndrome and disseminated intravascular coagulation (DIC): The role of surgery, recombinant activated factor VII and intravenous immunoglobulin (IVIG).

Severe sepsis with multi-organ failure is associated with a high mortality rate. This case report highlights the challenges and modalities available in the management of a lady with refractory shock and disseminated intravascular coagulation (DIC) due to toxic shock syndrome (TSS) from genital tract sepsis. Early surgical intervention to remove the source of infection, the use of recombinant activated factor VII to treat intractable disseminated intravascular coagulation and intravenous immunoglobulin to neutralise the circulating exotoxins, have been employed and shown to drastically improve outcomes.

Analysis of Humoral Immune Responses to Surface and Virulence-Associated Chlamydia abortus Proteins in Ovine and Human Abortions by Use of a Newly Developed Line Immunoassay.

The obligate intracellular bacterium Chlamydia abortus is the causative agent of enzootic abortion of ewes and poses a significant zoonotic risk for pregnant women. Using proteomic analysis and gene expression library screening in a previous project, we identified potential virulence factors and candidates for serodiagnosis, of which nine were scrutinized here with a strip immunoassay. We have shown that aborting sheep exhibited a strong antibody response to surface (MOMP, MIP, Pmp13G) and virulence-associated (CPAF, TARP, SINC) antigens. While the latter disappeared within 18 weeks following abortion in a majority of the animals, antibodies to surface proteins persisted beyond the duration of the study. In contrast, nonaborting experimentally infected sheep developed mainly antibodies to surface antigens (MOMP, MIP, Pmp13G), all of which did not persist. We were also able to detect antibodies to these surface antigens in C abortus-infected women who had undergone septic abortion, whereas a group of shepherds and veterinarians with occupational exposure to C abortus-infected sheep revealed only sporadic immune responses to the antigens selected. The most specific antigen for the serodiagnosis of human C abortus infections was Pmp13G, which showed no cross-reactivity with other chlamydiae infecting humans. We suggest that Pmp13G-based serodiagnosis accomplished by the detection of antibodies to virulence-associated antigens such as CPAF, TARP, and SINC may improve the laboratory diagnosis of human and animal C abortus infections.

Antibiotics for treating septic abortion.

BACKGROUND: A septic abortion refers to any abortion (spontaneous or induced) complicated by upper genital tract infection including endometritis or parametritis. The mainstay of treatment of septic abortion is antibiotic therapy alone or in combination with evacuation of retained products of conception. Regimens including broad-spectrum antibiotics are routinely recommended for treatment. However, there is no consensus on the most effective antibiotics alone or in combination to treat septic abortion. This review aimed to bridge this gap in knowledge to inform policy and practice. OBJECTIVES: To review the effectiveness of various individual antibiotics or antibiotic regimens in the treatment of septic abortion. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and POPLINE using the following keywords: 'Abortion', 'septic abortion', 'Antibiotics', 'Infected abortion', 'postabortion infection'. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 19 April, 2016. SELECTION CRITERIA: We considered for inclusion randomised controlled trials (RCTs) and non-RCTs that compared antibiotic(s) to another antibiotic(s), irrespective of route of administration, dosage, and duration as well as studies comparing antibiotics alone with antibiotics in combination with other interventions such as dilation and curettage (D&C). DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from included trials. We resolved disagreements through consultation with a third author. One review author entered extracted data into Review Manager 5.3, and a second review author cross-checked the entry for accuracy. MAIN RESULTS: We included 3 small RCTs involving 233 women that were conducted over 3 decades ago.Clindamycin did not differ significantly from penicillin plus chloramphenicol in reducing fever in all women (mean difference (MD) -12.30, 95% confidence interval (CI) -25.12 to 0.52; women = 77; studies = 1). The evidence for this was of moderate quality. "Response to treatment was evaluated by the patient's 'fever index' expressed in degree-hour and defined as the total quantity of fever under the daily temperature curve with 99°F (37.2°C) as the baseline".There was no difference in duration of hospitalisation between clindamycin and penicillin plus chloramphenicol. The mean duration of hospital stay for women in each group was 5 days (MD 0.00, 95% CI -0.54 to 0.54; women = 77; studies = 1).One study evaluated the effect of penicillin plus chloramphenicol versus cephalothin plus kanamycin before and after D&C. Response to therapy was evaluated by "the time from start of antibiotics until fever lysis and time from D&C until patients become afebrile". Low-quality evidence suggested that the effect of penicillin plus chloramphenicol on fever did not differ from that of cephalothin plus kanamycin (MD -2.30, 95% CI -17.31 to 12.71; women = 56; studies = 1). There was no significant difference between penicillin plus chloramphenicol versus cephalothin plus kanamycin when D&C was performed during antibiotic therapy (MD -1.00, 95% CI -13.84 to 11.84; women = 56; studies = 1). The quality of evidence was low.A study with unclear risk of bias showed that the time for fever resolution (MD -5.03, 95% CI -5.77 to -4.29; women = 100; studies = 1) as well as time for resolution of leukocytosis (MD -4.88, 95% CI -5.98 to -3.78; women = 100; studies = 1) was significantly lower with tetracycline plus enzymes compared with intravenous penicillin G.Treatment failure and adverse events occurred infrequently, and the difference between groups was not statistically significant. AUTHORS' CONCLUSIONS: We found no strong evidence that intravenous clindamycin alone was better than penicillin plus chloramphenicol for treating women with septic abortion. Similarly, available evidence did not suggest that penicillin plus chloramphenicol was better than cephalothin plus kanamycin for the treatment of women with septic abortion. Tetracyline enzyme antibiotic appeared to be more effective than intravenous penicillin G in reducing the time to fever defervescence, but this evidence was provided by only one study at low risk of bias.There is a need for high-quality RCTs providing reliable evidence for treatments of septic abortion with antibiotics that are currently in use. The three included studies were carried out over 30 years ago. There is also a need to include institutions in low-resource settings, such as sub-Saharan Africa, Latin America and the Caribbean, and South Asia, with a high burden of abortion and health systems challenges.

Maternal near miss and mortality due to postpartum infection: a cross-sectional analysis from Rwanda.

BACKGROUND: The objective of this study is to evaluate 'near miss' and mortality in women with postpartum infections. METHODS: We performed a retrospective review of all patients referred to the University Teaching Hospital of Kigali (CHUK) between January 2012 and December 2013. We identified 117 patients with postpartum infections. Demographic data, length of admission, location of referral, initial surgery and subsequent treatment modalities including antibiotic administration and secondary surgery were recorded. The primary outcome of interest was a composite of maternal mortality and "near miss" defined as more than one laparotomy with/without hysterectomy and prolonged hospitalization. RESULTS: Diagnoses at CHUK were: pelvic peritonitis (56 %), deep surgical site infection including fasciitis (17 %), and endometritis (15 %). The primary procedures performed prior to transfer were: cesarean section (81 %), septic abortion management (12 %), and vaginal delivery (7 %). Antibiotics were initiated prior to transfer in 66 % of women. Surgery was required in 73 % of patients. Hysterectomies were performed in 22 % of patients. Maternal death occurred in 5 % of the patient population. The primary outcome of severe maternal morbidity and mortality occurred in 90 patients (77 %). CONCLUSION: Peritonitis-primarily as a result of cesarean deliveries-is associated with significant morbidity and mortality in our population.

Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management.

Disseminated intravascular coagulation (DIC) is a life-threatening situation that can arise from a variety of obstetrical and nonobstetrical causes. Obstetrical DIC has been associated with a series of pregnancy complications including the following: (1) acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture); (2) placental abruption; (3) preeclampsia/eclampsia/hemolysis, elevated liver enzymes, and low platelet count syndrome; (4) retained stillbirth; (5) septic abortion and intrauterine infection; (6) amniotic fluid embolism; and (7) acute fatty liver of pregnancy. Prompt diagnosis and understanding of the underlying mechanisms of disease leading to this complication in essential for a favorable outcome. In recent years, novel diagnostic scores and treatment modalities along with bedside point-of-care tests were developed and may assist the clinician in the diagnosis and management of DIC. Team work and prompt treatment are essential for the successful management of patients with DIC.

An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa.

BACKGROUND: Septic incomplete miscarriages remain a cause of maternal deaths in South Africa. There was an initial decline in mortality when a strict protocol based approach and the Choice of Termination of Pregnancy Act in South Africa were implemented in this country. However, a recent unpublished audit at the Pretoria Academic Complex (Kalafong and Steve Biko Academic Hospitals) suggested that maternal mortality due to this condition is increasing. The objective of this investigation is to do a retrospective audit with the purpose of identifying the reasons for the deteriorating mortality index attributed to septic incomplete miscarriage at Steve Biko Academic Hospital. METHODS: A retrospective audit was performed on all patients who presented to Steve Biko Academic Hospital with a septic incomplete miscarriage from 1(st) January 2008 to 31(st) December 2010. Data regarding patient demographics, initial presentation, resuscitation and disease severity was collected from the "maternal near-miss"/SAMM database and the patient's medical record. The shock index was calculated for each patient retrospectively. RESULTS: There were 38 SAMM and 9 maternal deaths during the study period. In the SAMM group 86.8% and in the maternal death group 77.8% had 2 intravenous lines for resuscitation. There was no significant improvement in the mean blood pressure following resuscitation in the SAMM group (p 0.67), nor in the maternal death group (p 0.883). The shock index before resuscitation was similar in the two groups but improved significantly following resuscitation in the SAMM group (p 0.002). Only 31.6% in the SAMM group and 11.1% in the maternal death group had a complete clinical examination, including a speculum examination of the cervix on admission. No antibiotics were administered to 21.1% in the SAMM group and to 33.3% in the maternal death group. CONCLUSION: The strict protocol management for patients with septic incomplete miscarriage was not adhered to. Physicians should be trained to recognise and react to the seriously ill patient. The use of the shock index in the identification and management of the critically ill pregnant patient needs to be investigated.

Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piaui, Brazil.

BACKGROUND: Maternal near miss (MNM) investigation is a useful tool for monitoring standards for obstetric care. This study evaluated the prevalence and the determinants of severe maternal morbidity (SMM) and MNM in a tertiary referral hospital in Teresina, Piauí, Brazil. METHODS: A transversal and prospective study was conducted between September 2012 and February 2013. The cases were included according to criteria established by the WHO. Odds ratio, their respective confidence intervals, and multivariate analyses were examined. RESULTS: Five thousand eight hundred forty one live births, 343 women with SMM, 56 cases of MNM, and 10 maternal deaths were investigated. The rate for severe maternal outcomes was 11.2 cases per 1000 live births, the rate of MNM was 9.6 cases/1000 live births, and the rate for mortality was 171.2 cases/100,000 live births. Management criteria were most frequently observed among MNM/death cases. Hypertensive diseases (86.1%) and hemorrhagic complications (10.0%) were the main determinants of MNM, but infectious abortion was the most common isolated cause of maternal death. There was a correlation between MNM/death and hospitalized more than 5 days (p = 0.023) and between termination of pregnancy by cesarean (p = 0.002) and APGAR < 7 in the 1(st) minute (p = 0.015). CONCLUSIONS: SMM and MNM were quite prevalent in the population studied. Women whose condition progressed to MNM/death had a higher association with terminating pregnancy by cesarean, longer hospitalization times, and worse perinatal results. The results from the study can be useful to improve the quality of obstetric care and consequently diminish maternal mortality in the region.