Risk Factors, Trends, and Outcomes Associated With Postpartum Sepsis Readmissions.

OBJECTIVE: To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis. METHODS: We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure. RESULTS: Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum. CONCLUSION: Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions.

Pregnancy-related Acute Kidney Injury in Public Hospital in South India: Changing Trends.

BACKGROUND: Pregnancy-related acute kidney injury (PRAKI) is a common problem in the developing world. MATERIALS AND METHODS: In this retrospective observational study at a tertiary care hospital in South India we evaluated records for the maternal, fetal, and renal outcomes in women with PRAKI. RESULTS: Over a 10-year period, 395 patients of PRAKI were seen constituting 8.1% of all acute kidney injury (AKI). The mean age of patients was 27 ± 3 years. A total of 176 (44.5%) had pre-eclampsia, 132 (33.4%) had puerperal sepsis, 76 (19.2%) had antepartum hemorrhage or postpartum hemorrhage (APH 30/PPH 46), nine (2.2%) had hemolytic uremic syndrome (HUS). Obstruction was seen in two patients. Eleven had underlying glomerulonephritis out of three had lupus nephritis. Forty-five of 395 (11.39%) had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, that is, 25.5% of those with pre-eclampsia. Sixteen (4.0%) had placental abruption. A total of 288 (72.9%) presented postpartum. Renal biopsy done in 103 (26%) showed patchy cortical necrosis (PCN) in 25 (22.3%), diffuse cortical necrosis (DCN) in 23 (20.3%), acute tubular necrosis (ATN) in 20 (19.4%), acute interstitial nephritis (AIN) in 10 (9.7%), while nine (8.7%) had thrombotic microangiopathy (TMA). Glomerular disease was seen in 11. Cortical necrosis (CN) was seen in 48 patients of which 10 (20.83%) had abruption placenta, 25 (52%) had puerperal sepsis, 11 (22.9%) had postpartum hemorrhage (PPH), and two (4.1%) had TMA. A total of 290 (73.4%) required dialysis. About 76% improved while 8.3% progressed to end-stage renal disease (ESRD). Maternal mortality (MM) was 5%. There were 42 intrauterine deaths and 30 deaths in the neonatal period. DISCUSSION: Pregnancy-related acute kidney injury in developing countries is more common as compared to the West. Only 49% patients had booked pregnancy, that is, received regular antenatal care. Apart from pre-eclampsia which is also the major cause in the West and was the etiology in 44% of patients with PRAKI in our study, sepsis (33%) and maternal hemorrhage (19%) were also significant. Immediate recovery from PRAKI was 75% however about 8% develop end-stage kidney disease (ESKD) while in the west ESKD occurred in only about 2%. CONCLUSION: Pregnancy-related acute kidney injury is an important cause of maternal and fetal morbidity and mortality. Pre-eclampsia emerged as the most common cause of PRAKI and CN was the most common histological lesion. Proper antenatal care and management may improve pregnancy outcomes.

Association between interleukin-19 gene polymorphisms and maternal puerperal infection.

Any bacterial infection of the genital tract after childbirth is called maternal puerperal infection. This infection accounts for 13% of pregnancy-related deaths and is the fifth leading cause of maternal mortality. Endometritis (postpartum uterine infection) has been associated with preeclampsia and maternal lethal bleeding in recent decades. In some studies, the presence of meconium in the amniotic fluid has been implicated in the development of endometritis. The study aimed to evaluate the association between interleukin-19 gene polymorphisms and maternal puerperal infection. In this study, 300 pregnant women with a gestational age of at least 37 weeks were studied. Patients were divided into two groups of 150 controls and cases. In the case group, amniotic fluid was impregnated with meconium, and in the control group, it was clear fluid. Both groups underwent cesarean section, and all received prophylactic antibiotics before surgery. Patients were evaluated for purpura infection in the first 40 days after delivery. Five ml of venous blood was taken from each patient and transferred to a tube containing EDTA anticoagulant. Genomic DNA was isolated using a particular kit. Then, the polymerase chain reaction was performed by the ARMS method. Data were analyzed using the chi-square test and SPSS software version 19 in case and control groups. This study's results indicate no significant difference in the frequency of AG, GG, and AA genotypes at position rs2243191 and rs1028181 IL-19 gene polymorphism between patients with puerperal infection and the control group (P>0.05). Also, no significant difference was observed in the frequency of both G and A alleles in the mentioned situations between patients and the control group (P>0.05). Based on the results of this study, no significant relationship was observed between IL-19 gene polymorphism at rs2243191 and rs1028181 locus and puerperal infection.

Características relacionadas à ocorrência de infecção puerperal em mulheres submetidas ao parto cesáreo / Characteristics related to the occurrence of puerperal infection in women submitted to cesarrel delivery

Objetivo: Este artigo de revisão sistemática tem como objetivo analisar as principais características relacionadas à infeção puerperal em mulheres submetidas ao parto cesáreo. Fonte dos dados: Foi realizada busca nas bases de dados on-line Biblioteca Virtual de Saúde (BVS) e PubMed. Seleção dos estudos: Selecionaram-se artigos publicados nos últimos 11 anos (2010-2021), totalizando 12 artigos analisados. Coleta de dados: Realizou-se a busca dos artigos a partir dos descritores infecção puerperal, mortalidade materna, cesárea, fatores de risco em inglês e português. Em seguida à adequação aos critérios de inclusão (artigos em inglês, português e espanhol, com publicação nos últimos 11 anos, realizados em humanos) e exclusão (artigos duplicados, revisão de literatura, estudos de caso e dissertações), a análise dos títulos e dos resumos dos artigos encontrados permitiu a exclusão daqueles que se afastavam do tema em estudo. Síntese dos dados: Dentre os fatores sociodemográficos, destacam-se mulheres nos extremos de idade, negras, residentes na zona rural, com baixo nível econômico e escolar, primíparas e tabagistas. Em relação aos fatores clínicos, obesidade, HIV, diabetes mellitus, doenças cardiovasculares, hipertensão arterial, pré-eclâmpsia e eclâmpsia, anemia e infecções geniturinárias apresentaram-se como fatores de risco para infecção puerperal. Fatores obstétricos também foram avaliados, identificando-se como variáveis importantes o parto cesáreo, rotura prematura de membranas, tempo de membrana rota, trabalho de parto maior que 12 horas, parto prematuro e trabalho de parto induzido, hemorragia pós-parto, transfusão prévia e mecônio em líquido amniótico. Por fim, as características assistenciais trazem o baixo número de consultas de pré-natal e número de toques vaginais antes e após a ruptura de membranas como variáveis de risco. Conclusão: Muitos dos fatores identificados são passíveis de controle, e a sua reversão contribui para a redução dos índices de infecção puerperal e, consequentemente, de mortalidade materna.(AU)

Objective: This systematic review article aims to analyze the main characteristics related to puerperal infection in women undergoing cesarean delivery. Source of data: A search was performed in the online databases Virtual Health Library (VHL) and Pub- Med. Selection of studies: Articles published in the last 11 years were selected, totaling 12 analyzed articles. Data collection: Articles were searched based on the keywords puerperal infection, maternal mortality, cesarean section, risk factors in English and Portuguese. Following the adaptation to the inclusion criteria (articles in English, Portuguese and Spanish, publication in the last 11 years, carried out in humans) and exclusion (duplicates, literature review, case studies and dissertations), the analysis of the titles and abstracts of the found articles allowed the exclusion of those who departed from the topic under study. Summary of the findings: Among the sociodemographic factors, women of extreme age, blacks, residents in the rural area, with low economic and educational status, primiparous women and smokers, stand out. Regarding clinical factors, obesity, HIV, Diabetes Mellitus, Cardiovascular Diseases, Hypertension, Pre-eclampsia and Eclampsia, Anemia and genitourinary infections were risk factors for puerperal infection. Obstetric factors were also evaluated, identifying as important variables cesarean delivery, premature rupture of membranes, ruptured membrane time, labor longer than 12 hours, premature labor and induced labor, postpartum hemorrhage, previous transfusion and meconium in amniotic fluid. Finally, the care characteristics bring the low number of prenatal consultations, the number of vaginal touches before and after rupture of membranes as risk variables. Conclusion: Many of the identified factors are possible to control and their reversion contributes to the reduction of puerperal infection rates and consequently maternal mortality.(AU)

Fascitis necrotizante por Enterococcus gallinarum en una puérpera. Presentación de un caso / Necrotizing fasciitis due to Enterococcus gallinarum in a pospartum patient. Case report

RESUMEN Fundamento: La fascitis necrotizante es una infección que se desarrolla de manera rápida, afecta la piel, tejido celular subcutáneo, fascia superficial y en ocasiones la profunda, en heridas quirúrgicas al producir necrosis hística y severa toxicidad sistémica. Es una afectación sistémica acompañante, que a su vez a ella se asocian factores predisponentes endógenos como: diabetes mellitus, obesidad, alcoholismo, infección por VIH, y exógenos: cirugía ginecobstétrica, inyecciones, traumatismos; por lo que estos pacientes resultan ser enfermos críticos en las unidades de cuidados intensivos, con un curso clínico no uniforme, al llevar a una evolución fulminante cuando corresponde con la variante hiperaguda o fulminante. Objetivo: Describir la presencia de fascitis necrotizante hiperaguda causada por Enterococcus gallinarum, en una puérpera. Reporte de caso: Puérpera que se le practicó parto distócico por cesárea electiva a las 38.3 semanas, a las 24 h presentó manifestaciones generales que se acompañaron de lesiones en la piel; se le realizó cirugía ginecobstétrica, su evolución fue tórpida y falleció por fallo multiorgánico a los 3 días debido a las consecuencias de fascitis necrotizante hiperaguda o fulminante, causada esta por un Enterococcus gallinarum. Conclusiones: La fascitis necrotizante es una enfermedad poco frecuente y mortal si no se trata a tiempo; su diagnóstico resulta difícil en su fase inicial, debido a que casi siempre es clínico. El tratamiento quirúrgico debe ser urgente, combinarse este con antibióticoterapia sistémica, debido al germen causal y la toxicidad que producen.

ABSTRACT Background: Necrotizing fasciitis is an infection that develops rapidly, affecting the skin, subcutaneous cellular tissue, superficial fascia and sometimes deep fascia, in surgical wounds by producing hystenotic necrosis and severe systemic toxicity. It is a supplementary systemic affectation, which in turn is associated with endogenous predisposing factors such as: diabetes mellitus, obesity, alcoholism, HIV infection, and exogenous: gynecobstetric surgery, injections, traumatisms; so these patients are critical patients in intensive care units, with a non-uniform clinical progression, leading to a fulminant evolution when parallel to the hyperacute or fulminant variant. Objective: To describe the presence of hyperacute necrotizing fasciitis caused by Enterococcus gallinarum in a puerperal. Case report: A puerperal who suffered from dystocia delivery by elective cesarean section at 38.3 weeks, at 24 h presented general manifestations accompanied by skin lesions; she underwent gynecobstetric surgery, her evolution was torpid and she died of multiorgan failure after 3 days due to the consequences of hyperacute or fulminant necrotizing fasciitis, caused by Enterococcus gallinarum. Conclusions: Necrotizing fasciitis is a rare and fatal disease if not treated in time; its diagnosis is difficult in its early phase because it is often clinical. Surgical treatment should be urgent and combined with systemic antibiotic therapy due to the causative germ and the toxicity they produce.

Beta-endorphin inhibits the inflammatory response of bovine endometrial cells through δ opioid receptor in vitro.

Postpartum uterine infections are common reproductive diseases in postpartum cows. Evidence has shown that plasma ß-endorphins increase during bovine uterine inflammation. However, the effect of ß-endorphins on the inflammatory response in bovine endometrium has not been clarified. The aim of this study was to investigate the effect of ß-endorphins on the inflammatory response of bovine endometrial epithelial and stromal cells, and to explore the possible mechanism. The cells were treated with E. coli lipopolysaccharide (LPS) to simulate inflammation, which was characterized by the significant activation of NF-κB signaling pathway and the increased gene expression of the downstream proinflammatory cytokines (approximately 1.2- to 15-fold increase, P < 0.05). By using Western blot and qPCR techniques, we found that ß-endorphins inhibited the key protein expression of NF-κB pathway, and the gene expressions of TNF, IL1B, IL6, CXCL8, nitric oxide synthase 2, and prostaglandin-endoperoxide synthase 2 (P < 0.05). The co-treatment of ß-endorphins and opioid antagonists showed that the anti-inflammatory effect of ß-endorphins could be blocked (P < 0.05) by non-selective opioid antagonist naloxone or δ opioid receptor antagonist ICI 154129, but not the µ opioid receptor antagonist CTAP (P > 0.05). In conclusion, ß-endorphins may inhibit the inflammatory response of bovine endometrial epithelial and stromal cells through δ opioid receptor.

Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections.

OBJECTIVES: Gestational IDA has been linked to adverse maternal and neonatal outcomes, but the impact of iron supplementation on outcome measures remains unclear. Our objective was to assess the effects of gestational IDA on pregnancy outcomes and compare outcomes in pregnancies treated with either oral or intravenous iron supplementation. METHODS: We evaluated maternal and neonatal outcomes in 215 pregnancies complicated with gestational IDA (Hb<100 g/L) and delivered in our tertiary unit between January 2016 and October 2018. All pregnancies from the same period served as a reference group (n=11,545). 163 anemic mothers received oral iron supplementation, and 52 mothers received intravenous iron supplementation. RESULTS: Gestational IDA was associated with an increased risk of preterm birth (10.2% vs. 6.1%, p=0.009) and fetal growth restriction (FGR) (1.9% vs. 0.3%, p=0.006). The gestational IDA group that received intravenous iron supplementation had a greater increase in Hb levels compared to those who received oral medication (18.0 g/L vs. 10.0 g/L, p<0.001), but no statistically significant differences in maternal and neonatal outcomes were detected. CONCLUSIONS: Compared to the reference group, prematurity, FGR, postpartum infections, and extended hospital stays were more common among mothers with gestational IDA, causing an additional burden on the families and the healthcare system.

Infecção do sítio cirúrgico após cesariana em uma maternidade de Manaus, Brasil: a importância do uso racional da antibioticoterapia / Surgical site infection after cesarean section in a maternity hospital in Manaus, Brazil: the importance of rational antibiotic therapy

Objetivo: Descrever o perfil epidemiológico e microbiológico das puérperas com diagnóstico de infecção após cesárea, caracterizando as infecções de sítio cirúrgico e o tratamento. Métodos: Coorte prospectiva de parturientes submetidas a parto cesáreo em maternidade pública de Manaus, Amazonas, Brasil, com diagnóstico de infecção de sítio cirúrgico, entre 1º de julho de 2019 e 30 de abril de 2020. Foram coletados dados epidemiológicos. Para a investigação do perfil microbiológico, foi realizada a identificação da cultura a partir da secreção da infecção do sítio cirúrgico e do antibiograma das culturas. Resultados: Um total de 81 pacientes foi diagnosticado com infecção de sítio cirúrgico durante o período de estudo. A taxa de infecção de sítio cirúrgico na maternidade em estudo foi de 6,0%. As pacientes possuíam baixa escolaridade e baixa renda mensal, com ocupações que requerem menor qualificação, sendo a maioria solteira. Entre as pacientes, 70,4% eram obesas e 28,4% apresentaram sobrepeso; 45,6% delas tiveram parto cesáreo de emergência e 29,6% não usaram antibióticos profiláticos. Staphylococcus aureus foi a cultura identificada mais frequentemente e apresentou resistência ao antibiótico mais prescrito: a gentamicina. Conclusão: A taxa de infecção do sítio cirúrgico foi alta durante o período do estudo. Ressaltamos a necessidade de um protocolo eficaz de identificação bacteriana e acompanhamento da puérpera. O conhecimento das características epidemiológicas e microbiológicas pode auxiliar no planejamento dos cuidados realizados pelas instituições de saúde para minimizar os casos de infecção de sítio cirúrgico e suas consequências.(AU)

Objective: To describe the epidemiological and microbiological profiles of puerperal women diagnosed with the infection after cesarean sections, characterizing the surgical site infections and treatment. Methods: Prospective cohort of parturients underwent cesarean delivery at a public maternity hospital in Manaus, Amazonas, Brazil, diagnosed with surgical site infection between July 1, 2019, and April 30, 2020. Epidemiological data were collected. To investigate the microbiological profile, both culture identification from surgical site infection secretion and antibiogram for the cultures were performed. Results: A total of 81 patients were confirmed to have surgical site infection during this study period; The surgical site infection rate in the maternity hospital under study was 6.0%. The patients presented a low level of education and monthly income, with occupations that require lower qualification, and most of them are single. Seventy point four percent of the patients were obese, and 28.4% were overweight. Forty-five point six percent of patients had an emergency cesarean delivery, and 29.6% did not use prophylactic antibiotics. Staphylococcus aureus was the most frequent culture identified from surgical site infection secretion and presented resistance to the most prescribed antibiotic, Gentamicin. Conclusion: The rate of surgical site infection was high during the study period. We highlight the need for an effective bacterial identification protocol and monitoring of puerperal women. Knowledge of epidemiological and microbiological characteristics can assist in the planning of care performed by the health institutions to minimize cases of surgical site infection and its consequences.(AU)

Infecciones Respiratorias Virales y la Placenta / Respiratory viral infections and the placenta

Las enfermedades infecciosas que comprometen el aparato respiratorio, generalmente son más graves en las gestantes y en las puérperas en comparación con las no embarazadas. Dentro de estas infecciones, se encuentran las producidas por agentes virales como la influenza estacional, pandémica y zoonótica, los coronavirus SARS, el MERS; y desde el año 2019 el SARS-CoV-2 causante de la actual pandemia COVID-19. Las noxas virales pueden ejercer un efecto deletéreo sobre el feto debido a respuesta inflamatoria vía cascada de citoquinas o daño directo a nivel de algunos tejidos. Los efectos del SARS-CoV-2 a nivel placentario, no están bien entendidos, los hallazgos histopatológicos incluyen alteraciones de la perfusión venosa materna y fetal y signos de inflamación placentaria en diferentes porcentajes. La placenta es un órgano altamente especializado que confiere una protección especial generando un ambiente protegido manteniendo un equilibrio de factores inmunes y bioquímicos que favorecen el desarrollo fetal. Su estructura funciona como una barrera protectora dificultando o impidiendo el paso de noxas al producto de la gestación. Diversos patógenos, incluyendo los virus pueden alterar los diferentes componentes celulares de la placenta. En la siguiente revisión describimos los más recientes hallazgos de la interacción con la placenta de diversos virus respiratorios y sus consecuencias en la salud materno fetal(AU)

Infectious diseases of the respiratory system generally present greater severity in women during pregnancy or puerperium, than in non-pregnant women. Among them, we find those produced by viral agents such as seasonal, pandemic and zoonotic influenza, SARS coronaviruses, MERS; and since 2019 the SARS-CoV-2, the cause of the current COVID-19 pandemic. Viral noxae can exert a deleterious effect on the fetus due to an inflammatory response via the cytokines cascade or direct damage at some tissues. The effects of SARS-CoV-2 on the placenta is not well understood, the histopathological findings include alterations of maternal and fetal perfusion and signs of placental inflammation in different degrees. The placenta is a highly specialized organ that confers a special protection by generating a protected environment maintaining a balance of immune and biochemical factors that favor the fetal development. Its structure works as a protective barrier, hindering or preventing the passage of noxae to the fetus. Several pathogens, including viruses, can alter different cellular components of the placenta. In the review, we describe the most recent findings of the interaction of various respiratory viruses with the placenta and their consequences on maternal and fetal health(AU)

Management of clinical chorioamnionitis: an evidence-based approach.

This review aimed to examine the existing evidence about interventions proposed for the treatment of clinical chorioamnionitis, with the goal of developing an evidence-based contemporary approach for the management of this condition. Most trials that assessed the use of antibiotics in clinical chorioamnionitis included patients with a gestational age of ≥34 weeks and in labor. The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period. In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping. The administration of additional antibiotic therapy does not appear to be necessary after vaginal or cesarean delivery. However, if postdelivery antibiotics are prescribed, there is support for the administration of an additional dose. Patients can receive antipyretic agents, mainly acetaminophen, even though there is no clear evidence of their benefits. Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant. However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate. Once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age. Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications. The time interval between the diagnosis of clinical chorioamnionitis and delivery is not related to most adverse maternal and neonatal outcomes. Patients may require a higher dose of oxytocin to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation. The benefit of using continuous electronic fetal heart rate monitoring in these patients is unclear. We identified the following promising interventions for the management of clinical chorioamnionitis: (1) an antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole that provides coverage against the most commonly identified microorganisms in patients with clinical chorioamnionitis; (2) vaginal cleansing with antiseptic solutions before cesarean delivery with the aim of decreasing the risk of endometritis and, possibly, postoperative wound infection; and (3) antenatal administration of N-acetylcysteine, an antioxidant and antiinflammatory agent, to reduce neonatal morbidity and mortality. Well-powered randomized controlled trials are needed to assess these interventions in patients with clinical chorioamnionitis.

Las locuras puerperales: una lectura comparada entre Argentina y Colombia, 1880-1950 / Puerperal insanity: a comparative reading of Argentina and Colombia, 1880-1950

Resumen El objetivo es comprender la aparición y propagación de locuras puerperales en Argentina y Colombia, a finales del siglo XIX y principios del XX, así como su decadencia o desvanecimiento hacia la década de 1940-1950. Investigación histórico-hermenéutica, según los conceptos de "campo de visibilidad" y "nicho ecológico" de una enfermedad transitoria. No existió correlación entre embarazo, parto y puerperio con el estado delirante que motivaba la internación, atribuido a factores predisponentes y, asimismo, tuvieron una autonomía nosográfica en virtud de etiopatogenias singulares. Al tiempo que empezó a emerger el tipo clínico locura puerperal, se entrecruzaron el campo disciplinar de la obstetricia con el alienismo, con una mayor preponderancia del primero.

Abstract Our goal is to understand the appearance and spread of forms of puerperal insanity in Argentina and Colombia in the late nineteenth and early twentieth century, as well as their decline or disappearance around the 1940s. This is a historical and hermeneutical study, which uses the concepts of "field of visibility" and "ecological niche" for a transitory disease. There was no correlation between pregnancy, childbirth and puerperium and the state of delirium that led to commitment, which was attributed to predisposing factors; furthermore, forms of puerperal insanity were nosographically distinct due to their unique etiopathogeneses. As clinical cases of puerperal insanity started to emerge, the disciplinary field of obstetrics converged with psychiatry, with the former exerting more weight.

Risk factors for postpartum sepsis: a nested case-control study.

BACKGROUND: The Majority (99%) of maternal deaths occur in low and middle-income countries. The three most important causes of maternal deaths in these regions are postpartum hemorrhage, pre-eclampsia and puerperal sepsis. There are several diagnostic criteria used to identify sepsis and one of the commonly used criteria is systematic inflammatory response syndrome (SIRS). However, these criteria require laboratory investigations that may not be feasible in resource-constrained settings. Therefore, this study aimed to develop a model based on risk factors and clinical signs and symptoms that can identify sepsis early among postpartum women. METHODS: A case-control study was nested in an ongoing cohort of 4000 postpartum women who delivered or were admitted to the study hospital. According to standard criteria of SIRS, 100 women with sepsis (cases) and 498 women without sepsis (controls) were recruited from January to July 2017. Information related to the socio-demographic status, antenatal care and use of tobacco were obtained via interview while pregnancy and delivery related information, comorbid and clinical sign and symptoms were retrieved from the ongoing cohort. Multivariable logistic regression was performed and discriminative performance of the model was assessed using area under the curve (AUC) of the receiver operating characteristic (ROC). RESULTS: Multivariable analysis revealed that 1-4 antenatal visits (95% CI 0.01-0.62). , 3 or more vaginal examinations (95% CI 1.21-3.65), home delivery (95% CI 1.72-50.02), preterm delivery, diabetes in pregnancy (95% CI 1.93-20.23), lower abdominal pain (95% CI 1.15-3.42)) vaginal discharge (95% CI 2.97-20.21), SpO2 < 93% (95% CI 4.80-37.10) and blood glucose were significantly associated with sepsis. AUC was 0.84 (95% C.I 0.80-0.89) which indicated that risk factors and clinical sign and symptoms-based model has adequate ability to discriminate women with and without sepsis. CONCLUSION: This study developed a non-invasive tool that can identify postpartum women with sepsis as accurately as SIRS criteria with good discriminative ability. Once validated, this tool has the potential to be scaled up for community use by frontline health care workers.

Masa pélvica en la mujer puérpera. Presentación de caso / Pelvic mass in puerperal woman. Case presentation

El término infección puerperal se utiliza para describir cualquier infección bacteriana del aparato genital después del parto. Durante gran parte del siglo XX las infecciones puerperales, la preeclampsia y la hemorragia obstétrica formaron parte de la tríada letal de mortalidad materna. La ecografía, la resonancia magnética y la tomografía axial computarizada son la triada de elección para el diagnóstico del abdomen agudo en el puerperio. El mismo resulta difícil debido a factores intrínsecos y es entonces, cuando el radiólogo adquiere un papel crucial. Se presentó un caso de una mujer de 30 años, con 8 días de habérsele practicado una cesárea con un puerperio inmediato normal. Posteriormente presentó dolor abdominal, fiebre, escalofríos y masa palpable en fosa iliaca izquierda. Se practicaron técnicas de imágenes se plantea una masa ovárica izquierda, se realizó laparotomía exploradora y se concluyó como absceso ovárico (AU).

The term puerperal infection is used to describe any bacterial infection of the genital tract after delivery. During much of the twentieth century puerperal infections, preeclampsia and obstetric hemorrhage were part of the lethal triad of maternal mortality. Ultrasonography, magnetic resonance imaging and computed tomography are the triad of choice for the diagnosis of acute abdomen in the puerperium, which is difficult due to intrinsic factors and it is when radiologist plays a vital role. The authors present the case of a woman, aged 30 years, at the 8th day after undergoing a cesarean section with a normal immediate puerperium, who later presented abdominal pain (AU).

Mortality Synopsis Among Women of Reproductive Age Group in Nigeria: A Hospital-Based Study.

PURPOSE: Identification of health problems of women of reproductive age, using a reliable mortality data, is essential in evading preventable female deaths. This study aimed at investigating mortality profile of women of reproductive age group in Nigeria. MATERIALS AND METHODS: This is a descriptive, retrospective study involving women of reproductive age group of 15-49 years that died at DELSUTH from 1st January 2016 to 31st December 2018. The age, date of death and cause of death were retrieved from the hospital records and subsequently analyzed using SPSS version 21. RESULTS: One hundred and eighty-seven eligible deaths were encountered in this study, constituting 17.5% of all deaths in the hospital. Twenty four (12.8%) cases were of maternal etiology while 163 (87.2%) were of non-maternal causes. Non-communicable disease, communicable disease and external injuries accounted for 100 (53.5%), 44 (23.5%) and 19 (10.2%) deaths among the non-maternal causes. The mean age and the peak age group are 34.4 years and the 4th decade respectively. The leading specified non-maternal causes of death (in descending order) are AIDS/TB, cerebrovascular accidents (CVA), breast cancer, road traffic accident (RTA), diabetes, perioperative death and sepsis while the leading maternal causes of death are abortion, postpartum hemorrhage, eclampsia and puerperal sepsis. CONCLUSION: Most deaths affecting WRAG are preventable, with non-maternal causes in excess of maternal causes. There is need for holistic life-long interventional policies and strategies that will address the health need of these women, using evidence-based research findings.

Factores asociados a la presentación de sepsis puerperal en provincia Guantánamo, 2017-2018 / Factors associated with the presentation of puerperal sepsis in Guantanamo province, 2017-2018 / Fatores associados à apresentação de sepse puerperal na província de Guantánamo, 2017-2018

RESUMEN Introducción: La sepsis y el choque séptico representan una de las complicaciones más graves durante el puerperio. Objetivos: Identificar los factores asociados a la presentación de sepsis puerperal en las pacientes que ingresaron en el Servicio de Cuidados Intensivos del Hospital General Docente "Dr. Agostinho Neto" durante el período 2017-2018. Método: Se realizó un estudio explicativo-observacional, longitudinal, retrospectivo y tipo caso control. Resultados: La endomiometritis fue la principal causa de ingreso con el 79,5 %. Las variables que se comportaron como predictoras de sepsis puerperal fueron la paridad-multípara, la edad gestacional menor de 37 semanas, el parto por cesárea, el antecedente de preclampsia, de sepsis vaginal y sepsis urinaria, la rotura prematura de membranas y el trabajo de parto mayor a 12 horas. Las variables que constituyeron factores de riesgo independiente para la morbilidad por sepsis grave fueron el exceso de base <- 4 (OR=11,9; IC 95 %; 3,9-35,3; p<0,05) la proteína C reactiva >8 mg/L (OR=9,67; IC 95 %; 5,9-14,24), la SatO2< 75 (OR=6,35; IC 95 %; 1,72-23,4), el anión gap >16 mmol/L (OR=5,88; IC 95 %; 3,86-8,97), el APACHE II y la escala SOFA (Sequential Organ Failure Assessment) al ingreso con el (OR=2,57; IC 95 %; 0,97-6,80) y el (OR=2,67; IC 95 %; 1,95-3,66), respectivamente. Conclusiones: La sepsis puerperal significa una problemática en el Hospital General Docente "Dr. Agostinho Neto" de Guantánamo, por lo que su reconocimiento y tratamiento adecuados son las claves para disminuir la morbilidad por esta causa.

ABSTRACT Introduction: Sepsis and septic shock represent one of the most serious complications during the puerperium. Objective: To identify the factors associated with the presentation of puerperal sepsis in patients admitted to the Intensive Care Service of the General Teaching Hospital "Dr. Agostinho Neto" during the 2017-2018 period. Method: An explanatory, observational, longitudinal, retrospective and case-control study was conducted. Results: Endomyometritis was the main cause of admission with 79.5%. The variables that behaved as predictors of puerperal sepsis were multiparous parity, gestational age under 37 weeks, delivery by caesarean section, history of preclampsia, vaginal sepsis and urinary sepsis, premature rupture of membranes and work of delivery greater than 12 hours. The variables that constituted independent risk factors for severe sepsis morbidity were base excess <- 4 (OR=11.9; 95% CI; 3.9-35.3; p <0.05) protein C reactive> 8 mg/L (OR=9.67; 95% CI; 5.9-14.24), SatO2 <75 (OR=6.35; 95% CI; 1.72-23.4), the gap anion> 16 mmol/L (OR=5.88; 95% CI; 3.86-8.97), APACHE II and the SOFA (Sequential Organ Failure Assessment) scale upon admission with (OR=2, 57; 95% CI; 0.97-6.80) and (OR=2.67; 95% CI; 1.95-3.66), respectively. Conclusions: Puerperal sepsis means a problem at the "Dr. Agostinho Neto" General Teaching Hospital in Guantanamo, so that its recognition and adequate treatment are the keys to reducing morbidity from this cause.

RESUMO Introdução: Sepse e choque séptico representam uma das complicações mais graves durante o puerpério. Objetivo: Identificar os fatores associados à apresentação de sepse puerperal em pacientes internados no Serviço de Terapia Intensiva do Hospital Geral de Ensino "Dr. Agostinho Neto" no período 2017-2018. Método: Estudo explicativo, observacional, longitudinal, retrospectivo e caso-controle. Resultados: A endomiometrite foi a principal causa de admissão com 79,5%. As variáveis que se comportaram como preditores de sepse puerperal foram: paridade multípara, idade gestacional abaixo de 37 semanas, parto por cesariana, história de pré-eclâmpsia, sepse vaginal e sepse urinária, ruptura prematura de membranas e trabalho de parto. entrega superior a 12 horas. As variáveis que constituíram fatores de risco independentes para morbidade grave por sepse foram excesso de base <- 4 (OR=11,9; IC 95%; 3,9-35,3; p<0,05) proteína C reativo> 8 mg/L (OR=9,67; IC 95%; 5,9-14,24), SatO2 <75 (OR=6,35; IC 95%; 1,72-23,4), o ânion de gap> 16 mmol/L (OR=5,88; IC 95%; 3,86-8,97), APACHE II e SOFA (Sequential Organ Failure Assessment) na admissão com (OR=2, 57; IC95%; 0,97-6,80) e (OR=2,67; IC95%; 1,95-3,66), respectivamente. Conclusões: Sepse puerperal representa um problema no Hospital Geral Dr. Agostinho Neto, em Guantánamo, para que seu reconhecimento e tratamento adequado sejam as chaves para reduzir a morbidade por essa causa.

Provider volume and maternal complications after Caesarean section: results from a population-based study.

BACKGROUND: A large literature search suggests a relationship between hospital/surgeon caseload volume and surgical complications. In this study, we describe associations between post-operative maternal complications following Caesarean section and provider caseload volume, provider years since graduation, and provider specialization, while adjusting for hospital volumes and patient characteristics. METHODS: Our analysis is based on population-based discharge abstract data for the period of April 2004 to March 2014, linked to patient and physician universal coverage registry data. We consider all hospital admissions (N = 20,914) in New Brunswick, Canada, where a Caesarean Section surgery was recorded, as identified by a Canadian Classification of Health Intervention code of 5.MD.60.XX. We ran logistic regression models to identify the odds of occurrence of post-surgical complications during the hospital stay. RESULTS: Roughly 2.6% of admissions had at least one of the following groups of complications: disseminated intravascular coagulation, postpartum sepsis, postpartum hemorrhage, and postpartum infection. The likelihood of complication was negatively associated with provider volume and provider years of experience, and positively associated with having a specialization other than maternal-fetal medicine or obstetrics and gynecology. CONCLUSIONS: Our results suggest that measures of physician training and experience are associated with the likelihood of Caesarean Section complications. In the context of a rural province deciding on the number of rural hospitals to keep open, this suggests a trade off between the benefits of increased volume versus the increased travel time for patients.

Risk factors, changes in serum inflammatory factors, and clinical prevention and control measures for puerperal infection.

BACKGROUND: To investigate the risk factors and changes in serum inflammatory factors in puerperal infection, and propose clinical prevention measures. METHODS: A total of 240 subjects with suspected puerperal infection treated in our hospital from January 2017 to December 2017 were collected, among which puerperal infection was definitely diagnosed in 40 cases, and it was excluded in 40 cases. Levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) were compared between the two groups, and the change trends of IL-6 and hs-CRP were recorded. RESULTS: Levels of IL-6, hs-CRP, and TNF-α in puerperal infection group were higher than those in non-infection group (P < .05). Levels of IL-6 and hs-CRP at enrollment and 1-3 days after enrollment in infection group were higher than those in non-infection group (P < .05). The body mass index >25, placenta previa, placenta accreta, postpartum hemorrhage, premature rupture of membrane, gestational diabetes mellitus, and anemia during pregnancy were relevant and independent risk factors for puerperal infection. Puerperal infection occurred in uterine cavity, vagina, pelvic peritoneum, pelvic tissue, incision, urinary system, etc, and gram-negative (G+) bacteria were dominated in pathogens. CONCLUSION: The inflammatory response of patients with puerperal infection is significantly enhanced.

Infecção puerperal / Puerperal infection

Em 1992, a Organização Mundial da Saúde (OMS) propôs a seguinte definição: Sepse puerperal é uma infecção do trato genital ocorrendo, em qualquer momento, entre a ruptura das membranas ou o trabalho e o 42º dia após o parto, no qual estão presentes dois ou mais dos seguintes eventos: • Dor pélvica; • Febre (temperatura oral de 38,5 °C ou superior em qualquer ocasião); • Corrimento vaginal anormal, por exemplo, presença de pus; • Cheiro anormal/mau cheiro do corrimento vaginal; • Atraso na redução do tamanho do útero (<2 cm/dia durante os primeiros oito dias). 1. O conceito de infecção puerperal deve ser complementado com o de morbidade febril puerperal, pela dificuldade de caracterizar a infecção que ocorre logo após o parto. 2. Outras definições que se fazem necessárias são: • Bacteremia: presença de bactérias na corrente sanguínea; • Sepse: síndrome clínica caracterizada pela resposta da hospedeira a um processo infeccioso, acompanhada de uma resposta inflamatória sistêmica; • Sepse grave: sepse associada à disfunção de um ou mais órgãos (sistema nervoso central, renal, pulmonar, hepática, cardíaca, coagulopatia, acidose metabólica); • Choque séptico: sepse com hipotensão refratária à ressuscitação volêmica. 3. A OMS incluiu o termo "infecção puerperal", pois hoje estão morrendo mulheres com infecções de outros locais do corpo.