Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case-Control Study.

BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.

Epidural Analgesia for Pain Management in Acute Pancreatitis during Pregnancy and Its Effect on Maternal and Fetal Outcome.

Background: Acute pancreatitis (AP) during pregnancy is a rare presentation with an estimated incidence of 1 case per 1000 to 10,000 pregnancies. Severe epigastric and abdominal pain is the earliest and the most common symptom of AP, and adequate pain relief is an integral part of patient management. The aim of our study was to investigate the different pain relief modalities that are used in pregnant women with AP and the efficacy of each method used, in terms of better pain relief and maternal-fetal outcomes. Methods: This was a retrospective observational study over a period of 6 years conducted at a tertiary care hospital. Pregnant women with clinical and biochemical diagnoses of acute pancreatitis were included in the study. Patient's history and clinical and biochemical data were collected from the medical records of the hospital. Results: A total of 12 patients were included in the study, 5 out of 12 patients had gall stones associated with AP, 2 patients had hypertriglyceridemia, and 1 each had preeclampsia and eclampsia. Epidural analgesia at the level of L1-L2 spinal level showed a reduction of VAS scores from 8 or 9 to 1 or 2, indicating excellent pain as compared to t intravenous (i/v) infusion of fentanyl or i/v boluses of injection tramadol, in whom VAS was never reduced below 3. With satisfactory results, labour analgesia and anesthesia for caesarean section was provided via the same catheter in 2 and 3 patients, respectively. Maternal and fetal outcomes were comparable in all the patients. Conclusion: AP in pregnancy, when diagnosed early and managed accordingly, leads to better maternal and fetal outcomes. Epidural analgesia was better than intravenous analgesia in terms of pain management and better recovery of acute pancreatitis patients. In these patients, labour analgesia and anesthesia for caesarean section can be provided through the same catheter, making it a potential novel modality in the treatment of acute pancreatitis in pregnancy.

Tracheal Resection for Symptomatic Tracheal Stenosis During Pregnancy.

A 31-year-old multipara was diagnosed with tracheal stenosis that developed after intubation after an intentional benzodiazepine overdose in the first trimester of pregnancy. Tracheal dilations only temporarily improved her dyspnea at rest. A definitive repair by tracheal resection and reconstruction was performed at 28 weeks' gestation. Her symptoms resolved, and she delivered vaginally at 36 weeks' gestation after spontaneous labor.

Continuous positive airway pressure with pressure support ventilation is effective in treating acute-onset bilateral recurrent laryngeal nerve palsy.

Acute bilateral recurrent laryngeal nerve injury leading to acute vocal cord paralysis (VCP) is a serious complication of head and neck surgery, often requiring emergent surgical intervention. Although well documented, its presentation may be sudden and unexpected, occurring despite lack of obvious intraoperative nerve injury. There is limited literature on airway management strategies for patients with acute bilateral VCP before attaining a secure airway. We report a case of acute VCP that was successfully treated with continuous positive airway pressure via facemask ventilation. This effective temporizing strategy allowed clinicians to plan and prepare for tracheostomy, minimizing potential complications.