Brenna Anderson

The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy

OBJECTIVEnWe sought to design an emergency department sepsis scoring system to identify risk of intensive care unit (ICU) admission in pregnant and postpartum women.nnnSTUDY DESIGNnThe Sepsis in Obstetrics Score (S.O.S.) was created by modifying validated scoring systems in accordance with recognized physiologic changes of pregnancy. The S.O.S. was applied to a retrospective cohort of pregnant and postpartum patients from February 2009 through May 2011 with clinical suspicion of sepsis. The primary outcome was ICU admission. Secondary outcomes were telemetry unit admission, length of stay, positive blood cultures, positive influenza swabs, perinatal outcome, and maternal mortality. Receiver operating characteristic curves were constructed to estimate the optimal score for identification of risk of ICU admission.nnnRESULTSnIn all, 850 eligible women were included. There were 9 ICU (1.1%) and 32 telemetry (3.8%) admissions, and no maternal deaths. The S.O.S. had an area under the curve of 0.97 for ICU admission. An S.O.S. ≥6 (maximum score 28) had an area under the curve of 0.92 with sensitivity of 88.9%, specificity of 95.2%, positive predictive value of 16.7%, and negative predictive value of 99.9% for ICU admission, with an adjusted odds ratio of 109 (95% confidence interval, 18-661). An S.O.S. ≥6 was independently associated with increased ICU or telemetry unit admissions, positive blood cultures, and fetal tachycardia.nnnCONCLUSIONnA sepsis scoring system designed specifically for an obstetric population appears to reliably identify patients at high risk for admission to the ICU. Prospective validation is warranted.

Systemic immune response to Trichomonas vaginalis infection during pregnancy.

Objective: The objective of this study was to characterize the systemic immune response in women with trichomoniasis in pregnancy as compared with uninfected women. Study Design: A nested case control study was performed on 195 serum samples. Serum concentrations of cytokines, chemokines, and C-reactive protein (CRP) were compared between infected and uninfected women. Cytokines and chemokines were measured using a multiplex bead assay. The CRP concentrations were determined using a standard enzyme-linked immunosorbent assay method. Results: The median serum concentration of granulocyte–macrophage colony-stimulating factor (GM-CSF) was significantly higher in the trichomonas-infected group compared with the uninfected group (8.9 pg/mL vs. 5.7 pg/mL; P <0.001). The mean log-transformed CRP values were higher in the infected group compared with the uninfected group (1.66 vs. 1.27; P = 0.03). Conclusions: The results of this study suggest that trichomoniasis during pregnancy can lead to a systemic immune response in some women as exhibited by elevation in the serum concentrations of both GM-CSF and CRP.

Fetal echocardiographic findings are not predictive of death in twin-twin transfusion syndrome.

Objective. The purpose of this study was to determine whether fetal echocardiographic findings are predictive of prognosis in recipient fetuses with twin‐twin transfusion syndrome (TTTS). Methods. A cohort of 30 pregnancies with TTTS between 1990 and 2001 was included. Diagnosis and staging of TTTS were made according to the Quintero system. Fetal echocardiographic findings of cardiomegaly, right ventricular hypertrophy, and tricuspid regurgitation were evaluated for relationship with fetal death. Power analysis revealed an approximately 80% power to detect a 2‐fold increased risk of fetal death, with α = .05. Logistic regression was used to determine the relationship between echocardiographic findings and death. Results. Most pregnancies were Quintero stage 1, n = 13 (43%), and ranged in severity to Quintero stage 5, n = 4 (13%). Cardiac findings in the recipient fetus that were assessed for a relationship with death included cardiomegaly at the initial appearance of TTTS or at the most severe evaluation findings, right ventricular hypertrophy at initial appearance or at the most severe evaluation findings, or tricuspid regurgitation at initial appearance or at the most severe evaluation findings. Fetal or neonatal death in the recipient twin was not related to the presence of cardiac findings (odds ratio, 0.77; 95% confidence interval, 0.16–3.74). Conclusions. Fetal echocardiographic findings, whether evaluated at initial appearance or over the course of serial evaluations, were not related to fetal or neonatal death in recipient twins with TTTS.

Is postpartum pyelonephritis associated with the same maternal morbidity as antepartum pyelonephritis

Objective: Pregnant women with pyelonephritis are at higher risk for significant morbidty than nonpregnant women with pyelonephritis. The risk from pregnancy may continue into the postpartum period. Many of the physiologic and hormonal changes that occur during pregnancy persist after delivery. The objective of this study was to compare maternal morbidity in postpartum and antepartum pyelonephritis. Methods: A retrospective cohort analysis included all pregnant and postpartum women hospitalized for pyelonephritis at a single tertiary care hospital between January 2004 and June 2007. The postpartum period was defined as up to 6 weeks from delivery. The primary outcome measure was maternal morbidity measured by length of hospitalization. Results: 256 cases of antepartum pyelonephritis and 23 cases of postpartum pyelonephritis were included in the analysis. Women in both groups were admitted for a mean of 4 days (p = 0.3). Women who were diagnosed in the postpartum period were more likely to be febrile (91.3% vs. 51.7%, p = 0.0001) and had a higher temperature on presentation (102.9°F vs. 99.1°F p < 0.0001). Discussion: Pyelonephritis was equally morbid in the postpartum and antepartum periods. Postpartum pyelonephritis may warrant the same close inpatient observation as antepartum pyelonephritis.

Compliance with group B streptococcus testing prior to labor and delivery.

We tested whether group B streptococcus (GBS) screening is performed as recommended by the Centers for Disease Control and Prevention (CDC) and evaluated the need for a rapid GBS test for women with full-term pregnancies. A retrospective cohort analysis at a single, large academic institution was performed. Women who delivered full-term (>37 weeks) infants and had documented prenatal care were included. The primary outcome was documented screening. One hundred sixty-five full-term pregnancies were included; 158 women [95.76%; 95% confidence interval (CI), 92.68 to 98.83%] were screened prior to presentation at labor and delivery. This frequency was significantly greater than the a priori hypothesis of 90% ( P = 0.01). Of the 158 women ever screened, 15 had GBS bacteriuria and 143 had genital culture performed. However, only 118 of the 143 (80.61%; 95% CI, 74.57 to 86.64%) were cultured at the appropriate time as recommended by the CDC (between 35 and 37 weeks). This screening frequency was significantly lower than the a priori hypothesis of 90% ( P < 0.001). Most full-term women presenting to labor and delivery have been screened for GBS. However, screening performed at the appropriate gestational age per CDC recommendations was lower than expected. Rapid GBS testing does not appear to be necessary for this population.

Improving universal prenatal screening for human immunodeficiency virus

OBJECTIVE: To evaluate the effect of implementation of a human immunodeficiency virus (HIV) educational intervention on universal screening for HIV in a prenatal clinic setting. METHODS: In this retrospective cohort study, frequencies of offering and acceptance of HIV testing were compared before and after an educational intervention performed by an HIV-focused nurse. The records of 293 women seeking prenatal care before the intervention and 206 women seeking prenatal care after the intervention were reviewed for offering and acceptance of HIV testing. Fishers exact test and logistic regression were used to evaluate the relationship between the educational intervention and the offering and acceptance of HIV testing. RESULTS: The frequency of HIV test offering at first visit and test acceptance before the educational intervention were 96.5% and 74.8%, respectively, and after the intervention were 99.5% and 84.3%, respectively. This improvement in offering (3% change) and acceptance (9.5% change) was statistically significant (offering at first visit: OR = 7.27, 95% CI = 1.02 to 316.9; test acceptance: OR = 1.82, 95% CI = 1.14 to 2.88). Test acceptance was statistically significantly improved in the post-intervention group after controlling for confounding variables (OR = 2.02, 95% CI = 1.2 to 3.39). CONCLUSION: The addition of an HIV-focused nurse to a clinic setting improved the frequency of test offering at first visit and of acceptance of HIV testing by pregnant women.

Varicella zoster meningitis in a pregnant woman with acquired immunodeficiency syndrome.

Between 6000 and 7000 women in the United States infected with human immunodeficiency virus (HIV) give birth annually. It is well known that HIV-related immunosuppression significantly increases the risk for acquiring opportunistic infections (OIs). However, there is limited information regarding the relationship of pregnancy in the setting of HIV/AIDS infection, subsequent development of OIs, and maternal and fetal outcomes. A pregnant 36-year-old woman with AIDS was diagnosed with varicella zoster meningitis. Weight-based therapy with acyclovir was initiated with clinical improvement in symptoms. Care of a pregnant HIV-infected patient with an OI poses a unique diagnostic and therapeutic challenge for clinicians. Early diagnosis and initiation of appropriate treatment may provide an opportunity to improve both maternal and fetal outcomes.