Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery: Temporal Trends and Independent Associations for Severe Sepsis
ABSTRACT BACKGROUND:Sepsis is currently the leading cause of direct maternal death in the United Kingdom. In this study, we aimed to determine frequency, temporal trends, and independent associations for severe sepsis during hospitalization for delivery in the United States.METHODS:Data were obtained from the Nationwide Inpatient Sample for the years 1998 through 2008. The presence of severe sepsis was identified by the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. Logistic regression analysis was used to assess temporal trends for sepsis, severe sepsis, and sepsis-related death and also to identify independent associations of severe sepsis.RESULTS:Of an estimated 44,999,260 hospitalizations for delivery, sepsis complicated 1:3333 (95% confidence interval [CI], 1:3151-1:3540) deliveries, severe sepsis complicated 1:10,823 (95% CI, 1:10,000-1:11,792) deliveries, and sepsis-related death complicated 1:105,263 (95% CI, 1:83,333-1:131,579) deliveries. While the overall frequency of sepsis was stable(P = 0.95), the risk of severe sepsis and sepsis-related death increased during the study period, (P < 0.001) and (P = 0.02), respectively. Independent associations for severe sepsis, with an adjusted odds ratio and lower bound 95% CI higher than 3, include congestive heart failure, chronic liver disease, chronic renal disease, systemic lupus erythematous, and rescue cerclage placement.CONCLUSIONS:Maternal severe sepsis and sepsis-related deaths are increasing in the United States. Severe sepsis often occurs in the absence of a recognized risk factor and underscores the need for developing systems of care that increase sensitivity for disease detection across the entire population. Physicians should enhance surveillance in patients with congestive heart failure, chronic liver disease, chronic renal disease, and systemic lupus erythematous and institute early treatment when signs of sepsis are emerging.
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ABSTRACT: To design an emergency department (ED) sepsis scoring system to identify risk of intensive care unit (ICU) admission in pregnant and postpartum women. The 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 between February 2009 and 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 (ROC) curves were constructed to estimate the optimal score for identification of risk of ICU admission. 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 AUC of 0.97 for ICU admission. An S.O.S. ≥ 6 (maximum score 28) had an AUC of 0.92 with a sensitivity of 88.9%, a specificity of 95.2%, a positive predictive value of 16.7%, and a 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. A 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.American journal of obstetrics and gynecology 03/2014; 211(1). DOI:10.1016/j.ajog.2014.03.010 · 3.97 Impact Factor
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ABSTRACT: We determined the contribution of vascular BK and L-type Ca(2+) channel dysregulation to exaggerated mortality in cecal ligation/puncture (CLP)-induced septic BK channel β1-subunit knockout (BK β1-KO, smooth muscle specific) mice. CLP-induced hemodynamic changes and mortality were assessed over 7 days in wild-type (WT) and BK β1-KO mice that were either untreated, given volume resuscitation (saline) or saline + calcium channel blocker nicardipine. Some mice were sacrificed 24 hours post-CLP to measure tissue injury, vascular and immune responses. CLP-induced hypotension was similar in untreated WT and BK β1-KO mice, but BK β1-KO mice died sooner. At 24 hours post-CLP (mortality latency in BK β1-KO mice), untreated CLP-BK β1-KO mice showed more severe hypothermia, lower tissue perfusion, polymorphonuclear neutrophil infiltration-independent severe intestinal necrosis, and higher serum cytokine levels than CLP-WT mice. Saline resuscitation improved survival in CLP-WT, but not CLP-BK β1-KO mice. Saline + nicardipine treated CLP-BK β1-KO mice exhibited longer survival times, higher tissue perfusion, less intestinal injury and lower cytokines vs. untreated CLP-BK β1-KO mice. These improvements were absent in treated CLP-WT mice, although saline + nicardipine improved blood pressure similarly in both septic mice. At 24 hours post-CLP, BK and L-type Ca(2+) channel functions in vitro were maintained in mesenteric arteries from WT mice. Mesenteric arteries from BK β1-KO mice had blunted BK/enhanced L-type Ca(2+) channel function. We conclude that vascular BK channel deficiency exaggerates mortality in septic BK β1-KO mice by activating L-type Ca(2+) channels leading to blood pressure-independent tissue ischemia.AJP Regulatory Integrative and Comparative Physiology 05/2014; 307(2). DOI:10.1152/ajpregu.00117.2014 · 3.53 Impact Factor
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ABSTRACT: The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use.Mayo Clinic Proceedings 07/2014; 89(8). DOI:10.1016/j.mayocp.2014.04.024 · 5.81 Impact Factor