Outcomes and management of pregnancy and puerperal group A streptococcal infections: A systematic review

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Abstract

Introduction

Group A streptococcus ( Streptococcus pyogenes) is one of the most lethal bacterial pathogens of humans, with increased risk of progression to septic shock and multiorgan failure in the pregnant population. The objective of this study is to systematically review the outcomes and management strategies for pregnancy and puerperal group A streptococcus infections in an effort to provide further guidance for prevention and treatment of a rare but lethal infection worldwide.

Material and methods

A comprehensive search using puerperium and streptococcus pyogenes terms was completed across several registered databases. A total of 902 articles investigating pregnancy and puerperal group A streptococcus infection were identified, with 40 studies fulfilling inclusion criteria of original research articles in humans published from 1990 onwards reporting four or more unique cases of group A streptococcus in pregnancy or postpartum. This study was registered in PROSPERO: CRD42020198983.

Results

A total of 1160 patients with pregnancy and puerperal group A streptococcus infection were identified. Most infections occurred postpartum (91.9%), with 4.7% reported antepartum and 0.6% intrapartum. Bacteremia was present in 49.0% of patients and endometritis in 45.9%. Puerperal sepsis was described in 28.2% of cases and progressed to streptococcal toxic shock syndrome in one‐third of such cases. Overall, the case fatality ratio was 2.0%, with one‐third of the deaths from antenatal cases including 3/22 (13.6%) cases of septic abortion and 10/46 (21.7%) antenatal cases of group A streptococcus infection.

Conclusions

Group A streptococcus infection remains an important contributor to pregnancy and puerperal morbidity and mortality. Early recognition, diagnosis and aggressive management are important for favorable outcomes given the serious risk of sepsis and streptococcal toxic shock syndrome.

Abstract

Group A streptococcal infection remains an important contributor to puerperal morbidity and mortality despite advances in infection control protocols. Early recognition, diagnosis and aggressive management are important for favorable outcomes given the serious risk of sepsis and toxic shock syndrome.

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Most cited references 63

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Global causes of maternal death: a WHO systematic analysis.

Lale Say, Doris Chou, Alison Gemmill … (2014)

Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003-09, with a novel method, updating the previous WHO systematic review. We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model. We identified 23 eligible studies (published 2003-12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27·5% (672 000, 95% UI 19·7-37·5) of all deaths. Haemorrhage accounted for 27·1% (661 000, 19·9-36·2), hypertensive disorders 14·0% (343 000, 11·1-17·4), and sepsis 10·7% (261 000, 5·9-18·6) of maternal deaths. The rest of deaths were due to abortion (7·9% [193 000], 4·7-13·2), embolism (3·2% [78 000], 1·8-5·5), and all other direct causes of death (9·6% [235 000], 6·5-14·3). Regional estimates varied substantially. Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality. © 2014 World Health Organization; licensee Elsevier. This is an Open Access article published without any waiver of WHO's privileges and immunities under international law, convention, or agreement. This article should not be reproduced for use in association with the promotion of commercial products, services, or any legal entity. There should be no suggestion that WHO endorses any specific organisation or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

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The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004.

Rosalyn O'Loughlin, Angela A Roberson, Paul R Cieslak … (2007)

Invasive group A Streptococcus (GAS) infection causes significant morbidity and mortality in the United States. We report the current epidemiologic characteristics of invasive GAS infections and estimate the potential impact of a multivalent GAS vaccine. From January 2000 through December 2004, we collected data from Centers for Disease Control and Prevention's Active Bacterial Core surveillance (ABCs), a population-based system operating at 10 US sites (2004 population, 29.7 million). We defined a case of invasive GAS disease as isolation of GAS from a normally sterile site or from a wound specimen obtained from a patient with necrotizing fasciitis or streptococcal toxic shock syndrome in a surveillance area resident. All available isolates were emm typed. We used US census data to calculate rates and to make age- and race-adjusted national projections. We identified 5400 cases of invasive GAS infection (3.5 cases per 100,000 persons), with 735 deaths (case-fatality rate, 13.7%). Case-fatality rates for streptococcal toxic shock syndrome and necrotizing fasciitis were 36% and 24%, respectively. Incidences were highest among elderly persons (9.4 cases per 100,000 persons), infants (5.3 cases per 100,000 persons), and black persons (4.7 cases per 100,000 persons) and were stable over time. We estimate that 8950-11,500 cases of invasive GAS infection occur in the United States annually, resulting in 1050-1850 deaths. The emm types in a proposed 26-valent vaccine accounted for 79% of all cases and deaths. Independent factors associated with death include increasing age; having streptococcal toxic shock syndrome, meningitis, necrotizing fasciitis, pneumonia, or bacteremia; and having emm types 1, 3, or 12. GAS remains an important cause of severe disease in the United States. The introduction of a vaccine could significantly reduce morbidity and mortality due to these infections.

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Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial.

N Ihendyane, Sven Haidl, Jan Sjölin … (2003)

The efficacy and safety of high-dose intravenous polyspecific immunoglobulin G (IVIG) as adjunctive therapy in streptococcal toxic shock syndrome (STSS) were evaluated in a multicenter, randomized, double-blind, placebo-controlled trial. The trial was prematurely terminated because of slow patient recruitment, and results were obtained from 21 enrolled patients (10 IVIG recipients and 11 placebo recipients). The primary end point was mortality at 28 days, and a 3.6-fold higher mortality rate was found in the placebo group. A significant decrease in the sepsis-related organ failure assessment score at days 2 (P=.02) and 3 (P=.04) was noted in the IVIG group. Furthermore, a significant increase in plasma neutralizing activity against superantigens expressed by autologous isolates was noted in the IVIG group after treatment (P=.03). Although statistical significance was not reached in the primary end point, the trial provides further support for IVIG as an efficacious adjunctive therapy in STSS.

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Author and article information

Contributors

Kristin Harris:

ORCID: https://orcid.org/0000-0003-1738-8657

kristin.harris@unityhealth.to

Journal

Journal ID (nlm-ta): Acta Obstet Gynecol Scand

Journal ID (iso-abbrev): Acta Obstet Gynecol Scand

Journal ID (doi): 10.1111/(ISSN)1600-0412

Journal ID (publisher-id): AOGS

Title: Acta Obstetricia et Gynecologica Scandinavica

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Print): 0001-6349

ISSN (Electronic): 1600-0412

Publication date (Electronic): 12 January 2023

Publication date Collection: February 2023

Volume: 102

Issue: 2 ( doiID: 10.1111/aogs.v102.2 )

Pages: 138-157

Affiliations

[ ¹ ] Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology St. Michael's Hospital, University of Toronto Toronto Ontario Canada

[ ² ] Department of Obstetrics and Gynecology University of Toronto Toronto Ontario Canada

[ ³ ] Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology Mount Sinai Hospital, University of Toronto Toronto Ontario Canada

[ ⁴ ] Sidney Liswood Health Sciences Library Mount Sinai Hospital Toronto Ontario Canada

[ ⁵ ] Department of Obstetrics and Gynecology St. Michael's Hospital, University of Toronto Toronto Ontario Canada

Author notes

[*] [* ] Correspondence

Kristin Harris, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, 30 Bond St, Toronto ON M5B 1W8, Canada.

Email: kristin.harris@ 123456unityhealth.to

Author information

Kristin Harris https://orcid.org/0000-0003-1738-8657

Article

Publisher ID: AOGS14500 Other ID: AOGS-22-0375.R1

DOI: 10.1111/aogs.14500

PMC ID: 9889326

PubMed ID: 36636775

SO-VID: 201f50e0-8d25-4541-b23e-e1e88b4aa766

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

History

Date revision received : 03 November 2022

Date received : 03 June 2022

Date accepted : 06 December 2022

Page count

Figures: 5, Tables: 2, Pages: 20, Words: 5411

Custom metadata

source-schema-version-number 2.0

cover-date February 2023

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.2.5 mode:remove_FC converted:31.01.2023

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: group a streptococcus,pregnancy,puerperium,streptococcus pyogenes

Data availability:

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: group a streptococcus, pregnancy, puerperium, streptococcus pyogenes

Outcomes and management of pregnancy and puerperal group A streptococcal infections: A systematic review

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Introduction

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Abstract

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HLA-G and immune tolerance in pregnancy

Most cited references 63

Global causes of maternal death: a WHO systematic analysis.

The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004.

Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial.

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