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Clinical Variables Associated With Adverse Maternal Outcomes in Puerperal Group A Streptococci Infection

Kaiser, Jennifer E., MD, MA; Bakian, Amanda V., PhD; Silver, Robert M., MD; Clark, Erin A. S., MD

doi: 10.1097/AOG.0000000000002648
Contents: Medical Complications of Pregnancy: Original Research

OBJECTIVE: To identify clinical variables associated with increased risk of composite adverse outcome in a cohort of women with puerperal group A streptococci infection.

METHODS: Our prospective case registry enrolled patients between 1991 and 2017. Chart abstraction was conducted for admission demographic and clinical data in patients with culture-proven puerperal group A streptococci infection. We created a composite variable of signs of capillary leakage including pulmonary edema, pleural effusion, ascites, and abdominal distention. The composite adverse outcome included death, hysterectomy, intensive care unit admission, mechanical ventilation, and blood transfusion. Clinical characteristics were compared between those with a composite adverse outcome and those without. We fit unadjusted log-linear models with robust error variance to measure the relative risk of a composite adverse outcome associated with clinical and demographic variables among patients with group A streptococci.

RESULTS: Thirty-five of 71 (49%) patients had an adverse outcome. Women who had adverse outcomes had higher admission heart rates (126±19 vs 112±22 beats per minute, P=.008) and respiratory rates (26±10 vs 20±5 breaths per minute, P=.01), lower systolic blood pressure (98±24 vs 114±19 mm Hg, P=.004), and were more likely to have signs of capillary leakage (77% vs 20%, P<.001) and symptoms of capillary leakage (dyspnea, cough, shoulder pain, abdominal bloating, and chest pain) (40% vs 17%, P=.03) compared with those without adverse outcomes. Log-linear models indicated that these clinical variables were individually associated with increased risk of a composite adverse outcome. The relative risk of an adverse outcome was 3.5 times higher among women with signs of capillary leakage (relative risk 3.67, 95% CI 1.94–6.94, P<.001).

CONCLUSION: Vital sign parameters consistent with severe infection correlate with adverse outcomes in women with puerperal group A streptococci infection. Signs of capillary leakage are most strongly associated with a composite adverse outcome. These clinical characteristics, particularly signs of capillary leakage, are potentially useful to guide clinical care.

Vital sign parameters consistent with severe infection and signs of capillary leakage are associated with adverse maternal outcomes in puerperal group A streptococci infection.

Departments of Obstetrics and Gynecology and Psychiatry, University of Utah, Salt Lake City, Utah.

Corresponding author: Jennifer E. Kaiser, MD, MA, University of Utah School of Medicine, Suite 2B200, 30 N 1900 E, Salt Lake City, UT 84132; email:

Supported by the Burroughs Wellcome Fund and the University of Utah Department of Obstetrics and Gynecology.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented as a poster at the Infectious Disease Society for Obstetrics and Gynecology Annual Meeting, August 10–12, 2017, Park City, Utah.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received December 22, 2017. Received in revised form March 15, 2018. Accepted March 23, 2018.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.