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Capillary leakage predicts hysterectomy in postpartum group A strep



– Systemic capillary leakage – which involves acute respiratory distress, ascites, pleural effusion, and abdominal distention – significantly increases the risk of hysterectomy in women with postpartum group A Streptococcus infection, according to findings from a single-site study.

The investigators at the University of Utah in Salt Lake City analyzed 71 cases of culture-proven infection at the university since 1991. They compared the 33 women who had hysterectomies, ICU admissions, pressor support, or mechanical ventilation with the 38 women who did not.

The goal was to identify predictors of poor outcomes and clarify when hysterectomy is the appropriate clinical decision. “These are young women, and it might have been their first pregnancy. You don’t want to remove their uterus if they don’t need it, but we know if women get really sick, they need that source control within 6-12 hours of presentation,” said Jennifer Kaiser, MD, the study’s lead investigator and an ob.gyn. fellow at the University of Utah.

Dr. Jennifer Kaiser of the University of Utah

Dr. Jennifer Kaiser

As expected, sepsis-related vital sign abnormalities were predictive, “but the most [useful] finding was objective concern for capillary leak,” a marker of systemic inflammatory response. Acute respiratory distress, ascites, pleural effusion, and abdominal distention strongly predicted adverse outcomes in themselves, but they were overwhelmingly predictive when they occurred together (OR 19.93, 95% CI 5.96-66.57, P less than .0001), especially for hysterectomy (OR 51.43, 95% CI 6.29-420.41, P less than .002).

“Capillary leak is an important objective clinical parameter that should be evaluated and considered with due exigency. I think this has not been well recognized,” Dr. Kaiser said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. The finding “should prompt you to mobilize a team for hysterectomy, or if you are at a smaller hospital, to think about transporting the patient to a higher level hospital that can perform hysterectomy and offer ICU care,” she added.

The investigators also found that a traditional marker for severe infection – uterine and cervical motion tenderness – did not predict adverse outcomes among the 71 women. Many patients with severe disease don’t actually have tenderness, Dr. Kaiser said.

It also didn’t matter whether the organism was isolated from the uterus or the blood. It’s sometimes thought uterine positivity predicts “worse prognosis, but that didn’t pan out,” she said.

Capillary leakage was a concern in 27 (82%) of the 33 women who had adverse outcomes, compared with 7 (18%) of the women who fared better, and included acute respiratory distress (30% versus 0%); ascites (73% versus 3%); pleural effusion (58% versus 5%), and abdominal distention (61% versus 18%). In total, 21 of the 33 women with adverse outcomes (64%) had hysterectomies. There were no deaths in the group.

Postpartum group A Streptococcus infections are more common in Utah than in other parts of the country, and it’s not known why. The next step for the investigators is to look at genealogies and genetic factors that may predispose women to severe infections, Dr. Kaiser said.

There was no industry funding for the work and Dr. Kaiser reported having no relevant financial disclosures.

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