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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 64-66

Successful anesthesia case of emergency cesarean section complicated with pregnancy-related group: A streptococcus sepsis


Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu-City, Aichi, Japan

Date of Submission30-Jul-2021
Date of Acceptance15-Nov-2021
Date of Web Publication14-Mar-2022

Correspondence Address:
Dr. Taiki Kojima
Department of Anesthesiology, Aichi Children's Health and Medical Center, 426 Nana-chome, Morioka-cho, Obu-city, Aichi 478-8710
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_66_21

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  Abstract 


Pregnancy-related Group A streptococcus (GAS) sepsis is a rare, rapidly progressing life-threatening disease. Previous reports described the clinical features of pregnancy-related GAS sepsis, however, the evidence regarding general anesthesia is extremely limited. This report aims to alert anesthesiologists that pregnancy-related GAS sepsis is an emerging life-threatening disease and to describe the clinical issues when performing general anesthesia in the emergency cesarian section. We describe the case of a 37-year-old pregnant woman with undiagnosed pregnancy-related GAS sepsis who exhibited rapid, progressive circulatory collapse. Attentive anesthesia management and smooth transition to the cesarean section resulted in saving both the mother and baby without any complications. The evidence regarding anesthesia management in pregnancy-related GAS sepsis is extremely lacking. To make the diagnosis of GAS sepsis before initiating the emergency cesarean section was challenging under rapid deterioration. Anesthesiologists should consider GAS sepsis in pregnancy with aggressive septic features and prepare for the fatal intraoperative complications during general anesthesia.

Keywords: Cesarean section, group A streptococcus, sepsis


How to cite this article:
Kawatsu Y, Miyazu M, Kojima T. Successful anesthesia case of emergency cesarean section complicated with pregnancy-related group: A streptococcus sepsis. J Obstet Anaesth Crit Care 2022;12:64-6

How to cite this URL:
Kawatsu Y, Miyazu M, Kojima T. Successful anesthesia case of emergency cesarean section complicated with pregnancy-related group: A streptococcus sepsis. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2022 May 19];12:64-6. Available from: https://www.joacc.com/text.asp?2022/12/1/64/339546




  Introduction Top


Pregnancy-related Group A streptococcal (GAS) sepsis is an uncommon yet highly fatal disease to pregnant mothers and their unborn children.[1],[2] A recent study reported that the incidence of pregnancy-related GAS sepsis has increased in recent years.[3] However, the evidence of perioperative management for this life-threatening infection is still lacking. We report the case of pregnancy-related GAS sepsis to describe the perioperative clinical issues of this emerging life-threatening disease.


  Case Report Top


A previously healthy 37-year-old pregnant woman (height, 172 cm; body weight, 55.8 kg; body mass index, 18.9 kg/m2; gravida 2, para 1; age of gestation, 36 weeks and 5 days) presented high fever and lower abdominial pain since one day prior to admission without respiratory and gastrointestinal symptoms. There was no history of sick contact of streptococcal pharyngitis. Her prenatal data was nonsignificant, without pathogenic bacterial (i.e., GAS and group B streptococcus) presence in the vaginal smear. Upon hospital consultation, the patient was alert, and the initial vital signs were as follows: blood pressure (BP), 120/68 mm Hg; heart rate (HR), 111 beats/min (bpm); respiratory rate (RR), 15 breaths/min; oxygen saturation (SpO2), 97% (room air); and body temperature (BT), 39.5°C. The complete blood count and coagulation panel results were the following: white blood cell count, 11,700/μL; hemoglobin count, 12.4 g/dL; platelet count, 163,000/μL; activated partial thromboplastin time, 25.5 s; prothrombin international normalized ratio, 1.01; and fibrinogen, 500 mg/dL. After 5 h upon hospital arrival, the patient suddenly collapsed without aggravating factors. Immediately, two peripheral intravenous (PIV) lines (20 gauge) and a central line were placed, and initiated norepinephrine infusion (BP, 63/33 mm Hg; HR, 109 bpm; RR, 18 breaths/min; SpO2, 99% [oxygen, 12 L/min]; BT, 38.8°C). Cardiotocography showed severe late deceleration (minimum fetal HR, 60–70 bpm), with frequent uterine contractions (every 3 min). Subsequently, the patient was transferred to the operating suite for emergency cesarean section. In the operating suite, the patient was somnolent. The initial vital signs were as follows: BP, 102/70; HR, 98 bpm; and SpO2, 97% (oxygen, 12 L/min) on norepinephrine infusion (0.3 mcg/kg/min). After preoxygenation (oxygen, 6 L/min) for 3 min, we administered midazolam (3 mg) and rocuronium (40 mg) after the patient lost consciousness. Video laryngoscopy (McGRATH®) obtained a Cormack–Lehane grade I glottic view, and the airway was secured using a 7.0 mm cuffed endotracheal tube without adverse events. We started sevoflurane for amnesia at 1.0–5.0% inspiratory concentration with continuing remifentanil infusion (0.15–0.3 μg/kg/min) and norepinephrine infusion (0.25–0.3 μg/kg/min). The fetus was delivered 8 min. after skin incision. The maternal arterial blood gas showed pH, 7.265; partial pressure of carbon dioxide (Paco2), 29.3 mm Hg; partial pressure of oxygen (Pao2), 332.0 mm Hg (FiO2 1.0); bicarbonate ion, 12.9 mEq/L; Base excess (BE), -12.6 mEq/L; Lactate acid, 26.0 mg/dL. The patient was stable during the rest of the procedure. The neonate's Apgar scores were 2, 7, and 8 at 1, 5, and 10 min., respectively. The umbilical artery blood gas test results were as follows: pH, 6.195; PaCO2, 70.6 mm Hg; PaO2, 14.6 mm Hg; bicarbonate ion, 13.6 mEq/L; BE, −21.3 mEq/L; and lactate acid, 123.0 mg/dL. The surgery was completed without major complications. Total fluid loss including blood and amniotic fluid was approximately 930 mL. On hospital day 2, norepinephrine was discontinued and the patient was extubated. On hospital day 21, the patient and the baby were discharged without any significant complications. The diagnosis of GAS sepsis was confirmed by the positive results in the two pairs of blood cultures.


  Discussion Top


Pregnancy-related GAS sepsis has been rarely recognized until recent years. According to a UK report, the incidence of postpartum invasive GAS infections increased exponentially from 2010 to 2016.[3] Pregnancy-related GAS infections might have been more commonly recognized as a subtype of invasive GAS infections, with high maternal and fetal mortality. Tanaka et al. reported that GAS accounts for 53.4% of the maternal sepsis-related deaths in Japan and that more than half of maternal deaths were caused by GAS sepsis occurs within 24 h after hospital admission.[4] In the present case, the mother manifested a sudden circulatory collapse. The early symptoms of pregnancy-related GAS sepsis are nonspecific. Yamada et al. described that high fever was present in almost all cases, whereas upper respiratory infection (URI) and gastrointestinal (GI) symptoms existed in nearly half of the cases.[5] Placental abruption occurs simultaneously in most of the cases.[5] In the present case, the patient manifested a high fever and lower abdominal pain upon admission. However, placental abruption and purulent myometritis were not identified intraoperatively. Under general anesthesia in a patient with pregnancy-related GAS sepsis, complications including hemodynamic instability, ARDS, multiple organ failure (i.e., liver and kidney), disseminated intravascular coagulopathy (DIC), and life-threatening massive hemorrhage caused by inadequate uterine contraction and/or placental abruption may occur.[6],[7] Hence, several reliable large-bore PIV lines should be secured for rapid fluid resuscitation and transfusion. When inducing general anesthesia, the anesthesiologist should be vigilant about the risk for sudden hemodynamic collapse secondary to sepsis and decreased preload caused by uterine compression against the inferior vena cava. Additionally, considering the risks for ARDS-induced rapid progressive hypoxia and aspiration, modified RSI might be useful.[8] Major bleeding caused by DIC, and atonic uterine and/or placental abruption might occur intraoperatively; thus, a sufficient amount of blood products should be readily available. The suitable timing to perform a cesarean section remains controversial. According to the National Institute for Health and Care Excellence (NICE) guideline,[9] this case was classified as urgency 1 (immediate threat to the life of the woman or fetus), which recommends performing an immediate cesarean section. However, the NICE guideline does not state specific cases of severe sepsis. The close fetal monitoring determined the timing for an emergency caesarean section. In conclusion, pregnancy-related GAS sepsis is an emerging, life-threatening disease that anesthesiologists need to be aware of the aggressive septic features and the lethal intraoperative complications during general anesthesia.

Acknowledgements

The authors would like to thank H. Hirate M.D., H. Terashima M.D., and Y. Makino M.D. for useful discussion.

Consent for publication

This case report obtained consent from the patient's family in accordance with the Health Insurance Portability and Accountability Act of 1996. and was approved by the institutional ethics committee.

Author Contributions

Yuta Kawatsu, M.D. drafted the manuscript and approved the final version of the manuscript.

Mitsunori Miyazu, M.D. critically revised the manuscript and approved the final version of the manuscript.

Taiki Kojima, M.D. drafted the manuscript composition, critically revised the manuscript and approved the final version of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hughes BL. Group A Streptococcus puerperal sepsis: An emerging obstetric infection? BJOG 2019;126:54.  Back to cited text no. 1
    
2.
Nelson GE, Pondo T, Toews KA, Farley MM, Lindegren ML, Lynfield R, et al. Epidemiology of invasive group A streptococcal infections in the United States, 2005-2012. Clin Infect Dis 2016;63:478-86.  Back to cited text no. 2
    
3.
Leonard A, Wright A, Saavedra-Campos M, Lamagni T, Cordery R, Nicholls M, et al. Severe group A streptococcal infections in mothers and their newborns in London and the South East, 2010-2016: Assessment of risk and audit of public health management. BJOG 2019;126:44-53.  Back to cited text no. 3
    
4.
Tanaka H, Katsuragi S, Hasegawa J, Tanaka K, Osato K, Nakata M, et al. The most common causative bacteria in maternal sepsis-related deaths in Japan were group A Streptococcus: A nationwide survey. J Infect Chemother 2019;25:41-4.  Back to cited text no. 4
    
5.
Yamada T, Yamada T, Yamamura MK, Katabami K, Hayakawa M, Tomaru U, et al. Invasive group A streptococcal infection in pregnancy. J Infect 2010;60:417-24.  Back to cited text no. 5
    
6.
Tarvade S, Lane AS. Ante-partum necrotizing myometritis due to Streptococcal toxic shock. J Intensive Care Soc 2015;16:172-8.  Back to cited text no. 6
    
7.
Irani M, McLaren R Jr, Savel RH, Bogatyryova O, Khoury-Collado F. Streptococcal toxic shock syndrome occurring in the third trimester of pregnancy: A case report. J Obstet Gynaecol Res 2017;43:1639-43.  Back to cited text no. 7
    
8.
Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, et al. Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med 2019;380:811-21.  Back to cited text no. 8
    
9.
NCCWCH National Collaborating Centre for Women's and Children's Health; commissioned by National Institute for Health and Clinical Excellence (NICE): Caesarean section: Clinical guideline. 2nd ed. RCOG Book Company London; 2011.  Back to cited text no. 9
    




 

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