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

Kristin Harris; Leslie K Proctor; Shiri Shinar; Eleni Philippopoulos; Mark H Yudin; Kellie E Murphy

doi:10.1111/aogs.14500

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

Acta Obstet Gynecol Scand. 2023 Feb;102(2):138-157. doi: 10.1111/aogs.14500. Epub 2023 Jan 12.

Authors

Kristin Harris¹, Leslie K Proctor², Shiri Shinar³, Eleni Philippopoulos⁴, Mark H Yudin⁵, Kellie E Murphy³

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.

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.

Keywords: Streptococcus pyogenes; group A streptococcus; pregnancy; puerperium.

Publication types

Systematic Review
Review

MeSH terms

Female
Humans
Parturition
Postpartum Period
Pregnancy
Puerperal Infection* / therapy
Sepsis*
Shock, Septic* / diagnosis
Shock, Septic* / microbiology
Shock, Septic* / therapy
Streptococcal Infections* / diagnosis
Streptococcal Infections* / therapy
Streptococcus pyogenes