Streptococcal toxic shock syndrome in third trimester: a report of two cases and literature review

Objective To analyze the clinical characteristics of streptococcal toxic shock syndrome (STSS) caused by Streptococcus pyogenes (S. pyogenes) in the third trimester to improve clinical awareness of this disease. Methods A retrospective study was conducted to analyze the clinical data of two patients with STSS caused by S. pyogenes in Jinan Maternal and Child Health Care Hospital and nine reported cases of healthy pregnant women infected with S. pyogenes at 28-42 gestational weeks with detailed data retrieved from Chinese National Knowledge Infrastructure and PubMed database from January 1997 to December 2018. Results The two cases admitted to our hospital were both multiparas, with onset in winter and no specific symptoms in early stage. Disseminated intravascular coagulation (DIC) was developed in both cases on admission. In one case, the fetal heart rate was reduced and disappeared soon after admission. The other patient was diagnosed as stillbirth on admission. Both patients died and blood culture revealed infection of group A streptococcus. Nine previous cases were reported in one Chinese and five English articles. No high-risk pregnancy or premature rupture of membranes was reported in these 11 cases. Among the 11 cases, ten were positive for S. pyogenes indicated by blood or tissue culture and one was positive for streptococcal toxin. Ten cases had high fever and three presented with respiratory symptoms in early stage. Abdominal pain and watery diarrhea were common symptoms and all patients developed multiple organ dysfunction and DIC. Cases occurred in winter or spring were more common. Nine women died within 36 h after the onset of fulminant symptoms. Only two survived and hospitalized for 90 d and 25 d, respectively, after emergent cesarean section indicated by reduced fetal heart rate. Unfortunately, both neonates died after birth. For the babies, there were seven intrauterine fetal deaths, one stillbirth and three live births, but only one survived (whose mother developed respiratory cardiac arrest 90 min after delivery). Conclusions STSS caused by S. pyogenes in pregnant women exacerbates rapidly with a high mortality. Early identification of clinical manifestations and rapid progress of the disease are crucial for early diagnosis and treatment, which may help improve maternal and fetal outcomes. Key words: Shock, septic; Streptococcal infections; Streptococcus pyogenes; Pregnancy trimester, third