Leptospirosis in pregnancy: A systematic review

Abstract

Introduction Leptospirosis is a leading zoonotic disease worldwide with more than 1 million cases in the general population per year. With leptospirosis being an emerging infectious disease and as the world’s environment changes with more floods and environmental disasters, the burden of leptospirosis is expected to increase. The objectives of the systematic review were to explore how leptospirosis affects pregnancy, its burden in this population, its effects on maternal and fetal outcomes and the evidence base surrounding treatment options. Methods We performed a systematic review of published and unpublished literature using automated and manual methods to screen nine electronic databases since inception, with no language restriction. Two reviewers independently screened articles, completed the data extraction and assessment of risk of bias. Due to significant heterogeneity and paucity of data, we were unable to carry out a meta-analysis, but we conducted a pooled analysis of individual patient data from the case reports and case series to examine the patient and disease characteristics, diagnostic methods, differential diagnoses, antibiotic treatments, and outcomes of leptospirosis in pregnancy. The protocol for this review was registered on the International Prospective Register of Systematic Reviews, PROSPERO: CRD42020151501. Results We identified 419 records, of which we included eight observational studies, 21 case reports, three case series and identified four relevant ongoing studies. Overall the studies were with moderate bias and of ‘fair’ quality. We estimated the incidence of leptospirosis in pregnancy to be 1.3 per 10,000 in women presenting with fever or with jaundice, but this is likely to be higher in endemic areas. Adverse fetal outcomes were found to be more common in pregnant patients who presented in the second trimester compared with patients who presented in the third trimester. There is overlap between how leptospirosis presents in pregnancy and in the general population. There is also overlap between the signs, symptoms and biochemical disturbances associated with leptospirosis in pregnancy and the presentation of pregnancy associated conditions, such as Pre-Eclampsia (PET), Acute Fatty Liver of Pregnancy (AFLP) and HELLP Syndrome (Haemolysis Elevated Liver enzymes Low Platelets). In 94% of identified cases with available data, there was an indicator in the patient history regarding exposure that could have helped include leptospirosis in the clinician’s differential diagnosis. We also identified a range of suitable antibiotic therapies for treating leptospirosis in pregnancy, most commonly used were penicillins. Conclusion This is the first systematic review of leptospirosis in pregnancy and it clearly shows the need to improve early diagnosis and treatment by asking early, treating early, and reporting well. Ask early—broaden differential diagnoses and ask early for potential leptospirosis exposures and risk factors. Treat early—increase index of suspicion in pregnant patients with fever in endemic areas and combine with rapid field diagnosis and early treatment. Report well—need for more good quality epidemiological studies on leptospirosis in pregnancy and better quality reporting of cases in literature.

Tropical Infections Induced Fulminant Hepatitis in Peripartum Managed Successfully: Tales of Fate

“…Both of these mechanisms along with the direct cytotoxic effects of Leptospira lead to renal and hepatic injury. Leptospirosis in pregnancy is rather uncommon, with only a few cases being reported [21]. Unusual presentation of leptospirosis with features mimicking pregnancy-related liver disease such as the case described above has been reported before [21].…”

Leptospirosis in Pregnancy: Prevalence, Risk Factors, Clinical Characteristics, and Outcomes in a North Indian Population

“…Clinical characteristics that have been identified as being associated with leptospirosis in pregnancy [5] such as cardio-vascular problems (cardiac complications and hypertensive disorders), deranged liver function, respiratory problems and low haemoglobin were compared between the two groups. Mortality and maternal complications such as postpartum haemorrhage and sepsis were also compared.…”

“…There are several diagnostic methods for testing seroprevalence of Nevertheless, ELISA is considered the best pragmatic method as it is a rapid test, is easily available, has better sensitivity and specificity and does not require expert knowledge in handling samples and performing tests. In pregnancy, leptospirosis infection could have serious consequences for both the mother and the fetus if not diagnosed early and left untreated [5].…”

“…Therefore, early detection through ELISA could be an affordable and pragmatic screening test for women suspected to have an infection in the endemic areas. However, the challenge currently seems to be non-inclusion of leptospirosis as a differential diagnosis for women who present with features of AFLP and HELLP even in endemic areas [5].…”

“…However, only 13% of published studies in leptospirosis from the WHO region of south-east Asia is on pregnancy according to Selvarajah et al [5]. There have not been any detailed epidemiological studies for leptospirosis in pregnancy in India with almost all published studies being case reports [5]. In recognition of this limitation, our aim was to conduct a cross-sectional study to understand the epidemiological context of leptospirosis in pregnancy in India with the following specific objectives:…”