Antibiotic Prophylaxis to Prevent Obesity-Related Induction Complications in Nulliparae at Term: a pilot randomized controlled trial

BACKGROUND

Women with obesity are at increased risk of complications during and after labor and delivery, including puerperal infection and cesarean delivery. As labor induction has become increasingly common, it is crucial to find ways to decrease complication rates in this high-risk population.

OBJECTIVE

This study aimed to explore the effect of prophylactic antibiotics during labor induction of nulliparous women with obesity on the rates of cesarean delivery and puerperal infection and to estimate the parameters needed to calculate the sample size for a larger, multicenter trial.

STUDY DESIGN

In this randomized, placebo-controlled pilot trial, nulliparous patients with a body mass index of ≥30 kg/m2 were randomized to either prophylactic antibiotics (500 mg azithromycin for 1 dose and 2 g cefazolin every 8 hours for up to 3 doses) or placebo, administered starting at the beginning of labor induction. The exclusion criteria were known fetal anomaly, fetal demise, multifetal gestation, ruptured membranes >12 hours, infection requiring antibiotics at the start of labor induction, and/or allergy to azithromycin or beta-lactam antibiotics. The co-primary outcomes were rates of puerperal infection (composite of chorioamnionitis, endometritis, and/or cesarean delivery wound infection) and cesarean delivery. Participants were followed up for 30 days after delivery, and maternal and neonatal demographic and outcome data were collected. Proportions and 95% confidence limits were calculated for each of these outcomes.

RESULTS

From January 2019 to May 2021, 101 patients were randomized in the class III stratum (1 patient who was randomized ultimately did not undergo labor induction). From February 2020 to May 2021, 38 and 47 patients were randomized to class I and II strata, respectively (to assess the effect of obesity class on the outcomes expected to be influenced by antibiotic prophylaxis). In the antibiotics and placebo groups, the rates of cesarean delivery were 29.0% (95% confidence interval, 19.8-38.3) and 39.8% (95% confidence interval, 29.8-49.7), respectively, and puerperal infection occurred in 8.6% (95% confidence interval, 2.9-14.3) and 9.7% (95% confidence interval, 3.7-15.7), respectively. In the subgroup with class III obesity, in the antibiotics and placebo groups, the rates of cesarean delivery were 33.3% (95% confidence interval, 20.4-47.9) and 46.0% (95% confidence interval, 32.2-59.8), respectively, and puerperal infection occurred in 7.8% (95% confidence interval, 0.5-15.2) and 10.0% (95% confidence interval, 1.7-18.3), respectively. Note that this pilot study was not powered to detect differences of this magnitude but rather to estimate parameters.

CONCLUSION

The administration of prophylactic antibiotics during labor induction of nulliparous patients with obesity resulted in a 27% lower cesarean delivery rate overall and a 28% lower rate in patients with class III obesity. A larger trial is warranted to evaluate these differences.

Screening asymptomatic households for Streptococcus pyogenes pharyngeal carriage as a part of in-hospital investigation of puerperal sepsis

BACKGROUND

Invasive group A streptococcal (iGAS) infection in the peripartum setting is a rare but devastating disease occasionally occurring as a health care-associated infection (HAI). Current guidelines suggest enhanced surveillance and streptococcal isolate storage after a single case of iGAS, as well as a full epidemiological investigation that includes screening health care workers (HCWs) from several sites after 2 cases. Current guidelines do not recommend routine screening of household members of a patient with iGAS.

METHODS

We conducted studies of 3 patients with iGAS puerperal sepsis and related epidemiologic and molecular investigations.

RESULTS

Identical GAS emm gene types were found in pharyngeal cultures of 3 asymptomatic spouses of patients with iGAS puerperal sepsis. HCWs screened negative for GAS, and emm typing indicated that other iGAS cases from this hospital were sporadic and not related to the puerperal cases.

CONCLUSIONS

The concurrent presence of the same emm type in a household member practically excludes the option of an inadvertent HAI or facility outbreak. Hence, we suggest that screening close family members for asymptomatic GAS carriage should be performed early as a part of infection prevention measures, as doing so would have significant utility in saving time and resources related to a full epidemiological inquiry.

Pelvic Examination at the 6-Week Postpartum Visit After Cesarean Birth

INTRODUCTION

The objective of this study was to assess the utility of the pelvic examination at the 6-week postpartum visit after cesarean birth.

METHODS

Data were collected from retrospective chart review in an obstetric resident clinic in Detroit, Michigan. Women included were those who had a cesarean birth between January 2012 and June 2014.

RESULTS

Of 388 women who had a cesarean birth, 211 (54.4%) presented for the 6-week postpartum visit and underwent pelvic examination. Of these women, 185 (87.7%) were asymptomatic, and 26 (12.3%) reported vaginal discharge. No other concerns were elicited. Of those with symptoms, 4 (15%) had no finding, 13 (50%) had bacterial vaginosis (BV) alone, 2 (8%) had BV and Candida sp, 2 (8%) had BV and Trichomonas vaginalis, 2 (8%) had T vaginalis alone, and 3 (11%) had Chlamydia trachomatis. One woman with C trachomatis had tested positive during pregnancy and possibly had treatment failure. Of the 185 asymptomatic women, 91 (49%) were deemed to have vaginal discharge on examination and underwent testing for Neisseria gonorrhoeae and C trachomatis; results were negative in all cases.

DISCUSSION

In this population, it appears unnecessary to perform routine pelvic examination on asymptomatic women at the 6-week postpartum visit after cesarean birth. When vaginal discharge was noted during pelvic examination of asymptomatic women, no pathology was identified.

The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan

BACKGROUND

Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk.

METHODS/DESIGN

The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics.

DISCUSSION

This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

[A postpartum woman with toxic shock syndrome: group A streptococcal infection, a much feared postpartum complication.]

BACKGROUND

The development of toxic shock syndrome (TSS) after an invasive group A streptococcal (GAS) infection in the postpartum period is a much feared complication. The mortality rate of TSS with necrotizing fasciitis is 30 to 50%.

CASE DESCRIPTION

We present the case of a woman with atypical pelvic pain which was the first symptom of toxic shock syndrome as a consequence of a GAS infection. Clinical deterioration necessitated a hysterectomy. Also a fasciotomy was performed as consequence of lower extremity compartment syndrome. After this, multiple debridement operations were necessary, followed by split skin grafts.

CONCLUSION

This case illustrates the extremely serious complications of GAS infection. In some cases aggressive surgical intervention is necessary, in addition to an optimal antibiotic treatment regime. Ideally, the treatment of a GAS-induced TSS should be managed by a multidisciplinary medical team.

Puerperal infections of the genital tract: a clinical review

Puerperal genital tract infections, although less common in the 21st century, continue to affect maternal mortality and morbidity rates in the United States. Puerperal genital tract infections include endometritis as well as abdominal and perineal wound infections. These infections interrupt postpartum restoration, increase the potential for readmission to a health care facility, and can interfere with maternal-infant bonding. In addition, unrecognized or improperly treated genital tract infection could extend to other sites via venous circulation or the lymphatic system and increase the risk of severe complications or sepsis. Midwives are leaders in education, low rates of intervention, and prompt recognition of deviation from normal. Because puerperal genital tract infection usually begins after discharge, detailed education for women will encourage preventative health care, prompt recognition, and treatment.

Actinomycotic osteomyelitis of the cranial vault presenting with headache: an unusual presentation

A case of left parietal calvarial actinomycotic osteomyelitis in a young woman is described. She had no predisposing illnesses. She had delivered a live child at term and presented in the puerperal period. No extracranial focus of infection was identified. She responded well to a combination of surgery and medical therapy and had an excellent outcome. The authors emphasise the importance of establishing a histopathological diagnosis since radiological signs are non-specific and unreliable.

The impact of Q fever-phase-specific milk serology for the diagnosis of puerperal and chronic milk shedding of C. burnetii in dairy cows

C. burnetii infection might be associated with puerperal shedding; additionally, the chronic shedding of this pathogen in milk has been observed in individual animals. A longitudinal survey was performed in an endemically infected dairy cow herd with 100 cows in order to compare phase-specific milk-serology with pathogen shedding. From March 2010 through December 2011, 870 individual milk samples from 212 cows were analysed using both quantitative (q) PCR and phase-specific antibody-ELISA. The mean milk-shedding/cow was calculated for 137 cows with > or = 3 milk samples per cow. In addition, 110 puerperal swabs were collected after August 2010. The cows yielding three successive qPCR-positive milk samples or > 3 qPCR-positive milk samples, irrespective of the sequence of positive/negative results, were classified as chronic shedders (CS). Milk shedding was observed during the entire study, but a major period of puerperal shedding occurred from February through October 2011; 35/52 swabs tested positive, whereas only 3/58 swabs collected outside this period were positive. The PhI/PhII(+)-pattern in primiparous cows (< 36 months old) was consistent with puerperal shedding in the herd, but not at the individual level. This pattern was observed in older cows, irrespective of the period of puerperal shedding. Four primiparous CS-cows showed low-level mean shedding < 100 C.b./ml milk, and the PhI-titre increased from negative or weakly positive to more than 500 at the end of the first lactation. Puerperal shedding during the second parturition was observed in three of these cows. Six multiparous CS-cows with mean shedding exceeding 100 C.b./ml milk were characterised with stable PhI-titres of > or = 500. The three available puerperal swabs tested negative. Only one multiparous CS-cow showed low-level shedding and a PhI-titre below 500 for the entire study. In conclusion, the PhI-/PhII(+)-pattern in primiparous cows indicated puerperal shedding at the herd level, and a PhI-titre > or = 500 is a suitable screening method for the detection of chronic shedding in milk.

[Clinical statistical study on puerperal sepsis risk factors]

The aim of this study was to assess some risk factors involved in puerperal sepsis, such as: cesarean delivery, diabetes mellitus, preterm delivery and obesity, history of infections and anemia. The authors highlighted that new prevention methods and techniques could reduce the incidence and severity of post-cesarean puerperal sepsis (uterine infarction, peritonitis, toxic shock syndrome with Group A streptococcus).

Preliminary report on anaerobic culture at Mymensingh Medical College Hospital in Bangladesh

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. This study was undertaken to isolate and identify the anaerobic bacterial agents of puerperal sepsis among the patients admitted in Mymensingh Medical College Hospital (MMCH) during the period from July 2006 to June 2007. Endocervical swabs/secretions were collected from 50 cases of puerperal sepsis and were cultured anaerobically. Anaerobiasis was done by using gas pack (BD GAS PAK TM EZ) in anaerobic jar. Out of 50 samples, 42(84%) yielded growth in cultures. Among 42 culture positive cases, 20(40%) were Aerobic organisms and 22(44%) were mixed, i.e., Aerobic and Anaerobic bacteria. The isolated Anaerobic organisms were Peptostreptococcus 14(63.63%), Bacteroides fragilis 3(13.64%), Prevotella melaninogenica 3(13.64%) and Clostridium perfringens 2(9.09%). As a preliminary study, it was observed that anaerobic culture could be carried out with available logistic arrangement. So, it was recommended to design further study on anaerobic bacterial isolation with particular emphasis on their antimicrobial susceptibility.

MRSA breast abscesses in postpartum women

BACKGROUND

Infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are being increasingly observed in patients who lack traditional risk factors. While mastitis and breast abscesses are commonly encountered in post-natal women, CA-MRSA breast infections have rarely been reported.

MATERIALS AND METHODS

We reviewed 15 postpartum women with methicillin-resistant Staphylococcus aureus (MRSA) breast abscesses observed in our unit from June 2005 to April 2007. Ultrasonographic examination was performed in all cases. MRSA infection was diagnosed on microbiological analysis cultured from the abscesses of these patients.

RESULTS

The median age of the patients was 31.5 years. The majority of the patients were primiparae (80%). Only one patient was immunocompromised. None of the patients had history of previous breast infection and none developed recurrence. Eleven patients (73.3%) underwent aspiration of pus and four patients (26.7%) underwent incision and drainage. All the cultures were sensitive to co-trimoxazole and vancomycin. Eight (53.3%) of the cultures were also sensitive to erythromycin.

CONCLUSION

CA-MRSA is an emerging problem in our obstetric population. CA-MRSA breast infections are clinically responsive to common oral antibiotics such as co-trimoxazole and erythromycin. A high index of suspicion is essential to avoid delay in the clinical response to empirical beta-lactams as these patients may benefit from an early change of antibiotics.

Determinants of post-caesarean wound infection at the University College Hospital Ibadan Nigeria

OBJECTIVE

To determine the risk factors that predispose patients to post-caesarean wound infection at a tertiary health institution in developing country.

METHOD

It was an observational study of all women that had caesarean (elective and emergency) delivery between July and September, 2004. The outcome of their post-caesarean wound was assessed. Statistical analysis (Bivariate and logistic regression) of the identified risk factors in patients who developed wound infection was performed at a 95% level of confidence.

RESULTS

The post-caesarean wound infection rate was 16.2%. The identified risk factors were lower educational status, multiple pelvic examination, offensive liquor at surgery and patients that are unbooked. Following logistic regression, women with up to primary school were 20 times more likely than those with secondary education and above to develop wound infection (95% CI OR = 1.8 to 250.0).

CONCLUSION

The outcome showed that the identified determinants of post-caesarean wound infection were comparable with earlier reports. Women with lower educational status are more at risk in this study. Therefore, these women need special attention to reduce the risk.

Postpregnancy genital tract and wound infections

Despite the widespread application of standard aseptic techniques during vaginal birth, cesarean birth, and/or termination of pregnancy, postpregnancy infections remain a significant source of maternal morbidity and mortality. Obstetric infection accounts for more than 12% of maternal deaths. Infection occurs most frequently in women who have cesarean births, and following spontaneous or elective termination of pregnancy. Infection is estimated to be the second highest cause of under-reported maternal death in the United States. This article identifies measures to aid in primary prevention and recognition of obstetric infections in order to facilitate early diagnosis and treatment.

Does histologic chorioamnionitis correspond to clinical chorioamnionitis?

OBJECTIVE

To evaluate the degree to which histologic chorioamnionitis, a frequent finding in placentas submitted for histopathologic evaluation, correlates with clinical indicators of infection in the mother.

STUDY DESIGN

A retrospective review was performed on 52 cases with a histologic diagnosis of acute chorioamnionitis from 2,051 deliveries at University Hospital, Newark, from January 2003 to July 2003. Third-trimester placentas without histologic chorioamnionitis (n = 52) served as controls. Cases and controls were selected sequentially. Maternal medical records were reviewed for indicators of maternal infection.

RESULTS

Histologic chorioamnionitis was significantly associated with the usage of antibiotics (p = 0.0095) and a higher mean white blood cell count (p = 0.018). The presence of 1 or more clinical indicators was significantly associated with the presence of histologic chorioamnionitis (p = 0.019).

CONCLUSION

Histologic chorioamnionitis is a reliable indicator of infection whether or not it is clinically apparent.

Glomerulonephritis induced by methicillin-resistant Staphylococcus aureus infection that progressed during puerperal period

A 28-year-old Japanese woman developed fever, leg edema, purpura, and abdominal pain during the puerperal period, showing nephrotic syndrome with microscopic hematuria. At first she was thought to have Henoch-Shönlein purpura nephritis and was given steroids at another hospital. Because anasarca and massive urinary protein excretion developed, she was referred to our hospital. Renal biopsy specimens showed endocapillary proliferative glomerulonephritis with massive IgA and C3d deposition along the capillary loops and in the mesangium. A bacteriological study detected methicillin-resistant Staphylococcus aureus (MRSA) in cultures of vaginal secretions, urine, stool, and pharyngeal mucus samples. Based on the diagnosis of MRSA nephritis, anti-MRSA therapy with antibiotics was started, and MRSA became negative for each culture, and urinary protein decreased. Two months after the first renal biopsy, a second renal biopsy was performed, which revealed feeble endocapillary proliferation with mild IgA and C3d deposition in the mesangium. This case showed that the delivery procedure can cause MRSA nephritis after MRSA infection, and that steroid therapy should be avoided in the early phase of this type of nephritis.

Bacterial complications of postpartum uterine involution in cattle

The bacterial contamination of the postpartum uterus is a frequent finding which by itself does not disturb the anatomical and histological restoration of tubular genital tract. The improper balance between uterine infection and the intrauterine antimicrobial self-defence mechanisms, however, often results in complications, such as puerperal metritis, clinical endometritis, pyometra and subclinical endometritis. After reviewing the bacteriology of uterine involution, and the predisposing factors for its bacterial complications, this paper defines the different clinical forms, and summarizes their pathology, furthermore, the recent progress in diagnostic considerations and principles of current treatments for these diseases of bovine genitals.

Chromobacterium violaceum: a case report of an unusual bacterium causing puerperal sepsis

Human infections by Chromobacterium violaceum are rare. Till date 6 cases have been reported from southern and eastern parts of India. We report here a case of puerperal sepsis by C. violaceum, probably the first case from Eastern part of Orissa. The patient was successfully treated with amikacin and gatifloxacin.

Isolation of Enterococcus faecalis from a case of nonpuerperal breast abscess

Nonpuerperal breast abscess (NPBA) has different etiology as compared to the mastitis occurring in post partum women. The condition presents either as acute suppurative infection or chronic type. Organisms usually implicated are Staphylococcus aureus, coagulase negative staphylococci, and anaerobes. Mostly the infection is polymicrobial in nature. Herein, we report the isolation of Enterococcus faecalis from a case of acute suppurative NPBA.

Postpartum pyomyoma

Leiomyomata are common benign tumors of the uterus and female pelvis. Myomas have been reported in 25% of Caucasian American women and 50% of African-American women. The true incidence is unknown, but descriptions of 50% have been found at postmortem examinations. Considering the high incidence of uterine myomata in women of reproductive age, they are reported as complications in only 2% of pregnancies. Pyomyoma (suppurative leiomyoma) a rare complication results from infarction and infection of a leiomyoma. Without a strong clinical suspicion and surgical intervention, fatalities may occur. Since 1945, only 15 cases have been described in the literature, mostly in pregnant or postmenopausal women after ascending infection. This report documents a pyomyoma that presented as a postpartum enlargement of a previously known leiomyoma. This case is unique because the patient did not undergo a hysterectomy at the time of exploratory laparotomy. Six months after the procedure, normal cyclic bleeding was noted.

Postpartum retroperitoneal fasciitis: a case report and review of literature

We present a case of a postpartum female with iliopsoas fasciitis in the puerperium. Two days after a spontaneous vaginal delivery at 38 weeks without any complications, the patient complained of pain in the left thigh and hip, associated with a temperature of 38 degrees C. Consequently, she could not walk 4 days after delivery and her body temperature had increased to 39 degrees C. Extreme left flank pain and tenderness in the left pelvic wall were prominent, whereas the tenderness in the pelvis was moderate. Magnetic resonance imaging led us to diagnose iliopsoas fasciitis. This was complicated by sepsis but improved after a protracted antibiotic treatment without any surgical intervention. A literature review revealed that serious complications, including sepsis or permanent functional disturbance, could arise although retroperitoneal fasciitis and/or abscesses are very rare after vaginal delivery. Iliopsoas fasciitis could be considered when patients complain of extreme pain in the pelvic wall, sacroiliac joint region, or thigh-symptoms that are uncommon in uncomplicated endometritis.

Clinical evaluation of postpartum vaginal mucus reflects uterine bacterial infection and the immune response in cattle

Bacteria contaminate the uterus of most dairy cattle after parturition and endometritis causes infertility. An endometritis score can be ascribed based on the vaginal mucus character and odour but it is not clear if the clinical score reflects the number of uterine bacteria or the inflammatory response. The present study tested the hypothesis that clinical evaluation of endometritis reflects the number of bacteria present in the uterus, and the acute phase protein response. Swabs (n = 328) were collected from the uterine lumen of dairy cattle, 21 and 28 days postpartum, vaginal mucus was scored for character and odour, and blood samples collected for acute phase protein measurement. Bacteria were identified following aerobic and anaerobic culture, and the bacterial growth density was scored semi-quantitatively. When bacteria were categorised by their expected pathogenic potential in the uterus, purulent or fetid odour vaginal mucus was associated with the growth density of pathogenic bacteria but not opportunist contaminants. When bacteria were analysed independently, Arcanobacterium pyogenes, Proteus and Fusobacterium necrophorum growth densities were associated with mucopurulent or purulent vaginal mucus. The bacterial growth densities for A. pyogenes, Escherichia coli, non-hemolytic Streptococci, and Mannheimia haemolytica were associated with a fetid mucus odour. Peripheral plasma concentrations of alpha(1)-acid glycoprotein were higher if there was a fetid compared with a normal vaginal mucus odour (1.50 +/- 0.09 mg/mL versus 1.05 +/- 0.02 mg/mL, P < 0.001), but did not differ significantly between vaginal mucus character scores. The evaluation of the character and odour of vaginal mucus reflects the number of bacteria in the uterus, and the acute phase protein response.

Abdominal rectus muscle sheath abscess after spontaneous vaginal delivery. A case report

Postpartum infections cause severe morbidity of the mother. Abdominal wound infection and abscess formation are common complications after cesarean delivery. We report a case with abscess formation inside the abdominal rectus muscle sheath after normal, spontaneous vaginal delivery. A 32-year-old woman, para 2, had a normal vaginal delivery at term. The second postpartum day she complained of lower abdominal pain and was unable to stand up or walk. The fourth day, cellulitis of the skin of the lower abdomen developed and was treated with broad-spectrum intravenous antibiotics. The seventh day the patient developed septic fever and an abdominal rectus muscle sheath abscess was diagnosed. The abscess was treated with incisions and evacuation and the patient was discharged the 12th postoperative day. The abscess in this case, as hematoma formation was not preceded, was referred to ascending contamination via the lymphatic vessels.

The diagnosis and treatment of a patient with puerperal infection and subdural hygromas

We describe a patient readmitted after developing a persistent postural headache resulting from an accidental lumbar puncture during labor 10 days earlier. Magnetic resonance imaging demonstrated bifrontal subdural hygromas and diffuse pachymeningeal enhancement. The patient had signs of a puerperal infection, and an epidural patch was performed with dextran 40 instead of blood, after which gradual improvement was noted. The patient was discharged totally asymptomatic 3 days later.

Association between postpartum pyrexia and uterine bacterial infection in dairy cattle

The temperature of 90 dairy cattle was recorded for the first 10 days after parturition and the animals were categorised as either normal (< 39.7 degreesC) or pyrexic. Swabs were collected from the uterine lumen seven, 14, 21 and 28 days after parturition for aerobic and anaerobic culture; bacteria were identified and their growth was scored semiquantitatively. Blood samples were collected three times a week for the estimation of the concentrations of acute phase proteins. The cows' temperatures were often above the accepted normal range, but it was not a good indicator of the number of bacteria in the uterus. However, pyrexia was correlated with the presence of specific uterine pathogens (P < 0.05) and in particular with Prevotella species (P < 0.01). The pyrexic animals had a higher plasma concentration of the acute phase protein (alpha1-acid glycoprotein (P < 0.05). Although pyrexia is an indicator of postpartum inflammation, additional clinical signs are necessary to identify uterine bacterial infection.

Diagnosis of postpartum infections: clinical criteria are better than laboratory parameter

BACKGROUND

Physiologic increases in the leukocyte count and segmental neutrophil percentage during pregnancy alter the ability of these indices to predict infection.

METHODS

Women with cesarean deliveries were assessed by leukocyte counts and segmented neutrophil percentage as well as clinical signs to detect postoperative infection.

RESULTS

In 157 consecutive patients undergoing cesarean deliveries there was a significant physiologic increase between the preoperative and postoperative leukocyte count (12.4 +/- 3.9/uL vs. 14.8 +/- 3.4/uL, P < 0.001). The leukocyte count after delivery did not discriminate whether or not the patient would develop a postpartum infection or have significant hyperpyrexia.

CONCLUSION

Due to physiologic changes associated with pregnancy, the leukocyte count and segmented neutrophil percentage do not predict infection. Therefore clinical findings are most important in diagnosing postpartum infections.

Post-partum endomyometritis diagnosis and treatment: A review

Over the past 80 years, obstetrical treatment strategies devised to control current problems have resulted in the emergence of new types of infection. These, in turn, have caused modifications in diagnostic techniques and treatment specifics. Currently, the two most obvious changes influencing post-partum infection care are shortened post-partum hospital care, and the widespread use of intra-partum antibiotics to prevent early onset Group B streptococcal sepsis in the newborn. In the present review, risk factors for post-partum infection are delineated and strategies for prophylaxis and treatment are given.

Group A streptococcus and streptococcal toxic shock syndrome: a postpartum case report

Streptococcal toxic shock syndrome from group A streptococcal disease is rare in the postpartum period, yet it is associated with high morbidity and mortality. Early diagnosis and treatment can lessen complications. Midwives can improve provision of postpartum care by being adequately educated about signs and symptoms of this disease, thereby enhancing their ability to recognize it and obtain the appropriate referral or collaborative medical care. A clinical presentation of postpartum streptococcal toxic shock syndrome, including provider follow-up, is presented.

Early and definitive diagnosis of toxic shock syndrome by detection of marked expansion of T-cell-receptor VBeta2-positive T cells

We describe two cases of early toxic shock syndrome, caused by the superantigen produced from methicillin-resistant Staphylococcus aureus and diagnosed on the basis of an expansion of T-cell-receptor VBeta2-positive T cells. One case-patient showed atypical symptoms. Our results indicate that diagnostic systems incorporating laboratory techniques are essential for rapid, definitive diagnosis of toxic shock syndrome.

Maternal postpartum group B beta-hemolytic streptococcus ventriculoperitoneal shunt infection

BACKGROUND

Women with cerebrospinal fluid shunts require special management during the course of pregnancy.

CASE REPORT

We describe a case of delayed postpartum ventriculoperitoneal shunt infection by Group B streptococcus in a 19-year-old who presented complaining of headache and a fever. The CSF culture from the shunt tap and the distal shunt tip both grew Group B beta-hemolytic streptococcus.

CONCLUSION

Women who are colonized with Group B streptococcus and who have cerebrospinal fluid shunts should receive perinatal antibiotic prophylaxis, and may require more extended prophylactic antibiotics with cesarean section deliveries to prevent catheter tip colonization and subsequent shunt infection.

Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency

OBJECTIVE

We reviewed the cases of 23 patients who were admitted to the hospital with a primary diagnosis of histopathologically confirmed necrotizing fasciitis in the lower abdomen or pelvis. Rapid demise of a healthy postpartum women piqued our interest in trying to identify the early signs and symptoms that may lead to earlier diagnosis and treatment of this often fatal disease.

STUDY DESIGN

A retrospective analysis of charts of all patients who were admitted to the gynecology and obstetrics services of our hospital systems with a diagnosis of necrotizing fasciitis for the past 14 years was performed. Age, comorbid factors, precipitating events, weight, symptoms and signs, microbiologic factors, radiographs, surgical therapy, and morbidity were correlated.

RESULTS

Definitive operation was accomplished within 48 hours of the diagnosis of necrotizing fasciitis in all but 3 patients. Of the 17 patients who were not puerperal, 88% of the women were obese; 65% of the women were hypertensive, and 47% of the women were diabetic. Of the total 23 patients, 70% of the women complained of severe pain, and 35% of the women had radiographic diagnostics for necrotizing fasciitis ("gas"). Four patients had diverting colostomies, and 39% of the patients had flaps or synthetic grafts. Three patients died (mortality rate, 13%). One patient who was puerperal died of a severe rapid septicemia; the 2 late deaths were the result of systemic candidiasis.

CONCLUSION

Necrotizing fasciitis is a rapidly progressive, often lethal, infectious disease process that requires early aggressive debridement. Any patient with inordinate pain and unilateral edema in the pelvis, especially in the puerperium, should be suspected of having this disease. Radiographic studies are often diagnostic of this condition. The triad of pelvic pain, edema, and any sign of septicemia carries an extremely grave prognosis and mandates immediate surgical intervention.

Postpartum endogenous Candida endophthalmitis

Candida albicans is the most common pathogen causing intraocular fungal infection. Postpartum endogenous Candida endophthalmitis, however, is extremely rare. We report the case of a 33-year-old postpartum woman who presented with a 5-day history of decreased vision and had a positive blood culture for C. albicans. Fundus examination showed vitreous haze and multiple pre-retinal whitish lesions with indistinct borders. Systemic investigations revealed acute renal failure and cardiomegaly. After treatment with intravenous antifungal therapy, vitrectomy, and intravitreal injection of antimycotics, systemic and intraocular infections were eradicated successfully.

Two cases of delayed diagnosis of postpartal streptococcal toxic shock syndrome

BACKGROUND

Puerperal sepsis due to group A beta-hemolytic streptococcal (GAS) toxic shock syndrome is associated with very high morbidity and mortality. Luckily it is now rare, but diagnosis is not always easy. This report demonstrates the problem of recognizing this disease, and summarizes the current knowledge on the pathomechanism and management of streptococcal toxic shock syndrome.

CASE

Two cases of postpartum streptococcal toxic shock syndrome due to GAS are described. In both cases the correct diagnosis was delayed for several days. The first patient was sent home with the diagnosis of German measles; the second patient was transferred to our neurological intensive care unit with the diagnosis of meningitis. Both patients were admitted to the intensive care unit in profound shock, both developed multiple organ failure, and one patient died.

CONCLUSIONS

GAS may produce virulence factors that cause host tissue pathology. Besides aggressive modern intensive care treatment, early diagnosis and correct choice of anti-streptococcal antibiotics are crucial. A possible adverse effect of non-steroidal anti-inflammatory agents requires confirmation in a multicenter study.