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Objectives: We compared complication rates after surgical abortions performed by physician assistants with rates after abortions performed by physicians., Methods: A 2-year prospective cohort study of women undergoing surgically induced abortion was conducted. Ninety-one percent of eligible women (1363) were enrolled., Results: Total complication rates were 22.0 per 1000 procedures (95% confidence interval [CI] = 11.9, 39.2) performed by physician assistants and 23.3 per 1000 procedures (95% CI = 14.5, 36.8) performed by physicians (P =.88). The most common complication that occurred during physician assistant-performed procedures was incomplete abortion; during physician-performed procedures the most common complication was infection not requiring hospitalization. A history of pelvic inflammatory disease was associated with an increased risk of total complications (odds ratio = 2.1; 95% CI = 1.1, 4.1)., Conclusions: Surgical abortion services provided by experienced physician assistants were comparable in safety and efficacy to those provided by physicians.

Objective: The study was undertaken to investigate the outcome of pregnancies in Gaucher disease, particularly in enzyme-treated women., Study Design: A retrospective study was performed of pregnant women evaluated at a referral clinic., Results: There were 43 (17 treated, 26 untreated) women with 66 pregnancies (23 treated, 43 untreated). The live birth rate was 78.3% among treated, 86.0% among untreated. One treated woman had three spontaneous abortions; 3 untreated women had one each. Four pregnancies in each group had postpartum bleeding, 7 requiring transfusions. Postpartum infections were prevalent among treated. Cesarean sections were generally for historic reasons. There was no exacerbation of Gaucher disease, except one bone crisis., Conclusion: Most untreated women with milder disease enjoyed an uncomplicated course. Enzyme-treated patients (ie, with more severe disease) had more bleeding and infections post partum, but few had spontaneous abortions. Hematologic consultation is recommended. A review of world experience with pregnant patients with Gaucher disease is included.

Puerperal infections are an important cause of maternal morbidity and mortality in developing nations. Investigators have noted several risk factors for developing puerperal sepsis. However, the relative importance of these risk factors varies and has to be determined for each setting. Therefore the aim of the present work was to determine the risk factors for puerperal sepsis in Alexandria, Egypt. A case-control design was used to study the risk factors of puerperal sepsis in Alexandria. The study included 160 puerperal sepsis cases and 160 controls. Puerperal sepsis cases were recruited from the fever hospital as well as from 3 rural health units and three urban health offices in Alexandria. A pre-designed interviewing questionnaire was used to collect data about risk factors of puerperal sepsis. Logistic regression analysis indicated that very low socio-economic score (OR = 6.4), no ANC (OR = 4.5), delivery at a governmental maternity hospital (OR = 203.4), frequent vaginal examinations (OR = 5.1), anemia during puerperium (OR = 4.3), unsanitary vaginal douching during puerperium (OR = 19.9) and unhygienic preparation of diapers used immediately after delivery (OR = 12.1) were significantly related to the occurrence of puerperal sepsis. Improving infection control measures during delivery, limiting the frequency of vaginal examinations, and avoiding all unhygienic practices related to delivery are strongly recommended.

Objective: To elicit factors associated with the postpartum development of septic pelvic thrombophlebitis in a single large referral tertiary patient population., Methods: A nine-year single institution retrospective case review of all patients with enigmatic fever and septic pelvic thrombophlebitis was analyzed., Results: A total of 55 patients with septic pelvic thrombophlebitis were provided care during the study interval. The average gestational age at delivery was 36.8 +/- 4.3 weeks. The most prevalent concurrent medical complication of pregnancy was preeclampsia (45%) while chorioamnionitis affected only 13%. The average length of ruptured membranes was 22.8 +/- 56.8 hours (median 10.5, 95% confidence interval [CI] 7.0-38.7 hours), with 22% of patients undergoing amnion rupture at the time of cesarean delivery. Prolonged (>24 hours) amnion rupture occurred in only 9% of patients. Most affected patients were delivered abdominally (91%) but a minority delivered vaginally (9%). Antibiotic therapy for presumed infection was initiated at 27.4 +/- 24.6 hours postpartum. Subsequently intravenous heparin therapy was initiated 128.9 +/- 54.2 hours thereafter enigmatic fever defervesed 37.2 +/- 36.8 hours later (median 34.0, 95% CI 27.2-47.3 hours). Patients received 6.3 +/- 1.8 days of heparin therapy., Conclusion: In this series, septic pelvic thrombophlebitis was frequently preceded by cesarean delivery and commonly associated with preeclampsia. Unexpectedly, a small number of patients suffered prolonged rupture of membranes or chorioamnionitis. We speculate that the cesarean delivery of a population of at-risk patients with preeclampsia may predispose them to develop septic pelvic thrombophlebitis.

Within a four-week period, five patients were admitted to the maternity ward of the Utrecht Children's Hospital diagnosed with puerperal sepsis due to group-A streptococcal infection. The clinical presentation was different for each patient. All patients recovered upon adequate antibiotic treatment. One of the children died, possibly due to sepsis and hypotension of his mother. As group-A streptococci can be extremely contagious and an epidemic was suspected, measures for additional hygiene were taken. Furthermore, all personnel at the maternity ward and the obstetric centre were tested. T-serotyping, M-genotyping, exotoxin A- and C-gene amplification and pulsed field gel electrophoresis were used to characterize the cultured group-A streptococci. Cross-contamination was not found. Therefore, this increase in puerperal sepsis was attributed to polyclonal expansion rather than an epidemic. All mothers of newly born children who present with fever and lower abdominal pain should be suspected of group-A streptococcal infection. Evaluation and treatment in hospital is indicated due to a sometimes fulminant course. When group-A streptococci are cultured again in a new pregnancy, eradication therapy during pregnancy or prophylactic treatment during birth should be considered to prevent recurrent infection.

Objective: The purpose of this study was to determine whether meconium-stained amniotic fluid is associated with puerperal infection and whether the quality of the meconium is further associated with this risk., Study Design: We designed a retrospective cohort study of all deliveries beyond 37 weeks gestational age from 1992 to 2002 at a single community hospital. Data were collected on rates of chorioamnionitis, endomyometritis, quality of amniotic fluid, and length of labor and analyzed with bivariate and multivariate analyses., Results: We found that, among the 43,200 women who were delivered at term, 18.9% of the women had meconium staining (8.8% thin, 5.5% moderate, 4.6% thick). Compared with deliveries with clear amniotic fluid, those with meconium-stained amniotic fluid had higher rates of chorioamnionitis (2.3% vs 4.1%, P<.001) and endomyometritis (1.0% vs 1.7%, P<.001). Further, the severity of meconium staining was associated with increased rates of infection., Conclusion: We found that the presence and severity of meconium-stained amniotic fluid is associated with puerperal infection even when being controlled for confounders.

The distribution of morbidity and mortality in newborns, as well as morbidity of parturient women, in maternity hospitals of Moscow official have been analyzed according to statistical data for 1996-1999. The methods of cluster analysis (k-medium and tree classification by the method of the next door neighbours) were used. The evaluation of the stability of the distribution of morbidity and mortality in maternity hospitals was made with the use of chi 2 criterion. The specific features of the distribution of morbidity and mortality of newborns, as well as morbidity of parturient women, in the hospitals under study were detected. The methodological approach to the evaluation of epidemiological safety in maternity hospitals was proposed.

Objective: This study was undertaken to compare the efficacy of 3 days versus 7 days of ampicillin in prolonging gestation for at least 7 days in women with preterm premature rupture of membranes (PPROM)., Study Design: We performed a randomized clinical trial comparing 3 days of ampicillin with 7 days ampicillin in patients with PPROM. Our primary outcome was the prolongation of pregnancy for at least 7 days. Secondary outcomes included rates of chorioamnionitis, postpartum endometritis, and neonatal morbidity and mortality., Results: Forty-eight patients were randomly selected. There was no statistically significant difference in the ability to achieve a 7-day latency (relative risk 0.83, 95% CI 0.51-1.38). In addition, there was no statistically significant difference in the rates of chorioamnionitis, endometritis, and our composite neonatal morbidity., Conclusion: In patients with PPROM, length of antibiotic therapy does not change the rate of a 7-day latency or affect the rate of chorioamnionitis, postpartum endometritis, or neonatal morbidity.

Background: There is a need to assess the cost-benefit of different models of antibiotic administration for the prevention of post cesarean infection, particularly in resource-scarce settings., Design: Randomized, nonblinded comparative study of a single combined preoperative dose of gentamicin and metronidazole vs. a post cesarean scheme for infection prophylaxis., Methods: Pregnant women (n = 288) with indication for emergency cesarean section were randomly allotted to two groups. Group 1 (n = 143) received the single, combined dose of prophylactic antibiotics and group 2 (n = 145) received, over 7 days, the postoperative standard scheme of antibiotics followed in the department. Both groups were followed up during 7 days for detection of signs of wound infection, endometritis, peritonitis and urinary tract infection., Main Outcome Measures: Prevalence of postoperative infection, mean hospital stay and costs of antibiotics used., Results: Women completing the study (n = 241) were distributed into group 1 (n = 116) and group 2 (n = 125). No significant difference was found neither in the prevalence of postoperative infection nor in the mean hospital stay. No death occurred. The cost of the single dose of prophylactic antibiotics was less than one-tenth of the cost of the standard postoperative scheme., Conclusion: In our setting, the administration of a single dose of 160 mg of gentamicin in combination with 500 mg of metronidazole before emergency cesarean section for prevention of infection is clinically equivalent to existing conventional week-long postoperative therapy, but at approximately one-tenth of the cost.

Background: We wished to determine the incidence of nosocomial infections in the mother and the newborn during the early postpartum period., Material and Methods: Over a three-month period, the same investigator collected 50 different clinical and microbiological, standardized data related to infectious diseases in parturients and their newborns., Results: Data were collected on 804 deliveries. The overall rate of nosocomial infection was 2.9% (23/804). For vaginal deliveries, the rate was 1.9% (12/615) and for deliveries by Cesarean section, the rate was 5.8% (11/189). Of 745 newborns followed until discharge from hospital, 0.7% (5/745) had a nosocomial infection., Conclusion: These results are in line with previously published rates of nosocomial infections, which varied between 0.2% to 2.3% for vaginal deliveries, 1.6% to 18.9% for Cesarean section, and 0.2 to 4% in newborns. Regular surveys of the incidence or the prevalence of nosocomial infections are necessary to monitor the effectiveness of educational programs, aimed to reduce hospital acquired infections.

We designed a prospective study to assess the contributing factors in puerperal breast abscess and to evaluate the treatment options. During the 4-year study period, 128 nursing women with breast infection were followed. Of these, 102 had mastitis (80%) and 26 had breast abscess (20%). Ultrasonographic examination was performed in all cases. Patient age, parity, localization of infection, cracked nipples, duration of lactation, duration of symptoms, milk culture results, breast infections during previous lactation period, treatment options, healing time, and recurrence were recorded prospectively. All mastitis patients were treated with antibiotics and none developed an abscess. Ten abscesses were aspirated, and 16 abscesses were treated by incision and drainage. Healing times were similar. There was no significant difference between mastitis and abscess groups regarding age, parity, localization of breast infection, cracked nipples, positive milk cultures, or mean lactation time. Duration of symptoms and healing were longer in cases of abscess. Multivariate analyses showed that duration of symptoms was the only independent variable for abscess development. Recurrent mastitis developed in 13 patients (10.2%) within a median of 24 weeks of follow-up. Delayed treatment of mastitis can lead to abscess formation, and it can be prevented by early antibiotic therapy. Ultrasonography is helpful for detecting abscess formation. In selected cases the abscess can be drained with needle aspiration with excellent cosmesis.

Objective: To evaluate the association of uterine rupture during a trial of labor after cesarean with postpartum fever after the prior cesarean delivery., Methods: We conducted a nested, case-control study in a cohort of all women undergoing a trial of labor after cesarean over a 12-year period in a single tertiary care institution. The current study was limited to all women undergoing a trial of labor after cesarean at term with a symptomatic uterine rupture and who also had their prior cesarean at the same institution. Four controls, who all had their prior cesarean at the same institution, were matched to each case by year of delivery, number of prior cesareans, prior vaginal delivery, and induction in the index pregnancy. Medical records were reviewed for maximum postpartum temperature for the previous cesarean. Fever was defined as a temperature above 38C. Conditional logistic regression analysis was performed taking into account potential confounding factors., Results: There were 21 cases of uterine rupture included in the analysis. The rate of fever following the prior cesarean was 38% (8/21) among the cases, and 15% (13/84) in the controls, P =.03. Multiple logistic regression analysis examining the association of uterine rupture and postpartum fever adjusting for confounders revealed an odds ratio of 4.0, 95% confidence interval 1.0, 15.5., Conclusion: Postpartum fever after cesarean delivery is associated with an increased risk of uterine rupture during a subsequent trial of labor.

Objective: To determine whether hypothermia during Cesarean delivery is a risk factor for postoperative infection., Methods: An historical cohort investigation was conducted on all women delivered by Cesarean at our center during 2001. Initial recovery-room temperature, taken via the oral or axillary route, was used as a surrogate for intraoperative temperature. Adding 0.5 degrees C to axillary temperatures generated oral temperature equivalents. Women with chorioamnionitis were excluded, as were those with an initial recovery-room temperature that exceeded 37.9 degrees C or was recorded more than 20 minutes after the end of surgery. Prophylactic antibiotics (cefazolin, 1 g) were given during Cesarean delivery., Results: A total of 42 women (7.6%) were diagnosed with postoperative infections. Infections included endometritis (n = 25), wound abscess (n = 7), wound cellulitis (n = 7) and urinary tract infection (UTI) (n = 4). No cases of septic pelvic thrombophlebitis or pelvic abscess occurred. One woman had both endometritis and a UTI. Mean temperatures were higher, rather than lower, for women who subsequently had postoperative infections compared with those who did not (36.4 +/- 0.8 degrees C vs. 35.9 +/- 0.7 degrees C; p < 0.001). Mean temperatures for the various postoperative infections were as follows: endometritis, 36.5 +/- 0.8 degrees C (p < 0.001 vs. uninfected group); wound abscess 36.0 +/- 0.8 degrees C (p = 0.63); wound cellulitis, 36.3 +/- 0.6 degrees C (p = 0.14); UTI, 36.7 +/- 0.9 degrees C (p = 0.04)., Conclusions: Women who develop post-Cesarean infections have higher initial recovery-room temperatures than those who do not develop such infections. This suggests the presence of subclinical infection at the time of Cesarean. Evaluating whether intraoperative warming has any role during Cesarean delivery requires a randomized clinical trial.

Objective: To measure the rate of wound infection after cesarean section and assess risk factors for such infection., Methods: A prospective surveillance was conducted at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, during the period January 2000 through to December 2000. This included a total of 754 cesarean sections. The following risk factors, which were studied included, age, parity, gravida, gestational age, antenatal care, type of cesarean section emergency or elective, previous history of cesarean section, duration of operation, rank of surgeon, use of antibiotics, wound infection, complications and length of stay in the hospital. Post discharge surveillance was carried out 5-10 days later to check for wound infection., Results: The overall wound infection rate was 4.5% (95% confidence interval [CI], 3-6%). In the multivariate analysis, the independent risks factors for wound infection were age of the mother less than 20 years (Odds ratio (OR) = 12.13: 95% CI 1.43-118.50: P = 0.039), the duration of surgery, more than one and a half hour (OR = 23.9: 95% CI 10.36-55.78: P = < .001) and medical complications namely diabetes mellitus (OR = 2.28: 95% CI 1.01-5.05: P = 0.03). There was a statistical significant relationship between wound infection and length of stay (P < 0.001)., Conclusion: A protocol for prophylactic antibiotics is needed, in addition to a new strategy to reduce the nosocomial infection, in order to decrease the incidence of wound infection after cesarean section.

Objective: To review our experience with pregnancies in women with myasthenia gravis (MG)., Study Design: Sixty nine pregnancies among 65 women with MG patients managed by our department over 28 years were included. The course of the disease in pregnancy, mode of delivery and postpartal period were evaluated., Results: One pregnancy miscarried. In 15% of patients the MG deteriorated in pregnancy a further 16% in the puerperium. 17% of pregnancies were delivered by cesarean section, one due to myasthenia exacerbation. All women with puerperal infections developed exacerbations. One neonatal death, not attributable to myasthenia, was recorded. Transitory neonatal myasthenia gravis (TNMG) was diagnosed in 30% infants. Its incidence was inversely associated with maternal disease duration (P < 0.05). Newborns of thymectomized mothers showed lower rate of neonatal myasthenia compared to those of non-thymectomized women (P < 0.05)., Conclusions: MG patients can have normal pregnancy and delivery but the course is unpredictable. Shorter disease history and infection predispose to puerperal exacerbation. Maternal thymectomy lessens the likelihood of neonatal myasthenia. An interdisciplinary approach is required for managing the pregnant women with MG.

Background: We studied the effect of the prepregnancy body mass index (BMI) and weight gain during pregnancy on the rate of puerperal complications after spontaneous vaginal delivery., Methods: This is a prospective cohort study of 11,114 women delivered spontaneously between 36 and 43 week's gestation at a university hospital, between January 1996 and December 2000. Postpartum complications were analyzed according to prepregnancy BMI category (low < 19.8; normal 19.8-26; high 26.1-29; obese > 29) and weight gain during pregnancy. Weight gain was defined as low, normal or high according to the National Academy of Science recommendations for BMI., Results: Overall, 7.3% women had complications. Anemia and readmission were significantly more common in lean women than in women with normal BMI (3.5% versus 2.6%; P = .021 and 1.0% versus 0.3%; P < .001, respectively). Obese women had significantly more infectious complications (especially urinary tract infection) than women with normal BMI (6.3% versus 3.8%; P = .005)., Conclusions: These results suggest that obese women should be screened for puerperal urinary tract infection. Weight gain during pregnancy has no influence on puerperal complications.

In 1998, 20.2% of the approximately 4 million births in the United States occurred via cesarean delivery. Routine antibiotic prophylaxis has significantly reduced morbidity, yet each year between 41,000 and 206,000 women develop a subsequent infection of the uterus or surgical incision. A thorough understanding of the pathophysiology and complex interaction of risk factors for metritis and wound infection is vital for perinatal nurses. Nurses have a critical role in the identification and treatment of postcesarean infection.

This study examines the prevalence of self-reported reproductive tract infections (RTIs) and treatment seeking among married, recently pregnant women in Uttar Pradesh state, India. Associations between RTI symptom reporting and background characteristics are examined in a population-based sample of 18,506 married women with a pregnancy in the 3 years prior to a 1995 statewide survey. Logistic regression analyses are used to assess the effects of sociodemographic covariates on the probability of reporting an RTI symptom. Nearly one out of four women reports experiencing at least one RTI symptom, with the most common symptoms being abnormal vaginal discharge and pain during urination. Reporting of RTI symptoms significantly increases if the woman's last pregnancy did not end in a live birth or if she has low economic status. Symptom reports also increase with age and decrease with parity. Only one-third of women reporting an RTI symptom sought treatment. The results indicate that survey interviews can be a cost-effective option for measuring the magnitude of RTI symptoms experienced and identifying sociodemographic influences. The findings suggest the need for improved RTI screening procedures and treatment at health facilities in this populous state of northern India.

Background: So far, there has been no systematic detection of asymptomatic bacteremia in pregnant women. Consequently, its possible effects on newborn infants have not been discussed. The aim of this study was to determine the incidence of asymptomatic bacteremia in pregnant and parturient women and neonates as well as to assess its influence on the health condition of newborn infants during the first three months of life., Methods: A total of 626 blood cultures were taken from 353 pregnant women (with single-fetus pregnancy)and their newborns: 156 during pregnancy, and immediately after delivery from 235 mothers and their 235 newborns. Blood culture results were clinically and statistically analyzed along with data on the development of the newborns., Results: Positive blood culture was found in 12% of pregnant women, in 19% of parturient women and 25% of the newborns. The most often isolated bacteria were: Staphylococcus epidermidis in 36 cases (18%), Escherichia coli in 35 cases (17.5%) and Enterococcus in 20 cases (10%). Asymptomatic bacteremia was found to be in a statistically significant correlation with signs and symptoms of life-threatening conditions (p<0.01), early-onset and late-onset infections and other disorders occurring in newborn infants (p<0.05), mostly of the female sex., Conclusion: It seems that asymptomatic bacteremia cannot be considered harmless but appears to influence the health of newborns.

We screened automated ambulatory medical records, hospital and emergency room claims, and pharmacy records of 2,826 health maintenance organization (HMO) members who gave birth over a 30-month period. Full-text ambulatory records were reviewed for the 30-day postpartum period to confirm infection status for a weighted sample of cases. The overall postpartum infection rate was 6.0%, with rates of 7.4% following cesarean section and 5.5% following vaginal delivery. Rehospitalization; cesarean delivery; antistaphylococcal antibiotics; diagnosis codes for mastitis, endometritis, and wound infection; and ambulatory blood or wound cultures were important predictors of infection. Use of automated information routinely collected by HMOs and insurers allows efficient identification of postpartum infections not detected by conventional surveillance.

A 7-month outbreak of 15 cases of postpartum sepsis with group A haemolytic Streptococci (GAS) was stopped when a carrier was identified. Comparing delivery dates with duty rotas revealed that the carrier had been present during delivery in 13 of the 15 cases. The epidemic GAS type, T3-13-B3264, was found in a carbuncle in her groin and in atopic dermatitis lesions behind her ears and on her eyelids. Thus, it was not the microbiological screening of staff that helped detect the carrier. The outbreak went unnoticed for 6 months, as no 2 cases were diagnosed by the same physician and 5 cases were diagnosed by different general practitioners. The main risk factors for infection were presence of the carrier relative risk (relative risk RR 47.8, 95% confidence interval (CI) 10.9-209.5) and suturing of episiotomy (RR 11.0; 95% CI 2.6-47.9). We recommend that a thorough epidemiological investigation should be carried out in every single case of GAS postpartum infection. Despite initial intravenous treatment with penicillin, 8 patients experienced > 15 recurring postpartum GAS infections, such as endometritis, wound infection, tonsillitis, erysipelas and Brodie's abscess. Eradication of GAS should be confirmed after completion of treatment.

Objective: To compare the maternal outcome, in terms of postpartum infection, of deliveries conducted by trained traditional birth attendants (TBAs) with those conducted by untrained birth attendants., Methods: The study took place in a rural area of Bangladesh where a local NGO (BRAC) had previously undertaken TBA training. Demographic surveillance in the study site allowed the systematic identification of pregnant women. Pregnant women were recruited continuously over a period of 18 months. Data on the delivery circumstances were collected shortly after delivery while data on postpartum morbidity were collected prospectively at 2 and 6 weeks. All women with complete records who had delivered at home with a non-formal birth attendant (800) were included in the analysis. The intervention investigated was TBA training in hygienic delivery comprising the 'three cleans' (hand-washing with soap, clean cord care, clean surface). The key outcome measure was maternal postpartum genital tract infection diagnosed by a symptom complex of any two out of three symptoms: foul discharge, fever, lower abdominal pain., Results: Trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45.0 vs. 19.3%, p < 0.0001). However, no significant difference in levels of postpartum infection was found when deliveries by trained TBAs and untrained TBAs were compared. The practice of hygienic delivery itself also had no significant effect on postpartum infection. Logistic regression models confirmed that TBA training and hygienic delivery had no independent effect on postpartum outcome. Other factors, such as pre-existing infection, long labour and insertion of hands into the vagina were found to be highly significant., Conclusions: Trained TBAs are more likely to practice hygienic delivery than those that are untrained. However, hygienic delivery practices do not prevent postpartum infection in this community. Training TBAs to wash their hands is not an effective strategy to prevent maternal postpartum infection. More rigorous evaluation is needed, not only of TBA training programmes as a whole, but also of the effectiveness of the individual components of the training.

This study examines the validity of a survey instrument on near-miss obstetric complications. Three groups of women--with severe complications, with mild complications, and with a normal delivery--were identified retrospectively in three hospitals in South Benin and interviewed at home. The concept of "near-miss" was used to identify women with severe episodes of morbidity. The questionnaire was able to detect, with some accuracy, eclamptic fits, abnormal bleeding in the third trimester for a recall period of at least three to four years, and all episodes of bleeding independent of timing within a period of two years. Questions concerning dystocia and infections of the genital tract generated disappointing results except when information on treatment was included. Overall, better results were achieved for antepartum and acute events. Severity made a positive difference only in the case of eclampsia, with an increase in sensitivity. The implications of the results for using women's recall of obstetric complications in surveys are discussed.

The analysis of reports of the obstetric and pediatric hospitals of Moscow for 1991-1998 revealed that, simultaneously with the deterioration of the quality of life of the population, not only a decrease in the birth rate, but also a rise in different forms of pathology in pregnant women and puerperae could be observed. The deterioration of the health characteristics of mothers was accompanied by the growth of high risk groups among newborns as well. Thus, the number of children, born sick or falling sick while staying in the obstetric clinics of Moscow, rose from 208 to 299 o/oo. Simultaneously with the growth of somatic pathology, a significant rise in infectious morbidity rate among newborns from 15 to 43 o/oo and a rise in death rate among newborns due to infectious pathology were noted. A complex of prophylactic measures is proposed. Their introduction will make it possible to decrease the probability of the appearance of severe forms of pathology in pregnant women and newborns, to ensure the effectiveness of epidemiological surveillance of hospital infections and to prevent their further growth among puerperae and newborns.

Objective: Description of a cluster of 6 patients who developed a puerperal infection with group A haemolytic streptococci (Streptococcus pyogenes, GAS) out of 10 patients who delivered during a 2-day period in the hospital in Gouda, the Netherlands, and of the epidemiological and microbiological search for the source., Design: Descriptive., Method: After the report on the fourth patient the suspicion of a hospital infection arose. Hospital staff, family members and environment were screened for GAS. All isolated GAS were serotyped and genotyped. Epidemiological data, like time of admission, delivery and discharge, used delivery room and maternity unit ward, were recorded. All regional midwives and general practitioners were informed and asked to be alert for puerperal endometritis in patients after hospital deliveries., Results: All 6 patients and 2 health care workers proved to have an identical type of GAS. The environmental cultures were negative. By analysing the epidemiological data the most probable cause of this cluster was found to be one health care worker. After stressing the importance of good hand disinfection no additional cases were seen.

Mycotic cerebral aneurysm is a relatively rare but very serious complication of infective endocarditis. Infective endocarditis is a rare but a potentially fatal complication of pregnancy. We report here two very rare cases of infective endocarditis associated with mycotic cerebral aneurysm in peripartum women. In one case, cardiac surgery was performed prior to cerebral surgery and after delivery. In the other case, emergency cerebral surgery was performed due to rupture on the day cardiac surgery had been scheduled, 45 days after delivery. The surgical management of a patient with infective endocarditis and mycotic cerebral aneurysm is reviewed. The surgical strategy for a pregnant patient is also reviewed.

Objective: To examine the effect of labor induction length on maternal and neonatal outcome., Methods: Inductions of labor were reviewed retrospectively, comparing 27 patients with infectious complications to 313 with no infections. Univariate analysis, t-test, chi2, and Fisher exact test were used for statistical analysis. Forward stepping logistic regression was used in a multivariate model to identify odds ratio (OR) and 95% confidence intervals (CI)., Results: There was a statistically significant increased risk of maternal infection with increasing induction time. In univariate analysis, cesarean delivery, duration of induction, duration of oxytocin administration, nulliparity, use of internal monitors, increased maternal weight gain, and low cervical dilatation at start of induction were all associated with increased maternal infection risk. Multivariate analysis showed duration of induction for each additional 2 hours (OR 1.09; 95% CI 1.01, 1.18) and nonwhite ethnicity (OR 5.95; 95% CI 1.72, 20.49) to be associated significantly with maternal infection. Maternal infection was associated with lower Apgar scores and increased neonatal intensive care unit admissions. In patients who delivered vaginally, a logistic regression model estimated infectious morbidity at 40 hours to be 10%. The cesarean rate was not increased with prolonged induction., Conclusion: Prolonged induction is associated with a small increased risk of infectious morbidity, with an estimated 10% incidence noted after 40 hours of induction in women who deliver vaginally.

Patients with puerperal sepsis following delivery at Ife State Hospital (ISH) of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) Ile-Ife over a 10-year period spanning January 1986 to December 1995 were reviewed. One hundred and forty-six patients were diagnosed as having puerperal sepsis and there were 8428 deliveries giving an incidence of 1.7%. The incidence was higher among the unbooked patients 71.2%. Predisposing factors were: anaemia in pregnancy, 69.2%; prolonged labour (labour lasting up to 12 h or more), 65.7%; frequent vaginal examinations in labour (more than five), 50.7%; premature rupture of membranes, 31.5%; and non-adherence to asepsis during delivery. The case mortality rate was 4.1%. Antenatal care and supervised hospital delivery should be encouraged in order to prevent or reduce this serious post-partum morbidity.

Puerperal fever caused by group A streptococci (GAS) is a most serious infection deriving from the birth canal after childbirth or caesarian section and is manifest by fever and/or local signs of infections. Secundary infections in the umbilicus or skin can occur in the newborn child. As approximately 5% of the Danish population are carriers of GAS in nose, throat, rectum and/or vagina the risk of infection is present especially in childbirth. GAS epidemics in the community result in increased risk of hospital-acquired GAS infections. In the literature it is recommended to take action and implement preventive strategies when two simultaneous cases occur in one department. We describe the course of seven GAS infections in six patients (two children) in the same obstetric ward over a seven-week period, the elucidation by case-control analysis and the implementation of preventive measures. The importance of good hygienic practices is highlighted.

From September 1993 to March 1995 a prospective, descriptive study was performed at Obstetrical Department of the General Hospital 2A the Mexican Institute of Social Security. An attempt to know the real puerperal infection incidence in our own hospital to be able to make hypothesis and take specific measures in puerperal infection control. Dairy account of interesting data of cases under inclusion criteria. Entering data in personal computer. Graphics and analysis were accomplished using Lotus 123, Statgraphics, EPI-6 of CDC and Freelance computational programs. Search of central tendency measures were performed, (media, median, mode, standard deviation). Odds ratio and relative risk were calculated, including hospitalization time and its temporary variation to data cross. X square and pi were including hospitalization time and its temporary variation to data cross. X square and pi were determined to statistic validates. The cumulated rate of general puerperal infection were 1.2%. By stratification, the cumulated rate of infection after cesarean section, vaginal delivery and miscarriage were 5.4%, 0.8% and 0.3%, respectively. There was predominance of infection after cesarean section, over infection after vaginal delivery and after miscarriage. (monthly media of 24.6, 7.3 and 0.47, respectively). The puerperal infection was present principally in primiparous and in patients with one previous cesarean section. The patients in which the termination of pregnancy was by cesarean section, (0.015 infection cumulated incidence), had an infection risk 5.76 and 18.66 times greater than the patients with vaginal delivery and miscarriage. (Relative risk of 6.76 and 19.66) The site of puerperal infection was implicated in combinations or isolated, under nine clinical situation. The five most frequent clinical situation, between these nine, in incidence order from major to minor were the following: Endometritis alone, Endometritis combined with wound abscess. Endometritis with urinary infection, complicated endometritis, (sub vesical abscess, parametritis, peritonitis, salpingitis), and wound abscess alone). The greater hospitalization time was present in cases of complicated endometritis followed by wound abscess alone or combined. Complicated endometritis, (incidence 0.0010), compel us to hysterectomy in 15 cases. No death was registered among the patients with puerperal infection studied.

The author undertakes a study to investigate the protracted delivery with different duration of prematurely ruptured membranes, to investigate and to compare the morbidity and structure of patients. To investigate the lochia secretions and to compare the microflora of the patients with ruptured membranes at different times with a view to their influence by antibiotic prophylaxis. At the end author makes appropriate conclusions.

In a German multicenter survey, 2206 gynaecological patients in 72 randomly selected hospitals were examined for the prevalence of nosocomial infections and possible risk factors. Hospital-acquired infections were diagnosed in 1.45% of the patients. The most common localisation was the urinary tract (0.91%). Septicaemia, vaginitis and infections of the upper and lower airways were only rarely seen. The following endogenous risk factors were identified: diseases of the cardiovascular system (16.1%), malignancies (12.2%) preexisting infections (6.1%), obesity (5.9%), and diabetes (5.0%). The most common exogenous risk factors were peripheral venous catheters (19.9%), catheterisation of the urinary tract (7.2%) and wound drainage (28.6%). 49% of the patients who underwent caesarean section and 50% of the hysterectomy patients received antimicrobial chemoprophylaxis.

The epidemics of puerperal fever in the 18th and 19th centuries began soon after the creation of Lying-in hospitals in the mid-18th century. The primary purpose of these hospitals was to provide physicians with training in obstetrics in general and in forceps deliveries in particular. The first reports describing epidemics of puerperal fever, its contagiousness and control were made by British physicians in the latter half of the 18th century. Alexander Gordon provided epidemiological evidence of contagion in 1792, and Oliver Wendell Holmes in the USA reviewed these reports in his paper on outbreaks of puerperal fever around Boston in 1843. Ignaz Semmelweis in Vienna, unaware of previous work on this disease, re-discovered the actions required to control the contagion in 1847, but published his paper much later in 1861. A few enlightened doctors struggled to prove that puerperal fever was contagious and could be spread by doctors and midwives. Their peers and colleagues predominantly displayed apathy and ignorance until forced to act by the weight of evidence. However, it was the multitude of parturient women who paid the ultimate price for these iatrogenic epidemics.

Objective: To assess frequency, risk factors, and microbiology of bacteremia within 15 minutes of placental separation during cesarean delivery., Methods: Ninety-three women undergoing cesarean delivery after a minimum of 4 hours of labor or ruptured membranes were compared with 26 women not in labor undergoing cesarean. Blood cultures for aerobic and anaerobic bacteria were obtained within 15 minutes of delivery of the placenta and before prophylactic antibiotic administration. Chorioamnionic membranes were also cultured. Demographic, labor, delivery, and postpartum characteristics were abstracted from the medical record., Results: Bacteremia was detected in 13 (11%) of 119 women. Bacteremia occurred in 13 (14%) of 93 women after labor or rupture of membranes compared with zero of 26 women not in labor (P = .02). Isolates included group B streptococcus (n = 5), Gardnerella vaginalis (n = 5), Streptococcus pneumoniae (n = 1), Peptostreptococcus sp (n = 1), and mixed flora of Prevotella bivia, G vaginalis, and viridans streptococci (n = 1). Bacteremia was associated with earlier median gestational age, lower median birth weight, and a positive chorioamnionic membrane culture. After adjustment for gestational age, intrauterine monitoring was also significantly associated with bacteremia., Conclusion: Bacteremia was common after labor in this population, especially in preterm deliveries and those with positive chorioamnionic-placental culture. Many of the isolates are capable of causing endocarditis. Appraisal of the risk of bacteremia and the risk of bacterial endocarditis should be made in individual patients to assess the need for antibiotic prophylaxis.

Background: Necrotizing fasciitis is an uncommon, rapidly progressive, life-threatening infection involving the subcutaneous tissue and fascia. Usually, it is a synergistic polymicrobic infection that occurs in patients with coexisting factors predisposing them to bacterial inoculation and the spread of infection., Cases: We report a monomicrobial variant of necrotizing fasciitis affecting three otherwise healthy pregnant or postpartum women. The necrotizing fasciitis involved either the lower extremity or the abdominal wall. The causative bacteria were Streptococcus pyogenes (two cases) and Staphylococcus aureus (one). All patients presented with an acute fulminant infection, including one woman who died from overwhelming sepsis., Conclusion: These cases raise a question about the possible role of increased bacterial virulence and the immunologic changes of pregnancy as potential predisposing factors in the development of necrotizing fasciitis.

The analysis of reports of from maternity clinics and children's hospitals in the Russian Federation for the period of 1986-1994 showed that simultaneously with deterioration of the quality of life of the population not only a drop in the birth rate was registered, but also a significant increase in the appearance of different forms of pathology in pregnant and parturient women occurred. The deterioration of the characteristics of maternal health was accompanied by an increase in the number of high risk groups also among newborns. Thus, in the maternity clinics of the Russian Federation the number of children born sick or becoming sick shortly after birth rose 2.5-fold. Simultaneously with an increase in somatic pathology there was a significant rise in the number of cases of generalized infection among parturient women form 0.3 to 1.2%/1000, and cases of infections diseases among newborns from 10.4 to 21.5%/1000, as well as in infant mortality due to infections pathology. A complex of prophylactic measures is proposed; the realization of theses measures will make it possible to decrease the probability of the development of new severe forms of pathology in pregnant women and newborns, as well as to ensure effective epidemiological surveillance on hospital infections and to prevent their further rise among parturient women and newborns.

Spontaneous and induced abortions have been suggested to increase the risk of intrapartum infection in the following pregnancy. We conducted a case-control study using data from the Washington State Birth Registry for the years 1989-1991. The study population comprised women delivering a singleton livebirth. A case was defined by the presence of intrapartum fever (N = 2,550). Controls (1:3) were selected from the remaining births (N = 7,326). We calculated Mantel-Haenszel summary odds ratios by stratified analysis. We evaluated the validity of intrapartum fever recorded on the birth certificate using data from an ongoing case-control study on clinical amnionitis in Washington State. We found intrapartum fever to be highly specific (0.98) and moderately sensitive (0.57) for a diagnosis of clinical amnionitis. We saw no increased risk of intrapartum fever after a fetal loss or termination when using women with no prior pregnancy as the reference group. On the other hand, we found a threefold elevated risk for both induced and spontaneous abortion when using women with a prior livebirth as the reference group. Our findings indicate that an abortion in a woman's first pregnancy does not have the same protective effect of lowering the risk for intrapartum infection in the following pregnancy as does a livebirth.

The University of Erlangen has been engaged in clinical obstetrics for approximately 170 years. During this time, Erlangen University's delivery house, opened in 1828 and at first having considerably less than 50 births a year, developed into a perinatal centre with approximately 1,700 births a year. For the period from 1880 to 1981, a group of MD students reviewed the existing records and evaluated 60,000 births with respect to more than 40 parameters. Part of the results obtained are shown with special reference to operative obstetrics. Apart from the general influence of the scientific development on decisions and results within obstetrics, individual factors were also recognizable, factors which are linked with the experiences, insights and specialized working areas of the particular head of the hospital.

Objective: This study was done to determine the impact of the method of placental removal and the site of uterine repair on postcesarean infectious morbidity rates in women receiving prophylactic antibiotics at cesarean delivery., Study Design: This prospective study included 284 women who underwent cesarean delivery and who were randomly assigned to four groups based on the method of placental removal and the site of uterine repair: group 1, spontaneous placental removal and in situ uterine repair; group 2, spontaneous placental removal and exteriorized uterine repair; group 3, manual placental removal and in situ uterine repair; and group 4, manual placental removal with exteriorized uterine repair. Exclusion criteria were repeat cesarean deliveries without labor, active infection at the time of cesarean delivery, and patient refusal to participate., Results: There was no significant difference among the groups in maternal age, race, parity, weight, the length of time from rupture of membranes (ROM) or the number of vaginal examinations from ROM to cesarean delivery, or preoperative hematocrit. Intraoperatively, the type of uterine incision, anesthesia administered, incidence of meconium-stained amniotic fluid, Apgar scores, and cord gases were similar between groups. The incidence of postcesarean endometritis was greater in group 4 (32 [45 percent] of 71, p = 0.003) compared with group 1 (17 [24 percent] of 71), group 2 (12 [30 percent] of 71); and group 3 (13 [18 percent] of 71)., Conclusions: Manual placental removal and exteriorization of the uterus for repair of the surgical incision increases the infectious morbidity rate in women receiving prophylactic antibiotics at the time of cesarean delivery and increases the length of hospitalization.