Search

An investigation to determine the throat and vaginal colonization rates of group B streptococci among second- and third-trimester pregnant women was performed. Group B streptococci were recovered from 25.4 per cent of third-trimester and 14.8 per cent of second-trimester parturient (p = less than 0.025). Serotype distribution of isolates was similar among these two study groups. No significant differences in colonization rates were noted on the basis of age, race, parity, or complications of pregnancy.However, postpartum fever occurred in 22 per cent of colonized and only 4 per cent of noncolonized second-trimester parturients. The reason for this significant increase in group B streptococcal colonization rates with advancing gestation remains speculative.

A prospective incidence study into wound infection after caesarean section was carried out. Thirty-one centres in England and Wales participated and 2370 patients were entered into the study. One-hundred-and-forty-one patients (6.0 per cent) acquired wound infections, according to the definitions used (i.e. with both clinical and microbiological evidence of infection). If all inflamed wounds has been cultured, the infection rate would have been considerably higher, (calculated at 14.0 per cent). Patients with infected wounds spent an extra 2.4 days in hospital. Factors associated with wound infection included size of hospital, obesity, time in labour, number of vaginal examinations and various operative procedures.

Women who attended the gynaecology clinic or were admitted to the postpartum ward of Korle Bu Hospital, Accra, Ghana were tested for infection with Chlamydia trachomatis and Neisseria gonorrhoeae. Eight (4.9%) of 162 gynaecological patients were infected with C trachomatis and five (3.1%) with N gonorrhoeae, and respective prevalences among 148 postpartum women were 7.7% (3/39) and 3.4% (5/148). Among 40 gynaecological patients who were not pregnant and whose principal complaint was of lower abdominal pain, 4 (10%) were infected with C trachomatis and none with N gonorrhoeae. Antibodies against serovars D, E, F, and G were common, and three typable isolates were serovar G. C trachomatis would appear to be more common than N gonorrhoeae in obstetric and gynaecological patients in Ghana.

The incidence of puerperal endometritis in 5058 patients who were delivered during a one year study period was recorded prospectively. Caesarean section was performed in 774 cases (15.3%) and intrauterine fetal heart rate monitoring was used in 2016 cases (39.9%). After vaginal delivery, the incidence of endometritis was 1.5% in those monitored externally and 2.4% in those monitored internally (P less than 0.05). After Caesarean section, endometritis occurred in 8.0% of those monitored externally and in 16.4% of those monitored internally for varying times (P less than 0.01). The duration of monitoring had no significant effect on these infection rates. The risk of puerperal endometritis after internal fetal monitoring seemed to be the same as after one vaginal examination.

Cultures of Streptococcus equisimilis (Lancefield group C) from three outbreaks of illness were found to carry the T-protein antigen 204. Strains of this type were not otherwise represented in a collection of 743 cultures of these 'pyogenes-like' streptococci isolated from other outbreaks of infection or as random isolates. Two of the three outbreaks were of pharyngitis. The third arose in a maternity unit where the organism was isolated from mothers with puerperal fever, from staff and also from the environment. Representative strains were found to carry M-protein antigens as judged by their ability to survive and multiply in fresh normal human blood. Comparison of absorbed rabbit antiserum to the M antigens in opsonic and precipitin tests showed that a distinct M antigen was present on isolates from one outbreak of sore throat and that all cultures from the other two incidents shared a common M antigen. Samples of serum were also available from patients in the outbreak of puerperal sepsis. Most patients developed antibodies to one or more streptococcal antigens including the M protein, streptolysin O, streptokinase and the hyaluronidase specific for strains of group C and group G streptococci.

The authors documented thirty cases of bacteremia, all in gynecologic and obstetric patients, over a four-year period at a university hospital. Sixteen of the patients had polymicrobial infections. Most of the patients recovered completely whether or not antimicrobial therapy directed against Gardnerella vaginalis was given. G vaginalis bacteremia may occur more often than has been reported.

An outbreak of puerperal fever caused by group G streptococci is described. Transmission of the organism may have occurred via contamination of automated douches. When these were disinfected and kept free of the organism the outbreak ended abruptly.

On the first postpartum day, 53 patients (17.2 per cent) had asymptomatic bacteriuria. Spontaneous resolution of bacteriuria occurred in 40 (75.5 per cent) of the 53 patients by the third postpartum day--the most appropriate time to identify patients with true asymptomatic bacteriuria.

Our data show that it possible to reduce the maternal morbidity - mainly by reduction of the severe complications following caesarean sections. The higher maternal risk during and after operative delivery (forceps, caesarean section) should prompt the physician to analyse the indication and frequency of operative interventions within certain periods of time.

We investigated the relationship of route of delivery and of antepartum Chlamydia trachomatis cervical infection to selected forms of puerperal infectious morbidity, including intrapartum fever, or early (less than 48 hours) postpartum fever not attributable to infections of sites outside the uterus and late (48 hours to 6 weeks) postpartum endometritis. Infectious morbidity occurred in 27 (44%) of 62 women who underwent cesarean section and in 33 (10%) of 329 who underwent vaginal delivery (p less than 0.001). Postsection infectious morbidity was not correlated with C. trachomatis infection and was largely limited to early postpartum fever. Among women who underwent vaginal delivery, infectious morbidity occurred in 10 (34%) of 29 women with and in 23 (8%) of 300 without C. trachomatis infection (p less than 0.001), and chlamydial infection was associated only with intrapartum fever and late postpartum endometritis. Separate matched case-control analyses confirmed that cesarean section was associated with an increased risk of early postpartum fever (p = 4 x 10(-8)); whereas among women who underwent vaginal delivery, antepartum C trachomatis infection was associated with an increased risk of development of intrapartum fever or late postpartum endometritis (p = 0.002).

The rate of significant bacteriuria in the puerperium was studied prospectively in 3554 women who were delivered at the State Maternity Hospital. The influence of catheterisation during labour and before Caesarean section, urinary tract infection during pregnancy, puerperal endometritis and impaired glucose metabolism on the rate of significant postpartum bacteriuria was studied. Catheterisation significantly increased the rate of significant bacteriuria in patients who were delivered vaginally. A single catheterisation before Caesarean section did not increase the incidence of significant bacteriuria in comparison with the incidence of patients not catheterised before surgery. Patients with urinary tract infection diagnosed during pregnancy are at risk of developing significant postpartum bacteriuria. Patients with postpartum endometritis had twice the rate of significant bacteriuria than patients not developing postpartum endometritis, but the difference was not statistically significant. The presence of impaired glucose metabolism did not affect the rate of significant postpartum bacteriuria.

The frequency of puerperal febrile complications is considerably higher following cesarean section than after vaginal delivery. In a retrospective investigation of 234 planned operations and 506 emergency operations, a significantly different frequency of febrile morbidity (FM) was found following the two types of operation (7.7% vs. 20.9%). The development of FM following emergency operation was investigated in relation to factors such as age, parity, repeat cesarean section, surgeon's experience, peroperative bleeding, rupture of membranes, frequency of vaginal exploration, gestational weeks, pre- and postoperative anemia. We found some predisposing factors to FM and of these five, each was significant, but a multiple regression analysis showed that only rupture of the membranes, and pre- and postoperative anemia have an independent significant explanatory value (p less than 0.01).

A 6 month survey of hospital-acquired uterine infection was done on the obstetric service of the Los Angeles County-University of Southern California (LAS-USC) Medical Center to determine the impact of the duration of monitoring upon the incidence of maternal infection. There were significantly more infections among the population monitored and in women undergoing cesarean section. In diminishing order, the incidence of infection was: cesarean section monitored, 90 of 223 (40.4 per cent); cesarean section not monitored, 56 of 271 (20.4 per cent); elective repeat cesarean section, 1 of 21 (5 per cent); vaginal delivery monitored, 33 of 1,236 (2.7 per cent); and vaginal delivery not monitored, 49 of 3,445 (1.4 per cent). In comparing those patients with infection and those free of infection following equivalent routes of delivery, there was no statistical difference in the duration of monitoring. These results suggest that the interval of monitoring alone is not a significant clinical factor in the development of maternal soft-tissue pelvic infection in a high-risk obstetric population.

The authors studied the frequency of the purulent-septic diseases in puerperants and neonates and the percentage among them of affections of staphylococcus etiology, their seasonal incidence and nidality. The phage-type reference of the strains of staphylococci circulating at the maternity home, and their connection with the staphylococcus carrier state among the personnel and the extent of spread of the purulent-septic diseases was determined. There was revealed an interrelationship between the incidence of recording of the purulent-septic diseases at the maternity home and the level of staphylococcus carrier state among the medical personnel. The sum total positive culture percentage in serous mastitis, endometritis and in case of suture disjunction due to purulent complications was 63.5, and in case of purulent-septic diseases of neonates -- 55--65. Strains belonging to the "epidemic" phage types are widespread at the maternity homes.

We conducted two studies to determine how herd management practices and traits of individual cows affect performance of the herd and of the cow within a herd. Management practices, reproductive performance of the herd, and relationships between management and reproductive performance were characterized on 83 dairy farms with 7596 cows. Data included 21 management variables (e.g., facilities, herd health program, estrous detection program) and 8 performance variables obtained from Dairy Herd Improvement or unofficial records (e.g., size of herd, production, days open). Although varying among herds, annual average herd incidences of reproductive disorders and reproductive performance were similar to those reported. Managerial practices influenced incidences of retained placenta and uterine infection, days open of cows not bred and of all cows, services per conception, and percentages of herd open more than 100 days and culled for low production. Veterinarian was the most consistent variable influencing herd reproductive performance. Data also were collected from production and lifetime records of 2532 cows in 19 herds. Reproductive performance was affected by season of calving, production, maturity, and reproductive disorders. Several cows with extremely poor reproductive records were maintained.

The first case of Plasmodium falciparum malaria acquired in Italy after the eradication of the disease is reported. The P. falciparum strain was sensitive to chloroquine in vitro and in vivo. It seems most likely that an infective mosquito of tropical origin was responsible for transmission.

Twenty-one patients were seen with puerperal sepsis owing to group B streptococci (GBS), resulting in an attack rate of 2/1,000 deliveries. Most were young primiparous black women from a population with a known high incidence of GBS carriage. The association among abdominal delivery, endometritis, and puerperal sepsis was striking. Cultures of the birth canal or lochia were commonly positive for the same serotype recovered from the blood. Forty-seven patients with nonbacteremic GBS infections were seen; 27 had endometritis or amnionitis. Twenty patients had GBS urinary tract infection: Eight infections occurred prenatally, seven at delivery, and five post partum. Seven neonates developed serious GBS infections; intrauterine exposure occurred in at least four cases. Fetal exposure to GBS also occurred in three of four cases in which parturients with GBS bacteremia were delivered of their infants by cesarean section. Because of the high incidence of puerperal and perinatal GBS infections in this population, antibiotic prophylaxis regimens may be beneficial.

A screening programme for the detection of asymptomatic bacteriuria in patients attending an antenatal clinic is described. The results obtained from the use of urinary antiseptics in a controlled trial over a period of two years are presented. The number of patients developing clinical pyelonephritis, fetal maturity at delivery and birth weight were recorded for treatment and control groups and compared with the equivalent results obtained from the total population of patients seen at the clinic.

Experience with Lactomer absorbable surgical staples (Auto Suture Poly CS 57 disposable surgical stapler) in 62 cesarean sections was compared with an equal number of operations performed with standard techniques. The technique of application of the stapler evolved with experience. Countertraction to staplers with Allis' clamps prevented uterine V incisions. Operative time was longer for the stapled suture group for primary cesarean sections, but was unchanged for repeat procedures. Excellent hemostasis of the uterine incision was achieved even when varicose sinusoidal veins were present. Significant reductions of hemoglobin deficits from 2.16 to 1.31 gm/dl, postoperative anemia from 29% to 6.4%, and endometritis from 22.5% to 6.4% occurred respectively in nonstapled and stapled groups. A reduced hospital stay, shortened by 2.1 days, saved each patient +F42950. Blood loss estimates by surgeons or anesthetists were often at variance. Surgeons' acceptance of the procedure grew with experience. On the basis of these results, use of absorbable staples offers certain advantages in reducing blood loss, infection, and hospital stay in cesarean deliveries.

In a one-year evaluation of the Obstetric-Gynecologic Services of the Los Angeles County University of Southern California Medical Center, bacteremia was confirmed on 144 occasions in 139 patients. This represented an over-all incidence of 7/1,000 admissions with gram-negative bacteremia observed in 3.1/1,000 admissions. There were four deaths in this series. The most frequently recovered aerobes were Escherichia coli, enterococci, and beta hemolytic streptococci, not Group A or D, while the most commonly isolated anaerobes were peptostreptococci, peptococci, and Bacteroides. These patterns of bacterial isolation should be acknowledged in antibiotic strategies for septic patients. There is a positive correlation between the incidence of intrapartum maternal and fetal monitoring and postpartum maternal bacteremia. The oncology patients were the most seriously ill women with bacteremia.

During a seven-year programme of surveillance and control of infection data were collected by a specialist hygiene nurse on 47 551 gynaecological, obstetric and post-partum patients. The infection rate was highest (40.5%) after major surgical procedures. Infection rate after cesarian section was 16%, eight times the rate after vaginal delivery (2%). The most frequent type of infection was of the urinary tract (70%), usually asymptomatic bacteriuria. Next most frequent were pelvic infections, abdominal wound infections, and phlebitis via an intravenous entry in long-term parenteral nutrition. During the period of observation bacteriuria rate decreased by 75%, the other nosocomial infections by 64%, febrile standard morbidity by 81%. The decrease is largely due to the infection surveillance programme with the employment of a specialist hygiene nurse.

The authors consider the hemorrhagic-infective complications associated with cesarean section. The review comprised 2200 subjects undergoing cesarean section from 1983 to 1987 in the Obstetrics and Gynecology Unit (Director: D. Dargent) of the University of Lyon (France). The incidence of cesarean sections was 14.9%, and endometritis was diagnosed in 17% of cases. The incidence of infective complications was 25% of cases and that of major hemorrhage 1%. The authors conclude that the potential complications must be carefully considered whenever contemplating delivery by cesarean section.

We have investigated the prevalence of endocervical Ureaplasma urealyticum and its association with abnormal pregnancy outcomes in two large unselected cohorts of pregnant women. The overall prevalences of infection in the two groups were 72.5 and 81.2%, respectively. In univariate analysis endocervical U. urealyticum was not associated with spontaneous abortion or preterm low birth weight. It was also not associated with low birth weight or postpartum endometritis/fever, either in univariate analysis or by conditional logistic regression. Endocervical colonization is not in itself a risk factor for ascending prepartum infection and abnormal outcome. For methodologic reasons prospective studies and treatment trials will not be helpful unless subgroups of infected women in whom the infection is a risk for adverse outcome can be clearly defined.

Caesarean sections complicated with peritonitis were analysed in a period of 10 years. In the whole group of 2238 caesarean sections done in the years 1977-1986 peritonitis developed in 8 cases (0.36%). In this group total or supracervical hysterectomy was done between the 4th and the 7th days of puerperium. Diagnostic difficulties in puerperal peritonitis and advantages of early surgical intervention for saving the life of the women in puerperium are stressed.

An outbreak of puerperal infection in a maternity unit caused by group A streptococci is described. During a 2 week period, seven mothers suffered from postpartum endometritis and one baby from conjunctivitis. The search for the route of spread involved sampling patients, personnel and the environment. Culture results suggested that infection was probably spread by a hand shower. On the basis of laboratory experiments a new routine for disinfection of these showers was instituted.

During the years 1959 to 1978 inclusive 2165 women with rheumatic or congenital heart disease had vaginal deliveries at three large Dublin maternity hospitals. There were two (0.09%) cases of puerperal infective endocarditis, neither of which was unequivocally related to preceding childbirth during this period. Routine peripartum antibiotic prophylaxis was not given to either. A questionnaire of the practice of 19 obstetricians in Ireland showed that 12 (63%) gave antibiotics routinely during labour and after delivery in cardiac patients, five (26%) did not, and two (11%) used them occasionally. Peripheral vein blood was drawn serially from 0 to 30 minutes after vaginal delivery to determine the incidence of asymptomatic puerperal bacteraemia. A total of 299 cultures was obtained from 83 normal women and single blood cultures were positive in three women (3.6% of patients, 1.0% of cultures). A review of the published reports showed that well-documented cases of infective endocarditis and of asymptomatic puerperal bacteraemia after normal vaginal delivery are uncommon. There is evidence that antibiotic prophylaxis may increase the risk of developing antibiotic-resistant endocarditis. Recommended prophylactic regimens carry a considerable risk of drug toxicity. These facts, coupled with a lack of direct evidence in support of the efficacy of antibiotic prophylaxis, suggest that routine peripartum antibiotic prophylaxis is not indicated.

The clinical and microbiologic risk factors for postpartum endometritis were studied prospectively in 77 patients undergoing cesarean section without antibiotic prophylaxis at Harbor-University of California at Los Angeles Medical Center. Intraoperative cultures were obtained from the amniotic fluid, lower uterine segment, and abdominal wound for isolation of genital mycoplasmas, aerobes, and anaerobes. Postsection endometritis developed in 21 (27%) patients and was significantly associated with presence of either high-virulence bacteria (predominantly, coliforms, streptococci, anaerobic cocci, and bacteroides) (35% to 60% versus 10% to 24%; p less than 0.05) or Ureaplasma urealyticum (15% to 42% versus 0% to 10%; p less than 0.05) at any site compared with afebrile women. Multivariate analysis identified primary cesarean section, younger maternal age, presence of ruptured membranes, and presence of Ureaplasma as significant risk factors independent of other confounding variables (p less than 0.01). It is suggested that genital mycoplasmas could play a primary role in some cases of postsection endometritis or that they are cofactors or markers for the presence of other high-virulence aerobic and anaerobic bacteria.