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The transmission of Chlamydia trachomatis from the infected cervix of a mother to the eye of an infant, with resultant inclusion conjunctivitis, was documented in humans and in primates 75 years ago by cytologic methods. With modern microbiologic methodology it is possible to quantitate this transmission. It is now known that 2%-24% (usually 7%-12%) of cervices are infected before delivery and that 18%-50% (usually 20%-25%) of infants born to culture-positive mothers develop conjunctivitis. In addition, nasopharyngeal infection occurs in 15%-20% of infants, and 3%-18% develop pneumonia due to C. trachomatis. Bronchiolitis and otitis media are less common infections. The consequence of rectal and vaginal colonization remains unknown, as does the significance of the increase in antibody titers against C. trachomatis throughout early childhood. Early studies suggesting that C. trachomatis was a prominent cause of postpartum endometritis and a cause of premature delivery have not been confirmed in larger prospective studies when mycoplasma species were simultaneously studied. A subset of mothers with active infection, as evidenced by IgM antibody against C. trachomatis, may have earlier delivery, but it is clear that evaluation of the contribution of C. trachomatis to maternal and fetal risk will require larger studies with evaluation of possible concurrent mycoplasmal infection.

A woman with Staphylococcus aureus meningitis following postpartum endometritis presented with lumbar backache and fever of several weeks' duration. Thick, green exudate was aspirated at lumbar puncture hours before death. Histologic examination demonstrated subacute inflammation of the meninges and chronic inflammation of the endometrium. Although rare, postpartum endometritis followed by low back pain and fever should alter the physician to the possibility of serious infection involving the central nervous system. Diagnosis and treatment at this early stage would be expected to decrease mortality.

Moxalactam, a new cephalosporin antibiotic with a broad spectrum of activity, was evaluated for safety and therapeutic efficacy in the treatment of genital tract infections in women. Fifty-three patients with postpartum endometritis or acute or chronic pelvic inflammatory disease were treated with 2 g of moxalactam iv every 8 hr, usually for five days or longer. Appropriate cultures of peripheral blood, endometrium, cul-de-sac aspirates, urine, wound, and endocervix (only for Neisseria gonorrhoeae) were performed. Overall, 90.6% (48 of 53) of the patients were successfully treated with moxalactam--86.2% (25 of 29) and 95.8% (23 of 24) of the patients with endometritis and pelvic inflammatory disease, respectively. Therapy failed in one of five bacteremic patients with endometritis. Of all the bacteria isolated from appropriate culture sites, 58% (224 of 383) were anaerobes, with anaerobic gram-negative rods--particularly Bacteroides bivius-and gram-positive cocci being predominant. Of 206 anaerobic strains tested with moxalactam by agar dilution techniques, 82% (169 of 206) were susceptible (minimal inhibitory concentration [MIC], less than or equal to 8 micrograms/ml), 11.6% (24 of 206) were moderately susceptible (MIC, 16-32 micrograms/ml), and 6.3% (13 of 206) were resistant (MIC, greater than or equal to 64 micrograms/ml). Among the aerobic isolates, enterococci were uniformly resistant. Thus, moxalactam performed well as a single agent in this open clinical trial for women with infections of the genital tract.

In a Nairobi hospital where ocular prophylaxis against ophthalmia neonatorum has been discontinued, 1,019 women were screened for Neisseria gonorrhoeae and Chlamydia trachomatis during labour and 7 and 28 days postpartum. The prevalence of gonococcal infection was 7% and that of chlamydial was 29%. 52.4% of gonococcal isolates produced penicillinase. The incidence of ophthalmia neonatorum was 23.2 per 100 live births, and incidences of gonococcal and chlamydial ophthalmia were 3.6 and 8.1 per 100 live births, respectively. Of 181 cases of neonatal conjunctivitis, 31% were caused by C trachomatis, 12% by N gonorrhoeae, and 3% by both. In 67 babies exposed to maternal gonococcal infection and 201 exposed to maternal chlamydial infection, rates of transmission to the eye were 42% and 31%, respectively, and to the throat were 7% and 2%. Gonococcal transmission rate was higher in mothers with concomitant chlamydial infection (68%; p = 0.01). Postpartum endometritis was associated with ophthalmia neonatorum (p less than 0.001). Ocular prophylaxis at birth for gonococcal ophthalmia should be reintroduced.

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.

The Copper T-220C intrauterine device was modified for use in early postpartum insertions. Biodegradable extensions consisting of No. 2 chromic suture were added to the horizontal arms of the device to enhance retention. This new device, Delta-T IUD, was inserted in 100 patients within 55 hours of the delivery of the placenta. No uterine perforations or cervical lacerations occurred in this study. There was one accidental pregnancy 4 months following the IUD insertion. Seven IUDs were removed for bleeding and pain. There was one case of postpartum endometritis. Seventeen IUD expulsions occurred. Expulsions were more frequent at the beginning of the study and when the IUD was inserted more than 30 minutes after delivery of the placenta. The immediate postpartum insertion of IUDs with the event rates observed in this study is acceptable in situations where alternatives for other family planning modalities or interval insertion of intrauterine devices are not feasible.The Copper T-220C IUD was modified for early use in postpartum insertion. Biodegradable extensions consisting of No. 2 chronic sutures were added to the horizontal arms of the device to enhance retention. This new device, Delta-T, was inserted in 100 patients within 55 hours of delivery of the placenta. No uterine perforations or cervical lacerations occurred during this study. There was 1 accidental pregnancy 4 months following IUD insertion. 7 IUDs were removed for bleeding and pain. There was 1 case of postpartum endometritis. 17 IUD expulsions occurred. Expulsions were more frequent at the beginning of the study and when the IUD was inserted more than 30 minutes after delivery of the placenta. The immediate postpartum IUD insertion with the event rates observed in this study is acceptable in situations where alternatives for other family planning modalities or interval insertion of IUDs are not feasible.

1. 1. Manual exploration of the postpartum uterus has been made an integral part of the delivery routine at this hospital, requiring no extra preparation or anesthesia. 2. 2. Of the 3,022 postpartum uteri explored, placental tissue was removed from 65 (2.15 per cent) which were presumably empty. 3. 3. Only 9 cases (0.3 per cent) of delayed postpartum hemorrhage due to retained secundines occurred in these patients, and 5 of these might possibly be attributed to the inexperience of the operators. 4. 4. Eight patients (0.26 per cent) of the 3,022 whose uteri were explored required treatment for postpartum endometritis. 5. 5. The number of late postpartum hemorrhages at this hospital has decreased since the adoption of this procedure.

JAMA: What are the most important facts that practitioners should know about diseases caused by Chlamydia trachomatis ? Holmes: I believe that there are five crucial facts concerning chlamydial infections that practitioners should know. Chlamydial infections are epidemic in this country, yet they are neither well recognized nor correctly treated in many instances. Nationally, we are observing alarming increases in the number of cases of ectopic pregnancy and salpingitis, a large proportion of which may result from chlamydial infection. Since each of these ectopic pregnancies represents one fetal death, this constitutes an epidemic of fetal deaths. Chlamydial infections during pregnancy should receive much greater attention. These infections may lead to postpartum endometritis in the mother and may be transmitted to the infant, causing pneumonia or eye infection. Our group has disturbing data showing that the fetuses of women who have chlamydial infections during pregnancy are at increased risk

We studied associations of Mycoplasma hominis, Ureaplasma urealyticum, and Chlamydia trachomatis genital infections with pregnancy outcomes, controlling by logistic and multiple linear regression for known risk factors and for the presence of the other two infections. A sample of 1204 Navajo women enrolling for prenatal care had endocervical C trachomatis, M hominis, and U urealyticum cultures and serum samples taken at enrollment and when possible after 30 weeks. Low birth weight (less than 2500 g) was associated with M hominis infection among women with a history of spontaneous abortion. Mycoplasma hominis infection was also associated with postpartum endometritis, but only among women undergoing a cesarean section (odds ratio, 4.7; 95% confidence intervals, 1.22 to 18.3). Although women with recent C trachomatis infection (IgM titer greater than 1:32 on either sample or IgG seroconversion) were at greater risk of low birth weight (19% [3/16]) than women with chronic infection (4.5% [6/133]; relative risk, 4.2), this subgroup at risk was small (11% of women with classifiable C trachomatis infection). Mycoplasma hominis and C trachomatis infections may be important preventable causes of adverse pregnancy outcomes in identifiable subgroups of women.