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Objective: To identify the clinical characteristics of pregnancy associated group A streptococcus (GAS) infection and predictors for intensive care unit (ICU) admission., Methods: A retrospective cohort study of culture-proven pregnancy-related GAS infections in tertiary hospital Electronic medical records were reviewed, for cases of cultures positive GAS that were identified between January 2008 and July 2021. A GAS infection was defined by the isolation of the pathogen from a sterile liquid or tissue site. Blood and urine cultures were obtained from all patients with peripartum hyperpyrexia (fever >38 °C). Medical Personnel screening included cultures of the throat, rectum, and skin lesions (if present). In cases of hemodynamic instability patients were transferred ad hoc to ICU, according to the obstetrician and intensivist judgment., Results: Of the 143,750 who delivered during the study period, 66 (0.04%) were diagnosed as having a pregnancy associated GAS infection. Of these, 57 patients presented postpartum, and represented the study cohort. The most common presenting signs and symptoms among puerperal GAS, were postpartum pyrexia (72%), abdominal pain (33%), and tachycardia (>100 bpm, 22%). 12 women (21.0%) developed streptococcal toxic shock syndrome (STSS. Predictors for STSS and ICU admission were: antibiotic administration >24 h from presentation postpartum, tachycardia, and a C-reactive protein level >200 mg/L. Women that received antibiotic prophylaxis during labor had a significantly lower rate of STSS (0 vs 10, 22.7%; p  = .04)., Conclusion: Deferral of medical intervention >24 h from the first registered abnormal sign had the most important impact on deterioration of women with invasive puerperal GAS. Antibiotic prophylaxis during labor in women with GAS may reduce associated complications.

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/m 2 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., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Postpartum sepsis is one of the leading causes of maternal mortality and morbidity in developing countries. This formative research elicits local terms used for postpartum illnesses and symptoms of postpartum sepsis with the aim of improving postpartum diagnosis and management in Pakistan., Methods: We conducted 34 in-depth interviews with recently delivered women (RDW), traditional birth attendants (TBAs), healthcare providers and family members of RDW from rural Sindh to explore local Sindhi terms used to describe postpartum sepsis and related symptoms. During interviews, all participants were asked to orally free list common symptoms of postpartum illnesses; those who were aware of the concept were asked to free list possible symptoms of postpartum sepsis. The responses were recorded by the interviewer. Free listing data were analyzed for frequency and salience., Results: Most participants, including TBAs, were not familiar with the concept of postpartum sepsis as a distinct disease or of a local term denoting the concept. Almost all could identify and report symptoms related to postpartum sepsis in the local language. Only physicians were able to recognize the term postpartum sepsis and related symptoms. Multiple local terms were used for a particular symptom; still others were used to denote gradations of severity. 'Bukhar' (fever) was the most commonly named symptom although it was often considered a normal part of puerperium. Many postpartum illnesses were related to the highly non-specific local term 'kamzori' (weakness)., Conclusions: Better awareness about local terminology used in rural areas related to postpartum sepsis could improve communication, care-seeking patterns, diagnosis and management., (© The Author(s) 2021. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Recently, ACOG released updated definitions for intraamniotic infection (IAI): maternal fever (≥38.0 °C) and ≥1 symptom (fetal tachycardia, maternal white blood cell count >15,000/mm 3 or purulent discharge). Treatment was no longer recommended for women with fever <39.0 °C plus maternal tachycardia or fundal tenderness (previous criteria). The objective of this study was to compare postpartum infectious morbidity among women meeting previous criteria (but not the new IAI criteria) to women meeting new IAI criteria., Methods: Retrospective cohort of women delivering vaginally at a single academic center. Demographics, antepartum and intrapartum characteristics of women who met diagnostic criteria for chorioamnionitis (previous criteria) compared to those who met IAI criteria using bivariate statistics. The primary outcome was a composite of postpartum infection, including: endometritis, perineal infection, sepsis, urinary tract infection, pyelonephritis. Backward-stepwise elimination used to estimate odds of primary outcome., Results: Of 229 women who met previous IAI criteria, 51 (22.3%) did not meet new IAI criteria. Women no longer meeting IAI criteria were younger (25 versus 27 years, p  = .02), more likely to have gestational hypertension (16.0 versus 3.4%, p  < .01), and less likely to have third or fourth degree lacerations (2.0 versus 13.4%, p  = .02). No difference in antibiotic receipt was observed. Postpartum infection occurred in 16/229 (7.0%) women overall; five (9.8%) in those not meeting new IAI criteria, and 11 (6.2%) meeting new IAI criteria. After adjusting for confounders, there was no difference in odds of postpartum infection (aOR 1.65, 95% CI 0.55-4.99)., Conclusions/implications: Among women who met old ACOG criteria for IAI, but not the new criteria, postpartum infection occurred in nearly 10%. This number could be higher if these women were not treated with antibiotics.

Objectives: Gestational IDA has been linked to adverse maternal and neonatal outcomes, but the impact of iron supplementation on outcome measures remains unclear. Our objective was to assess the effects of gestational IDA on pregnancy outcomes and compare outcomes in pregnancies treated with either oral or intravenous iron supplementation., Methods: We evaluated maternal and neonatal outcomes in 215 pregnancies complicated with gestational IDA (Hb<100 g/L) and delivered in our tertiary unit between January 2016 and October 2018. All pregnancies from the same period served as a reference group (n=11,545). 163 anemic mothers received oral iron supplementation, and 52 mothers received intravenous iron supplementation., Results: Gestational IDA was associated with an increased risk of preterm birth (10.2% vs. 6.1%, p=0.009) and fetal growth restriction (FGR) (1.9% vs. 0.3%, p=0.006). The gestational IDA group that received intravenous iron supplementation had a greater increase in Hb levels compared to those who received oral medication (18.0 g/L vs. 10.0 g/L, p<0.001), but no statistically significant differences in maternal and neonatal outcomes were detected., Conclusions: Compared to the reference group, prematurity, FGR, postpartum infections, and extended hospital stays were more common among mothers with gestational IDA, causing an additional burden on the families and the healthcare system., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

Postpartum uterine diseases, such as puerperal metritis and clinical endometritis may affect over 40 % of cows in dairy farms. Regardless of their severity, these diseases are one of the main reasons for impaired fertility, causing declines in dairy cow productivity and hence, resulting in economic losses. Although uterine diseases have been the topic of scientific discussion for many years, until now it was not possible to agree on uniform definitions for the different kinds of manifestation. By including technical innovations and testing procedures, enormous scientific progress and a deeper knowledge of the physiology as well as the pathologic mechanisms have been achieved. Bovine metritis and endometritis may be regarded as multifactorial diseases caused by a combination of microbial infection, the dysregulation of the immune system, and additional risk factors. These interactions have been analyzed on microbial and molecular biological levels as well as by the use of bioinformatics and molecular genetics. As a result, new species of bacteria and inflammatory mediators possibly contributing to the development of uterine diseases have recently been described. Additionally, metabolic and genetic risk factors and their roles in leading to fertility impairment have been evaluated. In conclusion, it was possible to identify new approaches for possible therapeutic and preventive methods, a subset of which may already be implemented into daily practical routine. This article provides an overview of recent scientific results concerning bovine metritis and endometritis with a focus on microbial, microbiological and immunological studies., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The Majority (99%) of maternal deaths occur in low and middle-income countries. The three most important causes of maternal deaths in these regions are postpartum hemorrhage, pre-eclampsia and puerperal sepsis. There are several diagnostic criteria used to identify sepsis and one of the commonly used criteria is systematic inflammatory response syndrome (SIRS). However, these criteria require laboratory investigations that may not be feasible in resource-constrained settings. Therefore, this study aimed to develop a model based on risk factors and clinical signs and symptoms that can identify sepsis early among postpartum women., Methods: A case-control study was nested in an ongoing cohort of 4000 postpartum women who delivered or were admitted to the study hospital. According to standard criteria of SIRS, 100 women with sepsis (cases) and 498 women without sepsis (controls) were recruited from January to July 2017. Information related to the socio-demographic status, antenatal care and use of tobacco were obtained via interview while pregnancy and delivery related information, comorbid and clinical sign and symptoms were retrieved from the ongoing cohort. Multivariable logistic regression was performed and discriminative performance of the model was assessed using area under the curve (AUC) of the receiver operating characteristic (ROC)., Results: Multivariable analysis revealed that 1-4 antenatal visits (95% CI 0.01-0.62). , 3 or more vaginal examinations (95% CI 1.21-3.65), home delivery (95% CI 1.72-50.02), preterm delivery, diabetes in pregnancy (95% CI 1.93-20.23), lower abdominal pain (95% CI 1.15-3.42)) vaginal discharge (95% CI 2.97-20.21), SpO2 < 93% (95% CI 4.80-37.10) and blood glucose were significantly associated with sepsis. AUC was 0.84 (95% C.I 0.80-0.89) which indicated that risk factors and clinical sign and symptoms-based model has adequate ability to discriminate women with and without sepsis., Conclusion: This study developed a non-invasive tool that can identify postpartum women with sepsis as accurately as SIRS criteria with good discriminative ability. Once validated, this tool has the potential to be scaled up for community use by frontline health care workers.

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., (Copyright © 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Sepsis remains a contemporary threat, and its frequency remains high amongst an aging population. Its definition has been regularly revisited, but the impact of the translational research studying it remains very modest compared to the results seen after the introduction of hygiene and the use of antibiotics. In the past, the main forms of sepsis were hospital gangrene (also known as nosocomial fever or putrid fever) that affected the wounded, and puerperal fever that affected women shortly after delivery. In 1858, Armand Trousseau stated that these two pathologies were identical. Lucrezia Borgia, who died in 1519, is undoubtedly the most famous woman to die from puerperal fever. The notion of sepsis as a real epidemic was deplored. For decades doctors remained deaf to the recommendations of their clairvoyant colleagues who advocated for the use of hygienic measures. It was as early as 1795 that Alexander Gordon (UK) and later in 1843, Oliver Holmes (USA), called for the use of hygienic practices. In 1847, Ignaz Semmelweis, a Hungarian physician, provided an irrefutable demonstration of the importance of hygiene in the prevention of contamination by the hands of the practitioners. But Ignaz Semmelweis' life was a tragedy, his fight against the medical nomenklatura was a tragedy, and his death was a tragedy! Nowadays, Ignaz Semmelweis is receiving the honor that he deserves, but never received during his life. Carl Mayrhofer, Victor Feltz, and Léon Coze were the first to associate the presence of bacteria with sepsis. These observations were confirmed by Louis Pasteur who, thanks to his prestige, had a great influence on how to undertake measures to prevent infections. He inspired Joseph Lister who reduced mortality associated with surgery, particularly amputation, by utilizing antiseptic methods.

This report presents the relapse and treatment of streptococcal infection in the postpartum period in a patient with severe group A streptococcal sepsis.

Purpose: The purpose of this study is to build and validate a statistical model to predict infection after caesarean delivery (CD)., Methods: Patient and surgical variables within 30 d of CD were collected on 2419 women. Postpartum infection included surgical site infection, urinary tract infection, endomyometritis and pneumonia. The data were split into model development and internal validation (1 January-31 August; N = 1641) and temporal validation subsets (1 September-31 December; N = 778). Logistic regression models were fit to the data with concordance index and calibration curves used to assess accuracy. Internal validation was performed with bootstrapping correcting for bias., Results: Postoperative infection occurred in 8% (95% CI 7.3-9.9), with 5% meeting CDC criteria for surgical site infections (SSI) (95% CI 4.1-5.8). Eight variables were predictive for infection: increasing BMI, higher number of prior Caesarean deliveries, emergent Caesarean delivery, Caesarean for failure to progress, skin closure using stainless steel staples, chorioamnionitis, maternal asthma and lower gestational age. The model discriminated between women with and without infection on internal validation (concordance index = 0.71 95% CI 0.67-0.76) and temporal validation (concordance index = 0.70, 95% CI 0.62, 0.78)., Conclusions: Our model accurately predicts risk of infection after CD. Identification of patients at risk for postoperative infection allows for individualized patient care and counseling.

BACKGROUND Crohn's disease (CD) is an inflammatory bowel disease affecting approximately 1 in 3000 people in the United States. Since the inflammation of CD is transmural, patients are at risk for fistula and abscess formation. Retroperitoneal abscesses are one type of which physicians must be aware. CASE REPORT We present the case of a 29-year-old woman with CD who complained of right hip and flank pain that began when she was 6-months pregnant. After delivery, she continued to complain of severe right flank pain and was admitted to the hospital 1 month later. CT scan imaging revealed a complicated retroperitoneal and right flank abscess, possibly due to a colonic intramural fistula. She developed severe acute necrotizing soft-tissue infection requiring 13 days of intensive care. She required debridement of the necrotizing infection of the right flank, drainage of the abscess, and washout for intraperitoneal sepsis. The patient tolerated the procedures well and was discharged 1 month later. CONCLUSIONS Given that the clinical manifestation of retroperitoneal fistula with abscess is insidious and its formation is less common than intraperitoneal abscesses, we hope healthcare providers learn from this case to avoid morbidity and mortality. When presented with a pregnant CD patient complaining of nonspecific abdominal symptoms, providers should consider fistulization and/or abscess formation. The option to evaluate pregnant patients using noninvasive methods, such as ultrasound or low-dose CT scan, can decrease radiation exposure to the fetus and prevent delays in diagnosis and treatment.

Background: Maternal and fetal outcomes associated with botulism and botulinum antitoxin use during pregnancy and the postpartum period have not been systematically reviewed., Methods: We searched Global Health, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Medline databases from inception to May 2015 for studies published on botulism or botulinum antitoxin use during pregnancy and the postpartum period, as well as the Centers for Disease Control and Prevention National Botulism Surveillance database. Our search identified 4517 citations., Results: Sixteen cases of botulism during pregnancy (11 in the third trimester) and 1 case during the postpartum period were identified. Ten cases were associated with confirmed or likely foodborne exposure; 2 cases were attributed to wound contamination related to heroin use, and the source of 5 cases was unknown. Eleven women with botulism had progressive neurologic deterioration and respiratory failure, requiring intensive care unit admission. Four women had adverse outcomes, including 2 deaths and 2 women who remained in a persistent vegetative state. No neonatal losses or cases of congenital botulism were reported. Among the 12 cases that reported neonatal data, 6 neonates were born preterm. No adverse maternal or neonatal events were identified as associated with botulinum antitoxin therapy among 11 patients who received it., Conclusions: Our review of 17 cases of botulism in pregnant/postpartum women found that more than half required ventilator support, 2 women died, and 6 infants were born prematurely. A high level of clinical suspicion is key for early diagnosis and treatment of botulism. Care of pregnant women or new mothers with botulism can include preparation for possible intubation., (Published by Oxford University Press for the Infectious Diseases Society of America 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Puerperal fever was a major cause of maternal death in Europe in the 19(th) century. Many efforts were made to investigate the cause of the epidemic but failed. In 1846, Semmelweis, a young obstetrician in Vienna General Hospital, started his historical investigation. His breakthrough was largely due to his doctor friend's accidental injury during autopsy and his consequential death. Semmelweis found the pathological findings in his friend's post mortem examination were very similar to puerperal fever. He postulated his friend's death might be caused by "cadaverous particles" from cadavers and further inferred that puerperal fever might also be caused by the cadaverous particles that doctors brought to the delivering women after autopsy classes. He advocated hand-washing with chlorinated lime solution to wash off those particles, which rapidly reduced the maternal mortality in his department by 80% (from 10.65% to 1.98%). However, what his unprecedented work brought him was only denial, mockery and career setback rather than support, honor and compliments. Under substantial psychological pressure, he had a mental breakdown and died in a psychiatry asylum at the age of 47. He was a pioneer in epidemiological investigations before John Snow and in aseptic techniques before Joseph Lister, but his work is still often neglected.

Background: Fever is a well-known side effect of misoprostol, but clinically difficult to distinguish from an intra uterine infection. The aim of this study was to determine the incidence of fever in terminations of pregnancy (TOP) using misoprostol and to evaluate fever as indication of intra uterine infection., Methods: A retrospective cohort study was performed. Consecutive second trimester TOP with misoprostol between January 2008 and October 2012 were selected. We included 403 cases and determined the incidence of fever. To examine intra uterine infection as plausible cause of fever, pathological examination reports of placentas were reviewed for signs of infections., Results: The incidence of fever was 42%. Logistic regression showed a dose dependent association between dosage misoprostol and degree of fever (OR 1.86; 95% CI: 1.3-2.7). There was no association between fever and epidural analgesia. Fever has a sensitivity of 55% and a specificity of 58% as a marker of intra uterine infection. The positive predictive value of fever for an intra uterine infection is 4% and the negative predictive value is 98%., Conclusion: Administration of misoprostol for the indication TOP is strongly associated with fever during labor. Fever is a poor predictor of intra uterine infection in the context of TOP.

Postpartum uterine health in dairy cows is crucial for the maintenance of good reproductive performance. In order to improve uterine health and reduce puerperal intrauterine infection, 608 Holstein cows received a weekly PGF 2α protocol (3 i.m. injections of PGF 2α at 7, 14 and 21 d postpartum). For comparison, 593 cows in the control group received injections of sterile saline at the same time. Uterine score at 14 d postpartum, the prevalence of endometritis at 21-27 d postpartum, and subsequent reproduction performance was evaluated. Cows in the treated group exhibited higher tonicity (P<0.05) of the uterus, with less prevalence of endometritis (10.4%, 63/608 vs. 34.6%, 205/593; P<0.001), and required shorter time to the first AI postpartum (67.5±3.4 d vs. 84.4±3.7 d, P<0.05) and to pregnancy (114.5±5.4 d vs. 131.4±5.8 d, P<0.05). In conclusion, the present study demonstrated that uterine health in Holstein cows can be promoted while puerperal infection can be suppressed by this weekly postpartum PGF 2α protocol., (Copyright © 2016. Published by Elsevier Urban & Partner Sp. z o.o.)

Infectious endometritis is among the leading causes of subfertility in the mare. However, the best way to reliably diagnose these cases of infectious endometritis can be confusing to the veterinary practitioner. The goal of this article is to describe how to perform various sample collection techniques, what analyses can be performed on these samples, and how to interpret the results of these analysis. Additionally, future technologies will be presented that are not currently used in equine reproduction practice., (Published by Elsevier Inc.)

The periparturient period is one of the most critical periods in the productive life of a dairy cow, and is the period when dairy cows are most susceptible to developing new intramammary infections (IMI) leading to mastitis. Acute phase proteins (APP) such as haptoglobin (Hp), mammary associated serum amyloid A3 (M-SAA3) and C-reactive protein (CRP) have been detected in milk during mastitis but their presence in colostrum and milk in the immediate postpartum period has had limited investigation. The hypothesis was tested that APP are a constituent of colostrum and milk during this period. Enzyme linked immunosorbent assays (ELISAs) were used to determine each APP's concentration in colostrum and milk collected daily from the first to tenth day following calving in 22 Holstein-Friesian dairy cows. Haptoglobin was assessed in individual quarters and composite milk samples while M-SAA3 and CRP concentration were determined in composite milk samples. Change in Hp in relation to the high abundance proteins during the transition from colostrum to milk were evaluated by 1 and 2 dimension electrophoresis and western blot. In 80% of the cows all APPs were detected in colostrum on the first day following parturition at moderately high levels but gradually decreased to minimal values in the milk by the 6th day after calving. The remaining cows (20%) showed different patterns in the daily milk APP concentrations and when an elevated level is detected could reflect the presence of IMI. Demonstration that APP are present in colostrum and milk following parturition but fall to low levels within 4 days means that elevated APP after this time could be biomarkers of post parturient mastitis allowing early intervention to reduce disease on dairy farms.

Background: The objective of this study is to evaluate 'near miss' and mortality in women with postpartum infections., Methods: We performed a retrospective review of all patients referred to the University Teaching Hospital of Kigali (CHUK) between January 2012 and December 2013. We identified 117 patients with postpartum infections. Demographic data, length of admission, location of referral, initial surgery and subsequent treatment modalities including antibiotic administration and secondary surgery were recorded. The primary outcome of interest was a composite of maternal mortality and "near miss" defined as more than one laparotomy with/without hysterectomy and prolonged hospitalization., Results: Diagnoses at CHUK were: pelvic peritonitis (56 %), deep surgical site infection including fasciitis (17 %), and endometritis (15 %). The primary procedures performed prior to transfer were: cesarean section (81 %), septic abortion management (12 %), and vaginal delivery (7 %). Antibiotics were initiated prior to transfer in 66 % of women. Surgery was required in 73 % of patients. Hysterectomies were performed in 22 % of patients. Maternal death occurred in 5 % of the patient population. The primary outcome of severe maternal morbidity and mortality occurred in 90 patients (77 %)., Conclusion: Peritonitis-primarily as a result of cesarean deliveries-is associated with significant morbidity and mortality in our population.

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., (© 2016 by the American College of Nurse-Midwives.)

Background: The South Asian region has the second highest risk of maternal death in the world. To prevent maternal deaths due to sepsis and to decrease the maternal mortality ratio as per the World Health Organization Millenium Development Goals, a better understanding of the etiology of endometritis and related sepsis is required. We describe microbiological laboratory methods used in the maternal Postpartum Sepsis Study, which was conducted in Bangladesh and Pakistan, two populous countries in South Asia., Methods/design: Postpartum maternal fever in the community was evaluated by a physician and blood and urine were collected for routine analysis and culture. If endometritis was suspected, an endometrial brush sample was collected in the hospital for aerobic and anaerobic culture and molecular detection of bacterial etiologic agents (previously identified and/or plausible)., Discussion: The results emanating from this study will provide microbiologic evidence of the etiology and susceptibility pattern of agents recovered from patients with postpartum fever in South Asia, data critical for the development of evidence-based algorithms for management of postpartum fever in the region.

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.

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.

Introduction: Pyogenic sacroiliitis, a rare form of septic arthritis, occurs in patients following trauma, intravenous drug use, genitourinary infections and pregnancy. Here we report a rare case where both acupuncture and pregnancy served as predisposing risk factors to the development of this infection., Case Presentation: A 33-year-old white woman received several sessions of acupuncture treatment during her gestation at the site of her sacroiliac joint for sciatica; she developed biopsy-confirmed sacroiliitis with methicillin-sensitive Staphylococcus aureus during the immediate postpartum period. The diagnosis, medical management and treatment course are described., Conclusions: Low back and pelvic pain are common conditions during pregnancy and postpartum. Acupuncture is a common modality of medication-free treatment used by many patients. Recognition of the potential complications of such therapies can lead to early diagnosis, accurate treatment, decreased morbidity and increased chances for a successful outcome.

Pulmonary cryptococcosis is likely to be misdiagnosed due to relatively non-specific clinical and radiological features. It is more frequently associated with immuno-suppressed conditions especially acquired immuno-deficiency syndrome (AIDS) and pulmonary tuberculosis (PTB). Four cases of pulmonary cryptococcosis were diagnosed over a period of eleven years. All patients in this case series were human immune-deficiency virus (HIV)-negative. The predisposing factors in these patients were diabetes mellitus (DM), acute lymphoblastic leukaemia (ALL), post-partum and pregnancy in one each of the patients. Relapse was seen in two cases. All the patients survived due to strict follow-up. Pulmonary cryptococcosis is common in non-AIDS patients and it warrants rapid diagnosis, treatment and follow-up to prevent relapse., (© 2015 Blackwell Verlag GmbH.)

A 40-year-old South Asian woman was admitted in active labor at 38 weeks' gestation. She had an unremarkable medical history with routine prenatal care, negative HIV testing results, and an uneventful pregnancy. She received a Bacillus Calmette-Guérin vaccine during childhood and reportedly had a subsequent positive purified protein-derivative test result 1 year prior to conception. She never smoked and had seven normal term pregnancies.

Background: Retroperitoneal infection can be lethal. Optimal management is still elusive to describe because of the small number of case reports. We presented here a case of retroperitoneal abscess caused by Clostridium difficile arising in the puerperal period., Methods: Case report and review of recent English-language literature., Results: The patient presented with surgical incision dehiscence. A gas-forming fluid collection was discovered in the pelvic retroperitoneal fascia by computed tomography, but the patient did not show marked symptoms of sepsis. Emergency laparotomy drainage and debridement were performed. Clostridium difficile was isolated, and she was treated with a three-week course of vancomycin. The patient recovered without major morbidity. Recent case reports describe variation in the course of the disease and management options for puerperal retroperitoneal infection., Conclusion: Puerperal retroperitoneal abscess caused by C. difficile can present with minimal symptoms. Prompt recognition, early surgical intervention, and optimal use of antibiotics can reduce morbidity and prevent death.

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., (2014 BMJ Publishing Group Ltd.)

Maternal postpartum fever that is suggestive of endometritis often triggers evaluation of the mother and newborn infant for bacterial infection. Two neonates whose mothers had persistent postpartum fever despite broad-spectrum antimicrobial therapy developed disseminated herpes simplex virus (HSV) infection. Obstetric and pediatric healthcare providers should be mindful of possible HSV infection if there is postpartum fever unresponsive to antibiotics, and both mother and neonate should be evaluated appropriately and treated promptly.

Ignaz Semmelweiss made one of the most important contributions to modern medicine when he instituted handwashing in an obstetric clinic in Austria in 1847, decreasing mortality there from more than 10% to 2%. Unfortunately, puerperal sepsis remains a leading cause of maternal mortality throughout the world. Group A streptococcus (GAS), Streptococcus pyogenes, is an organism associated with high rates of morbidity and mortality from puerperal infections. When associated with sepsis, known as streptococcal toxic shock syndrome, mortality rates approach 30-50%. Group A streptococcus can cause invasive infections in the form of endometritis, necrotizing fasciitis, or streptococcal toxic shock syndrome. The clinical presentation of women with puerperal GAS infections is often atypical with extremes of temperature, unusual and vague pain, and pain in extremities. Toxin production by the organism may allow GAS to spread across tissue planes and cause necrosis while evading containment by the maternal immune system in the form of a discrete abscess. Endometrial aspiration in addition to blood cultures may be a useful rapid diagnostic tool. Imaging may appear normal and should not dissuade the clinician from aggressive management. When suspected, invasive GAS infections should be treated emergently with fluid resuscitation, antibiotic administration, and source control. The optimal antibiotic regimen contains penicillin and clindamycin. Source control may require extensive wound or vulvar debridement, hysterectomy, or a combination of these, which may be life-saving. The benefit of immunoglobulins in management of puerperal GAS infections is unclear.

Cryptococcus spp. cerebral abscesses are uncommon in immunocompetent subjects. The recommended induction treatment is the administration of amphotericin B plus flucytosine combined with resection for lesions ≥3cm. In this paper, we describe an HIV-negative woman diagnosed with a large cryptococcoma in the immediate postpartum period. The lesion was not resected, and due to amphotericin B intolerance, she received an extended course of fluconazole monotherapy. There was no disease recurrence during the 4 years of follow-up. The abrupt onset of her symptoms following delivery suggests that she developed a postpartum immune reconstitution syndrome. This case also demonstrates that in specific situations fluconazole monotherapy can be attempted in immunocompetent patients with cryptococcoma.

Infections during pregnancy are relatively prevalent, and the majority of cases are managed well in the community. Occasionally, however, infections may be life-threatening. Sepsis may be associated with multiple organ dysfunction and a high mortality. The treatment of sepsis is time critical and requires early fluid resuscitation and antibiotics. Early involvement of other specialties and allied health-care professionals to provide a multidisciplinary approach to patient care is important. Continuous monitoring of maternal vital signs and provision of supportive care for multiple organ dysfunction are best done within the intensive care unit. Despite advances in patient care, the mortality rate associated with maternal sepsis remains high. Health-care services in low-income countries face particular problems that account for an increased incidence of puerperal sepsis and maternal mortality. These include lack of access to health care, septic abortions and a greater incidence of human immunodeficiency virus. The key to management of sepsis is early recognition, aggressive resuscitation, antibiotic administration and source control., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

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., (© 2013 by the American College of Nurse-Midwives.)

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.

Puerperal mastitis and breast abscess caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a condition rarely described in Europe to date. We report and comment on a case of CA-MRSA puerperal breast abscess in a 22-year-old primiparous mother. This aetiology was suspected before the antibiotic susceptibility profile of the strain isolated from the abscess was known on account of a history of previous skin colonisation detected in her baby. Additionally, the most striking epidemiological and therapeutic aspects, potential consequences of cross-infection between mother and child, and infection control management of this entity are briefly reviewed and discussed.

The objectives of this study were to assess the risk factors for metritis, its effects on milk yield and on reproductive performance, and the efficacy of ceftiofur therapy in Holstein dairy cows. Cows (n=303) from a commercial dairy herd in Argentina were studied. Cows were scored for body condition, and blood samples were collected on d -14, 7, 21, 31, 41, and 50 relative to parturition. Cows having a watery, purulent, or brown, and fetid vaginal discharge (VD) and rectal temperature ≤ 39.2°C were diagnosed as having clinical metritis, and those having a similar VD and rectal temperature >39.2°C were diagnosed as having puerperal metritis. Both clinical and puerperal metritis cows were randomly assigned to control (no treatment) or ceftiofur group (2.2mg/kg×3 consecutive days). Cure was declared if clear VD was observed at 21 d in milk (DIM). Blood samples were analyzed for nonesterified fatty acids, β-hydroxybutyrate, and blood urea nitrogen using commercial kits, and for insulin-like growth factor-1, insulin, and leptin by RIA. Data were analyzed with PROC MIXED, GENMOD, PHREG, and LIFETEST from SAS (SAS Institute Inc., Cary, NC). The risk for metritis increased with dystocia, retained fetal membranes, and dead calf [AOR (adjusted odds ratio)=2.58, 95% CI: 1.189-5.559], and as prepartum nonesterified fatty acids levels increased (AOR=1.001, 95% CI: 0.999-1.002). Conversely, risk decreased as prepartum insulin-like growth factor-1 increased (AOR=0.65, 95% CI: 0.349-1.219). Cows having either clinical or puerperal metritis produced less milk by 90 DIM than did healthy cows (2,236 ± 172 vs. 2,367 ± 77 vs. 2,647 ± 82 kg, respectively). Cows with puerperal metritis had lower risk for pregnancy by 100 DIM (AOR=0.189, 95% CI: 0.070-0.479) and a lower hazard rate for pregnancy by 150 DIM (hazard rate: 0.753, 95% CI: 0.621-0.911), and took longer to get pregnant (129 vs. 111 vs. 109 d, for puerperal metritis, clinical metritis, and healthy cows, respectively). Ceftiofur treatment was not associated with cure rate or milk yield but was related to increased risk for pregnancy at timed artificial insemination (AOR=2.688, 95% CI: 0.687-10.832), and for lower risk of reproductive cull (AOR=0.121, 95% CI: 0.014-1.066). In conclusion, abnormal calving and negative energy balance are associated with increased risk for metritis. Metritis, especially puerperal metritis, correlates with reduced milk production and poor reproductive performance. Finally, the likelihood for having a normal VD (indicative of cure) increased 2.6% for every day of increase in postpartum time and was 2 times higher for cows with clinical metritis than for those with puerperal metritis., (Copyright © 2013 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the radiological and clinical features of adult non-puerperal mastitis and to determine the most accurate method of preventing unnecessary surgical procedures., Methods: Clinical and imaging findings were retrospectively reviewed in 51 females with non-puerperal mastitis, which was confirmed by biopsy/surgical pathology. All 51 patients had pre-operative MRI; 45 patients also had sonograms and 25 also had mammograms, pre-operatively., Results: Of the 51 cases with non-puerperal mastitis, 94.1% (48/51) were confirmed as having acute or chronic inflammation, and the other 3 had plasma cell mastitis; areola papillaris inflammation was found in 39.2% (20/51) of the cases. Overall, 6 of the 25 cases that were examined with mammography and 2 of the 45 cases that were examined with sonography appeared normal, but all 51 lesions were positively identified on MRI. Asymmetrical density (12/25) on mammograms and solitary or separated/contiguous, clustered, hypoechoic mass-like lesions (31/45) on ultrasound were the most common signs of non-puerperal mastitis. On enhanced MRI, 90.2% (46/51) of patients showed non-mass-like enhanced lesions. Multiple regional enhancements in the pattern of distribution (32/46) and separated or contiguous, clustered, rim-like enhancements in the pattern of internal enhancement (29/46) were the most common manifestations in non-mass-like enhanced lesions. Of the 51 patients, mastitis Type 1 and Type 2 in the time-signal intensity curve were detected in 47.1% and 51.0% of the patients, respectively. The breast imaging reporting and data system categories with the highest number of patients were Category 0 (9/25) on mammography, Category 4a on sonography (18/45) and Category 4a on MRI (29/51)., Conclusion: The findings from mammography and ultrasound are non-specific; therefore, using MR can be helpful in the diagnosis, especially in the presence of non-mass-like enhancements that are multiple, regional, separated, or contiguous, clustered and rim-like., Advances in Knowledge: Mastitis is often neglected because of the lack of typical clinical signs and symptoms. This study has assessed and described the clinical features and imaging findings of adult non-puerperal mastitis on mammograms, sonograms and MRI and found that MRI is more specific in the diagnosis of disease.

The objective of this study was to compare two strategies for screening and subsequent treatment of acute puerperal metritis (APM) in dairy cows. Therefore, we conducted a study on 79 cows with APM (cows with an enlarged uterus with fetid watery red-brown vaginal discharge and fever >39.5 °C) and 114 healthy control cows. Cows with APM were divided into two groups (treated, N = 67 cows; not treated, N = 12 cows). The treated animals were further subdivided into two groups (treated between Day 1 and 4 post partum, N =12 and treated between Day 5 and 10, N = 55). Serum haptoglobin concentrations, milk yield, cure rate, prevalence of endometritis, and cervical diameter on days in milk (DIM) 21 to 27 were compared between the groups. Cows were defined as cured when their rectal temperature was <39.5 °C 4 days after treatment and fever did not rebound over 39.4 °C until the end of the screening period which was DIM 10. The results of this study did not show any significant differences in cure rates, milk yield, or serum haptoglobin concentrations on DIM 2, 5, and 10 and subsequent uterine health (DIM 21-27). Considering this study as a proof of concept study, we conclude that there might not be a negative effect after a screening and treatment protocol beginning at DIM 5 and leaving early APM cows untreated. This hypothesis needs to be confirmed by a larger field study. Furthermore, antimicrobial therapy could be avoided in 12 of 55 cows (21.8%) in group 2 because of the protocol implementing treatments after DIM 5. These cows did not show signs of APM during the following 5 days. Therefore, these animals were considered as self-recovered leading to a cure rate of at least 21.8% (12 of 55 cows)., (Copyright © 2013 Elsevier Inc. All rights reserved.)

For the clinician, necrotizing soft-tissue infections have remained a daunting opponent since the first writings on the subject over 2000 years ago. Early disease may be incorrectly diagnosed as cellulitis, and this delay in correctly diagnosing and expeditiously proceeding to radical surgical debridement may lead to a high degree of mortality. Although several inciting events and risk factors have been described that allow for the development and progression of this disease, the diagnosis is still made clinically. Only aggressive surgical management in combination with broad-spectrum antibiotics will offer a chance at improving patient outcomes.