[Intensive therapy of puerperal disorders with a life-threatening state caused by sepsis]

The paper reviews intensive, complex therapeutical procedure introduced in 19 critically ill puerperal women due to severe sepsis. In 6 cases only the generative organ was the primary source of infection. It is underlined that sepsis can predispose to various complications and multiorgan failure.

Postpartum toxemia: hypertension, edema, proteinuria and unresponsiveness in an unknown female

Eclampsia, or toxemia of pregnancy, is a disorder of pregnancy characterized by seizures associated with hypertension, edema, and proteinuria. Toxemia of pregnancy carries significant maternal and fetal morbidity and mortality. Eclampsia most commonly occurs in the antepartum period. A minority of cases, however, may initially manifest in the postpartum period. We present the case of a 28-year-old female with postpartum eclampsia presenting to the Emergency Department with altered mental status. A review of the literature concerning postpartum toxemia and a discussion of appropriate management strategies follows.

Low birthweight and post partum endometritis-myometritis

BACKGROUND

The study aims at confirming or rejecting the hypothesis of an association between birthweight and post partum uterine infection.

METHODS

A case-referent study was performed on 51 puerperal women with clinical signs of endometritis-myometritis. To each case an otherwise healthy puerperal woman was recruited and matched for age, parity and days after delivery.

RESULTS

The proportion of women having had newborns with birthweight < 2500 g was 20/49 among cases and 2/50 among referents (odds ratio 16.6; 95% CI 3.5-152.3). Preterm births were registered in 15/50 cases and 2/49 referents (odds ratio 10.1; 95% CI 2.1-94.5). The average gestational age at delivery was approximately 2 weeks shorter among cases than among referents (37.5 versus 39.5 weeks).

CONCLUSIONS

Low birth weight was ten times more prevalent among women with puerperal infection than among healthy puerperal women. The findings indicate that giving birth to a low birth weight baby is strongly associated with ensuing puerperal infection, possibly by a subclinical antenatal intrauterine infection, predisposing to both adverse fetal and maternal outcomes of pregnancy.

Postpartum fever

Postpartum fever is a common obstetric complication. It often results from endometritis but can also be caused by urinary tract infection, would infection or phlebitis. The rate of endometritis is higher among patients who have a cesarean delivery, compared with those who have a vaginal delivery. Postpartum febrile episodes in which temperatures are less than 38.4 degrees C (101.1 degrees F) often resolve without intervention, especially when they occur in the first 24 hours after delivery. Treatment options for patients whose febrile episodes do not resolve spontaneously or are higher than 38.7 degrees C (101.6 degrees F) during the first 24 hours or higher than 38.0 degrees C (100.4 degrees F) on any two of the first 10 days postpartum include administration of antibiotics with specific activity against anaerobic bacteria. Additional diagnostic modalities, such as computed tomography, ultrasonography, heparin administration and surgical exploration, should be employed when the patient fails to respond to antibiotic therapy.

[Postpartum parvovirus B19-associated acute pure red cell aplasia and hemophagocytic syndrome]

A 30-year-old postpartum woman was admitted to our hospital because of progressive anemia, malaise, night sweating, headache and low grade fever which began 9 days after delivery (day 0). She had normocytic hypochromic anemia accompanied with marked decrease in reticulocytes. In addition, a temporary decrease in platelets and white blood cells especially neutrophils were observed. Bone marrow smears showed an apparent decrease in erythroid cells and the presence of giant proerythroblasts (1.2%) as well as hemophagocytes (1.2%). IgM and IgG antibody against human parvovirus B19 (HPV) was detected on day 22 of the disease although negative results were obtained on day 3. The presence of the virus in the blood on admission was confirmed by dot-blot analysis. Thus, this case was diagnosed as acute pure red cell aplasia and hemophagocytic syndrome caused by HPV infection. This patient had been given iron for iron deficiency anemia before delivery and the iron deficiency was still present after the episode of the present disease although the iron metabolism data was perturbed during the disease. These findings suggest that HPV could cause acute pure red cell aplasia not only in patients with hemolytic anemia but also in patients with iron deficiency anemia or after acute bleeding. Furthermore it is suggested that pancytopenia often observed on HPV infection could be at least partly caused by hemophagocytic syndrome.

Risk factors in puerperal endometritis-myometritis. An incident case-referent study

Postpartum endometritis-myometritis (PPEM) was identified in 51 women after vaginal delivery, who were compared with 51 healthy referent parturients, matched for age, parity and days postpartum. Socio-economic background data, past and current obstetric history and clinical data from recent delivery were analyzed. Endocervical and intracavitary cultures and blood cultures were performed and serological analyses of syphilis and HIV antibodies were carried out. No socio-economic factor studied discriminated significantly between cases and referents. Previous stillbirth (OR 9.44) and previous low-birthweight delivery (OR 3.90) occurred significantly more often among cases. In recently past pregnancy preterm delivery (OR 10.07), low birthweight (OR 16.55) and serious neonatal morbidity (OR 14.27) were significantly more common among cases. Cases and referents differed also significantly in body mass index < 22.5 (OR 3.41), left mid-upper-arm circumference < 25 cm (OR 2.66), haemoglobin < 100 g/l (OR 3.12) and high-risk classification in antenatal care (OR 11.95). Bacterial intracavitary cultures tended to be positive and have anaerobes more frequently in cases than in referents. It is concluded that women with PPEM in the setting studied belong to a group at risk also regarding adverse fetal outcome, both in recently past and in previous pregnancies.

The return of life-threatening puerperal sepsis caused by group A streptococci

A dramatic decline in the prevalence of serious puerperal infection caused by group A beta-hemolytic streptococci has been observed throughout most of the twentieth century, and it is currently a very uncommon cause of maternal morbidity and mortality. We report on two term pregnancies complicated by profound multisystem organ failure caused by group A streptococcal puerperal sepsis. This report serves to highlight the apparent return of serious group A streptococcal puerperal sepsis and to emphasize the clinical implications and sequelae attributable to an old yet virulent enemy.

Association of abnormal uterine discharge with new intramammary infection in the early postpartum period in multiparous dairy cows

The association of abnormal uterine discharge with the development of intramammary infection (IMI) was studied in 62 multiparous Holstein cows during the nonlactating period and from lactation days 3 through 30. Duplicate milk samples were obtained from each mammary gland at approximately day 30 of the nonlactating period. Milk samples for bacteriologic culture also were obtained from each gland from all cows at the end of the previous lactation, at parturition, and on a minimum of 7 additional dates during the first 30 days of lactation. Beginning after parturition and continuing once weekly for 4 weeks, each cow was examined, using a vaginal speculum to visually estimate the quantity of abnormal uterine discharge in the vagina. Additionally, uterine swab specimens were obtained for aerobic bacteriologic culture. Cows were allotted to groups on the basis of the maximal amount of abnormal uterine discharge observed at any 1 of the 4 examinations. Cows in group 1 had normal discharge or < 30 ml of abnormal discharge; in group 2, > or = to 30 ml of abnormal discharge, observed only on examination by vaginal speculum; and in group 3, > or = to 30 ml of abnormal discharge visible externally. A difference was not detected in the development of new IMI in the nonlactating period between cows that subsequently developed uterine discharge and those that did not. Although significant differences were not found, a tendency for lactating cows with abnormal uterine discharge to be at increased risk for developing new IMI was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Puerperal toxic shock syndrome caused by Group A beta-hemolytic streptococci]

This case report describes the history of a young female with a streptococcal toxic shock syndrome secondary to a puerperal sepsis. The syndrome was complicated by severe hypotension, reversible kidney dysfunction, adult respiratory distress syndrome, coagulation disturbances, myositis and rhabdomyolysis. This latter complication required amputation of both lower legs.

Prognosis and long-term follow-up of a twin after antenatal death of the co-twin

It is generally believed that among twin pregnancies with one fetal loss prior to delivery, the surviving twin has an increased rate of perinatal mortality and childhood morbidity (cerebral palsy and mental retardation). By using data from the National Medical Birth Registry of Sweden between 1973 and 1983, we identified 206 gestations with the death of at least one twin (in 36 pregnancies both twins died) prior to delivery. The original medical records were retrieved for study. The presence of childhood morbidity for 65 of 129 surviving (8 years of age or older) twins born between 1973 and 1980 was evaluated by a questionnaire sent to rehabilitation centers for disabled children, as well as to offices for the Provision of Care for the Mentally Retarded. Perinatal mortality for a twin after the antenatal death of the co-twin was considerable. Fifty percent of survivors died before 34 weeks' gestation, and 18.7% thereafter. At follow-up, 8 years or more after birth, three twins (4.6%) were handicapped. Our results indicate the need for careful monitoring of the surviving twin fetus after one twin has succumbed prenatally.

Breast-feeding during primary maternal human immunodeficiency virus infection and risk of transmission from mother to infant

Examination of breast-fed infants of the complete cohort of Australian women whose primary human immunodeficiency virus (HIV) infection occurred postpartum allows for an estimate of risk of transmission of HIV. Ten women with no other risk factors were infected via blood transfusion postpartum. They breast-fed for up to 9 months; 2 of their infants were infected. Another woman, who shared needles for intravenous drug use, seroconverted 6-10 months post-partum. She breast-fed for 14 months. Retrovirus was visualized in the cellular and cell-free fraction of her milk by electron microscopy. Infection in her infant was confirmed at 12 months. Thus, 3 of the 11 babies at risk became infected, providing an estimate of risk of 27% for breast-feeding during primary maternal infection (95% confidence interval, 6-61%). These data establish the association of primary maternal HIV infection and breast-feeding with a high risk of transmission to infants.

[Human parvovirus-induced transient anemia and leukopenia after delivery]

A 30-year-old female at 27 weeks' gestation, was hospitalized on September 24 1990 because of the premature rupture of the amniotic sac. She underwent Caesarean section on the same day with 700 ml blood loss, but no blood transfusion was required. For several days after the operation, her hemoglobin level remained 7.8 g/dl and did not increase significantly in spite of parenteral iron therapy. On the 9th postoperative day, chills and pyrexia developed with leukopenia. Bone-marrow aspiration revealed severe erythroblastopenia with giant proerythroblasts, suggesting recent HPV infection, which was confirmed by the presence of anti-HPV IgM and HPV antigen by ELISA. The hemoglobin level gradually decreased to 6.0 g/dl by the 21st day, then began to increase rapidly. The serum of acute-phase containing HPV antigens inhibited BFU-E and CFU-E but not CFU-GM. The serum of convalescent-phase inhibited neither erythroid colony growth nor myeloid colony growth. These results indicate that the inhibitory effect of HPV in colony assay is highly specific for erythropoiesis and that HPV play a role in transient cessation of erythropoiesis. The reason, however, for leukopenia in HPV infection remained unclear. This case shows that HPV infection may induce severe hematological disorders even in normal person under erythropoietic stress.

[Analysis of lochial acid-base equilibrium in an uncomplicated course of the postpartum period and in endometritis]

Lochial acid-base status was analyzed in 45 puerperants in whom the postpartum period ran an uncomplicated course or was complicated by endometritis. The normal course of the puerperium is associated with the development of metabolic acidosis in the uterine cavity, and this acidosis is completely compensated for at the expense of gas alkalosis. In slight endometritis metabolic acidosis augments, and grave endometritis is associated with the development of marked acidosis at the expense of the development of tissue hypoxia in the presence of metabolic acidosis.

Profile of right-sided endocarditis: an Indian experience

The clinical profile of right-sided infective endocarditis in India was studied from a review of records of patients with infective endocarditis admitted to this hospital. From November 1982 to November 1989, 109 patients with infective endocarditis showed vegetations on cross-sectional echocardiography confirming the diagnosis of infective endocarditis. In 19 (17.4%) patients, only the right side of the heart was involved: specifically the tricuspid valve alone in 10; tricuspid and pulmonary valves in 4; tricuspid valve and right ventricular outflow tract in 1; tricuspid valve and right ventricular free wall in 1; pulmonary valve alone in 2; and bifurcation of pulmonary trunk in 1. Eleven patients (57.9%) had underlying congenital heart disease whereas the remaining 8 patients (42.1%) did not have any underlying heart disease. The latter group, therefore, had isolated right-sided infective endocarditis. Previous illnesses leading to isolated right-sided infective endocarditis were: puerperal sepsis in 4; septic abortion in 1; staphylococcal pneumonia in 2; and epididymoorchitis in one. Eight out of 11 patients with congenital heart disease did not report any previous illness. In the remaining 3, right-sided endocarditis followed cardiac surgery in one; dental extraction without prophylaxis in one; and pulmonary balloon valvoplasty in one. All patients with isolated right-sided infective endocarditis had features of septicaemia, but a murmur of tricuspid regurgitation was audible in only 4 (50%) of them. We conclude that, unlike western reports, the pattern of right-sided infective endocarditis in India is different. No drug addict with right-sided infective endocarditis was seen; puerperal sepsis and septic abortion were the commonest causes of isolated right-sided infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

Crescentic glomerulonephritis associated with puerperal sepsis

Acute renal failure developed in a young female having puerperal sepsis due to beta-haemolytic streptococci. The patient succumbed to her illness and an autopsy revealed extensive crescentic glomerulonephritis. The association between chronic visceral sepsis and glomerulonephritis is discussed.

[A case of postpartum fever caused by Mycoplasma hominis infection]

A 26-year-old housewife was admitted to our hospital with a history of high fever after previous cesarean delivery. She had premature rupture of the membrane on the 41st week of pregnancy and the amniotic fluid was found to be cloudy on the fourth day after rupture. Therefore, cesarean delivery was performed. On the first day of operation, her body temperature increased up to 38 degrees C in spite of the treatment with Latamoxef (LMOX), 3 g/day. A sample of intrauterine material yielded M. hominis in pure culture. After administration of Minocycline (MINO) with antimycoplasmal activity, the clinical symptoms improved by the 11th day of operation. Sera obtained after the infection showed antibodies to M. hominis in ELISA study. These results suggested that the cause of this postpartum fever was M. hominis infection.

[Ultraviolet irradiation of blood in surgery]

The results of complex treatment of 81 patients with pyoinflammatory diseases with the use of blood ultraviolet irradiation are discussed. A marked clinical effect was noted, the terms of treatment reduced by 5-10 days, the outcomes improved, and the number of complications decreased. Irradiation of autologous blood by ultraviolet rays led to modulation of the indices of antimicrobial protection, increase of the intensity of the histochemical reaction to peroxidase up to 40-50%, and diminution of pH in the neutrophil phagosomes to 5.0. The ultrastructure and ability of thrombocytes to store serotonin were restored, and intensity of their metabolic processes increased, the membrane phospholipid composition changed, and juvenile platelet forms appeared.

Near fatal puerperal fever due to Mycoplasma hominis

We describe a case of severe septicaemia caused by Mycoplasma hominis in a 23 year old patient following childbirth. She developed disseminated intravascular coagulation and acute respiratory distress syndrome which have not hitherto been described in association with septicaemia due to this organism. Investigation and treatment leading to full recovery is outlined.

[A cured case of adult respiratory distress syndrome caused by septicemia of Staphylococcus aureus]

A 33-year-old woman was admitted as an emergency case because of shock condition after delivery. Physical examination revealed fever, cyanosis and coarse crackles throughout the entire chest. Laboratory data showed leukocytosis and increase of CRP value. Adult respiratory distress syndrome (ARDS) was diagnosed based on progressive severe hypoxemia and bilateral diffuse alveolar shadows on chest X-ray film. The cause of ARDS was considered to be septicemia as staphylococcus aureus was cultured from lochia. The patient was intubated, then artificially ventilated employing PEEP. Chemotherapy using three different kinds of antibiotics was started, combined with the administration of corticosteroid and a protease inhibitor, Urinastatin. The patient finally recovered completely.

[Central and organic hemodynamics during the treatment of infection by splenosorption]

Patients with sepsis have been found to have two types of alterations of central hemodynamics: hyperdynamic and hypodynamic ones, as well as alterations of the hepatic blood flow. The use of splenosorption results in normalization of the parameters of the central and hepatic hemodynamics. The positive hemodynamic effect of splenosorption seems to be associated with the increased nonspecific resistance as well as the activation of the endogenous mechanisms of defense.

Mastitis and toxic shock syndrome

Toxic shock syndrome (TSS) secondary to mastitis or breast abscess is only seldom described. We report a case of definite TSS due to postpartum staphylococcal mastitis which evolved over a period of 3 weeks to a breast abscess, recurring after 2 months. Only the episode of acute mastitis was complicated with TSS, while Staph. aureus could be isolated during the period of mastitis from milk and during drainage of the second breast abscess.