Surgical management of diffuse peritonitis complicating obstetric/gynecologic infections

A retrospective review of 176 women undergoing surgery for diffuse peritonitis secondary to pelvic infections from 1972 to 1976 was conducted. Mortality with septic abortion was 27.3% (12 of 44), with pelvic inflammatory disease 7.1% (eight of 113), and with puerperal sepsis 6.7% (one of 15). Overall mortality was 13.1% (23 of 176). Mortality was lower (P less than .05) with surgery within 24 hours (7.5%, six of 80) than after 24 hours (17.7%, 17 of 96). Mortality was lower (P less than .01) with specific antianaerobic antibiotics (zero of 36) than without (16.4%, 23 of 140). Mortality was 21.3% with hysterectomy (ten of 47) and 10.1% (13 of 129) with conservative surgery, however hysterectomy was usually performed in the more severe cases (septic abortion 75%, puerperal sepsis 66%, pelvic inflammatory disease 3%). Mortality declined from 17.6% in 1972 to 1974 (21 of 119) to 3.5% in 1975 to 1976 (two of 57). Significant differences between the two periods included an increased use of specific antianaerobic antibiotics (8.4%/45.5%) and an increased incidence of early surgery (35.3%/66.6%) in the latter years. This series emphasizes the overriding importance of early surgery and the need for the inclusion of specific antianaerobic antibiotic agents in the chemotherapeutic regimen.

[Prevention of tubal sterility]

The prevention of tubal sterility necessitates not only the diagnosis and treatment of venereal infections, but also the prevention of post-partum, post-abortum, and especially iatrogenic infections. Equally, the surgeon has a role to play, for many tubal sterilities follow traumatic surgical interventions in young women and adolescents.

Results of conservative management of premature rupture of the membranes

The maternal and fetal outcome of a conservative management protocol, at a tertiary care center, for premature rupture of membranes between 25 and 34 weeks' gestation was reviewed for the 2-year period 1980 to 1981. There were 139 patients with premature rupture of the membranes prior to 37 weeks' gestation, 47 with premature rupture of the membranes less than 24 hours prior to delivery, and 92 in whom premature rupture of the membranes occurred 24 hours or more before delivery. There was a significant difference in the incidence of chorioamnionitis and endometritis between patients in whom premature rupture of the membranes occurred 24 hours or more before delivery and patients in whom delivery took place within 24 hours (p less than 0.001). However, neither prolongation of pregnancy with premature rupture of the membranes beyond 24 hours nor use of betamethasone was associated with any increase in maternal or neonatal infectious morbidity. Neonatal mortality was 3.3% and was related only to lower gestational age.

Acute emphysematous thyroiditis

Acute emphysematous thyroiditis is a severe pyogenic infection of the thyroid gland characterized by the production of gas. Although earlier writers of the pre-antibiotic era had referred to 'gangrene of the thyroid with gas formation' (1-3), only 5 cases of gas-forming or emphysematous thyroiditis have been specifically documented. In this report, the sixth case of acute emphysematous thyroiditis is presented and the clinical features of this rare but potentially lethal infection of the thyroid gland are described. The pathogenesis and management of the disease are discussed.

[Severe pregnancy hemostasis disorders: diagnosis and therapeutic procedures]

We evaluated 21 pregnant patients with severe disorders of haemostasis by retrospective chart analyses, 15 patients were treated with intravenous heparin (10.000 to 20.000 I.U.) during and after surgery. Eighteen of 21 patients developed renal failure and 8 died. Postoperative bleeding complications making laparotomies mandatory occurred in 10 patients. These bleeding complications are seen in relation to the heparin treatment instituted immediately after surgery. We do not favor the administration of heparin during the immediate obstetrical postoperative period, the more as Antithrombin III-concentrate is now available. Surgical intervention in order to achieve haemostasis is of paramount therapeutic importance. Drainage of infections remains furthermore the most important task in those obstetrical emergency cases where infections play a predominant role. To maintain or to re-establish the normovolemic perfusion ameliorates the rheological conditions which should monitored with care.

Nonmenstrual toxic shock syndrome: a review of 130 cases

One hundred and thirty cases of toxic shock syndrome not associated with menstruation have been reported to the Centers for Disease Control, including 57 with onset in 1981 (12% of reported cases in 1981). These cases show that the syndrome occurs in a wide range of clinical settings and is associated with Staphylococcus aureus infections at a variety of sites: focal cutaneous and subcutaneous lesions, surgical-wound infections, postpartum infections, adenitis, bursitis, deep abscesses, and "primary" bacteremia. Although the clinical characteristics of nonmenstrual toxic shock syndrome are identical to those for menstrual toxic shock syndrome, the epidemiologic and demographic features are different. Of particular interest is the contrast in the racial distribution of the menstrual and nonmenstrual cases. Toxic shock syndrome can occur in persons of any age, race, or sex and must be considered in the differential diagnosis for any patient with a compatible illness.

Bacteremia in obstetrics: clinical course

The authors reviewed all documented cases of bacteremia in obstetric patients between 1975 and 1979, with emphasis on the clinical course. The incidence of bacteremia was 7.5:1000 obstetric admissions and 9.7% of those patients sampled. One hundred seventy-six bacteremic obstetric patients had the following diagnoses: endoparametritis (123), pyelonephritis (29), chorioamnionitis (14), and other (10). No deaths, clinical evidence of septic shock, or cases of postinfection endocarditis were found. The most common bloodstream isolates were Escherichia coli (57), group B streptococcus (28), and Bacteroides sp (26). The patients with endoparametritis had a fever index of 86.2 +/- 47.1F-hours, an average hospital stay of 6.5 +/- 3.1 days, a 7.3% rate of complications, and a 19.5% rate of failure of primary antibiotics. The patients with chorioamnionitis had a fever index of 32.7 +/- 48.9F-hours and an average hospital stay of 4.8 +/- 2.3 days. These clinical measures are comparable with those in the general population with the same diagnoses at the authors' hospital. In this obstetric population, prompt, vigorous treatment rendered the clinical course of bacteremic patients with genital infections remarkably similar to that of nonbacteremic patients with the same kinds of infection.