Aminoglycoside dosing in obese puerperal women

We compared serum aminoglycoside levels in two groups of obese puerperal women being treated for endometritis. In these obese puerperal women (weights as much as 100 kg), the aminoglycoside dose did not have to be adjusted for excess weight initially, but it seems that determination of antibiotic levels should be performed in view of the large doses.

Piperacillin versus clindamycin plus gentamicin for pelvic infections

Piperacillin, a new semisynthetic penicillin, has broad spectrum activity against most clinically important aerobic and anaerobic bacteria. In the present study, piperacillin was compared with a combination of clindamycin and gentamicin for the treatment of 83 women with pelvic infection (42 with endometritis, 29 with posthysterectomy cuff infections, 11 with acute salpingitis, and one with a wound infection). There were 179 bacterial isolates, 98 (53%) aerobic and 81 (45%) anaerobic. Of the 42 patients treated with piperacillin, there were three (7.1%) clinical failures compared with one (2.4%) in the 41 patients treated with clindamycin-gentamicin. A single drug, piperacillin, was shown to be as safe and effective as the combined clindamycin plus gentamicin therapy for pelvic infections.

Correlation of laboratory and clinical criteria in the prediction of postcesarean endomyometritis

The objective of this investigation was to develop a rapid diagnostic test to identify patients at exceptionally high risk for postcesarean endomyometritis. Intraoperative samples of endometrium, chorioamniotic membrane, and amniotic fluid were obtained from 70 patients undergoing nonelective cesarean section and were processed for bacterial culture, Gram stain, and histologic examination. Endomyometritis occurred in 57% of patients. Women with positive bacterial cultures (growth of high virulence organisms on the primary plates), positive Gram stains (bacteria in any oil immersion field), and histologic evidence of leukocytic infiltration in the chorioamniotic membrane and endometrium (greater than or equal to ten white blood cells per high-power field) were more likely than were patients with negative findings to develop endomyometritis. All of the laboratory tests evaluated were specific but insensitive predictors of infection. Assessment of duration of ruptured membranes and length of labor provided a diagnostic test that was as clinically useful in predicting postoperative infection as were any of the laboratory studies evaluated.

Management of premature rupture of membranes and unfavorable cervix in term pregnancy

One hundred thirty-four indigent patients at term who had premature rupture of membranes and a cervix unfavorable for induction of labor (80% effacement or less, 2 cm dilation or less) were randomized to compare expectant with intervention management. Women with any medical or obstetric condition warranting immediate intervention were excluded from the study. Patients treated expectantly were placed at bed rest and observed for labor or infection. Patients managed by intervention were given oxytocin if labor did not ensue within 12 hours of rupture of the membranes. Patients in the intervention protocol had longer labor (P less than .02) and a higher incidence of both cesarean delivery (P less than .05) and intraamniotic infection (P less than .05). There was only one case of proven neonatal sepsis, and this occurred in a patient managed by induction of labor. There was no statistically significant difference between groups in mean length of maternal hospitalization.

The course of labor in term patients with chorioamnionitis

Labor records and internal fetal monitor tracings of 65 patients with uncomplicated term pregnancies who entered labor spontaneously and then developed chorioamnionitis were reviewed. Eighty-eight percent of patients were nulliparous. Seventy-five percent had abnormal labor, characterized by decreased uterine contractility, and 34% required cesarean delivery because of failure to progress in labor. The most common fetal heart rate abnormalities were diminished or absent variability (77%) and tachycardia (67%); 15% of the tracings had a sinusoidal pattern. Despite the high prevalence of abnormal fetal heart rate tracings, only one infant had a 5-minute Apgar score less than 7. It is concluded that chorioamnionitis has an inhibitory effect on labor. Compared to uninfected women, certain infected patients appear to require higher doses of oxytocin and greater uterine activity to effect a given change in cervical dilation.

Mycoplasma hominis and intrauterine infection in late pregnancy

Amniotic fluid was collected via a transcervical intrauterine catheter from patients with clinical evidence of intrauterine infection and from uninfected comparison patients. The amniotic fluid was cultured for Mycoplasma hominis and Ureaplasma urealyticum, as well as for aerobic and anaerobic bacteria. Two series of patients are reported. In the first, there were 52 patients with intraamniotic infection and 52 matched controls. Eighteen patients (35%) with intraamniotic infection and four control patients (8%) had M. hominis in the amniotic fluid (P less than .001). Twenty-six patients (50%) with intraamniotic infection and 26 control patients (50%) had U. urealyticum in the amniotic fluid. In the second series, samples were collected consecutively. M. hominis was isolated from 32% (19/60) of specimens from patients with signs of infection and from 14% (8/56) of afebrile comparison patients (P less than .02). U. urealyticum was recovered from 43% and 39% of these fluids, respectively; the difference was not significant. When M. hominis was found in amniotic fluids of patients with signs of infection, the amniotic fluid usually contained greater than or equal to 10(2) cfu of a high virulent bacterial isolate per milliliter. Qualitative cultures showed that M. hominis in the amniotic fluid is associated with clinical intrauterine infection.

A case-control study of wound abscess after cesarean delivery

A retrospective, case-control study was performed to determine risk factors for, and complications of, wound abscess after cesarean delivery. The records of 64 patients with abscess and 64 controls were examined. The following variables were significantly associated with wound abscess: labor duration, interval from rupture of membranes to delivery, number of vaginal examinations, duration of internal fetal monitoring, operating time, and estimated blood loss. Also strongly associated were presence of endometritis or chorioamnionitis, fever in labor, and an indication of dystocia. The mean hospital stay was six days longer in patients with wound abscess. Fascial dehiscence requiring repair was present in 4.7%.

Inhibition of group B streptococci by amniotic fluid from patients with intra-amniotic infection and from control subjects

This study describes the inhibition of group B streptococci by amniotic fluid from 50 patients with intra-amniotic infection and 50 matched, noninfected control subjects. Patients were matched for gestational age, time from rupture of membranes to delivery, and time from rupture of membranes to collection of the sample of fluid. Study patients had the clinical diagnosis of intra-amniotic infection and greater than or equal to 10(2) colony-forming units of a high-virulence organism per milliliter. None of the control patients became infected or received antibiotics. We collected the amniotic fluid in the study patients prior to antibiotic therapy. A comparison of bacterial growth in the amniotic fluid versus the amniotic fluid plus phosphate showed that only eight (16%) of the intra-amniotic infection samples of fluid were inhibitory, whereas 18 (36%) of the control samples of fluid were inhibitory (X2 = 5.20, p less than 0.02). However, a comparison of group B streptococci growth in amniotic fluid and Todd-Hewitt broth did not show a statistically significant difference. We conclude that the amniotic fluid bacterial inhibitory assay with group B streptococci is technically more difficult to perform and interpret.

Randomized comparison of ceftazidime versus clindamycin-tobramycin in the treatment of obstetrical and gynecological infections

A randomized comparison of ceftazidime versus clindamycin-tobramycin was performed for the treatment of obstetrical and gynecological infections. Entry criteria were an oral temperature of greater than or equal to 38 degrees C and a clinical diagnosis of endometritis, salpingitis, or pelvic cellulitis after hysterectomy. All patients with endometritis had cultures of intrauterine material obtained via a transcervical single-lumen catheter. The patients with pelvic cellulitis had material from the vaginal apex aspirated for culture, and all patients with salpingitis had a culdocentesis for culture of intraperitoneal material. Of 38 patients who received ceftazidime, 34 had endometritis after cesarean section, 3 had endometritis after abortion, and 1 had pelvic cellulitis. Of 39 patients who received clindamycin-tobramycin, 35 had endometritis after cesarean section, 3 had salpingitis, and 1 had pelvic cellulitis. The most common bacterial isolates were Lactobacillus sp., Bacteroides bivius, Escherichia coli, other gram-negative aerobic bacilli, group B streptococci, and other aerobic streptococci. Bacteremia occurred in 9.0% of the patients. Of the patients receiving clindamycin-tobramycin and ceftazidime, 34 (87.2%) and 34 (89.5%), respectively, responded to therapy. All the clinical failures occurred in patients with endometritis after cesarean section. Clinical failures had persistent fever despite 3 or more days of treatment. One of the patients receiving clindamycin-tobramycin developed an urticarial rash after her infection had resolved. No patient in either group developed diarrhea. In these small groups of patients, there were no significant differences in cure rate, side effects, or length of hospital stay.

A double-blind, randomized comparison of moxalactam versus clindamycin-gentamicin in treatment of endomyometritis after cesarean section delivery

A double-blind comparison of clindamycin plus gentamicin versus moxalactam plus placebo was performed for the treatment of endomyometritis after cesarean section delivery. Entry criteria were uterine tenderness, temperature greater than or equal to 101 degrees F, and leukocytosis. Uterine specimens were obtained for culture via a single-lumen transcervical catheter. Bacteremia occurred in 10% of patients. Among the 57 patients treated with clindamycin plus gentamicin, there were two clinical failures and four side effect failures (diarrhea in two, allergic reaction in two). Among the 56 patients in the moxalactam group, there were four clinical failures and one side effect failure (diarrhea). Both regimens had good cure rates, with no significant differences in cures or postoperative hospital stay.

Serum gentamicin levels in patients with post-cesarean endomyometritis

Serum gentamicin levels were measured by agar diffusion bioassay in 38 patients undergoing treatment with clindamycin-gentamicin for post-cesarean endomyometritis. Patients received intravenous gentamicin in a dose of 1 mg/kg actual body weight every eight hours. All trough levels were less than 1 microgram/ml. The mean 30-minute postinfusion level was 5.78 +/- 2.43 micrograms/ml (mean +/- SD). The range of postinfusion concentrations was 1 to 12 micrograms/ml. Postinfusion concentrations were less than 5 micrograms/ml in 13 patients, but none of these individuals experienced a clinical failure of antimicrobial therapy. There were no statistically significant differences in mean age, weight, hematocrit, serum creatinine, estimated creatinine clearance, or administered dose in patients with therapeutic gentamicin levels and patients with apparent subtherapeutic levels. The authors conclude that postinfusion gentamicin concentrations fluctuate widely in obstetric patients receiving 1 mg/kg/dose and that apparent subtherapeutic postinfusion levels still may be clinically efficacious, depending upon the antimicrobial susceptibility of the infecting microorganisms.

Pelvic vein thrombophlebitis: diagnostic dilemma and therapeutic challenge

Pelvic vein thrombophlebitis is an unusual, but extremely serious, complication of pelvic surgery. It occurs in approximately 0.5 to 1 per cent of patients who develop operative site infections. It may present as two distinct clinical syndromes: acute ovarian vein thrombosis and diffuse thrombosis of multiple small pelvic vessels. Accurate diagnosis is hampered by the absence of a reliable, specific, and noninvasive test for the disorder. Treatment of pelvic vein thrombophlebitis requires administration of broad spectrum antibiotics, intravenous heparin, and, in selected cases, ovarian vein and vena cava ligation.

A controlled study of amniotic fluid immunoglobulin levels in intraamniotic infection

The authors studied the levels of immunoglobulins (Ig) in the amniotic fluid of 46 patients with intraamniotic infection and of 46 matched controls. Amniotic fluid was collected through a transcervical intrauterine catheter. All infected patients had clinical signs of intraamniotic infection and at least 10(2) colony-forming units/milliliter of a high-virulence organism. None of the controls became infected. The matching criteria were gestational age, labor, interval from rupture of the membranes to delivery, and interval from rupture of the membranes to amniotic fluid collection. The authors tested each amniotic fluid sample for immunoglobulins G, M, and A by a single radial immunodiffusion technique. The mean IgG level in amniotic fluid for the intraamniotic infection group was 33.9 +/- 38.5 mg/dl, and the mean level for the control group was 17.9 +/- 11.1 mg/dl. The authors concluded that the mean IgG level in amniotic fluid from patients with intraamniotic infection is significantly higher than in controls (P less than .02).

A controlled study of genital mycoplasmas in amniotic fluid from patients with intra-amniotic infection

Amniotic fluid (AF) was collected via a transcervical, intrauterine catheter from 52 patients with clinical intra-amniotic infection (IAI) and from 52 matched, uninfected controls. The AF was cultured for Mycoplasma hominis and Ureaplasma urealyticum as well as for aerobic and anaerobic bacteria. Eighteen (35%) patients with IAI and four (8%) controls had M. hominis in AF (P less than 0.001). Twenty-six (50%) patients with IAI and 26 (50%) control patients had U. urealyticum in AF (difference not significant). In the AF specimens of patients with IAI, 15 (83%) of the 18 with M. hominis also contained greater than or equal to 10(2) colony-forming units (cfu) of a high-virulence bacterial isolate/ml (P less than 0.05). Within the limitations of the experimental design, U. urealyticum in AF is not associated with clinical IAI, whereas, with qualitative cultures, M. hominis in AF is. However, in IAI, M. hominis is isolated most commonly from the AF of patients with greater than or equal to 10(2) cfu of a high-virulence bacterial isolate/ml.

A prospective, controlled study of maternal and perinatal outcome after intra-amniotic infection at term

A study was made of the outcome for mothers and their neonates with both clinical and bacteriologic evidence of intra-amniotic infection at term. Samples of amniotic fluid from patients with intra-amniotic infection showed greater than 10(2) colony-forming units per milliliter of a high-virulence isolate, whereas samples from control patients showed no growth or low-virulence isolates only. Control patients were uninfected during labor and were matched on the basis of gestational age, interval from rupture of membranes to delivery, and mode of delivery. There were 67 matched pairs. The mean interval from diagnosis of intra-amniotic infection to delivery was 3.1 +/- 2.2 hours (+/- SD). Mothers with intra-amniotic infection had a significantly longer hospital stay and greater fever index after delivery than did control patients. Intrapartum bacteremia was documented in six of 50 (12%) women with intra-amniotic infection. The cesarean birth rate was 36%. There was one case of probable septic shock and one of postpartum hemorrhage among women with intra-amniotic infection. Infants in the intra-amniotic infection group had a significantly longer hospital stay than did the control infants. Among 59 infants for whom blood culture results were available, bacteremia was documented in five (8%) with intra-amniotic infection. Definite radiographic evidence of pneumonia was present in 4%; there were no cases of meningitis. There was one perinatal death in the intra-amniotic infection group. Overall, the maternal and perinatal outcome after intra-amniotic infection at term was excellent.

Acute intraamniotic infection due to Streptococcus pneumoniae

In isolated instances, Streptococcus pneumoniae has been reported to be the cause of genital tract infection. In such cases, pelvic infection usually has occurred in association with a primary infection in the respiratory tract and a subsequent bacteremia. The authors describe 2 cases of acute intraamniotic infection due to the pneumococcus. Both cases occurred in the absence of any other site of infection. The potential serious complications of pneumococcal infection are emphasized.

Endometrial culture techniques in puerperal patients

Four techniques for obtaining endometrial cultures in puerperal patients were compared in 18 uninfected women undergoing postpartum tubal ligation. Four culture specimens were obtained from each patient in the following sequence: transfundal aspiration, transcervical brush biopsy of the endometrium through a double-lumen catheter, transcervical lavage of the endometrial cavity through a double-lumen catheter, and aspiration of the secretions from the lower uterine segment through a single-lumen catheter. Quantitative cultures for aerobic and anaerobic bacteria were performed on all specimens. Cultures from the single-lumen aspirate had the greatest variety of different organisms and the highest colony counts of individual organisms. The brush and lavage techniques were equally effective in reducing, but not eliminating, contamination of endometrial specimens with cervical organisms. The authors conclude that, of the techniques evaluated in these uninfected patients, the most satisfactory procedure for routinely obtaining endometrial cultures is brush biopsy or lavage through a double-lumen catheter.

Premature rupture of the membranes

Since 1970 there have been many changes in our knowledge of premature rupture of the membranes (PROM). Studies of its causes have focused on clinical variables, physical properties of the membranes, and subclinical infection, while new diagnostic techniques have included biochemical and histochemical tests, as well as intrauterine dye injection. Within the last decade, new approaches in management have employed corticosteroids, tocolytics, and amniocentesis. Because of limitations of current studies, however, it is difficult to compare one study to another. Consequently, management of PROM remains a major dilemma. This review provides a summary and commentary on recent works.

Moxalactam for treatment of pelvic infections after cesarean delivery

Moxalactam was given to 136 women for treatment of uterine infections after cesarean delivery. After an intravenous loading dose of 2 g, 36 women received 3 g daily and 100 were given 6 g daily. The clinical success rates of these two regimens were 86% and 89%, respectively; however, in four of five women for whom treatment with the 3-g daily dose failed, extensive surgery was necessary for cure. A total of 395 pathogens was isolated from these women with polymicrobial infections, and almost 90% were susceptible to moxalactam at less than or equal to 32 micrograms/ml. Adverse effects of therapy were minimal. Thus, moxalactam given initially as a dosage of 6 g daily is effective for treatment of women with pelvic infections after cesarean delivery.

The pharmacokinetics of prophylactic antibiotics administered by intraoperative irrigation at the time of cesarean section

Thirty patients at term undergoing cesarean section received intraoperative irrigation with either cefamandole, cephalothin, or ampicillin to prevent postoperative infection. Serum drug levels were measured at 15, 60 and 120 minutes after completion of irrigation. Serum levels at each sampling interval were highest for cefamandole and lowest for cephalothin. Les than 2% of the total drug dose was excreted in the urine during the first 2 postoperative hours. In most patients, maximum serum antibiotic concentrations exceeded minimal inhibitory concentrations for several recognized pelvic pathogens. It is concluded that the mechanism of action of intraoperative irrigation may in part be due to systemic absorption of antibiotic and not simply to a local effect on the endometrium. Moreover, the degree of systemic absorption may be sufficient to cause allergic drug reactions and to exert selective pressures for the emergence of drug-resistant microorganisms.

A double-blind, randomized comparison of clindamycin-gentamicin versus cefamandole for treatment of post-cesarean section endomyometritis

Among patients with endomyometritis after cesarean section, a double-blind comparison of clindamycin-gentamicin versus cefamandole-placebo therapy was performed. Study criteria were: exclusion--use of prophylactic antibiotics or allergy to the drugs used; entry--uterine tenderness, oral temperature greater than or equal to 101 degrees F, and leukocytosis. Uterine specimens for culture were obtained via a single-lumen transcervical catheter. Most common isolates were Bacteroides bivius, Escherichia coli, and anaerobic cocci. Bacteremia occurred in 9.0%. Therapy results were: [Chart: see text]. Therapeutic failures were defined as persistent fever despite 3 or more days of treatment. Among the six clindamycin-gentamicin therapeutic failures, one patient had a resistant organism, and one had a pelvic mass. Among the 13 cefamandole-placebo therapeutic failures, three patients had resistant organisms, and one had a pelvic mass. Cause of persistent fever was not evident in the other patients. Side effects that necessitated discontinuation of therapy were: clindamycin-gentamicin group--diarrhea (six), allergic response (one); cefamandole-placebo group--diarrhea (two), allergic response (one). If the common practice of excluding side-effect failures is followed, there were more cures in the clindamycin-gentamicin group (P = 0.06).