Influencia de algunos factores del parto y el periparto que influyen en la endometritis puerperal / Influence of some factors of delivery and peridelivery influencing on puerperal endometritis

Con la finalidad de identificar los factores maternos del parto y el periparto que influyen en la endometritis, se realizó una investigación retrospectiva, transversal y analítica en el hospital docente ginecoobstétrico "Justo Legón Padilla", entre el 1ro. de enero y el 31 de diciembre de 2001. El grupo estudio estuvo conformado por 179 pacientes que presentaron endometritis posparto, mientras que el grupo control fue tomado de forma aleatoria simple (n = 230). Para la recogida de los datos se utilizó un formulario que incluía variables de la madre, el parto y el periparto. El análisis estadístico se realizó por la frecuencia porcentual, la media y la desviación estándar. Para la comparación de los grupos se utilizó el Chi cuadrado con diferentes niveles de significación: p < 0.05 (significativo), p < 0,01 (muy significativo) y p < 0,001 (altamente significativo). Se obtuvo una asociación significativa entre la adolescencia, la añosa, la primigesta, el embarazo postérmino, la cesárea, 20 o más horas de bolsa rota, 10 o más horas de trabajo de parto, 4 o más tactos vaginales y el líquido amniótico meconial, con la endometritis. Concluimos que todas las variables antes mencionadas constituyen factores de riesgo para que se produzca una infección posparto

Histerectomía puerperal: estudio de 14 años / Puerperal hysterectomy: a 14-year study

Se realizó un estudio retrospectivo, longitudinal y descriptivo en el hospital docente "Julio Trigo López", con el objetivo de caracterizar las histerectomías puerperales en el período comprendido entre Mayo de 1989 a diciembre del 2002 . El universo estuvo comprendido por 99 pacientes para una tasa de incidencia de 21,8 por 100 000 nacimientos. Se encontró que la cesárea se destaca como proceder de riesgo en el 55,7 por ciento de los casos. Las causas fundamentales que llevaron a estas pacientes a la histerectomía fue la atonía en un 28,2 por ciento de los casos, seguida por la infección en un 25,2. Sólo el 25,2 por ciento de las pacientes histerectomizadas presentaron alguna complicación en el posoperatorio. La tasa de mortalidad materna por histerectomía puerperal fue muy baja en este período de estudio, para el 1,1 por cada 10 000 nacimientos

The diagnosis and treatment of a patient with puerperal infection and subdural hygromas.

We describe a patient readmitted after developing a persistent postural headache resulting from an accidental lumbar puncture during labor 10 days earlier. Magnetic resonance imaging demonstrated bifrontal subdural hygromas and diffuse pachymeningeal enhancement. The patient had signs of a puerperal infection, and an epidural patch was performed with dextran 40 instead of blood, after which gradual improvement was noted. The patient was discharged totally asymptomatic 3 days later.

Septic pelvic thrombophlebitis and preeclampsia are related disorders.

OBJECTIVE: To elicit factors associated with the postpartum development of septic pelvic thrombophlebitis in a single large referral tertiary patient population. METHODS: A nine-year single institution retrospective case review of all patients with enigmatic fever and septic pelvic thrombophlebitis was analyzed. RESULTS: A total of 55 patients with septic pelvic thrombophlebitis were provided care during the study interval. The average gestational age at delivery was 36.8 +/- 4.3 weeks. The most prevalent concurrent medical complication of pregnancy was preeclampsia (45%) while chorioamnionitis affected only 13%. The average length of ruptured membranes was 22.8 +/- 56.8 hours (median 10.5, 95% confidence interval [CI] 7.0-38.7 hours), with 22% of patients undergoing amnion rupture at the time of cesarean delivery. Prolonged (>24 hours) amnion rupture occurred in only 9% of patients. Most affected patients were delivered abdominally (91%) but a minority delivered vaginally (9%). Antibiotic therapy for presumed infection was initiated at 27.4 +/- 24.6 hours postpartum. Subsequently intravenous heparin therapy was initiated 128.9 +/- 54.2 hours thereafter enigmatic fever defervesed 37.2 +/- 36.8 hours later (median 34.0, 95% CI 27.2-47.3 hours). Patients received 6.3 +/- 1.8 days of heparin therapy. CONCLUSION: In this series, septic pelvic thrombophlebitis was frequently preceded by cesarean delivery and commonly associated with preeclampsia. Unexpectedly, a small number of patients suffered prolonged rupture of membranes or chorioamnionitis. We speculate that the cesarean delivery of a population of at-risk patients with preeclampsia may predispose them to develop septic pelvic thrombophlebitis.

Association between postpartum pyrexia and uterine bacterial infection in dairy cattle.

The temperature of 90 dairy cattle was recorded for the first 10 days after parturition and the animals were categorised as either normal (< 39.7 degreesC) or pyrexic. Swabs were collected from the uterine lumen seven, 14, 21 and 28 days after parturition for aerobic and anaerobic culture; bacteria were identified and their growth was scored semiquantitatively. Blood samples were collected three times a week for the estimation of the concentrations of acute phase proteins. The cows' temperatures were often above the accepted normal range, but it was not a good indicator of the number of bacteria in the uterus. However, pyrexia was correlated with the presence of specific uterine pathogens (P < 0.05) and in particular with Prevotella species (P < 0.01). The pyrexic animals had a higher plasma concentration of the acute phase protein (alpha1-acid glycoprotein (P < 0.05). Although pyrexia is an indicator of postpartum inflammation, additional clinical signs are necessary to identify uterine bacterial infection.

Higher rates of post-partum complications in HIV-infected than in uninfected women irrespective of mode of delivery.

OBJECTIVE: To inform the debate on the use of elective caesarean section (CS) delivery in HIV-infected women, we investigated the occurrence of clinical events in the immediate post-partum period in women delivering in 13 European centres. DESIGN: Two separate matched case-control studies (vaginal and elective CS deliveries) among infected women (cases) and uninfected controls delivering between 1992 and 2002. METHODS: The prevalence of minor and major post-partum complications was assessed overall for infected and uninfected women; within mode of delivery group (vaginal/CS) the complication rates of infected cases were compared with uninfected controls in a matched analysis. RESULTS: Overall complication rates were 29.2% (119 of 408) for HIV-infected women, 19.4% (79 of 408) for uninfected women, 42.7% (135 of 316) for CS deliveries and 12.6% (63 of 500) for vaginal deliveries. There were no major complications in women delivering vaginally; but, compared with controls, HIV-infected cases were at increased risk of puerperal fever [odds ratio (OR), 4.5; 95% confidence interval (CI), 1.55-13.07), especially after medio-lateral episiotomy. In the CS group, there were six major complications (five among cases, one control) (OR, 5.1; 95% CI, 0.58-45) and cases had an increased risk of minor complications (OR, 1.51; 95% CI, 1.22-2.41) compared with controls, mainly anaemia not requiring blood transfusion. CONCLUSION: HIV-infected pregnant women are at increased risk of post-partum complications regardless of mode of delivery, but modification of clinical practice, particularly use of prophylactic antibiotics, would reduce this risk. Infected women should be informed about risks of vertical transmission and post-partum complications, and be involved in mode of delivery decisions.

Enoxaparin for postpartum ovarian vein thrombosis. A case report.

BACKGROUND: Intravenous heparin is a recognized treatment for ovarian vein thrombosis. Although an effective, less cumbersome alternative exists with lowmolecular-weight heparins, the literature does not contain reports of their use for this condition. We report a case of postpartum ovarian vein thrombosis managed with enoxaparin. CASE: A 29-year-old woman, gravida 1, para 1001, was readmitted with postpartum endomyometritis. After 5 days of appropriate antibiotics, computed tomography of the abdomen/pelvis demonstrated a right ovarian vein thrombus. Enoxaparin was initiated, resulting in a rapid clinical improvement, and hospital discharge was achieved within 36 hours. CONCLUSION: Enoxaparin treatment for avarian vein thrombosis is an alternative to intravenous heparin that may permit a shorter hospital stay without the need for coagulation profile monitoring.

Recurrent group A Streptococcal genital infection after Puerperal sepsis.

Recurrent group A streptococcal infection is a well-known phenomenon. It is well documented as a problem in pharyngotonsillitis and skin infections. This report describes a case of recurrent genital infection after puerperal sepsis caused by group A streptococci.

Incidence, treatment and outcome of peripartum sepsis.

BACKGROUND AND METHODS: Clinical and microbiological features of maternal sepsis in the peripartum period (7 days before to 7 days after delivery) were analyzed to determine possible risk factors, optimal treatment and outcome. In 43 483 deliveries during 1990-98, laboratory-confirmed bacteremia was found in 41 (5.1%) out of 798 clinically suspected septic infections. RESULTS: Preterm deliveries were associated with a crude 2.7-fold risk for peripartum sepsis as compared to term deliveries. Antepartum sepsis was associated with a crude 2.6-fold risk for cesarean section, while postpartum sepsis was 3.2 times more likely to occur after cesarean section than after vaginal delivery. A combination of cefuroxime and metronidazole was used in 80% (33/41) of all treatments. All mothers recovered well, and only one suffered from septic shock. In total, 42 bacterial strains, representing 18 different bacterial species, were isolated from the blood cultures; 37 strains (88%, 37/42) were aerobic and five (12%, 5/42) were anaerobic. The most common species were betahemolytic streptococci, Escherichia coli and Staphylococcus aureus. Most microbes (81%, 34/42) were found to be susceptible to first- or second-generation cephalosporins. CONCLUSION: Our analysis shows that peripartum sepsis is associated with preterm pregnancies and cesarean sections. Treatment of peripartum sepsis with second-generation cephalosporin is usually effective, and the outcome is good.

Prevention and treatment of postpartum endometritis.

Postpartum endometritis is an important cause of maternal morbidity after cesarean section. Prophylactic antibiotic therapy reduces the risk by approximately 60%. The benefit of antibiotic therapy for laboring women has been established. For nonlaboring patients, there is still some uncertainty. Intravaginal metronidazole as surgical preparation and oral methylergometrine after delivery are two interventions that show promise as additional prophylactic interventions. The gold standard therapy, once endometritis has been diagnosed, is intravenous clindamycin and gentamicin. If an alternative regimen is chosen, it should have a similar spectrum, including good coverage for gram-positive anaerobes such as Bacteroides fragilis. Antibiotic therapy can be discontinued once the patient is afebrile without continued oral antibiotics. Treatment failure occurs in approximately 10% of cases and should trigger investigation of other infectious complications. Prolonged fever of undetermined etiology is not uncommon and requires prolonged antibiotic therapy, with or without heparin.

[A pseudo-epidemic of puerperal sepsis]. / Een pseudo-epidemie van kraamvrouwenkoorts.

Within a four-week period, five patients were admitted to the maternity ward of the Utrecht Children's Hospital diagnosed with puerperal sepsis due to group-A streptococcal infection. The clinical presentation was different for each patient. All patients recovered upon adequate antibiotic treatment. One of the children died, possibly due to sepsis and hypotension of his mother. As group-A streptococci can be extremely contagious and an epidemic was suspected, measures for additional hygiene were taken. Furthermore, all personnel at the maternity ward and the obstetric centre were tested. T-serotyping, M-genotyping, exotoxin A- and C-gene amplification and pulsed field gel electrophoresis were used to characterize the cultured group-A streptococci. Cross-contamination was not found. Therefore, this increase in puerperal sepsis was attributed to polyclonal expansion rather than an epidemic. All mothers of newly born children who present with fever and lower abdominal pain should be suspected of group-A streptococcal infection. Evaluation and treatment in hospital is indicated due to a sometimes fulminant course. When group-A streptococci are cultured again in a new pregnancy, eradication therapy during pregnancy or prophylactic treatment during birth should be considered to prevent recurrent infection.

Breast gangrene as a complication of puerperal sepsis.

Gangrene of the breast, although rare, has been reported following anticoagulant treatment, trauma, and infection. Two cases of breast gangrene due to puerperal sepsis have been reported. We report a case of right breast gangrene as a complication of puerperal sepsis in a female patient.

Group A streptococcal sepsis and ovarian vein thrombosis after an uncomplicated vaginal delivery.

BACKGROUND: Group A streptococcal puerperal sepsis is an uncommon peripartum infection that can quickly progress to a fulminant, multisystemic infection and life-threatening toxin-mediated shock. This infection can be asymptomatic during a short hospital stay after a routine delivery. Early treatment with antibiotics might not alter the course of tissue destruction caused by the exotoxin A. METHODS: Literature searches were performed using the key words "puerperal infections," "streptococcal infections," "septic sacroiliitis," "postpartum septic arthritis," and "postpartum ovarian vein thrombosis." After patient consent was obtained, a report was prepared documenting the disease course, diagnosis, and treatment of a case of puerperal sepsis with multiple serious complications. RESULTS AND CONCLUSION: Puerperal sepsis occurs when streptococci colonizing the genital tract or acquired nosocomially invade the endometrium, adjacent structures, lymphatics, and bloodstream. A lack of symptoms early in the course of infection is common; later, minor somatic complaints can quickly progress to septic shock as effects of the exotoxin A are manifest. Women who complain of fever, pelvic pain, or unexplained systemic symptoms in the early postpartum period should have a detailed history and physical examination. All sites of suspected infection should be cultured. If sepsis is suspected, diagnostic imaging includes chest radiographs, contrast-enhanced computed tomographic scans, or magnetic resonance imaging to rule out ovarian vein thrombosis, pelvic abscess, or sacroiliac septic arthritis. Broad-spectrum antibiotic coverage must be initiated immediately after collection of cultures. Clindamycin plus a beta-lactam antibiotic is preferred for streptococcal toxic shock syndrome.

[Pain in the symphyseal region after parturition: possibly osteomyelitis]. / Pijnklachten in de symfyseregio na een bevalling: mogelijk osteomyelitis.

A 29-year-old woman 3 weeks after her first childbirth suffered from atypical and progressive pain in the pelvis, which turned out to be a symptom of osteomyelitis of the pubic bone. She recovered after treatment with antibiotics and 6 weeks' stabilization of the pelvis. Symptoms of osteomyelitis resemble those of pubic osteitis, symphyseal rupture and symphysiolysis. Radiologically, osteomyelitis is characterized by development of infiltrates, cortical involvement and local osteopenia. Isolation of micro-organisms in a bone culture after puncture is regarded as proof of the diagnosis. The treatment is primarily with antibiotics, if abscesses or sequestra develop these should be relieved and/or removed.

Streptococcus pneumoniae peritonitis postpartum.

A peritonitis caused by an ascending infection is a rare complication postpartum. A 37-year-old woman presented with a secondary peritonitis due to Streptococcus pneumoniae. The patient had given birth to a healthy boy 4 weeks before and showed no symptoms of a bronchitis on admission. An operation was performed after the patient developed an acute abdomen, showing a diffuse peritonitis. High vaginal swabs and blood cultures taken on admission were positive for S. pneumoniae as well as the specimen taken during the operation. Thus we concluded that this was a case of an ascending infection. After antibiotic therapy with penicillin the patient could be discharged 8 days after the operation.

Post-parturition infectious endocarditis in a patient with a normal mitral valve.

A 29-year-old woman with no history of heart disease was admitted for the treatment of congestive heart failure. Six months earlier, she had given birth, then 20 days later developed a fever and cardiac failure ensued. An echocardiogram demonstrated severe mitral valve regurgitation. Her blood cultures were positive, and we made a diagnosis of mitral valve regurgitation due to infectious endocarditis. Despite treatment for congestive heart failure and antibiotic therapy, resulting in negative blood cultures, her congestive heart failure did not improve, and vegetation on the mitral valve was observed by echocardiography. We successfully removed the infected tissue with mitral valve plasty.

Sepsis puerperal: prevención y tratamiento / Puerperal sepsis: prevention and treatment

La sepsis puerperal todavía constituye una de las causas más importantes de morbilidad y muerte materna en todo el mundo, incluyendo a nuestro país. En el Instituo Mexicano del Seguro Social (IMSS) ha representado la tercera causa más frecuente de este tipo de muerte desde hace más de 10 años. Ha sido asociada, entre otros factores, con falta de acciones médico-preventivas sistematizadas durante la vigilancia prenatal y con la calidad limitada de la atención obstétrica hospitalaria. Por lo anterior, el propósito de este trabajo consiste en recapitular los criterios y procedimientos técnicos-médicos más aceptados actualmente para la prevención y tratamiento de las principales formas clínicas de la infección puerperal, como la sepsis posaborto, posoparto y la corioamnioítis, con el fin de contribuir a su difusión entre el personal médico de los tres niveles de atención en el IMSS, y favorecer su aplicación en la práctica diaria