Uterine clostridial myonecrosis after thermal balloon endometrial ablation.

BACKGROUND: We present a case of a patient who had development of uterine clostridial myonecrosis after elective thermal balloon endometrial ablation in the absence of identifiable risk factors. CASE: A 51-year-old woman underwent uneventful thermal balloon endometrial ablation for the treatment of menorrhagia. The next day, she presented with acute inflammatory syndrome, severe intravascular hemolysis, and acute kidney injury. The blood cultures and the high vaginal swab showed moderate growth of Clostridium species. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Her postoperative course was uneventful, and renal function gradually recovered. CONCLUSION: Clostridial myonecrosis after uncomplicated surgery, although rare, should be considered in the differential diagnosis of the acutely septic patient with massive hemolysis, regardless of the presence of patient's risk factors.

Group A Streptococcus causing a life-threatening postpartum necrotizing myometritis: a case report.

During childbirth, group A Streptococcus (GAS) can cause a diverse spectrum of disorders ranging from asymptomatic infection to puerperal sepsis and toxic shock syndrome. We report on a healthy parturient who survived a life-threatening necrotizing myometritis due to GAS following an unremarkable spontaneous delivery. Approximately 29 h after an unremarkable spontaneous vaginal delivery, a generally healthy 28-year-old multiparous woman developed a life-threatening necrotizing myometritis due to GAS. The patient subsequently underwent a total abdominal hysterectomy. Following the surgery, she made a prompt and complete recovery. The course of this extremely rare complication might be so fulminant that the diagnosis is sometimes made after the patient cannot be saved. Clinicians should still consider GAS in life-threatening infections occurring during the perinatal period.

Effects of chronic specific urogenital infections on contractility of the human isolated pregnant myometrium.

The contractile activity of the isolated myometrium of pregnant women with mycoplasma, chlamydia and mixed infections has been studied by pharmacological organ bath method. We found that mycoplasma infection decreased while chlamydia or mixed infection increased myometrium contraction evoked by oxytocin or prostaglandin F2alpha. The results of this study could be important for the prediction of possible complications during pregnancy and labour in women with chronic specific urogenital infections.

Non-surgical management of post-cesarean endomyometritis associated with myometrial gas formation.

We present a case of post-cesarean delivery, nonclostridial endomyometritis in which uterine (myometrial) gas formation raised concern for myonecrosis and need for hysterectomy. The patient fully recovered without surgery. Myometrial gas formation in this setting and in an otherwise stable patient may be an insufficient reason for hysterectomy.

Therapeutic effects of cefozopran on polymicrobial infections associated with Enterococcus faecalis in a Rat pyometra model.

Enterococcus faecalis plays an important role as a pathogen in polymicrobial infections. We evaluated the efficacy of cefozopran (CZOP) using polymicrobial pyometra rats. Rats were infected with a mixed intrauterine inoculation of E. faecalis plus either Bacteroides fragilis or Prevotella bivia (minimal inhibitory concentration of CZOP; E. faecalis: 6.25 micrograms/ml, B. fragilis: 12.5 micrograms/ml, P. bivia: 12.5 micrograms/ml). Immediately after inoculating 10(5) CFU of each organism/rat, CZOP (either 40 mg/kg, i.v., q.i.d., for 5 days or 80 mg/kg, i.v., b.i.d., for 5 days) was administered. The intrauterine inflammatory change and bacterial counts in the CZOP-treated group were compared with those in the nontreated control group. CZOP significantly (p < 0.01) decreased the bacterial counts except for B. fragilis in the regimen of 80 mg/kg b.i.d. However, the 40 mg/kg, q.i.d., regimen significantly (p < 0.05) reduced bacterial counts compared to 80 mg/kg, b.i.d. These results suggest that CZOP in a more divided dose is efficacious for the treatment of polymicrobial infections associated with E. faecalis in pyometra.

In vitro and in vivo antibacterial activities of a new carbapenem BO-2727 for use in obstetrics and gynecology.

The antibacterial activity of BO-2727 against 100 clinical isolates of Streptococcus agalactiae (20 strains), Escherichia coli (20 strains), Peptostreptococcus magnus (20 strains), Bacteroides fragilis (20 strains) and Prevotella bivia (20 strains) was compared with those of imipenem, panipenem, meropenem, biapenem and ceftazidime (CAZ). Minimal inhibitory concentrations (MICs) for 50% of tested strains (MIC50s) of BO-2727 against S. agalactiae, E. coli, P. magnus, B. fragilis and P. bivia were 0.05, 0.05, 0.1, 0.78 and 0.78 mg/l, respectively. MIC90s of BO-2727 against S. agalactiae, E. coli, P. magnus, B. fragilis and P. bivia were 0.05, 0.05, 0.1, 0.78 and 0.78 mg/l, respectively. The efficacy of BO-2727 was evaluated using a polymicrobial pyometra model (E. coli and B. fragilis) in rats. Both the inflammatory changes in the uterus, from the point of view of neutrophil accumulation, and the bacteriological response in the treated group were milder than those in either the nontreated group or the CAZ-treated group. These results indicate that BO-2727 may be useful for the treatment of polymicrobial infections in patients with pyometra.

A new type of fulminant group A streptococcal infection in obstetric patients: report of two cases.

A new type of fulminant group A streptococcal infection in obstetric patients is described. The illness occurs in late stage of pregnancy, and is preceded by an episode of upper respiratory tract infection. This is followed by sudden onset of septicemia, subsequent hematogenous infection of the myometrium by the bacteria, and development of acute purulent myometritis. Shock and multiorgan failure ensue rapidly. Prognosis of both the mother and fetus is very poor, as recognition of this serious condition is difficult until the late stage of the disease. This type of infection is entirely different from classical puerperal sepsis in that the illness starts before delivery, and that there was no evidence of ascending bacterial infections of the birth canal, such as acute endometritis or chorioamnionitis, in affected mothers. The underlying mechanism for this serious infection remains unknown.

Why patients fail antibiotic prophylaxis at cesarean delivery: histologic evidence for incipient infection.

A prospective, blinded study was conducted to test the hypothesis that antimicrobial prophylaxis failure after cesarean delivery is associated with incipient infection of the uterus, as determined by histologic evaluation of bacterial invasion and acute inflammatory cell response. One hundred nineteen patients undergoing cesarean delivery and receiving antibiotic prophylaxis were included in this study. At the time of the operation, a hysterotomy biopsy was obtained for hematoxylin and eosin staining. Marked histologic differences were noted in decidual inflammation, myometrial inflammation, and myometrial polymorphonuclear cell invasion in those patients who subsequently developed endometritis (N = 7) compared with subjects without postpartum endometritis. Using two techniques for in situ identification of bacteria within myometrial tissue (acridine orange and fluorescein DNA probe to bacterial ribosomal RNA), all clinically infected parturients demonstrated large numbers of organisms in the myometrial layer of the biopsy specimen, compared with few organisms seen in a matched subset of noninfected controls. These data support the concept that incipient infection at the time of cesarean delivery may limit the effectiveness of antimicrobial prophylaxis. Use of rapid-diagnosis methodologies may allow timely identification of these at-risk patients so that therapeutic antibiotics can be initiated.