Invasive Group A streptococcal postpartum endometritis associated with multi-organ infarctions: an uncommon case presentation and literature review.

Background: Streptococcal Toxic Shock Syndrome (STSS) is a serious condition that can arise from streptococcal postpartum endometritis. It is associated with a substantial increase in mortality rate and can rarely result in multiorgan infarction. Early recognition plays a vital role in patients' outcome. Objective: To report a case of complicated STSS and review the literature for previous case reports of streptococcal postpartum endometritis to determine if STSS diagnostic criteria (published by the Centers for Disease Control and Prevention) were fulfilled. Case presentation: This is a 41-year-old woman who presented 5 days after an uncomplicated vaginal delivery with endometritis complicated by invasive group A ß-hemolytic streptococcus (GAS) infection and confirmed toxic shock syndrome. The patient was initially admitted to the critical care unit due to hemodynamic compromise requiring intravenous (IV) fluids, IV antibiotic therapy with penicillin and clindamycin, and IV immunoglobulin therapy. The patient subsequently developed multi-organ infarctions, acute respiratory distress syndrome requiring noninvasive respiratory support, and severe reactive arthritis. Literature review revealed 15 case reports of GAS postpartum endometritis, five met criteria for confirmed STSS. One patient died from severe septic shock leading to cardiopulmonary arrest. Thirteen out of 15 cases of postpartum endometritis occurred after uncomplicated vaginal delivery. Conclusion: STSS is a serious and possibly fatal medical condition that requires early diagnosis and treatment to prevent poor patient outcomes and death. Careful consideration to the patient's postpartum clinical presentation with the implementation of an intradisciplinary approach should be utilized.

Public Health Agency of Sweden's Brief Report: Pregnant and postpartum women with severe acute respiratory syndrome coronavirus 2 infection in intensive care in Sweden.

The Public Health Agency of Sweden has analyzed how many pregnant and postpartum women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been treated in intensive care units (ICU) in Sweden between 19 March and 20 April 2020 compared with non-pregnant women of similar age. Cases were identified in a special reporting module within the Swedish Intensive Care Registry (SIR). Fifty-three women aged 20-45 years with SARS-CoV-2 were reported in SIR, and 13 of these women were either pregnant or postpartum (<1 week). The results indicate that the risk of being admitted to ICU may be higher in pregnant and postpartum women with laboratory-confirmed SARS-CoV-2 in Sweden, compared with non-pregnant women of similar age.

Clinical Variables Associated With Adverse Maternal Outcomes in Puerperal Group A Streptococci Infection.

OBJECTIVE: To identify clinical variables associated with increased risk of composite adverse outcome in a cohort of women with puerperal group A streptococci infection. METHODS: Our prospective case registry enrolled patients between 1991 and 2017. Chart abstraction was conducted for admission demographic and clinical data in patients with culture-proven puerperal group A streptococci infection. We created a composite variable of signs of capillary leakage including pulmonary edema, pleural effusion, ascites, and abdominal distention. The composite adverse outcome included death, hysterectomy, intensive care unit admission, mechanical ventilation, and blood transfusion. Clinical characteristics were compared between those with a composite adverse outcome and those without. We fit unadjusted log-linear models with robust error variance to measure the relative risk of a composite adverse outcome associated with clinical and demographic variables among patients with group A streptococci. RESULTS: Thirty-five of 71 (49%) patients had an adverse outcome. Women who had adverse outcomes had higher admission heart rates (126±19 vs 112±22 beats per minute, P=.008) and respiratory rates (26±10 vs 20±5 breaths per minute, P=.01), lower systolic blood pressure (98±24 vs 114±19 mm Hg, P=.004), and were more likely to have signs of capillary leakage (77% vs 20%, P<.001) and symptoms of capillary leakage (dyspnea, cough, shoulder pain, abdominal bloating, and chest pain) (40% vs 17%, P=.03) compared with those without adverse outcomes. Log-linear models indicated that these clinical variables were individually associated with increased risk of a composite adverse outcome. The relative risk of an adverse outcome was 3.5 times higher among women with signs of capillary leakage (relative risk 3.67, 95% CI 1.94-6.94, P<.001). CONCLUSION: Vital sign parameters consistent with severe infection correlate with adverse outcomes in women with puerperal group A streptococci infection. Signs of capillary leakage are most strongly associated with a composite adverse outcome. These clinical characteristics, particularly signs of capillary leakage, are potentially useful to guide clinical care.

Effect of puerperal metritis on reproductive and productive performance in dairy cows in Argentina.

The objectives of this study were to evaluate the reproductive and productive performance of dairy cows with and without puerperal metritis and to evaluate the effectiveness of using a long-acting ceftiofur preparation. Dairy cows in one dairy farm, calving from July 2009 to January 2010, were examined between 3 and 14 days postpartum and classified on the basis of vaginal discharge into three groups: cows with normal discharge (control; C); cows with a bloody mucus purulent or pathologic nonfetid discharge (PnFD), and cows with bloody mucopurulent or purulent fetid discharge (PFD). Cows in C and PnFD groups were not treated, whereas those in the PFD group were randomly allocated to receive 2.2 mg/kg of ceftiofur subcutaneously behind the ear (PFD-T) or remain untreated (PFD-No T). From the 640 cows examined, 58.2% formed the C group, 13.4% formed the PnFD group, and 28.4% formed the PFD group. Survival curves differed between cows in the C group and PFD-No T group (P = 0.0013) and between PFD-No T versus PFD-T group (P = 0.0006). Survival curves of PnFD were intermediate and did not differ from those in the C group (P = 0.2) and PFD-T group (P = 0.1) but tended to be different from the PFD-No T group (P = 0.056). The postpartum interval to achieve a 25% pregnancy rate was 72 days for cows in the C group, 73 days for the PFD-T group, 83 days for PnFD group, and 95 days for the PFD-No T group. The chance of pregnancy in a cow in the C group was 1.98 times higher (95% confidence interval = 1.33, 3.08) and in cows in the PFD-T group was 2.16 times higher (95% confidence interval = 1.37, 3.50) than that in the PFD-No T group. Finally, the chance of pregnancy in cows in the PnFD group tended to be higher (P = 0.08) than that in the PFD-No T group but did not differ from the other two groups. Cumulative 305-day milk production was higher (P < 0.0001) in C group than those with vaginal discharge, regardless of fetidness and regardless of treatment. It is concluded that puerperal metritis affects the reproductive and productive performance of dairy cows and the treatment with ceftiofur was effective in reducing the adverse effects on reproductive performance but not on milk production.

Postparturient disorders and backfat loss in tropical sows associated with parity, farrowing duration and type of antibiotic.

The present study investigated the incidence of postparturient disorders and backfat loss in primiparous and multiparous sows under tropical climates in relation to duration of farrowing and type of antibiotic used postpartum. In total, 81 sows (42 primiparous and 39 multiparous sows) were included. The sows were categorised according to the duration of farrowing into three groups: <2 (n = 58), 2-4 (n = 19) and >4 h (n = 4). According to the antibiotic used postpartum, the sows were divided into two groups: group I (enrofloxacin type 1, n = 36) and group II (enrofloxacin type 2, n = 45). Rectal temperature, the presence of abnormal vaginal discharge, the occurrence of postpartum dysgalactia syndrome (PDS) and the sows' appetite were determined at days 0, 1, 2 and 3 postpartum. Backfat thickness was measured before farrowing and at 21 days postpartum. The mean duration of farrowing was 114.5 ± 60.2 min. Stillborn piglets in the sows with a long duration of farrowing (>4 h, mean 287.9 min) was higher than in sows with a short duration (<2 h, mean 85.5 min) of farrowing (29.2 and 7.9 %, P = 0.044). Primiparous sows lost more backfat during lactation than multiparous sows (15.7 and 4.8 %, P = 0.004). The incidence of abnormal vaginal discharge (P = 0.046) and PDS (P = 0.057) was less frequent in group II than in group I sows. In conclusion, primiparous sows and sows with a long duration of farrowing had a high risk of postparturient disorders. The type of antibiotic had an effect on the incidence of abnormal vaginal discharge and PDS in sows.

[Risk-factors for development of suppurative-inflamatory infections in puerperas].

In this article there are shown data of epidemiolgycal analysis of parturition cases (analysis is performed with use of descriptive and evaluative method) for detection of potential risk factors for development of suppurative-inflamatory infections in puerperas. Study was performed in obstetric hospital of the " Imedis Clinica" within 2014 year. 3248 parturition cases were analysed, among them 2373 (73,06% cases of physiological birth and 875 (26,99%) caesarium operation cases. From all cases were detected only 296 (9,211%) cases complicated with basic forms of suppurative-inflamatory infections. Also was performed analysis of post-parturation complications, dependet on anamnesys of pregnants. As a result it was detected, that most significant risk factors for devolpment of suppurative-inflamatory infections in puerperas with physiological birth were genitourinay inflamatory diseases while pregnancy, prolonged (more than 6 hours) parturition period. In cases with caesarian operation, such factors, apart from operation itself, were genitourinary inflamatory diseases while pregnancy, prolonged (more than 5 hours) waterless period, tribal activities before operation, tribal activities more than 5 hours, operation duration longer than 30 minutes and huge haemorage while surgery.

Puerperal group A streptococcal infection: beyond Semmelweis.

Ignaz Semmelweiss made one of the most important contributions to modern medicine when he instituted handwashing in an obstetric clinic in Austria in 1847, decreasing mortality there from more than 10% to 2%. Unfortunately, puerperal sepsis remains a leading cause of maternal mortality throughout the world. Group A streptococcus (GAS), Streptococcus pyogenes, is an organism associated with high rates of morbidity and mortality from puerperal infections. When associated with sepsis, known as streptococcal toxic shock syndrome, mortality rates approach 30-50%. Group A streptococcus can cause invasive infections in the form of endometritis, necrotizing fasciitis, or streptococcal toxic shock syndrome. The clinical presentation of women with puerperal GAS infections is often atypical with extremes of temperature, unusual and vague pain, and pain in extremities. Toxin production by the organism may allow GAS to spread across tissue planes and cause necrosis while evading containment by the maternal immune system in the form of a discrete abscess. Endometrial aspiration in addition to blood cultures may be a useful rapid diagnostic tool. Imaging may appear normal and should not dissuade the clinician from aggressive management. When suspected, invasive GAS infections should be treated emergently with fluid resuscitation, antibiotic administration, and source control. The optimal antibiotic regimen contains penicillin and clindamycin. Source control may require extensive wound or vulvar debridement, hysterectomy, or a combination of these, which may be life-saving. The benefit of immunoglobulins in management of puerperal GAS infections is unclear.

Short communication: Metritis affects milk production and cull rate of Holstein multiparous and primiparous dairy cows differently.

Metritis, a common transition disease in dairy cows, reduces milk production during the duration of the disease. To our knowledge, no work has investigated the short-term effects of metritis on feed intake and the long-term consequences on milk yield and risk of culling. The objectives were to determine the effect of metritis on 305-d lactation curves, dry matter intake (DMI), reproduction, and the probability of being culled. Identifying differences in response to metritis between primiparous and multiparous cows was of interest. Milk records were collected twice daily from Holstein cows diagnosed with puerperal metritis (11 primiparous and 16 multiparous) or classified as healthy (14 primiparous and 43 multiparous) during the first 3 wk after calving. Metritic cows were treated at the discretion of the herd veterinarian. Lactation curves of healthy and metritic cows were compared using a mixed model with a Wilmink function. Differences in DMI, days open, and the number of services per conception were assessed using mixed models. The probabilities that cows with and without metritis were not bred, were bred but never confirmed pregnant, or were culled were compared using Fisher's exact tests. Primiparous and multiparous animals were assessed separately. Multiparous cows with metritis produced less milk (35.1±1.5 vs. 39.2±1.0 kg/d), ate less during the 3 wk after calving (12.2±1.2 vs.14.0±0.8 kg/d), and were more likely to be culled (50.0%) than healthy cows (20.9%). The decision to cull was likely influenced by the lower milk yield in early lactation as a result of metritis; the decision to cull was made early, as 7 of the 8 culled metritic cows were not bred. No differences were found in any measurement between primiparous cows with and without metritis. These results indicate that metritis in early lactation has long-term effects on multiparous cows but not primiparous cows.

Significance of nitric oxide concentration in plasma and uterine secretes with puerperal endometritis in dairy cows.

Endometritis is an inflammation of the endometrial lining of the uterus without systemic signs, which is associated with chronic postpartum infection of the uterus with pathogenic bacteria. Nitric oxide (NO) is an inflammatory mediator that among other effects causes smooth muscle relaxation and mediated cytoimmunity and inflammation toxicity. To see if the nitric oxide concentration in plasma and uterine secrets is related with postpartum endometritis, NO concentrations in plasma and uterine secrets were measured in dairy cows with puerperal endometritis (clinical endometritis (n = 60) and subclinical endometritis (n = 58)). Cows with clinical or subclinical endometritis showed higher concentrations of NO in both plasma and uterine secrets when compared with normal cows and the highest concentrations of NO in plasma and uterine secrets were found in dairy cows with clinical endometritis. Expression level of NOS2 mRNA in endometrial biopsies from cows with puerperal endometritis was also higher and the highest expression of NOS2 mRNA was found in cows with clinical endometritis. The results showed that concentrations of NO in plasma and uterine fluid are related with the degree of endometritis which may be useful to diagnose the endometritis in dairy cows.

Sepsis neonatal por estreptococos pyogenes / Neonatalll sepsis by streptococcus pyogenes

Se presenta el caso de un paciente masculino, recién nacido a término adecuado para la edad gestacional, quien nace por parto vaginal, con el antecedente de fiebre en la madre durante el periodo de postparto inmediato. Los padres consultan a los 2 días de vida pues le notan dificultad repiratoria, hipoactividad y rechazo a la leche materna. El paciente se interna y se aborda como una sepsis. Durante su estancia en el servicio de neonatología del Hospital Nacional de Niños asocia fallo respiratorio que amerita ventilación mecánica asistida por varios días en diferentes ocasiones, derrame pleural exudativo, convulsiones de origen hipóxico isquémico. Con reporte de hemocultivos positivos por estreptococos pyogenes. El esteptococos pyogenes o estreptococo b-hemolítico del grupo A, fue un problema en los comienzos del siglo pasado, siendo frecuente en las infecciones puerperales y del recién nacido. En la actualidad es un germen sumamente raro en los procesos de sepsis neonatal. La gravedad de la enfermedad causada por este microorganismo en el periodo neonatal varía desde una onfalitis crónica de bajo grado a una septicemia, una meningitis fulminante y la muerte. El presente artículo pretende hacer un resumen del paciente, con su evolución clínica, radiológica y además ejemplificar todas las complicaciones que tuvimos con este germen tan poco frecuente en la actualidad en sepsis neonatal.

We present herein the case of a newborn patient of appropriategestational age weight ( 3700 grams), born by vaginal delivery, from a mother that had had 2 previous pregnancies (2 normal deliveries). During the immediate puerperium she had fever.The parents consulted at the age of 2 days, stating that they had noticed difficult breathing since his birth, hipoactivity and poor appetite. He was admitted to the hospital and underwentseveral studies searching for the origin and germ causing the sepsis. He developed respiratory failure and needed mechanical ventilation for several days on different occasions. He had exudative pleural effusion and hypoxic ischemic seizures. Later on, his blood cultures were positive for Streptococcus pyogenes. Streptococcus pyogenes or Streptococcus β- hemolytic group A infection, used to be a common entity in the beginning of the past century, it was commonly associatedwith puerperal infections and newborn infections, but its incidence declined and nowadays, is uncommon during theneonatal period. Its clinical manifestations could vary fromchronic omphalitis up to a low grade septicemia or fulminant meningitis. Since its incidence has declined, at the present time; is an unusual infection of the neonatal period. Ampicillin and gentamicin are currently recommended as first-line antimicrobials, ampicillin replacing the previously recommended penicillin.

Group A streptococcal puerperal sepsis: initial characterization of virulence factors in association with clinical parameters.

Group A beta-hemolytic streptococcus (GAS) is an uncommon but potentially fatal source of postpartum infection. Pathogenesis in invasive GAS infections has been linked to bacterial virulence factors. In this study, we sought to provide an initial description of potential virulence factors in association with puerperal morbidity by virtue of specific M-protein type antigens. Women with confirmed GAS puerperal infection in the Salt Lake City region were prospectively identified over a 6-year interval (1991-1997). From this cohort, GAS isolates were analyzed with respect to M-serotype and presence of genes encoding the Streptococcal Pyogenic Exotoxins A and B (SPE-A and SPE-B). Bacterial isolates from 18 subjects with GAS puerperal infection underwent M-serotyping and PCR-based genotyping for the speA and speB genes. Among these, 8/18 subjects manifest criteria of severe disease. All 18 isolate strains expressed speB; 6/18 isolates expressed speA. Of the M-serotypes, 8/8 severe disease isolates expressed M-types 1 (N=3) or 28 (N=5). Pulse-field gel electrophoresis did not indicate an outbreak strain among similar isolates. We conclude that in this initial characterization, morbidity among women with GAS puerperal infection is associated with M-types 1 and 28, but not speB genotype.

Puerperal pyrexia: a review. Part I.

UNLABELLED: Puerperal pyrexia and sepsis are among the leading causes of preventable maternal morbidity and mortality not only in developing countries but in developed countries as well. Most postpartum infections take place after hospital discharge, which is usually 24 hours after delivery. In the absence of postnatal follow-up, as is the case in many developing countries, many cases of puerperal infections can go undiagnosed and unreported. Besides endometritis (endomyometritis or endomyoparametritis), wound infection, mastitis, urinary tract infection, and septic thrombophlebitis are the chief causes of puerperal infections. The predisposing factors leading to the development of sepsis include home birth in unhygienic conditions, low socioeconomic status, poor nutrition, primiparity, anemia, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations in labor, cesarean section, obstetrical maneuvers, retained secundines within the uterus and postpartum hemorrhage. Maternal complications include septicemia, endotoxic shock, peritonitis or abscess formation leading to surgery and compromised future fertility. The transmissions of infecting organisms are typically categorized into nosocomial, exogenous, and endogenous. Nosocomial infections are acquired in hospitals or other health facilities and may come from the hospital environment or from the patient's own flora. Exogenous infections come from external contamination, especially when deliveries take place under unhygienic conditions. Endogenous organisms, consisting of mixed flora colonizing the woman's own genital tract, are also a source of infection in puerperal sepsis. Aseptic precautions, advances in investigative tools and the use of antibiotics have played a major role in reducing the incidence of puerperal infections. Part I of this review provides background information and definitions, discusses the incidence and risk factors, explains the microbiology and pathophysiology of various infections, and delineates the signs and symptoms of major puerperal infection. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that world wide puerperal sepsis is a leading cause of maternal mortality, state that many of the predisposing factors are preventable, explain that both nosocomial infections as well as exogenous infections are serious factors, and relate that septic techniques and antibiotics can play a major role in reducing the incidence of puerperal infections.

Clinical and parasitological characteristics of puerperal malaria.

BACKGROUND: Women with semi-immunity to malaria who live in regions where the disease is endemic are at increased risk for more frequent and severe episodes of malaria during pregnancy. Recent findings indicate that this increased risk might persist beyond delivery, but the underlying mechanisms for this change in risk are poorly understood. METHODS: One hundred fifty women were included in a cohort study in Lambaréné, Gabon, and were actively followed up weekly for 10 weeks after delivery, as were nonpregnant control women who had been matched to them by location and age. Parasites in samples of placenta and blood were genotyped by use of polymerase chain reaction amplification of the merozoite surface antigen 2 gene and the subtelomeric variable open reading frame gene of Plasmodium falciparum. RESULTS: Eleven puerperal women had cases of clinical malaria, compared with 1 control woman (rate ratio, 9.8; P=.006). Eighteen puerperal women had P. falciparum parasitemia, compared with 6 control women (rate ratio, 2.7; P=.03). Five of 16 puerperal women (31%) with parasitemia on follow-up had identical parasites in their placentas and blood, and 11 of these cases (69%) were the result of reinfection. Puerperal women remained at equal risk for the development of parasitemia throughout the first 10 weeks after delivery. Use of bed nets, use of chloroquine prophylaxis during pregnancy, presence of malaria episodes during pregnancy, gravidity, and age were not associated with the acquisition of parasitemia during follow-up. CONCLUSIONS: Compared with nonpregnant women, puerperal women have a considerably increased risk for the development of malaria and/or parasitemia. This increased risk is caused both by the recurrence of P. falciparum parasitemia and by the increased susceptibility to new infections, although the latter plays a more significant role.

Influence of puerperal uterine infection on uterine involution and postpartum ovarian activity in dairy cows.

This article presents the results of a clinical trial designed to study the effect of puerperal uterine infection on uterine involution and on ovarian activity in dairy cows, monitored twice weekly from parturition until the sixth week postpartum (wpp). Infection significantly retarded uterine involution assessed by the uterine body diameter and a score of intrauterine fluid volume (IUFV). By the sixth wpp, cows with normal puerperium (controls) and cows that showed mild puerperal endometritis had similar uterine body diameter and IUFV, indicating spontaneous recovery within the postpartum voluntary waiting period. However, in cows with severe puerperal endometritis, although uterine body diameter had regressed to pregravid size, IUFV remained significantly higher than in control and mild endometritis cows, indicating that chronic endometritis was established. The IUFV score was positively and significantly correlated with uterine swab bacterial growth density and allowed diagnosis of endometritis after the third wpp. Cows with mild or severe endometritis had a significantly higher prevalence and persistence of pathogenic bacteria (Escherichia coli, Actinomyces pyogenes, Gram-negative anaerobes - GNA) than controls. Actinomyces pyogenes was associated to GNA in 74% of isolations. Ovarian activity measured by ultrasound scanning of the ovaries and plasma progesterone (P4) concentrations was more abnormal (prolonged anoestrus, prolonged luteal phases and ovarian cysts) in cows with severe endometritis than in controls.

[Cerebrovascular disease in the tropics]. / Enfermedad cerebrovascular en los trópicos.

OBJECTIVES: To review the clinical manifestations, diagnosis, and therapy of diseases causing cerebrovascular disease (CVD) in the tropics. DEVELOPMENT: Most prevalent conditions causing CVD in the tropics include: sickle cell disease, Takayasu s arteritis, cysticercosis, infective endocarditis, Chagas disease, viral hemorrhagic fevers, gnathostomiasis, leptospirosis, snake bites, cerebral malaria, puerperal venous thrombosis, and tuberculosis. These conditions may cause cerebral infarcts or hemorrhages, and in most instances are related to either vascular damage secondary to angiitis or hemorrhagic diathesis with bleeding in other organs. In some patients, the severity of the neurological picture makes impossible to identify an specific stroke syndrome and cerebrovascular complications are only recognized on neuroimaging studies or autopsy. CONCLUSIONS: There is a group of tropical infectious and non infectious diseases that may cause cerebral infarcts or hemorrhages. Prompt diagnosis and therapy are needed to reduce the severity or brain damage and to avoid recurrent strokes.