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We report our experience in a woman with a twin pregnancy. The patient suffered severe Escherichia coli chorioamnionitis and the outcomes were different between the two babies after birth. The first baby had only a mild infection, but the second suffered sepsis and subsequent perinatal death. These differences in outcome appeared to be due to amniotomy performed for the first baby after late labor stage I to augment uterus contractions. Removal of infectious amniotic fluid from the amniotic cavity might thus have prevented the spread of the chorioamnionitis. E. coli sometimes causes severe infection during pregnancy and the perinatal period. In this case, a large number of enteropathogenic E. coli (serotype O-6) was cultured from blood, stool, pharyngeal swab, gastric juice and puncture fluid from the thoracic cavity of the second baby. O-6 is classified an enterotoxigenic strain mainly causing diarrhea because of endotoxin released from bacteria. O-6 has not hitherto been reported as a cause of severe infection in chorioamnionitis and perinatal sepsis.
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PMID:Does amniotomy influence the prognosis of babies in cases with severe chorioamnionitis? Report of a twin pregnancy with varying outcome. 1070 15

The causes of non-haemorrhagic obstetric shock (pulmonary thromboembolism, amniotic fluid embolism, acute uterine inversion and sepsis) are uncommon but responsible for the majority of maternal deaths in the developed world. Clinically suspected pulmonary thromboembolism should be treated initially with heparin and objective testing should be performed. If the diagnosis is confirmed, heparin is usually continued until delivery, following which anticoagulation in the puerperium is achieved with either warfarin or heparin. Amniotic fluid embolism is a rare complication of pregnancy, occurring most commonly during labour. The management of amniotic fluid embolism involves maternal oxygenation, the maintenance of cardiac output and blood pressure, and the management of any associated coagulopathy. Acute uterine inversion arises most commonly following mismanagement of the third stage of labour. The shock in uterine inversion is neurogenic in origin, although there may also be profound haemorrhage. The management of this condition includes maternal resuscitation and replacement of the uterus either manually, surgically or by hydrostatic pressure. Genital tract sepsis remains a significant cause of maternal death, the most common predisposing factor being prolonged rupture of the fetal membranes. The management of septic shock in pregnancy includes resuscitation, identification of the source of infection and alteration of the systemic inflammatory response.
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PMID:Non-haemorrhagic obstetric shock. 1078 58

Pelvic inflammatory disease (PID) is a generic term relating to a broad range of conditions. The term is used to describe infections of the fallopian tubes, uterus, ovaries, or peritoneum. PID is a potentially life-threatening condition in any woman, but HIV-positive women are at serious risk of severe complications or death. PID is caused when infection-producing organisms spread upwards from the vagina through the cervix to the upper reproductive organs. Untreated sexually transmitted diseases are a leading cause of PID. Consequences include chronic pelvic pain, abdominal abscesses, inflammation of the covering of the liver, sepsis, and death. Sterility may also result from PID. PID is generally treated with a combination of antibiotics, and it is crucial to treat other concurrent infections as well. Early treatment of PID in HIV-positive women is essential.
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PMID:Pelvic inflammatory disease. 1136 14

The gram-positive bacterium Listeria monocytogenes is the causative agent of listeriosis, a highly fatal opportunistic foodborne infection. Pregnant women, neonates, the elderly, and debilitated or immunocompromised patients in general are predominantly affected, although the disease can also develop in normal individuals. Clinical manifestations of invasive listeriosis are usually severe and include abortion, sepsis, and meningoencephalitis. Listeriosis can also manifest as a febrile gastroenteritis syndrome. In addition to humans, L. monocytogenes affects many vertebrate species, including birds. Listeria ivanovii, a second pathogenic species of the genus, is specific for ruminants. Our current view of the pathophysiology of listeriosis derives largely from studies with the mouse infection model. Pathogenic listeriae enter the host primarily through the intestine. The liver is thought to be their first target organ after intestinal translocation. In the liver, listeriae actively multiply until the infection is controlled by a cell-mediated immune response. This initial, subclinical step of listeriosis is thought to be common due to the frequent presence of pathogenic L. monocytogenes in food. In normal individuals, the continual exposure to listerial antigens probably contributes to the maintenance of anti-Listeria memory T cells. However, in debilitated and immunocompromised patients, the unrestricted proliferation of listeriae in the liver may result in prolonged low-level bacteremia, leading to invasion of the preferred secondary target organs (the brain and the gravid uterus) and to overt clinical disease. L. monocytogenes and L. ivanovii are facultative intracellular parasites able to survive in macrophages and to invade a variety of normally nonphagocytic cells, such as epithelial cells, hepatocytes, and endothelial cells. In all these cell types, pathogenic listeriae go through an intracellular life cycle involving early escape from the phagocytic vacuole, rapid intracytoplasmic multiplication, bacterially induced actin-based motility, and direct spread to neighboring cells, in which they reinitiate the cycle. In this way, listeriae disseminate in host tissues sheltered from the humoral arm of the immune system. Over the last 15 years, a number of virulence factors involved in key steps of this intracellular life cycle have been identified. This review describes in detail the molecular determinants of Listeria virulence and their mechanism of action and summarizes the current knowledge on the pathophysiology of listeriosis and the cell biology and host cell responses to Listeria infection. This article provides an updated perspective of the development of our understanding of Listeria pathogenesis from the first molecular genetic analyses of virulence mechanisms reported in 1985 until the start of the genomic era of Listeria research.
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PMID:Listeria pathogenesis and molecular virulence determinants. 1143 15

The relationship between genital tract infection and preterm delivery has been established on the basis of biochemical, microbiological, and clinical evidence. In theory, pathogenic bacteria may ascend from the lower reproductive tract into the uterus, and the resulting inflammation leads to preterm labor, rupture of the membranes, and birth. A growing body of evidence suggests that preterm labor and/rupture of the membranes are triggered by micro-organisms in the genital tract and by the host response to these organisms, ie, elaboration of cytokines and proteolytic enzymes. Epidemiologic and in vitro studies do not prove a cause-and-effect relationship between infection and preterm birth. However, the preponderance of evidence indicates that treatment of asymptomatic bacteriuria and symptomatic lower genital tract infections such as bacterial vaginosis (BV), trichomoniasis, gonorrhea, and chlamydia will lower the risk of preterm delivery. Based on current evidence, pregnant women who note an abnormal vaginal discharge should be tested for BV, trichomonas, gonorrhea, and chlamydia. Those who test positive should be treated appropriately. A 3- to 7-day course of antibiotic treatment for asymptomatic bacteriuria during pregnancy is clinically indicated to reduce the risk of pyelonephritis and preterm delivery. Routine screening for chlamydia and gonorrhea should be performed for women at high risk of acquiring sexually transmitted diseases. The practice of routine screening for BV in asymptomatic women who are at low risk for preterm delivery cannot be supported based on evidence from the literature. Routine screening for asymptomatic bacteriuria during pregnancy is cost-effective, particularly in high-prevalence populations. The results of antibiotic trials for the treatment of preterm labor have been inconsistent. In the absence of reasonable evidence that antimicrobial therapy leads to significant prolongation of pregnancy in the setting of preterm labor, antibiotics should be used only for protecting the neonate from group B streptococci sepsis. They should not be used for the purpose of prolonging pregnancy. Multiple investigations have shown that, in patients with preterm premature rupture of the membranes, prophylactic antibiotics are of value in prolonging the latent period between rupture of the membranes and onset of labor and in reducing the incidence of maternal and neonatal infection. The most extensively tested effective antibiotic regimen for prophylaxis involves erythromycin alone or in combination with ampicilln. Controversy still exists regarding the appropriate length and route of antibiotic prophylaxis.
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PMID:Infection, antibiotics, and preterm delivery. 1170 17

The level of maternal mortality appears to be higher in France than in other European countries according to the data collected in the 1995 European survey. We performed a retrospective analysis of severe hemorrhage, pregnancy induced hypertension, and maternal sepsis in 1995 in the Lorraine region and reviewed the management scheme used in each case. There was one maternal death and 223 cases of severe maternal morbidity (110 cases of hemorrhage, 105 cases of pregnancy induced hypertension, 8 cases of maternal sepsis). The frequency of these maternal diseases was an estimated 8 per 1000 births. Ninety percent of the children (90.7%) were living 7 days after birth. Pregnancy after the age of 35 years, obesity, and an intermediate level of vocational training were well-documented high risk factors in the Lorraine area. All of the women who developed complications had been followed regularly during their pregnancy. High parity and a scarred uterus were high risk factors for post partum hemorrhage. About 45% (45.5%) of the patients were transferred to an emergency unit for intensive care. Pregnancy-induced hypertension was treated within the normal hospital network, most of the mothers being transferred to a reference center prior to delivery. This retrospective study demonstrates the need for reporting more information on medical records. The data observed improved our knowledge of the prevalence and management of the main causes of direct maternal death in the Lorraine area. It improved our knowledge on the prevalence and management of the main causes of direct maternal death in Lorraine area.
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PMID:[Severe complications of pregnancy and delivery: the situation in Lorraine based on the European investigation]. 1188 10

A review of maternal mortality at the University of Nigeria Teaching Hospital (UNTH) Enugu between January 1976 and December 1985 has been made. Deaths up to 6 weeks of puerperium from direct, indirect, and incidental causes were included but abortions were excluded. There were 47,361 deliveries and 127 maternal deaths giving a maternal mortality rate of 2.7/1000. There has been a downward trend in the mortality rate from 5.46 in 1976 to 1.99 in 1985. Comparing mortality rates according to booking status, it was observed that mortality rates were 48 times higher in unbooked patients. It was observed that overall that deaths increased with increasing maternal age except in the 26-30 age group. Whereas only 0.16% of women aged 26-30 died, 2% of women 40 died. The highest mortality rates are in primigravida and grand multipara. The main causes of death were obstructed labor plus ruptured uterus (35%), obstetric hemorrhage (25.98%), eclampsial severe/preeclampsia (11%), and sepsis (10.24%). Other causes of death include anesthetic, amniotic fluid embolism, jaundice in pregnancy, congestive cardiac failure, pulmonary embolism, and severe anemia. Factors influencing this high mortality include antenatal care, maternal age, and parity. The majority of these deaths are avoidable through adequate blood transfusions, attention to details and better case management, improved medical services, recognition of severe problems by patients and family, and immediate medical care. Futhermore, faults may lie either with the patient, the hospital, the medical team, the government or the system or a combination of these factors. The ways to reduce the high maternal mortality are improved standard of living, raising the literacy level, improved structural facilities and social amenities, better communication and transportation, increased number of hospitals, blood transfusion services, better case management, and a high level of utilization of available facilities.
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PMID:Maternal mortality at the University of Nigeria Teaching Hospital, Enugu: a 10-year survey. 1217 83

Analysis of hospital records from January 1983 to December 1985 at the Komfo Anokye Teaching Hospital in Kumasi, Ghana revealed a maternal mortality rate of 12.5/1000 births. During this period, 27,592 births and 342 maternal deaths occurred. The primary cause of death was hemorrhage(32.14%). Other leading causes of maternal deaths include hepatic failure (19.53%),postpartum hemorrhage (18.75%), eclampsia (11.01%), sepsis (10.71%), ruptured uterus (8.33%), and anemia (4.76%). Comparison of deaths with clinic attendants and non-clinic attendants revealed 43.68% more deaths with non-clinic attendants. 29.02% of the maternal deaths were among primipara and 31.09% among grandmultipara. Furthermore, 41.9% of the deaths were among women 24 years. A health profile of the Ashanti-Akim district indicated 14.8% of the population are females in the reproductive range; 47.1% live in areas having a population of 500; 55.1% reside within a 8 km radius of a health center; a 1:19,500 physician/population ratio; 45% greater home births in rural areas and 9% in urban areas; traditional birth attendants (TBAs) delivered 63% of all births. Adequate data gathering and maternal death registration are current problems. Through education, TBAs could collect available information on maternal mortality, make regular visits to the areas, and bring awareness to the population of the need for medical care. TBAs could provide a valuable contribution to the health care systems in improving maternal-child health and assist in reducing maternal mortality rates.
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PMID:Maternal mortality in Ghana: is there a place for traditional birth attendants (TBAs) as reporters of maternal mortality-related data? 1217 85

The hospital of Attat in central Ethiopia serves 300,000 people. In 1987 there were 777 deliveries in the hospital, maternal mortality was 21.2/1000 live births, and the rate of stillbirths was 212/1000 total births. In 1976 a residence or tokul with 15 beds was inaugurated for pregnant women with obstetrical problems to mitigate obstetrical emergencies because of the difficulty of transportation to the hospital. Average stay was 15 days with prenatal care by a hospital nurse visiting the tokul once a day. There were 15 villages around the hospital with 15,000 inhabitants, and a 5-member development committee met with a public health matters. In 1987 a total of 151 pregnant women were admitted, most with a history of obstetrical problems. 34 had caesareans (19 of 25 with previous caesareans), 7 had assisted delivery, and 30 had spontaneous delivery. Only 7 of 15 with previous uterine rupture gave birth via the abdominal route, the others delivered vaginally. There were 635 deliveries of women who entered the hospital directly. Only 142 out of 151 women who stayed at the tokul gave birth in the hospital: 9 of them went home. Many of the direct hospital cases had severe problems: 45 suffered uterine rupture and 23 had craniotomy of the stillborn fetus. 88 (25%) of 348 abnormal deliveries required caesarean section, while there were 44 (72%) caesareans in 61 abnormal deliveries in the tokul group. 13 women died in the direct admission group vs. none in the tokul cases. The maternal mortality rate was 21.2/1000 live births. Rupture of the uterus caused 5 deaths, eclampsia 3, hepatic coma 2, grave sepsis 2, and placenta previa 1. There were 161 fetal deaths in 635 pregnancies of the direct referral group. The stillborn rate was 253.5 vs. 28.2/1000 births in the tokul group.
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PMID:[Residences for pregnant women reduce the risk of obstetrical catastrophies]. 1217 50

Vasectomy is usually done under local anesthesia. After isolating the vas by blunt and sharp dissection, a length of 1/2-1 inch is excised between clamps. Cut ends are then ligated with silk or chromic catgut. After ligating bleeders, if any, the wound is closed,y The patient may leave immediately. Skin sutures are removed after 7 days. Hamartoma and sepsis are the only complications. The patient should use other contraceptive measures for 3 months. Ideally, repeated semen examinations should be carried out until they are negative for spermatozoa. For women, the best time for sterilization is during the early puerperal period before the uterus has involuted back into the pelvis, usually the 4th-7th day. The operation can be done under local anesthesia, or, if the patient prefers, general anesthesia. A midline incision 3-4 inches is made. Tubes are identified and 1/2-1 inch of each tube is excised. The cut ends are ligated with chromic catgut or silk. The wound is then closed in layers. Complications are rare.
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PMID:The techniques of vasectomy and puerperal sterilization. 1225 24


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