Severe Maternal Infection Research Articles

Long-term Risk of Neuropsychiatric Disease After Exposure to Infection In Utero

ImportanceThe developmental origins of mental illness are incompletely understood. Although the development of autism and schizophrenia are linked to infections during fetal life, it is unknown whether more common psychiatric conditions such as depression might begin in utero.ObjectiveTo estimate the risk of psychopathologic conditions imparted from fetal exposure to any maternal infection while hospitalized during pregnancy.Design, Setting, and ParticipantsA total of 1 791 520 Swedish children born between January 1, 1973, and December 31, 2014, were observed for up to 41 years using linked population-based registries. Children were excluded if they were born too late to contribute person-time, died before being at risk for the outcome, or were missing particular model data. Infection and psychiatric diagnoses were derived using codes from hospitalizations. Directed acyclic graphs were developed from a systematic literature review to determine Cox proportional hazards regression models for risk of psychopathologic conditions in the children. Results were evaluated using probabilistic and simple bias analyses. Statistical analysis was conducted from February 10 to October 17, 2018.ExposuresHospitalization during pregnancy with any maternal infection, severe maternal infection, and urinary tract infection.Main Outcomes and MeasuresInpatient diagnosis of autism, depression, bipolar disorder, or psychosis among offspring.ResultsA total of 1 791 520 Swedish-born children (48.6% females and 51.4% males) were observed from birth up to age 41 years, with a total of 32 125 813 person-years. Within the directed acyclic graph framework of assumptions, fetal exposure to any maternal infection increased the risk of an inpatient diagnosis in the child of autism (hazard ratio [HR], 1.79; 95% CI, 1.34-2.40) or depression (HR, 1.24; 95% CI, 1.08-1.42). Effect estimates for autism and depression were similar following a severe maternal infection (autism: HR, 1.81; 95% CI, 1.18-2.78; depression: HR, 1.24; 95% CI, 0.88-1.73) or urinary tract infection (autism: HR, 1.89; 95% CI, 1.23-2.90; depression: HR, 1.30; 95% CI, 1.04-1.61) and were robust to moderate unknown confounding. Within the directed acyclic graph framework of assumptions, the relationship between infection and depression was vulnerable to bias from loss to follow-up, but separate data from the Swedish Death Registry demonstrated increased risk of suicide among individuals exposed to pregnancy infection. No evidence was found for increased risk of bipolar disorder or psychosis among children exposed to infection in utero.Conclusions and RelevanceThese findings suggest that fetal exposure to a maternal infection while hospitalized increased the risk for autism and depression, but not bipolar or psychosis, during the child’s life. These results emphasize the importance of avoiding infections during pregnancy, which may impart subtle fetal brain injuries contributing to development of autism and depression.

Development of a novel bedside index for the early identification of severe maternal infection

ObjectivesInternational consensus reports have recently recommended that the Systemic Inflammatory Response Syndrome (SIRS) criteria for the diagnosis of sepsis should cease and that new bedside criteria need to be developed to improve prevention, early diagnosis and treatment.The aim of this retrospective audit was to evaluate a suite of four bedside clinical criteria, called the Early Maternal Infection Prompts (EMIP), in helping to identify women with a suspected severe infection who were admitted to a High Dependency Unit (HDU) in a large tertiary referral stand-alone maternity hospital. Study designThe four EMIP criteria were decided based on existing national obstetric guidelines and a review of the recent literature on maternal critical illnesses. Cases were identified from the HDU registry for the three years 2015-2017. Individual charts were retrieved, and the four EMIP parameters were measured at the time of the clinical assessment that led to the HDU admission. Clinical and sociodemographic details were computerised for analysis. ResultsOf 73 women admitted with suspected severe maternal infection, the handwritten records were available in 69. The mean age was 31.3 years, 71% were multiparous and 26.1% were obese. Three quarters of cases were antenatal admissions. Infection was confirmed microbiologically in 56 (81.1%) of cases. There were no maternal deaths. There was no case of organ dysfunction diagnosed but two women required vasopressors to maintain blood pressure. Recordings of the maternal vital signs were not always fully completed before admission. In 69.1% (n = 47) of cases the temperature was elevated ≥ 37.5 C, in 81.2% (n = 56) of cases the heart rate was increased ≥ 100 bpm, in 51.9% (n = 27) cases the respiratory rate was increased ≥ 20 bpm, and in 25.4% (n = 17) cases the systolic blood pressure was ≤100 mmHg. At least one of the four EMIP criteria was abnormal in 91.3% (n = 63) of cases of suspected severe infection. ConclusionsThe audit confirmed that this bedside index has potential in helping to identify maternal infection early before sepsis develops. Prospective studies are required to evaluate the index in different settings, for different infections and at the different stages of maternal infection.

Listerioza – rzadka choroba o poważnym rokowaniu

ABSTRAKTListerioza jest chorobą zakaźną wywołaną przez Gram-dodatnią bakterię występującą przede wszystkim w produktach spożywczych pochodzenia zwierzęcego spożywanych na zimno. Do zakażenia dochodzi najczęściej drogą pokarmową. Choroba dotyka głównie osób z obniżoną odpornością, kobiet ciężarnych i noworodków, u których może występować w postaci wczesnej lub późnej, w zależności od czasu, w jakim doszło do zakażenia. Przebieg choroby jest bardzo ciężki, śmiertelność bardzo wysoka, a powikłania neurologiczne występują u 10–15% dzieci. W pracy przedstawiono przypadek noworodka z wrodzonym zakażeniem Listeria monocytogenes.

The global maternal sepsis study and awareness campaign (GLOSS): study protocol

BackgroundMaternal sepsis is the underlying cause of 11% of all maternal deaths and a significant contributor to many deaths attributed to other underlying conditions. The effective prevention, early identification and adequate management of maternal and neonatal infections and sepsis can contribute to reducing the burden of infection as an underlying and contributing cause of morbidity and mortality. The objectives of the Global Maternal Sepsis Study (GLOSS) include: the development and validation of identification criteria for possible severe maternal infection and maternal sepsis; assessment of the frequency of use of a core set of practices recommended for prevention, early identification and management of maternal sepsis; further understanding of mother-to-child transmission of bacterial infection; assessment of the level of awareness about maternal and neonatal sepsis among health care providers; and establishment of a network of health care facilities to implement quality improvement strategies for better identification and management of maternal and early neonatal sepsis.MethodsThis is a facility-based, prospective, one-week inception cohort study. This study will be implemented in health care facilities located in pre-specified geographical areas of participating countries across the WHO regions of Africa, Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific. During a seven-day period, all women admitted to or already hospitalised in participating facilities with suspected or confirmed infection during any stage of pregnancy through the 42nd day after abortion or childbirth will be included in the study. Included women will be followed during their stay in the facilities until hospital discharge, death or transfer to another health facility. The maximum intra-hospital follow-up period will be 42 days.DiscussionGLOSS will provide a set of actionable criteria for identification of women with possible severe maternal infection and maternal sepsis. This study will provide data on the frequency of maternal sepsis and uptake of effective diagnostic and therapeutic interventions in obstetrics in different hospitals and countries. We will also be able to explore links between interventions and maternal and perinatal outcomes and identify priority areas for action.

WHO GLOSS: a global study to promote the reduction of preventable maternal and neonatal deaths related to sepsis.

The study aims to promote the reduction of preventable maternal and neonatal deaths related to sepsis worldwide. To achieve this goal, the study will test new WHO criteria for early identification of maternal sepsis across both low and high resource settings, describe and analyze the frequency and outcomes of suspected or confirmed maternal sepsis for mothers and infants. Additionally, in the European participating countries, the study will describe the patterns of anti-microbial usage amongst women with suspected maternal sepsis, explore migration status amongst women with possible severe maternal infection and describe any variations in their management.

A molecular portrait of maternal sepsis from Byzantine Troy.

Pregnancy complications are poorly represented in the archeological record, despite their importance in contemporary and ancient societies. While excavating a Byzantine cemetery in Troy, we discovered calcified abscesses among a woman's remains. Scanning electron microscopy of the tissue revealed 'ghost cells', resulting from dystrophic calcification, which preserved ancient maternal, fetal and bacterial DNA of a severe infection, likely chorioamnionitis. Gardnerella vaginalis and Staphylococcus saprophyticus dominated the abscesses. Phylogenomic analyses of ancient, historical, and contemporary data showed that G. vaginalis Troy fell within contemporary genetic diversity, whereas S. saprophyticus Troy belongs to a lineage that does not appear to be commonly associated with human disease today. We speculate that the ecology of S. saprophyticus infection may have differed in the ancient world as a result of close contacts between humans and domesticated animals. These results highlight the complex and dynamic interactions with our microbial milieu that underlie severe maternal infections.

Expectant management of preterm preeclampsia in Indonesia and the role of steroids

Objective: To present the outcome of expectant management of preterm preeclampsia in Indonesia, and the effect of ongoing treatment with methylprednisolone (MP) on maternal and perinatal outcome.Material and methods: Prospective RCT on 48 patients with early-onset preeclampsia. Following the administration of dexamethasone for fetal lung maturation, patients were randomized to receive 25 mg MP group IV for the first week, decreasing to 12.5 mg during 2nd week and continued till birth, or matching IV placebo treatment (PL group). Prolongation of entry to delivery interval served as primary outcome measurement.Results: The average time gained with expectant management was almost 14 days. However, there was no difference of mean time interval between entry to delivery between the PL (13.8 days) and MP (13.7 days) groups. Antenatal ongoing treatment with IV MP also did not improve maternal and/or perinatal outcome and might be associated with a higher risk for severe maternal infections – in particular tuberculosis.Conclusion: Expectant management of preterm preeclampsia is a realistic option in a major Indonesian perinatal referral center. Steroids (outside the use for fetal lung maturation) should not be used in the expectant management of preterm preeclampsia in Indonesia.

Cesarean delivery on maternal request in China: what are the risks and benefits?

The purpose of this study was to describe the risks and benefits of cesarean delivery on maternal request (CDMR) in a Chinese population. A retrospective cohort study of mode of delivery was conducted at the largest obstetric center in Shanghai, China, from 2007-2013. Eligibility criteria included singleton term nulliparous women with vertex presentation; women with major fetal anomalies or stillbirth before labor were excluded. A total of 66,226 women were included in the analysis: 40,560 women (61.2%) had planned vaginal birth, with 32,833 spontaneous vaginal deliveries (80.9%), 4990 intrapartum CDs (12.3%), and 2737 assisted vaginal deliveries (6.7%). A total of 16,333 women (24.7%) underwent CDMR. We observed no significant difference between the CDMR and planned vaginal delivery groups in the frequencies of maternal intensive care unit admission (0.2% vs 0.2%), severe postpartum hemorrhage (0.5% vs 0.5%), maternal infection (1.3% vs 1.3%), organ injuries (0.4‰ vs 0.5‰), and thromboembolic disorders (0.1‰ vs 0.1‰). The perinatal mortality rate was similar in the 2 groups (0.4‰ vs 0.6‰; adjusted odds ratio, 0.51; 95% confidence interval, 0.20-1.30; P = .159). The frequencies of birth trauma (0.2‰ vs 1.1‰), neonatal infection (0.4% vs 0.7%), hypoxic ischemic encephalopathy (0.4‰ vs 1.8‰), and meconium aspiration syndrome (0.2‰ vs 0.6‰) were lower; the frequency of respiratory-distress syndrome (0.6% vs 0.4%) was higher in the CDMR group. Compared with nulliparous women who tried vaginal delivery, women who underwent CDMR had similar short-term maternal outcomes with some neonatal benefit.

PO-0537 Is Vertical Enterovirus Infection Transmission Possible By Breast Milk?

Introduction Enterovirus infections are frequent in childhood. Especially in the neonatal period these can cause severe neonatal infections. Transmission either occurs vertically or nosocomially. Breast milk as a possible source of vertical infection has only been described in a single case. History We report the case of a preterm infant of 32 weeks of gestation delivered by caesarean section due to severe maternal enterovirus infection. Pregnancy was unremarkable until 31 5/7 weeks of gestation, when the mother suffered from meningitis and was admitted to the prenatal ward. Due to clinical deterioration a caesarean section was performed. Maternal CSF as well as anal swab contained echovirus type 30. Clinical Course Within the first days after birth the neonate developed clinical signs of infection (CRP 1.5 mg/dl, platelets 18.000/µl). Antibiotic therapy was initiated and the patient´s condition slowly improved. Neonatal virus PCR’s from nasopharynx and rectum yielded echovirus type 30. Additionally breast milk was tested and a copy number of more than 8 million copies per ml was quantified. At that stage we detected only a moderate amount of Enterovirus in the maternal anal swab while the maternal oral swab had already turned negative again. Conclusion Enterovirus infections in neonates are more frequent than previously recognised. Transmission by breast feeding according to the viral load in the breast milk is more than likely.

Absence of fetal transmission of H1N1 despite severe maternal infection

To the editor: Influenza infection displays a spectrum of clinical severity dependent upon host immune status and viral strain. The outbreak of H5N1 in humans has been accompanied by both severe pneumonia and viral spread beyond the lung. In 2007, a postmortem study of two adults and one fetus infected with H5N1 1 demonstrated infection of lung, liver, small intestine, brain, and placenta indicating transmission across the placenta. The recent H1N1 pandemic 2 has been notable for the involvement of young, healthy adults. We recently observed an H1N1 infection in a pregnant 26‐year‐old female that led to severe maternal disease and spontaneous abortion. The patient presented to the emergency room (ER) with acute onset of upper respiratory infection (URI). She had been in a state of good health without significant past medical history except for a pregnancy of approximately 16 weeks. The patient and her significant other had developed nasal congestion, cough, and fever the previous day. Medical evaluation confirmed the URI but a chest X‐ray showed no evidence of bacterial infection. Given the severity of infection and systemic signs and symptoms, there was concern for possible influenza infection. Nasopharyngeal swabs were sent for viral culture, Tamiflu was prescribed, acetaminophen was administered, and the patient was discharged. Two days later the patient returned to the ER with complaints of worsening URI, now accompanied by more severe myalgias, headaches, diarrhea, and elevated heart rate (pulse 175). On questioning, the patient indicated she had not been able to afford the Tamiflu prescription so she had only taken acetaminophen at home. The patient was placed on nasal oxygen. Despite aggressive therapy, receiving 4 l of intravenous fluids, her pulse rate decreased only minimally. The patient was started on antibiotics and Tamiflu, but within 3 hours she spontaneously aborted her fetus. Four days after her initial ER visit the patient’s nasopharyngeal swab culture grew Influenza A, swine origin 2009 A (H1N1). The patient continued to do poorly and developed adult respiratory distress syndrome (ARDS) requiring aggressive intervention. After 2 weeks, evaluation of acute neurological deterioration demonstrated multifocal hypoattenuated lesions on head CT scan. She was diagnosed with “influenza encephalitis” but no CSF tap was performed because of suspected increased intracranial pressure for which she was treated with steroids, mannitol, and Lasix. Her neurological condition stabilized, and after 1 month of hospitalization she was discharged to a chronic care facility. Pathological examination demonstrated a 470 g second trimester placenta with severe acute deciduitis. By weights and measures, the abortus was estimated to be 15‐week gestation. No systemic or CNS histopathology was observed. Extensive immunohistochemical and in situ hybridization with S35 labeled probes for influenza demonstrated no evidence of infection in any systemic organ or the CNS. Nucleic acids were extracted from paraffin blocks of H1N1 (A/Mexico/4108/09) infected mouse lung and the human placenta, umbilical cord, and fetal organs (cerebral cortex, cerebellum, lung, liver, heart, and spleen) then assessed with PCR for H1N1 sequences. H1N1 sequences were detected in the positive mouse control but not the human tissues. In summary, this 26‐year‐old female suffered severe H1N1 infection with CNS complications. Three to 4 days after symptom onset, she spontaneously aborted a 15‐week fetus that showed no evidence of influenza infection. Therefore despite severe maternal infection, H1N1 did not transmit across the human placenta during acute infection as has been reported with H5N1 infection.

Peripartum Infections and Associated Maternal Mortality in Rural Malawi

To assess associations between maternal mortality and severe morbidity and human immunodeficiency virus (HIV) infection, uptake of antiretroviral therapy, obstetric infections, and nonobstetric infections in a rural Malawian district, where the estimated HIV prevalence is 21%. We studied the incidence and outcomes of maternal peripartum infections between September 2007 and September 2009 at the district hospital. We used a facility-based prospective cohort study design, including all cases of severe maternal peripartum infection up to 42 days postpartum, and recorded maternal and pregnancy-related characteristics. We assessed the association between mortality and covariates (including nonobstetric infection, HIV prevalence, and uptake of antiretroviral therapy) using univariable and multivariable logistic regression models. In total, 140 infections occurred: 79 (56%) obstetric and 53 (38%) nonobstetric (eight unknown). Half of the women were HIV-positive. Multivariable analysis showed that nonobstetric infection was the most important explanatory variable for mortality (adjusted odds ratio [OR] 4.23, 95% confidence interval [CI] 1.53-11.73). HIV-positive women not on antiretroviral therapy were at higher risk of mortality (adjusted OR 3.02, 95% CI 1.06-8.60) but there was no significant mortality increase among those on treatment (adjusted OR 0.51, 95% CI 0.10-2.71). The most common infections were puerperal sepsis (obstetric, case fatality rate 7%) and pneumonia (nonobstetric, case fatality rate 41%). Untreated HIV infection and nonobstetric infections are independently associated with maternal mortality. Prompt treatment of HIV and nonobstetric infections in pregnant women must be prioritized to reduce maternal mortality. II.

Maternal infection and cerebral palsy in term infants with periventricular leucomalacia

WITH PERIVENTRICULAR LEUCOMALACIA BO JACOBSSON, GUDRUN HAGBERG, HENRIK HAGBERG, Perinatal Center, Goteborg, Sweden Dept. of Pediatrics, Goteborg, Sweden OBJECTIVE: Previous studies have investigated maternal infection during delivery as a possible risk factor for cerebral palsy (CP) in term infants. Infants born at term with diagnosed CP and periventricular leukomalacia (PVL) have, however, been excluded. The aim of this study was to investigate the relationship between maternal infections during pregnancy and PVL combined with CP in the offspring. STUDY DESIGN: A population-based case-control study. Term infants with CP and PVL (CP/PVL) (n = 44) born in 1983-94 were included and matched with a control group (n = 88). All records were scrutinized for any infectious disease or use of antibiotics during pregnancy. Cystic and atrophic PVL were diagnosed by a computed tomographic scan. RESULTS: Mothers with any event of infectious disease noted in their records had an increased risk of having a child with CP/PVL (19/44 cases, 21/88 controls [OR 2.42 {1.12-5.25}]), and if the mothers had suffered any event of amore serious infectious disease during pregnancy, they had an even higher risk (6/44 cases, 1/88 controls [OR 13.74 {1.60-118}]). Apgar score < 7 at 1, 5, or 10 minutes did not constitute a risk factor for CP in this particular subgroup of infants. CONCLUSION: Infection in pregnant women was significantly associated with CP/PVL in term infants, especially in those pregnancies complicated by a more severe maternal infection. In spite of a previously demonstrated close correlation between Apgar score at birth and unexplained CP in term infants, depressed viability at birth did not confer an increased risk of CP/PVL. Speculatively, maternal infection during late mid-pregnancy may inflict fetal white matter injury, but not preterm birth, resulting in PVL/CP in infants born at term without signs of intrapartal asphyxia.

Streptococcus bovis bacteremia and fetal death

BACKGROUND: Preterm premature rupture of membranes leading to intraamniotic infection and fetal death may be due to unusual bacterial species. CASE: A young multipara presented at 24 weeks and 6 days’ gestation with rupture of membranes of 2 days’ duration. She was febrile and hypotensive. No fetal heart activity was noted. Antibiotics, fluid resuscitation, and oxytocin were begun with delivery of a 798-g stillborn fetus. Maternal and fetal cultures demonstrated Streptococcus bovis as the infectious agent. CONCLUSION: Unusual bacteria such as S bovis are sometimes responsible for severe maternal and fetal infections. Aggressive fluid resuscitation, uterine evacuation, and triple antibiotic therapy until culture results are available are indicated.

Maternal sepsis and intrauterine fetal death resulting from Candida tropicalis chorioamnionitis in a woman with a retained intrauterine contraceptive device

Candida spp. are ubiquitous organisms reportedly colonizing up to 10% of pregnant women during mid-gestation. Detailed microbiologic laboratory techniques revealed that Candida albicans (86%), followed by Candida glabrata (9%) were the most frequently isolated strains. Candida tropicalis was identified in less than 1% only of these women. Other rarely isolated Candida spp. were Candida pseudotropicalis , Candida krusei , and Candida famata ( 1 ). Despite the high incidence of asymptomatic or symptomatic vaginal candidiasis, chorioamnionitis with subsequent fetal infection are very rare ( 2, 3 ). This is the first report, to our knowledge, of an intraamniotic candidiasis complicated by severe maternal septicemia. A 35-year-old Vietnamese woman living in Germany, gravida 3, para 1, conceived while using an intrauterine contraceptive device (IUD), which was in situ for an unknown period. She presented at our hospital at 19 weeks of gestation with a history of 3 weeks of malaise and intermittent lower abdominal pain. She was afebrile and the lower abdomen was tender. There was an elevated maternal C-reactive protein level of 3.4 × 102 g/l, but no leukocytosis. Ultrasonography revealed a fetus with a generalized hydrops, including ascites and bilateral pleural effusions. No heart beat was detectable. The IUD was located in the fundus uteri. For the purpose of induction of labor 1 mg gemeprost was placed intravaginally. Chorioamnionitis was suspected, and intravenous antibiotic treatment with ampicillin was commenced. After 8 h admission the patient started to feel cold. Her temperature was elevated up to 39.0 °C, and she developed a leukocytosis of 9.8 × 109/l. The patient's maternal C-reactive protein level rose to 14.5 × 102 g/l. The antibiotic regimen was modified and gentamycin and clindamycin were added. Less than 10 h from initial presentation a stillborn female hydropic fetus weighting 285 g was delivered. Instrumental removal of the placenta was necessary and performed under full anesthesia. The IUD was located and extracted. The operative procedure was complicated by uterine bleeding resulting from a rapidly developing atonia, requiring intravenous administration of oxytocin, methylergometrin, and dinoproston. During the next 24 h the patient was hypotensive (75/40 mmHg, central venous pressure + 1 mmHg) and tachycardic (125 b.p.m.). She suffered from frequent fever attacks of up to 39.7 °C, and her white blood cell count fell from 19.2 × 109/l to 5.2 × 109/l. A marked decrease in platelets from 154 × 109/l to 77 × 109/l was noticed. Plasma coagulation parameters were no longer within their range (fibrinogen 1.4 g/l, partial thromboplastin time (PTT), (normal from 30 to 40 sec.) 59.6 s, AT III 62%). Suspecting maternal septicemia, blood cultures were taken, and were found to be positive for Candida tropicalis 2 days after presentation. The microbiologic culture of the vaginal swabs showed a heavy yeast growth, subsequently identified as C. tropicalis. Yeasts were never isolated from the IUD. After receiving the microbiologic result the antibiotic regimen was changed to a combination of amphotericin, vancomycin, and imipenem. After slight improvement of the patient's condition, she again deteriorated rapidly on the fourth postoperative day. She developed a severe fever attack of up to 42 °C. Her white blood count rose from 2.4 × 109/l to 12.4 × 109/l. For further management the patient was transferred to the intensive care unit of the Department of Anesthesiology. Fortunately, she recovered as a result of on-going antibiotic treatment and usual supportive intensive care procedures. Daily amphotericin infusions were continued for 10 days. She was discharged on day 10 in a good condition. Since the first report of fetal candidiasis in 1958, 57 cases, including this case, have been reported in the English language literature. As in the above reported case, 20 of these were associated with an IUD in situ. A very low incidence of maternal febrile morbidity (4%) indicating hematogenous spread was noted in this collective. The first reference to C. tropicalis as an intrauterine pathogen was by Whyte et al. in 1982 (4) who isolated C. tropicalis from a placenta of a pregnancy complicated by intrauterine Candida infection. Nichols and coworkers, in 1995 (5), presented the first case of C. tropicalis chorioamnionitis at 25 weeks of gestation diagnosed antenatally with confirmed congenital infection. In concordance with our findings, autopsy revealed fetal ascites, infiltration of alveoli and terminal airways by granulocytes, and a marked acute chorioamnionitis. In both the aforementioned publications, there was no evidence for systemic maternal infection; neither were the pregnancies complicated by a retained IUD. Our report confirms that an intraamniotic infection with C. tropicalis in an asymptomatic pregnant women can lead to hematogenous dissemination, manifesting in a severe maternal infection requiring intensive care treatment.

A Comparison of Aztreonam and Two Regimens of Gentamicin in a Rabbit Model of Intra-Amniotic Infection and Sepsis

To compare aztreonam in a standard dose with two gentamicin doses in the early treatment of experimental intra-amniotic infection in rabbits induced by intracervical inoculation with Escherichia coli. Timed pregnant rabbits on day 21 (70% of gestation) were inoculated intracervically with 10(4)-10(5) colony-forming units of E coli. After inoculation, the animals were treated with one of three regimens: 1) aztreonam at 90 mg/kg/day ("standard" dose in humans), 2) gentamicin at 4.5 mg/kg/day ("standard" dose in humans), or 3) higher-dose gentamicin at 6.0 mg/kg/day, each given in three divided doses daily. Outcomes included fever, delivery, and presence of a live fetus. At necropsy, cultures were taken from endometrium, amniotic fluid, and blood. Data were analyzed by Fisher exact test because the expected cell size was fewer than five. Compared with rabbits treated with aztreonam, those treated with gentamicin 4.5 mg/kg/day delivered significantly more often (P = .002), had more positive cultures (P < .001), and had significantly fewer live fetuses (P < .001). Compared with rabbits treated with gentamicin 6.0 mg/kg/day, those treated with gentamicin 4.5 mg/kg/day delivered more often (P = .003), had fewer live fetuses (P = .02), and had more positive cultures (P = .02). There were no significant differences between the aztreonam and gentamicin 6.0 mg/kg/day groups. This study demonstrates in an animal model that aztreonam and gentamicin at 6.0 mg/kg/day are more effective than gentamicin at 4.5 mg/kg/day (a dose that is widely used empirically in humans) in the early treatment of experimental intra-amniotic infection in rabbits. Aztreonam was as effective as gentamicin at 6.0 mg/kg/day. In this rabbit model, in which intra-amniotic infection is accompanied by maternal sepsis, 4.5 mg/kg/day of gentamicin was not adequate for the treatment of severe maternal infection.

Sexually Transmitted Diseases in Pregnancy

Sexually transmitted diseases may have a significant impact on the pregnant woman and her fetus and neonate. Infection at various stages of pregnancy may result in severe maternal disease, congenital defects, premature delivery, or neonatal infection. The clinician caring for pregnant women must be aware of the multitude of sexually transmitted diseases and their potential risks during pregnancy.

CYSTIC FIBROSIS AND PREGNANCY: A National Survey

In a survey of 119 cystic fibrosis (CF) centres in the U.S.A. and Canada, information was obtained on 129 pregnancies in 100 patients with CF. 97 pregnancies were completed resulting in 86 viable infants, only one of whom had CF. This is close to the expected incidence and attests to the recessive nature of the transmission of CF, the commonest lethal genetic disorder of Caucasians. Shortened gestation and increased maternal and perinatal mortality were related to severe maternal pulmonary infection. Increased respiratory and cardiac work, and especially hypervolæmia, are hazards for pregnant women with CF, and when combined with advanced pulmonary disease may lead to increased perinatal complications. Maternal hypoxia and transplacental passage of antibiotics may affect the fetus; however, there were no congenital anomalies in this series in spite of frequent use of antibiotics by these mothers. Unless the clinical score is high, pregnancy should be avoided in CF patients.

Synergistic effects of maternal malnutrition and infection on the infant. Recommendations for prospective studies in man.

Certain infections in the pregnant woman may be accompanied by deleterious effects on the fetus, regardless of the presence of fetal infection. Severe maternal infection can lead to fetal death in utero or to premature labor; less severe infections in the mother seem to be involved in the pathogenesis of fetal growth retardation. The Figure is a set-theory diagram to illustrate a basic mechanistic concept, that various normal nutritional, biochemical, metabolic, or endocrine processes in the mother may be altered during states of infection or pregnancy. Individual maternal processes (illustrated by capital letters in the several sets) may be enhanced or suppressed as a typical physiologic response to pregnancy (lower middle set) or may remain unaltered. Infection (top middle set) initiates many specific responses in the host. In a pregnant woman, individual maternal processes may remain unchanged or may exhibit synergistic, antagonistic, or noncorrelating responses to the combination of both

Lack of transplacental transmissibility of MHV-3 virus

The authors have studied the transmissibility of the virus MHV-3 by the transplacental route from experimentally infected pregnant mice to their fetuses at term, delivered by caesarean section and likewise by the transplacental or vaginal route from the infected mother to mice spontaneously delivered and entrusted to healthy wet-nurses. In both cases, in spite of the severe maternal infection, no virus was detected in the liver of the young. Other experiments have demonstrated the full susceptibility of mice, in the first hours after birth, to the infection experimentally induced by the intraperitoneal incoulation of virus. The obtained results allow the conclusion that infectious virus does not pass to the young by the transplacental or vaginal route.