Mark T. Peters

The return of life-threatening puerperal sepsis caused by group A streptococci

A dramatic decline in the prevalence of serious puerperal infection caused by group A beta-hemolytic streptococci has been observed throughout most of the twentieth century, and it is currently a very uncommon cause of maternal morbidity and mortality. We report on two term pregnancies complicated by profound multisystem organ failure caused by group A streptococcal puerperal sepsis. This report serves to highlight the apparent return of serious group A streptococcal puerperal sepsis and to emphasize the clinical implications and sequelae attributable to an old yet virulent enemy.

Fetal syphilis: correlation of sonographic findings and rabbit infectivity testing of amniotic fluid.

Fetal syphilis is the presumed diagnosis when the sonographic findings of fetal hydrops are found in the presence of maternal syphilis. In the absence of fetal hydrops, the diagnosis of fetal infection is difficult. We hypothesized that intra‐amniotic infection would be accompanied by anatomic placental and fetal abnormalities that could be detected by ultrasonography. Rabbit infectivity testing (RIT), intratesticular inoculation of rabbits with amniotic fluid, can be used to confirm intra‐amniotic infection with Treponema pallidum. Twenty‐one gravidas with untreated early (primary, secondary, and early latent) syphilis underwent sonography and amniocentesis for RIT at 24 weeks of gestation or later. Antenatal sonographic findings were compared to their amniotic fluid RIT results. Hepatomegaly was significantly (P < 0.01) associated with amniotic fluid infection detected by RIT. Antenatal detection of hepatomegaly, which is probably the initial sonographic manifestation of hydrops fetalis, may ultimately identify the fetus affected with congenital syphilis.

Mode of delivery in multiple birth of higher order.

A retrospective review of triplets delivered at a Boston perinatal center from 1977 to 1986 was performed. Comparison was made between this group (study group) and previously published data on triplets in our institution (control group). Since 1977 there was a more liberal use of abdominal delivery. Cesarean sections (CS) of all triplets with malpresentation was our protocol. Of the 15 sets of triplet pregnancies in the study group, 11 were delivered by CS and 4 by vaginal delivery, vs only 1 CS in the control group which consisted also of 15 triplets. The corrected mortality rate in the study group was lower than in the control group (2.6% vs 7.1%) but did not reach statistical significance. Apgar scores at 1 and 5 minutes were significantly higher in the study group (P less than 0.002). Apgar scores for the third triplet were also higher in the study group (P less than 0.05). In comparing the combined mortality and morbidity between the study group and the control group, no difference was found in the first triplet, but those of the second and third triplets were significantly lower in the study group. Of interest is the finding that the combined mortality and morbidity was not different statistically among the first, second, and third triplets in the study group, while in the control group an increase from the first to the third triplet was noted (21%, 31%, and 43%, respectively). A more liberal approach toward abdominal delivery of pregnancies of higher fetal number is advocated.

Randomized, Double-Blinded, Placebo-Controlled Trial of Amoxicillin/Clavulanic Acid to Prevent Preterm Delivery in Twin Gestation

Objective: The objective of this study was to determine whether prophylactic treatment with oral broad-spectrum antimicrobial therapy improves pregnancy outcomes in twin gestations. Methods: Patients with twin gestations between 24 and 32 weeks were randomized to receive amoxicillin/clavulanic acid or placebo. Those patients randomized before 24 weeks received a 1-week course at 24 and at 28 weeks gestation. Those patients entered later than 24 weeks received a 1-week course either at 28 weeks or at enrollment (up to 32 weeks). Other than antibiotic use, the management of the groups was identical and unchanged from the routine care of twin gestations. Results: Of 149 twin pregnancies enrolled, 76 were randomized to the drug group and 73 to the placebo group. There was no significant difference in mean gestational age at delivery (35.9 vs. 35.7 weeks), birth weight (2,358 vs. 2,344 g), mean neonatal nursery stay (9.9 vs. 11.7 days), or respiratory distress syndrome (6/76 vs. 4/73) in the drug vs. placebo group, respectively. Conclusions: The addition of prophylactic oral broad-spectrum antimicrobial therapy to the standard antepartum management of twin gestations had no demonstrable effect on the gestational age at delivery, birth weight, or neonatal complications. There did not appear to be any beneficial effect of the prophylactic use of amoxicillin/clavulanic acid in this clinical setting.

Fetal syphilis: Correlation of sonographic findings and rabbit infectivity testing of amniotic fluid

Fetal syphilis is the presumed diagnosis when the sonographic findings of fetal hydrops are found in the presence of maternal syphilis. In the absence of fetal hydrops, the diagnosis of fetal infection is difficult. We hypothesized that intra-amniotic infection would be accompanied by anatomic placental and fetal abnormalities that could be detected by ultrasonography. Rabbit infectivity testing (RIT), intratesticular inoculation of rabbits with amniotic fluid, can be used to confirm intra-amniotic infection with Treponema pallidum. Twenty-one gravidas with untreated early (primary, secondary, and early latent) syphilis underwent sonography and amniocentesis for RIT at 24 weeks of gestation or later. Antenatal sonographic findings were compared to their amniotic fluid RIT results. Hepatomegaly was significantly (P < 0.01) associated with amniotic fluid infection detected by RIT. Antenatal detection of hepatomegaly, which is probably the initial sonographic manifestation of hydrops fetalis, may ultimately identify the fetus affected with congenital syphilis.

Mode of Delivery in Multiple Birth of Higher Order

A retrospective review of triplets delivered at a Boston perinatal center from 1977 to 1986 was performed. Comparison was made between this group (study group) and previously published data on triplets in our institution (control group). Since 1977 there was a more liberal use of abdominal delivery. Cesarean sections (CS) of all triplets with malpresentation was our protocol. Of the 15 sets of triplet pregnancies in the study group, 11 were delivered by CS and 4 by vaginal delivery, vs only 1 CS in the control group which consisted also of 15 triplets. The corrected mortality rate in the study group was lower than in the control group (2.6% vs 7.1%) but did not reach statistical significance. Apgar scores at 1 and 5 minutes were significantly higher in the study group (P less than 0.002). Apgar scores for the third triplet were also higher in the study group (P less than 0.05). In comparing the combined mortality and morbidity between the study group and the control group, no difference was found in the first triplet, but those of the second and third triplets were significantly lower in the study group. Of interest is the finding that the combined mortality and morbidity was not different statistically among the first, second, and third triplets in the study group, while in the control group an increase from the first to the third triplet was noted (21%, 31%, and 43%, respectively). A more liberal approach toward abdominal delivery of pregnancies of higher fetal number is advocated.

The Respiratory Burst and the Onset of Human Labor, Preterm Labor, and Premature Rupture of the Membranes

The respiratory burst is implicated in many different and diverse areas of biology. This should not be surprising. If phagocytosis and/or pinocytosis are truly the mechanisms that cells use for eating and drinking, one should expect no boundaries. In the field of obstetrics, the respiratory burst may be implicated in the onset of human labor, preterm labor, and premature rupture of the fetal membranes. The common denominator in all these events could well be brought about by phagocytosis or a phagocytosis-like phenomenon and the accompanying respiratory burst.