Patrick Duff

The course of labor in term patients with chorioamnionitis

Labor records and internal fetal monitor tracings of 65 patients with uncomplicated term pregnancies who entered labor spontaneously and then developed chorioamnionitis were reviewed. Eighty-eight percent of patients were nulliparous. Seventy-five percent had abnormal labor, characterized by decreased uterine contractility, and 34% required cesarean delivery because of failure to progress in labor. The most common fetal heart rate abnormalities were diminished or absent variability (77%) and tachycardia (67%); 15% of the tracings had a sinusoidal pattern. Despite the high prevalence of abnormal fetal heart rate tracings, only one infant had a 5-minute Apgar score less than 7. It is concluded that chorioamnionitis has an inhibitory effect on labor. Compared to uninfected women, certain infected patients appear to require higher doses of oxytocin and greater uterine activity to effect a given change in cervical dilation.

Pelvic vein thrombophlebitis: diagnostic dilemma and therapeutic challenge.

Pelvic vein thrombophlebitis is an unusual, but extremely serious, complication of pelvic surgery. It occurs in approximately 0.5 to 1 per cent of patients who develop operative site infections. It may present as two distinct clinical syndromes: acute ovarian vein thrombosis and diffuse thrombosis of multiple small pelvic vessels. Accurate diagnosis is hampered by the absence of a reliable, specific, and noninvasive test for the disorder. Treatment of pelvic vein thrombophlebitis requires administration of broad spectrum antibiotics, intravenous heparin, and, in selected cases, ovarian vein and vena cava ligation.

A double-blind, randomized comparison of moxalactam versus clindamycin-gentamicin in treatment of endomyometritis after cesarean section delivery

A double-blind comparison of clindamycin plus gentamicin versus moxalactam plus placebo was performed for the treatment of endomyometritis after cesarean section delivery. Entry criteria were uterine tenderness, temperature greater than or equal to 101 degrees F, and leukocytosis. Uterine specimens were obtained for culture via a single-lumen transcervical catheter. Bacteremia occurred in 10% of patients. Among the 57 patients treated with clindamycin plus gentamicin, there were two clinical failures and four side effect failures (diarrhea in two, allergic reaction in two). Among the 56 patients in the moxalactam group, there were four clinical failures and one side effect failure (diarrhea). Both regimens had good cure rates, with no significant differences in cures or postoperative hospital stay.

Randomized comparison of ceftazidime versus clindamycin-tobramycin in the treatment of obstetrical and gynecological infections.

A randomized comparison of ceftazidime versus clindamycin-tobramycin was performed for the treatment of obstetrical and gynecological infections. Entry criteria were an oral temperature of greater than or equal to 38 degrees C and a clinical diagnosis of endometritis, salpingitis, or pelvic cellulitis after hysterectomy. All patients with endometritis had cultures of intrauterine material obtained via a transcervical single-lumen catheter. The patients with pelvic cellulitis had material from the vaginal apex aspirated for culture, and all patients with salpingitis had a culdocentesis for culture of intraperitoneal material. Of 38 patients who received ceftazidime, 34 had endometritis after cesarean section, 3 had endometritis after abortion, and 1 had pelvic cellulitis. Of 39 patients who received clindamycin-tobramycin, 35 had endometritis after cesarean section, 3 had salpingitis, and 1 had pelvic cellulitis. The most common bacterial isolates were Lactobacillus sp., Bacteroides bivius, Escherichia coli, other gram-negative aerobic bacilli, group B streptococci, and other aerobic streptococci. Bacteremia occurred in 9.0% of the patients. Of the patients receiving clindamycin-tobramycin and ceftazidime, 34 (87.2%) and 34 (89.5%), respectively, responded to therapy. All the clinical failures occurred in patients with endometritis after cesarean section. Clinical failures had persistent fever despite 3 or more days of treatment. One of the patients receiving clindamycin-tobramycin developed an urticarial rash after her infection had resolved. No patient in either group developed diarrhea. In these small groups of patients, there were no significant differences in cure rate, side effects, or length of hospital stay.