Puerperal Group A Streptococcal Infection

Abstract

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.

Clinical Characteristics of and Preventative Strategies for Peripartum Group A Streptococcal Infections

“…More than 120 M variants are characterized and used for epidemiologic investigations. 3 Compared with nonpregnant women, pregnant women are at a 20-fold increased risk for invasive group A streptococcal infection 4 with 85% of infections occurring during the postpartum period. 5 Risk factors for intrapartum and postpartum group A streptococcal infection include upper respiratory tract infection with pharyngeal colonization before delivery and contact with carriers of group A streptococcal infection during pregnancy 6 or risk factors attributed to the delivery such as premature rupture of membranes, 7 mucosal damage, and emergency cesarean deliveries.…”

Obstetric Sepsis

“…34 Intravenous fluid hydration is the first step and crystalloid fluid such as normal saline (0.9%) and lactated Ringer's is preferred over colloids for volume replacement. 11,12,30,33 The 5 indicators of adequate fluid resuscitation set by the bundle demonstrate improved perfusion via improved preload, afterload, urine output, and oxygen transport. 15 Decreasing lactate levels indicate aerobic metabolism resuming and thereby adequate perfusion to tissues.…”

“…5,[10][11][12][13][14][15]27,30,33 The therapeutic goals of initial resuscitation are to reverse hypotension and subsequent hypoperfusion as well as the anaerobic metabolic effects of sepsis, which are indicated by the lactate level. 10,13,15,27,33 Lactate levels are a key aspect of the bundle and can be used as a guide in determining the degree of organ hypoxia or determine if organ perfusion is improving with volume replacement. Increased lactate levels are associated with adverse perinatal outcomes such as preterm delivery, ICU or critical care admission, and prolonged hospital admission.…”

Facing Change: When to Embrace, When to Resist

“…It is not surprising that this approach can sometimes lead to heated debates-let us not forget the important work of Semmelweis on hand washing. 8 But it is equally important that we constantly try to bring the discussion back to the data and to what practices the current data actually support. Where the data is lacking, practitioners should then use liberal amounts of emotional IQ and develop consensus-based guidelines (and/or follow preexisting ones) wherever possible.…”