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Septic shock as a result of group A beta-hemolytic streptococcal meningitis with empyema in pregnancy
BRIEF COMMUNICATIONS objectively to find increased number of stressful events. His findings are in agreement with the present study. Among the Psychotherapeutic interventions, Omer and colleagues found hypnosis with tocolytic therapy to be better in inhibiting preterm labor [1]. Mamelle and colleagues found significant (p b 0.01) reduction in preterm delivery rate when psychological support was given [5]. In the present study, transcendental meditation and sequential muscle relaxation along with tocolytics was found to be more effective. Psychotherapeutic intervention in the form of progressive muscle relaxation revealed higher rates of pregnancy prolongation in 107 subjects studied by Janke [6]. Subjects with more stressful life events and poor psychosocial status had preterm labor at an early gestational age. Tocolysis along with psychotherapeutic intervention is more effective than tocolysis alone in inhibiting preterm labor and prolonging pregnancy. This helps to achieve a neonate who is delivered at a later gestational age with less requirements of neonatal intensive care facilities and hence these interventions may be useful, especially for developing countries.
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References [1] Omer H, Everly Jr GS. Psychological factors in preterm labor. Critical review and theoretical synthesis. Am J Psychiatry 1988;145(12):1507–13 [1]. [2] Newton RW, Webester PAC, Bince PS. Psychosocial stress in pregnancy and its relation to the onset of premature labor. BMJ 1979;2:411–4. [3] Goldenberg RL, Hickey CA, Cliver SA. Abbreviated scale for the assessment of psychosocial status in pregnancy — development and evaluation. Acta Obstet Gynecol Scand 1997; 165(76):19–29. [4] Gunter RM. Psychopathology and stress in life — experiences of mothers of premature infants. Am J Obstet Gynecol 1963; 86:333–9. [5] Mamelle NJ, Seguelle M, Munza F, Berland M. Prevention of preterm birth in patients with symptoms of preterm labor. The benefit of psychological support. Am J Obstet Gynecol 1997;177 (4):747–52. [6] Janke J. Effect of relaxation therapy in preterm labor. J Obstet Gynecol Neonatal Nurs 1999;2893:255–63.
Septic shock as a result of group A beta-hemolytic streptococcal meningitis with empyema in pregnancy M.T. Verhulsdonk a,1 , D.R. Hassell b , S.G. Oei a,⁎ a b
Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands Department of Emergency Medicine, Máxima Medical Center, Veldhoven, The Netherlands
Received 21 December 2006; received in revised form 9 March 2007; accepted 15 March 2007
KEYWORDS Sepsis; Pregnancy; Empyema; Group A beta-hemolytic streptococcus
⁎ Corresponding author. Máxima Medical Center Veldhoven, Department of Obstetrics and Gynecology, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands. Tel.: +31 40 8888385; fax: +31 408888387. E-mail addresses: [email protected] (R. Sascha Dua), [email protected] (M.T. Verhulsdonk), [email protected] (S.G. Oei). 1 Bomanshof 179, 5611 NN Eindhoven, The Netherlands. Tel.: +31 402134374. doi:10.1016/j.ijgo.2007.03.013
Septic shock from group A beta-hemolytic streptococcal (GAS) meningitis with empyema is rarely observed in pregnancy. This condition is more common in the puerperium. Sepsis due to GAS is one of the major causes of pregnancy related death worldwide [2]. Group A beta-hemolytic streptococcus produces streptococcal pyrogenic exotoxins, inducing over-activity of the immune system. The resulting cascade of cytokines is the major cause of high virulence and mortality (10–30%) by GAS [1]. Rapid diagnosis and multidisciplinary care can prevent this condition from quick deterioration beyond control. An unconscious 33 year old woman in her fourth pregnancy, with a gestational age of 34 weeks, was transported to the hospital with signs of septic shock. Her Glasgow coma scale (GCS) score upon admission was 9 (E2M5V2). There were no signs of labor. Cardiotocography showed a tachycardia (200 bpm) with decelerations and decreased variability. The GCS was 4 (E2M1V1) after thirty minutes. Cerebral spinal fluid (CSF) analysis suggested bacterial meningitis. The woman was intubated due to respiratory insufficiency. Dexamethasone was administered
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BRIEF COMMUNICATIONS
Figure 1
Cerebral computed tomography (CT) with (left) and without (right) contrast medium.
to suppress intracranial hypertension. Ceftriaxone and amoxicillin, and inotropic therapy was initiated for sepsis control and the prevention of cardiac failure, respectively. Cerebral computed tomography showed subdural infusion, hypodensity over the right convexity, and a midline shift (Fig. 1). The diagnosis meningitis with empyema was made. Six hours after admission there was a spontaneous rupture of membranes with full cervical dilation and regular contractions. A female infant weighing 3010 g with respective Apgar scores of 1 and 4 at 1 and 5 min was delivered by vacuum extraction. Umbilical blood gas analysis showed an arterial pH of 7.11, a venous pH of 7.19 and a base excess of − 15 mmol/L. The patient was transported to a neurosurgical unit where a cerebral abscess was drained by craniotomy. A GAS population was isolated from blood and the abscess. The patient and infant made a full recovery. Management of septic shock in pregnancy requires immediate attention of a multidisciplinary team. Hospital sepsis guidelines should be followed. Antibiotic therapy consisting of intravenously administrated beta-lactams and aminoglycosides
is considered safe in pregnancy [1]. Initial management of septic shock from GAS meningitis in pregnant women should be similar to management in non-pregnant women. In septic shock, the fetal condition is compromised by utero-placenta hypotension resulting from poor maternal circulation and organ failure [2]. Route and timing of the delivery are determined by the maternal condition [2,3].
References [1] Sriskandan S, Kemball-Cook G, Moyes D, Canvin J, Tuddenham E, Cohen J. Contact activation in shock caused by invasive group A streptococcus pyogenes. Crit Care Med 2000;28:3684–91. [2] Fernandez-Perez ER, Salman S, Pendem S, Farmer JC. Sepsis during pregnancy. Crit Care Med Oct 2005;33(10 suppl):S286–93 [Review]. [3] Wax JR, Pinette MG, Blackstone J, Cartin A. Brain abscess complicating pregnancy. Obstet Gynecol Surv Mar 2004;59(3):207–13 [Review].
197
References [1] Omer H, Everly Jr GS. Psychological factors in preterm labor. Critical review and theoretical synthesis. Am J Psychiatry 1988;145(12):1507–13 [1]. [2] Newton RW, Webester PAC, Bince PS. Psychosocial stress in pregnancy and its relation to the onset of premature labor. BMJ 1979;2:411–4. [3] Goldenberg RL, Hickey CA, Cliver SA. Abbreviated scale for the assessment of psychosocial status in pregnancy — development and evaluation. Acta Obstet Gynecol Scand 1997; 165(76):19–29. [4] Gunter RM. Psychopathology and stress in life — experiences of mothers of premature infants. Am J Obstet Gynecol 1963; 86:333–9. [5] Mamelle NJ, Seguelle M, Munza F, Berland M. Prevention of preterm birth in patients with symptoms of preterm labor. The benefit of psychological support. Am J Obstet Gynecol 1997;177 (4):747–52. [6] Janke J. Effect of relaxation therapy in preterm labor. J Obstet Gynecol Neonatal Nurs 1999;2893:255–63.
Septic shock as a result of group A beta-hemolytic streptococcal meningitis with empyema in pregnancy M.T. Verhulsdonk a,1 , D.R. Hassell b , S.G. Oei a,⁎ a b
Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands Department of Emergency Medicine, Máxima Medical Center, Veldhoven, The Netherlands
Received 21 December 2006; received in revised form 9 March 2007; accepted 15 March 2007
KEYWORDS Sepsis; Pregnancy; Empyema; Group A beta-hemolytic streptococcus
⁎ Corresponding author. Máxima Medical Center Veldhoven, Department of Obstetrics and Gynecology, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands. Tel.: +31 40 8888385; fax: +31 408888387. E-mail addresses: [email protected] (R. Sascha Dua), [email protected] (M.T. Verhulsdonk), [email protected] (S.G. Oei). 1 Bomanshof 179, 5611 NN Eindhoven, The Netherlands. Tel.: +31 402134374. doi:10.1016/j.ijgo.2007.03.013
Septic shock from group A beta-hemolytic streptococcal (GAS) meningitis with empyema is rarely observed in pregnancy. This condition is more common in the puerperium. Sepsis due to GAS is one of the major causes of pregnancy related death worldwide [2]. Group A beta-hemolytic streptococcus produces streptococcal pyrogenic exotoxins, inducing over-activity of the immune system. The resulting cascade of cytokines is the major cause of high virulence and mortality (10–30%) by GAS [1]. Rapid diagnosis and multidisciplinary care can prevent this condition from quick deterioration beyond control. An unconscious 33 year old woman in her fourth pregnancy, with a gestational age of 34 weeks, was transported to the hospital with signs of septic shock. Her Glasgow coma scale (GCS) score upon admission was 9 (E2M5V2). There were no signs of labor. Cardiotocography showed a tachycardia (200 bpm) with decelerations and decreased variability. The GCS was 4 (E2M1V1) after thirty minutes. Cerebral spinal fluid (CSF) analysis suggested bacterial meningitis. The woman was intubated due to respiratory insufficiency. Dexamethasone was administered
198
BRIEF COMMUNICATIONS
Figure 1
Cerebral computed tomography (CT) with (left) and without (right) contrast medium.
to suppress intracranial hypertension. Ceftriaxone and amoxicillin, and inotropic therapy was initiated for sepsis control and the prevention of cardiac failure, respectively. Cerebral computed tomography showed subdural infusion, hypodensity over the right convexity, and a midline shift (Fig. 1). The diagnosis meningitis with empyema was made. Six hours after admission there was a spontaneous rupture of membranes with full cervical dilation and regular contractions. A female infant weighing 3010 g with respective Apgar scores of 1 and 4 at 1 and 5 min was delivered by vacuum extraction. Umbilical blood gas analysis showed an arterial pH of 7.11, a venous pH of 7.19 and a base excess of − 15 mmol/L. The patient was transported to a neurosurgical unit where a cerebral abscess was drained by craniotomy. A GAS population was isolated from blood and the abscess. The patient and infant made a full recovery. Management of septic shock in pregnancy requires immediate attention of a multidisciplinary team. Hospital sepsis guidelines should be followed. Antibiotic therapy consisting of intravenously administrated beta-lactams and aminoglycosides
is considered safe in pregnancy [1]. Initial management of septic shock from GAS meningitis in pregnant women should be similar to management in non-pregnant women. In septic shock, the fetal condition is compromised by utero-placenta hypotension resulting from poor maternal circulation and organ failure [2]. Route and timing of the delivery are determined by the maternal condition [2,3].
References [1] Sriskandan S, Kemball-Cook G, Moyes D, Canvin J, Tuddenham E, Cohen J. Contact activation in shock caused by invasive group A streptococcus pyogenes. Crit Care Med 2000;28:3684–91. [2] Fernandez-Perez ER, Salman S, Pendem S, Farmer JC. Sepsis during pregnancy. Crit Care Med Oct 2005;33(10 suppl):S286–93 [Review]. [3] Wax JR, Pinette MG, Blackstone J, Cartin A. Brain abscess complicating pregnancy. Obstet Gynecol Surv Mar 2004;59(3):207–13 [Review].