Puerperal Sepsis

by John W. Wood II

 Puerperal Fever is known to be caused by an infection of haemolytic streptococci (1).  Haemolytic Streptococci are bacteria that produce active haemolysins causing a clear zone of hemolysis on a blood agar medium in the area of the colony (2).  The main bacterial strain seen is known as Streptococcus pyogenes (1).  S. pyogenes is a group A streptococcus that is known to be gram positive, spherical bacteria that grows in long chains.  (4, 5)It is the cause of all group A streptococcal infections that can infect a number of body systems (4,5).   S. pyogenes has an incubation period of ten days.  (5).  S. pyogenes produces beta hemolysis when placed on a blood agar plate.   S. pyogenes has several virulence factors that enable it to host tissues, evade the immune response and spread by penetrating host tissue layers (5).  A carbohydrate capsule composed of hyaluronic acid surrounds the bacterium protecting it from phagocytosis caused by neutrophils.  The Capsule and the M protein embedded in the cell wall facilitate an attachment with the host cell (4).  Humans are the only known reservoir for Puerperal Sepsis. 

  

Puerperal Sepsis epidemics began to emerge in the mid-eighteenth century with the introduction of lying-in hospital used to provide physicians training in obstetrics in general and forceps in particular (1).  Childbed Fever, another name for Puerperal Sepsis, was first reported in Britain in 1792 by Alexander Gordon.  It is known that puerperal fever is an endogenous condition found in women who had recently given birth to a child either in a hospital setting, or with the aid of a midwife.  However, this condition also has an exogenous factor as noted on the hands and smocks of doctors as well as midwifes (1).  Dr. Oliver Wendell Holmes advocated hand washing techniques in 1843 (6).  Dr Holmes believed that Puerperal Sepsis was passed from patient to patient by the hands of doctors and medical students.  Dr. Holmes implemented a rule to help prevent the spread of Puerperal Sepsis.  This rule stated: if a doctor had two patients infected with Puerperal Sepsis that doctor was to remove themselves from obstetrical practice for one month (6). 

 

Dr. Ignaz Semmelweis was a medical student at the Vienna Hospital in the late 1840s.  Dr. Semmelweis noted that the mortality rate in the hospital ward staffed by medical students was three times higher than that of the adjacent ward staffed by midwifes (6).  Semmelweis called the passing of Puerperal Sepsis from cadaver to patient the “cadaveric principle” (7).  Due to this principle, Semmelweis ordered doctors and medical students in the Vienna Hospital to wash their hands between cadaver dissection and delivery (6).  The mortality rate at Vienna Hospital dropped to less than one percent with routine hand washing (6). Dr. Semmelweis recorded the number of births and number of deaths from Puerperal Sepsis in the two Vienna clinics from 1841-1846.  The first clinic, staffed by medical students, proved to have a much higher death rate than that of the clinic staffed by midwives (1).  1842 proved to have the highest mortality rate at 15.8% (1).  The highest mortality rate in the midwife clinic was 7.5%, also in 1842 (1).  Puerperal Sepsis killed 100,000 women a year worldwide in the late 1800s. 

 

Symptoms of Puerperal Sepsis include chills, soreness in the womb, fever, cold sweats and excessive thirst (3).  Symptoms that appear to a lesser extent include headache, back pain, nausea and vomiting (3).  Puerperal Sepsis is diagnosed based on accumulation of the symptoms listed above and an examination of the body systems involved.  In the case of Puerperal Sepsis the body system involved is the uterus, however other systems such as the lungs, brain urinary tract and bowels (2).  In the 1800s when Puerperal Sepsis was seen in a high incidence rate all doctors could do to diagnose this condition was observe the symptoms as this deadly disease took its course.  Today tests can be run to identify a sepsis infection.  These tests include a white blood count, bodily fluid cultures and chest x-rays (2).

 

The last known case of Puerperal Sepsis occurred in Europe in 2004 (8).  Jessica Palmer died six days after giving birth to her son.  The wide availability of antibiotics has all but eliminated Puerperal Sepsis.  In Jessica’s case her infection was not property diagnosed, and the infection was past the stage of being cured by antibiotics (8).  Jessica’s death could have been prevented if the midwife would have treated her infection signs more seriously.  

 

 References

 

1.  Joseph W. Bigger, MD.  “An Investigation into the Etiology of Puerperal Fever.”      April 25, 1925.  Available from:   http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2226242.  Accessed March 5, 2008. 

 

  1. ANON.  “Haemolytic Streptococci.”  October 3, 2005.  Available from: http://www.biology-online.org/dictionary/Haemolytic_streptococci.  Accessed March 5, 2008.
  2. Ignaz Semmelweis.  “The Etiology, Concept and Prophylaxis of Childbed Fever.” January 2008.  Available from: http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/article/viewFile/178/353.  Accessed March 6, 2008.
  3. CR Starr.  “Role of Hyaluronidase in Subcutaneous Spread and Growth of Group A Streptococcus.” January 2006.  Available from: http://www.ncbi.nlm.nih.gov/pubmed/16368955.  Accessed March 6, 2008.
  4. Bisno, Brito and Collins.  “Molecular Basis of Group A Streptococcal virulence.”  April 2003.  Available from: http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=12679262&dopt=Abstract.  Accessed March 6, 2008.
  5. ANON.  “The History of Hand-Washing.”  2006.  Available from: http://www.hygenius.com/history.htm.  Accessed March 6, 2008.
  6. K. Codell Carter and Barbara R. Carter.  “Childbed Fever: A Scientific Biography of Ignaz Semmelweiss.”  December 15, 1999.  Available from: http://www.annals.org/cgi/content/full/121/12/999.  Accessed March 9, 2008.
  7. ANON.  “Jessica’s trust: Raising Awareness of Childbed fever.”  An ongoing website put together by Jessica Parmer’s husband, Harry.  Available from: http://www.jessicastrust.org.uk/.  Accessed March 9, 2008