Serious group A streptococcal infection around delivery

To differentiate the features of serious, perinatal, group A streptococcal infection from other types of streptococcal toxic shock syndrome.

Thirty-eight obstetric cases that were fatal or fulfilled the criteria of Centers of Disease Control and Prevention for streptococcal toxic shock syndrome were reviewed. Three cases were from Asahi General Hospital, 26 from MEDLINE (1966-December 1998), four from Japana Centra Revuo Medicina (1987-November 1998) using the search terms "Streptococcus," "Streptococcus pyogenes," "Streptococcal infection," "pregnancy," "labor," "delivery," "sepsis," and "shock," and five from official records of the Ministry of Health and Welfare of Japan. Cases of early pregnancy or cases that had unclear intervals between delivery and deterioration were eliminated. INTEGRATION AND RESULTS: The 30 cases were divided into two groups by interval between delivery and deterioration. Seventeen cases deteriorated before, during, or within 12 hours of delivery (perinatal group). They were compared with 13 cases of the puerperal group. The mortality rates for infants and mothers in the perinatal group were higher than those of the puerperal group (infant: ten of 17 versus zero of 13, mother: 15 of 17 versus seven of 13). The other differences of description were unusually strong labor (eight of 17 versus one of 13), obvious serious inflammation (zero of 17 versus ten of 13), and evidence of serious sepsis (eight of 17 versus zero of 13). Purulent myometritis without neighboring inflammation was found in our three cases. In ten cases, subjects or their family members had preceding sore throats.

The cases in the perinatal group had characteristic features. We suspected that after invading the myometrium through the upper respiratory tract, large amounts of cocci were dispersed into the systemic circulation of the mother by active uterine contractions caused by purulent myometritis. Unusual clinical signs were important for diagnosis.