Puerperal fever

Puerperal fever (from the latin puer, child), also called childbed fever, can develop into puerperal sepsis, which is a serious form of septicaemia contracted by a woman during or shortly after childbirth or abortion.

The most common infection causing Puerperal Fever is genital tract sepsis. Historically its spread was usually attributable to unsanitary conditions, but in modern medicine can still be caused by the naturally occurring Group A Streptococcus (GAS, Streptococcus pyogenes) bacterium and Group B Streptococcus (GBS, Streptococcus agalactiae, which usually causes less severe maternal disease)^[1].

Other types of infection that can lead to sepsis in the puerperum include urinary tract infection, mastitis and respiratory tract infection (more common after anaesthesia).

Other causal organisms, in order of prevalence, include staphylococci, coliforms, anaerobes, chlamydia, mycoplasma and very rarely, Clostridium welchii.

Puerperal fever is now rare in the West due to improved hygiene during delivery, and deaths have been reduced by antibiotics.

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History

Hospitals for childbirth became common in the 17th century in many European cities. These "lying-in" hospitals were established at a time when there was no knowledge of antisepsis or epidemiology, and patients were subjected to crowding, frequent vaginal examinations, and the use of contaminated instruments, dressings, and bedding. It was common for a doctor to deliver one baby after another, without washing his hands or changing clothes in between.

The first recorded epidemic of puerperal fever occurred at the Hôtel-Dieu de Paris in 1646. Hospitals throughout Europe and America consistently reported death rates between 20% to 25% of all women giving birth,punctuated by intermittent epidemics with up to 100% fatalities of women giving birth, in childbirth wards.^[2]

A number of physicians began to suspect contagion and hygiene as causal factors in spreading puerperal fever. In 1795, Alexander Gordon of Aberdeen, Scotland suggested that the fevers were infectious processes, that physicians were the carrier, and that "I myself was the means of carrying the infection to a great number of women.”^[3] Thomas Watson, Professor of Medicine at King's College Hospital, London, wrote in 1842: "Wherever puerperal fever is rife, or when a practitioner has attended any one instance of it, he should use most diligent ablution." Watson recommended handwashing with chlorine solution and changes of clothing for obstetric attendants "to prevent the practitioner becoming a vehicle of contagion and death between one patient and another." ^[4]

Prevention via hygienic measures

In 1843, Oliver Wendell Holmes published The Contagiousness of Puerperal Fever and controversially concluded that puerperal fever was frequently carried from patient to patient by physicians and nurses and suggesting that hand-washing, clean clothing, and avoidance of autopsies by those aiding birth would prevent the spread of puerperal fever.^[5] Holmes stated that ". . . in my own family, I had rather that those I esteemed the most should be delivered unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease."^[6]

Holmes' conclusions were ridiculed by many contemporaries, including Charles Meigs, a well-known obstetrician, who stated "Doctors are gentlemen, and gentlemen's hands are clean."^[7]

In 1844, Ignaz Semmelweis was appointed assistant lecturer in the First Obstetric Division of the Vienna General Hospital (Allgemeines Krankenhaus), where medical students received their training. Working without knowledge of Holmes' essay, Ignaz Semmelweis noticed his ward’s 16% mortality rate from fever was substantially higher than the 2% mortality rate in the Second Division, where midwifery students were trained. Ignaz Semmelweis also noticed that puerperal fever was rare in women who gave birth before arriving at the hospital. Semmelweis noted that doctors in First Division performed autopsies each morning on women who had died the previous day but the midwives were not required or allowed to perform such autopsies. He made the connection between the autopsies and puerperal fever after a colleague, Jakob Kolletschka, died of septicaemia after accidentally cutting his hand while performing an autopsy.

Semmelweis began experimenting with various cleansing agents and, from May 1847, ordered that all doctors and students working in the First Division wash their hands in chlorinated lime solution before starting ward work, and later before each vaginal examination. The mortality rate from puerperal fever in the division fell from 18% in May 1847 to less than 3% in June–November of the same year.^[8] While his results were extraordinary, he too was treated with skepticism and ridicule (see Rejection of Semmelweis).

The true mechanism of puerperal fever was not generally understood until the start of the 20th century. In 1879 Louis Pasteur showed that streptococcus was present in the blood of women with puerperal fever. By the turn of the century, the need for antiseptic techniques was widely accepted, and their practice along with the mid-century introduction of new antibiotics greatly diminished the rate of death during childbirth.

Modern Occurrence

In 2004 a mother, Jessica Palmer, died of puerperal fever, caused by Group A Streptococcus in the UK. The case was much publicised in the media, and the mother's widower subsequently set up a website to highlight the continuance of the disease, its symptoms and how easily treatable it is.

References

1. ^ Oxford Textbook of Medicine
2. ^ Loudon I. Deaths in childbed from the eighteenth century to 1935. Med History 1986; 30: 1-41
3. ^ Oliver Wendell Homes: The Contagiousness of Puerperal Fever paragraph 16
4. ^ The Medical Journal of Australia."The contagiousness of childbed fever: a short history of puerperal sepsis and its treatment"
5. ^ Oliver Wendell Holmes: The Contagiousness of Puerperal Fever
6. ^ Harvard Gazette: How Oliver Wendell Holmes helped conquer the black death of childbed
7. ^ Wertz RM, Wertz DC. Lying-in: a history of childbirth in America. New York: New York Free Press, 1977.
8. ^ Raju TN. Ignac Semmelweis and the etiology of fetal and neonatal sepsis. J Perinatol 1999; 19(4): 307-310.