Fetal scalp abscess secondary to intrauterine monitoring FERDINAND ANGEL Houston,

J. WERCH,

PLAVIDAL, M.D.,

M.D. F.A.C.O.G.

Texas

Thirty-one cases of fetal scalp abscess secondary to internal fetal monitoring ozfer a 32 month period were rezfiewed. The over-all incidence was 1:230 monitored labors, or 0.4 per cent. Twenty-nine infants were cultured, with no growth in 10, Staphylococcus epidermidis in 11, and pathogenic organisms in the remainder. Gram stains of the exudates generally supported the culture results. All cases responded to drainage, local care, and systemic antibiotics, with no deaths. One case of osteomyelitis of the skull was conjirmed roentgenographically. A strong correlation between prolonged rupture of the membranes and scalp abscess was obseroed, but no &jnite infectious origin was conjirmed. The etiology of scalp abscess secondary to monitoring remains obscure.

INTRAPARTLJM FETAL monitoring is now considered a standard procedure for evaluation of labor and fetal condition in nearly all obstetric units. The direct monitoring technique presently provides more precise data, but complications related to the insertion of the catheter or application of the scalp electrode have been observed. Perhaps the most common and major fetal complication related to the scalp electrode is the development of a scalp abscess. This has been reported by Corder0 and Han’ but was believed to be a fairly rare problem with vague etiology. The present study reviews the experience with scalp abscess secondary to fetal monitoring over a 32 month period at the Jefferson Davis Hospital Obstetric Service.

September, 1974, approximately 7,200 patients were monitored during labor with the internal monitor for fetal heart rate, fetal electrocardiogram, and intrauterine pressure. Because of the patient load and large percentage of “high-risk” gravid patients, only those patients with obstetric or fetal complications were monitored. The monitor was applied in the following manner. The patient was placed in the “frog-leg” position in the labor bed. The perineum, external genitals, and medial aspects of the thighs were prepped with povidoneiodine* sponges, and the perineum was draped with sterile towels. A sterile vaginal examination was then performed to confirm cervical dilatation, presenting part of the fetus, and rupture of the membranes. The pressure catheter was then inserted in the standard fashion. Two different types of fetal scalp clips were used during the study period. From March through December, 1972, a clip-type device was used (silver chloride clip), which required introduction of a plastic amnioscope against the presenting part for visualization and application of the electrode with sterile forceps. Since January, 1973, the screw-type electrode (spiral electrode) has been used exclusively; this is applied manually without visualization of the presenting part. The electrode and pressure catheter are then connected to the fetal monitor.? All preceding and subsequent vaginal examinations

Material and methods The Obstetric Service of the Baylor College of Medicine at Jefferson Davis Hospital handles approximately 9,000 deliveries per year. The service is entirely a clinic population, consisting of approximately 60 per cent black, 25 per cent Mexican-American, and 15 per cent white patients, all from the Harris County area. Over the study period, March, 1972, through From the Department College of Medicine.

of Obstetrics

Received

for publication

Accepted

September

June

and Gynecology,

Baylor

4, 1975.

18, 1975.

Reprint requests: Dr. Angel Werch, Medicine, Houston, Texas 77025.

Baylor

College

*Betadine, Rd., Yonkers, Korometrics

of

65

Purdue Frederick New York 10701. Systems, Inc.

Co.,

99-101

Saw

Mill

River

66

Plavidal

Table

and Werch

I. Monitor

data Duration

Indicationfor

Case

St U’.t

-L.Y * G. B.* K. S.: E. T.* CPD = Cephalopelvic *Female infant tMale infant.

were

carried used

out for

Infections and Nurse any

which purulent or aspirated. The

presence transferred

aerobic these dent. on

the

and

PROM

fashion and

Newborn A scalp

medium plated

were

exuded

or could

lesions

was

of to

such the

anaerobic

blood

of the

Intensive cultures

agar,

and

placed

directly

as from

the

and

obtained

when

pediatrics plated

incubation cultures, thioglycollate

the laboratory, where plates and incubated

for 48 hours. Since June, used for transfer medium,

rupture

residirectly medium,

and when

of the membranes.

plated

on

box

with

5 per

and

90

then

as cultures fluid were

blood

agar,

incubated

cent

per

identified.

subob-

carried with

cent

by

the

and

urine

Staff.

scalp

trauma

nursery

prior

the abscess were considered infants’ charts and maternal determine protocols,

at 37”

case history, and subsequent

in the records diagnostic follow-up.

spinal of the antibilikewise

those and

48

as well

systemic were

Only

cent

C. for

cultures

local and and cleansing

Pediatric

in the

anaerobic 5 per

orifices and frequently when indicated as part

intrapartum

instrumentation

the

dioxide,

nitrogen

Blood

of other body also obtained

out no

in

carbon

sepsis work-up. Appropriate otic therapy and local care

infant

Nursery,

MacConkey’s

in

9 7 3 13

hours,

be expressed

the then

; 20 2 8 10 4 10 4 3 6 3

hydrogen,

defined scalp

noted;

were

indicated by Gram stained,

recorded

was fetal

Care

9 3 12 3 8 .a 4 21 7 8 16

are

Surveillance

abscess

drainage

and sent to on blood agar

jars at 35” C. broth has been

are

lesion

.5

or prolonged

povidone-

(hr.)

-

glove

Disease

and sent to the laboratory for sequent identification. Anaerobic tained,

with

Nurseries

Infectious

Davis.

= premature

lubrication.

or fluctuant

were believed Exudates were chocolate,

a sterile

by the

at Jefferson pustular

was

in

preparation

in

supervised

disproportion;

of

Monitoring

Oxytocin augmentation Oxytocin augmentation, possible CPD Pre-eclampsia, possible CPD Oxytocin augmentation Pre-eclampsia, possible CPD PROM for 24 hours Poor progress of labor, possible CPD PROM for 48 hours Poor progress of labor, possible CPD PROM for 72 hours PROM for 30 hours Possible postmaturity, induction Poor progress of labor, possible CPD Pre-eclampsia, possible CPD PROM for 24 hours, pre-eclampsia PROM for 28 hours, prematurity Pre-eclampsia PROM for 66 hours PROM for 6 hours, oxytocin augmentation PROM for 5 days PROM for 2 weeks, meconium passage Pre-eclampsia, oxytocin augmentation PROM for 8 hours, oxytocin augmentation PROM for 8 hours, anemia, prematurity PROM for 24 hours Pre-eclampsia Pre-eclampsia PROM for 26 hours, possible CPD Diabetes, oxytocin augmentation PROM for 48 hours Pre-eclampsia, possible CPD

D. M.t K. C.* S. B.t D. M.* E. N.t G. A.? M. D.? J. G.t A. L.* F. J.: L. M.t R. B.t P. s.* D. T.* L. D.t R. D.* F. D.t P. D.t E. E.t L. A. R. W.t P. w.* T. J.*

iodine

monitoring

infants no

scalp

to observation study were criteria,

group. reviewed

of The to

treatment

transfer they were in Gas-Pak 1974, meat and cultures

be

There were secondary

recorded cases, the

in the monitor

3 1 cases of fetal scalp to fetal monitoring 32

month electrode

abscess believed instrumentation

study period. In all of these puncture site was thought

to

Volume Number

Table

Fetal scalp abscess and intrauterine monitoring

125 1

II. Time

Case

of diagnosis

and Gram

stain and culture

Days after delivery abscess diagnosed

J. D.* R. G.* D. M.$ K. C.* S. B.* D. M.* E. N.$ G. A.$ M. D.$

Gram Not

results in scalp abscesses

Culture

stain

done

Few gram-positive cocci Few gram-positive cocci One cluster of gram-positive cocci only Not done Not done Gram-positive cocci in pairs Not done Gram-positive cocci in chains

* ?i.FS F. J.$

Gram-positive Not done Gram-positive Gram-positive

R. B.# P. s.* D. T.* L. D.j: R. D.* F. D..+ P. D.$ E. E.$ L. S.f A. W.# R. W.S P. w.* T. J.* J. A.* D. E.* G. B.*

3 9 2 2 3 3 3 2 3 5 2 4 4 4 6

Not done No organisms seen Few gram-positive cocci No organisms seen Not done Gram-positive cocci Gram-positive cocci, Gram-negative No organisms seen Not done No organisms seen Few gram-positive cocci No organisms seen Rare Gram-negative rods Gram-positive cocci No organisms seen Gram-positive cocci in chains

9 9

Gram-positive cocci Few clusters of gram-positive

K. S.$ E. T.*

10

cocci in pairs

result.5

No growth7 No growth Diphtheroids No growtht No culturet No culture? Anaerobic Streptococcus, Candida No growth Alpha Streptococcus Staphylococcus

4 5 2 4

L. ht.+

67

epidermidis

Alpha Streptococcus Staphylococcus

cocci, gram-negative rods cocci in pairs and chains

cocci

epidermidist

Klebsiella, Proteus, Enterococcus Group B beta Streptococcus Staphylococcw Staphylococcus Staphylococcus

epidermidti epidermidis aweus

No growth? Staphylococcus

epidermidis

No growth? Staphylococcus

rods

epidermidis

Klebsiella Staphylococcus

epidermidist

Anaerobic Streptococcus No growth Staphylococcus

epidnmidis

No growth Citrobacter No growth No growtht Staphylococcus epidermidis, Beta Streptococcus Staphylococcus epidennidis Staphylococcus epidermidis

t

*Female infant. tNo anaerobic culture result available. $Male infant.

to be the origin of the infection. There were no other scalp abscesses noted during the same time which were not secondary to other instrumentation in the Newborn Nursery (primarily intravenous sites) or to other documented obstetric trauma (laceration, forceps abrasion, vacuum extractor injury, or scalp injury at cesarean section). During this period, there were approximately 7,200 patients monitored, for an incidence of scalp abscess of 0.4 per cent, or 1: 230 monitored patients. There were eight cases in approximately 1,800 patients for the clip electrode (1 :225) and 23 in approximately 5,400 patients for the screw electrode, or 1 : 235 patients, or essentially no difference in incidence. Listed in Table I are the 3 1 cases, with the indication for monitoring, duration of internal monitoring, and type of scalp electrode used. The mean duration of monitoring for the 28 cases in which this information

was available was 7.8 hours, with a range of 2 to 21 hours. Table II lists the time from delivery to diagnosis of the abscess and Gram stain and culture results where available. Purulent drainage was the material cultured in all cases in which microbiological studies were obtained; this was collected by incision and drainage, aspiration, or spontaneous drainage. No culture was obtained in two cases because the abscesses were noted at the time of discharge examination and treated with local care only for several days. The mean time from delivery to appearance of the abscess was four days, with a range of two to 10 days. All of the abscesses described were from 1 to 3 cm. in diameter. Of the 29 abscesses cultured by the above-described techniques, no growth was obtained in 10. Review of the charts revealed that anaerobic cultures were not performed (or results were not available) in eight of

68

Plavidal and Werch

May

Am. .J, Obstet.

Table

III. Culture

data

Organism cultured Staphylococcus epidermidti Staphylococcus aureus Alpha Streptococcus

Beta Streptococcus Enterococcus Anaerobic Streptococcus Aerobic gram-negative bacilli Klebsiella Proteus Citrobacter Diphtheroids Candida (not albicans)

No. times cultured 11 1 2 2 1 2 3 2 1 1 1 1

Positive cultures (%) 58 5 10 10 5 10 15 10

5 5 5 5

these 29 cases. Therefore, the culture results in Table II represent only aerobic organisms for these designated cases. Nineteen cultures resulted in an identifiable organism. Gram stain results are reported directly as described in the hospital chart. Those designated as “not done” represent cases in which no stain results were available on the chart or apparently no stain was performed. Results of Gram stains were recorded in 23 of the 31 cases, or 75 per cent. No organisms were seen on six smears, or 26 per cent, while the quantitations “few,” “rare,” and “one cluster” were used to describe seven others, or another 30 per cent of the smears. There was apparent agreement between the smear and culture result in 14 of the 23 cases, or 61 per cent. Of those cultures which yielded no growth, no organisms were seen in three of the seven cases in which smears were done. In addition, three more of these cases had smears which showed few or only one cluster of gram-positive cocci. There was apparent disagreement between the smear and culture in six cases; however, two of these probably represent contaminants (diphtheroids and Citrobacter), and two others represent negative smears with cultures growing only Staphyloroccus

Table number

epidermidis.

III lists the specific organisms found and the and percentage of positive cultures. Staphylococcus upidermidis was by far the most common organism, accounting for 11 of the 19 positive cultures (58 per cent), and in three of these it was found along with a pathogenic organism. Staphylococcus aureus was found in only one case, while the aerobic Streptococci (alpha and beta hemolytic) were present in four cases, or 20 per cent of the cultures. Anaerobic organisms were only found in three of the cultures, with anaerobic Streptococci the most frequent. Gramnegative aerobic bacilli were only cultured in two cases

1. ltn6

Gvnecol.

for a total of three organisms. The Citrobacter, diphtheroids, and Candida in one case each were believed to be laboratory contaminants. The correlation of prolonged or premature rupture of the membranes (PROM) with fetal monitoring and subsequent scalp abscess is apparent by the high incidence of this complication with the development of the infection. Fifteen (48 per cent) of the 31 gravid patients whose infants developed scalp abscesses w-ere monitored with the primary indication of ruptured membranes at term without labor. Twelve of these (39 per cent) were ruptured for greater than 24 hours, and one was for approximately two weeks. There were no neonatal deaths attributable to the scalp abscess in this series; however, four of the infants presented with apparent sepsis of unknown origin until the fluctuant mass became observable. It is unknown whether the abscess was the definite source of sepsis in these cases. Positive blood cultures were obtained in three of the infants, including one who had no growth from the abscess drainage. In most cases these were clinically believed to represent contarninants. All abscesses were treated locally with aspiration or incision and drainage, povidone-iodine, pHisoHex,‘+ or peroxide washes, and bacitracin, %Iycitracin,t or Neosporin$ ointments. In addition, 22 infants were treated with parenteral antibiotics for a course of’ live to 12 days. Methicillin and kanamycin were the primary drugs of choice; however, gentamicin and ampicillin were also frequently used. The average duration of hospital stay directly related to treatment of the abscess in these 3 1 infants was 10 days. Follow-up clinic examinations, when available, revealed no evidence of recurrent or long-term disability. One case of apparent osteomyelitis of the skull was diagnosed in this series. case report A J-day-old male infant (baby of Patient E. N.), product of the term pregnancy of an 1&year-old black primigravida, who was monitored in labor for seven hours because of failure of labor to progress and delivered vaginally, presented with a 2 by 3 cm. draining abscess over the left frontal area. On the fourth postpartum day, the abscess was incised for *Winthrop Labs., Div. of Sterling Drug Inc., CtOPark Ave.. New York, New York 10016. tThe Upjohn Co., 7171 49001. $Burroughs Wellcome Corhwallis Rd., Research 27709.

Portage & Co. Triangle

Rd., (U.

Kalamazoo, S. Park.

Michigan

A.), Inc., 3030 North Carolina

Volume Number

Fetal scalp abscess and intrauterine monitoring

125 1

Fig. 1. Lateral radiogram scalp in the frontal area.

of the skull shows edema of the

further drainage, and kanamycin and methicillin were administered intramuscularly for a total of 10 days. There was slow improvement with persistent induration and drainage, and Tegopen* was continued orally for 10 more days, as was local care with povidoneiodine washes and Neosporin ointment. The edema and drainage persisted for approximately three weeks before gradual full resolution. Roentgenograms of the skull (Figs. 1 and 2) showed frontal scalp edema and thickening of the outer table of the skull secondary to new bone formation, consistent with osteomyelitis. The Gram stain showed gram-positive cocci in pairs, and the abscess grew anaerobic Streptococcus. Blood culture was negative.

Comment The incidence of scalp abscess in this study, 1 : 230, is consistent with the 1: 200 to 400 occurrence in other reported series.2 Chan and colleagues,3 in their review of morbidity in 1,150 monitored patients, had no scalp abscesses attributable to the fetal electrode, while Paul and Hot? found two cases in 600 monitored patients. The abscess is a frequently mentioned potential complication, but, as noted by Corder0 and Han,’ it is still quite rare (0.34 per cent). The large number of cases in this report reflects primarily the great number of monitored labors at Jefferson Davis during this time. It is likely that more cases were missed, since apparently well infants may be discharged from the nursery as early as 36 hours after birth, long before evidence of the abscess could be noted. *Bristol-Myers 10022.

Co., 345 Park Ave., New York, New York

69

Fig. 2. Skull radiogram shows thickening of the outer table of the skull secondary to new bone formation. (Courtesy of E. B. Singleton, M.D., Department of Radiology, St. Luke’s Episcopal Hospital-Texas Childrens Hospital, Houston, Texas.)

Clearly pathogenic organisms were returned in only 11 cultures from the 31 cases, and these represent a wide range of bacterial flora, with no predominant organism. This is consistent also with Cordero and Han’s’ report, in which only one of seven cases had a positive abscess culture. The frequent culture ofStaphylococcus epidermidis may represent only skin contamination in these cases, but a possible etiologic role in the development of the abscess cannot be definitely excluded. None of these infants had blood cultures yielding this same organism, and all responded well to standard therapy in three to seven days. The frequent findings of normal flora, contaminants, and no growth are consistent with Corder0 and Hon’s suggestion that these abscesses indeed may not be primarily infectious in origin but could represent a chemical or pressure reaction to the electrode. The lack of consistent and high-yield anaerobic culture techniques in this study is certainly a weakness in the clarification of the infectious etiology of the abscesses. The retrospective nature of the study makes it difficult to supply such accurate data. However, Gram stains were frequently performed (75 per cent of the abscesses), and agreement between the smear and culture is apparent in over 60 per cent of the cases. Furthermore, five of the nine discordant smears represent no organisms with only Staphylococcus epidermidis on culture or no growth with only rare organisms on smear. Over all, the Gram stain data support the finding of infrequent pathogenic organisms in the scalp abscesses studied in our series.

70

Plavidal

and Werch

The present study does bring out a previously unnoticed observation, in that 40 per cent of the infants who developed scalp abscesses were delivered of mothers who had PROM for more than 24 hours. None of these mothers clinically developed amnionitis, and all had an essentially benign postpartum course. Again, there was a paucity of definitely pathogenic organisms cultured even in these cases (three of 12). No previous case of osteomyelitis of the skull secondary to the monitor and abscess formation has been reported. This potentially serious infection resolved well in the case reported here with treatment of the abscess, and there have been no known sequelae. No viral cultures were obtained from these infants, as this etiology was not suspected clinically. Adams and colleagues5 have recently reported scalp infection with herpesvirus hominis Type II at the monitor probe site and suggested this as a possible etiology. However rare the occurrence or benign the course of scalp abscess in newborn infants, any source of further complications in an already possibly compromised

infant is a most serious problem. The prolongation of the hospital stay by 10 days in these infants is, in itself, a serious medical manpower and financial problem. Furthermore, the still vague etiology of these abscesses complicates prevention. Since pathogenic organisms were only rarely identifiable in this study, the role of prophylactic antibiotics is questionable. Observation of a careful aseptic technique in application of the monitor and subsequent vaginal examinations is important. Based on our experience. these monitored offspring of mothers with rupture of the membranes for greater than 24 hours particularl! should be watched carefully for the development of a scalp abscess; treatment with drainage. topical care, and parenteral antibiotics has been uniformly successful. The cooperation of Judy Ortega, R.N.. Inteciious Disease Surveillance Nurse at Jefferson Davis Hospital, in preparation of this study is appreciated.

REFERENCES

1. Cordero, L., and Han, E. H.: Scalp abscess: A rare complication of fetal monitoring, J. Pediatr. 78: 533, 1971. 2. Paul, R. H., and Hon, E. H.: Clinical fetal monitoring: a survey of current usage, Obstet. Gynecol. 37: 779, 1971. 3. Chan, W. H., Paul, R. H., and Toews, J.: Intrapartum fetal monitoring: Maternal and fetal morbidity and perinatal mortality, Obstet. Gynecol. 41: 7, 1973.

4. Paul, R. H., and Hon, E. H.: Clinical fetal monitoring 1V: Experience with a spiral electrode, Obstet. Gynecol. 41: 777, 1973. 5. Adams, G., Purohit, D., Bada, H., and Andrews, B. F.: Neonatal infection by herpes virus hominis Type II. A complication of intrapartum fetal monitoring, Clin. Res. 23: 69A, 1975.