Pastewella multocida chorioamnionitis from vagina1 transmission GEOFFREY P.WONG‘, NEVIOcIMOLA12,3, JAMES E. DIMMICK‘AND THOMAS R.


From the Departments of ’Obstetrics, Gynecology and ‘Pathology, University of British Colombia, Vancouver, British Columbia, and the 3Departmentof Pathology, British Columbia’s Children’s hospital, Vancouver, British Columbia, Canada

Actu Obstet Gynecol Scand 1992; 11: 384387

A 21 year old primigravida with a twin pregnancy developed Posteurellu multocidu chorioamnionitis. Infection occurred at 27 weeks gestational age after prolonged rupture of membranes. The twin in the separate sac presenting proximal to the cervix suffered infection and died shortly after birth whereas the other twin was not infected. The bacterium is believed to have caused ascending infection from asymptomatic colonization of the vaginal tract.

Key words: pasteurella multocida; chorioarnnionitis Submitted November 29, 1991 Accepted March 17, 1992

Pasteurella multocida, a facultative gram negative coccobacillary bacterium, is commonly a component of the oral bacterial flora in a variety of animals. In addition, P. multocidu has been reported as a cause of human infection although a high proportion of infections are presumed to be secondary to animalinflicted wounds, especially from cats and dogs. There are few reports of obstetrical or perinatal infections (1-8), but serious morbidity is common among these. We report herein a patient with a twin pregnancy who developed P. multocida chorioamnionitis after prolonged rupture of membranes which resultcd in premature delivery and neonatal death of one of the twins.

Case report A 21 year old primigravida with a twin pregnancy was admitted to hospital at 27 weeks gestation with a history of spontaneous premature rupture of membranes of one day’s duration. The previous course of Acta Ohsfel Gynecol Scand 71 (1YY2)

her pregnancy had been essentially uneventful. Upon admission, there was no labor or evidence of chorioamnionitis. Ultrasound examination revealed twin A to be in complete breech presentation. Growth parameters suggested a mild degree of intrauterine retardation and the amniotic fluid volume was decreased. Twin B was visualized in cephalic presentation in an intact second sac; fetal growth and the amniotic fluid volume were normal. A cervical swab obtained upon admission yielded a heavy growth of both Group B streptococci and Escherichia cali. The patient was given 500 mg of ampicillin orally 4 times a day for 7 days and she was otherwise managed conservatively in hospital for premature rupture of membranes. O n the 17th day, 8 days after the ampicillin was discontinued, the patient was pyrexic. Maternal and fetal tachycardia were apparent. Mild uterine tenderness was elicited. Her white blood cell count had increased to 16.7 x 10’IL. (admission WBC 9 x 109/L.) and there was a predominance of polymorphonuclear cells. The patient also developed mild uterine contractions. A diagnosis of chorioamnion-

Pastewella multocida chorioamnionitis


Table I. Demographic and clinical data of patients with obstetrical and perinatal Pusfeurellu spp. infections Reference Gestational Animal age contact

Maternal culture

Newborn culture

Pregnancy complication

Neonatal outcome





blood, joint


premature labor







blood, CSF nasopharynx

post-pdrtum fever


maternal tetracycline



cat scratch


cord blood


omphalitis, death

maternal ampicillin




blood, vagina


post-partum fever


maternal amoxycillin, topical choramphenicol



cat scratch

peritoneal fluid, blood


peritonitis, sepsis


cephalothin, ampicillin, penicillin








topical chloramphenicol




blood, vagina


post-partum sepsis


cephalothin, tobramycin



cat bite



sepsis, maternal death






1 twin death chorioamnionitis, pre-term labor

this report 29



cefoxiti, ampicillin, gentamicin

not determinable

itis was made. A n emergency cesarean section was performed. The birthweight of the male twin A was 1050 gm. and the Apgar scores were 1 and 2 at 1 and 5 minutes respectively. The female twin B weighed 1240 gm. at birth, and the Apgar scores were 1 and 7. A throat swab from twin A yielded a pure growth of a facultative gram negative bacterium that was subsequently identified as Pasteurella multocida (conventional biochemicals and API 20E). Modified Kirby-Bauer susceptibility testing revealed a sensitive profile to ampicillin, penicillin, and cefoxitin. An aspiration of the amniotic fluid at the time of surgery also yielded the same bacterium. The mother continued to be febrile for the first two postoperative days despite perioperative administration of cefoxitin. The maternal post-operative fever rapidly resolved after intravenous administration of ampicillin; the latter chosen when P. multocida was identified from cultures. Both neonates received ampicillin and gentamicin from birth. Twin A died, however, after 9 hours. At autopsy, the deceased twin had external features which reflected oligohydramnios. There was also moderate pulmonary hy-

poplasia, complicated by hyaline membrane disease. Pneumonia and ingested purulent exudate present in the stomach attested to the presence of amniotic and fetal infection. Cultures of blood and cerebrospinal fluid as well as a throat swab from twin B were negative. Twin B continued to d o well in the neonatal intensive care nursery. Histopathological studies of the placenta and fetal membranes confirmed the clinical diagnosis of chorioamnionitis. Maternal blood cultures prior to antibiotic administration and a maternal vaginal swab after the initiation of antibiotics did not yield P. multocida. A culture of the placenta was negative although it was unknown in retrospect how the cultured placental site related to the two amniotic sacs. The patient was discharged on the fifth post-operative day with instructions to continue her oral ampicillin. She was well on follow-up examination 4 weeks after her discharge. Upon reviewing the antenatal history, the mother did not specifically recall minor trauma from animal sources. She did, however, live on a farm and had exposure to cats, dogs, and chickens.

Actu Ohstet Gynecol Scund 71 (1YY2)


G. P. Wong et al.

Discussion P. rnultocida is associated most often with 3 forms of human infection: a. most commonly a localized infection, cellulitis and/or iymphadenitis following an animal inflicted wound, b. respiratory disease in patients with underlying chronic pulmonary disorders, and c. systemic infection in patients with impaired host defenses, potentially resulting in meningitis, brain abscess, endocarditis, peritonitis, and septic arthritis. (9).

There are 8 previous publications of Pasteurella spp. infection occuring perinatally in humans (Table I). These descriptions include infection of mother, products of cenception, or both. For 3 patients, wounds from cats were apparently the cause of the infection. Animal contact was noted in 6 of the 9 reports. The presenting symptom during pregnancy was most often maternal fever, but other systemic manifestations of infection were also recognized. A high proportion of offspring have died directly or indirectly as a result of infection either in utero o r shortly after birth. Although maternal bacteremias have been documented, it is still unclear whether the intrauterine infections have occurred as a result of secondary transplacental infection or as a result of vaginal-uterine spread. Vaginal delivery was the most common route reported. Our patient had been treated with a 7 day course of oral ampicillin antenatally, and there was absence of animal contact during the 17 days that she was in hospital after spontaneous premature rupture of membranes. She also did not specifically recall having had a wound inflicted by an animal. The source therefore of her P. multocida chorioamnionitis was most likely vaginal. This hypothesis is strengthened by the infection of twin A who was localized in a separate sac which had been involved in the premature rupture. The initial cervical swab from our patient did not yield I? rnultocida, but the presence of the bacterium may have been obscured by the heavy growth of Group B steptococci, E. coli, and other usual vaginal flora. Positive vaginal cultures for P. multocida have been previously reported. Colonization of the vagina might occur via hand inoculation after contact with infected animal saliva. Secondly, it is possible that frequent and/or transient gastrointestinal carriage after contamination of the oral cavity from the animal resorvoir may lead to perineal and then vagnial colonization. Pasteurella spp. infections of the genito-urinary tract have been reported in non-pregActu Ohatet Gynrcol S c a d 71 (1992)

nant females, although most of the latter patients were immunocompromised by systemic disease or advanced genital tract malignancies. (10-14) These anecdotes provide further evidence that the female genital tract may harbor pasteurellae. P. rnultocida is usually susceptible to penicillin, ampicillin, cephalosporins, chloramphenicol, and tetracycline. It is of interest that a 7 day course of oral ampicillin given to our patient antenatally for the eradication of Group B streptococci did not eradicate P. multocida.. Difficulty with eradication of the bacterium after antibiotic administration has been previously experienced. (4,s) While the failure to eradicate the bacterium could conceivably have been a function of poor antibiotic absorption, we propose that the inability to eradicate carriage may be much more complex and may possibly be analogous to the relative inability to eradicate Group B streptococci from the vaginal reservoir. Nevertheless, it is possible that a prolonged use of an antibiotic to which the bacterium is susceptible may have prevented ascending infection, or have been therapeutic in Twin A . Although pasteurellae have been associated with serious maternal and fetal complications, infection during pregnancy is rare. The report herein is the only such infection that we have confirmed over a 4 year period which includes approximately 32,000 deliveries. While systemic maternal disease might b e prevented by prompt therapy of recognized wound infections, recommendations cannot be had, at this time, specifically related to the prevention of vaginally transmitted infection.

References 1. Robinson R. Human infection with fasteurella septica. Br Med J 1944; 2: 725. 2. Bates HA, Controni G, Elliott N, Eitzman DV. Septicemia and meningitis in a newborn due to fasteurella multocida. Clin Ped 1965; 4: 668-70. 3. Strand CL, Helfman L. fasteurella multocida chorioamnionitis associated with premature delivery and neonatal sepsis and death. Am J Clin Path 1971; 55: 713-6. 4. Khan MS, Stead SE. Neonatal Pasteurella multocida conjunctivitis following zoonotic infection of mother. J Infect 1979; 1: 289-90. 5. Karn WK, Haverkos HW, Rodman HM, Schmeltz R, Van Thiel DH. Human pasteurellosis: the first reported case of f'asteurella multocida septicemia and peritonitis during pregnancy. Am J Obstet Gynecol 1980; 138: 351-2. 6. Bogaerts J . Lepage P, Kestelyn P, Vandepitte J. Neonatal conjunctivitis caused by fasteurella ureae. Eur 3 Clin Microbiol 1985; 4: 427-8.

Pasteurella multocida chorioamnionitis 7. Grief Z, Moscona M, Loeb D, Spira H. Puerperal Pasteurella multocida septicemia. Eur J Clin Microbiol 1986; 5 : 657-8. 8. Rasaiah B, Otero JG, Russell IJ, et al. Pasteurella muitocida septicemia during pregnancy. Can Med Assoc J 1986; 135: 1369-72. 9. Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections; report of 34 cases and review of the literature. Medicine 1984; 63: 133-54. 10. Wong PC, Chan-Teoh CH. A report of three strains of Pasteurella septica isolated in Hong Kong. J Clin Path 1964; 17: 107-10. 11. Dixon JMS, Keresteci AG. Renal infection with Pasteurella multocida. Can Med Assoc J 1967; 97: 28-9. 12. Hubbert WT, Rosen MN. 11. Pasteurella multocida


infection in man unrelated to animal bite. Am J Pub Health 1970; 60: 1109-17. 13. Komorowski RA, Farmer SG. Pasfeurella urinary tract infections. J Urol 1974; 111: 817-8. 14. Warren JS, Smith JW. Pasteurella multocida urinary tract infection. Arch Pathol Lab Med 1984; 108: 401-2.

Address for correspondence: Nevio Cimolai, M.D., F.R.C.P.(C) Program of Microbiology Department of Pathology British Columbia’s Children’s Hospital 4480 Oak Street Vancouver, British Columbia Canada V6H 3V4

Actu Ohstet Gynecoi Scund 71 (lYY2)

Pasteurella multocida chorioamnionitis from vaginal transmission.

A 21 year old primigravida with a twin pregnancy developed Pasteurella multocida chorioamnionitis. Infection occurred at 27 weeks gestational age afte...
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