WEBVTT - Ep 73 Puerperal Fever: Seriously, wash your hands 0:00:01.840 --> 0:00:05.360 In the afternoon of the nineteenth of August seventeen ninety, 0:00:05.559 --> 0:00:08.160 John Lowe came to my house, requesting me to go 0:00:08.280 --> 0:00:11.800 immediately to his wife, who he said had fevered after 0:00:11.880 --> 0:00:15.560 delivery and was in great danger. I accordingly went and 0:00:15.640 --> 0:00:18.320 found her in a dangerous situation. She complained of an 0:00:18.320 --> 0:00:21.160 acute pain in the lower part of the abdomen, attended 0:00:21.160 --> 0:00:23.639 with a very great degree of fever, the velocity of 0:00:23.640 --> 0:00:25.680 the pulse being at the rate of one hundred and 0:00:25.680 --> 0:00:28.639 forty strokes in a minute. I had no difficulty in 0:00:28.680 --> 0:00:32.839 ascertaining the patient's disorder, having had previous opportunities of seeing it, 0:00:32.920 --> 0:00:35.479 both in London and in the course of my practice 0:00:35.479 --> 0:00:38.839 in Aberdeen. For this was the fifteenth case I had 0:00:38.880 --> 0:00:43.279 attended since the epidemic began, And in every respect this 0:00:43.440 --> 0:00:46.280 answered the description of that known to practitioners by the 0:00:46.320 --> 0:00:51.000 appellation of the pupil fever, a distemper which so frequently 0:00:51.040 --> 0:00:54.160 proves fatal to women in childbed, baffling the skill of 0:00:54.200 --> 0:00:57.520 the most eminent physicians. On the twenty first, when I 0:00:57.600 --> 0:00:59.800 visited her in the morning, I was happy to find 0:00:59.840 --> 0:01:02.200 that she had been pretty easy throughout the night and 0:01:02.280 --> 0:01:05.479 had enjoyed some hours sleep. She was in a profuse sweat, 0:01:05.520 --> 0:01:07.880 which I hoped would prove critical, but I was sorry 0:01:07.920 --> 0:01:10.880 to find that I was disappointed in my expectation, for 0:01:11.000 --> 0:01:13.360 when I returned in the afternoon, I found that the 0:01:13.400 --> 0:01:17.760 sweat had disappeared, being succeeded by a diarrhea. The patient 0:01:17.840 --> 0:01:20.720 now complained of very great pain, and the swelling of 0:01:20.760 --> 0:01:24.440 the abdomen seemed to increase. On the twenty second, I 0:01:24.520 --> 0:01:27.039 was sorry to find that the disease was making rapid 0:01:27.080 --> 0:01:29.760 progress in spite of all the remedies employed, and that 0:01:29.840 --> 0:01:33.319 the patient's health was sinking. All hopes of recovery were 0:01:33.360 --> 0:01:38.080 now totally abandoned. The patient's agony was now extremely great, 0:01:38.319 --> 0:01:41.920 and she called loudly for relief. I therefore thought proper 0:01:41.959 --> 0:01:45.000 to administer opium to mitigate pain and, if possible, to 0:01:45.040 --> 0:01:48.520 procure rest. I went early in the morning of the 0:01:48.520 --> 0:01:51.360 twenty third to visit my distressed patient and found that 0:01:51.400 --> 0:01:54.720 the storm was lulled into a calm. The friends received 0:01:54.760 --> 0:01:57.800 me with transports of joy, vainly, thinking that her danger 0:01:57.880 --> 0:02:01.880 was over. The patient supposed herself perfectly well, asked my 0:02:01.920 --> 0:02:04.880 permission to rise, for she seemed to feel no pain, 0:02:04.960 --> 0:02:07.800 and suffered me to touch and press the abdomen without 0:02:07.840 --> 0:02:11.359 showing any signs of uneasiness, a proof that the parts 0:02:11.360 --> 0:02:14.520 were in a state of gangrene. The friends, ignorant of 0:02:14.560 --> 0:02:17.400 this circumstance, were quite overjoyed to see the patient so 0:02:17.520 --> 0:02:21.600 composed after such excruciating pain. However, it was evident from 0:02:21.639 --> 0:02:24.760 the ghastly appearance of the countenance, from the tumbufaction of 0:02:24.800 --> 0:02:27.560 the abdomen, with the absence of pain, from the sunk 0:02:27.600 --> 0:02:30.919 state of her pulse, and from the coldness of the extremities, 0:02:31.320 --> 0:02:34.839 that death was not far off. Accordingly, in a few 0:02:34.880 --> 0:02:36.520 hours the scene was closed. 0:03:20.600 --> 0:03:21.919 Good God erin. 0:03:22.760 --> 0:03:30.320 Yeah, that was from an account by Alexander Gordon, whom 0:03:30.400 --> 0:03:38.680 I will talk about later in this episode. It's horrifying. Yeah, Hi, 0:03:39.120 --> 0:03:43.000 I'm Aaron Welsh and I'm Aaron Ollman. Updyke and this 0:03:43.160 --> 0:03:44.640 is this podcast will kill you. 0:03:45.760 --> 0:03:48.160 It's really going to be an upper of an episode. 0:03:48.560 --> 0:03:55.200 Yeah, sorry, guys. This week we are talking about child 0:03:55.200 --> 0:03:57.120 bed fever, pupil fever. 0:03:57.760 --> 0:04:03.520 Puper ol, sepsis, maternal fear, who calls it maternal perrypartum infection. 0:04:04.240 --> 0:04:09.920 There we go lots of different pathogens under this umbrella. 0:04:10.160 --> 0:04:15.200 Aaron. It's so it's funny because one of the things 0:04:15.240 --> 0:04:18.760 that you said to me before we started doing this 0:04:18.800 --> 0:04:21.440 episode is that you felt like it was more in 0:04:21.480 --> 0:04:24.120 some ways more typical than the ones that we've done recently, 0:04:24.160 --> 0:04:27.160 in that like the biology and the history are very separate. 0:04:27.640 --> 0:04:30.520 There's not a lot of like overlap. But for me, 0:04:30.680 --> 0:04:34.599 this was not a typical episode. I was like, could 0:04:34.640 --> 0:04:38.680 we structure this like a medical mystery, except that it's 0:04:38.720 --> 0:04:40.880 not a mystery, but it kind of is. 0:04:41.600 --> 0:04:44.679 Oh that that could have been fun. 0:04:44.720 --> 0:04:45.920 It could have been fun. I know. 0:04:46.839 --> 0:04:49.120 No, I mean I as I was. As I was 0:04:49.160 --> 0:04:52.560 researching it too, I was like, Okay, well, my story 0:04:52.600 --> 0:04:56.880 is very clear. And part of the reason that we 0:04:56.960 --> 0:04:59.080 wanted to do this episode is because, you know, we 0:04:59.120 --> 0:05:04.080 had learned about pupil fever in various classes, and it's 0:05:04.120 --> 0:05:08.039 like such a good, interesting story and so crucial to 0:05:08.360 --> 0:05:12.360 the history of medicine, right, But I don't think that 0:05:12.480 --> 0:05:17.279 I realized just how difficult a topic it would be 0:05:17.320 --> 0:05:17.719 to cover. 0:05:17.880 --> 0:05:21.160 So yeah, but it's fine, it's gonna be fun. We'll 0:05:21.240 --> 0:05:24.280 learn a lot. I'm really excited to hear the whole story. 0:05:24.560 --> 0:05:27.920 In terms of the history altogether because I've only heard 0:05:27.920 --> 0:05:29.000 bits and pieces, so. 0:05:29.200 --> 0:05:32.800 Oh I it's been one of my absolute, I think 0:05:32.839 --> 0:05:34.440 favorite ones to research for sure. 0:05:34.720 --> 0:05:38.960 Excellent. Well, before we can get into the episode, of course, 0:05:39.360 --> 0:05:40.440 it's quarantin any time. 0:05:40.960 --> 0:05:44.240 It's quarantine anytime. What are we drinking this week? 0:05:44.640 --> 0:05:47.200 This week we're drinking the Filthy Animal. 0:05:49.160 --> 0:05:51.880 And as you will learn later in the episode, this 0:05:51.960 --> 0:05:54.560 is because at the end of all of our episodes, 0:05:54.600 --> 0:05:57.760 if you've never stayed tuned to the final very end, 0:05:57.760 --> 0:06:00.960 which we can't blame you, we always off by saying, 0:06:01.240 --> 0:06:06.440 wash your hands, you filthy animals. And that's basically what Semmelweiss, 0:06:06.680 --> 0:06:09.240 who's a key player in this story, was saying to 0:06:09.360 --> 0:06:11.640 all of the doctors around him to try to stop 0:06:11.680 --> 0:06:13.800 pupil fever from spreading. 0:06:13.960 --> 0:06:16.119 Yeah, he was just walking around being like, wash your hands, 0:06:16.120 --> 0:06:20.480 you're filthy animals, and everyone was like, ah, you didn't 0:06:20.480 --> 0:06:21.960 listen exactly. 0:06:22.279 --> 0:06:24.440 So what's in the Filthy Animal? 0:06:24.839 --> 0:06:29.520 Well, it's jim Time simple syrup and watermelon blended up. 0:06:29.560 --> 0:06:31.920 It's like a really beautiful drink. 0:06:32.240 --> 0:06:34.280 It's beautiful and really refreshing. 0:06:34.720 --> 0:06:35.160 Summary. 0:06:35.760 --> 0:06:36.920 Yeah, I like it. 0:06:38.120 --> 0:06:41.080 We'll post the full recipe for that Quarantini as well 0:06:41.120 --> 0:06:44.240 as our non alcoholic plusy Brita on our website, this 0:06:44.279 --> 0:06:46.600 podcast will kill You dot com and on all of 0:06:46.640 --> 0:06:48.920 our social media channels other business. 0:06:49.160 --> 0:06:53.560 Basically, go to our website. You'll find lots of stuff there, transcripts, 0:06:53.880 --> 0:06:58.839 alcohol free episodes, book lists of various sorts. Just go there. 0:06:58.960 --> 0:07:04.599 It's great, it's great, it's really great. Yeah, Okay, should 0:07:04.640 --> 0:07:06.080 we get into this episode. 0:07:06.560 --> 0:07:07.160 Let's do it. 0:07:07.240 --> 0:07:34.040 Okay, we'll take a quick break and then dive in. So, 0:07:34.960 --> 0:07:40.360 like I said already, this isn't a very typical episode 0:07:40.480 --> 0:07:47.360 because puperile fever isn't really one single disease, and in fact, 0:07:47.520 --> 0:07:50.120 it's not even really a term that we use anymore. 0:07:50.160 --> 0:07:53.880 We kind of already mentioned there are so many names 0:07:54.600 --> 0:07:58.200 for this illness, which really does make it difficult to 0:07:58.240 --> 0:08:00.920 get a handle on in terms of like the current 0:08:00.960 --> 0:08:05.040 status too, But we're gonna do our best. Some of 0:08:05.040 --> 0:08:07.480 the names that you can find that we haven't already mentioned, 0:08:07.960 --> 0:08:14.000 puperial sepsis, maternal sepsis, it's also called child bed fever. 0:08:14.760 --> 0:08:18.520 There's so many names. But the World Health Organization defined 0:08:18.880 --> 0:08:24.880 maternal peripartum infections, which means they defined it as a 0:08:25.000 --> 0:08:31.960 bacterial infection of the genital tract during childbirth, like during labor, 0:08:32.720 --> 0:08:37.640 even before birth, but after like rupture of the amniotic membrane, 0:08:37.679 --> 0:08:42.520 but before delivery, or in the post birth the postpartum 0:08:42.559 --> 0:08:47.920 period up to forty two days postpartum. Oh, okay, that 0:08:48.200 --> 0:08:53.679 is associated with childbirth. So bacterial infection of the genital 0:08:53.720 --> 0:08:58.400 tract associated with childbirth. And what's important about this definition 0:08:58.440 --> 0:09:02.239 specifically is that it does it include some other infections 0:09:02.280 --> 0:09:06.800 that used to sometimes get lumped in to postpartum sepsis 0:09:06.920 --> 0:09:11.400 or maternal sepsis, like mastitis which is an infection of 0:09:11.480 --> 0:09:16.960 the ducts in the breast or UTIs, even pneumonia. It 0:09:17.040 --> 0:09:21.960 also does not include infections in surgical sites, so like 0:09:22.120 --> 0:09:25.640 a C section incision, just an infection of the skin 0:09:25.760 --> 0:09:27.600 would not be included in this definition. 0:09:28.080 --> 0:09:33.560 Okay, so it's really both locational and time specific. 0:09:33.160 --> 0:09:36.440 Exactly, right. Okay, Yeah, So now that we have that 0:09:36.480 --> 0:09:39.760 out of the way, I'm kind of just going to 0:09:39.880 --> 0:09:42.120 run through this. It's not going to be super detailed 0:09:42.160 --> 0:09:46.440 on like all of the bacterial virulence factors and things 0:09:46.440 --> 0:09:49.360 because it's just too much. But what we will do 0:09:49.480 --> 0:09:52.920 is go through where in the body these infections happen 0:09:53.040 --> 0:09:56.360 because the genital attract is actually kind of a large area. 0:09:57.200 --> 0:10:01.160 We'll talk about why they're problematic, how we know that 0:10:01.240 --> 0:10:03.800 an infection is happening, like what symptoms are we actually 0:10:03.880 --> 0:10:06.600 talking about, how do we define this? And then we'll 0:10:06.600 --> 0:10:10.000 talk about the risk factors for transmission, what pathogens we're 0:10:10.040 --> 0:10:13.600 actually dealing with, and finally, who gets it or what 0:10:13.679 --> 0:10:15.679 the risk factors are for transmission. 0:10:16.160 --> 0:10:19.000 Sounds good, Well, sounds horrible. 0:10:18.640 --> 0:10:22.680 But yeah it does. It sounds horrible. It's pretty horrible. 0:10:23.960 --> 0:10:27.640 So pure peril sepsis maternal. I'm just gonna call it MPI. 0:10:27.800 --> 0:10:28.400 Can I do that? 0:10:28.920 --> 0:10:29.240 Sure? 0:10:29.679 --> 0:10:34.600 Okay? MPI can mean infection in a number of different organs, 0:10:35.000 --> 0:10:41.760 but most often probably it could mean endometritis. Endometritis is 0:10:41.800 --> 0:10:46.040 an infection or inflammation of the endometrium, the lining of 0:10:46.080 --> 0:10:51.120 the uterus, and so this makes a lot of sense 0:10:51.160 --> 0:10:54.280 in the context of childbirth. This is not a disease 0:10:54.280 --> 0:10:57.840 that you can only get after childbirth, but in the 0:10:57.840 --> 0:11:01.439 context of childbirth, the inside of your uterus is exposed 0:11:01.440 --> 0:11:03.680 to the outside world in a way that it isn't 0:11:03.720 --> 0:11:07.480 normally right right either, because the cervix is dilated, and 0:11:07.520 --> 0:11:11.520 then there's a vaginal delivery and bacteria can migrate upwards, 0:11:12.200 --> 0:11:15.320 or if a c section happens, then the uterus is 0:11:15.520 --> 0:11:19.440 literally exposed on the abdomen and then put back in place. 0:11:20.240 --> 0:11:23.840 But on top of that, after delivery, you have kind 0:11:23.880 --> 0:11:27.440 of a raw surface exposed inside the uterus because the 0:11:27.480 --> 0:11:32.120 placenta that had been attached has been removed. So there's 0:11:32.200 --> 0:11:35.360 not only like roots of infection, but there's also a 0:11:35.440 --> 0:11:40.280 surface that's more susceptible potentially gotcha. Okay. So that's one 0:11:40.360 --> 0:11:44.360 possible infection that can happen post birth. Another is an 0:11:44.400 --> 0:11:47.640 infection that can actually start a little bit earlier in pregnancy. 0:11:47.760 --> 0:11:51.440 It could happen any time in theory during pregnancy, but 0:11:51.520 --> 0:11:57.800 that's called choreo amminitis or intra amniotic infection IAI. And 0:11:57.880 --> 0:12:00.240 this is an infection of any part of like the 0:12:00.280 --> 0:12:03.480 lining of the amniotic sac, which is what holds all 0:12:03.520 --> 0:12:06.400 the fluid that cushions the fetus. It could be an 0:12:06.400 --> 0:12:12.439 infection of the placenta just basically any part within there, okay. 0:12:12.840 --> 0:12:16.560 And so that can happen during pregnancy but then result 0:12:16.880 --> 0:12:20.080 like in a continued infection that can continue after delivery 0:12:20.080 --> 0:12:25.240 as well. But a maternal peripartum infection can have a 0:12:25.400 --> 0:12:31.240 number of other possibilities as well. A peritonitis is infection 0:12:31.440 --> 0:12:36.440 of the abdominal wall itself, which can happen as a complication, 0:12:37.000 --> 0:12:41.440 like if the endometritis spreads outside of the uterus, but 0:12:41.480 --> 0:12:44.040 it can also just happen in the setting, for example 0:12:44.040 --> 0:12:47.359 of a c section, if the peritoneal cavity, the abdominal 0:12:47.400 --> 0:12:49.560 cavity becomes contaminated in some way. 0:12:50.080 --> 0:12:50.760 Gotcha. 0:12:50.880 --> 0:12:53.679 It can also mean a vaginal infection or a soft 0:12:53.760 --> 0:12:57.040 tissue infection, especially if you have like a third or 0:12:57.080 --> 0:13:01.559 fourth degree tear that happens during delivery. It can also 0:13:01.600 --> 0:13:04.760 mean something that's a lot more rare, but called septic 0:13:05.040 --> 0:13:08.240 pelvic thrombophlebitis. 0:13:07.240 --> 0:13:09.319 Which sounds very bad. 0:13:09.640 --> 0:13:13.400 It's as bad as it sounds. This is an infection 0:13:13.480 --> 0:13:17.800 that involves bacterial infection of the veins that surround the 0:13:17.960 --> 0:13:24.720 uterus that cause like hypercoagulability, and it spreads. Overall. In general, 0:13:25.640 --> 0:13:29.280 not good infections, But the biggest concern with any of 0:13:29.360 --> 0:13:32.240 these organ systems or any of these tissues that become 0:13:32.280 --> 0:13:37.120 infected is when that infection spreads beyond that single organ 0:13:37.280 --> 0:13:40.520 or that single tissue and enters the blood stream, right, 0:13:41.120 --> 0:13:45.760 that results in bacteremia, so bacteria in your blood or septicemia, 0:13:45.840 --> 0:13:51.560 bacteria replicating and growing in your bloodstream and potentially septic shock, 0:13:51.840 --> 0:13:55.400 which can lead of course to death. Okay, So in 0:13:55.440 --> 0:13:58.960 the context of childbirth, the vagina, the uterus, the abdomen, 0:13:59.040 --> 0:14:02.080 these are just sites of entry for what can easily 0:14:02.120 --> 0:14:04.400 become an invasive, widespread infection. 0:14:04.880 --> 0:14:08.439 Right. Also, I did not know the difference between bacteremia 0:14:08.520 --> 0:14:11.000 and septicemia until this moment. 0:14:11.679 --> 0:14:13.959 Why thank you. I also had to look it up 0:14:15.400 --> 0:14:17.160 because I kept seeing them both and I was like, 0:14:17.320 --> 0:14:20.560 why is that different? So you can just have bacteria 0:14:20.600 --> 0:14:24.160 in your blood and technically that's bacteremia, but if they're 0:14:24.200 --> 0:14:27.960 not like replicating, growing, that would be when you have septoicemia. 0:14:28.000 --> 0:14:30.560 So septocemia is like extreme scary. 0:14:30.640 --> 0:14:33.480 Right, It's yeah, yeah, very bad. 0:14:34.440 --> 0:14:37.320 So that's like all the different types of infections that 0:14:37.360 --> 0:14:39.560 you can have, and you'll notice those are all like 0:14:39.720 --> 0:14:43.520 much more specific. And that makes sense because now we can, 0:14:44.080 --> 0:14:46.920 like with medical technology that exists today, we can actually 0:14:46.920 --> 0:14:48.160 differentiate all of these. 0:14:49.200 --> 0:14:52.760 So how does having this umbrella term sort of help? 0:14:53.640 --> 0:14:56.520 Great question? I think it helps in a number of ways. 0:14:56.720 --> 0:15:00.840 Some of these conditions are quite rare. For example, like 0:15:00.880 --> 0:15:03.560 septic pelvic thrombuffal bitis. That's very rare, so if you 0:15:03.560 --> 0:15:06.200 were looking at stats of only that, your numbers would 0:15:06.200 --> 0:15:08.520 be really low, whereas if you lump it in with 0:15:08.560 --> 0:15:11.760 all of these other ones. But also some of these conditions, 0:15:12.080 --> 0:15:15.880 for example, choreoaminitis can happen much earlier in pregnancy and 0:15:15.960 --> 0:15:20.240 result in pregnancy loss, like spontaneous pregnancy loss, but if 0:15:20.280 --> 0:15:23.960 it happens around the time of delivery, then it's kind 0:15:23.960 --> 0:15:28.520 of it might cause different problems down the line. And 0:15:28.840 --> 0:15:31.880 same thing with endometritis. That's something that can happen outside 0:15:31.880 --> 0:15:34.760 the context of childbirth, but if it happens within the context, 0:15:34.840 --> 0:15:37.840 then you'd want to know that that happened within that context. 0:15:38.080 --> 0:15:40.840 So I think by grouping them together, you're looking at 0:15:40.880 --> 0:15:43.760 a broad picture of all these different types of bacterial 0:15:43.800 --> 0:15:47.240 infections that can happen specific to the context of childbirth. 0:15:47.960 --> 0:15:51.000 The other thing, though, and it's a good question that 0:15:51.040 --> 0:15:53.240 you asked that, Aaron, because the other thing about all 0:15:53.240 --> 0:15:56.200 these infections is that even though we can differentiate them 0:15:56.200 --> 0:16:03.280 all in terms of symptoms, they're all very similar okay, okay. 0:16:03.640 --> 0:16:05.360 And so that's the other thing is that for a 0:16:05.440 --> 0:16:08.600 long time we probably weren't differentiating them all because does 0:16:08.640 --> 0:16:13.120 it matter exactly what tissue type is infected When you're 0:16:13.160 --> 0:16:15.960 looking at someone who just gave birth and all of 0:16:15.960 --> 0:16:19.000 a sudden, they spike a fever right up to one 0:16:19.080 --> 0:16:23.720 hundred and two fahrenheit or thirty nine celsius, and they're 0:16:23.760 --> 0:16:27.520 sweaty and they're pale, their heart rate is elevated, they're 0:16:27.560 --> 0:16:32.560 breathing hard. They're sick, right, and they're sick probably in 0:16:32.600 --> 0:16:35.880 the context of this traumatic delivery that just happened, or 0:16:36.320 --> 0:16:39.960 even this non traumatic delivery that just happened. And so 0:16:40.040 --> 0:16:42.280 I think that's another reason too why you lump it 0:16:42.360 --> 0:16:45.360 all together. That makes sense in terms of some of 0:16:45.400 --> 0:16:48.200 the other symptoms. Aside from fever, which of course is 0:16:48.280 --> 0:16:51.560 kind of the biggest sign, which is why it got 0:16:51.560 --> 0:16:56.040 the name puparel fever, other symptoms that tell you that 0:16:56.080 --> 0:16:59.080 you're dealing with an infection of the genital tract are 0:16:59.120 --> 0:17:03.680 things like abdomin pain or like paint tenderness in the uterus, 0:17:04.359 --> 0:17:08.320 and not just the tenderness that's normal after delivery, but 0:17:08.400 --> 0:17:11.000 like a deep, a deeper tenderness and like a more 0:17:11.880 --> 0:17:15.600 I don't know how to describe it, a more painful tenderness. 0:17:16.200 --> 0:17:20.280 And then also some vaginal discharge is fairly common, especially 0:17:20.359 --> 0:17:24.560 with endometritis. You can have a very like purulent, like 0:17:24.640 --> 0:17:28.000 pus filled drainage that can happen from the uterus. And 0:17:28.040 --> 0:17:30.960 then of course you have all these other general signs 0:17:31.000 --> 0:17:34.040 of infection, things like I already mentioned, like you have 0:17:34.119 --> 0:17:37.800 an elevated heart rate, elevated breathing rate. If you were 0:17:37.920 --> 0:17:41.119 to take a white blood cell count that would be elevated, 0:17:42.320 --> 0:17:44.840 and like I said already, to the big concern here 0:17:44.880 --> 0:17:49.040 is if that infection spreads to the bloodstream, because that 0:17:49.119 --> 0:17:55.200 can result in shock and potentially death. Yeah, so I've 0:17:55.240 --> 0:17:59.760 said already this is bacterial infection. What bacteria are we 0:17:59.800 --> 0:18:03.399 talk talking about. It's a lot, It's a lot, and 0:18:03.440 --> 0:18:06.800 so Aerin I think even though I tried really hard 0:18:06.880 --> 0:18:09.439 not to read about semelweis and not step on your 0:18:09.480 --> 0:18:14.840 toes at all, I think that largely in that time frame, 0:18:15.760 --> 0:18:19.440 it's thought that it was group A strep aka Streptococcus 0:18:19.480 --> 0:18:22.439 piogenies that was the big contributor. Is that correct? 0:18:23.040 --> 0:18:27.720 That's also what I read, But I think they didn't know, 0:18:28.600 --> 0:18:31.960 but it seemed like, yeah, strap biogenies was the first 0:18:32.200 --> 0:18:35.480 causative agent to be isolated and characterized. From what I. 0:18:35.440 --> 0:18:37.800 Recab, that makes a lot of sense because it was 0:18:37.800 --> 0:18:42.160 so interesting because I kind of knew that context. But today, 0:18:42.400 --> 0:18:48.080 when you read about like MPIs in general, it strep A, 0:18:48.520 --> 0:18:52.040 so group A strip or strap piogenies really doesn't even 0:18:52.119 --> 0:18:55.240 come up as a very big topic of conversation in 0:18:55.280 --> 0:18:58.240 most of the articles about it, which is very interesting. 0:18:59.280 --> 0:19:02.359 Caveat that that you can find like separate articles that 0:19:02.400 --> 0:19:07.280 are all about group A strep in the peripartum period, right, 0:19:07.800 --> 0:19:11.160 But when you read about endometritis, when you read about 0:19:11.320 --> 0:19:14.120 chorea aminitis, and when you read about just like general 0:19:14.800 --> 0:19:19.040 maternal sepsis and you use all these sort of buzzword terms, 0:19:19.440 --> 0:19:21.879 group AA strap is like, yeah, it's on the list 0:19:22.160 --> 0:19:25.639 along with a whole bunch of other things. Why, I 0:19:26.200 --> 0:19:28.360 don't really know. Let's kind of let's talk about. 0:19:28.200 --> 0:19:32.040 It, Okay, Okay, I have some guesses, maybe, but I. 0:19:32.520 --> 0:19:35.040 Have several guesses, so we'll see if our guesses are 0:19:35.080 --> 0:19:39.960 the same guesses. So we'll start by talking about strep 0:19:40.000 --> 0:19:44.399 biogenies and what might make it a particularly interesting bug 0:19:44.440 --> 0:19:46.159 to talk about, and then I'll go through what the 0:19:46.240 --> 0:19:48.960 other bacteria are too. But I'm not going to get 0:19:48.960 --> 0:19:52.120 into a lot of detail on strep biogenies because it's 0:19:52.160 --> 0:19:59.480 also the causative agent of necrotizing fasciitis, which spoiler listeners 0:19:59.560 --> 0:20:03.160 were going to be covering shortly in this season. 0:20:03.560 --> 0:20:05.360 Yes, yeah, so you'll. 0:20:05.200 --> 0:20:07.359 Learn all you want to know about the details of 0:20:07.359 --> 0:20:12.600 stret piogenies later. But in short, it's a gram positive 0:20:12.920 --> 0:20:17.879 little ball forms little chains like beads on a string 0:20:17.920 --> 0:20:20.360 when you look at it under a microscope, and it's 0:20:20.359 --> 0:20:25.639 a pretty common group of bacteria. Strett Piogenies can exist 0:20:25.680 --> 0:20:28.040 on our skin, it can exist in our throat. I 0:20:28.040 --> 0:20:31.040 think twenty five percent of kids are colonized in their 0:20:31.080 --> 0:20:34.080 throat and like five percent of adults. It's what causes 0:20:34.119 --> 0:20:36.879 strep throat right, Like, so you've all probably heard of 0:20:37.000 --> 0:20:42.200 stret piogenies. It also, like I said, causes deeper infections 0:20:42.240 --> 0:20:46.800 like necrotizing fasciitis if it's untreated. Strep Piogenies is what 0:20:46.920 --> 0:20:50.480 leads to rheumatic fever, rheumatic heart disease, a number of 0:20:50.480 --> 0:20:55.159 different post infectious type syndromes. But it's also, of course 0:20:55.320 --> 0:20:59.800 a potential cause of MPIs, and one of the reasons 0:21:00.520 --> 0:21:04.639 likely is that during pregnancy and the postpartum period, people 0:21:04.680 --> 0:21:10.879 are twenty times more likely to become infected with strept 0:21:10.920 --> 0:21:16.760 piogenies compared to non pregnant people. Huh, why something about 0:21:16.800 --> 0:21:20.800 pregnancy makes you far more susceptible to stret parogenes. To 0:21:20.920 --> 0:21:25.840 answer your question of why, we don't know, except that 0:21:26.160 --> 0:21:30.520 it might have to do with pregnancy in general is 0:21:30.560 --> 0:21:33.360 a state of aminosuppression, so it might just be that 0:21:33.359 --> 0:21:37.000 that specific type of aminosuppression makes you more susceptible. There 0:21:37.000 --> 0:21:40.520 are some people that say because being around children is 0:21:40.560 --> 0:21:44.000 a risk factor for stret piogenies colonization in general, since 0:21:44.160 --> 0:21:46.600 children are more likely to have it than adults, just 0:21:46.640 --> 0:21:50.119 like without being sick, just hanging around. So if someone 0:21:50.200 --> 0:21:53.080 is pregnant, they might also be around kids or have 0:21:53.160 --> 0:21:56.880 other young kids. So I don't know, that's kind of whatever, 0:21:58.000 --> 0:22:02.320 but in any case, times more likely to become infected 0:22:02.480 --> 0:22:06.240 during pregnancy and postpartum like that short, short postpartum period, 0:22:07.359 --> 0:22:10.280 because the thing about people who get strap a postpartum 0:22:10.440 --> 0:22:14.280 is they often are already colonized and then it just 0:22:14.359 --> 0:22:17.760 becomes an infection postpartum when that bacteria swims into the 0:22:17.760 --> 0:22:21.840 bloodstream right right. And while it's not the most common 0:22:21.920 --> 0:22:25.840 cause of peripartum infections today as far as I can tell, 0:22:26.359 --> 0:22:29.520 because it's really hard to get numbers on what is 0:22:29.600 --> 0:22:33.960 causing all these different MPIs. If you look at all 0:22:34.200 --> 0:22:38.040 invasive group A strep infections, about two to four percent 0:22:38.119 --> 0:22:41.320 of them are somehow associated with pregnancy. So that's of 0:22:41.480 --> 0:22:44.960 everyone in the world who gets an invasive group A 0:22:45.080 --> 0:22:48.680 strep infection, two to four percent of those are associated 0:22:48.720 --> 0:22:53.400 with pregnancy. I don't know the proportion of all MPIs 0:22:53.800 --> 0:22:59.560 that are due to group A strap However, when group 0:22:59.560 --> 0:23:06.879 A strepp is the causative agent, it is extremely virulent, okay, Yeah, 0:23:06.920 --> 0:23:11.159 And when and if it progresses to something like toxic shock, 0:23:11.359 --> 0:23:14.600 mortality can be as high as thirty to fifty percent 0:23:14.880 --> 0:23:15.720 even today. 0:23:16.680 --> 0:23:20.119 That's like with the use of antibiotics. 0:23:19.640 --> 0:23:22.280 That's yeah, if it progresses to shock, so that would 0:23:22.320 --> 0:23:25.080 probably mean that you didn't correctly identify it and treat 0:23:25.119 --> 0:23:30.400 it before it progressed that far. Okay, Yeah, So it's 0:23:30.560 --> 0:23:33.359 I think because of that. Because it's so virulent, it 0:23:33.440 --> 0:23:37.520 often has a very quick onset like within twenty four 0:23:37.520 --> 0:23:40.159 to forty eight hours after delivery, and then people can 0:23:40.240 --> 0:23:42.520 just get really sick from it. So I think because 0:23:42.520 --> 0:23:45.320 of that, it's like one of the really scary ones, 0:23:45.400 --> 0:23:47.760 even though it maybe isn't one of the most common 0:23:47.880 --> 0:23:53.040 causes of infection. Okay, so that's group A strap. There's 0:23:53.040 --> 0:23:55.000 a whole nother group of strip that we get to 0:23:55.040 --> 0:23:59.879 talk about, and that is group B strep aka streped 0:24:00.040 --> 0:24:04.480 caucus A galactae. I think I probably pronounced it wrong. 0:24:05.760 --> 0:24:08.440 And what I think is so interesting is that today 0:24:08.680 --> 0:24:11.600 you hear a lot more about group B strep in 0:24:11.680 --> 0:24:15.240 the context of pregnancy then you hear about group A strap. 0:24:15.800 --> 0:24:19.200 And that's because this is something that we actually test 0:24:19.359 --> 0:24:23.320 for in the US, at least during pregnancy, because we 0:24:23.440 --> 0:24:26.600 know that group B strep is a very important cause 0:24:26.680 --> 0:24:32.520 of meningitis in newborns. Yeah, and so we know that 0:24:32.960 --> 0:24:35.719 by testing for group B strap, because this is another 0:24:35.760 --> 0:24:40.119 bacteria that just can often colonize the vagina and the rectum. 0:24:40.480 --> 0:24:43.040 So if you test pregnant people for group B strep 0:24:43.080 --> 0:24:46.720 and then treat them with antibiotics during labor, it drastically 0:24:46.720 --> 0:24:51.040 reduces the probability of that bacteria being transmitted to the 0:24:51.040 --> 0:24:54.520 baby during delivery and then reduces that baby's risk of 0:24:54.560 --> 0:24:55.920 meningitis significantly. 0:24:56.560 --> 0:25:00.760 And so is the same treatment used for group B 0:25:01.000 --> 0:25:01.920 that's also used for. 0:25:01.840 --> 0:25:05.679 Group A the same bacteria. Yeah, you'd use like a 0:25:05.720 --> 0:25:07.280 penicillin right type. 0:25:07.320 --> 0:25:09.800 Okay, so that would treat both yeah, okay, okay, And 0:25:09.840 --> 0:25:11.760 so is that part of the reason why we see 0:25:11.760 --> 0:25:13.320 so few nowadays. 0:25:13.880 --> 0:25:16.000 It's a good question. We I mean, we don't test 0:25:16.080 --> 0:25:21.720 for group A strep, so okay, Yeah, but it's it's 0:25:21.760 --> 0:25:24.800 a good question. But group B strep, even though we 0:25:24.880 --> 0:25:28.080 know that it definitely can cause, you know, illness in newborns, 0:25:28.119 --> 0:25:31.800 it's also has the potential to cause a perinatal infection, 0:25:31.880 --> 0:25:36.440 a parapartum infection as well in the pregnant person. Other 0:25:36.520 --> 0:25:41.600 bacterial species E. Coli super common cause in some studies, 0:25:42.440 --> 0:25:47.280