Ignaz Philipp Semmelweis – seine Wiener Zeit
Sepp Leodolter (Wien)
Semmelweis studierte in Pest und Wien Medizin und wurde 1844 in Wien zum Doktor der Medizin promoviert. 1846 wurde er Assistent von Professor Johann Klein (1788 – 1856) an der 1. geburtshilflichen Klinik am AKH und dort Zeuge eines regelrechten Massensterbens von Wöchnerinnen. An dieser Klinik lag die Kindbettfieber-bedingte Sterblichkeit bei bis zu 30 %.

Összefoglalás
Az anyai halálozási ráta napjainkban is igen magas. A WHO 1990-ben meghirdetett programja célként tűzte ki 25 év alatt a halálozási ráta 75%-os csökkentését. Az adatok elemzése 2016-ban megtörtént. Ezek alapján látható, hogy a csökkentés mértéke világszinten alig haladta meg a 40%-ot. Csupán tíz országban sikerült elérni a kitűzött célt. A szerző ismerteti az előfordulás gyakoriságát és annak okait. A WHO adatait összehasonlítja a magyarországi adatokkal. Ezekből kitűnik, hogy a halálozási mutatók az elmúlt tíz évben romlottak. A halálozás okai elsősorban a vérzés, az infekciók és a toxaemia/hypertonia. A hypertonia okozta halálozás csaknem fele a szülés utáni 6 hétben következik be. Elengedhetetlen azon várandósok kiszűrése, akik már a terhesség előtt túlsúlyosak voltak, illetve magas vérnyomás betegségük volt, mert ezen okok a legfontosabb kockázati tényezők. Fontos a prekoncepcionális gondozás, hogy csökkenteni tudjuk a rizikót. A várandósgondozás során szintén szükséges ezen állapotok kiszűrése és kezelése.

In the rich history of medicine the name of Ignác SEMMELWEIS will always be written with capital letters. This Hungarian great physician was called „the survivor of mothers“ because he discovered in 1847 that the incidence of puerperal fever, also known as childbed fever, could be drastically cut by simple use of handwashing standards in obstetrical clinics. Much about him and his achievements will, I am sure, be described elsewhere in this issue. However, for me as a person who spent more than last 40 years in performing ultrasound diagnosis of maternal and fetal infection, for this very special occasion it is most appropriate to give an overview of the ultrasound imaging of fetal manifestation of infections.

Abstract
Clinical chorioamnionitis is the most common infection related diagnosis made in labor and delivery units worldwide. It is traditionally believed to be due to microbial invasion of the amniotic cavity, which elicits a maternal inflammatory response characterized by maternal fever, uterine tenderness, maternal tachycardia and leukocytosis. The condition is often associated with fetal tachycardia and a foul smelling amniotic fluid. Recent studies in which amniocentesis has been used to characterize the microbiologic state of the amniotic cavity and the inflammatory response show that only 60% of patients with the diagnosis of clinical chorioamnionitis have proven infection using culture or molecular microbiologic techniques. The remainder of the patients have intra-amniotic inflammation without demonstrable microorganisms or a maternal systemic inflammatory response (fever) in the absence of intra-amniotic inflammation. The latter cases often represent a systemic inflammatory response after epidural anesthesia/analgesia has been administered. The most common microorganisms are Ureaplasma species and Gardnerella vaginalis. In the presence of ruptured membranes, the frequency of infection is 70%, which is substantially higher than patients who have intact membranes (25%). The amniotic fluid inflammatory response is characterized by an infiltration of neutrophils and monocytes. Both cell types are activated in the presence of infection and can produce inflammatory cytokines. The white blood cells in the amniotic fluid can be of fetal or maternal origin. The maternal inflammatory response is characterized by an elevation in the concentration of pyrogenic cytokines. The cytokine plasma concentrations in the fetal circulation are elevated even if there is no evidence of an intra-amniotic inflammatory response suggesting that maternal plasma cytokines may cross the placental barrier and induce a mild fetal inflammatory response. Placental pathology is of limited value in the diagnosis of proven intra-amniotic infection. The clinical criteria traditionally used in clinical medicine have accuracy around 50% and therefore, they cannot distinguish between patients with a proven intra-amniotic infection and those with intra-amniotic inflammation alone. Analysis of amniotic fluid with a bedside test for MMP-8 can allow the rapid identification of the patient at risk for infection and may decrease the need for antibiotic administration to neonates. An important consideration is whether antibiotics effective against Ureaplasma species should be administered to patients with clinical chorioamnionitis, given that these genital mycoplasmas are the most common organisms found in the amniotic fluid. The emergent picture is that clinical chorioamnionitis is a heterogeneous syndrome, which requires further study to optimize maternal and neonatal outcomes.

Handwashing between patients has become such an integral part of modern obstetrics that failure to wash one’s hands is unthinkable in a professional organizational culture, i.e., an organizational culture systematically committed to patient safety and quality of care. Unfortunately, many obstetricians do not know who pioneered this fundamental component of patient safety, Ignác Semmelweis (1818-1865), and the resistance that he encountered. The hypothesis that the transfer of “putrid matter” from the hands of physicians and medical students to gravid patients caused puerperal fever had been articulated as early as 1795 by the Scottish physician, Alexander Gordon (1752-1799), and supported by the prominent American physician, Oliver Wendell Holmes, Sr. (1809-1894).

Wash your hands!
These three words sum up the advice proffered by the Hungarian obstetrician Ignác Fülöp Semmelweis to members of the Vienna Medical Society in 1850 and helped set the stage for a transformational change in the practice of medicine and surgery. This early pioneer of antiseptic procedure was the first to discover that the spread of puerperal fever, commonly known as childbed fever, could be drastically cut by introducing hand hygiene in obstetric clinics.¹

Semmelweis Ignác (1818−1865) tudományos felfedezése látszólag, különösen mai szemmel nézve, igen egyszerű. Azt ismerte fel, hogy az orvosok és orvostanhallgatók – miközben belsőleg vizsgálják a szülőnőket – kezükkel olyan anyagokat visznek át a szervezetükbe, melyek halálos betegséget, vérmérgezést okozhatnak. Ugyanez a folyamat játszódik le akár a férfiak szervezetében is, ha sérülésen át vérkeringésükbe bejut ez az anyag a boncolás során, mint Kolletschka professzor esetében is 1847 márciusában. Ez vált a nagy felfedezés dátumává.