Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

A Retrospective Exploration of Pre-operative Antibiotic Prophylaxis with Cefazolin in Cesarean Sections: Implications for Obstetrics and Gynecologic Surgery

Background: Post-partum infection is a major contributor to maternal mortality and is responsible for approximately 10% of maternal fatalities worldwide. The risk of infection is substantially higher in cesarean section procedures. Approximately 8% of women who undergo cesarean sections are susceptible to infection. Although the body of evidence supporting the regular pre-operative utilization of prophylactic antibiotic treatment is steadily expanding, its usefulness in cesarean sections has not yet been standardized, and post-partum infection is still a serious medical challenge. We aimed to retrospectively assess the prophylactic effectiveness of cefazolin in combination with other antibiotic agents in cesarean sections. Materials and Methods: Both uni-variable and multi-variable analyses were conducted to identify factors that may affect cefazolin pre-operative antibiotic prophylaxis in elective cesarean section operations. The uni-variable analysis included timing of administration, operation duration, body mass index (BMI), and wound type. A multi-variable logistic regression model was then created to determine which variables provide independent information in the context of other variables. Results: Time of administration did not affect prophylactic cefazolin efficacy. However, prophylactic cefazolin was 1.43 and 1.77 times more effective when the operation lasted for 45 minutes or more, compared with operations that were shorter than 45 minutes. Patients with a BMI ranging from 18 to 29 kg/m2 showed increased efficacy of prophylactic cefazolin compared with obese patients with a BMI exceeding 30 kg/m2. The effectiveness of prophylactic cefazolin decreased by 95% in patients with clean-contaminated surgical incisions compared with those with clean surgical incisions. Conclusions: Our findings demonstrate that administering pre-operative prophylactic antibiotic agents to women undergoing cesarean section resulted in a reduction in post-partum infections, thereby reducing maternal mortality. Furthermore, optimal timing of administration, re-dosing if necessary, length of prophylactic medication, and dosing adjustments for obese patients are crucial factors in preventing surgical site infections and promoting antimicrobial stewardship.

Maternal morbidity and death associated with pregnancy loss before 28 weeks in Nigeria

OBJECTIVE

To determine the prevalence of maternal morbidity and death from pregnancy loss before 28 weeks in referral-level hospitals in Nigeria.

DESIGN

Secondary analysis of a nationwide cross-sectional study.

SETTING

Fifty-four referral-level hospitals.

POPULATION

Women admitted for complications arising from pregnancy loss before 28 weeks between 1 September 2019 to 31 August 2020.

METHODS

Frequency and type of pregnancy loss were calculated using the extracted data. Multilevel logistic regression was used to determine sociodemographic and clinical factors associated with early pregnancy loss. Factors contributing to death were also analysed.

MAIN OUTCOME MEASURES

Prevalence and outcome of pregnancy loss at <28 weeks; sociodemographic and clinical predictors of morbidity after early pregnancy loss; contributory factors to death.

RESULTS

Of the 4798 women who had pregnancy loss at <28 weeks of pregnancy, spontaneous abortion accounted for 49.2%, followed by missed abortion (26.9%) and ectopic pregnancy (15%). Seven hundred women (14.6%) had a complication following pregnancy loss and 99 women died (2.1%). Most complications (26%) and deaths (7%) occurred after induced abortion. Haemorrhage was the most frequent complication in all types of pregnancy loss with 11.5% in molar pregnancy and 6.9% following induced abortion. Predictors of complication or death were low maternal education, husband who was not gainfully employed, grand-multipara, pre-existing chronic medical condition and referral from another facility or informal setting.

CONCLUSION

Pregnancy loss before 28 weeks is a significant contributor to high maternal morbidity and mortality in Nigeria. Socio-economic factors and delays in referral to higher levels of care contribute significantly to poor outcomes for women.

Effect of prophylactic use of cefazolin in caesarean section on postoperative infection: A meta-analysis

Caesarean section rate is increasing and postoperative wound infection is a major health-threatening complication after caesarean section (CS). The aim of this study was to evaluate the efficacy of Cefazolin at different time for post-caesarean delivery. The aim of this study was to compare the use of Cefazolin at different times on infections after CS. The time of antibiotic use in CS can be divided into two groups: before skin incision (SI) and after cord clamping (CC). In this study, 268 relevant articles were found in the database, and finally, 10 articles were analysed. This study included a total of 5256 cases of caesarean section. The data on wound infections, endometritis, urinary tract infections and fever were analysed. Perform an analysis of the data using RevMan 5.3. The results showed that cefazolin before SI reduced wound infection compared to after CC (odds ratio [OR], 0.51; 95% CI: 0.37-0.69; p < 0.0001). Cefazolin prophylactically used before SI reduce endometritis after CS compared to after CC (OR, 0.52; 95% CI: 0.35-0.77; p = 0.001). There was no significant difference in urinary tract infections after CS between cefazolin prophylactically used before SI and after CC (OR, 0.80; 95% CI: 0.50-11.28; p = 0.35). There was no significant difference in fever after CS between the prophylactic use of cefazolin before SI and after CC (OR, 0.60; 95% CI: 0.26-11.43; p = 0.225). Cefazolin before SI reduces wound infection and endometritis after CS.

Comprehensive analysis of current epidemiology, clinical features and Prognostic Factors of puerperal endometritis: A retrospective cohort analysis

Background

Puerperal endometritis has not been recently investigated. We aimed to describe the current dimension of the endometritis in the context of other causes of puerperal fever and investigate the microbiology and need for curettage in these patients.

Methods

A retrospective cohort study was conducted based on a prospectively maintained database of patients with puerperal fever, (2014-2020) in which cases fulfilling criteria for endometritis were selected for further analysis. Description of clinical and microbiological features was performed and determination of the factors related with puerperal curettage requirement were studied using univariate and multivariate analysis through binary logistic regression.

Results

From 428 patients with puerperal fever, endometritis was the main cause of puerperal fever (233 patients, 52.7 %). Curettage was required in 96 of them (41.2 %). Culture of endometrial samples were performed in 62 (64.5 %), of which 32 (51.6 %) yielded bacterial growth. Escherichia coli was the most common microorganism in curettage cultures (46.9 %). Multivariate analysis identified the following predictive factors for curettage: the presence of pattern compatible with retained products of conception (RPOC) in transvaginal ultrasonography (odds ratio [OR]: 17.6 [95 % confidence interval [CI]: 8.4-36.6]; P-value < 0.0001), fever during the first 14 days after delivery (OR:5.1; [95 % CI: 1.57-16.5]; P-value 0.007), abdominal pain (OR: 2.9; [95 % CI: 1.36-6.1]; P-value 0.012) and malodorous lochia (OR:3.5; [95 % CI: 1.25-9.9]; P-value 0.017). Scheduled cesarean delivery was protective (OR: 0.11 [95 % CI 0.01-1.2]; P-value 0.08).

Conclusions

Endometritis is still the main cause of puerperal fever. Women requiring curettage typically presented with abdominal pain and foul-smelling lochia, an ultrasound image compatible with RPOC and fever in the first 14 days postpartum. Curettage culture is useful for the microbiological affiliation mostly yielding gram-negative enteric flora.

Prenatal Maternal Antibiotics Treatment Alters the Gut Microbiota and Immune Function of Post-Weaned Prepubescent Offspring

This study aimed to investigate the immediate and continual perturbation to the gut microbiota of offspring in the weeks post-weaning and how these may be modulated by treating pregnant C57BL/6J dams with antibiotics (ABX). We used a broad-spectrum antibiotic cocktail consisting of ampicillin 1 mg/mL, neomycin 1 mg/mL, and vancomycin 0.5 mg/mL, or vancomycin 0.5 mg/mL alone, administered ad-lib orally to dams via drinking water during gestation and stopped after delivery. We analyzed the gut microbiota of offspring, cytokine profiles in circulation, and the brain to determine if there was evidence of a gut-immune-brain connection. Computationally predicted metabolic pathways were calculated from 16s rRNA sequencing data. ABX treatment can negatively affect the gut microbiota, including reduced diversity, altered metabolic activity, and immune function. We show that the maternal ABX-treatment continues to alter the offspring's gut microbiota diversity, composition, and metabolic pathways after weaning, with the most significant differences evident in 5-week-olds as opposed to 4-week-olds. Lower levels of chemokines and inflammatory cytokines, such as interleukin (IL)-1α and IL-2, are also seen in the periphery and brains of offspring, respectively. In conclusion, this study shows maternal antibiotic administration alters gut microbiome profiles in offspring, which undergoes a continuous transformation, from week to week, at an early age after weaning.

Efficacy of adding azithromycin to antibiotic prophylaxis in caesarean delivery: a meta-analysis and systematic review

To explore the efficacy of adding azithromycin to antibiotic prophylaxis for patients undergoing caesarean delivery (CD), we conducted a statistical analysis of related randomised controlled trials (RCTs) and cohort studies in the existing literature. Studies that used the same study design and outcome indicators were included in our meta-analysis. We then carried out heterogeneity tests and effect quantity calculation. Our meta-analysis of RCTs showed that addition of azithromycin as prophylaxis in CD significantly reduced the risk of endometritis [relative risk (RR) = 0.62, 95% confidence interval (CI) 0.49-0.79; P < 0.0001] and wound infection (RR = 0.40, 95% CI 0.27-0.58; P < 0.00001). In addition, meta-analysis results of the cohort studies also confirmed the efficacy of azithromycin for endometritis (RR = 0.41, 95% CI 0.11-1.51; P = 0.18), wound infection (RR = 0.66, 95% CI 0.54-0.82; P = 0.0001) and composite infections outcome (RR = 0.80, 95% CI 0.66-0.96; P = 0.02). However, meta-analysis could not be used to evaluate the safety of adding azithromycin owing to inconsistencies in the outcome indicators used in different studies. Addition of azithromycin to antibiotic prophylaxis reduced the risk of surgical site infections in patients undergoing CD. However, additional subgroup studies involving non-elective CD and long-term follow-up studies on the safety of the offspring are required in the future.

Delivery method of the placenta in cesarean deliveries and the effect of uterine incision repair area on morbidity: A randomized controlled study

Objective

We evaluated the effects of spontaneous or manual delivery of the placenta and repair of uterine incision inside or outside the abdomen on intraoperative blood loss, postoperative infection morbidity, and postoperative hospitalization time.

Materials and Methods

We conducted a prospective randomized controlled study with 150 patients among 160 patients who were indicated to undergo emergency cesarean procedures in our tertiary hospital. We divided the patient population into four groups. These four groups were formed by comparing the way the placenta was delivered manually and by spontaneous traction with the repair of the uterus inside and outside the abdomen. Blood loss was determined using quantitative and gravimetric methods. A numeric rating scale was used, which is a one-dimensional method used for uterine sensitivity distribution and pain measurement.

Results

The amount of bleeding was 339 mL in group 1, 237 mL in group 2, 470 mL in group 3, and 490 mL in group 4, which were significantly different (p<0.001). The mean surgical time was 30.8±5.5 minutes in group 1, 30.7±4.4 minutes in group 2, 38.5±6.9 minutes in group 3, and 43.9 minutes in group 4 (p<0.001). When the distribution of uterine tenderness among the groups was examined in the fundus examinations performed on the postpartum 1^st day of the patients, we found a significant difference (p<0.001). When all groups were compared, there was a significant difference between group 1 and group 4 in terms of hospital stay (p<0.004). Among the contributing factors were endometritis, maternal body weight (p<0.053), advanced gestational week (p<0.004), prolonged surgical time (p<0.009), and the presence of meconium.

Conclusion

Manual removal of the placenta resulted in higher blood loss, increased uterine tenderness, and longer hospitalization compared with the spontaneous separation method. The uterine incision repair site did not affect morbidity.

Determinants of post cesarean section surgical site infection at public hospitals in Dire Dawa administration, Eastern Ethiopia: Case control study

INTRODUCTION

Post cesarean section surgical site infection increases both the duration of a patient's hospital stay and unplanned hospital costs. It can delays recovery, prolongs hospitalization, necessitates readmission, and adds to hospital bills and other morbidities as well as mortalities.

METHOD

Facility-based case-control study was conducted from 1st March to 20th April, 2019 among all the mother records enrolled from 1st January to 31st December, 2018 at Public hospitals in Dire Dawa administration. The records of the mothers' who had post-cesarean section surgical site infection (119) was extracted by a census and every three consecutive controls (357) for each case were collected by trained data collectors using a structured data extraction tool. Variables which had p-value <0.25 in bivariate analysis were considered as candidates for multivariable analysis. Statistical significance was declared at P-value ≤0.05 with adjusted odd ratio and 95% confidence interval in the multivariable logistic regression model.

RESULT

Age 20-34 years (AOR:5.4; 95%CI:2.35,12.7), age >35 years (AOR:8.9; 95%CI:1.8,43.9), ≥4 per vaginal examinations (AOR: 4.2; 95%CI:2.16,8.22), current history of Chorioamnionitis (AOR:5; 95%CI:1.05,23.9), previous history of cesarean section (AOR:6.2; 95%CI: 2.72,14.36), provision of antibiotics prophylaxis (AOR:3.2; 95%CI:1.81,5.62), perioperative HCT level <30% (AOR:6.9; 95%CI:3.45,14.1) and duration of rupture of membrane >12 hours (AOR:5.4; 95%CI:1.84,15.87) were the independent determinants of post-cesarean section surgical site infection.

CONCLUSION

Increased in age of the mother, higher number of per vaginal examination, having a history of chorioamnionitis, having previous history of cesarean section, not receiving antibiotics prophylaxis, lower perioperative hematocrit level and longer duration of rupture of membrane were statistically significant in multivariable analysis. Therefore; emphasis should be given for mothers who have higher age category, previous cesarean scar and history of choriamnionitis. In addition; provision of antibiotics should be comprehensive for all mothers undergoing cesarean section.

Compliance with antibiotic prophylaxis guidelines in caesarean delivery: a retrospective, drug utilization study (indication-prescription type) at an Ecuadorian hospital

BACKGROUND

Preoperative antibiotic prophylaxis is essential for preventing surgical site infection (SSI). The aim of this study was to evaluate compliance with international and local recommendations in caesarean deliveries carried out at the Obstetrics and Gynaecology Service of the Ambato General Hospital, as well as any related health and economic consequences.

METHODS

A retrospective indication-prescription drug utilization study was conducted using data from caesarean deliveries occurred in 2018. A clinical pharmacist assessed guidelines compliance based on the following criteria: administration of antibiotic prophylaxis, antibiotic selection, dose, time of administration and duration. The relationship between the frequency of SSI and other variables, including guideline compliance, was analysed. The cost associated with the antibiotic used was compared with the theoretical cost considering total compliance with recommendations. Descriptive statistics, Odds Ratio and Pearson Chi Square were used for data analysis by IBM SPSS Statistics version 25.

RESULTS

The study included 814 patients with an average age of 30.87 ± 5.50 years old. Among the caesarean sections, 68.67% were emergency interventions; 3.44% lasted longer than four hours and in 0.25% of the deliveries blood loss was greater than 1.5 L. Only 69.90% of patients received preoperative antibiotic prophylaxis; however, 100% received postoperative antibiotic treatment despite disagreement with guideline recommendations (duration: 6.75 ± 1.39 days). The use of antibiotic prophylaxis was more frequent in scheduled than in emergency caesarean sections (OR = 2.79, P = 0.000). Nevertheless, the timing of administration, antibiotic selection and dose were more closely adhered to guideline recommendations. The incidence of surgical site infection was 1.35%, but tended to increase in patients who had not received preoperative antibiotic prophylaxis (OR = 1.33, P = 0.649). Also, a significant relationship was found between SSI and patient age (χ2 = 8.08, P = 0.036). The mean expenditure on antibiotics per patient was 5.7 times greater than that the cost derived from compliance with international recommendations.

CONCLUSIONS

Surgical antibiotic prophylaxis compliance was far below guideline recommendations, especially with respect to implementation and duration. This not only poses a risk to patients but leads to unnecessary expenditure on medicines. Therefore, this justifies the need for educational interventions and the implementation of institutional protocols involving pharmacists.

Intrauterine bacterial growth in elective and non-elective caesarean sections

We assessed intrauterine bacterial growth for elective and non-elective caesarean sections (CSs). Aerobic uterine cultures were obtained from the uterine cavity immediately following placental removal from 1376 patients who underwent CS in one center during one year. About 13.8% (115/832) of elective CS were positive vs. 55.9% (304/544) of non-elective CS (p < .001). Of non-elective CSs, 28.6% (56/196) of those without ruptured membranes (ROM) were positive vs. 71.3% (248/348) with ROM (p < .001). Mean birth weight and 1-minute Apgar scores were significantly lower in women with positive cultures, elective and non-elective, than negative cultures. A higher percentage of women with positive uterine cultures presented with postpartum endometritis (p < .05). Intrauterine bacteria in elective CSs demonstrate that the uterine cavity is not sterile. Non-elective CS, particularly after membrane rupture, is a significant risk factor for positive uterine culture. Positive uterine culture is associated with lower birth weight, lower one-minute Apgar score and postpartum endometritis.Impact statementWhat is already known on this subject? Postpartum endometritis is a leading cause of postpartum febrile morbidity. Caesarean sections, in particular non-elective cesareans, are an important risk factor for the development of postpartum endometritis. Controversy exists concerning the sterility of the placenta and uterus. The diagnosis of endometritis is based mainly on clinical findings and does not necessitate bacterial isolation from the uterine cavity. Positive culture at caesarean section has been associated with positive postoperative culture and yet, currently, professional organisations do not recommend the routine sampling of intrauterine cultures during caesarean section.What do the results of this study add? Since positive uterine culture rate was higher in non-elective CSs and associated with lower birth weight and 1-minute Apgar score and postoperative endometritis, obtaining uterine culture in those cases might be of clinical value.What are the implications of these findings for clinical practice and/or further research? Obtaining routine intrauterine cultures during non-elective caesarean sections might be useful for detecting significant pathogens and tailoring antibiotic treatment in postpartum endometritis. Further studies are necessary in order to determine the impact of obtaining intrauterine cultures during caesarean sections, particularly non-elective cesareans.

Routine uterine culture swab during cesarean section and its clinical correlations: A retrospective comparative study

OBJECTIVES

Cesarean sections, particularly non-elective cesareans, are an important risk factor for the development of postpartum endometritis, a leading cause of postpartum febrile morbidity. We evaluated the yield of obtaining routine intrauterine culture during elective and non-elective cesarean sections, in the prevention and management of postpartum endometritis.

STUDY DESIGN

A retrospective comparative study investigating the distribution of uterine cultures obtained immediately after fetus and placenta delivery during cesarean sections performed in a single tertiary hospital during 2017. True pathogenic bacteria were included in the study analysis and considered as positive results, while other contaminant bacteria were excluded.

RESULTS

Positive uterine cultures were identified in 10.7 % (88/821) of cesarean sections, with no significant difference in prevalence between elective and non-elective cesareans. Escherichia coli (E.coli), isolated in 40.9 % of the positive cultures of all women, was the most common organism in non-elective cesareans vs. Group B Streptococcus (GBS) in elective cesareans. Higher rate of positive cultures was found in term vs. preterm cesareans (17.5 % vs 10.5 %, respectively, p-value = 0.04). E.coli was the most frequent pathogen reported in both women with intact membranes or premature rupture of membranes (46.3 % and 47.3 % respectively). Eight women (9.1 %) with positive cultures presented with postpartum fever; all had undergone non-elective cesarean section. In one-third of these cases the empirical antibiotic treatment was adjusted according to the uterine culture results and susceptibility testing results.

CONCLUSIONS

Obtaining routine intrauterine cultures during non-elective cesarean sections might be useful for detecting significant pathogens and tailoring the antibiotic treatment in postpartum endometritis.

Antibiotic Use Without Indication During Delivery Hospitalizations in the United States

OBJECTIVE

To analyze trends in unindicated antibiotic use during vaginal delivery hospitalization.

METHODS

This study used an administrative database to analyze antibiotic use during delivery hospitalizations from January 2006 to March 2015. Women were classified by mode of delivery and whether they had an evidence-based indication for antibiotics. Indications for antibiotics included preterm prelabor rupture of membranes (PROM), cesarean delivery, group B streptococcus (GBS) colonization, chorioamnionitis, endometritis, urinary tract infections, and other infections. The Cochran-Armitage test was used to assess trends of antibiotic administration. Unadjusted and adjusted analyses for antibiotic receipt including demographic, hospital, and obstetric and medical factors were performed with unadjusted and adjusted risk ratios (RRs) with 95% CIs as measures of association.

RESULTS

A total of 5,536,756 delivery hospitalizations, including 2,872,286 vaginal deliveries without an indication for antibiotics, were analyzed. The most common indication for antibiotics was cesarean delivery (33.6% of the entire cohort), followed by GBS colonization (15.8%), chorioamnionitis (1.7%), preterm PROM (1.6%), endometritis (1.2%), urinary tract infections (0.6%), and other infections (total less than 0.5%). The proportion of women receiving unindicated antibiotics decreased 44.4%, from 38.1% in 2006 to 21.2% in 2015. Adjusted risk for receipt of unindicated antibiotics was lower in 2015 vs 2006 (adjusted RR 0.56, 95% CI 0.55-0.57).

CONCLUSION

Use of antibiotics during vaginal delivery hospitalizations without an indication for antibiotic use declined significantly based on an analysis of a large administrative data set.

Is the efficacy of antibiotic prophylaxis for surgical procedures decreasing? Systematic review and meta-analysis of randomized control trials

OBJECTIVE

Rising antibiotic resistance could reduce the effectiveness of antibiotics in preventing postoperative infections. We investigated trends in the efficacy of antibiotic prophylaxis regimens for 3 commonly performed surgical procedures-appendectomy, cesarean section, and colorectal surgery-and 1 invasive diagnostic procedure, transrectal prostate biopsy (TRPB).

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed and Cochrane databases (through October 31, 2017) for randomized control trials (RCTs) that measured the efficacy of antibiotic prophylaxis for 4 index procedures in preventing postoperative infections (surgical site infections [SSIs] following the 3 surgical procedures and a combination of urinary tract infections [UTIs] and sepsis following TRPB).

RESULTS

Of 399 RCTs, 74 studies (9 appendectomy, 11 cesarean section, 39 colorectal surgery, and 15 TRPB) were included. Multilevel logistic regression models with random intercepts for each study showed no statistically significant increase in SSIs over time for appendectomy (adjusted odds ratio [aOR] per year, 1.03; 95% confidence interval [CI], 0.92-1.16; P=.57), cesarean section (aOR per year, 1.01; 95% CI, 0.96-1.05; P=.80), and TRPB (aOR per year, 0.95; 95% CI, 0.77-1.18; P=.67). However, there was a significant increase in SSIs proportion following colorectal surgery (aOR per year, 1.049; 95% CI, 1.03-1.07; P&lt;.001).

CONCLUSION

The efficacy of antibiotic prophylaxis agents in preventing SSIs following colorectal surgery has declined. Small number of RCTs and low infections rates limited our ability to assess true effect for simple appendectomy, cesarean section, or TRPB.

Single dose ceftriaxone and metronidazole versus multiple doses for antibiotic prophylaxis at elective caesarean section in Mulago hospital: A randomized clinical trial

Objective: To compare the incidence of post-operative infections among mothers who received single dose pre-operative ceftriaxone and metronidazole compared to multiple doses after delivery by elective caesarean section. Methods: This was (parallel, balanced randomization, 1:1) open label randomized controlled trial conducted Mulago Hospital, Department of Obstetrics and Gynaecology. Participants included in this study were pregnant women who had been admitted for elective caesarean section. The mothers were randomized to receive single dose of ceftriaxone and metronidazole minutes before the operation or multiple doses 30-60 during the operation and postoperatively. The primary outcome was post-operative wound infection. Secondary outcomes were clinical endometritis and febrile morbidity. The 174 eligible participants were randomized into one of the two treatment arms in a ratio of 1:1. The research assistants who collected the outcomes were blinded to the study allocation. Results: Of the 174 eligible participants who recruited; 87 were randomized to the single dose group while 87 to the multiple doses group. The participants were recruited from 17th September 2015 up to 29th February 2016. All the participants were followed up for two weeks after delivery.  Outcome data was available for 79 women in the single dose group and 81 women in the multiple dose group. There were no differences in the incidence of post-operative wound infections between the single dose arm versus the multiple dose arm (RR 1.895; 95% CI (0.2-21.4). There was no clinical endometritis and febrile morbidity observed during the 14 days of follow up. Conclusion: Single dose pre-operative antibiotic prophylactic with ceftriaxone and metronidazole is as effective as multiple doses in prevention of post-operative infectious morbidity in women who undergo elective caesarean section. We recommend the use of single dose ceftriaxone and metronidazole in women undergoing elective caesarean section in our setting. Trial registration: NCT02736682. Registration date, 7th April, 2016.

Outcome of caesarean section at the Edward Francis Small Teaching Hospital, Banjul The Gambia

BACKGROUND

Caesarean section is a very important procedure to decrease maternal and perinatal morbidity and mortality. Anecdotal evidence suggests that more than half of all caesarean sections done in The Gambia are done at the Edward Francis Small Teaching Hospital.

OBJECTIVE

The aim of the study was to determine the caesarean section rate at the Edward Francis Small teaching Hospital. The study also aimed to determine the socio-demographic factors associated with caesarean section and maternal and fetal outcomes of caesarean section at the hospital.

METHOD

A retrospective review of all caesarean sections carried out at the Edward Francis Small Teaching Hospital from 1st January 2014 to 31st December 2014 was done. Data was extracted from patients' record. Descriptive statistics was done using Epi Info 7 statistical software.

RESULTS

The Caesarean section rate in the hospital is 24.0%. The commonest indications for caesarean section were previous caesarean section (20.6%) and cephalopelvic disproportion (20.2%). There were 21 maternal deaths (1.8%) and 71 fresh stillbirths (6.0%) in the study population.

CONCLUSION

About a quarter of all deliveries in the hospital were caesarean sections most of which were done as emergencies. The commonest indications for caesarean section were cephalopelvic disproportion and previous caesarean section.

A randomized controlled double blind trial comparing the effects of the prophylactic antibiotic, Cefazolin, administered at caesarean delivery at two different timings (before skin incision and after cord clamping) on both the mother and newborn

BACKGROUND

Caesarean delivery (CD) increases the risk of postpartum infection by 5 to 20 fold. Prevention of surgical site infection (SSI) is the goal of antibiotic prophylaxis. This study was carried out to assess the optimum timing for prophylactic antibiotic administration and to assess the amount of the antibiotic crossing the placental barrier.

METHODS

Eligible mothers were recruited, after informed consent, once the decision for CD was made. Each mother received two injections, one prior to skin incision and one after cord clamping, (one being the study drug Cefazolin, and the other, a placebo) based on the randomization code. Demographic, maternal and neonatal monitoring data until discharge from hospital, and at the 6 weeks postpartum visit were collected. Levels of the prophylactic antibiotic were measured from the cord blood in every 8th neonate. The objective of the study was to compare the effects of the prophylactic antibiotic, intravenous Cefazolin 1 g, administered at Caesarean delivery (CD) at two different timings (before skin incision and after cord clamping) on both the mother and newborn. The secondary outcomes that were followed up were the number of maternal and neonatal readmissions. An appropriate test for significance, Fisher's exact test was used to find the association between risk variables and outcome.

RESULTS

The total numbers of mothers enrolled were 1106, of whom 553 mothers received antibiotic prior to skin incision (pre-incision) and 543 mothers received antibiotic after cord clamping (post-incision). The pre-incision group had significantly less febrile illness (RR = 0.48, 95% CI: 0.29 - 0.80) and SSI (RR = 0.14, 95% CI: 0.04 - 0.53) when compared with the post- incision group. The post-incision group significantly had >7 days hospital stay when compared to the 4-7 days stay of the pre-incision group (p = 0.005).There were no differences in any of the neonatal outcomes. The quantity of the antibiotic in the cord blood was only 2-3%.

CONCLUSIONS

Pre incision prophylactic antibiotic protected the mother from SSI and febrile illness and decreased the hospital stay significantly.

TRIAL REGISTRATION

The Clinical Trials Registry India (CTRI) was [ CTRI/2016/03/006710 dated, 04/03/2016].

Effect of Post-Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial

IMPORTANCE

The rate of obesity among US women has been increasing, and obesity is associated with increased risk of surgical site infection (SSI) following cesarean delivery. The optimal perioperative antibiotic prophylactic regimen in this high-risk population undergoing cesarean delivery is unknown.

OBJECTIVE

To determine rates of SSI among obese women who receive prophylactic oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind clinical trial comparing oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery for the prevention of SSI in obese women (prepregnancy BMI ≥30) who had received standard intravenous preoperative cephalosporin prophylaxis. Randomization was stratified by intact vs rupture of membranes prior to delivery. The study was conducted at the University of Cincinnati Medical Center, Cincinnati, Ohio, an academic and urban setting, between October 2010 and December 2015, with final follow-up through February 2016.

INTERVENTIONS

Participants were randomly assigned to receive oral cephalexin, 500 mg, and metronidazole, 500 mg (n = 202 participants), vs identical-appearing placebo (n = 201 participants) every 8 hours for a total of 48 hours following cesarean delivery.

MAIN OUTCOMES AND MEASURES

The primary outcome was SSI, defined as any superficial incisional, deep incisional, or organ/space infections within 30 days after cesarean delivery.

RESULTS

Among 403 randomized participants who were included (mean age, 28 [SD, 6] years; mean BMI, 39.7 [SD, 7.8]), 382 (94.6%) completed the trial. The overall rate of SSI was 10.9% (95% CI, 7.9%-14.0%). Surgical site infection was diagnosed in 13 women (6.4%) in the cephalexin-metronidazole group vs 31 women (15.4%) in the placebo group (difference, 9.0% [95% CI, 2.9%-15.0%]; relative risk, 0.41 [95% CI, 0.22-0.77]; P = .01). There were no serious adverse events, including allergic reaction, reported in either the antibiotic group or the placebo group.

CONCLUSIONS AND RELEVANCE

Among obese women undergoing cesarean delivery who received the standard preoperative cephalosporin prophylaxis, a postoperative 48-hour course of oral cephalexin and metronidazole, compared with placebo, reduced the rate of SSI within 30 days after delivery. For prevention of SSI among obese women after cesarean delivery, prophylactic oral cephalexin and metronidazole may be warranted.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01194115.

Intrauterine cleaning after placental delivery at cesarean section: a randomized controlled trial

OBJECTIVE

The objective of this study is to evaluate whether omission of intrauterine cleaning increases intraoperative and postoperative complications among women who deliver via cesarean section.

METHODS

We randomized 206 women undergoing primary elective cesarean deliveries to intrauterine cleaning or omission of cleaning. Postpartum endomyometritis rates across groups were the primary outcome. We also examined secondary outcomes. To detect a 20% difference in infection rate between the cleaned and the non-cleaned groups (two-tailed [alpha] = 0.05, [beta] = 0.2), 103 women were required per group. Analysis was by intention-to-treat.

RESULTS

Two hundred and six were randomized as follows: 103 to intrauterine cleaning and 103 to omission of cleaning after placental delivery. There were no statistically significant differences in the rate of endomyometritis between the two groups (2.0% versus 2.9%, RR =0.60; 95% CI 0.40-1.32). There were no statistically significant differences in postpartum hemorrhage rates (5.8% versus 7.7%, RR 0.75; 95% CI 0.6-1.2), hospital readmission rates (2.9 versus 3.8%, RR 0.75; 95% CI 0.5-1.6), time to return of gastrointestinal function, need for repeat surgery, or quantitated blood loss between the two groups.

CONCLUSIONS

Our randomized controlled trial provides evidence suggesting that omission of intrauterine cleaning during cesarean deliveries in women at low risk of infection does not increase intraoperative or postoperative complications.

[Epidemiological profile of maternal complications related to cesarean section at the Al Farabi Hospital in Oujda]

Au Maroc le taux de césariennes est passé de 2% en 1992 à 16% en 2011, cette augmentation est corrélée à une augmentation de la mortalité et de la morbidité per et post opératoire qui est de 19% dans notre série. Ce travail est le premier du genre à être effectué dans la région de l'oriental du Maroc dont l'objectif est d'analyser le profil épidémiologique détaillé des complications maternelles de la césarienne à partir de 2417 cas, à la maternité El farabi de Oujda, cette étude est une étude observationnelle descriptive rétrospective d'une série de 2416 patientes, ayant bénéficié d'une césarienne à la maternité de l'hôpital EL FARABI d'Oujda sur une période étalée entre le 1^er janvier 2011 et le 31 décembre 2013. 24464 accouchements étaient réalisés, dont 2416 cas par césarienne, soit un taux de 9.87%. La fréquence des complications liées à la césarienne était de 19.45%. Les complications postopératoires représentaient 63.6% des complications dominées par l'infection. Les complications hémorragiques représentaient 25.53% de toutes les complications. On a enregistré 4 cas de décès maternels. Si l'augmentation du taux de césariennes a contribué à l'amélioration du pronostic materno-fœtal, l'acte chirurgical en lui même n'est pas dénué de complications, ce qui nous incite à revoir ses indications pour une meilleure prise en charge de nos patientes.

Sonographic findings in acute puerperal endometritis: The hypoechoic rim sign and endomyometrial junction indistinctness

PURPOSE

To evaluate the accuracy of the sonographic subserosal hypoechoic rim sign and endomyometrial junctional indistinctness in identifying patients with acute endometritis during the puerperal period.

METHODS

Radiologic coding identified the ultrasound scans of all patients presenting to Auckland City Hospital between January 2014 and February 2016 who were diagnosed clinically as having acute endometritis during the post-partum or post-abortion period. After exclusion criteria were applied, the ultrasound scans of 31 patients with acute endometritis and 32 healthy controls were randomised and anonymised. Images were reviewed retrospectively by two independent reviewers to identify the presence of these signs.

RESULTS

The average sensitivity and specificity for readers identifying the subserosal hypoechoic rim sign in patients with acute endometritis were 71% and 92%, respectively. Interobserver reliability was good with an average kappa score of 0.63. Average sensitivity and specificity for endomyometrial junctional indistinctness were 79% and 72%, respectively, with good interobserver correlation (average kappa score 0.65). When both signs were either present or absent together, average sensitivity improved to 80.5% and average specificity was 91.7%.

CONCLUSION

We describe two new sonographic signs for puerperal endomyometritis that could improve the utility of ultrasound in the accurate and timely diagnosis of this condition.

Risk factors for surgical site infection following cesarean delivery: a retrospective cohort study

BACKGROUND

The rate of cesarean delivery is increasing in North America. Surgical site infection following this operation can make it difficult to recover, care for a baby and return home. We aimed to determine the incidence of surgical site infection to 30 days following cesarean delivery, associated risk factors and whether risk factors differed for predischarge versus postdischarge infection.

METHODS

We identified a retrospective cohort in Nova Scotia by linking the provincial perinatal database to hospital admissions and physician billings databases to follow women for 30 days after they had given birth by cesarean delivery between Jan. 1, 1997 and Dec. 31, 2012. Logistic regression with generalized estimating equations was used to determine risk factors for infection.

RESULTS

A total of 25 123 women had 33 991 cesarean deliveries over the study period. Of the 25 123, 923 had surgical site infections, giving an incidence rate of 2.7% (95% CI 2.54%-2.89%); the incidence decreased over time. Risk factors for infection (adjusted odds ratios ≥ 1.5) were prepregnancy weight 87.0 kg or more, gaining 30.0 kg or more during pregnancy, chorioamnionitis, maternal blood transfusion, anticoagulation therapy, alcohol or drug abuse, second stage of labour before surgery, delivery in 1997-2000 and delivery in a hospital performing 130-1249 cesarean deliveries annually. Women who gave birth earlier in the study period, those who gave birth in a hospital with 130-949 cesarean deliveries per year and those with more than 1 fetus were at a significantly higher risk for surgical site infection before discharge; women who smoked were at significantly higher risk for surgical site infection after discharge.

INTERPRETATION

Most risk factors are known before delivery, and some are potentially modifiable. Although the incidence of surgical site infection decreased over time, targeted clinical and infection prevention and control interventions could further reduce the burden of illness associated with this health-care-related infection.

Reducing surgical site infections following total hip and knee arthroplasty: an Israeli experience

PURPOSE

To assess the changes observed in surgical site infection (SSI) rates following total joint arthroplasty (TJA) after the introduction of an infection control programme and evaluate the risk factors for the development of these infections.

DESIGN

Prospective cohort study.

SETTING

Large tertiary medical centre in Israel.

METHODS

Data about SSIs and potential prophylaxis-, patient-, and procedure-related risk factors were collected for all patients who underwent elective total hip and total knee arthroplasty during the study period. Multivariant analyses were conducted to determine which significant covariates affected the outcome.

RESULTS

During the 76-month study period, SSIs (superficial and deep) occurred in 64 (4.4%) of 1554 patients. As compared with the 34 (7.7%) SSIs that occurred in the first 25 months, there were 23 (4.7%) SSIs in the following 25 months, and only 7 (1.3%) SSIs in the last third of the study (p = 0.058 and <0.001, respectively). A multiple logistic regression model indicated that risk factors for prosthetic joint infection were a National Nosocomial Infections Surveillance (NNIS) System surgical patient risk index score of 1 (OR 1.8; 95% CI 1.1-3.1) or 2 (OR 2.8; 95% CI 1.2-11.8). The incidence of SSI was not correlated with the timing, nor the duration of antibiotic prophylaxis.

CONCLUSIONS

The introduction of preventive measures and surveillance coincided with a significant reduction in SSIs following TJA in our institution. The risk of infection correlated with higher scores in the NNIS System surgical patient risk.

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews

BACKGROUND

The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting.

METHODS

Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS).

RESULTS

Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate.

CONCLUSIONS

Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.

Caesarean Birth in Romania: Safe Motherhood Between Ethical, Medical and Statistical Arguments

The number of caesarean sections increased significantly in Romania. In 2012, caesarean sections accounted for 41.2% of total births, according to a study of the Romanian National School for Public Health. This estimation is in agreement with the statistical data on caesarean sections recorded in one of the most important hospitals in Bucharest, Romania, Filantropia Hospital. Many factors have influenced the large number and sharply increasing trend of caesarean sections, from the historical ones, with roots in the communist regime, when abortions were outlawed, to current day doctors' medical practices and mothers' beliefs and fears related to the process of labor and the newborn's health. This paper aims to examine the pros and cons for caesarean birth. The analysis is presented from three perspectives: expressed by the doctor/medical caregiver, the patient/mother and some of the third parties indirectly involved in the medical decision: the foetus/newborn, the hospital/medical unit and the society as a whole, knowing that ethics is beyond the legal, economic or administrative frames.

Independent risk factors for surgical site infection after cesarean delivery in a rural tertiary care medical center

BACKGROUND

We aimed to determine the incidence of surgical site infection (SSI) after cesarean delivery (CD) and identify the risk factors in a rural population.

METHODS

We identified 218 SSI patients by International Classification of Disease codes and matched them with 3131 parturients (control) from the electronic record database in a time-matched retrospective quality assurance analysis.

RESULTS AND DISCUSSION

The incidence of SSI after CD was 7.0 %. Risk factors included higher body mass index (BMI) [40.30 ± 10.60 kg/m² SSI (95 % CI 38.73-41.87) vs 34.05 ± 8.24 kg/m² control (95 % CI 33.75-34.35, P < 0.001)], years of education [13.28 ± 2.44 years SSI (95 % CI 12.9-13.66) vs 14.07 ± 2.81 years control (95 % CI 13.96-14.18, P < 0.001)], number of prior births [2 (1-9) SSI vs 1 (1-11) control (P < 0.001)], tobacco use (OR 1.49; 95 % CI 1.06-2.09, P = 0.03), prior diagnosis of hypertension (OR 1.80; 95 % CI 1.34-2.42, P < 0.001), gestational diabetes (OR 1.59; 95 % CI 1.18-2.13, P = 0.003), and an emergency/STAT CD (OR 1.6; 95 % CI 1.1-2.3, P = 0.01).

CONCLUSIONS

Risk factors for SSI after CD included higher BMI, less years of education, higher prior births, tobacco use, prior diagnosis of hypertension, gestational diabetes, and emergency/STAT CD. The presence of ruptured membranes was protective against SSI.

Childbirth and consequent atopic disease: emerging evidence on epigenetic effects based on the hygiene and EPIIC hypotheses

BACKGROUND

In most high and middle income countries across the world, at least 1:4 women give birth by cesarean section. Rates of labour induction and augmentation are rising steeply; and in some countries up to 50% of laboring women and newborns are given antibiotics. Governments and international agencies are increasingly concerned about the clinical, economic and psychosocial effects of these interventions.

DISCUSSION

There is emerging evidence that certain intrapartum and early neonatal interventions might affect the neonatal immune response in the longer term, and perhaps trans-generationally. Two theories lead the debate in this area. Those aligned with the hygiene (or 'Old Friends') hypothesis have examined the effect of gut microbiome colonization secondary to mode of birth and intrapartum/neonatal pharmacological interventions on immune response and epigenetic phenomena. Those working with the EPIIC (Epigenetic Impact of Childbirth) hypothesis are concerned with the effects of eustress and dys-stress on the epigenome, secondary to mode of birth and labour interventions. This paper examines the current and emerging findings relating to childbirth and atopic/autoimmune disease from the perspective of both theories, and proposes an alliance of research effort. This is likely to accelerate the discovery of important findings arising from both approaches, and to maximize the timely understanding of the longer-term consequences of childbirth practices.

Changing perspectives of infectious causes of maternal mortality

OBJECTIVE

Infections significantly contribute to maternal mortality. There is a perceived change in the spectrum of such infections. This study aims to estimate the contribution of various types of infections to maternal mortality.

MATERIAL AND METHODS

We retrospectively reviewed records of maternal death cases that took place between 2003 and 2012 in the Christian Medical College, Vellore, India. The International Classification of Diseases-Maternal Mortality was used to classify the causes of deaths and World Health Organization near-miss criteria were used to identify organ dysfunction that occurred before death. Infections during pregnancy were divided into three groups, i.e., pregnancy-related infections, pregnancy-unrelated infections, and nosocomial infections.

RESULTS

In this study, 32.53% of maternal deaths were because of some type of infection as the primary cause. The contribution of pregnancy-related infections was comparable with that of pregnancy-unrelated infections (16.03% vs. 16.50%). Metritis with pelvic cellulitis, septic abortions, tuberculosis, malaria, scrub typhus, and H1N1 influenza (influenza A virus subtype) were among the most commonly encountered causes of maternal death due to infections. Another 7.07% of cases developed severe systemic infection during the course of illness as nosocomial infection. A significant majority of mothers were below 30 years of age, were primiparae, had advanced gestational age, and had operative delivery. Cardiovascular and respiratory system dysfunctions were the most common organ dysfunctions encountered.

CONCLUSION

The contribution of pregnancy-unrelated infections to maternal deaths is significant. Control of these diverse community-acquired infections holds the key to a reduction in maternal mortality along with the promotion of clean birthing practices. Nosocomial infections should not be underestimated as a contributor to maternal mortality.

Cesarean section surgical site infections in sub-Saharan Africa: a multi-country study from Medecins Sans Frontieres

Background

Surgical site infections (SSI) are a significant cause of post-surgical morbidity and mortality and can be an indicator of surgical quality. The objectives of this study were to measure post-operative SSI after cesarean section (CS) at four sites in three sub-Saharan African countries and to describe the associated risk factors in order to improved quality of care in low and middle income surgical programs.

Methods

This study included data from four emergency obstetric programs supported by Medecins sans Frontieres, from Burundi, the Democratic Republic of Congo (DRC), and Sierra Leone. Women undergoing from August 1 2010 to January 31 2011 were included. CS post-operative SSI data were prospectively collected. Logistic regression was used to model SSI risk factors.

Findings

In total, 1,276 women underwent CS. The incidence of SSI was 7.3 % (range 1.7–10.4 %). 93 % of SSI were superficial. The median length of stay of women without SSI was 7 days (range 3–63 days) compared to 21 days (range 5–51 days) in those with SSI (p < 0.001). In multivariate analysis, younger age, premature rupture of the membranes, and neonatal death were associated with an increased risk of SSI, while antenatal hemorrhage and the Lubutu, DRC project site were associated with a lower risk of developing an SSI.

Conclusions

This study demonstrates that surgery can be performed with a low incidence of SSI, a proxy for surgical safety, in sub-Saharan Africa. Protocols such as perioperative antibiotics and basic infrastructure such as clean water and sterilization can be achieved. Simple data collection tools will assist policymakers with monitoring and evaluation as well as quality control assurance of surgical programs in low and middle income countries.

Forceps, Actual Use, and Potential Cesarean Section Prevention: Study in a Selected Mexican Population

OBJECTIVE

Assessment of the frequency of complications observed with various forceps and operative vaginal delivery (OVD) techniques performed at the ABC Medical Center (Mexico City) to evaluate their safety, bearing in mind the importance of decreasing our country's high cesarean section incidence.

METHODS

We reviewed 5,375 deliveries performed between the years 2007 and 2012, only 146 were delivered by OVD.

RESULTS

Only 1.0% of the cases had a serious, life-threatening situation (uterine rupture). The Simpson forceps was the most favored instrument (46%) due to its simplicity of use, effectiveness, and familiarity. Prophylactic use was the most common indication (30.8%) and significant complications observed were vaginal lacerations (p = 0.016), relative risk (RR) of 3.4 (95% confidence interval [CI]: 1.15-10.04), and fourth degree perineal tear (p = 0.016), RR of 3.4 (95% CI: 1.15-10.04).

CONCLUSIONS

Forceps use and other OVD techniques are a safe alternative to be considered, diminishing C-section incidence and its complications.

Does uterine gauze packing increase the risk of puerperal morbidity in the management of postpartum hemorrhage during caesarean section: a retrospective cohort study

BACKGROUND

To compare the outcomes especially the puerperal morbidity of uterine gauze packing (UGP) with those of uterine balloon tamponade (UBT) in the management of postpartum hemorrhage (PPH) during caesarean section (c-section).

METHODS

It was considered success as no requirement for either a further therapy or hysterectomy for PPH. The postpartum infection risk was pragmatically measured as puerperal morbidity.

RESULTS

The identified PPH subjects were subdivided into two groups for comparison, in which UGP or UBT was used as second-line therapy for women undergoing c-sections between January 2010 and September 2014. Of the 318 c-section subjects initially treated by basic managements for expected PPH, 99 cases underwent UGP and 66 UBT as the second-line therapies to stop persistent bleeding. The success rates of the UGP and UBT groups were 90.91 and 87.88%, respectively. Only one patient in UBT group resorted to hysterectomy. The respective rates of puerperal morbidity were 10.10 and 13.64%, with risk ratio of 0.74 (95% CI: 0.32, 1.72). There were no significant differences between the two groups even after the adjustment for potential confounding factors.

CONCLUSION

UGP appears to be effective in treating PPH during c-section without an observed increase in the risk of potential postpartum infection when compared with UBT. UGP could be recommended as routine for patients who are not responding to conventional basic therapies in addressing PPH, along with the provision of appropriate training.

Indications for and Risks of Elective Cesarean Section

BACKGROUND

Rates of cesarean section have risen around the world in recent years. Accordingly, much effort is being made worldwide to understand this trend and to counteract it effectively. A number of factors have been found to make it more likely that a cesarean section will be chosen, but the risks cannot yet be clearly defined.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed, Scopus, and DIMDI databases, as well as on media communications, analyses by the German Federal Statistical Office, and guidelines of the Association of Scientific Medical Societies in Germany (AWMF).

RESULTS

The increased rates of cesarean section are thought to be due mainly to changed risk profiles both for expectant mothers and for their yet unborn children, as well as an increase in cesarean section by maternal request. In 1991, 15.3% of all newborn babies in Germany were delivered by cesarean section; by 2012, the corresponding figure was 31.7%, despite the fact that a medical indication was present in less than 10% of all cases. This development may perhaps be explained by an increasing tendency toward risk avoidance, by risk-adapted obstetric practice, and increasing media attention. The intraoperative and postoperative risks of cesarean section must be considered, along with complications potentially affecting subsequent pregnancies.

CONCLUSION

Scientific advances, social and cultural changes, and medicolegal considerations seem to be the main reasons for the increased acceptibility of cesarean sections. Cesarean section is, however, associated with increased risks to both mother and child. It should only be performed when it is clearly advantageous.

Antibiotic prophylaxis for caesarean section at a Ugandan hospital: a randomised clinical trial evaluating the effect of administration time on the incidence of postoperative infections

Background

Prophylactic antibiotics are used to prevent postoperative infections after caesarean section. Studies have suggested that the timing of prophylaxis plays an important role. Over the years, the role of the anaesthesiologist in the administration of prophylactic antibiotics has become prominent. Therefore, there is an increasing need for anaesthesia providers to understand the rationale of antibiotic prophylaxis. We therefore sought to compare the effect of antibiotics prophylaxis within 1 hour before skin incision and after skin incision on the incidence of postoperative infections in patients undergoing caesarean section at Mulago Hospital.

Methods

We conducted a single-blind randomised clinical trial conducted at Mulago Hospital evaluating 464 patients undergoing emergency caesarean section. Patients were randomly assigned a group number that allocated them to either arm of the study. They received the same prophylactic antibiotic according to their allotment, that is, either within 1 hour before skin incision or after skin incision as per current standards of practice in Mulago Hospital. They were followed up to detect infection up to 10 days postoperatively. The primary outcome was postoperative infection. The data collected were analysed with STATA version 12 using univariate and bivariate analysis.

Results

The risk of overall postoperative infection was significantly lower when prophylaxis was given within an hour before incision (RR O.77, 95% CI 0.62–0.97). We also found endometritis to be significantly reduced in the pre-incision group (RR 0.62; 95% CI 0.39–0.99; P value 0.036).

Conclusions

Giving prophylactic antibiotics before skin incision reduces risk of postoperative infection, in particular of endometritis.

Trial registration

Pan African Clinical Trial Registry PACTR201311000610495.

Date of trial registration: 12^th August 2013.

Bioanalytical development and validation of liquid chromatographic-tandem mass spectrometric methods for the quantification of total and free cefazolin in human plasma and cord blood

OBJECTIVES

Cefazolin is a commonly prescribed β-lactam antibiotic for prophylaxis against skin infections following surgery, including caesarean sections. Assessment of maternal and neonatal exposure is important for correlating drug concentrations to clinical outcomes. Thus, bioanalytical methods for the quantification of both total and free cefazolin in maternal plasma and cord blood can assist in the comprehensive evaluation of cefazolin exposure.

DESIGN AND METHODS

Specimen preparation for the measurement of total cefazolin was performed via protein precipitation with acetonitrile containing the internal standard cloxacillin. Ultrafiltration was used to isolate free cefazolin. Processed samples were analyzed on a Prelude SPLC system coupled to a TSQ triple quadrupole Vantage mass spectrometer. Methods were validated following FDA bioanalytical guidelines.

RESULTS

The analytical measuring ranges of these methods were 0.48-480 µg/mL and 0.048-48 µg/mL for total and free drug, respectively. Calibration curves were generated using 1/x² weighted linear regression analysis. Total cefazolin demonstrated inter- and intra-assay precision of ≤20% at the LLOQ and ≤11.2% at other levels. Free cefazolin demonstrated inter- and intra-assay precision of ≤18.5% at the LLOQ and ≤12.6% at other levels, respectively. Accuracy (%DEV), carryover, matrix effects, recovery and stability studies were also acceptable based on FDA recommendations. Furthermore, it was demonstrated that samples prepared in cord blood can be accurately quantified from an adult plasma calibration curve, with recoveries ≤9.1% DIF and ≤11.9% DIF for total and free cefazolin, respectively.

CONCLUSIONS

The described LC-MS/MS methods allow for the measurement of total and free cefazolin in both plasma and cord blood.

Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery

BACKGROUND

Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate.

OBJECTIVES

To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection.

AUTHORS' CONCLUSIONS

Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates.

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is cesarean section. Although guidelines endorse the use of prophylactic antibiotics for women undergoing cesarean section, there is not uniform implementation of this recommendation. This is an update of a Cochrane review first published in 1995 and last updated in 2010.

OBJECTIVES

To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. The clinically important primary outcomes were wound infection, endometritis, serious maternal infectious complications and adverse effects on the infant. We presented dichotomous data as risk ratios (RR), with 95% confidence intervals (CIs) and combined trials in meta-analyses. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We identified 95 studies enrolling over 15,000 women. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection (RR 0.40, 95% CI 0.35 to 0.46, 82 studies, 14,407 women), endometritis (RR 0.38, 95% CI 0.34 to 0.42, 83 studies, 13,548 women) and maternal serious infectious complications (RR 0.31, 95% CI 0.20 to 0.49, 32 studies, 6159 women). When only studies that included women undergoing an elective cesarean section were analyzed, there was also a reduction in the incidence of wound infections (RR 0.62, 95% CI 0.47 to 0.82, 17 studies, 3537 women) and endometritis (RR 0.38, 95% CI 0.24 to 0.61, 15 studies, 2502 women) with prophylactic antibiotics. Similar estimates of effect were seen whether the antibiotics were administered before the cord was clamped or after. The effect of different antibiotic regimens was studied and similar reductions in the incidence of infections were seen for most of the antibiotics and combinations.There were no data on which to estimate the effect of maternal administration of antibiotics on infant outcomes. No studies systematically collected and reported on adverse infant outcomes nor the effect of antibiotics on the developing infant immune system. No studies reported on the incidence of oral candidiasis (thrush) in babies. Maternal adverse effects were also rarely described.We judged the evidence for antibiotic treatment compared with no treatment to be of moderate quality; most studies lacked an adequate description of methods and were assessed as being at unclear risk of bias.

AUTHORS' CONCLUSIONS

The conclusions of this review support the recommendation that prophylactic antibiotics should be routinely administered to all women undergoing cesarean section to prevent infection. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection, endometritis and serious infectious complications by 60% to 70%. There were few data on adverse effects and no information on the effect of antibiotics on the baby, making the assessment of overall benefits and harms difficult. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is beneficial for women but there is uncertainty about the consequences for the baby.

Antibiotic prophylaxis for operative vaginal delivery

BACKGROUND

Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear.

OBJECTIVES

To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps deliveries, or both.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014).

SELECTION CRITERIA

All randomised trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age undergoing vacuum or forceps delivery for any indications. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium) compared with either placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and methodological quality. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. For this update, we assessed methodological quality of the one included trial using the standard Cochrane criteria and the GRADE approach. We calculated the risk ratio (RR) and mean difference (MD) using a fixed-effect model and all the review authors interpreted and discussed the results.

MAIN RESULTS

One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. This trial identified only two out of the nine outcomes specified in this review. It reported seven women with endomyometritis in the group given no antibiotic and none in prophylactic antibiotic group. This difference did not reach statistical significance, but the risk reduction was 93% (risk ratio (RR) 0.07; 95% confidence interval (CI) 0.00 to 1.21). There was no difference in the length of hospital stay between the two groups (mean difference (MD) 0.09 days; 95% CI -0.23 to 0.41). Overall, the risk of bias was judged as low. The quality of the evidence using GRADE was low for both endometritis and maternal length of stay.

AUTHORS' CONCLUSIONS

The data were too few to make any recommendations for practice. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.

Post partum infections: A review for the non-OBGYN

The epidemiology of infections in the puerperium (post partum period) is not well understood and remains underestimated because surveillance systems are often limited to the acute care setting. The most common source of persistent fever after delivery is genital tract infection for which diagnosis remains mostly clinical and antibiotic treatment empiric. This review will emphasize surgical site infections (SSIs) and endometritis. Septic thrombo-phlebitis, mastitis, urinary tract infections and rare infections will be covered in less detail. Puerperal sepsis will not be reviewed.

Essential childbirth and postnatal interventions for improved maternal and neonatal health

Childbirth and the postnatal period, spanning from right after birth to the following several weeks, presents a time in which the number of deaths reported still remain alarmingly high. Worldwide, about 800 women die from pregnancy- or childbirth-related complications daily while almost 75% of neonatal deaths occur within the first seven days of delivery and a vast majority of these occur in the first 24 hours. Unfortunately, this alarming trend of mortality persists, as 287,000 women lost their lives to pregnancy and childbirth related causes in 2010. Almost all of these deaths were preventable and occurred in low-resource settings, pointing towards dearth of adequate facilities in these parts of the world. The main objective of this paper is to review the evidence based childbirth and post natal interventions which have a beneficial impact on maternal and newborn outcomes. It is a compilation of existing, new and updated interventions designed to help physicians and policy makers and enable them to reduce the burden of maternal and neonatal morbidities and mortalities. Interventions during the post natal period that were found to be associated with a decrease in maternal and neonatal morbidity and mortality included: advice and support of family planning, support and promotion of early initiation and continued breastfeeding; thermal care or kangaroo mother care for preterm and/or low birth weight babies; hygienic care of umbilical cord and skin following delivery, training health personnel in basic neonatal resuscitation; and postnatal visits. Adequate delivery of these interventions is likely to bring an unprecedented decrease in the number of deaths reported during childbirth.

Essential interventions: implementation strategies and proposed packages of care

In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.

Antibiotic use and misuse during pregnancy and delivery: benefits and risks

Although pregnancy is considered as a physiological state, most pregnant women in developed countries receive multiple medications to prevent maternal or neonatal complications, with antibiotics among the most frequently prescribed. During pregnancy, antibiotics are often prescribed in the context of preterm labor, intrapartum fever, prevention of neonatal Group B Streptococcus fever, and cesarean section. Outside this period, they are commonly prescribed in the community setting for respiratory, urinary, and ear, nose and throat infection symptoms. Whereas some of the current indications have insightful reasons to justify their use, potential risks related to overuse and misuse may surpass the benefits. Of note, the recent 2014 World Health Assembly expressed serious concern regarding antibiotic resistance due to antibiotic overuse and misuse and urged immediate action to combat antibiotic resistance on a global scale. Most studies in the obstetrics field have focused on the benefits of antibiotics for short-term maternal and neonatal complications, but with very little (if any) interest in long-term consequences.

Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section

BACKGROUND

Caesarean section (CS) is the most common obstetric surgical procedure, with more than one-third of pregnant women having lower-segment CS. Bladder evacuation is carried out as a preoperative procedure prior to CS. Emerging evidence suggests that omitting the use of urinary catheters during and after CS could reduce the associated increased risk of urinary tract infections (UTIs), catheter-associated pain/discomfort to the woman, and could lead to earlier ambulation and a shorter stay in hospital.

OBJECTIVES

To assess the effectiveness and safety of indwelling bladder catheterisation for intraoperative and postoperative care in women undergoing CS.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing indwelling bladder catheter versus no catheter or bladder drainage in women undergoing CS (planned or emergency), regardless of the type of anaesthesia used. Quasi-randomised trials, cluster-randomised trials were not eligible for inclusion. Studies presented as abstracts were eligible for inclusion providing there was sufficient information to assess the study design and outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility and trial quality, and extracted data. Data were checked for accuracy.

MAIN RESULTS

The search retrieved 16 studies (from 17 reports). Ten studies were excluded and one study is awaiting assessment. We included five studies involving 1065 women (1090 recruited). The five included studies were at moderate risk of bias.Data relating to one of our primary outcomes (UTI) was reported in four studies but did not meet our definition of UTI (as prespecified in our protocol). The included studies did not report on our other primary outcome - intraoperative bladder injury (this outcome was not prespecified in our protocol). Two secondary outcomes were not reported in the included studies: need for postoperative analgesia and women's satisfaction. The included studies did provide limited data relating to this review's secondary outcomes. Indwelling bladder catheter versus no catheter - three studies (840 women) Indwelling bladder catheterisation was associated with a reduced incidence of bladder distension (non-prespecified outcome) at the end of the operation (risk ratio (RR) 0.02, 95% confidence interval (CI) 0.00 to 0.35; one study, 420 women) and fewer cases of retention of urine (RR 0.06, 95% CI 0.01 to 0.47; two studies, 420 women) or need for catheterisation (RR 0.03, 95% CI 0.01 to 0.16; three studies 840 participants). In contrast, indwelling bladder catheterisation was associated with a longer time to first voiding (mean difference (MD) 16.81 hours, 95% CI 16.32 to 17.30; one study, 420 women) and more pain or discomfort due to catheterisation (and/or at first voiding) (average RR 10.47, 95% CI 4.71 to 23.25, two studies, 420 women) although high levels of heterogeneity were observed. Similarly, compared to women in the 'no catheter' group, indwelling bladder catheterisation was associated with a longer time to ambulation (MD 4.34 hours, 95% CI 1.37 to 7.31, three studies, 840 women) and a longer stay in hospital (MD 0.62 days, 95% CI 0.15 to 1.10, three studies, 840 women). However, high levels of heterogeneity were observed for these two outcomes and the results should be interpreted with caution.There was no difference in postpartum haemorrhage (PPH) due to uterine atony. There was also no difference in the incidence of UTI (as defined by trialists) between the indwelling bladder catheterisation and no catheterisation groups (two studies, 570 women). However, high levels of heterogeneity were observed for this non-prespecified outcome and results should be considered in this context. Indwelling bladder catheter versus bladder drainage - two studies (225 women)Two studies (225 women) compared the use of an indwelling bladder catheter versus bladder drainage. There was no difference between groups in terms of retention of urine following CS, length of hospital stay or the non-prespecified outcome of UTI (as defined by the trialist).There is some evidence (from one small study involving 50 women), that the need for catheterisation was reduced in the group of women with an indwelling bladder catheter (RR 0.04, 95% CI 0.00 to 0.70) compared to women in the bladder drainage group. Evidence from another small study (involving 175 women) suggests that women who had an indwelling bladder catheter had a longer time to ambulation (MD 0.90, 95% CI 0.25 to 1.55) compared to women who received bladder drainage.

AUTHORS' CONCLUSIONS

This review includes limited evidence from five RCTs of moderate quality. The review's primary outcomes (bladder injury during operation and UTI), were either not reported or reported in a way not suitable for our analysis. The evidence in this review is based on some secondary outcomes, with heterogeneity present in some of the analyses. There is insufficient evidence to assess the routine use of indwelling bladder catheters in women undergoing CS. There is a need for more rigorous RCTs, with adequate sample sizes, standardised criteria for the diagnosis of UTI and other common outcomes.

Cesarean section in a high-parity community in Saudi Arabia: clinical indications and obstetric outcomes

BACKGROUND

The study of the indications for cesarean section (CS) and its outcomes are useful for hospitals, clinicians, and researchers in determining strategies to lower the primary and repeat CS rate. The aim of this study was to identify the indications for CS and the incidence of adverse maternal/fetal outcomes in a tertiary care setting.

METHODS

A retrospective cohort study of women (n = 4305) who gave birth by CS at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia (June 2008 to February 2011), was performed. All of the women's medical records were reviewed by two consulting physicians to obtain the primary indications for CS and determine the maternal characteristics, type of CS (emergency or elective), and birth weight. All adverse maternal and fetal outcomes were recorded. The point and interval estimates of the odds ratios were calculated using a logistic regression model to identify the significant predictors of adverse maternal and/or fetal outcomes.

RESULTS

Of a total of 22,595 deliveries from 2008 to 2011, 4,305 deliveries were CS deliveries (19.05%). Two-thirds (67%) of all CS deliveries were emergency CSs, and the remaining deliveries were elective CSs (33%). Difficult labor (35.9%), fetal distress (21.9%) and breech presentation (11.6%) were the most frequent indications of emergency CS, while previous CS (54.3%), breech presentation (20.4%) and maternal request (10.1%) ranked first for elective CS. Adverse maternal and fetal outcomes were diagnosed in 5.09% and 5.06% of deliveries, respectively, with a significantly higher incidence in the emergency (6.06% & 5.51% respectively) than in elective CS (3.10 & 4.16% respectively). Blood transfusion was the most frequent adverse maternal outcome (3.72%), followed by ICU admission (0.63%), HELLP (0.51%), and hysterectomy (0.30%), while IUGR (3.25%) was the most frequent adverse fetal outcome, followed by IUFD and the need for ICU admission (0.58% each). Adverse maternal outcomes were significantly predicted by high gravidity (OR = 2.84, 95% CI:1.26-6.39, p = 0.011) and preeclampsia (OR = 2.84, 95%CI:1.83-4.39, p < 0.001), while adverse fetal outcomes were predicted by: twinning (OR = 1.81, p = 0.002), hydramnios (OR = 6.70, p < 0.001), and preeclampsia (OR = 2.74, p < 0.001). Preterm delivery was a significant predictor for both adverse maternal and fetal outcomes (OR = 2.39, p < 0.001 & OR = 4.57, p < 0.001, respectively).

CONCLUSIONS

Difficult labor and previous CS were the main indications for CS in Saudi Arabia. High gravidity was a significant predictor of adverse maternal outcomes. Encouraging Saudi women to consider embarking on fewer pregnancies could act as a safeguard against mandatory CSs for subsequent births in multigravida and grand-multigravida Saudi females. Future prospective study that addresses women with repeat CSs and their association with adverse maternal and fetal outcomes is recommended.

Risk factors and complications of puerperal sepsis at a tertiary healthcare centre

Objective: To determine the risk factors and complications of puerperal sepsis.

Methods: This was an observational prospective Cohort study conducted from January 2011 to December 2011 at the Obstetrics and Gynaecology Department Liaquat University of Medical & Health Sciences Jamshoro/Hyderabad, Sindh Pakistan. During this study period, all the women who delivered in this hospital or referred to this hospital within 42 days after delivery with puerperal pyrexia/sepsis diagnosed on clinical examination as well as with relevant investigations were included in the study. Women with other ailments like malaria, typhoid fever and postpartum eclampsia during the puerperal period were excluded. The subjects were registered on predesigned proforma after giving informed written consent. The data was collected and analyzed using SPSS version 17.

Results: During this period there were 3316 obstetrical admission and out of these 129(3.89%) women had puerperal sepsis. Most of these women 84(65.11%) were aged 31 years and above, multiparous 101 (78.29%), and unbooked 98 (75.96%) cases. Common risk factors found were absent membranes in 108(83.72%) of the women, delivered or undelivered and mismanaged, referred cases 95(73.64%), are being delivered in this hospital 34(26.35%). Morbidities seen were septicemia in 35 (27.13%) cases, and disseminated intra vascular coagulation in 23(17.82%) cases, while 11 (8.52%) of the women died.

Conclusion: Common risk factors were anaemia; suboptimal personal hygiene as well as improper sterilization which resulted in severe health hazards such as septicemia, disseminated intravascular coagulation as well as death.

Prevalence and predictors of antibiotic administration during pregnancy and birth

Background

Antibiotic treatment during pregnancy and birth is very common. In this study, we describe the estimated prevalence of antibiotic administration during pregnancy and birth in the COPSAC₂₀₁₀ pregnancy cohort, and analyze dependence on social and lifestyle-related factors.

Methods

706 pregnant women from the novel unselected Copenhagen Prospective Study on Asthma in Childhood (COPSAC₂₀₁₀) pregnancy cohort participated in this analysis. Detailed information on oral antibiotic prescriptions during pregnancy filled at the pharmacy was obtained and verified longitudinally. Information on intrapartum antibiotics, social, and lifestyle-factors was obtained by personal interviews.

Results

The prevalence of antibiotic use was 37% during pregnancy and 33% intrapartum. Lower maternal age at birth; adjusted odds ratio (aOR) 0.94, 95% CI, [0.90-0.98], p = 0.003 and maternal smoking; aOR 1.97, 95% CI, [1.07-3.63], p = 0.030 were associated with use of antibiotics for urinary tract infection during pregnancy. Maternal educational level (low vs. high), aOR 2.32, 95% CI, [1.24-4.35], p = 0.011, maternal asthma; aOR 1.99, 95% CI, [1.33-2.98], p < 0.001 and previous childbirth; aOR 1.80, 95% CI, [1.21-2.66], p = 0.004 were associated with use of antibiotics for respiratory tract infection during pregnancy. Lower gestational age; aOR 0.72, 95% CI, [0.61-0.85], p < 0.001, maternal smoking; aOR 2.84, 95% CI, [1.33-6.06], p = 0.007, and nulliparity; aOR 1.79, 95% CI, [1.06-3.02], p = 0.030 were associated with administration of intrapartum antibiotics in women giving birth vaginally.

Conclusion

Antibiotic administration during pregnancy and birth may be influenced by social and lifestyle-factors. Understanding such risk factors may guide preventive strategies in order to avoid unnecessary use of antibiotics.