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Bahl R, Hotton E, Crofts J, Draycott T. Assisted vaginal birth in 21st century: current practice and new innovations. Am J Obstet Gynecol 2024; 230:S917-S931. [PMID: 38462263 DOI: 10.1016/j.ajog.2022.12.305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 03/12/2024]
Abstract
Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.
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Affiliation(s)
- Rachna Bahl
- Department of Obstetrics and Gynaecology, University Hospitals Bristol National Health Service Trust, Bristol, United Kingdom; Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
| | | | - Joanna Crofts
- Department of Obstetrics and Gynaecology, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, United Kingdom; Department of Obstetrics and Gynaecology, North Bristol National Health Service Trust, Bristol, United Kingdom
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Mahdi LH, Hasoon BA, Sulaiman GM, Mohammed HA, Jawad KH, Al-Dulimi AG, Essa RH, Albukhaty S, Khan R. Anti-microbial efficacy of L-glutaminase (EC 3.5.1.2) against multidrug-resistant Pseudomonas aeruginosa infection. J Antibiot (Tokyo) 2024; 77:111-119. [PMID: 38017084 DOI: 10.1038/s41429-023-00678-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 09/12/2023] [Accepted: 10/28/2023] [Indexed: 11/30/2023]
Abstract
The aims of this study were isolation-purification and characterization of L-glutaminase from L. gasseri BRLHM clinical isolates and investigation of its efficiency as an antimicrobial agent against multidrug-resistant P. aeruginosa. The MICs of L-glutaminase and gentamicin reference were evaluated by the well-diffusion method. The biofilm on the IUD contraceptive was visualized using atomic force microscopy (AFM) image analyses. The purified L-glutaminase possessed significant antimicrobial activity against P. aeruginosa isolates (p < 0.05), and the antibiofilm formation activity of the purified L-glutaminase was stronger than the antibiofilm activity of the referral standard drug, gentamicin (P < 0.05), which were checked by the inhibition of the biofilm formation on the IUD contraceptive device. Investigations indicated that L-glutaminase may have a crucial role in future clinical applications.
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Affiliation(s)
- Likaa H Mahdi
- Department of Biology, College of Science, Mustansiriyah University, Baghdad, Iraq
| | - Buthenia A Hasoon
- Division of Biotechnology, Department of Applied Sciences, University of Technology, Baghdad, Iraq
| | - Ghassan M Sulaiman
- Division of Biotechnology, Department of Applied Sciences, University of Technology, Baghdad, Iraq.
| | - Hamdoon A Mohammed
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, Qassim University, Qassim, 51452, Saudi Arabia.
- Department of Pharmacognosy and Medicinal Plants, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt.
| | - Kareem H Jawad
- Department of LASER and Optoelectronic Engineering, University of Technology, Baghdad, Iraq
| | - Ali G Al-Dulimi
- Department of Dentistry, Bilad Alrafidain University College, Diyala, 32001, Iraq
| | - Rajwa H Essa
- Department of Biology, College of Science, Mustansiriyah University, Baghdad, Iraq
| | - Salim Albukhaty
- Department of Chemistry, College of Science, University of Misan, Maysan, 62001, Iraq
- College of Medicine, University of Warith Al-Anbiyaa, Karbala, Iraq
| | - Riaz Khan
- Manav Rachna International Institute of Research and Study (MRIIRS), Faridabad, HR, 121 001, India.
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Izewski JM, Bell BZ, Haas DM. Antibiotics in Labor and Delivery. Obstet Gynecol Clin North Am 2023; 50:137-150. [PMID: 36822699 DOI: 10.1016/j.ogc.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Infections are common in obstetric care and often require specific antibiotics, depending on the infection site and prevailing organisms. Summaries of antibiotic recommendations and treatment algorithms are provided for the following conditions: routine labor, group B streptococcus prophylaxis, preterm prelabor rupture of membranes, operative vaginal delivery, cesarean delivery, obstetric anal sphincter lacerations, chorioamnionitis, postpartum endometritis, infections of the urinary tract, and bacterial endocarditis prophylaxis.
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Humphreys ABC, Linsell L, Knight M. Factors associated with infection after operative vaginal birth-a secondary analysis of a randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth. Am J Obstet Gynecol 2023; 228:328.e1-328.e11. [PMID: 36027955 DOI: 10.1016/j.ajog.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND A recent randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth showed that women allocated prophylactic intravenous amoxicillin and clavulanic acid had a significantly lower risk of developing confirmed or suspected infection within 6 weeks after operative vaginal birth (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.49-0.69; P < .001). Some international and national guidelines have subsequently been updated to include prophylactic antibiotics after operative vaginal birth. However, the generalizability of the trial results may be limited in settings where the episiotomy rate is lower (89% of women in the trial had an episiotomy). In addition, there was a high burden of infection in the prophylactic antibiotics group despite the administration of prophylactic antibiotics. It is essential to identify modifiable risk factors for infection after operative vaginal birth, including the timing of antibiotic administration. OBJECTIVE This study aimed to evaluate if the effectiveness of the prophylactic antibiotic in reducing confirmed or suspected infection was independent of perineal trauma, identify risk factors for infection after operative vaginal birth, and investigate variation in efficacy with the timing of antibiotic administration. STUDY DESIGN This study was a secondary analysis of 3225 women with primary outcome data from the prophylactic antibiotics for the prevention of infection following operative vaginal birth randomized controlled trial. Women were divided into subgroups according to the perineal trauma experienced (episiotomy and/or perineal tear). The consistency of the prophylactic antibiotics in preventing infection across the subgroups was assessed using log-binomial regression and the likelihood ratio test. Multivariable log-binomial regression was used to investigate factors associated with infection. The multivariable risk factor model was subsequently fitted to the group of women who received amoxicillin and clavulanic acid to investigate the timing of antibiotic administration. RESULTS Of the 3225 women included in the secondary analysis, 2144 (66.5%) had an episiotomy alone, 726 (22.5%) had an episiotomy and a tear, 277 (8.6%) had a tear alone, and 78 (2.4%) had neither episiotomy nor tear. Among women who experienced perineal trauma, amoxicillin and clavulanic acid administration was protective against infection in all subgroups compared with placebo with no significant interaction between subgroup and trial allocation (P=.17). Moreover, 2925 women were included in the multivariable risk factor analysis. The following were associated with adjusted risk ratios of infection: episiotomy, 2.94 (95% confidence interval, 1.62-5.31); forceps, 1.37 (95% confidence interval, 1.12-1.69) compared to vacuum extraction; primiparity, 1.34 (95% confidence interval, 1.05-1.70); amoxicillin and clavulanic acid administration, 0.60 (95% confidence interval, 0.51-0.72); body mass index of 25.0 to 29.9 kg/m2, 1.21 (95% confidence interval, 1.00-1.47), and body mass index of ≥30 kg/m2, 1.22 (95% confidence interval, 0.98-1.52) compared to body mass index of <25 kg/m2. Each 15-minute increment between birth and antibiotic administration was associated with a 3% higher risk of infection (adjusted risk ratio, 1.03; 95% confidence interval, 1.01-1.06). CONCLUSION Timely prophylactic antibiotics should be administered to all women after operative vaginal birth, irrespective of the type of perineal trauma. The use of episiotomy, forceps birth, primiparity, and overweight were associated with an increased risk of confirmed or suspected infection after operative vaginal birth.
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Affiliation(s)
- Anna B C Humphreys
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Department of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
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Dunk SA, Owen J, Lu MY, Kim DJ, Szychowski JM, Subramaniam A. Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity. Am J Obstet Gynecol MFM 2022; 4:100705. [PMID: 35931367 DOI: 10.1016/j.ajogmf.2022.100705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND A recent study from the United Kingdom suggested that a single dosage of adjunctive amoxicillin/clavulanic acid with operative vaginal delivery reduces maternal infectious morbidity by 40% (from 19% to 11%). However, 89% of their study population received an episiotomy. OBJECTIVE This study aimed to evaluate whether operative vaginal delivery is an independent risk factor for composite maternal postpartum infectious morbidity in a population with a low episiotomy rate. STUDY DESIGN This was a retrospective cohort study of patients with viable singleton vaginal deliveries after ≥34 weeks gestation at a single perinatal center (2013-2018). The patients were categorized by the mode of delivery: spontaneous vaginal delivery or operative vaginal delivery (forceps or vacuum-assisted). The primary outcome was a composite of maternal infectious morbidity up to 6 weeks after delivery, defined as (1) endometritis, (2) perineal wound morbidity (infection, breakdown, or dehiscence), or (3) culture-proven urinary tract infection. The patient characteristics and outcomes were compared between the groups using appropriate tests. Multivariable models were used to estimate the association between operative vaginal delivery and study outcomes compared with spontaneous vaginal delivery, with adjustment for selected confounders. RESULTS Of 14,647 deliveries meeting the inclusion criteria, 732 (5.0%) were operative vaginal deliveries: 354 (48%) forceps and 378 (52%) vacuums. Overall, 210 (1.4%) patients developed the morbidity composite. Patients having an operative vaginal delivery were more likely to be nulliparous, have labor inductions, develop intrapartum chorioamnionitis, receive an episiotomy, and sustain a third- or fourth-degree laceration. After adjusting for confounding factors, no significant association was observed between operative vaginal delivery and composite morbidity (adjusted odds ratio, 1.4 [0.8-2.4]) or any of its individual components. Administration of postpartum antibiotics and documented fever were also similar between groups. There was also no significant association between instrument (forceps vs vacuum) and the maternal infection composite. CONCLUSION In this single-center US cohort, operative vaginal delivery was not an independent risk factor for maternal composite postpartum infectious morbidity.
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Affiliation(s)
- Sarah A Dunk
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam).
| | - John Owen
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Michelle Y Lu
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Dhong-Jin Kim
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Jeff M Szychowski
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Biostatistics, The University of Alabama at Birmingham, Birmingham, AL (Dr Szychowski)
| | - Akila Subramaniam
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
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Balis B, Debella A, Ketema I, Eshetu B, Zerihun E, Deressa Wayesa A, Habte S, Alemu A, Bekele H. Prevalence, indications, and outcomes of operative vaginal deliveries among mothers who gave birth in Ethiopia: A systematic review and meta-analysis. Front Glob Womens Health 2022; 3:948288. [PMID: 36212904 PMCID: PMC9535624 DOI: 10.3389/fgwh.2022.948288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundOperative vaginal deliveries represent an alternative to address problems during the second stage of labor. Clinicians have access to two different instruments obstetrics forceps and vacuum which should be conducted with indication. Understanding the pooled prevalence of operative vaginal deliveries, its indications, and outcomes would help in adopting suitable measures to reduce operative vaginal deliveries-related maternal and neonatal complications. Therefore, this systematic review and meta-analysis aimed to determine the prevalence, indications, and outcomes of operative vaginal deliveries among mothers who gave birth in Ethiopia.MethodsA literature search was done through databases such as PubMed, SCOPUS, Web of Sciences, CAB Abstract, and CINHAL (EBSCO) to search studies that have been conducted in Ethiopia. Relevant sources were consulted to retrieve unpublished studies. Original observational studies that reported the prevalence, indication and outcomes of operative vaginal deliveries conducted in the English language were identified and screened. Studies were independently assessed for inclusion, data extraction, and risk of bias.ResultsTwelve studies were reviewed. The overall pooled prevalence of operative vaginal delivery among mothers who gave birth in Ethiopia was 10% (95% CI: 8 to 13) with I2 = 98.82% and a p-value ≤ 0.001. Fetal distress, prolonged labor, and maternal exhaustion were the most common feto-maternal indications of OVDs whereas; neonatal death, poor Apgar score, admission to neonatal intensive care unit, perianal tear, and postpartum hemorrhage were complications that occur following the operative vaginal deliveries in Ethiopia.ConclusionThis systematic review and meta-analysis showed one out of 10 mothers undergo operative vaginal deliveries. Almost all feto-maternal complications that arise following operative vaginal deliveries were preventable. Thus, concerned stakeholders should encourage quality OVDs practice by avoiding unnecessary indications and scaling up the skill of health professionals through special training.Systematic review registrationhttp://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022311432.
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Affiliation(s)
- Bikila Balis
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Adera Debella
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Indeshaw Ketema
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Bajrond Eshetu
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Ebisa Zerihun
- Department of Nursing, College of Health Science, Oda Bultum University, Chiro, Ethiopia
| | - Alemayehu Deressa Wayesa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Sisay Habte
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Adisu Alemu
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- *Correspondence: Habtamu Bekele
| | - Habtamu Bekele
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Adisu Alemu
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Li W, Jiang M, Lu R. The impact of shared governance on the adverse mood of parturients with gestational hypertension and perinatal indicators of newborns. J OBSTET GYNAECOL 2022; 42:1823-1828. [PMID: 35465804 DOI: 10.1080/01443615.2022.2039909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Wenyan Li
- Nursing Department, Ganzhou Maternal and Child Health Hospital, Ganzhou, China
| | - Manxiang Jiang
- Trauma Center, Ganzhou People's Hospital, Ganzhou, China
| | - Ruiying Lu
- Department of Obstetrics, Ganzhou Maternal and Child Health Hospital, Ganzhou, China
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Huang Y, Yin X, Wang X, Zhou F, Cao X, Han Y, Sun S. Is a single dose of commonly used antibiotics effective in preventing maternal infection after cesarean section? A network meta-analysis. PLoS One 2022; 17:e0264438. [PMID: 35385475 PMCID: PMC8985944 DOI: 10.1371/journal.pone.0264438] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/10/2022] [Indexed: 11/18/2022] Open
Abstract
Objective This study aimed to compare the efficacy of different antibiotic classes and dosages in preventing maternal infection after cesarean delivery. Methods Databases were searched for randomized controlled trials (RCTs) published between January 1980 and January 2021 on antibiotic use for the prevention of maternal infection after cesarean delivery. The outcomes were endometritis, febrile morbidity, and wound infection, reported as odds ratios (OR) and surface under the cumulative ranking curve analysis scores. Results A total of 31 RCTs met the inclusion criteria. In the network meta-analysis (NMA) for endometritis, pooled network OR values indicated that the following interventions were superior to placebo: cephalosporins (OR: 0.18, 95% credibility interval [CrI]: 0.07–0.45), penicillins (OR: 0.19, 95% CrI: 0.07–0.50), penicillins (multiple doses) (OR: 0.20, 95% CrI: 0.05–0.65), combination therapies (OR: 0.22, 95% CrI: 0.09–0.54), and cephalosporins (multiple doses) (OR: 0.25, 95% CrI: 0.08–0.74). In the NMA for febrile morbidity, placebo was more effective than the other interventions. In the NMA for wound infection, pooled network OR values indicated that the following interventions were superior to placebo: penicillin (OR: 0.14, 95% CrI: 0.05–0.37), cephalosporins (OR: 0.19, 95% CrI: 0.08–0.41), cephalosporins (multiple doses) (OR: 0.20, 95% CrI: 0.06–0.58), combination therapies (OR: 0.29, 95% CrI: 0.13–0.57), macrolides (OR: 0.33, 95% CrI: 0.15–0.74), and penicillins (multiple doses) (OR: 0.40, 95% CrI: 0.17–0.91). Conclusions Compared with placebo, a single dose of commonly used antibiotics may prevent maternal infection after cesarean delivery. However, the incidence of febrile morbidity was not reduced.
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Affiliation(s)
- Ye Huang
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xinbo Yin
- Department of Emergency Medicine, National Clinical Research Center of Geriatric Disorders (Xiangya Hospital), Central South University, Changsha, Hunan, China
| | - Xiaokai Wang
- Department of Emergency Medicine, National Clinical Research Center of Geriatric Disorders (Xiangya Hospital), Central South University, Changsha, Hunan, China
| | - Fangyi Zhou
- Department of Emergency Medicine, National Clinical Research Center of Geriatric Disorders (Xiangya Hospital), Central South University, Changsha, Hunan, China
| | - Xiaoxia Cao
- Department of Emergency Medicine, National Clinical Research Center of Geriatric Disorders (Xiangya Hospital), Central South University, Changsha, Hunan, China
| | - Yeqiong Han
- Department of Emergency Medicine, National Clinical Research Center of Geriatric Disorders (Xiangya Hospital), Central South University, Changsha, Hunan, China
| | - Shichang Sun
- Department of Emergency Medicine, National Clinical Research Center of Geriatric Disorders (Xiangya Hospital), Central South University, Changsha, Hunan, China
- * E-mail:
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Darkwah TO, Afriyie DK, Sneddon J, Cockburn A, Opare-Addo MNA, Tagoe B, Amponsah SK. Assessment of prescribing patterns of antibiotics using National Treatment Guidelines and World Health Organization prescribing indicators at the Ghana Police Hospital: a pilot study. Pan Afr Med J 2021; 39:222. [PMID: 34630834 PMCID: PMC8486929 DOI: 10.11604/pamj.2021.39.222.29569] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/26/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION irrational or inappropriate prescribing of antibiotics is a major problem in healthcare and leads to antibiotic resistance. There is the need to understand the prescribing patterns and antibiotic stewardship in health facilities to support appropriate antibiotic use. A study was carried out to evaluate prescribing pattern of antibiotics at the Ghana Police Hospital using National Standard Treatment Guidelines (STG) and World Health Organization (WHO) prescribing indicators. METHODS a cross-sectional descriptive study was conducted at the Ghana Police Hospital. Data on prescriptions of antibiotics for both out-patients and in-patients was collected between December 2019 and March 2020. A pretested self-designed tool was used for data collection. All sampled prescriptions were assessed for appropriateness using the STG of 2017 and WHO "AWaRe" classification. The criteria used in assessment included dose, frequency, duration of treatment and choice of antibiotic prescribed for disease condition. Descriptive statistics were used in data analysis. RESULTS a total of 184 patient prescriptions (286 antibiotics) were included in this study. Results showed that antibiotics were mostly prescribed for dental and dental-related conditions (20.7%) and obstetric post-delivery prophylaxis (18.1%). Appropriateness of indicators for antibiotics prescribed assessed ranged between 89.2% to 97.6%. The most frequently prescribed antibiotics were metronidazole (25.9%), amoxicillin with clavulanic acid (22.0%), amoxicillin (16.4%) and ciprofloxacin (10.1%). Based on WHO "AWaRe" classification, the "access" group of antibiotics (74%) was the most prescribed, followed by "watch" group (24%). There were no antibiotics prescribed from the "reserve" group of antibiotics and another 2% that was not part of AwaRe classification. CONCLUSION study revealed that the level of appropriateness for prescribing indicators assessed was relatively high and majority of prescribed antibiotics were from the "access" and "watch" group. These observations suggest responsible prescribing of antibiotics at the Ghana Police Hospital and effective antibiotic stewardship should be sustained and improved.
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Affiliation(s)
| | | | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Glasgow, United Kingdom
| | - Alison Cockburn
- National Health Service (NHS) Lothian Antimicrobial Management Team, Western General Hospital, Crewe Road South, Edinburgh, United Kingdom
| | - Mercy Naa Aduele Opare-Addo
- Department of Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Benjamin Tagoe
- Department of Medical Pharmacology, University of Ghana Medical School, Accra, Ghana
| | - Seth Kwabena Amponsah
- Department of Medical Pharmacology, University of Ghana Medical School, Accra, Ghana
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Arendsen LP, Thakar R, Bassett P, Sultan AH. A double blind randomized controlled trial using copper impregnated maternity sanitary towels to reduce perineal wound infection. Midwifery 2020; 92:102858. [PMID: 33157498 DOI: 10.1016/j.midw.2020.102858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/23/2020] [Accepted: 10/12/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the effect of copper impregnated sanitary towels on the infection rate following vaginal delivery (VD). DESIGN Single center double blind randomized controlled trial. PARTICIPANTS Women aged 18 or over who had a sutured second-degree tear or episiotomy following VD. INTERVENTIONS All women were randomized to receive either a copper-oxide impregnated sanitary towel (study group) or a non-copper sanitary towel (control group). MAIN OUTCOME MEASURES The primary study outcome was the incidence of wound infection within a 30-day period from VD, assessed via telephone questionnaire. Secondary outcomes were length of hospital stay and risk factors of infection. RESULTS 450 women were enrolled in the study of whom 225 were randomized to the copper impregnated sanitary towel (study group) and 225 to the non-copper sanitary towel (control group) group. Follow-up rate was 98.2%. A total of 102 women (23.1%) developed an infection within 30 days following VD, 19 in the study group (8.6%) and 83 (37.4%) in the control group (P = <0.001, absolute risk reduction (ARR) of 28.8%). The incidence of superficial/deep and organ/space infections was significantly lower in the study group (7.7% vs. 30.2%, P = <0.001 and 4.6% vs. 31.5%, P = <0.001 respectively) with an ARR of 22.5% and 27.0% respectively. Multivariable analysis reported Asian ethnicity and prolonged rupture of membranes as significant risk factors; for the development of infection (OR 1.91, P = 0.03 and OR = 1.97, P = 0.04 respectively). CONCLUSIONS This is the first study to demonstrate a significant reduction in infection rate following VD with the use of copper impregnated sanitary towels.
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Affiliation(s)
- Linda Petra Arendsen
- Obstetrics and Gynaecology Department, Croydon University Hospital, 530 London Road, CR7 7YE, United Kingdom
| | - Ranee Thakar
- Obstetrics and Gynaecology Department, Croydon University Hospital, 530 London Road, CR7 7YE, United Kingdom
| | - Paul Bassett
- Statsconsultancy Ltd, 40 Longwood Lane, Amersham, Bucks, HP7 9EN, United Kingdom
| | - Abdul Hameed Sultan
- Obstetrics and Gynaecology Department, Croydon University Hospital, 530 London Road, CR7 7YE, United Kingdom; Honorary Reader, St George's University of London, Cranmer Terrace, SW17 0RE, United Kingdom.
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Barinov SV, Tirskaya YI, Kadsyna TV, Lazareva OV, Medyannikova IV, Tshulovski YI. Pregnancy and delivery in women with a high risk of infection in pregnancy. J Matern Fetal Neonatal Med 2020; 35:2122-2127. [PMID: 32576052 DOI: 10.1080/14767058.2020.1781810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background: Pregnant women with chronic genital and non-genital infections are at a high risk of infections complication during pregnancy and the postpartum period. Preterm birth is one of the leading causes of obstetric and neonatal complications and occurs in one in nine women. Forty per cent of preterm births are considered to be caused by the abnormal vaginal microbiome, and there is currently no consensus on the contribution of combined bacterial and viral infections.Aim: To assess the course of pregnancy and delivery in women with a high risk of chronic infections and the association with the presence of specific microorganisms in the genital microbiome.Materials and methods: We performed a prospective controlled observational study in 355 pregnant women with a high risk of chronic infections. The high risk was defined as presence acute or chronic genital or extragenital infections, reactivation of chronic infections/inflammatory diseases during current pregnancy and history of obstetric complications during previous pregnancies such as miscarriages, missed miscarriages, preterm deliveries, postpartum endometritis, and sepsis.Results: In women with a high risk of chronic infections, pregnancy was associated with recurrent threatened pregnancy loss (49.8%), preterm premature rupture of fetal membranes (64.3%), followed by prolonged oligohydramnios. Almost in one in two women (47.9%), pregnancy resulted in the delivery of preterm, low-birth-weight neonates. One in three women (30%) experienced uterine hypotony and bleeding after vaginal and cesarean delivery. Almost a third of women (32.1%) developed inflammatory complications postpartum, and more than half of complications (54.4%) was observed in women giving birth prematurely. Vaginal and cervical cultures in women who experienced preterm birth were dominated by non-obligate pathogens. We observed persistence of the Herpesviridae family both in the cervical canal and uterine cavity, specifically the Epstein-Barr virus (17.2%; 95% CI: 10%, 26.8%).Conclusions: Pregnancies in women with a high risk of chronic infections were associated with high rates of recurrent threatened pregnancy loss, preterm rupture of membranes and preterm delivery.
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Affiliation(s)
- S V Barinov
- Federal State Funded Educational Institution for Higher Education Omsk State Medical University, Ministry of Public Health, Russian Federation
| | - Y I Tirskaya
- Federal State Funded Educational Institution for Higher Education Omsk State Medical University, Ministry of Public Health, Russian Federation
| | - T V Kadsyna
- Federal State Funded Educational Institution for Higher Education Omsk State Medical University, Ministry of Public Health, Russian Federation
| | - O V Lazareva
- Federal State Funded Educational Institution for Higher Education Omsk State Medical University, Ministry of Public Health, Russian Federation
| | - I V Medyannikova
- Federal State Funded Educational Institution for Higher Education Omsk State Medical University, Ministry of Public Health, Russian Federation
| | - Yu I Tshulovski
- Federal State Funded Educational Institution for Higher Education Omsk State Medical University, Ministry of Public Health, Russian Federation
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Makokha-Sandell H, Mgaya A, Belachew J, Litorp H, Hussein K, Essén B. Low use of vacuum extraction: Health care Professionals' Perspective in a University Hospital, Dar es Salaam. SEXUAL & REPRODUCTIVE HEALTHCARE 2020; 25:100533. [PMID: 32505920 DOI: 10.1016/j.srhc.2020.100533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Use of vacuum extraction (VE) has been declining in low and middle income countries. At the highest referral hospital Tanzania, 54% of deliveries are performed by caesarean section (CS) and only 0.8% by VE. Use of VE has the potential to reduce CS rates and improve maternal and neonatal outcomes but causes for its low use is not fully explored. METHOD During November and December of 2017 participatory observations, semi-structured in-depth interviews (n = 29) and focus group discussions (n = 2) were held with midwives, residents and specialists working at the highest referral hospital in Tanzania. Thematic analysis was used to identify rationales for low VE use. FINDINGS Unstructured and inconsistent clinical teaching structure, interdependent on a fear and blame culture, as well as financial incentives and a lack of structured, adhered to and updated guidelines were identified as rationales for CS instead of VE use. Although all informants showed positivity towards clinical teaching of VE, a subpar communication between clinics and academia was stated as resulting in absent clinical teachers and unaccountable students. CONCLUSION This study draws connections between the low use of VE and the inconsistent and unstructured clinical training of VE expressed through the health care providers' points of view. However, clinical teaching in VE was highly welcomed by the informers which may serve as a good starting point for future interventions.
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Affiliation(s)
- Henrik Makokha-Sandell
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
| | - Andrew Mgaya
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden; Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania.
| | - Johanna Belachew
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
| | - Helena Litorp
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
| | - Kidanto Hussein
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden; Medical College, East Africa, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania; Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Birgitta Essén
- International Maternal and Child Health (IMCH), Department of women's and Children's Health, Uppsala University, 75185 Uppsala, Sweden.
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Still No Substantial Evidence to Use Prophylactic Antibiotic at Operative Vaginal Delivery: Systematic Review and Meta-Analysis. Obstet Gynecol Int 2020; 2020:1582653. [PMID: 32934656 PMCID: PMC7479451 DOI: 10.1155/2020/1582653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 05/01/2020] [Indexed: 12/22/2022] Open
Abstract
Background Postpartum maternal infection is still a common problem worldwide, mainly due to obstetric risk factors. The use of prophylactic antibiotic at operative vaginal delivery (OVD), taking it as a standalone risk factor, has been controversial. The purpose of this review was to rigorously evaluate the association of OVD with postpartum infection and shed light on such highly controversial issue. Methods A computer-based literature search was done mainly in the databases of PUBMED, HINARI health research, and the Cochrane library. Systematic review and meta-analysis were done by including 14 articles published between 1990 and August 2019. Results The average absolute risk of postpartum infection at OVD from seven large cohort studies was 1%. Few studies showed a weak association of OVD with postpartum infection without being adjusted to perineal wound, but the pooled meta-analysis showed statistically significant association with non-OVD. In the included randomized trial, 97% of the study participants had perineal wound for whom repairs were performed; the risks of maternal infection and perineal wound breakdown were comparable, and maternal infections other than perineal wound infection did not show significant difference between prophylactic antibiotic and placebo groups. The majority of included studies demonstrated a strong association of postpartum infection and perineal wound dehiscence with episiotomy and perineal tear. Conclusion Both the relative and absolute risks of postpartum infection at OVD are extremely low unless accompanied by episiotomy and 3rd/4tht degree perineal tear. From previous studies, there is no substantial evidence to use prophylactic antibiotic at OVD, but episiotomy and perineal tear.
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Hofmeyr GJ, Singata-Madliki M. The second stage of labor. Best Pract Res Clin Obstet Gynaecol 2020; 67:53-64. [PMID: 32360366 DOI: 10.1016/j.bpobgyn.2020.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/19/2020] [Accepted: 03/28/2020] [Indexed: 11/26/2022]
Abstract
The second stage of labor, from full cervical dilatation to complete birth of the baby or babies, constitutes the time of greatest risk for the baby. Birth attendants at all levels require training in the skills necessary to overcome difficulties that may arise unexpectedly during the second stage, particularly poor progress, shoulder dystocia, and breech birth. The mother should receive emotional support and encouragement to bear down instinctively when she feels the urge to do so, in the position she feels enables her to push most effectively, but not the supine position. The baby's heart rate should be monitored after every second contraction. Recent guidelines such as those of the World Health Organization(WHO) recommend allowing 2-3 h for the second stage of labor. Uterine fundal pressure has not been shown to be effective, and may be dangerous. Choosing between cesarean section and assisted vaginal birth to overcome delayed second stage requires relevant skill and experience.
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Affiliation(s)
- G J Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, Eastern Cape Department of Health, East London, South Africa; Obstetrics and Gynaecology Department, University of Botswana, Gaborone, Botswana.
| | - M Singata-Madliki
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, Eastern Cape Department of Health, East London, South Africa
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Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev 2020; 3:CD004455. [PMID: 32215906 PMCID: PMC7096725 DOI: 10.1002/14651858.cd004455.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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. This is an update of a review last published in 2017. 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 delivery, or both. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled 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. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium). DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility and risk of bias. 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. We assessed methodological quality of the two included studies using the GRADE approach. MAIN RESULTS Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials. AUTHORS' CONCLUSIONS Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.
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Affiliation(s)
- Tippawan Liabsuetrakul
- Prince of Songkla UniversityEpidemiology Unit, Faculty of MedicineHat YaiSongkhlaThailand90110
| | - Thanapan Choobun
- Prince of Songkla UniversityDepartment of Obstetrics and Gynecology, Faculty of MedicineHat YaiSongkhlaThailand90110
| | - Krantarat Peeyananjarassri
- Prince of Songkla UniversityDepartment of Obstetrics and Gynecology, Faculty of MedicineHat YaiSongkhlaThailand90110
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Iwabu K, Maeda Y, Tanimoto T. Prophylactic antibiotics after operative vaginal delivery. Lancet 2020; 395:189-190. [PMID: 31954461 DOI: 10.1016/s0140-6736(19)32631-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/28/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kaho Iwabu
- National Center for Child Health and Development, Tokyo 157-8535, Japan
| | - Yuto Maeda
- National Center for Child Health and Development, Tokyo 157-8535, Japan.
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Knight M, Chiocchia V, Partlett C, Rivero-Arias O, Hua X, Bowler U, Gray J, Gray S, Hinshaw K, Khunda A, Moore P, Mottram L, Owino N, Pasupathy D, Sanders J, Sultan AH, Thakar R, Tuffnell D, Linsell L, Juszczak E. Intravenous co-amoxiclav to prevent infection after operative vaginal delivery: the ANODE RCT. Health Technol Assess 2019; 23:1-54. [PMID: 31590702 DOI: 10.3310/hta23540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of direct and indirect maternal death in both the UK and globally. All forms of operative delivery are associated with an increased risk of sepsis, and the National Institute for Health and Care Excellence's guidance recommends the use of prophylactic antibiotics at all caesarean deliveries, based on substantial randomised controlled trial evidence of clinical effectiveness. A Cochrane review, updated in 2017 (Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev 2017;8:CD004455), identified only one small previous trial of prophylactic antibiotics following operative vaginal birth (forceps or ventouse/vacuum extraction) and, given the small study size and extreme result, suggested that further robust evidence is needed. OBJECTIVES To investigate whether or not a single dose of prophylactic antibiotic following operative vaginal birth is clinically effective for preventing confirmed or presumed maternal infection, and to investigate the associated impact on health-care costs. DESIGN A multicentre, randomised, blinded, placebo-controlled trial. SETTING Twenty-seven maternity units in the UK. PARTICIPANTS Women who had an operative vaginal birth at ≥ 36 weeks' gestation, who were not known to be allergic to penicillin or constituents of co-amoxiclav and who had no indication for ongoing antibiotics. INTERVENTIONS A single dose of intravenous co-amoxiclav (1 g of amoxicillin/200 mg of clavulanic acid) or placebo (sterile saline) allocated through sealed, sequentially numbered, indistinguishable packs. MAIN OUTCOME MEASURES Primary outcome - confirmed or suspected infection within 6 weeks of giving birth. Secondary outcomes - severe sepsis, perineal wound infection, perineal pain, use of pain relief, hospital bed stay, hospital/general practitioner visits, need for additional perineal care, dyspareunia, ability to sit comfortably to feed the baby, maternal general health, breastfeeding, wound breakdown, occurrence of anaphylaxis and health-care costs. RESULTS Between March 2016 and June 2018, 3427 women were randomised: 1719 to the antibiotic arm and 1708 to the placebo arm. Seven women withdrew, leaving 1715 women in the antibiotic arm and 1705 in the placebo arm for analysis. Primary outcome data were available for 3225 out of 3420 women (94.3%). Women randomised to the antibiotic arm were significantly less likely to have confirmed or suspected infection within 6 weeks of giving birth (180/1619, 11%) than women randomised to the placebo arm (306/1606, 19%) (relative risk 0.58, 95% confidence interval 0.49 to 0.69). Three serious adverse events were reported: one in the placebo arm and two in the antibiotic arm (one was thought to be causally related to the intervention). LIMITATIONS The follow-up rate achieved for most secondary outcomes was 76%. CONCLUSIONS This trial has shown clear evidence of benefit of a single intravenous dose of prophylactic co-amoxiclav after operative vaginal birth. These results may lead to reconsideration of official policy/guidance. Further analysis of the mechanism of action of this single dose of antibiotic is needed to investigate whether earlier, pre-delivery or repeated administration could be more effective. Until these analyses are completed, there is no indication for administration of more than a single dose of prophylactic antibiotic, or for pre-delivery administration. TRIAL REGISTRATION Current Controlled Trials ISRCTN11166984. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 54. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christopher Partlett
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Xinyang Hua
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - James Gray
- Department of Microbiology, Birmingham Women's & Children's NHS Foundation Trust, Birmingham, UK
| | - Shan Gray
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kim Hinshaw
- Department of Obstetrics and Gynaecology, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK.,Faculty of Health Sciences, University of Sunderland, Sunderland, UK
| | - Aethele Khunda
- Department of Women's Health, James Cook University Hospital, Middlesbrough, UK
| | - Philip Moore
- Department of Microbiology, Birmingham Women's & Children's NHS Foundation Trust, Birmingham, UK
| | - Linda Mottram
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nelly Owino
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, King's Health Partners, London, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK.,Department of Women's Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Derek Tuffnell
- Department of Women's Health, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Berghella V, Bellussi F. Antibiotics for operative vaginal delivery: practice-changing data. Lancet 2019; 393:2361-2362. [PMID: 31097212 DOI: 10.1016/s0140-6736(19)30845-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 03/28/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Vincenzo Berghella
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | - Federica Bellussi
- Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
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Knight M, Chiocchia V, Partlett C, Rivero-Arias O, Hua X, Hinshaw K, Tuffnell D, Linsell L, Juszczak E. Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial. Lancet 2019; 393:2395-2403. [PMID: 31097213 PMCID: PMC6584562 DOI: 10.1016/s0140-6736(19)30773-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Risk factors for maternal infection are clearly recognised, including caesarean section and operative vaginal birth. Antibiotic prophylaxis at caesarean section is widely recommended because there is clear systematic review evidence that it reduces incidence of maternal infection. Current WHO guidelines do not recommend routine antibiotic prophylaxis for women undergoing operative vaginal birth because of insufficient evidence of effectiveness. We aimed to investigate whether antibiotic prophylaxis prevented maternal infection after operative vaginal birth. METHODS In a blinded, randomised controlled trial done at 27 UK obstetric units, women (aged ≥16 years) were allocated to receive a single dose of intravenous amoxicillin and clavulanic acid or placebo (saline) following operative vaginal birth at 36 weeks gestation or later. The primary outcome was confirmed or suspected maternal infection within 6 weeks of delivery defined by a new prescription of antibiotics for specific indications, confirmed systemic infection on culture, or endometritis. We did an intention-to-treat analysis. This trial is registered with ISRCTN, number 11166984, and is closed to accrual. FINDINGS Between March 13, 2016, and June 13, 2018, 3427 women were randomly assigned to treatment: 1719 to amoxicillin and clavulanic acid, and 1708 to placebo. Seven women withdrew, leaving 1715 in the amoxicillin and clavulanic acid group and 1705 in the placebo groups. Primary outcome data were missing for 195 (6%) women. Significantly fewer women allocated to amoxicillin and clavulanic acid had a confirmed or suspected infection (180 [11%] of 1619) than women allocated to placebo (306 [19%] of 1606; risk ratio 0·58, 95% CI 0·49-0·69; p<0·0001). One woman in the placebo group reported a skin rash and two women in the amoxicillin and clavulanic acid reported other allergic reactions, one of which was reported as a serious adverse event. Two other serious adverse events were reported, neither was considered causally related to the treatment. INTERPRETATION This trial shows benefit of a single dose of prophylactic antibiotic after operative vaginal birth and guidance from WHO and other national organisations should be changed to reflect this. FUNDING NIHR Health Technology Assessment programme.
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Affiliation(s)
- Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christopher Partlett
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Xinyang Hua
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kim Hinshaw
- City Hospitals Sunderland NHS Foundation Trust and Faculty of Health Sciences, University of Sunderland, Sunderland, UK
| | - Derek Tuffnell
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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