Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial

Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial

OBJECTIVE

To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction.

DESIGN

A multicentre, open label, randomised controlled trial.

SETTING

Eight hospitals in Sweden, 2017-23.

PARTICIPANTS

717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site.

INTERVENTION

A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable.

MAIN OUTCOME MEASURES

The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI).

RESULTS

From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was -7.0% (96% CI -11.7% to -2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence.

CONCLUSIONS

Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02643108.

Reducing the postpartum length of stay: Implications for emergency department presentations at a tertiary women's hospital

AIMS

Postpartum length of stay (LOS) in Australian hospitals has reduced over the past three decades. Although a reduction in LOS likely reduces hospital costs in the immediate postpartum period, there is concern that this is increasing the burden on emergency services, domiciliary staff and primary care providers. The aims were to determine whether the recent reduction in LOS at an Australian tertiary obstetric hospital resulted in a change in emergency department (ED) presentations by women in the first six weeks postpartum, and newborns within the first 28 days of life.

METHODS

We conducted a cross-sectional cohort study of all newborns ≤28 days of age and women ≤6 weeks postpartum who presented to the ED during four comparable time periods (2019-2022) at an Australian tertiary obstetric hospital. Logistic regression was used to determine the relationship between neonatal and maternal postpartum ED presentations and year of birth.

RESULTS

Reduced postpartum LOS was associated with a significant increase in maternal and neonatal presentations to the ED (odds ratio (OR): 1.15 (95% confidence interval (CI): 1.08-1.23), and OR: 1.11 (95% CI: 1.03-1.19), respectively). For every 100 births, an extra six women and three neonates presented to the ED for postpartum care in 2022 compared with 2019. There was no difference in maternal or neonatal admissions throughout the study periods.

CONCLUSION

The increase in maternal and neonatal ED presentations associated with reduced LOS should prompt reassessment of postnatal practice and encourage further research into allocation of in-hospital resources and postpartum education.

Childbirth Acquired Perineal Trauma study (CHAPTER): a UK prospective cohort study protocol

INTRODUCTION

Childbirth-related perineal trauma (CRPT) is the most common complication of childbirth affecting 80% of women overall after vaginal birth. There remains a lack of comprehensive evidence relating to the prevalence of subsequent health problems. Current evidence is related to short-term outcomes, for example, pain, but there is less known about longer-term outcomes such as infection, wound dehiscence, pelvic floor function and psychological outcomes. This is a protocol for a cohort study assessing outcomes of women after CRPT.

METHODS AND ANALYSIS

A multicentre, prospective UK cohort study aiming to include 1000 women. All women who have sustained CRPT will be eligible for inclusion and will be followed-up for 12 months after childbirth. The primary outcome will be perineal infection at 6 weeks post-birth. Secondary outcomes will include antibiotic use for perineal infection, wound breakdown, use of analgesia, the requirement for admission or surgical intervention, urinary and faecal incontinence, anxiety and depressive symptoms, sexual function and impact on daily activities. Outcomes will be measured at 6 weeks, 6 months and 12 months post partum, with some outcomes being measured at all time points and others at selected most appropriate time points only. Outcome data will be obtained from a review of clinical notes and from patient questionnaires. Simple descriptive statistics will be used to summarise characteristics and outcomes, with categorical variables expressed as percentages and continuous variables as mean averages, alongside the corresponding standard deviatons.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Research Ethics Council with reference 23/WA/0169. Data collected from the Childbirth Acquired Perineal Trauma (CHAPTER) cohort study will highlight the prevalence and type of complications after CRPT and which women are more at risk. After the conclusion of this study, findings will be used to work with governmental organisations and Royal Colleges to target resources and ultimately improve care.

Single-dose oral azithromycin prophylaxis in planned vaginal delivery for sepsis prevention: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The use of oral azithromycin (AZI) as a preventive measure against postpartum infections of planned vaginal births has garnered a lot of interest in recent years and has been the subject of many randomized controlled trials (RCTs). However, the results from these trials have not been consistent. Therefore, we aim to perform a systematic review and meta-analysis to determine whether the use of a single-dose of oral AZI is clinically significant.

METHODS

We systematically searched PubMed, Embase, and Cochrane Central for RCTs from May to June 2023, comparing a single dose of oral AZI with placebo in patients undergoing planned vaginal delivery at a minimum of 28 weeks of gestational age. The main outcomes were puerperal and neonatal sepsis. Statistical analyses were performed using Review Manager 5.4.1 (Cochrane Collaboration). Heterogeneity was assessed with I2 statistics.

RESULTS

Four RCTs were included (mothers, n = 42 235; newborns n = 42 492). Approximately 49.8% of mothers received a single dose of oral AZI for sepsis prophylaxis. Compared with placebo, AZI significantly reduced the incidence of puerperal sepsis (risk ratio [RR], 0.65 [95% confidence interval (CI), 0.55-0.77]; P < 0.001), mastitis or breast abscess (RR, 0.58 [95% CI, 0.42-0.79]; P < 0.001), endometritis (RR, 0.65 [95% CI, 0.54-0.77]; P < 0.001), wound infection (RR, 0.81 [95% CI, 0.69-0.96]; P = 0.013), infection rate (RR, 0.62 [95% CI, 0.51-0.76]; P < 0.001), and fever (RR, 0.50 [95% CI, 0.28-0.89]; P = 0.018) in mothers. No statistically significant differences were identified between groups regarding maternal all-cause mortality and the use of prescribed postpartum antibiotics. Similarly, no statistical differences were noted in the neonatal group regarding sepsis, infection rate, and all-cause mortality.

CONCLUSION

AZI appears to be an effective preventive measure against many postpartum infections in mothers but a substantial impact on neonatal outcomes has not yet been conclusively observed.

The REPAIR study: oral antibiotics to prevent infection and wound dehiscence after obstetric perineal tear-a double-blinded placebo controlled randomized trial

BACKGROUND

Approximately 85% of women experience an obstetric tear at delivery and up to 25% subsequently experience wound dehiscence and/or infection. Previous publications suggest that intravenous antibiotics administrated during delivery reduces this risk. We do not know if oral antibiotics given after delivery can reduce the risk of wound dehiscence or infection. Our aim is to investigate whether three doses of oral antibiotics (amoxicillin 500 mg/clavulanic acid 125 mg) given after delivery can reduce the risk of wound dehiscence and infection in patients with a second-degree obstetric tear or episiotomy.

METHODS

We will perform a randomized, controlled, double-blinded study including 221women in each arm with allocation 1:1 in relation to the randomization. The study is carried out at Department of Obstetrics & Gynecology, Herlev University Hospital, Copenhagen, Denmark. The women will be included after delivery if they have had a second-degree tear or episiotomy. After inclusion, the women will have a clinical follow-up visit after 1 week. The tear and healing will be evaluated regarding signs of infection and/or dehiscence. The women will again be invited for a 1-year clinical examination including ultrasound. Questionnaires exploring symptoms related to the obstetric tear and possible complications will be answered at both visits. Our primary outcome is wound dehiscence and/or wound infection, which will be calculated using χ2 tests to compare groups. Secondary outcomes are variables that relate to wound healing, as pain, use of painkillers and antibiotics, need for further follow-up, as well as outcomes that may be related to the birth or healing process, urinary or anal incontinence, symptoms of prolapse, female body image, and sexual problems.

DISCUSSION

Reducing the risk of wound dehiscence and/or infection would decrease the number of control visits, prevent the need for longer antibiotic treatment, and possibly also decrease both short-term and long-term symptoms. This would be of great importance so the mother, her partner, and the baby could establish and optimize their initial family relation.

TRIAL REGISTRATION

The conduction of this study is approved the 2/2-2023 with the EU-CT number: 2022-501930-49-00.

CLINICALTRIALS

gov Identifier: NCT05830162.

Assisted vaginal birth in 21st century: current practice and new innovations

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.

Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis

Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.

Assisted vaginal delivery in the obese patient

Appropriate use of ventouse or obstetric forceps as options in the management of the second-stage of labor is good medical practice. The instruments are not inherently dangerous, however, the manner in which they are used may be. In addition to a working knowledge of the instruments, the operator must have the willingness to abandon an unsuccessful procedure. Awareness that failure of assisted vaginal delivery is more likely in women with BMI >30, hence, gives pause to consider trial in theatre with early recourse to cesarean delivery if unsuccessful Awareness that obesity is associated with increased risk of intrapartum complications, such as the need for second-stage assistance to achieve delivery, shoulder dystocia and postnatal complications, such as obstetric anal sphincter injury and febrile morbidity.

Assisted vaginal births: women who tear or have a surgical cut need prompt antibiotics

The studyHumphries 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. AJOG 2023;228:328.To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/assisted-vaginal-births-women-need-prompt-antibiotics/.

Deciphering the effect of maternal postpartum antibiotic prophylaxis on the infant gut microbiome: a whole metagenomic analysis

Aim: To analyze the impact of postpartum antibiotic (Ab) prophylaxis on the infant gut microbiome. Materials & methods: Whole metagenomic analysis was performed on breast milk and infant fecal samples collected from mother-infant pairs who belonged to two groups: an Ab group comprising mothers who had received a single course of Abs in the immediate postpartum period and a non-Ab group comprising mothers who had not received Abs. Results: The characteristic presence of Citrobacter werkmanii, an emerging multidrug-resistant uropathogen, and a higher relative abundance of genes encoding resistance to specific Abs were noted in samples from the Ab group compared with those from the non-Ab group. Conclusion: Policies regarding prophylactic Ab prescription across government and private health sectors in the postpartum period need to be strengthened.

Risk Factors for Perineal Wound Breakdown in Early Postpartum: A Retrospective Case-Control Study

We conducted a retrospective case-control study in patients presenting a perineal tear (second degree or higher) or episiotomy complicated by wound breakdown during maternity stay to identify risk factors associated with wound breakdown in early postpartum with a view to improving the quality of care. We collected ante- and intrapartum characteristics and outcomes at the postpartum visit. In all, 84 cases and 249 control subjects were included. In univariate analysis, primiparity, absence of history of vaginal delivery, a longer second phase of labour, instrumental delivery, and a higher degree of laceration emerged as risk factors for early perineal suture breakdown postpartum. Gestational diabetes, peripartum fever, streptococcus B, and suture technique did not emerge as risk factors for perineal breakdown. Multivariate analysis confirmed that instrumental delivery (OR = 2.18 [1.07; 4.41], p = 0.03) and a longer second phase of labour (OR = 1.72 [1.23; 2.42], p = 0.001) were risk factors for early perineal suture breakdown.

Postpartum perineal wound infection and its effect on anal sphincter integrity: Results of a prospective observational study

INTRODUCTION

Perineal wound infection can affect tissues at superficial, deep, and organ space levels. Women with obstetric anal sphincter injuries (OASIS) are at risk of infection; however, no study to date has investigated if infection can extend to affect the anal sphincter integrity. The aim of this study was to evaluate the clinical progression of perineal wound infection and its effect on the anal sphincter in women with or without OASIS using three-dimensional endoanal ultrasound (3D-EAUS).

MATERIAL AND METHODS

Women were recruited into the Prospective Observational Study Evaluating the Sonographic Appearance of the Anal Sphincter in Women With Perineal Wound Infection Following Vaginal Delivery (PERINEAL Study) between August 2020 and August 2021 (NCT04480684). 3D-EAUS was performed weekly until complete wound healing. Significant bacterial colonization was diagnosed using the MolecuLight i:X camera. The primary study outcome was a change in a sphincter defect angle from baseline (wound infection) until wound healing. A robust Poisson regression model was used to analyze the effect of significant bacterial loads on the anal sphincter.

RESULTS

Seventy-three women were included. A median of two ultrasound scans were performed in each patient (range 1-16). Five women (6.8%) had an OASI clinically diagnosed at delivery. In total, 250 EAUS were performed. An external anal sphincter defect was found on EAUS in 55 (22.0%) scans (n = 10 women). An external anal sphincter and internal anal sphincter defect was found in 26 scans (10.4%) (n = 3 women). During the course of the wound healing process, there was no significant change in defect size in wounds with or without significant bacterial colonization. In cases of an intact anal sphincter, wound infection did not disrupt its integrity.

CONCLUSIONS

We found that perineal wound infection does not disrupt an intact anal sphincter or OASIS. This new information can provide important information for clinicians and patients. As there are myths frequently encountered in cases of litigation when disruption of sphincter integrity is attributed to perineal infection, the findings of this study should be tested in larger studies in the future.

Antibiotics in Labor and Delivery

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.

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

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.

Immune-metabolic adaptations in pregnancy: A potential stepping-stone to sepsis

Physiological shifts during pregnancy predispose women to a higher risk of developing sepsis resulting from a maladapted host-response to infection. Insightful studies have delineated subtle point-changes to the immune system during pregnancy. Here, we present an overlay of these point-changes, asking what changes and when, at a physiological, cellular, and molecular systems-level in the context of sepsis. We identify distinct immune phases in pregnancy delineated by placental hormone-driven changes in homeostasis setpoints of the immune and metabolic systems that subtly mirrors changes observed in sepsis. We propose that pregnancy immune-metabolic setpoint changes impact feedback thresholds that increase risk for a maladapted host-response to infection and thus act as a stepping-stone to sepsis. Defining maternal immune-metabolic setpoint changes is not only vital for tailoring the right diagnostic tools for early management of maternal sepsis but will facilitate an unravelling of the pathophysiological pathways that predispose an individual to sepsis.

Prophylactic antibiotic use during labor and delivery in China: a nationwide, multicenter, hospital-based, cross-sectional study

BACKGROUND

Prophylactic antibiotic use during delivery is common in routine obstetric practice to prevent infection globally, especially in low- and middle-income countries. In China, however, little is currently known about the national estimates for prophylactic antibiotic use during delivery. Therefore, we aimed to describe the prevalence of prophylactic antibiotic use and guideline adherence using national data in China.

METHODS

This cross-sectional study analyzed a national dataset from the China Labor and Delivery Survey in 2015-2016. The primary outcomes were prophylactic antibiotic use and clinician adherence to WHO recommendations for the prevention and treatment of maternal peripartum infections. We estimated the weighted prevalence of the outcomes with Taylor series linearization and investigated the associated factors of the outcomes with logistic regression.

RESULTS

Of the 72,519 deliveries, the prevalence of antibiotic prophylaxis was 52.0%, varying from 92.8% in Shanxi to 17.3% in Hainan. The prevalence of clinician adherence to the WHO guideline was 79.9%, ranging from 93.4% in Shandong to 50.0% in Shanxi. Prophylactic antibiotic use was associated with cesarean delivery (AOR, 55.77; 95%CI, 25.74-120.86), operative vaginal delivery (AOR, 4.00; 95%CI, 1.64-9.78), preterm (AOR, 1.96; 95%CI, 1.60-2.41), premature rupture of membranes (PROM) (AOR, 2.80; 95%CI, 1.87-4.18), and meconium-stained amniotic fluid (AOR, 1.91; 95%CI, 1.30-2.81) in all deliveries and also episiotomy (AOR, 1.48; 95%CI, 1.02-2.16) in vaginal deliveries. Clinician adherence was positively associated with cesarean delivery (AOR, 5.72; 95%CI, 2.74-11.93) while negatively associated with operative vaginal delivery (AOR, 0.26; 95%CI, 0.11-0.61), PROM (AOR, 0.50; 95%CI, 0.35-0.70), and meconium-stained amniotic fluid (AOR, 0.66; 95%CI, 0.48-0.91) in all deliveries. In vaginal deliveries, clinician adherence was negatively associated with episiotomy (AOR, 0.67; 95%CI, 0.46-0.96) and severe perineal trauma (AOR, 0.09; 95%CI, 0.02-0.44). Besides, clinicians in general hospitals prescribed prophylactic antibiotics more likely (AOR, 2.79; 95%CI, 1.50-5.19) and had a lower adherence (AOR, 0.38; 95%CI, 0.20-0.71) than their peers in maternity hospitals.

CONCLUSIONS

We observed that about half of all deliveries in China received antibiotics for prophylaxis, and most deliveries were prescribed according to the WHO guideline. Furthermore, the two prevalence rates for prophylactic antibiotic use and clinician adherence varied widely across provinces of China.

Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity

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.

Drug in adhesive transdermal patch containing antibiotic-loaded solid lipid nanoparticles

The structure of the skin only allows those hydrophobic elements to penetrate through the depth of the skin with low molecular weight (less than 500 Da) and low daily dose (less than 100 mg/day). Skin penetration of many drugs such as antibiotics at a high daily dose remains an unresolved challenge. In this study a transdermal patch using cephalexin as an antibiotic drug model was developed. Cephalexin was loaded into α-tocopherol succinate-based solid lipid nanoparticles (SLNs). Cephalexin-loaded SLNs with a drug/lipid ratio of 20%, diameter of 180 ± 7 nm, and drug loading 7.9% led to the greatest inhibition zone of Staphylococcus aureus and showed the highest skin permeation capabilities. Cephalexin-loaded SLNs were distributed into poly-iso-butylene adhesive solution and final patches prepared using solvent casting. The physico-chemical characteristics, in vitro drug release, antimicrobial efficacy, and skin cell proliferation properties of patches were evaluated. Results indicated that the optimal transdermal patch formulation containing 90% adhesive solution, 7% cephalexin, and 3% cephalexin-loaded SLNs (with antibiotic content approximately 28% less) inhibited growth of S.aureus better than the formulation containing 90% adhesive solution and 10% cephalexin. In vitro evaluation of the growth of human fibroblast skin cells in media with the optimal patch exhibited greater proliferation (about 25.5%) than those in media without the patch.

The balance between protective and pathogenic immune responses to pneumonia in the neonatal lung is enforced by gut microbiota

Although modern clinical practices such as cesarean sections and perinatal antibiotics have improved infant survival, treatment with broad-spectrum antibiotics alters intestinal microbiota and causes dysbiosis. Infants exposed to perinatal antibiotics have an increased likelihood of life-threatening infections, including pneumonia. Here, we investigated how the gut microbiota sculpt pulmonary immune responses, promoting recovery and resolution of infection in newborn rhesus macaques. Early-life antibiotic exposure interrupted the maturation of intestinal commensal bacteria and disrupted the developmental trajectory of the pulmonary immune system, as assessed by single-cell proteomic and transcriptomic analyses. Early-life antibiotic exposure rendered newborn macaques more susceptible to bacterial pneumonia, concurrent with increases in neutrophil senescence and hyperinflammation, broad inflammatory cytokine signaling, and macrophage dysfunction. This pathogenic reprogramming of pulmonary immunity was further reflected by a hyperinflammatory signature in all pulmonary immune cell subsets coupled with a global loss of tissue-protective, homeostatic pathways in the lungs of dysbiotic newborns. Fecal microbiota transfer was associated with partial correction of the broad immune maladaptations and protection against severe pneumonia. These data demonstrate the importance of intestinal microbiota in programming pulmonary immunity and support the idea that gut microbiota promote the balance between pathways driving tissue repair and inflammatory responses associated with clinical recovery from infection in infants. Our results highlight a potential role for microbial transfer for immune support in these at-risk infants.

Characterizing the inclusion of pregnant and breastfeeding people in infectious diseases randomized controlled trials: a targeted literature review

OBJECTIVES

Severe complications of infectious diseases can occur during pregnancy. Evidence-based prevention and treatment strategies are critical to improve maternal and neonatal health outcomes. Despite this medical need, pregnant and breastfeeding people have been systematically excluded from biomedical research. The objective of this study was to characterize representation of pregnant and breastfeeding people in randomized controlled trials (RCTs) evaluating a broad range of interventions for infectious diseases.

METHODS

Pregnancy and breastfeeding inclusion criteria were examined in infectious diseases RCTs published between 1 January 2017, and 31 December 2019, in the top five highest impact general medicine and the top three highest impact infectious diseases and HIV journals.

RESULTS

Of 376 RCTs, 5.3% and 1.9% included pregnant and breastfeeding people, respectively. Justification for exclusion was documented in 36/271 (13.3%) studies that explicitly excluded pregnant people. Most studies excluding pregnant people (177/271, 65.3%) required at least one form of contraception, abstinence and/or negative pregnancy test(s) as part of participation. Only 11/271 (4.1%) studies excluding pregnant people allowed participants to continue the intervention if unintended pregnancy occurred during the study. When both pregnant and non-pregnant people were eligible, pregnant people made up <3% of participants. Only 2/48 (4.2%) vaccine studies included pregnant people; 13/234 (5.5%) drug studies included pregnant people. All studies of procedures, devices, behaviour/education and supplements/vitamins explicitly excluded or did not address pregnancy eligibility criteria. Only 2/20 (10.0%) RCTs including pregnant people collected pharmacokinetic data.

DISCUSSION

This study demonstrates widespread exclusion of pregnant and breastfeeding people from infectious disease RCTs.

Healing of disrupted perineal wounds after vaginal delivery: a poorly understood condition

Perineal injury following childbirth can result in complications such as wound infection and dehiscence. The reported incidence of these complications in the literature range between 0.1-23.6% and 0.2-24.6%, respectively. However, the healing of disrupted perineal wounds is poorly understood. In addition, it is a neglected area in maternity services. In this review, the authors explore the process of wound healing in the context of infected perineal wounds following childbirth. In addition, the authors describe the management of complications including hypergranulation, perineal pain and dyspareunia.

Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals

BACKGROUND

There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes.

OBJECTIVE

This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals.

STUDY DESIGN

The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria.

RESULTS

Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals.

CONCLUSION

Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.

Prevalence and clinical relevance of colonization with methicillin-resistant Staphylococcus aureus in the obstetric population

BACKGROUND AND AIMS

Routine screening for Methicillin-Resistant Staphylococcus aureus (MRSA) in pregnant women is common practice in many hospitals. However, little is known on its prevalence and clinical relevance in this population. In this prospective longitudinal study, we aimed to investigate the MRSA prevalence in our obstetric population, the rate of vertical transmission of MRSA and the potential clinical relevance of MRSA colonization for both mother and child. A possible correlation between GBS and MRSA colonization was also investigated.

MATERIALS AND METHODS

MRSA screening samples were collected at 35-37 weeks of gestation (from mother), at delivery and at discharge (from mother and newborn). All samples were analyzed by conventional microbiological methods and MRSA strains were subjected to spa-typing to investigate genetic similarity. The medical records of all positive mother-child pairs were analyzed to detect the occurrence of clinical infection in the postpartum period.

RESULTS

679 mother-child pairs were included between June 2014 and July 2016. Maternal MRSA positivity rate was 1.3% at 35-37 weeks (vaginal/anorectal), 3.1% at delivery (nose/throat) and 3.6% at discharge (nose/throat). MRSA positivity in neonates was 0.3% at delivery and increased to 3% at discharge (nose/umbilicus). Almost all MRSA positive children were born to MRSA positive mothers (OR 120.40, 95% CI: 38.42-377.32). Genetic similarity of the MRSA strains found in mother and child was illustrated for all but one case. 57.7% of the cases of MRSA colonization in our cohort were associated with livestock exposure. 31% of the MRSA positive mothers developed an infectious complication in the postpartum period. No neonatal infectious complications were observed. GBS positivity was not a predictive factor for MRSA colonization in our cohort.

CONCLUSION

The rate of MRSA colonization (overall 4.3%) in our obstetric population is similar to that described in the literature and that of the general population admitted to our hospital in the same period. Maternal MRSA colonization appeared to be an important risk factor for neonatal colonization. Whereas mothers were at higher risk of developing infectious morbidity in the postpartum period, no neonatal infectious complications were observed. We observed no correlation between GBS and MRSA colonization.

Risk analysis of poor wound healing in forceps delivery

AIM

This study aims to explore the risk factors leading to poor wound healing after forceps delivery.

METHOD

In this retrospective study, 74 patients undergoing forceps delivery with poor wound healing were compared with contemporary randomly selected 74 patients undergoing forceps delivery but with normal wound healing.

RESULTS

Compared to the normal healing group, the poor healing group had larger birthweight (p = 0.01), longer labor length (805.9 ± 356.4 min vs. 572.9 ± 306.3 min, p < 0.001), more virginal checks (4.0 ± 1.5 vs. 3.4 ± 1.7, p = 0.029), and more contaminated amniotic fluid (p = 0.043). More patients in poor healing group suffered from postpartum fever (52.7% vs. 21.6%, p < 0.001), postpartum hemorrhage (p < 0.001), and anemia after delivery (p < 0.001). Labor length (odds ratio (OR) 1.125, 95% confidence interval [CI] = 1.033-1.226), anemia after delivery (OR 3.621, 95% CI = 2.077-6.314), postpartum fever (OR 7.100, 95% CI = 2.505-20.124), and degree of laceration (OR 3.067, 95% CI = 1.258-7.479) were the risk factors of poor healing of perineal wound after forceps delivery, while postpartum antibiotics (OR 0.303, 95% CI = 0.098-0.937) and suture removal days (OR 0.272, 95% CI = 0.133-0.556) were the protective factors.

CONCLUSION

To promote the wound healing from the forceps delivery, obstetricians may consider to control the patient's labor length and degree of laceration, increase patient's nutrition, apply prophylactic antibiotics, and prolong the suture removal days.

Top 2020 studies relevant to primary care: From the PEER team

OBJECTIVE

To summarize high-quality studies for 10 topics from 2020 that have strong relevance to primary care practice.

SELECTING THE EVIDENCE

Study selection involved routine literature surveillance by a group of primary health care professionals. This included screening abstracts of high-impact journals and EvidenceAlerts, as well as searching the American College of Physicians Journal Club.

MAIN MESSAGE

Topics of the 2020 articles most likely to affect primary care practice included whether antibiotic prophylaxis reduces maternal infections following operative vaginal birth; which second-line agent after metformin reduces cardiovascular outcomes for patients with diabetes; whether gabapentin is effective for alcohol use disorder; whether compression stockings prevent recurrent cellulitis; guideline recommendations for management of dyslipidemia to reduce cardiovascular risk; whether intermittent fasting is superior to consistent mealtimes for weight loss; whether vitamin C added to iron supplementation increases hemoglobin more than iron alone; whether antacid-lidocaine combinations are superior to antacid alone for epigastric pain; whether dapagliflozin improves renal and cardiovascular outcomes in chronic kidney disease; and whether empagliflozin improves cardiovascular outcomes in patients with heart failure. Five "runner-up" studies are also briefly reviewed.

CONCLUSION

Research from 2020 produced several high-quality studies in diabetes and cardiovascular disease, but also included a variety of other conditions relevant to primary care such as vaginal operative births, alcohol use disorder, weight loss, and chronic leg edema.

Rationalising antibiotic use after low-risk vaginal deliveries in a hospital setting in India

BACKGROUND

In 2017, a postoperative multidrug resistant case of urinary tract infection made obstetricians at Sitaram Bhartia Institute of Science and Research introspect the antibiotic usage in labouring mothers. Random case file reviews indicated overuse and variability of practice among care providers. This prompted us to explore ways to rationalise antibiotic use.

METHODS

A multidisciplinary team of obstetricians, paediatricians and quality officers was formed to run this improvement initiative at a private hospital facility in India. Review of literature advocated formulating a departmental antibiotic policy. Creating this policy and implementing it using improvement methodology helped us rationalise antibiotic usage.

INTERVENTIONS

We aimed to reduce the use of antibiotics from 42% to less than 10% in uncomplicated vaginal deliveries. We tested a series of sequential interventions using the improvement methodology of Plan-Do-Study-Act (PDSA) cycles, an approach recommended by the Institute for Healthcare Improvement. Learning from the PDSA cycle of the previous intervention helped decide the subsequent change ideas. The interventions included creation of a departmental antibiotic policy, staff engagement, and modification in documentation, concept of dual responsibility and team huddles as feedback opportunities. Information was analysed to understand the progress and improvement with change ideas.

RESULTS

Background analysis revealed that antibiotic usage ranged from 24% to 69% and average rate of antibiotic prophylaxis was high (42.28%) in low-risk uncomplicated vaginal deliveries. The sequential changes resulted in reduction in antibiotic usage to 10% in the target population by 4 months. Sustained improvement was noted in the following months.

CONCLUSION

We succeeded in implementing a departmental antibiotic policy aligning it with existing international guidelines and our local challenges. Antibiotic stewardship was one of the first major steps in our journey to avoid multidrug-resistant infections. Sustaining outcomes will involve continuous feedback to ensure engagement of all stakeholders in a hospital setting.

Assessment of prescribing patterns of antibiotics using National Treatment Guidelines and World Health Organization prescribing indicators at the Ghana Police Hospital: a pilot study

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.

Diseases and complications of the puerperium

BACKGROUND

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

METHODS

This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

RESULTS

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

CONCLUSION

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.

Vertical transfer of antibiotics and antibiotic resistant strains across the mother/baby axis

Antibiotic resistance is a health and socioeconomic crisis recognized as a serious threat affecting humans worldwide. Overuse of antibiotics enhances the spread of multidrug-resistant bacteria, causing drug-resistant infections which can be difficult to treat. This resistance, mostly of the acquired type, is thus a major clinical issue. Acquired resistance can occur by horizontal transfer of genes between bacteria (community settings), by vertical transmission that can occur between mother and her offspring at birth and during lactation, or spontaneously due to antibiotic exposure. While there have been multiple studies about the horizontal transfer of antibiotic-resistance genes, not many studies have been conducted to study their vertical transmission. Vertical transmission is of importance as the early bacterial colonization of infants has an impact on their health and immune programming throughout life. This review discusses some possible mechanisms of mother-to-infant transmission of antibiotics and antibiotic-resistant strains and addresses the knowledge gaps for further studies.

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Objectif

Faire la synthèse d’études de grande qualité sur 10 sujets, publiées en 2020, qui sont d’une grande pertinence pour la pratique des soins primaires.

Sélection des données probantes

La sélection des études s’est faite à la suite d’une surveillance systématique de la littérature scientifique par un groupe de professionnels de la santé en soins primaires. Les résumés de revues à fort impact et les EvidenceAlerts ont été dépouillés, de même que l’American College of Physicians Journal Club.

Message principal

Au nombre des articles en 2020 qui influenceront fort probablement la pratique des soins primaires figurent ceux portant sur les questions suivantes : l’antibioprophylaxie réduit-elle les infections maternelles à la suite d’un accouchement vaginal opératoire? Quel agent de deuxième intention après la metformine réduit les risques cardiovasculaires chez les patients diabétiques? La gabapentine est-elle efficace pour les troubles liés à la consommation d’alcool? Les bas de contention préviennent-ils la cellulite récurrente? Le jeûne intermittent est-il supérieur à des repas à heures régulières pour perdre du poids? La vitamine C ajoutée aux suppléments de fer augmente-t-elle plus l’hémoglobine que le fer seul? Les combinaisons d’antiacides et de lidocaïne sont-elles supérieures aux antiacides seuls pour la douleur épigastrique? La dapagliflozine améliore-t-elle les issues rénales et cardiovasculaires dans les cas de néphropathie chronique? L’empagliflozine améliore-t-elle les résultats cardiovasculaires chez les patients souffrant d’insuffisance cardiaque? Cinq sujets d’intérêt additionnels sont aussi passés brièvement en revue.

Conclusion

La recherche a produit en 2020 plusieurs études de grande qualité sur le diabète et les maladies cardiovasculaires, de même que sur divers autres problèmes pertinents en soins primaires, comme les accouchements vaginaux opératoires, les troubles liés à la consommation d’alcool, la perte pondérale et l’œdème chronique des jambes.

FIGO good clinical practice paper: management of the second stage of labor

This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.

Introduction to host microbiome symbiosis in health and disease

Humans share a core intestinal microbiome and yet human microbiome differs by genes, species, enterotypes (ecology), and gene count (microbial diversity). Achievement of microbiota metagenomic analysis has revealed that the microbiome gene count is a key stratifier of health in several immune disorders and clinical conditions. We review here the progress of the metagenomic pipeline analysis, and how this has allowed us to define the host-microbe symbiosis associated with a healthy status. The link between host-microbe symbiosis disruption, the so-called dysbiosis and chronic diseases or iatrogenic conditions is highlighted. Finally, opportunities to use microbiota modulation, with specific nutrients and/or live microbes, as a target for personalized nutrition and therapy for the maintenance, preservation, or restoration of host-microbe symbiosis are discussed.

A global perspective on management of bacterial infections in pregnancy: a systematic review of international guidelines

INTRODUCTION

Maternal sepsis is a leading cause of maternal and neonatal mortality. Despite the availability of management protocols, there is disparity in case fatality rates for pregnancy-related sepsis compared to other maternity-related complications. The main aim of this systematic review was to assess concordance between international evidence-based guidelines for the prevention and management of childbirth-related bacterial infections.

MATERIAL AND METHODS

The PRISMA statement was followed during the conduct and reporting of this review. PubMed was searched electronically from 2009 to November 2019 for clinical guidelines covering the topic of childbirth-related infections and specific searches for relevant guidelines on the websites of the top five international professional bodies most commonly identified by our searches. We did not apply any language restrictions. Guidelines were included if they provided any information about the prevention or management of childbirth-related bacterial infections irrespective of whether the guideline stated a recommendation or not. Two independent reviewers undertook study selection, decisions about inclusion of selected guidelines and data extraction. Extracted information was synthesized under the following topics: Asymptomatic bacteriuria; group B streptococcal infection (GBS); preterm premature rupture of membranes (P-PROM); intrauterine infection; procedures; maternal sepsis; miscellaneous. Concordance was defined as absence of contradictory information between the different guidelines with regards to a specific topic, subtopic or recommendation. Quality of included guidelines was assessed against the AGREE II guideline reporting domains.

RESULTS

A total of 43 guidelines were selected of which 11 were excluded leaving 32 guidelines that fulfilled our inclusion criteria. None of the guidelines fulfilled all the quality assessment domains and 11 (34%) of the guidelines satisfied 1-2 of domains only. Two guidelines covered the topic of asymptomatic bacteriuria, nine for GBS, five for P-PROM and three covered each of intra-amniotic infections maternal sepsis, obstetric procedures and interventions topics. The remaining guidelines covered miscellaneous topics.

CONCLUSIONS

There was concordance between guidelines with regards to several aspects in the prophylaxis and treatment of bacteriological infections in pregnancy. Nevertheless, there were several areas of discordance, some of which reached the extent of contradictory information as in the case of antenatal screening for GBS.

The PRECIS-2 tool seems not to be useful to discriminate the degree of pragmatism of medicine masked trials from that of open-label trials

PURPOSE

To assess, with all available trial information, whether the assessment of the PRECIS-2 nine domains could provide a clear distinction between medicine masked pragmatic randomized controlled trials (pRCTs) and open-label pRCTs.

METHODS

A search was conducted of participant-level pRCTs on medicines published on 25 influential medical journals in July 2018-December 2019. All pre-licensing (phases 1-3) and cluster pRCTs were excluded. All trials' available reports were searched through the published article information, Google Scholar, and trial websites. Instead of providing a score to each PRECIS-2 domain, these were classified as E (explanatory), N (neutral), or P (pragmatic).

RESULTS

Of 128 pRCTs, 18 (14%) were participant-level pRCTs on medicines. The full trial protocol was available for 14 trials; 12 had published the protocol and nine had additional reports published. All trials were prospectively registered, and none was funded by industry. Ten and eight were masked and open-label trials, respectively. Masked pRCTS had 34% of pragmatic and 60% of explanatory domains; open-label pRCTS had 45% pragmatic and 45% explanatory domains. Among the 10 masked trials, only one had a majority of five pragmatic domains; among the eight open-label trials, four had a majority of six or five pragmatic domains. "Follow-up" was considered explanatory in the 18 pRCTs; "primary analysis" was pragmatic in 17 pRCTs.

CONCLUSION

The PRECIS-2 tool seems not to be sensitive enough to clearly discriminate between medicine masked pRCTs and open-label pRCTs. When conducting systematic reviews, it is suggested that the PRECIS-2 tool should not be used to support placing masked trials in the pragmatic side of the explanatory/pragmatic continuum.

A double blind randomized controlled trial using copper impregnated maternity sanitary towels to reduce perineal wound infection

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.

Early re-suturing of dehisced obstetric perineal wounds: A 13-year experience

OBJECTIVES

To describe post-operative outcomes following early re-suturing of obstetric perineal wound dehiscence.

STUDY DESIGN

This was a retrospective series of 72 women who underwent re- suturing of a dehisced perineal wound at a tertiary urogynaecology department during a 13-year period (December 2006 - December 2019).

RESULTS

Seventy-two women with complete perineal wound dehiscence opted for secondary re-suturing. Other accompanying symptoms included purulent discharge from the wound (22.2 %), perineal pain (23.6 %) and both purulent discharge and pain (26.4 %). The median time taken for the wound to heal completely following re-suturing was 28 days (IQR 14.0-52.0); 49.2 % had healed completely by four weeks, 63.5 % by six weeks and 76.2 % by eight weeks. The median number of out-patient follow-up appointments required was 2 (IQR 1.0-3.0). No post-operative complications were experienced in 63.6 % of women, one complication occurred in 25.8 % and two complications in 10.6 %. Complications included skin dehiscence (33.3 %), granuloma (33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus formation (5.9 %). Of the women who developed two complications, four developed skin dehiscence with granulation tissue and one had skin sinus formation. One developed granulation tissue with perineal pain. All complications were managed conservatively in an outpatient setting or surgically under local anaesthetic, without further complication. There was no significant difference (p = 0.443) in complication rates between the group (n = 10) with dehisced wounds with signs of wound infection (purulent discharge or the presence of both purulent discharge and pain) pre-operatively versus the group (n = 14) without signs of infection.

CONCLUSIONS

This study demonstrates the positive outcomes of early re-suturing of perineal wound dehiscence with faster healing, reduced follow-up requirements and few major complications. It provides information to clinicians who are uncertain about the effects of early re-suturing of perineal wounds which can be used to help counsel mothers with wound dehiscence on their management options.

Abuse of Antibiotics in Perinatology: Negative Impact for Health and the Economy

To use medications appropriately, patients need to be treated based on their clinical conditions, in doses that are based on their individual requirements, for an adequate amount of time, and at the lowest expense. The perinatal period is characterized by an excessive use of antibiotics. This antibiotic abuse can lead to antibiotic resistance, microbiome alterations, and dysbiosis, which have been associated with serious complications such as infections, abnormal brain development, allergies, autoimmune disorders, obesity, and an increase in mortality as well as an increase in health care expenditures. The need to optimize antibiotic utilization in perinatal medicine has never been more urgent; there is not much more time to wait.

Are routine antibiotics after operative vaginal birth beneficial?

Review of: Knight M, Chiocchia V, Partlett C, et al Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial. Lancet 2019;393:2395-403.

A one-stop perineal clinic: our eleven-year experience

Introduction and hypothesis

The perineal clinic is a dedicated setting offering assessment for various childbirth-related presentations including obstetric anal sphincter injuries (OASIs), perineal wound complications, pelvic floor dysfunction and other conditions such as female genital mutilation(FGM). We describe the clinical presentation and outcomes of women from a tertiary perineal clinic based on data collected over an 11-year period.

Methods

This is a retrospective observational study. A one-stop outpatient service was offered to all women who sustained OASIs (postnatally and antenatally in a subsequent pregnancy), perineal complications (within 16 weeks postpartum), FGM and/or peripartum symptoms of urinary/anal incontinence or prolapse. Assessment included history with validated questionnaires, examination and anal manometry and endoanal ultrasound when appropriate. Outcomes were compared among different grades of OASIs. Management of each type of presentation was reported with outcomes.

Results

There were 3254 first attendance episodes between 2006 and 2016. The majority (58.1%) were for OASIs, followed by perineal wound complications. Compared to the lower grades, the higher grades of OASI were associated with poorer outcomes in terms of symptoms, investigations and complications. Women with OASIs had unrelated symptoms such as urinary incontinence, perineal pain and wound infections that needed further intervention. A high proportion(42%) of wound complications required further specialist management.

Conclusion

We describe a dedicated, one-stop perineal clinic model for antenatal and postnatal women for management of perineal and pelvic floor disorders. This comprehensive and novel data will enable clinicians to better counsel women regarding of outcomes after OASI and focus training to minimize risks of morbidities.

Pregnancy and delivery in women with a high risk of infection in pregnancy

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.

Articles provided insufficient information to conduct an appropriate retrospective assessment of the pragmatic/explanatory features of medicine trials with the PRECIS-2 tool

PURPOSE

To assess whether, in the retrospective assessment of the pragmatic/explanatory features of pragmatic randomized controlled trials (pRCTs), the nine PRECIS-2 domain scores using the information provided in articles were modified after using the information reported in other publicly available sources.

METHODS

This is a cross-sectional study of participant-level pRCTs published in July 2018 to December 2019 in the four highest-impact general medicine journals. The articles described the main results of pRCTs assessing medicines in one or more arms that were not in the pre-licensing phases. The information reported in trial full protocols, published protocols, and other publications, registries, and trial websites were assessed and scored, and compared with that previously obtained after reviewing the information reported in the articles.

RESULTS

Out of 76 articles on pRCTs, 13 (17%) were included in the analysis. All were two-arm trials, assessing medicines only (n = 7), medicine vs device (n = 2), medicine vs surgery (n = 1), or medicine vs placebo (n = 3). Seven were open-label trials, and six had any type of masking. All except one had the full protocol available and/or published protocol; seven had other types of publication available. The assessment of the nine PRECIS-2 domains with the information reported in the 13 articles was changed in all trials after using the information included in other additional available sources. Between one (n = 1 article) and six (n = 2) domains were modified in each pRCT. The domains that most commonly changed were "organization" (n = 12), "recruitment" (n = 11), and "follow-up" (n = 8). "Primary outcome" and "primary analysis" were not modified in any trial. Eight percent of all domains could not be assessed due to inadequate or lack of information in seven articles; those were "recruitment" (n = 3), "organization" (n = 3), "setting" (n = 2), and "flexibility:adherence" (n = 1).

CONCLUSION

Articles describing the trial main results are usually insufficient for the appropriate retrospective assessment of the pragmatic/explanatory features of a pRCT by authors not involved in the conduct of the trial. To address this issue, editors should require the submission of the original full protocol and final full protocol with the history of amendments to be published as supplementary material to the article.

Still No Substantial Evidence to Use Prophylactic Antibiotic at Operative Vaginal Delivery: Systematic Review and Meta-Analysis

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 3^rd/4^tht degree perineal tear. From previous studies, there is no substantial evidence to use prophylactic antibiotic at OVD, but episiotomy and perineal tear.

SMFM Special Statement: Operative vaginal delivery: checklists for performance and documentation

The frequency of operative vaginal delivery has been declining, even though it can be an attractive alternative to cesarean delivery in selected cases. Performance of operative vaginal delivery required consideration of many indications, contraindications, and prerequisites. Optimal documentation of operative vaginal delivery requires the recording of several specific elements that are unique to forceps or vacuum delivery. A cognitive aid such as a checklist is well suited to this situation in which there are numerous elements to consider, a low frequency of performance, and teams with variable expertise. We propose 2 checklists to help ensure that all relevant elements are considered for every operative vaginal delivery: (1) a checklist for preparation and performance of the procedure and (2) a checklist for documentation. We suggest practical tips to help facilities adapt these checklists to their own circumstances and implement them on their units.

Use of the Robson Ten Group Classification System to categorise operative vaginal delivery

BACKGROUND

Operative vaginal delivery (OVD), either vacuum or forceps, can be used to expedite vaginal delivery. While rates of OVD have been reducing worldwide, rates in Ireland remain high. The Robson Ten Group Classification System (TGCS) was originally created to compare rates of caesarean delivery between healthcare units, although no similar system exists for the analysis of OVD.

AIMS

We sought to examine rates of OVD using the TGCS in an effort to understand which patient groups make significant contributions to the overall rate of OVD.

MATERIALS AND METHODS

This is a retrospective cohort study of all women delivering in a tertiary-level university institution in Dublin, Ireland, from 2007 to 2016. Mode of delivery for all patients was extracted from contemporaneously recorded hospital records. Rates of OVD were analysed according to the TGCS, and the contribution of each group to the overall hospital population was calculated.

RESULTS

There were 86 191 deliveries of women in our institution, of which 19.3% (16 673/86 191) had an OVD. Women in Group 1 (singleton, cephalic, nulliparous women at term in spontaneous labour) contributed the most to the overall rate of OVD, accounting for almost half of all OVDs (46.1% (7679/16 673)). Nulliparous women with a singleton, cephalic fetus at term who were induced (Group 2) were more likely to have an OVD than similar patients who laboured spontaneously (Group 1).

CONCLUSION

OVD accounts for almost one in five deliveries in our population and is predominately performed in nulliparous women. These groups may be the subject of interventions to lower rates of OVD. The Robson TGCS is a freely available tool to hospitals and birthing centres to facilitate comparison of rates of OVD on local and national levels.