Prevalence of postpartum infections: a population-based observational study

Obstetric infections and clinical characteristics of maternal sepsis: a hospital-based retrospective cohort study

Sepsis is responsible for 50% of intrahospital maternal deaths worldwide. Incidence is increasing in both low and middle-, and high-income countries. There is little data on incidence and clinical outcomes of obstetric infections including maternal sepsis in the Nordic countries. The aims of this study are to give estimates of the occurrence of obstetric infections and maternal sepsis in a Norwegian hospital cohort, assess the quality of management of maternal sepsis cases, and evaluate the usefulness of diagnostic codes to identify maternal sepsis retrospectively. We conducted a retrospective cohort study of pregnant, labouring, post-abortion, and postpartum women. We assessed the accuracy of the diagnostic code most frequently applied for maternal sepsis, O85. We found 7.8% (95% confidence interval 7.1-8.5) infection amongst pregnant, labouring, and postpartum women. The incidence of maternal sepsis was 0.3% (95% confidence interval 0.2-0.5), and the majority of sepsis cases were recorded in the postpartum period. Two thirds of women were given broad-spectrum antibiotics at the time sepsis was diagnosed, but only 15.4% of women with puerperal sepsis were given antimicrobials in accordance with national guidelines. When used retrospectively, obstetric infection codes are insufficient in identifying both maternal and puerperal sepsis, with only 20.3% positive predictive value for both conditions. In conclusion, obstetric infections contribute significantly to maternal morbidity in Norway's second largest maternity hospital. This study provides incidences of maternal infections for hospitalised patients in temporal relation to pregnancy, labour, abortion and the postpartum period, knowledge which is valuable for planning of health care services and allocation of resources. In addition, the study highlights areas where improvement is needed in clinical handling of maternal sepsis. There is need for studies on the management quality and use of correct diagnostic codes in this patient category.

Antibiotic use during pregnancy in Sweden: A nationwide utilization study covering 2007-2019

INTRODUCTION

Antibiotics are often prescribed during pregnancy. Assessing the current state of prenatal antibiotic use is therefore imperative for optimizing prescribing and identifying emerging research priorities. The study aimed to describe recent trends and patterns in antibiotic use during pregnancy among women who gave birth in Sweden, including user characteristics.

MATERIAL AND METHODS

Population-based descriptive study using linked nationwide registers. All pregnancies delivered in Sweden from 2007 to 2019 were included. Prevalence of use was defined as the percentage of pregnancies during which at least one prescription forantibiotics was filled. Temporal trends in the prevalence of antibiotic use by calendar year, trimester and weeks of gestation were assessed from time series graphs.

RESULTS

Prescriptions for systemic antibiotics were filled in 20.7% of 1 434 431 pregnancies overall, decreasing from 24.7% in 2007 to 18.0% in 2019. Phenoxymethylpenicillin (8.5%), pivmecillinam (6.5%), nitrofurantoin (4.7%), amoxicillin (1.6%) and cefadroxil (1.5%) use were the most prevalent. Their use decreased over the 13-year period, except for pivmecillinam, which increased from 4.0% to 7.4%. Prevalence of use was highest in the second trimester (9.5%), with weekly trends peaking at 13 and 34 weeks of gestation. Compared with non-users, antibiotic users more often belonged to the youngest and oldest age strata, carried multipleton pregnancies, had delivered before, had attained a lower education level and smoked in early pregnancy. A higher body mass index, asthma, chronic renal disease and diabetes mellitus were more prevalent among antibiotic users than among non-users.

CONCLUSIONS

Although outpatient antibiotic use during pregnancy in Sweden has been declining, one in five pregnancies was exposed to systemic antibiotics.

Tumour necrosis factor inhibitors and serious infections in reproductive-age women and their offspring: a narrative review

Tumour necrosis factor inhibitors (TNFi) are commonly used to treat patients with chronic inflammatory diseases, and function by inhibiting the pro-inflammatory cytokine tumour necrosis factor-α (TNF-α). Although beneficial in reducing disease activity, they are associated with an increased risk of serious infections. Data on the risk of serious infections associated with TNFi use during the reproductive years, particularly in pregnancy, are limited. For pregnant women, there is an additional risk of immunosuppression in the offspring as TNFi can be actively transported across the placenta, which increases in the second and third trimesters. Several studies have explored the risk of serious infections with TNFi exposure in non-pregnant and pregnant patients and offspring exposed in utero, indicating an increased risk in non-pregnant patients and a potentially increased risk in pregnant patients. The studies on TNFi-exposed offspring showed conflicting results between in utero TNFi exposure and serious infections during the offspring's first year. Further research is needed to understand differential risks based on TNFi subtypes. Guidelines conditionally recommend the rotavirus vaccine before 6 months of age for offspring exposed to TNFi in utero, but more data are needed to support these recommendations because of limited evidence. This narrative review provides an overview of the risk in non-pregnant patients and summarizes evidence on how pregnancy can increase vulnerability to certain infections and how TNFi may influence this susceptibility. This review focuses on the evidence regarding the risk of serious infections in pregnant patients exposed to TNFi and the risk of infections in their offspring.

Multiple Sclerosis and Family Planning: A Survey Study of the Patient Experience

Background and Objectives

Multiple sclerosis (MS) commonly affects women in their childbearing years, necessitating discussion between patients and their MS treatment team around the issues of family planning, pregnancy, and postpartum experiences. This study assessed the impact of a diagnosis of MS on women's reproductive decision-making and on their perception of counseling received surrounding pregnancy. It also sought to evaluate trends in pregnancy and postpartum experiences and determine whether experiences differed by race, ethnicity, and zip code.

Methods

Women with an MS diagnosis seen at the University of Virginia MS Clinic or at Virginia Commonwealth University (VCU) MS Clinic were invited to participate in a survey study. MS disease and pregnancy history, and, when appropriate, reasons for pregnancy avoidance were collected. Respondents who had >1 pregnancy following MS diagnosis were asked to evaluate the counseling they received from medical professionals and to share their pregnancy experiences including complications during pregnancy, delivery outcomes, and postpartum experience including breastfeeding.

Results

Of the 280 respondents, 76.6% were currently receiving MS specialty care. Most of them (79.3%) had not been pregnant following MS diagnosis. Of them, 20.1% indicated that this decision was driven by MS-related concerns: MS worsening with pregnancy (47%); ability to care for child secondary to MS (35%); passing MS onto child (19%); stopping disease-modifying therapies to attempt pregnancy (14%); lack of knowledge about options for pregnancy and MS (9%). Women with a more recent estimated decade of pregnancy were more likely to report neurologist counseling regarding MS and pregnancy (pregnancy before 2000: 40%, 2000-2010: 64.7%, 2010- present: 83.3%; χ2 0.020). Breastfeeding initiation was reported in 71.4% of postdiagnosis pregnancies (median duration 6 months, interquartile range 1.75-11).

Discussion

Over the past few decades, women with MS have received a wide range of evolving guidance surrounding family planning, pregnancy, and postpartum care. Survey data suggest improvements in MS/pregnancy counseling and medical management in recent years, which may be driven by an increase in research in the field. There remains an important need and opportunity to improve counseling of women with MS who are considering pregnancy.

Pregnancy and Inflammatory Rheumatological Diseases: A Single-Center Retrospective Cohort Study

Background Rheumatic diseases pose risks to pregnant women, leading to complications like preterm birth, congenital heart block, and pregnancy loss. These diseases are expected to deteriorate during pregnancy and further in the postpartum period. The impact of these diseases on the pregnancy will add further burden on the patient, fetus, physician, and healthcare system. Advances in diagnosis and treatment have improved outcomes making them similar to that of healthy women, but close follow-up in a multidisciplinary clinic is essential. The objective of this study is to study the outcome of pregnancy in women with rheumatological disease and the behavior of the disease during pregnancy. Methods A retrospective cohort study was conducted in King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, to compare the outcomes of pregnancy across three rheumatological diseases: Sjogren syndrome (SS), systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA) from 2016 to 2021. A total of 128 pregnancies in 107 women with rheumatological diseases were included in this study. Pregnancy measures and outcomes were investigated by assessing maternal health, fetal health, and pregnancy complications, specifically maternal disease activity, medications to control the disease, infection, preterm birth, birth weight, abortions/stillbirths, mode of delivery, bleeding, preeclampsia, congenital heart block, and neonatal lupus. Results There were 55 patients with RA (63 RA pregnancies), 44 with SLE (54 SLE pregnancies), and eight with primary SS (11 SS pregnancies). In most of the pregnancies (n= 108; 95.58%), the patients were in clinical remission before pregnancy. Lupus nephritis, which was in remission before pregnancy, has been reported in nine (16.67%) out of 54 SLE pregnancies. Vaginal delivery was the most common mode of delivery (n=87; 67.97%). On the other hand, there were 38 cesarean sections (29.69%). Rheumatological disease flares occurred in 10 pregnancies (7.87%). One hundred and twenty-two live births were delivered. Preterm infants were born in 25 pregnancies (20.16%), and 16 (13.22%) of the newborns needed neonatal intensive care unit (NICU) care. Interestingly, congenital heart block (CHB) was found in five (12.2%) neonates out of 41 anti-SS-related antigen A (anti-SSA) positive mothers; one of those five died from heart block. Eleven neonates were delivered with positive serology, and five were diagnosed with neonatal lupus. Conclusion The outcome of pregnancy in patients with rheumatological disease is favorable. A multidisciplinary team approach and close clinical follow-up are the cornerstone for such success. A small dose of prednisolone (5 mg or less) is safe and will not have a negative impact on maternal or fetal health. CHB is a concern for pregnant women with positive anti-SSA.

The Risk of Preterm Birth in Low Risk Pregnant Women with Urinary Tract Infections

OBJECTIVE

Urinary tract infections are among the most common infections during pregnancy. The association between symptomatic lower urinary tract infections during pregnancy and fetal and maternal complications such as preterm birth and low birthweight remains unclear. The aim of this research is to evaluate the association between urinary tract infections during pregnancy and maternal and neonatal outcomes, especially preterm birth.

STUDY DESIGN

This study is a secondary analysis of a multicenter prospective cohort study, which included patients between October 2011 and June 2013. The population consists of women with low risk singleton pregnancies. We divided the cohort into women with and without a symptomatic lower urinary tract infection after 20 weeks of gestation. Baseline characteristics and maternal and neonatal outcomes were compared between the two groups. Multivariable logistic regression analysis was used to correct for confounders. The main outcome was spontaneous preterm birth at <37 weeks.

RESULTS

We identified 4,918 pregnant women eligible for enrollment, of whom 9.4% had a symptomatic lower urinary tract infection during their pregnancy. Women with symptomatic lower urinary tract infections were at increased risk for both preterm birth in general (12 vs. 5.1%, adjusted OR 2.5; 95% CI 1.7-3.5) as well as a spontaneous preterm birth at <37 weeks (8.2 vs. 3.7%, adjusted OR 2.3; 95% CI 1.5-3.5). This association was also present for early preterm birth at <34 weeks. Women with symptomatic lower urinary tract infections during pregnancy are also at increased risk of endometritis (8.9 vs. 1.8%, adjusted OR 5.3; 95% CI 1.4-20) and mastitis (7.8 vs. 1.8%, adjusted OR 4.0; 95% CI 1.6-10) postpartum.

CONCLUSION

Low risk women with symptomatic lower urinary tract infections during pregnancy are at increased risk of spontaneous preterm birth. In addition, an increased risk for endometritis and mastitis postpartum was found in women with symptomatic lower urinary tract infection during pregnancy.

KEY POINTS

· UTIs increase the risk of preterm birth.. · UTIs increase the risk of endometritis postpartum.. · UTIs increase the risk of mastitis postpartum..

Perinatal Outcomes after Liver Transplantation: Is There a Role for Aspirin Treatment?

BACKGROUND

We aimed to describe perinatal outcomes and evaluate aspirin treatment effects in liver-transplanted pregnant women.

METHODS

A retrospective study examining perinatal outcomes in liver transplant recipients at a single center (2016-2022). The effect of low-dose aspirin treatment on the risk of developing hypertensive disease in these patients was evaluated.

RESULTS

Fourteen deliveries in 11 pregnant liver transplant recipients were identified. Primary liver disease was Wilson's in 50% of pregnancies. The median age was 23 years at transplant and 30 at conception. Tacrolimus was administered in all, steroids in 10 (71.43%), and aspirin (100 mg daily) in 7 (50.0%). Overall, two women (14.28%) developed preeclampsia, and one (7.14%) developed gestational hypertension. Median gestational age at delivery was 37 weeks (31-39 weeks), with six preterm births (between 31-36 weeks) and a median birthweight of 3004 g(range 1450-4100 g). None of those receiving aspirin developed hypertensive disease or suffered excessive bleeding during pregnancy, compared to two (28.57%) with pre-eclampsia in the non-aspirin group.

CONCLUSION

Liver-transplanted pregnant women comprise a unique and complex patient population with overall favorable pregnancy outcomes. Based on our single-center experience and due to its safety profile and potential benefit, we recommend low-dose aspirin in all liver transplanted patients during pregnancy for preeclampsia prevention. Further large prospective studies are needed to corroborate our findings.

Measurement of the prevalence of intervention/complication in puerperal women attending a university hospital during the pandemic of COVID-19 by the maternity safety thermometer

Abstract Objectives: measuring the prevalence of interventions and/or complications based on the Maternity Safety Thermometer (MST) criteria and verifying associations with sociodemographic, clinical, and obstetric factors. Methods: prospective observational study conducted with postpartum women admitted to the maternity ward of a tertiary hospital, from October 10th to December 30th, 2020. Data were collected from medical records and self-administered questionnaires from 260 patients. Results: harm-free care was detected in 17.7% of participants, 66.9% had low-temperature damage (one or less intervention/complication) and 33.1% of patients had elevated temperature damage (two or more intervention/complication). The most frequent intervention was the “scar”, given that 38.5% had abdominal scarring (cesarean section) and 26.5% had perineal scarring (2nd-degree tear or greater – spontaneous or by episiotomy). The second most frequent MST item was related to the perception of safety (30%), followed by complications to the newborn (12.3%), infection (11.2%), and hemorrhage (9.2%). Factors related to high temperature were: being of social class A or B, having a previous cesarean section, and being hospitalized during pregnancy. Conclusions: one-third of the participating women had two or more complications/interventions (high temperature by the MST), factors that are related to this temperature were: being of social class A or B, having a previous cesarean section, and being hospitalized during pregnancy.

Maternal Obesity: An Obstetric Risk

OBJECTIVE

To analyze the obstetric risks and to evaluate the effects of maternal obesity during pregnancy and postpartum period.

METHOD

This is a retrospective study of pregnant women with a BMI of more the 30 conducted at Bahrain Defence Force Hospital, West Riffa, Bahrain, from September 2019 to August 2020. Data includes demographic characteristics, and course of pregnancy from gestational age 24 weeks, through intrapartum to the postpartum period. Adverse maternal effects and delivery complications were the primary study outcomes. The BMI was calculated at the time of the booking visit. Comparative analysis was done to calculate the odds of each outcome taking a non-obese group (BMI less than 30) as a reference.  Results: The total number of pregnant women studied was 2972, out of which 1657 had BMI ≥30. In our study, women with high BMI were older (p<0.0001). High BMI was associated with high parity and higher miscarriage history. High BMI increased the risk of developing hypertension (OR 2.5; 95%CI 1.1-5.3). This analysis also found that high BMI was associated with increased risk of antepartum hemorrhage (OR 2.4; 95%CI 1-5.4), postpartum complications (OR1.6; 95%CI 1.1-2.2), and a hospital stay of more than five days (OR 1.6; 95%CI 1.3-2). High BMI patients were less likely to have Intrauterine growth restriction (OR 0.6; 95%CI 0.3-0.9). High BMI patients did not have an increased risk of gestational diabetes mellitus, induction of labor, or caesarean birth.

CONCLUSION

Higher BMI pregnant women are associated with higher incidences of hypertension. The high BMI group also had a significant relationship with antepartum hemorrhage and postpartum length of stay.

Incidence, antibiotic treatment and outcomes of lactational mastitis: Findings from The Norwegian Mother, Father and Child Cohort Study (MoBa)

BACKGROUND

Mastitis is a common and distressing maternal postpartum condition, but the relationship between mastitis timing and antibiotic treatment and breastfeeding outcomes and postnatal mental health is unclear.

OBJECTIVES

To describe the incidence of mastitis and treatment with antibiotics in first 6 months postpartum, and to investigate the impact of mastitis timing and antibiotic treatment on breastfeeding practices and postnatal mental health.

METHODS

This study is based on 79,985 mother-infant dyads in the Norwegian Mother, Father and Child Cohort Study (MoBa). Women were classified according to self-reported mastitis within first month ('early') or 1-6 months ('later') postpartum and antibiotic treatment. Breastfeeding outcomes included predominant or any breastfeeding and abrupt breastfeeding cessation until 6 months postpartum. Maternal mental health was assessed by self-report at 6 months postpartum.

RESULTS

The incidence of mastitis was 18.8%, with 36.8% reporting treatment with antibiotics. Women reporting early mastitis were less likely to report predominant breastfeeding (adjustedd relative risk [aRR] 0.92, 95% confidence interval [CI] 0.86, 0.99) and any breastfeeding for 6 months (aRR 0.97, 95% CI 0.96, 0.98) than women who did not report mastitis, and more likely to report abrupt breastfeeding cessation (aRR 1.37, 95% CI 1.23, 1.53). Late-onset mastitis was not associated with poorer breastfeeding outcomes. Among women reporting mastitis, the risk of abrupt breastfeeding cessation was higher in those also reporting antibiotic use. Mastitis was associated with an increased risk of mental health problems postpartum which was highest among those reporting no antibiotic use (aRR 1.29, 95% CI 1.18, 1.41), in contrast to those also reporting antibiotic use (aRR 1.08, 95% CI 0.96, 1.22).

CONCLUSIONS

Lactational mastitis and its associated treatment with antibiotics are common. Early (<1 month postpartum) mastitis appears to be a modest risk factor for suboptimal breastfeeding outcomes. In addition, mastitis is associated with poorer mental health.

Random amplified polymorphic DNA analysis reveals no clear link between Staphylococcus epidermidis and acute mastitis

Mastitis is commonly experienced by breastfeeding women. While Staphylococcus aureus is usually implicated in infectious mastitis, coagulase‐negative staphylococci (CoNS) are a possible alternative pathogen. This case‐control study examined the role of CoNS in mastitis using isolates cultured from breast milk of 20 women with mastitis and 16 women without mastitis. Gene sequencing determined bacterial species, and random amplified polymorphic DNA (RAPD) analysis investigated strain‐level variation. The majority of CoNS isolates were Staphylococcus epidermidis (182/199; 91%). RAPD analysis identified 33 unique S. epidermidis profiles, with no specific profile associated with mastitis cases.

Incidence of and Risk Factors for Lactational Mastitis: A Systematic Review

BACKGROUND

Lactational mastitis is a maternal morbidity that affects the wellbeing of women and their babies, including through breastfeeding discontinuation.

RESEARCH AIM

To systematically review the available global literature on the frequency of lactational mastitis, and to summarize the evidence on risk factors for lactational mastitis. We also describe gaps in the evidence and identify priority areas for future research.

METHODS

We systematically searched and screened 6 databases and included 26 articles, conducted meta-analysis of disease frequency, and narratively synthesized evidence on risk factors.

RESULTS

In 11 (42%) articles researchers reported a measure of disease frequency; 5 (19%) reported risk factors, and 10 (39%) included both. Overall, the quality of studies was low, related to suboptimal measurement of disease frequency, high risk of bias, reverse causality, and incomplete adjustment for confounding. Meta-analysis was based on 3 studies (pooled incidence between birth and Week 25 postpartum: 11.1 episodes per 1,000 breastfeeding weeks; 95% CI [10.2-12.0]); with high heterogeneity across contexts and highest incidence in the first four weeks postpartum. Researchers assessed 42 potential risk factors; nipple damage was the most frequently studied and strongly associated with mastitis. There was a scarcity of studies from low-resource settings.

CONCLUSIONS

Lactational mastitis is a common condition, but the wide variability in incidence across contexts suggested that a substantial portion of this burden might be preventable. Provision of care to breastfeeding women at risk for or affected by mastitis is currently constrained due to a critical lack of high quality epidemiological evidence about its incidence and risk factors.

Vitamin D deficiency at the time of delivery - Prevalence and risk of postpartum infections

Background

Postpartum infections are a common cause of morbidity after childbirth. Vitamin D deficiency has been shown to increase the risk for several infections in a non-pregnant population. Vitamin D deficiency has been described as common in pregnant women.

Objective

To investigate whether vitamin D deficiency in pregnant women in labor was associated with an increased risk of overall postpartum infectious morbidity within eight weeks of delivery. A secondary aim was to estimate the prevalence of vitamin D deficiency among pregnant women in Linköping, Sweden at the time of delivery.

Material and methods

Serum vitamin D levels in labor were analyzed for 1397 women. Vitamin D deficiency was defined as serum levels <50 nmol/L. All ICD-10 codes given to the women eight weeks postpartum were reviewed and postpartum infections were defined as the presence of an ICD-10 code suggestive of infection. The prevalence of postpartum infections among women with sufficient vitamin D levels was compared with women with vitamin D deficiency. Adjusted Odds Ratios and 95% confidence intervals for postpartum infections were calculated using multivariate logistic regression analysis.

Results

Fifty eight per cent of the women had serum vitamin D levels <50 nmol/L. The proportion of women with vitamin D deficiency varied, as expected, with season. No association between vitamin D deficiency and postpartum infections was found. For vitamin D 25–50 nmol/L the adjusted Odds Ratio was 0.85 (95% confidence interval 0.56–1.29) and for vitamin D <25 nmol/L the adjusted Odds Ratio was 1.15 (95% confidence interval 0.66–2.03). Women who smoked or who had a cesarean section had an increased risk of postpartum infections.

Conclusions

Vitamin D deficiency was more common than previously reported in Swedish pregnant women. No association between vitamin D deficiency and postpartum infections was found. Other well-known risk factors for postpartum infection were identified.

Worldwide Variation in Human Milk Metabolome: Indicators of Breast Physiology and Maternal Lifestyle?

Human milk provides essential substrates for the optimal growth and development of a breastfed infant. Besides providing nutrients to the infant, human milk also contains metabolites which form an intricate system between maternal lifestyle, such as the mother's diet and the gut microbiome, and infant outcomes. This study investigates the variation of these human milk metabolites from five different countries. Human milk samples (n = 109) were collected one month postpartum from Australia, Japan, the USA, Norway, and South Africa and were analyzed by nuclear magnetic resonance. The partial least squares discriminant analysis (PLS-DA) showed separation between either maternal countries of origin or ethnicities. Variation between countries in concentration of metabolites, such as 2-oxoglutarate, creatine, and glutamine, in human milk, between countries, could provide insights into problems, such as mastitis and/or impaired functions of the mammary glands. Several important markers of milk production, such as lactose, betaine, creatine, glutamate, and glutamine, showed good correlation between each metabolite. This work highlights the importance of milk metabolites with respect to maternal lifestyle and the environment, and also provides the framework for future breastfeeding and microbiome studies in a global context.

Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda

Background

There is a paucity of recent prospective data on the incidence of postpartum infections and associated risk factors in sub-Saharan Africa. Retrospective studies estimate that puerperal sepsis causes approximately 10% of maternal deaths in Africa.

Methods

We enrolled 4231 women presenting to a Ugandan regional referral hospital for delivery or postpartum care into a prospective cohort and measured vital signs postpartum. Women developing fever (> 38.0 °C) or hypothermia (< 36.0 °C) underwent symptom questionnaire, structured physical exam, malaria testing, blood, and urine cultures. Demographic, treatment, and post-discharge outcomes data were collected from febrile/hypothermic women and a random sample of 1708 normothermic women. The primary outcome was in-hospital postpartum infection. Multivariable logistic regression was used to determine factors independently associated with postpartum fever/hypothermia and with confirmed infection.

Results

Overall, 4176/4231 (99%) had ≥1 temperature measured and 205/4231 (5%) were febrile or hypothermic. An additional 1708 normothermic women were randomly selected for additional data collection, for a total sample size of 1913 participants, 1730 (90%) of whom had complete data. The mean age was 25 years, 214 (12%) were HIV-infected, 874 (51%) delivered by cesarean and 662 (38%) were primigravidae. Among febrile/hypothermic participants, 174/205 (85%) underwent full clinical and microbiological evaluation for infection, and an additional 24 (12%) had a partial evaluation. Overall, 84/4231 (2%) of participants met criteria for one or more in-hospital postpartum infections. Endometritis was the most common, identified in 76/193 (39%) of women evaluated clinically. Twenty-five of 175 (14%) participants with urinalysis and urine culture results met criteria for urinary tract infection. Bloodstream infection was diagnosed in 5/185 (3%) participants with blood culture results. Another 5/186 (3%) tested positive for malaria. Cesarean delivery was independently associated with incident, in-hospital postpartum infection (aOR 3.9, 95% CI 1.5–10.3, P = 0.006), while antenatal clinic attendance was associated with reduced odds (aOR 0.4, 95% CI 0.2–0.9, P = 0.02). There was no difference in in-hospital maternal deaths between the febrile/hypothermic (1, 0.5%) and normothermic groups (0, P = 0.11).

Conclusions

Among rural Ugandan women, postpartum infection incidence was low overall, and cesarean delivery was independently associated with postpartum infection while antenatal clinic attendance was protective.

Postpartum urinary tract infection by mode of delivery: a Danish nationwide cohort study

OBJECTIVES

To examine the association between postpartum urinary tract infection and intended mode of delivery as well as actual mode of delivery.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All live births in Denmark between 2004 and 2010 (n=450 856). Births were classified by intended caesarean delivery (n=45 053) or intended vaginal delivery (n=405 803), and by actual mode of delivery: spontaneous vaginal delivery, operative vaginal delivery, emergency or planned caesarean delivery in labour or prelabour.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was postpartum urinary tract infection (n=16 295) within 30 days post partum, defined as either a diagnosis of urinary tract infection in the National Patient Registry or redemption of urinary tract infection-specific antibiotics recorded in the Register of Medicinal Product Statistics.

RESULTS

We found that 4.6% of women with intended caesarean delivery and 3.5% of women with intended vaginal delivery were treated for postpartum urinary tract infection.Women with intended caesarean delivery had a significantly increased risk of postpartum urinary tract infection compared with women with intended vaginal delivery (OR 1.33, 95% CI 1.27 to 1.40), after adjustment for age at delivery, smoking, body mass index, educational level, gestational diabetes mellitus, infection during pregnancy, birth weight, preterm delivery, preterm prelabour rupture of membranes, pre-eclampsia, parity and previous caesarean delivery (adjusted OR 1.24, 95% CI 1.17 to 1.46).Using actual mode of delivery as exposure, all types of operative delivery had an equally increased risk of postpartum urinary tract infection compared with spontaneous vaginal delivery.

CONCLUSIONS

Compared with intended vaginal delivery, intended caesarean delivery was significantly associated with a higher risk of postpartum urinary tract infection. Future studies should focus on reducing routine catheterisation prior to operative vaginal delivery as well as improving procedures related to catheterisation.

Immune changes and dysphoric moods across the postpartum

PROBLEM

Little is known about postpartum immune recovery and relationships of common dysphoric moods, stress, immunology, and endocrinology.

METHOD OF STUDY

Healthy women (n = 72) were followed for six postpartum months with immune and hormone measures and dysphoric moods and stress scales. A panel of cytokines produced in mitogen-stimulated whole blood assays were measured at each time, along with plasma levels of hsC-reactive protein (hsCRP), Interleukin-6 (IL-6), and a panel of hormones.

RESULTS

Cellular immunity, measured by production of Interferon-gamma (IFNγ) and (Interleukin-2 (IL-2) from stimulated whole blood culture, was low in the early postpartum with changes by 3 months. Tumor necrosis factor alpha (TNFα) showed a similar pattern. Plasma levels of CRP and Interleukin-6 (IL-6) showed higher levels in the early postpartum. Mood disturbance scores dropped across the postpartum with a change in slope at 3 months. No significant relationships were found between immune, endocrine, and psychosocial measures.

CONCLUSION

Return to normal cellular immune function may take 3-4 months in the postpartum. Some aspects of early immunology (hsCRP and IL-6) probably reflect the latter stage of pregnancy, the stress of birth and the inflammation associated with involution. Dysphoric moods are higher in the early postpartum but are not related to immune factors or hormones.