Endometritis after hysteroscopic procedures in Ukraine: results a multicenter study.

OBJECTIVE: Aim: To determine the current prevalence of endometritis after hysteroscopic procedures and antimicrobial resistance of responsible pathogens in Ukraine. PATIENTS AND METHODS: Materials and Methods: Multicenter prospective cohort study was conducted from January 2020 to December 2022 in fifteen hospitals from twelve regions of Ukraine. Definitions of endometritis were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Antibiotic susceptibility was done by the disc diffusion test as recommended by EUCAST. RESULTS: Results: Among 13,872 patients with hysteroscopic procedures, 1027 (7.4%) endometritis were observed. Of these cases, 0.4% were detected after diagnostic hysteroscopy, and 7.0% were detected after operative hysteroscopy. Of all endometritis cases, 64.2% were detected after hospital discharge. The most commonly reported bacterial species were Escherichia coli (24.3%), followed by Enterobacter spp. (12.7%), Enterococcus spp. (8.3%), Pseudomonas aeruginosa (8.1%), Serratia marcescens (6.8%), Staphylococcus aureus (5.9%), Proteus mirabilis (5.8%), Klebsiella oxytoca (5.1%), Stenotrophomonas maltophilia (4.5%), Klebsiella pneumoniae (4.1%). A significant proportion of patients were affected by endometritis caused by bacteria developed resistance to several antimicrobials, varying widely depending on the bacterial species, antimicrobial group, and geographical region of Ukraine. CONCLUSION: Conclusions: Our data suggest a high prevalence of endometritis after hysteroscopic procedures. Risk for endometritis was higher after operative hysteroscopy compared with diagnostic hysteroscopy. Many most of patients were affected by endometritis caused by bacteria developed resistance to several antimicrobials. These data underscore the importance of tracking antimicrobial resistance of responsible pathogens of HAIs in hospitals.

Randomised Controlled Trial on Prophylaxis of Mastitis-Metritis-Agalactia Syndrome in Swine using Caulophyllum Logoplex and Lachesis Logoplex.

BACKGROUND: Mastitis-metritis-agalactia (MMA) syndrome occurs in the first days post-partum and causes piglet losses mainly due to malnutrition. One possibility for prophylaxis of MMA is via homeopathy. In this veterinary study, the effectiveness of a prophylactic administration of homeopathic remedies for the prevention of the occurrence of MMA in swine was evaluated. METHODS: In a randomised and blinded study, 60 sows were examined. Sows were randomly distributed in two groups: the experimental group (CL/LL) received a prophylactic administration of the complex homeopathic remedies Caulophyllum Logoplex and Lachesis Logoplex, and the placebo group was administered a sodium chloride (NaCl) solution in the same injection scheme as the experimental group. Clinical signs of MMA, behavioural changes, as well as production parameters, were recorded beginning with the day of farrowing until 5 days post-partum. RESULTS: The treatment group showed no significant effect on the occurrence of MMA in sows (CL/LL: 56.67% MMA positive sows; NaCl: 53.53% MMA positive sows). Treatment group had also no significant effect on health parameters (vaginal discharge, raised rectal temperature, shortage of milk) or behavioural parameters (impaired feeding behaviour and impaired general condition). For the production parameter average weight gain, statistically significant effects in the treatment group were detected. CONCLUSIONS: Prophylaxis with the homeopathic remedies Caulophyllum Logoplex and Lachesis Logoplex showed neither an improvement in MMA prevention nor an improvement in health parameters or behavioural traits in the present herd of sows.

Induction of labor versus expectant management in patients with idiopathic polyhydramnios.

OBJECTIVE: To evaluate whether induction of labor is associated with lower risk of cesarean section compared to expectant management in patients with isolated polyhydramnios. STUDY DESIGN: This is a single-center, retrospective cohort study of patients with pregnancies complicated by idiopathic polyhydramnios, documented between 34 and 38 weeks gestation, who were delivered between July 2012 and February 2020. The primary outcome was cesarean delivery. Secondary outcomes included chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, and composite neonatal morbidity. RESULTS: There were 194 patients included with idiopathic polyhydramnios - 115 underwent induction and 79 patients were expectantly managed. Planned induction was associated with a lower rate of CD compared with expectant management but did not meet statistical significance (19.1 % vs 30.4 %, aOR 0.51, 95 % CI 0.24, 1.05). A similar effect was seen when stratifying for parity: both nulliparous (9.1 % vs 16.3 %, aOR 0.59, 95 % CI 0.17, 1.98) and multiparous (32.7 % vs 47.2 %, aOR 0.45, 95 % CI 0.18, 1.15) patients had a lower CD rate when there was a planned induction, though neither group met statistical significance. No differences in maternal or fetal secondary outcomes were identified (chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, composite neonatal morbidity). CONCLUSION: Lower rates of cesarean section were associated with labor induction for patients with isolated polyhydramnios, but confidence intervals did not reach statistical significance.

Risk factors for postpartum haemorrhage in women with histologically verified placenta accreta spectrum disorders: a retrospective single-centre cross-sectional study.

BACKGROUND: Placenta accreta spectrum (PAS) disorders have been reported with an increasing frequency of up to 3%. The increase in the incidence can be explained by the rising rate of Caesarean section (CS), assisted reproductive technology (ART) and previous uterine surgeries. PAS disorders are usually associated with postpartum haemorrhage (PPH). In our study, we investigated the risk factors for increased blood loss in women with histologically verified PAS disorders independent of delivery mode. METHODS: In a retrospective single-centre cross-sectional study, 2,223 pregnant women with histologically verified PAS disorders were included. Risk factors for PPH in women with PAS disorders were examined and compared between women with PPH (study group; n = 879) and women with normal blood loss (control group; n = 1150), independent of delivery mode. PAS disorders were diagnosed histologically from the following specimens: placenta, placental-bed specimens, uterine curettage, uterine resection and/or total/partial hysterectomy. Medical data were extracted from clinical records of pregnant women with PAS disorders delivering at the University Hospital Basel between 1986 and 2019. The placenta data of women with PAS disorders were obtained and identified through a search from the database of the Department of Pathology, University Hospital Basel. RESULTS: Between 1986 and 2019, there were 64,472 deliveries at the University Hospital Basel. PAS disorders were histologically verified in 2,223 women (2,223/64,472), and the prevalence of PAS disorders was 3.45%. A total of 879 women with PAS disorders showed PPH, independent of delivery mode (43.3%). Due to missing data for 194 women, the final analysis was conducted with the remaining 2,029 women. Placenta praevia (O.R. = 6.087; 95% CI, 3.813 to 9.778), previous endometritis (O.R. = 3.011; 95% CI, 1.060 to 9.018), previous manual placenta removal (O.R. = 2.530; 95% CI, 1.700 to 3.796), ART (O.R. = 2.169; 95% CI, 1.593 to 2.960) and vaginal operative birth (O.R. = 1.715; 95% CI, 1.225-2.428) can be considered important risk factors, and previous CS (O.R. = 1.408; 95% CI, 1.016 to 1.950) can be considered a moderate potential risk factor of PPH in women with PAS disorders. CONCLUSIONS: Placenta praevia, previous endometritis, previous placenta removal, ART and vaginal operative birth can be considered important risk factors of PPH in women with PAS disorders. STUDY REGISTRATION: The study was registered under http://www. CLINICALTRIALS: gov (NCT05542043) on 15 September 2022.

Impact of Intraoperative Factors on the Development of Postpartum Septic Complications.

Background and Objectives: Triclosan-coated sutures (antibacterial sutures) can reduce the risk of postoperative surgical site infection. This study aimed to investigate the effect of intraoperative factors, including antibacterial sutures, on the risk of postpartum septic complications. Materials and Methods: The prospective study included patients who underwent caesarean section. The exclusion criterion was chorioamnionitis. The investigation group patient's (n = 67) uterus and fascial sheath of the abdominal wall were sutured with triclosan-coated polyglactin 910 sutures during surgery. The control group consisted of 98 patients using uncoated polyglactin 910 sutures only. The patients were contacted by phone after the 30th postoperative day. Results: No significant difference was found between the investigation group and the control group in the development of postpartum endometritis (11.7% in the investigation group vs. 8.4% in the control group, p = 0.401), wound infection (6.3% vs. 3.6%, p = 0.444) or patients experienced any septic complication (15.9% vs. 12%, p = 0.506). Postpartum endometritis was more common in patients who underwent instrumental uterine examination during the surgery (23.8% vs. 18%, p = 0.043). A moderately strong correlation was found for haemoglobin level on the third-fourth postoperative day with the development of postpartum septic complications, p < 0.001, Pearson coefficient -0.319. Post-caesarean delivery septic complications were not statistically more common in patients with blood loss greater than 1 L. The incidence of post-caesarean endometritis was 13.4%, and wound infection was 4.8% in this study's hospital, having five to six thousand deliveries per year. Conclusions: Using antibacterial sutures during caesarean section does not affect the incidence of postpartum septic complications. Instrumental uterine examination during caesarean section increases the risk of post-caesarean endometritis and is, therefore, not recommended. Haemoglobin level on the 3rd-4th postoperative day, rather than the estimated blood loss during surgery, affects the development of postpartum septic complications.

Current perspectives on endometrial receptivity: A comprehensive overview of etiology and treatment.

Recurrent implantation failure (RIF) remains a challenging problem in assisted reproductive technology (ART). Further insights into uterine abnormalities that can disturb embryo implantation should be obtained. This review provides an overview of the effects of organic and non-organic uterine disorders on endometrial receptivity. The results suggest that various uterine pathologies can lead to defective embryo implantation via multiple mechanisms. In particular, uterine adenomyosis dysregulates molecular and cellular interactions that are vital for successful embryo implantation with a background of chronic inflammation, which may be alleviated by pretreatment with a gonadotropin-releasing hormone agonist. Uterine myomas can cause endometrial deformation and adverse alterations in uterine contractility. Nonetheless, the effectiveness of myomectomy remains debated, and endometrial polyp removal may be considered, particularly in patients with RIF. Chronic endometritis abrogates the appropriate uterine immunological environment critical for embryo implantation. Abnormal endometrial microbiota have been suggested to influence endometrial receptivity; however, supporting evidence is currently scarce. Platelet-rich plasma therapy may be a potential treatment for thin endometria; nevertheless, further validation is required. Endometrial receptivity analysis can detect dysregulation of the window of implantation, and new non-invasive methods for predicting endometrial receptivity have recently been proposed. However, numerous issues still need to be fully clarified. Further clinical and basic studies are necessary to investigate the pathophysiology of defective endometrial receptivity and identify optimal treatments for patients undergoing ART, especially those with RIF.

Maternal obesity and the risk of postpartum infections according to mode of delivery.

OBJECTIVE: The aim of the present study was to assess the impact of different maternal Body Mass Index (BMI) classes on the risk of postpartum endometritis, wound infection, and breast abscess after different modes of delivery. Secondly to estimate how the risk of postpartum infection varies with different maternal BMI groups after induction of labor and after obstetric anal sphincter injuries. METHODS: A population-based observational study including women who gave birth during eight years (N = 841,780). Data were collected from three Swedish Medical Health Registers, the Swedish Medical Birth Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. Outcomes were defined by ICD-10 codes given within eight weeks postpartum. The reference population was uninfected women. Odds ratios were determined using Mantel-Haenszel technique. Year of delivery, maternal age, parity and smoking in early pregnancy were considered as confounders. RESULTS: There was a dose-dependent relationship between an increasing maternal BMI and a higher risk for postpartum infections. Women in obesity class II and III had an increased risk for endometritis after normal vaginal delivery aOR 1.45 (95% CI: 1.29-1.63) and for wound infections after cesarean section aOR 3.83 (95% CI: 3.39-4.32). There was no difference in how maternal BMI affected the association between cesarean section and wound infection, regardless of whether it was planned or emergent. Women in obesity class II and III had a lower risk of breast abscess compared with normal-weight women, aOR 0.47 (95% CI: 0.38-0.58). The risk of endometritis after labor induction decreased with increasing maternal BMI. The risk of wound infection among women with an obstetrical sphincter injury decreased with increasing BMI. CONCLUSION: This study provides new knowledge about the impact of maternal BMI on the risk of postpartum infections after different modes of delivery. There was no difference in how BMI affected the association between cesarean section and wound infections, regardless of whether it was a planned cesarean section or an emergency cesarean section.

Different methods of vaginal preparation before cesarean delivery to prevent postoperative infection: a systematic review and network meta-analysis.

OBJECTIVE: Precesarean vaginal antisepsis can benefit pregnant women with ruptured membranes. However, in the general population, recent trials have shown mixed results in reducing postoperative infections. This study aimed to systematically review clinical trials and summarize the most suitable vaginal preparations for cesarean delivery in preventing postoperative infection. DATA SOURCES: We searched PubMed, Web of Science, Cochrane Library, SinoMed databases, and the ClinicalTrials.gov clinical trials registry for randomized controlled trials and conference presentations (past 20 years, 2003-2022). Reference lists of previous meta-analyses were searched manually. In addition, we conducted subgroup analysis on the basis of whether the studies were conducted in developed or developing countries, whether the membranes were ruptured, and whether patients were in labor. STUDY ELIGIBILITY CRITERIA: We included randomized controlled trials comparing vaginal preparation methods for the prevention of postcesarean infection with each other or with negative controls. METHODS: Two reviewers independently extracted data and assessed the risk of bias and the certainty of the evidence. The effectiveness of prevention strategies was assessed by frequentist-based network meta-analysis models. The outcomes were endometritis, postoperative fever, and wound infection. RESULTS: A total of 23 trials including 10,026 cesarean delivery patients were included in this study. Vaginal preparation methods included 19 iodine-based disinfectants (1%, 5%, and 10% povidone-iodine; 0.4% and 0.5% iodophor) and 4 guanidine-based disinfectants (0.05% and 0.20% chlorhexidine acetate; 1% and 4% chlorhexidine gluconate). Overall, vaginal preparation significantly reduced the risks of endometritis (3.4% vs 8.1%; risk ratio, 0.41 [0.32-0.52]), postoperative fever (7.1% vs 11.4%; risk ratio, 0.58 [0.45-0.74]), and wound infection (4.1% vs 5.4%; risk ratio, 0.73 [0.59-0.90]). With regard to disinfectant type, iodine-based disinfectants (risk ratio, 0.45 [0.35-0.57]) and guanidine-based disinfectants (risk ratio, 0.22 [0.12-0.40]) significantly reduced the risk of endometritis, and iodine-based disinfectants reduced the risk of postoperative fever (risk ratio, 0.58 [0.44-0.77]) and wound infection (risk ratio, 0.75 [0.60-0.94]). With regard to disinfectant concentration, 1% povidone-iodine was most likely to simultaneously reduce the risks of endometritis, postoperative fever, and wound infection. CONCLUSION: Preoperative vaginal preparation can significantly reduce the risk of postcesarean infectious diseases (endometritis, postoperative fever, and wound infection); 1% povidone-iodine has particularly outstanding effects.

Effect of sterile vs clean gloves for cervical checks in labor on maternal infection at term: a randomized trial.

BACKGROUND: Intrapartum infection usually warrants immediate delivery and impacts 5-12% of term pregnancies, with the most commonly identified pathogenic organism being of the Ureaplasma genus. When performing cervical examinations during labor, providers in the United States commonly use sterile gloves, although there are no data currently to support that this practice reduces rates of infection. Furthermore, in nearly all other settings of Gynecologic care, aside from surgery in an operating room, nonsterile gloves are used. Even though the uterus could be sterile in normal pregnancies, the provider performing the cervical examination must traverse the milieu of vaginal bacteria in order to reach the cervix to perform the exam, introducing vaginal microbiota into the uterus regardless of the type of glove used. This prospective randomized controlled study examines whether the type of glove used (sterile vs clean) impacts the rates of intrapartum infection in patients receiving cervical examinations during labor or induction of labor at term.. OBJECTIVE: This study aimed to evaluate if the glove type (sterile vs clean) used for cervical examinations during labor affects the rates of intrapartum and postpartum infection. STUDY DESIGN: This randomized controlled trial assigned eligible and consenting participants to receive cervical examinations during labor with either sterile powder-free polyvinyl chloride examination gloves (current routine practice, control group) or clean powder-free nitrile examination gloves (nonsterile, experimental group). The primary outcome was rates of intrapartum infection (chorioamnionitis). Sample size calculations estimated that 300 participants would be needed with a rate of infection of 10% in the control group and 20% in the experimental group to demonstrate difference between the groups; however, the rates of infection were much lower than expected, at 5.4% and 4.4% in the sterile and clean glove group, respectively. At this point, it was determined futile to continue the study because a sample size of >29,000 participants would be needed, which would not be achievable at a single tertiary care referral center with approximately 3500 deliveries per year. The study was approved by the Eastern Virginia Medical School Institutional Review Board (IRB 21-09-FB-0206), and was registered at ClinicalTrials.gov (identifier NCT05603624; https://clinicaltrials.gov/ct2/show/NCT05603624). RESULTS: A total of 163 participants with singleton pregnancies completed the study; 74 (45%) were randomized to the sterile glove group, and 89 (55%) were randomized to the clean glove group. In the sterile glove group, 4 (5.4%) developed intrapartum infection (chorioamnionitis) and 1 (1.3%) developed postpartum infection (endometritis). In the clean glove group, 4 (4.4%) developed intrapartum infection and 2 (2.2%) developed postpartum infection. There was no significant difference in rates of intrapartum infection (P=1.0) or postpartum infection (P=1.0), or combined rates of infection (including both chorioamnionitis and endometritis; P=.99) between the sterile and the clean glove group. When comparing the participants from both groups who had any intrapartum or postpartum infection (n=11) with those who had no infection (n=152), the former were more likely to be nulliparous (P=.01), have lower gravidity (P<.01) and parity (P<.01), have longer times from first cervical examination to delivery (P=.02), have longer times from rupture of membranes to delivery (P=.0001), undergo cesarean delivery (P=.0002), and experience postpartum hemorrhage (P=.001). Although participants who were in labor for a longer time also likely had more cervical examinations, these data could suggest that duration of labor (P=.02) is more closely associated with infectious morbidity compared with the number of cervical examinations (P=.15). CONCLUSION: Using clean gloves for cervical examinations during labor is unlikely to increase risk of infection, and could reduce cost by up to 92.4% at our institution, saving over $25,000 annually.

Impact of intrauterine infusion of Platelets-Rich plasma on endometritis and reproductive performance of Arabian mare.

Equine endometritis is one of the most common causes of reproduction failure. To achieve better treatment outcomes, different diagnostic methods should be combined. In the current study, 39 repeat breeder mares were subjected to ultrasonography examination to detect excessive accumulation of intrauterine fluids and an abnormal oedema pattern, which revealed that 61.5% of mares were positive. Combined with endometrial cytology by low-volume uterine flush, 47.7% of smears contain neutrophils (more than 2-3 per HPF X100), and microbial culture. 92.3% of mares were infected with different bacterial isolates, such as Escherichia coli, Streptococci, Staphylococcus, Klebsiella pneumoniae, Klebsiella oxytoca, Citrobacter freundii, Providencia alcalifaciens, and Proteus mirabilis. All mares were given saline solution and gravity withdrawal before being given 20 IU of oxytocin (as ecbolic agents). Mares were divided into three groups; Group one (n = 15) received an intrauterine infusion of 20 mL of freshly prepared autologous platelet-rich plasma (PRP) 6 h after breeding, Group two (n = 15) was treated with three doses of systemic Enrofloxacin 5% during the estrus period, and Group three (n = 9) received only uterine lavage and 20 IU of oxytocin. PRP and Enrofloxacin resulted in a significant (p < .05) reduction in endometrial thickness (oedema; 5.05 and 6.74 mm, respectively) and disappearance of intrauterine fluids compared to the control (10.98 mm). Furthermore, PRP (days) and Enrofloxacin (17.89 days) reduced the days to the next oestrus compared to the control (18.58 and 17.89 vs. 21.19 days, respectively). Furthermore, the pregnancy rate improved to reach 70% in the PRP group and 60% in the Enrofloxacin group, while the control remained low at 22%. In conclusion, autologous PRP can be used as a low-cost alternative therapy for modulating the inflammatory process and effectively treating mares' endometritis.

Endometritis risk factors after arterial embolisation for postpartum haemorrhage.

Various complications of arterial embolisation (AE) for postpartum haemorrhage (PPH) are reported. Endometritis (EM) frequently causes abscesses, increasing hysterectomy risk. However, risk factors for EM after AE for PPH are unclear. We explored these risk factors. We included patients who underwent AE for PPH in our hospital from 2005 to 2020 and compared those who did (EM group) and did not develop EM after AE (non-EM group) in a case-control study. Twenty patients met the study criteria; eight patients (40%) had EM. There were no differences in risk factors between groups involved in infection, such as premature rupture of membranes. However, the contrast medium extravasation rate on computed tomography scans before the AE procedure was significantly higher in the EM group (p=.019) compared to the non-EM group. The greatest EM risk factor was contrast medium extravasation before AE for PPH, determined by classification and regression tree modelling (relative risk: 4.5).Impact StatementWhat is already known on this subject? Reportedly, the clinical success rate of arterial embolisation (AE) for critical haemorrhage in obstetrics is high, around 90%. However, information regarding AE complications is limited. Endometritis is one of these complications, which not only causes prolonged hospitalisation but may also require further treatment, such as hysterectomy. However, the incidence rate and risk factors for EM remain unknown.What do the results of this study add? In this study, 40.0% of patients developed EM after AE for PPH. Extravasation of contrast medium was the top risk factor (relative risk: 4.5 compared to those without EM, p=.019). The second-leading risk factor was a bleeding volume greater than 2500 mL (relative risk: 4.5 compared to those without EM, p=.019).What are the implications of these findings for future clinical practice and/or future research? We created an EM prediction model using extravasation and a bleeding volume greater than 2500 mL. The model was 87.5% sensitive and 66.7% specific. This prediction model allows for the early detection and treatment of EM by recognising high-risk patients and providing intensive postpartum management.

Spontaneous versus manual placental delivery during cesarean delivery: a systematic review and meta-analysis.

OBJECTIVE: Standardized techniques have been established for cesarean delivery to reduce cesarean delivery complication rates. Current recommendations suggest against manual removal of the placenta. The purpose of the present meta-analysis is to evaluate published data and provide a summary of the evidence. METHODS: For the purposes of this systematic review, we searched Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar, and Clinicaltrials.gov databases from inception till June 2021 for relevant randomized controlled trials. Effect sizes were calculated in R. RESULTS: Overall, 19 studies were included that involved 5797 parturient. We did not detect significant differences in the mean intraoperative blood loss among the two techniques (MD = 149.18 ml, 95% CI = -32.55, 330.92). Similarly, intraoperative duration was comparable among the two groups (MD = -0.89 min, 95% CI = -2.34, 0.57). The risk of intraoperative hemorrhage was comparable among the two groups (OR = 1.75, 95% CI = 0.48, 6.36), although the provided result is based on underpowered sample size. Consequently, the need of transfusion was not increased (OR = 1.31, 95% CI = 0.71, 2.44). Neither postpartum endometritis (OR = 1.50, 95% CI = 0.94, 2.40) nor infectious morbidity (OR = 1.82, 95% CI = 0.94, 3.52) increased with manual placental extraction. CONCLUSION: The findings of our study suggest that cephalad-caudad blunt expansion of the uterine incision may be safe; however, more data are needed to evaluate its impact on post-partum infectious morbidity as well as its safety in cases at increased risk of perioperative bleeding.

Single-dose versus multiple-dose antibiotics prophylaxis for preventing caesarean section postpartum infections: A randomized controlled trial.

BACKGROUND: Caesarean section, a common obstetric surgical procedure, is a major predisposing factor for puerperal infections, requiring the need for antibiotic prophylaxis. Evidence suggests that single-dose antibiotic prophylaxis has comparable efficacy to multiple-dose antibiotic prophylaxis, but with a lower cost and risk of antibiotic resistance. However, single-dose antibiotic prophylaxis after caesarean section is not generally used in many centres in sub-Saharan Africa. OBJECTIVE: This study aimed to compare the effectiveness of single- versus multiple-dose antibiotic prophylaxis to prevent post-caesarean section infections. METHODOLOGY: This open-label, randomized controlled trial involved 162 consenting patients admitted for caesarean section (elective or emergency) at the Federal Medical Centre Keffi. They were distributed randomly into treatment arm A or B. Subjects in both arms received intravenous ceftriaxone (1 g) and metronidazole (500 mg) 30-60 min before incision; subjects in arm B received additional parenteral doses for 48 h and then cefuroxime 500 mg tablets every 12 h and metronidazole 400 mg tablets every 8 h for 5 days. The patients were monitored for 2 weeks for evidence of wound infection, febrile morbidity and clinical endometritis. RESULT: There was no statistical difference in the incidence of wound infection (6.6% versus 7.4%; p = .882) and febrile morbidity (11.8% versus 11.1%, p = .807). However, clinical endometritis (0.0% versus 6.1%, p = .028) was statistically significant with none reported in the single-dose arm. CONCLUSION: Single-dose ceftriaxone and metronidazole is as effective as multiple doses for antibiotic prophylaxis to prevent post-caesarean section infections. Adoption of this approach in low-risk patients would reduce the cost of prophylactic antibiotics, workload for staff and antibiotic resistance.

Secondary postpartum hemorrhage: Incidence, etiologies, and clinical courses in the setting of a high cesarean delivery rate.

OBJECTIVES: To evaluate the incidence, etiologies, and clinical outcomes of secondary postpartum hemorrhage in a hospital with a high cesarean section rate and to compare the etiologies of secondary postpartum hemorrhage following cesarean delivery versus vaginal delivery. MATERIALS AND METHODS: This retrospective study included 123 women with secondary postpartum hemorrhage who were treated at a tertiary-level hospital between January 2004 and June 2018. Descriptive statistics and the chi-square test were used for data analysis. RESULTS: The incidence of secondary postpartum hemorrhage was 0.21%. The median onset of bleeding was 12 days after delivery. Fifty-two percent of the deliveries were by cesarean section. The most common etiology of secondary postpartum hemorrhage was endometritis (67.5%), followed by retained placental tissue (21.1%). Women who delivered by cesarean section had a higher rate of endometritis (80.0% vs 53.4%) and a lower rate of retained placental tissue (10.8% vs. 32.8%) than those who delivered vaginally. Surgical intervention included uterine evacuation in 29.3% and hysterectomy in 8.1% of the patients. Five percent of women were treated by embolization. CONCLUSIONS: Endometritis was the most common cause of secondary postpartum hemorrhage. Women who delivered by cesarean section were less likely to have retained placental tissue but were at higher risk for endometritis and uterine pseudoaneurysm than those who delivered vaginally.

Impact of manual removal of the placenta and intrauterine cleaning during elective cesarean delivery on maternal infectious morbidity and blood loss.

OBJECTIVE: to assess the impact of manual removal of the placenta and intrauterine cleaning during elective cesarean delivery on maternal infectious morbidity and blood loss. METHODS: This prospective multicenter trial was conducted on 436 pregnant women at term who were intended for elective cesarean delivery and allocated into four groups; group 1 (n = 110) who underwent manual removal of the placenta with intrauterine cleaning, group 2 (n = 106) who underwent manual removal of the placenta without intrauterine cleaning, group 3 (n = 108) who underwent spontaneous placental delivery with intrauterine cleaning and group 4 (n = 112) who underwent spontaneous placental delivery without intrauterine cleaning. Maternal operative blood loss, the rate of endometritis and surgical site infections (SSIs) was assessed and recorded. RESULTS: There was no significant difference between the four groups regarding drop of hemoglobin concentration, drop of hematocrit value, re-operation, re-admission to hospital, duration of hospital stay, the rate of endometritis and SSIs as well as maternal acceptability in terms of overall discomfort, overall satisfaction with delivery and recommendation to other women (p > .05). Intrauterine cleaning was associated with a significantly shorter duration of discharge of lochia and rapid return to daily activity compared to non-intrauterine cleaning (p < .05). CONCLUSION: Manual removal of the placenta and intrauterine cleaning have no deleterious impact on maternal blood loss and infectious morbidity after elective cesarean section. Also, intrauterine cleaning was associated with faster cessation of lochia and faster return to daily activity.

Prophylactic postoperative antibiotics after emergent cesarean delivery and risk of postpartum infection or wound complication.

BACKGROUND: Emergent cesarean delivery (CD) carries a high risk for postpartum infection. In cases with a "splash" povidone-iodine (PI) skin preparation, prophylactic postoperative antibiotics (PP-Abx) are sometimes utilized, but the benefit is unclear. OBJECTIVE: To evaluate if the use of PP-Abx decreases postpartum infection after emergent CD with "splash" PI skin preparation. STUDY DESIGN: Cohort study of patients undergoing emergent CD with PI skin preparation from July 2012 to April 2020 at a single institution. Cases were identified using a natural language search engine, DEEP-6, with key terms "emergent" and "cesarean delivery." Patients with chorioamnionitis or non-PI skin preparation (e.g. chlorhexidine) were excluded. The primary exposure was use of PP-Abx. The primary outcome was postpartum infection or wound complication, defined as a composite: endometritis, wound infection, cellulitis, seroma, hematoma, or intra-abdominal abscess. Rates of postpartum infection or wound complication were stratified by use of PP-Abx. Demographic and labor characteristics were evaluated as confounders. Statistics by χ2, t-test, and logistic regression (α = 0.05). RESULTS: In total, 481 patients underwent emergent CD; of those, 370 had PI skin preparation and were included. PP-Abx were given in 43% (160/370) of cases, including: cefazolin (n = 137), gentamicin/clindamycin (n = 18), azithromycin (n = 3), and vancomycin (n = 2). Those receiving PP-Abx were similar to those who did not, except the PP-Abx group was younger with longer CD duration. The rate of postpartum infection or wound complication was no different in patients who received PP-Abx compared to those who did not (12.6% vs. 9.5%, p = .34). This finding remained unchanged after multivariable adjustment (aOR 1.2, CI 0.61-2.4, p = .60). Moreover, the rate of postpartum infection or wound complication did not vary by antibiotic choice. CONCLUSIONS: After emergent CD with PI skin preparation, routine use of prophylactic postoperative antibiotics does not appear to reduce the rate of postpartum infection or wound complication, which is important as we consider antibiotic stewardship. More studies are needed to identify treatments that decrease infectious morbidity with emergent CD.

Type 1 Cytotoxic T Cells Increase in Placenta after Intrauterine Inflammation.

CD8+ T cells recognize non-self antigen by MHC class I molecules and kill the target cells by the release of proinflammatory cytokines such as interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF-α). Our group previously reported an increase of CD8+ T-cell trafficking in the placenta with exposure to Lipopolysaccharides (LPS). CD8+ cytotoxic T cells have been classified into distinct subsets based upon cytokine production: Tc1 cells produce IFN-γ, Tc2 cells produce interleukin 4 (IL-4). Accordingly, the purpose of this research is to analyze the subsets of placenta CD8+ T cells. We hypothesized that LPS injection would induce a change of properties of CD8+ T cell and Tc1/Tc2 ratio. We investigated the subsets of CD8+ T cell infiltration to placenta and their specific function in response to LPS-induced inflammation in a mouse model. At embryonic (E) day 17, pregnant CD-1 dams received an intrauterine injection of 25 µg LPS in100 µl PBS or 100 µl of PBS only. Flow cytometry was used to quantify CD8+ T cells, evaluate the phenotype and subtypes, and detect markers of Tc1 and Tc2 cells in placenta, at 6 hours and 24 hours post injection (hpi). Intracellular staining and flow cytometry were performed to characterize cytokines produced by CD8+ T cells. Standard statistical analysis were employed. After 6 and 24 hours of LPS injection, total CD8 T cells increased (P<0.05). Tc1 cells expanded (P<0.05) in LPS-treated dams compared with the PBS group. The Tc1/Tc2 ratio was significantly higher in the LPS group than the PBS group (P<0.05). The expression of TNF-α and IFN-γ were increased in LPS group both at 6hpi and 24 hpi (P<0.05). We identified functional placental CD8+ T cell subtypes and found a significant increase ratio of Tc1/Tc2. Following IUI, CD8+ T cells induced inflammatory response in the placenta primarily via the production of Type 1 cytokines such as IFN-γ and TNF-α. We have provided evidence of a Tc1-bias response and cytokines in the mouse model of IUI.

Adhesion barriers and topical hemostatic agents are risk factors for post-cesarean section infections.

BACKGROUND: Cesarean sections are the most common surgery worldwide, and post-cesarean section infections and hemorrhage are a major cause for morbidity and mortality. In recent years, many surgeons use adhesion barriers as well as hemostatic agents during primary and repeated cesarean section. The data regarding the safety of these agents is relatively limited. The objective of this study was to investigate whether the use of adhesion barriers and topical hemostatic agents pose a risk for post-cesarean section infections. METHOD: A case-control study composed of women who were admitted to the Soroka University Medical Center between the years 2012 and 2016 was conducted. The study group was composed of women admitted owing to post-cesarean section infections (cases) and those who underwent cesarean sections without post-cesarean section infection (control subjects). Matching was done according to date and surgery setting (elective versus emergency). A univariate analysis was followed by a multiple regression model in order to examine the association between adhesion barriers/hemostatic agents and post-cesarean section infections. RESULTS: During the study period, 113 patients developed postoperative infection (cases); 71.7% were diagnosed with surgical site infection, 7.1% with endometritis, and 21.2% with other infections. These were compared with 226 control subjects. In the univariate analysis, the use of adhesion barriers/hemostatic agents were found to be associated with post-cesarean section infection. Using a multivariable analysis controlling for previous cesarean section, skin closer technique, preterm delivery, and duration of surgery >60 minutes, the use of adhesion barriers as well as hemostatic agents was found to be independently associated with post-cesarean section infection (adjusted odds ratio = 2.11, 95% confidence interval = 1.17-3.84; adjusted odds ratio = 2.29, 95% confidence interval = 1.37-3.8, respectively) CONCLUSION: Adhesion barriers and hemostatic agents were found to be independently associated with post-cesarean section infections. Further larger studies are needed to reinforce our findings. The use of these materials should be carefully considered, and their cost-effectiveness re-examined.

Birth outcomes in women with body mass index of 40 kg/m2 or greater stratified by planned and actual mode of birth: a systematic review and meta-analysis.

INTRODUCTION: Pregnant women with a body mass index (BMI) ≥40 kg/m2 are at an increased risk of requiring planned- and unplanned cesarean deliveries (CD). The aim of this systematic review is to compare outcomes in women with BMI ≥ 40 kg/m2 based on planned and actual mode of birth. MATERIAL AND METHODS: Five databases were searched for English and French-language publications until February 2019, and all studies reporting on delivery outcomes in women with BMI ≥ 40 kg/m2 , stratified by planned and actual mode of birth, were included. Risk-of-bias was assessed using the Newcastle-Ottawa Scale. Relative risks (RR) and 95% confidence intervals were calculated using random-effects meta-analysis. RESULTS: Ten observational studies were included. Anticipated vaginal birth vs planned CD (5 studies, n = 2216) was associated with higher risk for postpartum hemorrhage (13.0% vs 4.1%, P < .001, numbers needed to harm (NNH = 11), I2  = 0%) but lower risk for wound complications (7.6% vs 14.5%, P < .001, numbers needed to treat (NNT = 15), I2  = 58.3%). Planned trial of labor vs repeat CD (3 studies, n = 4144) was associated with higher risk for uterine dehiscence (0.94% vs 0.42%, P = .04, NNH = 200, I2  = 0%), endometritis (5.1% vs 2.2%, P < .001, NNH = 35, I2  = 0%), prolonged hospitalization (one study, 30.3% vs 26.0%, P = .003, NNH = 23), low five-minute Apgar scores (4.9% vs 1.7%, RR 2.95 (2.03, 4.28), NNH = 30, I2  = 0%) and birth trauma (1.1% vs 0.2%, P < .001, NNH = 111, I2  = 0%). Successful vaginal birth vs intrapartum CD (n = 3625) was associated with lower risk of postpartum hemorrhage (15.1% vs 70%, P < .001, NNT = 2, I2  = 0%), wound complications (one study, 0% vs 4.4%, P = .007, NNT = 23), prolonged hospitalization (one study, 1.9% vs 6.7%, 0.04, NNT = 21) and low five-minute Apgar scores (one study, 1.0% vs 5.6%, P = .03, NNT = 22), but more birth trauma (5.9% vs 0.6%, P = .005, NNH = 19, I2  = 0%). Compared groups had dissimilar demographic characteristics. Although studies scored 6-7/9 on risk-of-bias assessment, they were at high-risk for confounding by indication. CONCLUSIONS: Evidence from observational studies suggests clinical equipoise regarding the optimal mode of delivery in women with BMI ≥ 40 kg/m2 and no prior CD. This question is best answered by a randomized trial. Based on an unplanned subgroup analysis, for women with BMI ≥ 40 kg/m2 and prior CD, repeat CD may be associated with better clinical outcomes.