Randomized control trial of intravenous acetaminophen for reduction of intrapartum maternal fever.

BACKGROUND: Intravenous acetaminophen reaches a higher mean peak plasma concentration than oral acetaminophen in a shorter period of time. The favorable pharmacokinetics of intravenous acetaminophen may be beneficial for treating intrapartum maternal fever. OBJECTIVE: The primary objective was to compare intravenous and oral acetaminophen in time to defervescence (temperature <38°C). The secondary objective was to compare intravenous and oral acetaminophen in the percentage of participants being afebrile and percent reduction in maternal temperature 30 minutes after administration of first dose. Other outcomes evaluated were histopathological placental findings; neonatal outcomes; oxidative stress; and levels of RANTES, interferon-δ, interleukin 1ß, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α in maternal and neonatal blood. STUDY DESIGN: This was a randomized, comparator-controlled, double-dummy, double-blind clinical trial. At the onset of intrapartum fever ≥38°C, patients ≥36 weeks' gestation were either randomized to the control or experimental study arm. Patients in the control arm received 1000 mg of oral acetaminophen capsules and an intravenous placebo resembling intravenous acetaminophen. Patients randomized to the experimental arm received 1000 mg of intravenous acetaminophen and oral placebo capsules resembling acetaminophen. Maternal temperatures and fetal heart rates were recorded at consecutive intervals following administration of the first dose of acetaminophen. Maternal blood, collected at the onset of fever and after delivery, and neonatal cord blood collected at delivery were evaluated for oxidative stress (glutathione levels), levels of RANTES and cytokines (interferon-δ, interleukin 1ß, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α). Placentas were collected for pathologic review. A P value of <.05 was considered statically significant. RESULTS: A total of 121 patients (55 in the intravenous and 66 in the oral group) were recruited from December 1, 2016, to February 28, 2018. Patient demographics and intrapartum factors were similar between both arms. The intravenous group showed a mean time of 54.86 minutes (95% confidence interval, 20.57-39.43) to defervescence vs 52.58 minutes (95% confidence interval, 16.58-43.42) in the oral group (P=.71). In addition, intravenous and oral acetaminophen showed similar results in percentage of patients being afebrile and percent reduction in maternal temperature 30 minutes after administration of the first dose. Histopathological findings, neonatal outcomes, oxidative stress markers, and RANTES and cytokine levels were not statistically significant between intravenous and oral acetaminophen groups. CONCLUSION: Intravenous acetaminophen did not demonstrate a higher efficacy than oral acetaminophen in treating intrapartum maternal fever. Select patients may benefit from intravenous acetaminophen for treatment of intrapartum fever, including those who cannot tolerate oral medication.

Vaginal cleansing with chlorhexidine gluconate or povidone-iodine prior to cesarean delivery: a randomized comparator-controlled trial.

BACKGROUND: Several randomized controlled trials have demonstrated that preoperative abdominal skin preparation with chlorhexidine gluconate is superior to povidone-iodine for the prevention of surgical site infections. Despite these results, povidone-iodine is still the most commonly used agent for vaginal preparation, even though it may not be ideal. OBJECTIVES: The objectives of the study were as follows: (1) to determine whether vaginal cleansing with a 4% chlorhexidine gluconate solution results in fewer wound infections as compared with povidone-iodine when used for vaginal antisepsis prior to cesarean delivery and (2) to compare rates of patient reported side-effects associated with vaginal application of 4% chlorhexidine gluconate solution and 10% povidone-iodine. STUDY DESIGN: This is a block randomized, comparator-controlled, open-label trial. Women undergoing nonemergent cesarean delivery were randomized to receive vaginal cleansing with either 4% chlorhexidine solution or 10% povidone-iodine solution prior to skin incision. The primary outcome was wound site infection occurring within 14 days of cesarean delivery including superficial or deep surgical site infection. Secondary outcomes included rates of endometritis, postoperative fever, and side effects (vaginal dryness, irritation, and desquamitization) occurring within 14 days of cesarean delivery. Risks were reported as odds ratios with 95% confidence intervals, with P < .05 considered as significant. RESULTS: From Dec. 1, 2016, through Feb. 28, 2018, a total of 1,114 patients met the inclusion criteria: 524 were randomized to the chlorhexidine gluconate arm and 590 to the povidone-iodine arm. Both arms were similar with regard to age, parity, body mass index, gestational age at delivery, indication for cesarean delivery, and incidence of membrane rupture. The rate of wound infection was significantly lower in the chlorhexidine arm as compared with povidone-iodine (0.6% vs 2.0%; P = .039, odds ratio, 0.28, 95% confidence interval, 0.08-0.98). Rates of endometritis (0.4% vs 0.5%, P = 1.000) and postoperative fever (2.5% and 2.7%, P = 0.892) were similar for the chlorhexidine and povidone-iodine groups, respectively. No adverse effects on the vaginal mucosa were noted for either solution. CONCLUSION: Vaginal cleansing with a 4% chlorhexidine solution prior to cesarean delivery resulted in fewer overall wound infections when compared with povidone-iodine solution with no patient-reported adverse reactions.

Unique presentation of occult breast cancer with uterine cervix metastasis.

We are reporting a case of occult breast cancer (OBC) diagnosed via biopsy of an asymptomatic cervical mass. While non-OBC has occasionally been reported as metastatic to the uterine cervix, OBC never has, to our knowledge. Awareness of this presentation can be beneficial for a more expedite diagnosis and treatment.

Post-cesarean delivery outpatient opioid consumption and perception of pain control following implementation of a restrictive opioid prescription protocol.

BACKGROUND: Cesarean delivery is the most common laparotomy performed in the United States and can be the first exposure to opioids for many women. Unnecessary consumption of opioids may lead to long-term addiction and further perpetuate this national health crisis. OBJECTIVES: The primary objective of the study was to assess whether a quality improvement initiative by means of a restrictive opioid prescription policy decreases opioid consumption and maintains patient satisfaction after cesarean delivery. A secondary objective is to correlate opioid consumption with demographic and perioperative factors. MATERIALS AND METHODS: A Plan, Do, Check, Act model was used to implement a quality improvement initiative. A restrictive opioid prescribing policy was put in place in July 2017 preventing all physicians from prescribing opioids to their patients upon discharge after cesarean delivery; patients could call their providers from home to request additional analgesia (opioid or nonopioid) if pain was not sufficiently controlled. From August 2017 to February 2018, a postdischarge telephone interview assessing pain control satisfaction and opioid consumption was conducted for all English-speaking patients in our hospital who underwent a cesarean delivery. Statistical analysis was performed using IBM SPSS 22.0, with P < .05 reported as statistically significant. RESULTS: A total of 283 parturients were interviewed 8-33 days after cesarean delivery (mean, 16 days). After implementation of the restrictive opioid prescription policy, we observed a decrease in opioid prescriptions at discharge after cesarean delivery from 97.9% to 0%, with an 18% prescription rate after discharge. Patients reported high satisfaction with their pain control, with 89% (n = 253) stating that their pain was adequately controlled upon discharge. Although 90% (n = 256) reported that they did not need any pain medication other than ibuprofen or acetaminophen, opioids were prescribed to 18% of patients (n = 51) after discharge, with only 51% of these women (n = 27) consuming them. In response to the restrictive opioid prescribing policy, only 13% of the women (n = 37) reported that they wished that a stronger pain medication had been prescribed after hospital discharge. Factors associated with opioid consumption postdischarge included white race/ethnicity, multiparity, and opioid consumption during inpatient hospitalization. CONCLUSION: Following implementation of the restrictive opioid prescribing policy, most women experienced adequate pain control after cesarean delivery. Patient satisfaction with pain control was high, showing that it is feasible to implement restrictive opioid prescription policies while maintaining a high satisfaction rate.