Intrapartum fever complicated with maternal bacteremia: prevalence, bacteriology, and risk factors.

PURPOSE: To assess the prevalence, microbial profile, and clinical risk factors of maternal bacteremia associated with intrapartum fever (IPF). METHODS: A retrospective cohort study, in a single tertiary university-affiliated medical center between 2012 and 2018. Demographic and labor characteristics of women, who delivered at term (37+0/7-41+6/7) and developed bacteremia following IPF were compared to a control group of women with IPF but without bacteremia. RESULTS: During the study period there were 86,590 deliveries in our center. Of them, 2074 women (2.4%) were diagnosed with IPF, of them, for 2052 women (98.93%) the blood maternal cultures were available. In 26 patients (1.25%) maternal bacteremia was diagnosed. A lower rate of epidural anesthesia (84.6% vs 95.9%, p = 0.02) and a higher rate of antibiotics prophylaxis treatment prior to the onset of fever (30.8%.vs 12.1%, p = 0.006) were observed in patients who developed maternal bacteremia in comparison to those who have not. Maternal hyperpyrexia developed after initiation of antibiotics or without epidural anesthesia remained significantly associated with maternal bacteremia after applying a multivariate analysis, (Odds Ratio 3.14 95% CI 1.27-7.14, p = 0.009; 4.76 95% CI 1.35-12.5, p = 0.006; respectively). CONCLUSION: Maternal fever developing after initiation of antibiotics or without epidural is associated with maternal bacteremia.

Average maternal hemoglobin decline after first elective cesarean section compared to higher order cesarean sections.

INTRODUCTION: Lower uterine segment scarring after cesarean section can decrease intraoperative bleeding during subsequent surgery. We examined whether first elective cesarean section is associated with greater average blood loss compared to repeated surgery. METHODS: Decrease in maternal hemoglobin and hematocrit after surgery was retrospectively compared between three study groups, women in their first, second and third or more cesarean section. Surgery length and need for blood transfusion were also compared. RESULTS: Out of 9401 cases reviewed between January 2010 November 2020, 3917 had a first cesarean section, 3159 s cesarean section and 2325 had a third or more cesarean section. Hemoglobin and hematocrit drops were highest after first cesarean section (1.1 vs 1.0 vs 1.0 mg/dL, P < 0.001 and 3.3 vs 3.0, vs 2.9%, P < 0.001, respectively). Surgery length was significantly longer and more patients after third cesarean section required blood transfusions (2.5% vs 1.4% vs. 0.8%, P < 0.001). First cesarean section, younger age and BMI >35 were associated with increased hemoglobin drop in univariate and multivariate analysis. CONCLUSIONS: Although repeated cesarean section is associated with longer surgery and higher need for blood transfusion, average hemoglobin drop after first cesarean section is higher. Scarring of the lower uterine segment can explain this paradoxical finding.

Fertility Preservation in Endometriosis: Does Patient Symptomatology Affect the Extent of the Ovarian Response?

This study is to identify factors and patient symptomatology affecting ovarian response in women with endometriosis who seek fertility preservation. An observational cross-sectional study was conducted from July 2017 to May 2020 at a tertiary university-affiliated medical center. We included patients who were treated in the endometriosis clinic and underwent fertility preservation. Patients completed an online questionnaire that was cross-referenced with electronic charts. An analysis related to patient data and fertility preservation cycles and a mediation analysis were performed. The mean patient age at time of fertility preservation was 35.2 (± 4.9) years. The mean accumulated number of oocytes vitrified per patient was 16.7 (± 12.1) oocytes. The correlation coefficient assessed between the number of oocytes vitrified per cycle and AMH was significantly positive at +0.472, p = 0.006. The examined reported symptoms were lethargy, chronic pelvic pain, dyschezia, dyspareunia, bowel-associated symptoms, and urinary tract symptoms. The number of oocytes vitrified correlated with the number of reported symptoms and clinical characteristics at - 0.497, p = 0.0001, and - 0.442, p = 0.0001, respectively. In a mediation analysis, the potential causality of surgical intervention in the relationship between the number of symptoms and ovarian response was - 0.300 (95% CI [0.15, 1.905], p = 0.05), and the calculated proportion of mediation was estimated to be 17%. We observed a significant negative association between the number of clinical symptoms and the quantity of vitrified oocytes. This relationship was only partly associated with prior surgical intervention. AMH was found to have the highest correlation with treatment success in patients with endometriosis undergoing fertility preservation.

Labor induction in third trimester non-viable fetus.

OBJECTIVE: We aimed to assess the efficacy of three different labor induction methods for non-viable third-trimester fetuses. METHODS: This retrospective cohort study included women who had an intra-uterine fetal death or termination of pregnancy at or after 28 weeks of gestation and underwent labor induction by either transcervical foley catheter and concomitant oxytocin infusion or regular doses of vaginal Prostin© or Propess©.The primary outcome was induction to the delivery interval. Secondary outcomes included the rate of women who delivered within 24 h, time spent in the delivery room, failed induction, adverse outcomes and reported occurrence of moderate to severe pain. RESULTS: Between January 2017 to June 2020, 107 women met the inclusion criteria. 25 women underwent induction of labor using transcervical foley catheter, 44 using Propess©, and 58 by Prostin©. The three groups were found to be demographically similar. The rate of women who delivered within 24 h was higher in the transcervical foley catheter group compared to the Propess© and Prostin© groups (72% vs 25% vs 29.3%, p < .001 respectively). Time to delivery was shorter among the transcervical foley catheter group compared to the Propess© and Prostin© groups (16.97 h vs 39.4 vs 39.3, p < .001 respectively). When comparing the Foley catheter group to both Propess© and Prostin©, moderate to severe pain was significantly more commonly reported in the prostaglandins groups (36.0% vs 50.0% vs 65.62%, p = .04). No difference was found in adverse outcomes, defined as intrapartum fever, post-partum hemorrhage and retained placenta. CONCLUSION: Cervical foley catheter with concomitant oxytocin infusion is the most effective method for induction of labor in third trimester non-viable in fetus compared to PGE2.

A virtual reality system for pain and anxiety management during outpatient hysteroscopy-A randomized control trial.

BACKGROUND: Visual and acoustic virtual reality (VR) has been increasingly explored as a non-pharmacological tool for pain relief in clinical settings. OBJECTIVE: We aimed to evaluate the effectiveness of VR as a distraction technique in the management of acute pain during operative hysteroscopy in the outpatient setting. METHODS: A prospective, open-label, randomized control trial in a tertiary university-affiliated medical centre between April and August 2020. Overall, 82 women were randomly allocated to undergo operative hysteroscopy either with the use of VR (n = 44, study group) or with standard treatment (control group, n = 38). VR was applied throughout the procedure and no anaesthesia was given. The primary outcome measures included self-reported intraoperative pain. Other objectives included vital parameters as pulse rate (PR) and respiratory rate (RR) before and during the first 3 min of the procedure. Pain and anxiety outcomes were measured as numeric rating scores. RESULTS: The baseline parameters were similar between groups. The mean duration for the procedure was 8.1 ± 3.2 vs. 7.3 ± 6.0 min for the study and the control groups (p = 0.23). There were no statistically significant differences between the reported pain scores during the procedure [median (interquartile range) 5.0 (3.0-7.2) vs. 5.0 (3.0-8.0), respectively; p = 0.67]. While neither intraoperative heart rate nor respiratory rate differed between groups [14.0 (13.0-16.0) vs. 14.0 (11.0-16.5); p = 0.77)], the increase of heart rate was found greater in the VR group [+7.0 (8.5) vs. +1.0 (12.2); p = 0.01]. CONCLUSION: VR was not effective in reducing pain during an outpatient operative hysteroscopy. SIGNIFICANCE: The use of a Virtual reality system was found ineffective in reducing pain during and after an office operative hysteroscopy without anaesthesia, in a thorough examination of both continuous physiological parameters and women's self-reported measures.

Predicting the need for blood transfusion requirement in postpartum hemorrhage.

OBJECTIVE: We aimed to assess the role of lactate and hemoglobin levels as predictors for the need for blood transfusion in post-partum hemorrhage (PPH). METHODS: A retrospective cohort study of women with PPH in a single university-affiliated tertiary medical center between August 2018 and June 2020. PPH was defined as an estimated excessive blood loss (of more than 500 ml following vaginal delivery and 1000 ml following a cesarean delivery) requiring at least one uterotonic drug and fluid resuscitation. Women were stratified by the need of requiring blood transfusion due to hemorrhage. The criteria for blood transfusion were: (1) clinically severe uncontrollable ongoing hemorrhage; (2) symptomatic anemia (maternal tachycardia >110 beats per minute, dizziness, syncope or presyncope) in the presence of Hb 7-8 g/dL; or (3) postpartum Hb level < 7 g/dL regardless of maternal symptoms or signs of anemia. Demographic, labor characteristics as well as laboratory data were collected. For all women the Shock Index (SI: heart rate divided by systolic blood pressure) was calculated. Women without available data on immediate (more than 15 min from the bleeding initiation) hemoglobin (Hb) level and lactate concentrations were excluded. RESULTS: Overall, out of 22,241 deliveries during the study, 94 women were included, of them 26 (23.4%) required blood transfusion. The antepartum Hb level was lower in the transfused group (11.7 ± vs 12.4 ± 1.0 re/dL, p = .01). No significant differences were found in demographic and labor characteristics. In multivariate logistic regression analysis, a lower immediate postpartum Hb and a higher SI higher were associated with blood transfusion requirement (adjusted odds ratio (aOR) 3.45 [CI] 1.82-7.69, p < .001] and aOR 1.25 [CI 1.03-1.55, p = .03], respectively). The combination of SI, immediate postpartum Hb and lactate concentration provided the best integration, with an area under the curve of 0.86, sensitivity 92.65%, specificity 61.54%, positive and negative predictive values of 86.3% and 76.2%, respectively. CONCLUSION: The combination of SI, immediate postpartum Hb and lactate levels is a good predictor for the need of blood requirement in PPH.

Early Preterm meconium stained amniotic fluid is an independent risk factor for peripartum maternal bacteremia.

OBJECTIVE: To investigate the association of maternal peripartum bacteremia and meconium stained amniotic fluid in early preterm deliveries. METHODS: We conducted a single center retrospective study, in a tertiary university affiliated medical center. The study cohort included women with culture proven maternal bacteremia who had a preterm delivery between 24-34 weeks of gestation. The control group composed of women with similar gestational age at delivery without bacteremia. Maternal characteristics were compared between the groups. RESULTS: During the six-years study period there were 86,590 deliveries in our center. 2625 (3.03 %) women had early preterm deliveries (24-34 weeks), of them 22 (0.84 %) were diagnosed with peripartum bacteremia. The groups were similar with regard to obstetric and demographic characteristics. In the peripartum maternal bacteremia group, we found significantly higher rates of MSAF (6.86 % vs 22.73 %, p = 0.036). Logistic regression of multivariable analysis demonstrated that MSAF is an independent risk factor for maternal bacteremia adjusted for gestational age, intrapartum fever and leukocytosis (Odd Ratio 4.29, 95 % CI 1.26-12.56, p = 0.012) CONCLUSION: Preterm MSAF is an independent risk factor for maternal bacteremia among women with early preterm delivery. More studies are needed to determine the need for broad spectrum antibiotic prophylaxis therapy in preterm deliveries complicated by MSAF.

Effect of liver fibrosis on survival in patients with intrahepatic cholangiocarcinoma: a SEER population-based study.

BACKGROUND: Intrahepatic cholangiocarcinoma (iCCA) is a biliary tract malignancy with rising incidence in recent decades. While the causative role of cirrhosis in the development of iCCA is well established, the role of cirrhosis as a prognostic factor in iCCA is debatable. MATERIALS AND METHODS: The study population consisted of 512 patients diagnosed with iCCA between 2004-2016 collected from the Surveillance, Epidemiology and End Results (SEER) database. The impact of fibrosis on overall and cancer-specific survival 12, 36 and 60 months following diagnosis, was evaluated in the entire cohort and in sub-groups stratified according to treatment approach and the American Joint Committee on Cancer (AJCC) tumor stage using a Cox proportional-hazards model. RESULTS: After adjusting for age, sex, race, year of diagnosis, AJCC stage, and surgical treatment strategy, advanced fibrosis was associated with worse cancer-specific survival across follow up periods (HR 1.49 (1.13-1.96, p = 0.005); HR 1.44 (1.14-1.83, p = 0.002) and HR 1.45 (1.15-1.83, p = 0.002) for 12, 36 and 60 months, respectively). Similar effects were observed for overall survival. Among patients that underwent surgical resection, advanced fibrosis was associated with worse overall survival and cancer-specific survival across follow up periods. Fibrosis was associated with worse overall and cancer-specific survival in patients with a later stage (III-IV) at diagnosis but this effect was not demonstrated in early stages. CONCLUSIONS: Patients with iCCA and advanced liver fibrosis have an increased risk of both overall and cancer-specific mortality compared to patients with earlier stages of fibrosis.