Increased Risk of Postpartum Infections After Caesarian and Vaginal Delivery in Women With Inflammatory Bowel Disease: A Danish Nationwide Cohort Study.

BACKGROUND: There is lack of knowledge concerning postpartum infections in women with inflammatory bowel disease (IBD). Our aim is to determine the 30-day postpartum infectious complications in women with and without IBD who have a caesarian section, normal vaginal delivery, or assisted vaginal delivery. METHODS: We used Danish national registries to establish a study population of liveborn, singleton births from January 1, 1997, through December 31, 2015. We examined 30-day postpartum maternal infectious complications in women with and without IBD, according to the mode of delivery. Statistical models were adjusted for multiple confounders. RESULTS: In all, 3255 women with and 207 608 without IBD had a caesarian section. Within 30 days postpartum, 4.5% of women with and 3.7% without IBD had an infectious complication. Increased infectious complications included overall infections (adjusted OR [aOR], 1.83; 95% confidence interval [CI], 1.35-2.47), infections of the gastrointestinal tract (aOR, 4.36, 95% CI 2.34-8.10), and infections of the skin and subcutaneous tissue (aOR, 4.45; 95% CI, 2.30-8.50). Other puerperal infections, urological and gynecological, and other infections were increased, although not significantly. For vaginal deliveries, 1.6% of 5771 women with IBD and 1.3% of 793 110 women without IBD had an infectious complication, and the aOR of infections of the gastrointestinal tract was 3.17 (95% CI, 1.47-6.85). There were too few outcomes to calculate the risk of infections after assisted vaginal delivery. CONCLUSIONS: The risk of a 30-day postpartum infectious complication is increased in women with IBD. Physicians should carefully monitor their patients postpartum to prevent these adverse outcomes.

Women with inflammatory bowel disease who have a caesarean section or a vaginal delivery are at increased risk for infections within the 30-day postpartum period. Physicians should be aware of this increased risk and work to minimize infectious complications after delivery.

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.

Antibiotic Prophylaxis to Prevent Obesity-Related Induction Complications in Nulliparae at Term: a pilot randomized controlled trial.

BACKGROUND: Women with obesity are at increased risk of complications during and after labor and delivery, including puerperal infection and cesarean delivery. As labor induction has become increasingly common, it is crucial to find ways to decrease complication rates in this high-risk population. OBJECTIVE: This study aimed to explore the effect of prophylactic antibiotics during labor induction of nulliparous women with obesity on the rates of cesarean delivery and puerperal infection and to estimate the parameters needed to calculate the sample size for a larger, multicenter trial. STUDY DESIGN: In this randomized, placebo-controlled pilot trial, nulliparous patients with a body mass index of ≥30 kg/m2 were randomized to either prophylactic antibiotics (500 mg azithromycin for 1 dose and 2 g cefazolin every 8 hours for up to 3 doses) or placebo, administered starting at the beginning of labor induction. The exclusion criteria were known fetal anomaly, fetal demise, multifetal gestation, ruptured membranes >12 hours, infection requiring antibiotics at the start of labor induction, and/or allergy to azithromycin or beta-lactam antibiotics. The co-primary outcomes were rates of puerperal infection (composite of chorioamnionitis, endometritis, and/or cesarean delivery wound infection) and cesarean delivery. Participants were followed up for 30 days after delivery, and maternal and neonatal demographic and outcome data were collected. Proportions and 95% confidence limits were calculated for each of these outcomes. RESULTS: From January 2019 to May 2021, 101 patients were randomized in the class III stratum (1 patient who was randomized ultimately did not undergo labor induction). From February 2020 to May 2021, 38 and 47 patients were randomized to class I and II strata, respectively (to assess the effect of obesity class on the outcomes expected to be influenced by antibiotic prophylaxis). In the antibiotics and placebo groups, the rates of cesarean delivery were 29.0% (95% confidence interval, 19.8-38.3) and 39.8% (95% confidence interval, 29.8-49.7), respectively, and puerperal infection occurred in 8.6% (95% confidence interval, 2.9-14.3) and 9.7% (95% confidence interval, 3.7-15.7), respectively. In the subgroup with class III obesity, in the antibiotics and placebo groups, the rates of cesarean delivery were 33.3% (95% confidence interval, 20.4-47.9) and 46.0% (95% confidence interval, 32.2-59.8), respectively, and puerperal infection occurred in 7.8% (95% confidence interval, 0.5-15.2) and 10.0% (95% confidence interval, 1.7-18.3), respectively. Note that this pilot study was not powered to detect differences of this magnitude but rather to estimate parameters. CONCLUSION: The administration of prophylactic antibiotics during labor induction of nulliparous patients with obesity resulted in a 27% lower cesarean delivery rate overall and a 28% lower rate in patients with class III obesity. A larger trial is warranted to evaluate these differences.

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.

New obstetric systemic inflammatory response syndrome criteria for early identification of high-risk of sepsis in obstetric patients.

OBJECTIVES: We aimed to establish new cut-off values for SIRS (Systemic Inflammatory Response Syndrome) variables in the obstetric population. METHODS: A prospective cohort study in pregnant and postpartum women admitted with systemic infections between December 2017 and January 2019. Patients were divided into three cohorts: Group A, patients with infection but without severe maternal outcomes (SMO); Group B, patients with infection and SMO or admission to the intensive care unit (ICU); and Group C, a control group. Outcome measures were ICU admission and SMO. The relationship between SIRS criteria and SMO was expressed as the area under the receiver operating characteristics curve (AUROC), selecting the best cut-off for each SIRS criterion. RESULTS: A total of 541 obstetric patients were enrolled, including 341 with infections and 200 enrolled as the reference group (Group C). The patients with infections included 313 (91.7%) in Group A and 28 (8.2%) in Group B. There were significant differences for all SIRS variables in Group B, compared with Groups A and C, but there were no significant differences between Groups A and C. The best cut-off values were the following: temperature 38.2 °C, OR 4.1 (1.8-9.0); heart rate 120 bpm, OR 2.9 (1.2-7.4); respiratory rate 22 bpm, OR 4.1 (1.6-10.1); and leukocyte count 16,100 per mcl, OR 3.5 (1.6-7.6). CONCLUSIONS: The cut-off values for SIRS variables did not differ between healthy and infected obstetric patients. However, a higher cut-off may help predict the population with a higher risk of severe maternal outcomes.

Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections.

OBJECTIVES: Gestational IDA has been linked to adverse maternal and neonatal outcomes, but the impact of iron supplementation on outcome measures remains unclear. Our objective was to assess the effects of gestational IDA on pregnancy outcomes and compare outcomes in pregnancies treated with either oral or intravenous iron supplementation. METHODS: We evaluated maternal and neonatal outcomes in 215 pregnancies complicated with gestational IDA (Hb<100 g/L) and delivered in our tertiary unit between January 2016 and October 2018. All pregnancies from the same period served as a reference group (n=11,545). 163 anemic mothers received oral iron supplementation, and 52 mothers received intravenous iron supplementation. RESULTS: Gestational IDA was associated with an increased risk of preterm birth (10.2% vs. 6.1%, p=0.009) and fetal growth restriction (FGR) (1.9% vs. 0.3%, p=0.006). The gestational IDA group that received intravenous iron supplementation had a greater increase in Hb levels compared to those who received oral medication (18.0 g/L vs. 10.0 g/L, p<0.001), but no statistically significant differences in maternal and neonatal outcomes were detected. CONCLUSIONS: Compared to the reference group, prematurity, FGR, postpartum infections, and extended hospital stays were more common among mothers with gestational IDA, causing an additional burden on the families and the healthcare system.

Factores asociados a la presentación de sepsis puerperal en provincia Guantánamo, 2017-2018 / Factors associated with the presentation of puerperal sepsis in Guantanamo province, 2017-2018 / Fatores associados à apresentação de sepse puerperal na província de Guantánamo, 2017-2018

RESUMEN Introducción: La sepsis y el choque séptico representan una de las complicaciones más graves durante el puerperio. Objetivos: Identificar los factores asociados a la presentación de sepsis puerperal en las pacientes que ingresaron en el Servicio de Cuidados Intensivos del Hospital General Docente "Dr. Agostinho Neto" durante el período 2017-2018. Método: Se realizó un estudio explicativo-observacional, longitudinal, retrospectivo y tipo caso control. Resultados: La endomiometritis fue la principal causa de ingreso con el 79,5 %. Las variables que se comportaron como predictoras de sepsis puerperal fueron la paridad-multípara, la edad gestacional menor de 37 semanas, el parto por cesárea, el antecedente de preclampsia, de sepsis vaginal y sepsis urinaria, la rotura prematura de membranas y el trabajo de parto mayor a 12 horas. Las variables que constituyeron factores de riesgo independiente para la morbilidad por sepsis grave fueron el exceso de base <- 4 (OR=11,9; IC 95 %; 3,9-35,3; p<0,05) la proteína C reactiva >8 mg/L (OR=9,67; IC 95 %; 5,9-14,24), la SatO2< 75 (OR=6,35; IC 95 %; 1,72-23,4), el anión gap >16 mmol/L (OR=5,88; IC 95 %; 3,86-8,97), el APACHE II y la escala SOFA (Sequential Organ Failure Assessment) al ingreso con el (OR=2,57; IC 95 %; 0,97-6,80) y el (OR=2,67; IC 95 %; 1,95-3,66), respectivamente. Conclusiones: La sepsis puerperal significa una problemática en el Hospital General Docente "Dr. Agostinho Neto" de Guantánamo, por lo que su reconocimiento y tratamiento adecuados son las claves para disminuir la morbilidad por esta causa.

ABSTRACT Introduction: Sepsis and septic shock represent one of the most serious complications during the puerperium. Objective: To identify the factors associated with the presentation of puerperal sepsis in patients admitted to the Intensive Care Service of the General Teaching Hospital "Dr. Agostinho Neto" during the 2017-2018 period. Method: An explanatory, observational, longitudinal, retrospective and case-control study was conducted. Results: Endomyometritis was the main cause of admission with 79.5%. The variables that behaved as predictors of puerperal sepsis were multiparous parity, gestational age under 37 weeks, delivery by caesarean section, history of preclampsia, vaginal sepsis and urinary sepsis, premature rupture of membranes and work of delivery greater than 12 hours. The variables that constituted independent risk factors for severe sepsis morbidity were base excess <- 4 (OR=11.9; 95% CI; 3.9-35.3; p <0.05) protein C reactive> 8 mg/L (OR=9.67; 95% CI; 5.9-14.24), SatO2 <75 (OR=6.35; 95% CI; 1.72-23.4), the gap anion> 16 mmol/L (OR=5.88; 95% CI; 3.86-8.97), APACHE II and the SOFA (Sequential Organ Failure Assessment) scale upon admission with (OR=2, 57; 95% CI; 0.97-6.80) and (OR=2.67; 95% CI; 1.95-3.66), respectively. Conclusions: Puerperal sepsis means a problem at the "Dr. Agostinho Neto" General Teaching Hospital in Guantanamo, so that its recognition and adequate treatment are the keys to reducing morbidity from this cause.

RESUMO Introdução: Sepse e choque séptico representam uma das complicações mais graves durante o puerpério. Objetivo: Identificar os fatores associados à apresentação de sepse puerperal em pacientes internados no Serviço de Terapia Intensiva do Hospital Geral de Ensino "Dr. Agostinho Neto" no período 2017-2018. Método: Estudo explicativo, observacional, longitudinal, retrospectivo e caso-controle. Resultados: A endomiometrite foi a principal causa de admissão com 79,5%. As variáveis que se comportaram como preditores de sepse puerperal foram: paridade multípara, idade gestacional abaixo de 37 semanas, parto por cesariana, história de pré-eclâmpsia, sepse vaginal e sepse urinária, ruptura prematura de membranas e trabalho de parto. entrega superior a 12 horas. As variáveis que constituíram fatores de risco independentes para morbidade grave por sepse foram excesso de base <- 4 (OR=11,9; IC 95%; 3,9-35,3; p<0,05) proteína C reativo> 8 mg/L (OR=9,67; IC 95%; 5,9-14,24), SatO2 <75 (OR=6,35; IC 95%; 1,72-23,4), o ânion de gap> 16 mmol/L (OR=5,88; IC 95%; 3,86-8,97), APACHE II e SOFA (Sequential Organ Failure Assessment) na admissão com (OR=2, 57; IC95%; 0,97-6,80) e (OR=2,67; IC95%; 1,95-3,66), respectivamente. Conclusões: Sepse puerperal representa um problema no Hospital Geral Dr. Agostinho Neto, em Guantánamo, para que seu reconhecimento e tratamento adequado sejam as chaves para reduzir a morbidade por essa causa.

Developing a Core Outcome Set for Cesarean Delivery Maternal Infectious Morbidity Outcomes.

OBJECTIVE: This study aimed to develop a core outcome set of primary outcomes for studies involving cesarean deliveries with infectious morbidity outcomes. STUDY DESIGN: Authors reported primary outcomes from 11 Cochrane systematic reviews (SRs), 12 other SRs, and 327 randomized controlled trials (RCTs). These outcomes were condensed into 20 primary outcome groups. Next, a modified Delphi technique was used to gain consensus on key outcomes. Authors from included SRs were sent a questionnaire consisting of a free response and multiple-choice questions. These data were used to propose a set of core outcomes. RESULTS: The most frequent outcomes in RCTs were composite "infectious outcomes" (24%) with the second most common being endometritis (12%). The most common reported SR outcomes were wound infection (21%) and endometritis (16%). For the Delphi survey free response portion, wound infection (88%) and endometritis (79%) were the most commonly endorsed outcomes. Chosen list outcomes were maternal mortality (83%), wound infection (83%), wound complications (86%), and postpartum endometritis (80%). The proposed final core outcome set for cesarean trials was endometritis (primary outcome), maternal mortality, wound infection, wound complications, febrile morbidity, and neonatal morbidity. CONCLUSION: Utilizing defined core outcomes in all studies of cesarean section can harmonize trial reports and allow data synthesis for meta-analyses.

Peritoneal adhesions are an independent risk factor for peri- and post-partum infectious morbidity.

OBJECTIVE: To investigate whether the presence of peritoneal adhesions during a second cesarean delivery resulting from the first cesarean delivery, are associated with peri- and post-partum infectious morbidity. STUDY DESIGN: A retrospective cohort study was undertaken, comparing maternal peri- and immediate post-partum infectious morbidity during the second cesarean delivery, between women with and without adhesions resulting from the first cesarean delivery. All women over 18 years old at their second cesarean delivery, with a singleton pregnancy between the years 1988-2016 were included in the analysis. Patients with previously diagnosed adhesions during the first cesarean delivery, a history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies, and births of newborns with known chromosomal or structural abnormalities were excluded from the analysis, resulting in a study population of 7925 women. Infectious morbidity was defined as a composite of chorioamnionitis, post-partum fever, urinary tract infection and surgical wound infection or disruption. In order to identify factors that are independently associated with infectious morbidity, multivariate logistic regression analyses were constructed to control for potential confounders. RESULTS: During the study period, 32.6% (n = 2581) women were diagnosed with adhesions at the second cesarean delivery. Second cesarean deliveries complicated with adhesions were characterized by higher rates of peri- and post-partum maternal infectious morbidity (6.5% vs. 9%, p < 0.001). Our study population comprises two ethnic groups- Jewish (54.3%) and Bedouin Arabs (45.7%). We have tested interactions with adhesions of all predictor variables in the model. Since we found a strong interaction between adhesions and ethnicity, stratified data are presented. Infectious morbidity was significantly associated with the presence of peritoneal adhesions only among Jewish women (adjusted OR 2.09, PV < 0.001, 95% CI 1.56-2.80), adjusting for potential confounding variables and significant interactions. CONCLUSION: Cesarean delivery complicated with adhesions attributable to a previous cesarean delivery, increase the risk for peri- and immediate post-partum infectious morbidity among Jewish women.

Chorioamnionitis and Infectious Complications after Vaginal Delivery.

OBJECTIVE: To estimate the incidence of and define risk factors for postpartum infectious complications after vaginal birth after cesarean (VBAC) complicated by chorioamnionitis. STUDY DESIGN: A secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Unit Cesarean Registry was performed. The primary outcome was a composite of postpartum infection: endometritis, sepsis, pelvic abscess, urinary tract infection, necrotizing fasciitis, and septic pelvic thrombophlebitis. Peripartum predictors were compared using parametric and nonparametric tests, as appropriate, and multivariate predictors assessed using logistic regression. RESULTS: A total of 559 subjects had chorioamnionitis in labor and a successful VBAC. Twenty-four (4.3%) subjects experienced the primary outcome, mainly due to endometritis (19/24). Significant factors included preterm delivery <32 weeks (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.32-7.06) and body mass index (BMI) ≥40 (OR: 4.63, 95% CI: 1.25-17.14). Receipt of postpartum antibiotics was protective against postpartum infection (OR: 0.28, 95% CI: 0.12-0.65). In multivariate analysis, preterm delivery <32 weeks, BMI ≥40, and receipt of postpartum antibiotics remained associated with postpartum infection. CONCLUSION: Nearly 5% of women with chorioamnionitis had a postpartum infectious complication after vaginal delivery, with higher rates in those delivering at <32 weeks and with prepregnancy BMI ≥40. Receipt of postpartum antibiotics decreased the odds of postpartum infection markedly.

Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries.

Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient's median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Maternofetal outcomes of obstructed labor among women who gave birth at general hospital in Ethiopia.

OBJECTIVE: Obstructed labor had different maternal outcomes such as uterine rupture, postpartum hemorrhage, puerperal sepsis, Vesico-Vaginal fistula (VVF), recto-vaginal fistula can leads to death. Besides fetal outcomes including birth asphyxia, still birth, neonatal jaundice and umbilical sepsis can occur. Identifying maternal and fetal outcomes of obstructed labor among women who gave birth at Suhul general Hospital, Shirie town, Tigray, Ethiopia has been done using a retrospective review of delivery charts and registration book. RESULTS: Majority of mothers 69 (75.8%) came from rural areas and 74.7% were married. Cephalo pelvic disproportion occurs in 59 (64.8%) and mal-presentation in 28 (30.8%) of obstructed labor. Fetal congenital anomaly (hydrocephalus) occurs in 3 (3.3%) of cases and pelvic mass constituted 1 (1.1%) of cause of obstructed labor. Above half of mothers delivered with obstructed labor had sepsis 23 (25.3%), post-partum hemorrhage 10 (11%), Vesico Vaginal Fistula 5 (5.5%) and anemia 15 (16.5%). From the well-known causes of obstructed labor; mal-presentation, Cephalo pelvic disproportion, fetal congenital anomaly, and pelvic mass were found to the common outcomes of obstructed labor in our study area. Besides Still birth, birth asphyxia, and birth injury were the others.

The effect of bladder catheterization on the incidence of urinary tract infection in laboring women with epidural analgesia: a meta-analysis of randomized controlled trials.

INTRODUCTION AND HYPOTHESIS: There is conflicting evidence on whether intermittent catheterization (IC) is less associated with urinary tract infection (UTI) and more likely to prevent urinary retention than continuous catheterization (CC). We aimed to compare the effect of IC with that of CC on the incidence of postpartum UTI, urinary retention and hemorrhage in laboring women with epidural analgesia. METHODS: Electronic searches were performed in PubMed, EMBASE and Cochrane Library from their inception to October 2018. We selected RCTs comparing IC with CC in laboring women with epidural analgesia. A meta-analysis was performed using the RevMan software, and a random-effects model was used to pool the effect size. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence. RESULTS: Six RCTs (N = 850) were included in this review. The meta-analyses indicated that there was no significant difference between the IC and CC group in the incidence of postpartum UTI (RR = 1.25, 95% CI: 0.91 to 1.71, P = 0.16), postpartum urinary retention (RR = 0.76, 95% CI: 0.21 to 2.77, P = 0.68) and postpartum hemorrhage (RR = 1.72, 95% CI: 0.60 to 4.95, P = 0.31). GRADE assessment results showed that the quality of evidence was low. CONCLUSIONS: Based on the available evidence, there is no measurable difference in rates of UTI between CC and IC, not that neither stragety decreases UTI, since the included trials do not address this.

From septicemia to sepsis 3.0-from Ignaz Semmelweis to Louis Pasteur.

Sepsis remains a contemporary threat, and its frequency remains high amongst an aging population. Its definition has been regularly revisited, but the impact of the translational research studying it remains very modest compared to the results seen after the introduction of hygiene and the use of antibiotics. In the past, the main forms of sepsis were hospital gangrene (also known as nosocomial fever or putrid fever) that affected the wounded, and puerperal fever that affected women shortly after delivery. In 1858, Armand Trousseau stated that these two pathologies were identical. Lucrezia Borgia, who died in 1519, is undoubtedly the most famous woman to die from puerperal fever. The notion of sepsis as a real epidemic was deplored. For decades doctors remained deaf to the recommendations of their clairvoyant colleagues who advocated for the use of hygienic measures. It was as early as 1795 that Alexander Gordon (UK) and later in 1843, Oliver Holmes (USA), called for the use of hygienic practices. In 1847, Ignaz Semmelweis, a Hungarian physician, provided an irrefutable demonstration of the importance of hygiene in the prevention of contamination by the hands of the practitioners. But Ignaz Semmelweis' life was a tragedy, his fight against the medical nomenklatura was a tragedy, and his death was a tragedy! Nowadays, Ignaz Semmelweis is receiving the honor that he deserves, but never received during his life. Carl Mayrhofer, Victor Feltz, and Léon Coze were the first to associate the presence of bacteria with sepsis. These observations were confirmed by Louis Pasteur who, thanks to his prestige, had a great influence on how to undertake measures to prevent infections. He inspired Joseph Lister who reduced mortality associated with surgery, particularly amputation, by utilizing antiseptic methods.

Determinants of puerperal sepsis among post partum women at public hospitals in west SHOA zone Oromia regional STATE, Ethiopia (institution BASEDCASE control study).

BACKGROUND: Puerperal sepsis is an infection of the genital tract, which occurs from rupture of amniotic sacs and within 42ndday after delivery. It happens mainly after discharge in the 1st 24 h of parturition. It is the third leading cause of direct maternal mortality in developing nations. It is also among preventable conditions. Even though multiple interventions were done to overcome these health problems, maternal mortality and morbidities were still significant. Mainly, in Ethiopia lack of clearly identified causes of maternal mortality and morbidity makes the problem unsolved. METHODS: Case-control study was conducted at public Hospitals in west shoa zone Oromia regional state, Ethiopia from February 01 to April 30/2018.women with puerperal sepsis (n = 67) were selected by convenience method. Controls (n = 213) were selected by systematic random sampling. Controls to cases ratio was 3:1 and structured questionnaire was used to interviewafter verbal consent was obtained. Data was entered in to epi -info 7.2 then exported to SPSS version 20.0 for analysis. A logistic regression model was used for data analysis. Those variables which have p-value < 0.05 were accepted that they are independent determinants of puerperal sepsis. RESULT: Rural residence (AOR [95%CI] = 2.5(1.029-6.054),Mothers with no formal education (AOR [95%CI] = 6.74([1.210-37.541]), up to primary level of education(AOR [95%CI] = 6.72(1.323-34.086), total monthly income of the mother or family<=500 ETB and 501-1500 ETB(AOR [95%CI] = 5.94(1.471-23.93) and (AOR [95%CI] =6.57 (1.338-32.265) respectively, Mothers having 1-2 times antenatal care(ANC)visit (AOR [95%CI] = 6.57([1.338-32.265]), Duration of Labor12-24 h (AOR [95%CI] = 3.12 (1.805-12.115),> = 25 h (AOR [95%CI] = 4.71([1.257-17.687]),vaginal examinations > = 5times (AOR [95%CI] = 4.00([1.330-12.029]), Delivery by C/S (AOR [95%CI] = 3.85 ([1.425-10.413]), Rupture of membrane > 24 h (AOR [95%CI] = 3.73([1.365-10.208]) and those Referred from other health institutions (AOR [95%CI] = 2.53([1.087-5.884],were independent determinants of puerperal sepsis in this study. CONCLUSION: Majority of determinants of puerperal sepsis were related with pregnancy and childbirth. Therefore, to tackle a problem of puerperal sepsis all concerning bodies should take measures during prenatal, natal and postnatal period.

Risk factors, clinical course and outcomes of pregnancy-related group A streptococcal infections: retrospective 13-year cohort study.

OBJECTIVES: To investigate the incidence, risk factors, clinical course and outcomes of pregnancy-related group A streptococcus (GAS) infection. METHODS: A retrospective 13-year cohort study of culture-proven pregnancy-related GAS infection was performed at two university hospitals serving heterogeneous, multicultural, urban and rural populations. RESULTS: Of 124 women diagnosed with pregnancy-related GAS infection, 115 (93%) were in the puerperium, an incidence of 0.8 cases per 1000 live births (95% confidence interval, 0.7-0.9). A multivariate analysis showed primiparity and cesarean delivery to be independent protective factors against puerperal GAS infection (adjusted odds ratios (95% confidence interval), 0.60 (0.38, 0.97) and 0.44 (0.23, 0.81), respectively). Of the nine remaining patients, eight were diagnosed after first trimester abortions and one had an infected ectopic pregnancy. Among the entire cohort (n = 124), the predominant manifestations were fever and abdominal tenderness. Twenty-eight patients (23%) had severe GAS infections. All were treated with ß-lactams, and most (n = 104, 84%) received clindamycin. Only four (3%) required surgical intervention; the rest fully recovered with conservative medical treatment including antibiotics. No recurrences, maternal deaths or neonatal complications were noted. CONCLUSIONS: Pregnancy-related GAS infection is not rare; it lacks specific signs and still carries significant morbidity. Primiparity, a presumable surrogate for diminished exposure to children and thus less GAS carriage, and cesarean delivery in which perioperative antibiotic prophylaxis was uniformly provided, appear as protective factors against puerperal GAS infection. This hints to the importance of community-acquired GAS and may support shifting efforts from infection-control-oriented nosocomial investigations to screening and prevention-driven policies.

The association of puerperal sepsis with HIV infection at two tertiary hospitals in Zimbabwe.

OBJECTIVE: To evaluate the association between HIV infection and puerperal sepsis among women in Zimbabwe. METHODS: A subanalysis was performed using data from a prospective cohort study conducted between September 2, 2014, and July 1, 2015, at two tertiary hospitals in Zimbabwe. Eligible participants were consecutive women who met the WHO criteria for puerperal sepsis. Variables assessed included HIV-infection status and the use of antiretroviral therapy. Severity of immunosuppression was defined by the number of T cells that expressed cluster of differentiation 4 (CD4). Endocervical swabs and blood samples were collected for microbial culture and susceptibility testing. RESULTS: In all, 33 (21.9%) of the 151 women included in the present analysis had HIV. Among women with HIV, severe immunosuppression (CD4-positive T cell count <200/mm3 ) was associated with a mean hospital stay of 19.0 days versus 10.2 days for mild-advanced immunosuppression (CD4-positive T cell count 200-500/mm3 ) and insignificant immunosuppression (CD4-positive T cell count >500/mm3 ; P=0.030). Use of antiretroviral therapy did not independently influence clinical outcomes. Furthermore, infection with HIV did not influence the microorganisms isolated from blood or endocervical samples. CONCLUSION: Severe immunosuppression was associated with increased length of hospitalization among women with HIV who had puerperal sepsis.

Factores de riesgo de infección puerperal en el Hospital General Docente Dr Agostinho Neto, Guantánamo 2016-2018 / Facores de risco de infecção puerperal no Hospital Geral Universitario Agostinho Neto, Guantánamo 2016-2018 / Risk factors of puerperal infection in the Teaching General Hospital Agostinho Neto, Guantánamo 2016-2018

Introducción: la prevención de la infección puerperal es una exigencia social. Objetivo: precisar la asociación entre rotura de membranas ovulares, infección cervicovaginal y corioamnionitis, y presentación de infección puerperal en puérperas atendidas en el servicio de Obstetriciadel Hospital General Docente Dr Agostinho Neto durante los años 2016-2018. Método: se realizó un estudio de casos y controles. El universo se conformó por todas las puérperas con infección puerperal (n=622) y de estas últimas se seleccionó una muestra por conveniencia de 60 pacientes, las que constituyeron el grupo de casos y se eligió un grupo de pacientes sin infección puerperal (n=120) que conformaron el grupo control. Se estudiaron las siguientes variables: edad en años, tiempo de rotura de membranas ovulares, diagnóstico de infección cervicovaginal y corioamnionitis y vía del parto. Resultados: predominaron las edades entre 20 y 29 años en los casos (41,7 por ciento) y controles (48,3 por ciento). Existieron evidencias estadísticamente significativas, con una confiabilidad del 95 por ciento, de que la rotura de membranas de más de 24 horas, la infección cervicovaginal y la corioamnionitis fueron factores de riesgo de infección puerperal. Predominó la vía vaginal en los casos (60 por ciento) y controles (61,7 por ciento), que no resultó estadísticamente significativa asociada a la infección puerperal. Conclusiones: las puérperas con rotura de membranas ovulares de más de 24 horas, infección cervicovaginal y corioamnionitis presentaron mayor riesgo de infección puerperal(AU)

Introduction: the prevention of puerperal infection is a social requirement. Objective: to specify the association between rupture of ovular membranes, cervicovaginal infection and chorioamnionitis and the presentation of puerperal infection in puerperal women attended in the Obstetrics Service of the Hospital Dr. Agostinho Neto during the years 2016-2018. Method: a study was conducted of cases and controls. The universe was formed by all puerperal puerperal infections (n=622), and of the latter a sample was selected for convenience of 60 patients, which constituted the group of cases; a group of patients without puerperal infection (n=120) who formed the control group was chosen. The following variables were studied: age in years, time of rupture of ovular membranes, diagnosis of cervicovaginal infection and chorioamnionitis and birth pathway. Results: ages between 20 and 29 years predominated in cases (41.7 per cent) and controls (48.3per cent). There was statistically significant evidence, with a reliability of 95per cent, that the rupture of membranes over 24 hours, cervicovaginal infection and chorioamnionitis were risk factors for puerperal infection. The vaginalroute predominated in the cases (60per cent) and controls (61.7per cent), which was not statistically significant associated with puerperal infection. Conclusions: puerperal women with ruptured ovular membranes over 24 hours, cervicovaginal infection and chorioamnionitis presented a higher risk of puerperal infection(AU)

Introdução: a prevenção da infecção puerperal é uma exigência social. Objetivo: Para esclarecer a associação entre a ruptura de membranas, infecção cérvico-vaginal e corioamnionite e apresentação de infecção puerperal em puérperas atendidas no Departamento de Obstetrícia Dr. Agostinho Neto Hospital durante os anos de 2016-2018. Método: foi realizado um estudo de casos e controles. O universo foi formado por todas as infecções puerperais no puerpério (n=622) e, deste último, uma amostra foi selecionada por conveniência de 60 pacientes, constituindo o grupo de casos; um grupo de pacientes sem infecção puerperal (n=120) que formou o grupo controle foi escolhido. As seguintes variáveis foram estudadas: idade em anos, tempo de ruptura das membranas ovulares, diagnóstico de infecção cervicovaginal e corioamnionite e via de nascimento. Resultados: as idades entre 20 e 29 anos predominaram nos casos (41,7por cento) e controles (48,3por cento). Houve evidência estatisticamente significativa, com uma confiança de 95por cento, que a ruptura das membranas durante mais de 24 horas, a infecção genital do corioamniotite e eram factores de risco infecção puerperal. A via vaginal predominou nos casos (60por cento) e controles (61,7por cento), o que não foi estatisticamente significante associado à infecção puerperal. Conclusões: puérperas com ruptura de membranas ovulares por 24 horas, infecção cervicovaginal e corioamnionite apresentaram maior risco de infecção puerperal(AU)

Sepse em gestantes atendidas em um hospital público de Curitiba - PR / Sepsis in pregnant women attended at a public hospital in Curitiba - PR

OBJETIVO: Avaliar a frequência de sepse em gestantes e puérperas atendidas em um hospital, identificar os principais focos originários de sepse na gestação e puerpério, e verificar os principais agentes etiológicos envolvidos em sua etiopatogenia. MÉTODOS: Estudo do tipo transversal descritivo realizado no Hospital do Trabalhador, em Curitiba (PR), de agosto de 2014 a agosto de 2016. Revisão e análise de 71 prontuários de pacientes diagnosticadas com sepse, sepse grave ou choque séptico. Os aspectos estudados foram idades gestacional, agente etiológico, foco infeccioso, principal trimestre gestacional acometido e prevalência de cada tipo de sepse. RESULTADOS: A frequência de sepse durante a gestação e o puerpério no período estudado foi de nove casos para cada mil gestantes. A ocorrência de sepse foi relacionada principalmente ao segundo semestre gestacional (39,4%). Os casos de sepse somaram 73,2% do total, enquanto os demais evoluíram com quadros de sepse grave e choque séptico . Escherichia coli representou 33,8%, sendo o urinário o foco infeccioso mais prevalente (70,4%). Ceftriaxona foi o antibiótico mais utilizado, tanto isoladamente quanto em associação (84,4%). Entre os desfechos para o feto, 85,9% não tiveram complicações. CONCLUSÕES: Os novos conceitos de sepse publicados pela Society of Critical Care Medicine (SCCM) e pela European Society of Critical Care Medicine (ESICM) contrariam os interesses dos países conhecidos como de baixos e médios recursos. Foi encontrado aumento da incidência de sepse gestacional, ocorrendo prevalência do foco urinário; consequentemente, o agente principal foi E. coli. Ademais, ocorreram importantes consequências perinatais como mortalidade e prematuridade. (AU)

OBJECTIVE: To evaluate the frequency of sepsis in pregnant and puerperal patients attended in a hospital, and to identify the main focus of sepsis during gestation and puerperium, and check the main etiological agents involved in its pathogenesis. METHODS: This is a cross-sectional and descriptive study carried out at Hospital do Trabalhador (city of Curitiba, state of Paraná), from August 2014 to August 2016. It is a review and analysis of the charts of 71 patient diagnosed with sepsis, severe sepsis, or septic shock. Aspects studied: gestational age, etiologic agent, infectious focus, main affected gestational trimester, and prevalence of each type of sepsis. RESULTS: The frequency of sepsis during pregnancy and puerperium was 9 cases for 1000 pregnant women. The occurrence of sepsis was mainly related to the second gestational semester (39.4%). Severe sepsis and septic shock comprised 73.2% of the cases. Escherichia coli accounted for 33.8%, and the most prevalent infectious focus was urinary (70.4%). Ceftriaxone was the most commonly used antibiotic, both alone and in combination (84.4%). Among the outcomes for the fetus, 85.9% had no complications. CONCLUSIONS: The new concepts of sepsis, published by the Society of Critical Care Medicine (SCCM), and by the European Society of Critical Care Medicine (ESICM) contradict the interests of the countries with low and medium resources. An increase in the incidence of gestational sepsis occurred, with a prevalence of urinary focus; consequently the main agent was Escherichia coli. In addition, there were important perinatal consequences such as mortality and prematurity. (AU)

A Challenging Case of Retroperitoneal Abscess in a Post-Partum Crohn's Disease Patient.

BACKGROUND Crohn's disease (CD) is an inflammatory bowel disease affecting approximately 1 in 3000 people in the United States. Since the inflammation of CD is transmural, patients are at risk for fistula and abscess formation. Retroperitoneal abscesses are one type of which physicians must be aware. CASE REPORT We present the case of a 29-year-old woman with CD who complained of right hip and flank pain that began when she was 6-months pregnant. After delivery, she continued to complain of severe right flank pain and was admitted to the hospital 1 month later. CT scan imaging revealed a complicated retroperitoneal and right flank abscess, possibly due to a colonic intramural fistula. She developed severe acute necrotizing soft-tissue infection requiring 13 days of intensive care. She required debridement of the necrotizing infection of the right flank, drainage of the abscess, and washout for intraperitoneal sepsis. The patient tolerated the procedures well and was discharged 1 month later. CONCLUSIONS Given that the clinical manifestation of retroperitoneal fistula with abscess is insidious and its formation is less common than intraperitoneal abscesses, we hope healthcare providers learn from this case to avoid morbidity and mortality. When presented with a pregnant CD patient complaining of nonspecific abdominal symptoms, providers should consider fistulization and/or abscess formation. The option to evaluate pregnant patients using noninvasive methods, such as ultrasound or low-dose CT scan, can decrease radiation exposure to the fetus and prevent delays in diagnosis and treatment.