Maternal and perinatal infectious morbidity in term prelabor rupture of membrane according to two induction of labor protocols.

PURPOSE: The optimal labor-induction protocol in women with prelabor rupture of membranes (PROM) is unknown. Whether the management of women with a previous cesarean delivery (CD) with PROM is different remains controversial. We investigated maternal and perinatal outcomes according to two induction protocols of 24 h vs. 12 h. METHODS: In July 2021, our protocol of induction of labor in term-PROM was extended from 12 h to 24 h post-PROM. We compared obstetrical and neonatal outcomes before and after the change. A subgroup analysis of women with previous CD was performed. Results were compared using a univariate analysis. A multivariable model was described to predict neonatal intensive care unit admission (NICU) and clinical chorioamnionitis. RESULTS: The 24 h and 12 h ROM-to-induction protocol groups included 962 and 802 women, respectively. In the 24 h group, a higher proportion of women labored spontaneously (p < 0.001), the rate of chorioamnionitis was higher (p = 0.017), and the CD rate was similar. Admission to the NICU (p = 0.012), antibiotic administration (p = 0.003), and respiratory distress (p = 0.002) were also greater in the 24 h induction group. Among women with a history of CD (n = 143), the need for oxytocin (p = 0.003) and delivery by CD (p = 0.016) were lower in the 24 vs. 12 h group. CONCLUSION: Our results advocate shared decision-making in the expectant management of term-PROM. Women should be informed of the lower chance for induction and the higher risk of infections and neonatal complications with a 24-h induction approach. Longer expectant management in women with a previous CD resulted in significantly lower induction and CD rates.

Antibiotic treatment of women with isolated intrapartum fever vs clinical chorioamnionitis: maternal and neonatal outcomes.

BACKGROUND: Clinical chorioamnionitis refers to the presence of maternal fever (≥38°C) and at least 2 clinical signs: (1) maternal tachycardia (>100 bpm), (2) fetal tachycardia (>160 bpm), (3) maternal leukocytosis >15,000/mm2, (4) purulent vaginal discharge, and (5) uterine tenderness. Few data exist to guide the appropriate management of women with isolated intrapartum fever in the absence of other clinical signs suggesting chorioamnionitis. OBJECTIVE: This study compared maternal and neonatal infectious outcomes and microbiological outcomes between women with isolated intrapartum fever and women with clinical chorioamnionitis. STUDY DESIGN: This 10-year retrospective study included all the laboring women at our institution, at ≥34 weeks of gestation, with a singleton pregnancy and body temperature of ≥38.0°C, with or without other evidences of infection. According to our department protocol, women with isolated intrapartum fever received intravenous ampicillin, whereas women with clinical chorioamnionitis received intravenous ampicillin plus gentamicin. The primary outcome was puerperal endometritis, compared between women with isolated intrapartum fever (treated with ampicillin) and women with clinical chorioamnionitis (treated with ampicillin plus gentamicin). The secondary maternal outcomes consisted of (1) maternal clinical outcomes, such as cesarean delivery, surgical site infection, postpartum hemorrhage, and postpartum length of stay, and (2) microbiological studies, including positive chorioamniotic membrane swabs and blood culture. Among the secondary neonatal outcomes were early-onset sepsis, neonatal intensive care unit admission, and length of stay. Of note, 2 multivariate logistic regression models were created. A model aimed to predict puerperal endometritis controlled for gestational age of >41 weeks, diabetes mellitus, obesity, positive group B streptococcus status, rupture of membrane ≥18 hours, meconium staining, positive chorioamniotic membrane swabs, cesarean delivery, and empiric postdelivery antibiotic administration. A model aimed to predict neonatal early-onset sepsis controlled for gestational age of 34 to 37 weeks, positive group B streptococcus status, rupture of membrane ≥18 hours, and positive chorioamniotic membrane swabs. RESULTS: Overall, 458 women met the inclusion criteria. Compared with women with clinical chorioamnionitis (n=231), women with isolated intrapartum fever (n=227) had higher rates of puerperal endometritis (3.9% vs 8.8%; P=.03), early-onset sepsis (0.4% vs 4.4%; P=.005), positive chorioamniotic membrane swabs (46.3% vs 63.9%; P<.001), and ampicillin-resistant Escherichia coli (35.5% vs 48.9%; P=.033). The rate of group B streptococcus-positive chorioamniotic membrane swabs was similar between the groups. In a subanalysis of women with negative or unknown group B streptococcus status, the puerperal endometritis and neonatal early-onset sepsis rates were higher among women with isolated intrapartum fever than women with suspected chorioamnionitis (8.7% vs 3.3% [P=.041] and 4.1% vs 0% [P<.001], respectively). In 2 multivariate analysis models, among women with isolated intrapartum fever treated with ampicillin compared with those with clinical chorioamnionitis treated with ampicillin and gentamicin, the odds ratio of antibiotic treatment of endometritis was 2.65 (95% confidence interval, 1.06-6.62; P=.036), and the odds ratio of neonatal early-onset sepsis was 8.33 (95% confidence interval, 1.04-60.60; P=.045). CONCLUSION: Women with intrapartum fever, with or without other signs of infection, were at increased risk of maternal and neonatal complications. The use of ampicillin as a sole agent in isolated intrapartum fever might promote ampicillin-resistant E coli growth in the chorioamniotic membranes and consequently lead to puerperal endometritis and early-onset sepsis. In this context, a broad-range antibiotic should be considered.

Endometritis posparto: experiencia en un hospital general

Objetivos: Conocer las características demográficas y clínicas de las pacientes con diagnóstico de endometritis puerperal en un hospital general. Diseño: Estudio de tipo descriptivo, serie de casos, retrospectivo. Institución: Servicio de Ginecología y Obstetricia, Hospital Nacional Cayetano Heredia (HNCH), Lima, Perú. Participantes: Puérperas. Material: Se seleccionó casos con diagnóstico de endometritis puerperal en el periodo de julio de 2011 a julio de 2012, de la base de datos de la Unidad de Epidemiología del HNCH. Se recolectó los datos en una ficha, en la que se incluyó las características demográficas, clínicas, antecedentes, factores de riesgo, diagnóstico, tratamiento, evolución y complicaciones. Principales medidas de resultados: Características de los casos de endometritis puerperal. Resultados: Se encontró 32 casos de endometritis puerperal, con prevalencia de 0,6%. La edad media fue 23 +/- 6,2; el 76% tenía educación secundaria y 72% era primípara. La vía de parto fue cesárea en 53% de los casos. El síntoma más frecuente fue sensación de alza térmica y el signo más frecuente loquios con mal olor. Entre los factores de riesgo, a un tercio de pacientes se les realizó más de 5 tactos vaginales, con un máximo de 8; 6 pacientes tuvieron rotura prematura de membranas y en 7 en pacientes se describió líquido meconial. La evolución de la totalidad de las pacientes fue favorable. Conclusiones: Conocer el impacto de la endometritis puerperal en un hospital general permitirá tomar las medidas preventivas para reducir la incidencia de casos de endometritis, por ejemplo, mejorando la profilaxis y tratamiento de la anemia, limitando los tactos vaginales así como promoviendo las normas de bioseguridad.

Objectives: To determine demographic and clinical characteristics of patients with diagnosis of postpartum endometritis at a national hospital. Design: Descriptive, series of cases, retrospective study. Setting: Gynecology and Obstetrics Service, Hospital Nacional Cayetano Heredia (HNCH), Lima, Peru. Participants: Women post partum. Material: Cases with puerperal endometritis from July 2011 through July 2012 were selected from the database of the Epidemiology Unit. Data collected included demographic characteristics, clinical history, risk factors, diagnosis, treatment, evolution and complications. Main outcome measures: Puerperal endometritis cases characteristics. Results: Thirty two cases of puerperal endometritis represented a prevalence of 0.6%. Mean age was 23 +/- 6.2 years, 76% finished high school and 72% were nulliparous. Delivery was by cesarean section in 53% of cases. Most common symptom was fever and the most frequent sign was foul-smelling lochia. Among risk factors, one third of patients underwent more than 5 vaginal examinations, with a maximum of 8; 6 patients had premature rupture of membranes and in 7 meconial amniotic fluid was described. All patients had favorable evolution. Conclusions: Understanding the impact of puerperal endometritis in a general hospital will lead to preventive measures to reduce its incidence by improving anemia prophylaxis and treatment, limiting vaginal exams and promoting biosafety standards.

Estrategia multimodal en la disminución de las endometritis puerperales de parto vaginal

Las infecciones intrahospitalarias suelen ser elevadas cuando no se tiene un control adecuado de los múltiples factores que participan en su presentación. Durante el año 2010 y parte del 2011, la tasa de endometritis puerperales en el parto vaginal llegó a triplicar los estándares nacionales, por lo cual diseñamos una intervención que constó de aplicar la estrategia multimodal de lavado de manos de la Organización Mundial de la Salud (OMS), que consiste en 1) cambio de sistema, 2) educación y entrenamiento, 3) retroalimentación, 4) recordatorios y 5) clima organizacional. Objetivos: Disminuir las tasas de endometritis puerperales en partos vaginales. Diseño: Cuasi experimental, prospectivo y longitudinal. Institución: Hospital Nacional Docente Madre Niño San Bartolomé, Lima, Perú. Participantes: Médicos asistentes, residentes, internos que rotaban en sala de partos. Intervenciones: Intervención en base a la Estrategia Multimodal de lavado de manos de la OMS. Principales medidas de resultados: Tasas de endometritis puerperal. Resultados: Las endometritis puerperales empezaron a disminuir de 1,1% entre 2010 y 2011 a 0,7% 2011 a 2012, y esta última cifra se ha mantenido casi constante por más de cinco meses. El uso de alcohol gel varió de 40 mL por mes a 750 mL por mes. Conclusiones: Con la intervención Estrategia Multimodal de lavado de manos de la OMS se obtuvo disminución de las endometritis puerperales en partos vaginales.

Hospital infections are high when there is no adequate control of the multiple factors involved. During 2010 and part of 2011 rate of vaginal delivery puerperal endometritis rate was three times that of national standards. Therefore, we applied the World Health Organization (WHO)s multimodal strategy intervention of hand washing that consists in 1) system change, 2) education and training, 3) feedback, 4) recalls, and 5) organizational climate. Objectives: To diminish puerperal endometritis rates in vaginal deliveries. Design: Quasi experimental, prospective a longitudinal study. Setting: Hospital Nacional Docente Madre Niño San Bartolome, Lima, Peru. Participants: Medical staff, residents, interns rotating in the delivery room. Interventions: Based on WHO Multimodal Strategy of hand washing. Main outcome measures: Rates of puerperal endometritis. Results: Puerperal endometritis started to decrease from 1.1% between 2010 and 2011 down to 0.7% between 2011 and 2012; this rate has been maintained almost constantly for over five months. Use of alcohol gel varied from 40 mL per month to 750 mL per month. Conclusions: Decrease of puerperal endometritis in vaginal deliveries was obtained by WHO Multimodal Strategy of hand washing intervention.