Prophylactic antibiotics reduce infectious morbidity from caesarean section. The timing of their administration, however, is a matter of controversy.To examine maternal and neonatal infectious morbidity in women receiving preoperative prophylaxis compared with those receiving intraoperative administration.Medline, Embase, Current Controlled Trials and Cochrane Central were searched from their inception dates to December 2011.Randomised controlled trials of a single dose of any antibiotic comparing preoperative with intraoperative administration were selected.Trial characteristics, outcomes and quality measures, based on the Cochrane tool for risk of bias, were independently extracted. The random effect model of DerSimonian and Laird to estimate relative risks (RRs) for maternal and neonatal outcomes was used.Six trials met the inclusion criteria, reporting on 2313 women and 2345 newborns. Preoperative administration was associated with a significant 41% reduction in the rate of endometritis compared with intraoperative administration (RR 0.59; 95% confidence interval [95% CI] 0.37-0.94; I2 0%). In the preoperative group, there were nonsignificant reductions in the rates of wound infection (RR 0.71; 95% CI 0.44-1.14; I2 0%), maternal febrile morbidity (RR 0.94; 95% CI 0.46-1.95; I2 0%), neonatal sepsis (RR 0.81; 95% CI 0.47-1.41; I2 0%), neonatal septic work-up (RR 0.93; 95% CI 0.71-1.21; I2 0%) and neonatal intensive-care unit admission (RR 0.92; 95% CI 0.65-1.28; I2 0%). There were nonsignificant increases in the rates of maternal pyelonephritis (RR 1.09; 95% CI 0.49-2.43; I2 0%) and neonatal pneumonia (RR 3.36; 95% CI 0.55-20.47; I2 0%).Compared with intraoperative administration, preoperative antibiotics significantly reduce the rate of endometritis. The lack of neonatal adverse effects should be cautiously interpreted given the limited power of the trials to detect such effects.

The purpose was to identify distinct inflammatory markers in endometrial tissues of women with abnormal uterine bleeding (AUB) and Chlamydia trachomatis infection.Archived endometrial specimens from 92 randomly selected premenopausal women with AUB were examined for C. trachomatis using the species-specific monoclonal antibody against major outer membrane protein (MOMP) and for histopathology associated with inflammation. Statistical analyses included single and multiple logistic regression. Diagnostic accuracy was summarized using receiver operating characteristic (ROC) curves.Chlamydia trachomatis was detected in 44 (48%) of 92 AUB specimens. There were statistically significant correlations of positive MOMP with higher counts of plasma cells (P < 0.01), macrophages (P < 0.0001), and lymphocytic foci (P = 0.01). The ROC curve for macrophages was the strongest predictor (area under the curve = 0.82) for C. trachomatis.The prevalence of C. trachomatis in women with AUB is under-estimated. Macrophages appear to be a strong marker for the presence of C. trachomatis in the endometrium.

Healthcare utilization (HCU) following a sexually transmitted disease (STD) diagnosis is poorly characterized.The goal was to quantify HCU for new/recurrent STDs and other relevant Ob-Gyn and mental health problems in the 18 months subsequent to an STD diagnosis.We compared HCU between a group of females aged 18 to 45 years who were Kaiser Permanente Medical Program members with a diagnosed STD (n = 1,205) and a medical center- and age group-matched sample of women seen for a non-STD diagnosis in the same time period (n = 4820), with controlling where appropriate for age, medical center, and chronic disease status.An STD diagnosis was associated with significantly greater likelihood of subsequent visits for STDs (relative risk [RR] = 3.8), pelvic inflammatory disease/endometritis (RR = 2.9), candidiasis (RR = 2.0), vaginitis (RR = 2.4), cervical dysplasia (RR = 1.7), menstrual disorders/abnormal bleeding (RR = 1.3), high risk/complicated/ectopic pregnancy (RR = 1.5), and behavioral/mental health problems (RR = 1.3) than for women seen for a non-STD diagnosis.Detrimental sequelae of STDs are reflected in substantially elevated near-term HCU following an STD diagnosis.

To compare two methods of uterine cleansing to remove residual amnion-chorion at the time of Cesarean delivery.All consenting uninfected parturients undergoing a non-emergency Cesarean delivery at the university were enrolled. All patients received antibiotic prophylaxis of a 1-g intravenous bolus of a first-generation cephalosporin immediately after cord clamping. Postpartum endometritis was defined as a temperature of > or = 100.4 degrees F (38 degrees C) on two occasions 6 h apart after the first 24 h with uterine tenderness and/or foul-smelling lochia.Between January 1998 and February 2000 there were 1400 patients enrolled in this investigation. A total of 153 women were determined to have chorioamnionitis present at surgery and 17 women refused participation, leaving 614 women in the uterine wipe group and 616 in the no wipe group. Maternal demographics were similar between patient groups (NS). Intrapartum factors including gestational age at time of Cesarean section, type of anesthesia used for the operative delivery, hours of amnion rupture prior to delivery, use of internal monitoring devices, type of skin incision, method of placental removal, total operative time and estimated blood loss were similar between patient groups (NS). An almost identical number of patients in each arm of the study developed post-Cesarean endometritis (65 out of 614, 10.5%, in the uterine wipe group vs. 66 out of 616, 10.7%, in the no wipe group; p = 1).Both methods of removing residual amnion-chorion membrane tissue and associated debris at surgery were comparably effective, but neither produced a dramatic reduction in the incidence of postoperative endometritis.

Bacterial vaginosis is characterized by a shift from the predominant lactobacillus vaginal flora to an overgrowth of anaerobic bacteria. Bacterial vaginosis is associated with an increased risk of gynecologic complications, including pelvic inflammatory disease, postoperative infection, cervicitis, human immunodeficiency virus (HIV), and possibly cervical intraepithelial neoplasia (CIN). The obstetrical risks associated with bacterial vaginosis include premature rupture of membranes, preterm labor and delivery, chorioamnionitis and postpartum endometritis. Despite the health risks associated with bacterial vaginosis and its high prevalence in women of childbearing age, bacterial vaginosis continues to be largely ignored by clinicians, particularly in asymptomatic women.

Objective:

The objective of the study was to determine the incidence of postcesarian febrile morbidity and relate this to hospital stay in a high-risk indigent population treated at a private non-teaching hospital.

Methods:

This was a retrospective chart review of all patients done between January 1995 and December 1996. Discharge summaries, antepartums, progress notes, and labs were reviewed for each patient. Of 257 charts reviewed, 5 were inadequate for various reasons. Board-certified surgeons performed and assisted in the operations. Twenty-one patients had scant prenatal care and 6 had no prenatal care. All patients had the abdomen scrubbed with Betadine soap prior to painting. No shaving was done. Gloves were changed after closure of uterine incision. The pelvis was copiously irrigated with 3-4 L of saline. The subcutaneous layer was irrigated from a height of 6-12" with 12 to 1 L of fluid. After this step, this layer is not touched by anything from the operating field.

Results:

Of 162 patients with primary cesarian, 20 had postoperative fever, 18 with endometritis, 2 with wound infections. All but 5 of these patients had labor as ruptured membranes of 12 hours or more. Four had prolonged 2nd stage. Of 28 failed VBACs, 2 had fever vs none for 59 elective repeat cesarians. The average hospital stay for febrile patients was 4.4 days vs 2.7 for afebrile patients. The incidence of wound infection was 0.8%. The incidence of fever was 12.2% for primary cesarians and 8.8% in the total study group of 249 patients.

Conclusion:

This study demonstrates that the adoption of simple measures presented in Methods can dramatically decrease the incidence and severity of postcesarian fever, especially wound infection, thereby allowing safe, early hospital discharge.

The purpose of this report is to evaluate the association between lower genital tract inflammation and objectively diagnosed endometritis. We analyzed the first 157 patients enrolled in the PEACH study, a multicenter randomized clinical trial designed to compare the effectiveness of outpatient and inpatient therapy for PID. Women less than 38 years of age, who presented with a history of pelvic discomfort for 30 days or less and who were found to have pelvic organ tenderness (uterine or adnexal tenderness) on bimanual examination, were initially invited to participate. After recruitment of the first 58 patients (group 1) we added the presence of leukorrhea, mucopurulent cervicitis, or untreated positive test for N. gonorrhoeae or C. trachomatis to the inclusion criteria (group 2, N = 99). We compared rates of endometritis in the two groups and calculated the sensitivity, specificity, and predicted values of the presence of white blood cells in the vaginal wet preparation. The rate of upper genital tract infection in group 1 was 46.5% (27/58) compared to 49.5% (49/99) in group 2. Microbiologic evidence of either N. gonorrhoeae or C. trachomatis increased from 22.4% in group 1 to 38.3% in group 2. The presence of vaginal white blood cells or mucopus has a high sensitivity (88.9%), but a low specificity (19.4%) for the diagnosis of upper genital-tract infection. Assessment of the lower genital tract for evidence of infection or inflammation is a valuable component of the diagnostic evaluation of pelvic inflammatory disease. The presence of either mucopus or vaginal white blood cells is a highly sensitive test for endometritis in patients with pelvic pain and tenderness.

The purpose of this study was to compare the clinical efficacy and safety of cefmetazole given by IV push with that of parenterally administered cefoxitin for the treatment of endometritis following cesarean delivery.In a single-blind, multicenter, prospective, randomized study, 355 patients with endometritis after cesarean delivery were enrolled and received medication. Administered was either cefmetazole sodium, 2 g by IV push over 1 min q 8 h, or cefoxitin sodium, 2 g IV q 6 h in a 2:1 ratio. The patients were followed for clinical responses and side effects.The cure rate for cefmetazole was 89% and for cefoxitin it was 79% (P = 0.006). The adverse events were similar in both groups.Cefmetazole was significantly more effective than cefoxitin in the treatment of endometritis following cesarean delivery.