Incidence Of Chorioamnionitis Research Articles

Can the use of azithromycin during labour reduce the incidence of infection among puerperae and newborns? A systematic review and meta-analysis of randomized controlled trials

ObjectiveThis systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns.Data sourcesWe independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024.MethodsWe included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity.ResultsThe pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55–0.77; I2, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52–0.74; I2, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24–0.78; P < .005); however, there was great heterogeneity among the studies (I2, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17–0.52; I2, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35–0.65; I2, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears.ConclusionIn this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.

Maternal and Perinatal Outcomes Amongst Nulliparous Singleton Pregnancies Electively Induced at 39Weeks: A Prospective Observational Study.

Given the uncertainty of inducing beyond 39weeks, we intended to study the maternal and neonatal mortality and morbidity associated with planned elective induction of labour (eIOL) at 390/7 to 396/7weeks. To study the maternal and perinatal outcomes, after eIOL, at 390/7 to 396/7weeks, amongst nulliparous singleton pregnancies, followed up for the duration of their hospital stay. All consecutive nulliparous, singleton gestations, undergoing eIOL, at 390/7 to 396/7weeks, with no plan for caesarean section (CS) or contraindication for vaginal delivery were prospectively recruited. The primary outcome studied was the incidence of CS and neonatal intensive care requirement, and the secondary outcomes studied were induction-delivery interval, incidence of chorioamnionitis, postpartum haemorrhage, meconium aspiration syndrome (MAS), APGAR ≤ 7 at 1min and neonatal mortality. Amongst the total 304 mothers electively induced at 390/7 to 396/7weeks, 80 (26.3%) mothers underwent CS and 48 (15.8%) neonates required intensive care. Fifteen (4.9%) babies required respiratory support at birth. The mean induction-delivery interval was 19h 42min ± 10h. There were 9(3%) cases of PPH and no reported cases of chorioamnionitis. Eleven (3.6%) babies had an APGAR < / = 7 at 1min and 9 (2.9%) had MAS, but there was no maternal or neonatal mortality. Induction of labour at 39weeks in low-risk nulliparous women did not result in a lower frequency of CS or adverse perinatal outcomes.

Impact of the "39-week rule" on adverse pregnancy outcomes: a statewide analysis.

The "39-week rule," adopted by the American College of Obstetricians and Gynecologists circa 2009, discouraged routine elective induction of labor in early-term gestations (37 weeks 0 days-38 weeks 6 days) to decrease the risk of adverse neonatal outcomes. However, little research exists regarding any unintended adverse pregnancy outcomes associated with this policy shift. This study aimed to quantify the difference in incidence of adverse pregnancy outcomes before and after the implementation of the 39-week rule. Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Classification of Diseases 9/10 codes were obtained for each birth. Our primary outcome was the incidence of any of the following adverse pregnancy outcomes: cesarean delivery, hypertensive disorders, chorioamnionitis, postpartum hemorrhage, high-degree lacerations, placental abruption, and intensive care unit admission. Propensity score analysis was used to control for age, body mass index, and race. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare the prerule and postrule groups. A total of 633,985 births were eligible for inclusion-412,632 from 2000 to 2008, and 221,353 from 2013 to 2017. There was a significant increase in the primary outcome in the postrule period (39.94% pre vs 42.76% post; P<.01). The incidence of all hypertensive disorders was significantly increased in the postrule period compared with the prerule period (7.75% pre vs 10.1% post; P<.01). The incidence of chorioamnionitis and cesarean delivery also increased in the postrule period (1.45% pre vs 1.92% post; P<.01; 29.6% pre vs 31.82% post; P<.01; respectively). There was a significant increase in the primary outcome following the implementation of the 39-week rule. Although the policy shift was driven by a desire to decrease adverse neonatal outcomes, aggregate benefit was not observed for pregnancy outcomes.

Labor Induction Outcomes with Outpatient Misoprostol for Cervical Ripening among Low-Risk Women.

In 2012, two Kaiser Permanente Northern California (KPNC) hospitals began offering outpatient cervical ripening with oral misoprostol under a study protocol. We evaluated inpatient time from admission to delivery and adverse maternal and neonatal outcomes associated with outpatient use of misoprostol for cervical ripening among low-risk women with term pregnancies. We conducted a retrospective cohort study comparing three groups: women who received misoprostol (1) outpatient, under a study protocol; (2) inpatient, at the study sites; and (3) inpatient, at all KPNC hospitals. Data were obtained from between 2012 and 2017. The primary outcome was time from inpatient admission to delivery. Secondarily, we evaluated maternal and neonatal outcomes, including the duration and maximum rate of oxytocin administered, rate of cesarean delivery, incidence of chorioamnionitis and blood transfusion, Apgar scores, and neonatal intensive care unit admissions. Demographic and clinical characteristics and outcomes of the outpatient group were compared with both inpatient misoprostol groups using the appropriate statistical test. Variables included in the regression analysis were either statistically significant in the bivariate analyses or have been reported in the literature to be potential confounders: maternal age at admission, race/ethnicity, body mass index, cervical dilation at initial misoprostol, and parity. We analyzed data from 10,253 patients: (1) 345 outpatients, under a study protocol; (2) 1,374 inpatients, at the study sites; and (3) 9,908 inpatients, at all the Kaiser hospitals. Women in the outpatient group were more likely to be white than both inpatient groups (63.3 vs. 56.3% at study sites and 47.1% in all hospitals, p = 0.002 and <0.001, respectively); other demographics were clinically comparable. Most women undergoing labor induction were nulliparous; however, a greater proportion in the outpatient group were nulliparous compared with inpatient groups (70.8 vs. 61.8% and 64.3%, p = 0.002 and 0.01). On inpatient admission for delivery, women who received outpatient misoprostol were more likely to have a cervical dilation of ≥3 cm (39.8 vs. 12.5% at study sites and 9.7% at all KPNC hospitals, p < 0.001 for both). The outpatient group had a shorter mean time between admission and delivery (23.6 vs. 29.4 at study sites and 29.8 hours at all KPNC, p < 0.001 for both). The adjusted estimated mean difference between the outpatient and inpatient group at all the Kaiser hospitals in time from admission to delivery was -6.48 hours (p < 0.001), and the adjusted estimated mean difference in cervical dilation on admission was +1.02 cm (p < 0.001). There was no difference in cesarean delivery rates between groups. The rate of chorioamnionitis in the outpatient group was higher compared with inpatients at all hospitals (17.7 vs. 10.6%, p < 0.001), but similar when compared with the inpatients at the study sites (17.7 vs. 15.4%, p = 0.29). Outpatient use of misoprostol for cervical ripening under the study protocol was associated with reduced inpatient time from admission to delivery compared with inpatient misoprostol. Although there was a higher rate of chorioamnionitis among outpatients under the study protocol compared with inpatients at all hospitals, there was no difference when compared with inpatients at the study sites. There was no difference in rates of cesarean delivery or maternal or neonatal complications with outpatient misoprostol. · Outpatient misoprostol patients had 6.46 fewer hours from admission to delivery compared with inpatients at all hospitals.. · There was no difference in the rate of cesareans between the outpatient versus inpatient misoprostol groups.. · Other maternal and neonatal complications were low and comparable among outpatients and inpatients who received misoprostol; this study was not large enough to assess rare safety outcomes..

Class III obesity is an independent risk factor for unsuccessful induction of labor

BACKGROUNDAlthough obesity is a known risk factor for cesarean delivery, there is a paucity of data on the course of induction of labor in these patients.OBJECTIVEWith emerging data on the safety of 39-week inductions, we aimed to: (1) determine if Class III obesity, including morbid obesity, is an independent risk factor for nonachievement of complete dilation and vaginal delivery after induction of labor, (2) evaluate the characteristics of the induction of labor course and immediate complications, and (3) evaluate the number of induction agents necessary to be associated with vaginal deliveries. We hypothesized that as body mass index increased, it would take longer to achieve complete cervical dilation, more induction agents would be required, and there would be a higher rate of cesarean delivery.STUDY DESIGNThis was a retrospective cohort study of singleton gestations undergoing induction of labor from 2013 to 2020 at a single center. Study groups were defined as nonobese (body mass index <30 kg/m2), non-Class III obesity (body mass index of 30–39.9 kg/m2), and Class III obesity (body mass index ≥40 kg/m2). The primary outcome was achievement of complete cervical dilation. Secondary outcomes included time from start of induction to complete dilation, cesarean delivery rates, doses of misoprostol used, combination of induction agents used, and incidence of chorioamnionitis and postpartum hemorrhage. Univariate and multivariate logistic regression analyses were used to estimate risks. A secondary analysis was performed on nulliparous patients.RESULTSA total of 3046 individuals met the inclusion criteria. As body mass index increased, the indications for induction were more likely to be maternal. Rate of achievement of complete dilation decreased with increasing body mass index (973 [88.5%] in the body mass index <30 group vs 455 [70.8%] in the body mass index ≥40 group; adjusted odds ratio, 0.3; 95% confidence interval, 0.2–0.4). The rate of cesarean delivery also increased (149 [13.5%] in the body mass index <30 group vs 207 [30.9%] in the body mass index ≥40 group; adjusted odds ratio, 3.2; 95% confidence interval, 2.5–4.2), as did the time to complete dilation (15.3 hours in the body mass index <30 group vs 18.8 hours in the body mass index ≥40 group; P<.001). Morbidly obese patients required higher doses and more types of induction agents. Misoprostol was used as the sole induction agent in 362 (35.1%) of patients in the body mass index <30 group vs 160 (25.4%) of patients in the body mass index ≥40 group (adjusted odds ratio, 0.6; 95% confidence interval, 0.5–0.8). In the body mass index ≥40 group, a greater number required a combination of misoprostol, mechanical ripening, and oxytocin for induction (147 [14.3%] in the body mass index <30 group vs 158 [25.0%] in the body mass index ≥40 group; adjusted odds ratio, 1.7; 95% confidence interval, 1.3–2.3). For nulliparous patients, the rate of cesarean delivery was significantly higher with increasing body mass index (118 [18.3%] in the body mass index <30 group and 157 [48.2%] in the body mass index ≥40 group; P<.001), with 5 more hours spent in labor (18.3 hours in the body mass index <30 group vs 23.3 hours in the body mass index ≥40 group; P<.001). Nulliparous patients were also more likely to require multiple induction agents (122 [20.3%] for body mass index <30 vs 108 [33.6%] for body mass index ≥40; P<.001).CONCLUSIONClass III obesity is an independent risk factor for nonachievement of complete dilation and vaginal delivery following induction of labor. Furthermore, inductions in these patients require more time and are more likely to require multiple agents.

Comparing the effectiveness and safety of Dinoprostone vaginal insert and double-balloon catheter as cervical ripening treatments in Chinese patients.

BackgroundThis retrospective study was to compare the effectiveness and safety of Dinoprostone vaginal insert vs. double-balloon catheter as cervical ripening agents for labor induction.MethodsPregnant women with Bishop score <7, who received either Dinoprostone vaginal insert 10 mg or Cook's double-balloon catheter for labor induction, were studied. The primary outcome was the rate of vaginal delivery within 48 h; the secondary outcomes were the proportion of women undergoing cesarean section, labor duration, oxytocin administration, changes in Bishop score, complications during labor, and maternal/neonatal outcomes.ResultsOne hundred and eighty-two women were included in Dinoprostone group, and 199 women were in double-balloon catheter group. The rate of vaginal delivery within 48 h was significantly higher in Dinoprostone group than that in double-balloon catheter group (90.11% vs. 75.38%, P = 0.0002). There were 18 cesarean section deliveries (9.89%) in Dinoprostone group and 49 cesarean section deliveries (24.62%) in double-balloon catheter group, with significant differences between two groups (P = 0.0002). The duration of labor was higher in Dinoprostone group, while the augmentation with oxytocin was significantly lower in Dinoprostone group than in double-balloon catheter group (all P < 0.0001). The incidence of chorioamnionitis was significantly higher in double-balloon catheter group as compared with Dinoprostone group (0 vs. 12, P = 0.0005), while neonatal outcomes were similar in two groups.ConclusionDinoprostone vaginal insert as cervical ripening agent is more effective for labor induction and with lower risks of chorioamnionitis as compared with double balloon catheter in Chinese populations.

Risk factors for postoperative ileus after cesarean delivery

Despite extensive data regarding risk factors for postoperative ileus in the general and colorectal surgery literature, few studies have identified risk factors specific to the obstetrical population. This study aimed to identify factors associated with postoperative ileus following cesarean delivery. This retrospective case-control study identified women who underwent cesarean delivery at a single hospital between January 2000 and January 2020 and subsequently developed postoperative ileus. Cases were matched in a 1:2 ratio with controls who underwent cesarean delivery and did not develop postoperative ileus. They were matched by age (±1 year) and body mass index (±1 kg/m2). Demographics, common comorbidities, obstetrical history, and delivery characteristics were analyzed. A total of 147 cases and 294 controls were identified. Cases and controls were similar in terms of parity, number of previous cesarean deliveries, labor preceding their cesarean delivery, incidence of chorioamnionitis, and presurgical diagnosis of hypothyroidism or chronic hypertension. Cases tended to have a diagnosis of preeclampsia (cases 23.1% vs controls 10.5%; P<.001) and were more likely to have been exposed to magnesium sulfate (cases 34.0% vs controls 15.0%; P<.001). Surgical considerations that were common in cases were exposure to general anesthesia (cases 37.4% vs controls 4.1%; P<.001), midline vertical skin incisions (cases 13.6% vs controls 1.4%; P<.001), classical hysterotomy (cases 8.8% vs controls 1.7%; P=.001), estimated blood loss >1000 mL (cases 44.4% vs controls 11.6%; P<.001), transfusion of blood products (cases 25.8% vs controls 2.0%; P<.001), and hysterectomy at the time of cesarean delivery (cases 6.1% vs controls 0.7%; P=.001). After a multivariable modeling using stepwise logistic regression of all variables found to be statistically significant, transfusion of blood products, estimated blood loss >1000 mL, and exposure to general anesthesia were the remaining surgical factors associated with the development of ileus. These variables reflect both the complexity and most likely the duration of surgery that was required, although we note that we did not have operative time as a variable to explore. Preeclampsia was also identified as a comorbidity linked to the development of ileus. A diagnosis of preeclampsia, exposure to general anesthesia, estimated blood loss >1 L, and transfusion of blood products were identified as potential risk factors for postcesarean ileus.

Ureaplasma parvum meningitis following atypical choroid plexus papilloma resection in an adult patient: a case report and literature review

BackgroundWhile Ureaplasma parvum has previously been linked to the incidence of chorioamnionitis, abortion, premature birth, and perinatal complications, there have only been rare reports of invasive infections of the central nervous system (CNS) in adults. Owing to its atypical presentation and the fact that it will yield sterile cultures using conventional techniques, diagnosing U. parvum meningitis can be challenging.Case presentationWe describe a case of U. parvum meningitis detected in an adult patient following surgical brain tumor ablation. After operation, the patient experienced epilepsy, meningeal irritation, and fever with unconsciousness. Cerebrospinal fluid (CSF) analysis showed leukocytosis (484 * 106 /L), elevated protein levels (1.92 g/L), and decreased glucose concentrations (0.02 mmol/L). Evidence suggested that the patient was suffering from bacterial meningitis. However, no bacterial pathogens in either CSF or blood were detected by routine culture or serology. The symptoms did not improve with empirical antibiotics. Therefore, we performed metagenomic next-generation sequencing (mNGS) to identify the etiology of the meningitis. Ureaplasma parvum was detected by mNGS in CSF samples. To the best of our knowledge, this case is the first reported instance of U. parvum meningitis in an adult patient in Asian. After diagnosis, the patient underwent successful moxifloxacin treatment and recovered without complications.ConclusionsAs mNGS strategies can enable the simultaneous detection of a diverse array of microbes in a single analysis, they may represent a valuable means of diagnosing the pathogens responsible for CNS infections and other clinical conditions with atypical presentations.

Asymptomatic full-term infants born to women with chorioamnionitis may not need routine antibiotics.

While infants with early-onset sepsis require antibiotics, there is little evidence to support their routine use in asymptomatic infants exposed to maternal chorioamnionitis. We aimed to ascertain the incidence of culture-proven sepsis in full-term infants exposed to chorioamnionitis and to determine whether asymptomatic infants need routine antibiotic treatment. This study was retrospective. Included were all full-term infants admitted to our neonatal intensive care unit between 1January 2017 and 31May 2018 who were given intravenous antibiotics for maternal chorioamnionitis. After identifying eligible infants, relevant maternal and infant data were collected from our medical records and the Neonatal Intensive Care Units Database. We selected 167 term infants from 7736 deliveries. The incidence of chorioamnionitis was 21 per 1000 deliveries. The mean gestational age was 39weeks (range 37-41), and 57% infants were male. Asymptomatic infants (76%) received intravenous antibiotics for an average of 2days compared to 4days in the symptomatic group (24%), p<0.001. No infant died or developed culture-positive sepsis. The risk of early-onset sepsis in well-appearing term infants of mothers with chorioamnionitis is low. Further studies are mandatory to determine whether asymptomatic infants of mothers with clinical chorioamnionitis need antibiotic treatment.

6 High-dose versus standard-dose oxytocin regimens to augment labor in nulliparas: a double-blind randomized clinical trial

To determine whether, compared to standard-dose oxytocin (SDO), high-dose oxytocin (HDO) for labor augmentation reduces the risk of cesarean in nulliparas. This double-blind, single center randomized trial (NCT02487797) included nulliparas with singleton gestations≥36 weeks in spontaneous labor who required oxytocin for augmentation. Those being induced or non-English speaking were excluded. Women were randomized 1:1 to SDO (initial and incremental rate of 2 mU/min) or HDO (initial and incremental rate of 6 mU/min) dosing. Oxytocin solutions were prepared by pharmacists using different concentrations but infused at the same initial and incremental volume rates (2 mL/h) so investigators, patients, and clinicians could remain masked to allocation. The primary outcome was cesarean delivery. Secondary maternal outcomes were labor duration, chorioamnionitis, endometritis, and postpartum hemorrhage. Secondary perinatal outcomes were perinatal death, Apgar score <3 at 5 minutes, umbilical artery acidemia, NICU admission, and a severe composite adverse outcome. Analysis was by intention to treat with p<0.05 considered significant. We planned to enroll 501 women per group to achieve 80% power to demonstrate a 6.6% absolute difference in cesarean, assuming a baseline incidence of 20% in the SDO group. 1003 women were randomized from 9/28/15 to 9/1/20. The incidence of cesarean was not significantly different between the groups. However, there was a significantly lower median labor duration, and a significant reduction in the incidence of chorioamnionitis in the HDO group compared with SDO (Table). There were no significant differences in other outcomes, specifically no increased risk of adverse neonatal outcomes (e.g., cesarean for non-reassuring fetal status, umbilical artery acidemia, severe perinatal composite) with HDO. The use of HDO for labor management did not result in a change in the incidence of cesarean. However, HDO was associated with a significant reduction in chorioamnionitis and duration of labor augmentation, without increases in neonatal complications.

Abstract 16414: Pathologic Description of the Association of Bronchopulmonary Dysplasia and Left-to-right Shunts

Introduction: Intracardiac left-to-right shunts, like atrial septal defect (ASD) and patent ductus arteriosus (PDA) have been shown to contribute to pulmonary hypertension in patients with bronchopulmonary dysplasia (BPD). There is no known comparison of heart and lung pathology in this population. The goal of our study was to characterize lung and heart pathology in patients with BPD and intracardiac shunts as well as correlate post-mortem changes with BPD classification. Hypothesis: Infants with greater degree of intracardiac shunt or persistent shunt will have more severe BPD classification and more severe heart and lung pathology. Methods: A retrospective cohort between 2011 and 2017 of 491 patients with BPD and prematurity were reviewed. There were 16 deceased patients, and 8 with autopsy who were included in the study. Outcomes measured were presence of shunt, pre and perinatal risk factors associated with BPD, degree of respiratory, inotropic and pulmonary vasodilator support, severity of BPD and heart and lung pathology on autopsy. Results: There was a low incidence of chorioamnionitis (12.5%), sepsis (12.5%), or maternal smoking (12.5%). Three patients had fetal growth restriction (37.5%). Seven patients (87.5%) received prenatal steroids and surfactant. At time of autopsy, 3 had an ASD, 3 had no shunt, 2 had shunts that had been closed; 1 patient had an ASD device closure, 3 had a PDA ligation and 1had PDA device closure. All patients had either a PDA or ASD at some point in infancy by echocardiogram. Six of the 8 patients had severe BPD and 2 had moderate BPD. All but one patient had abnormal right heart pathology(right atrial enlargement, right ventricular hypertrophy, and enlarged pulmonary artery) and abnormal lung pathology. One patient without right heart pathology had normal lung pathology, an isolated PDA that was ligated and moderate BPD. Patients who had moderate to large ASD (&gt; 6 mm) demonstrated worse lung and heart pathology. Conclusions: Infants with larger intracardiac shunts, were found to have more severe lung and heart disease. This data may suggest earlier closure of moderate to large intracardiac shunts, particularly ASD in this population may be beneficial to worsening cardiac and pulmonary disease in this population.

Effect of rivanol-induced abortion on placental histology: pitfalls in pathological interpretations

Objective: Placental pathology reflects the health condition of both mother and fetus during pregnancy, providing information about pathogenesis especially in adverse pregnancies, and may provide guidance on subsequent pregnancies. Description on the placental changes after long-term use of rivanol is lacking, and this evaluated the placental changes, with emphasis on the differential diagnosis from other primary placental lesions. Methods: A total of 85 placentas from rivanol induced abortion submitted to the Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University from Januaury 2017 to October 2019 were reviewed; and 81 gestational-age-matched cases of spontaneous abortion or preterm delivery during the same period were also included as the control group. Diagnoses were based on the consensus statement of 2016 Amsterdam Placental Workshop Group. Statistical differences were analyzed by individual diagnostic terms. Results: The maternal age in rivanol group was (30.5±4.1) (range 22-41) years, compared with (30.9±4.3) (range 22-44) years in the control group. Gestational age was (23.2±3.5) (range 17-35) weeks and (23.3±2.8) (range 17-33) weeks in the rivanol and control groups. The incidence of chorioamnionitis in rivanol group was 91.8%, significantly higher than the control (63.0%, P<0.05); and there were more stage 1 (subchorionic) maternal response in rivanol than in the control (61.0% vs.28.6%, P<0.05) groups. In addition, acute deciduitis was also more common in rivanol group (27.1% vs. 13.6%, P<0.05). No significant difference was observed in fetal inflammatory responses (vasculitis of vessels in chorion plate and umbilical cord); maternal malperfusion (narrowing of intervillous space, increased intervillous fibrin deposition, decidual arteriopathy, villous infarction and retroplacental hematoma); and fetal malperfusion (villous stromal hemorrhage and avascular villi). Conclusions: The chemical chorioamnionitis caused by rivanol is characterized by maternal inflammatory response of low stage and high grade. The use of rivanol has no obvious impact on the fetal inflammatory response, maternal malperfusion and fetal malperfusion. Such morphologic changes may reflect the original placental lesions.

Placental histopathological features of fetoscopic laser photocoagulation for monoaminotic diamniotic twin pregnancies

IntroductionThis study aimed to compare the histopathological placental features of monochorionic diamniotic (MCDA) twins who did and did not undergo fetoscopic laser photocoagulation (FLP). MethodsThis was a retrospective single-institution cohort study on MCDA twins who underwent FLP between October 2010 and December 2018. The control group included MCDA twins who did not undergo FLP and were delivered during the same period in the institute. The incidence of chorioamnionitis (CAM), funisitis, and other pathological findings was compared between the FLP and control groups after matching by gestational age at delivery. ResultsIn total, 292 MCDA pregnant women who underwent FLP and 356 controls gave birth during the study period. After matching the two groups in the ratio 1:1 by gestational age at delivery, each group comprised 194 subjects. The incidence of histological CAM with Blanc association (stage I, 6.2% vs. 3.1%, crude odds ratio (cOR) = 3.1, P = 0.052; stage II, 7.2% vs. 5.7%, cOR = 1.6, P = 0.30; stage III, 2.1% vs. 2.6%, cOR = 0.66, P = 0.52) and funisitis (artery, 5.2% vs. 3.6%, cOR = 1.3, P = 0.63; vein 7.2% vs. 4.1%, cOR = 1.6, P = 0.29) was not statistically significant difference between the FLP and control groups. The FLP group demonstrated a higher incidence of partial placental infarction than the control group (10.3% vs. 3.1%, cOR = 4.3, P = 0.004, adjusted OR = 2.8, P = 0.031). DiscussionFLP did not appear to increase the incidence of histological CAM or funisitis in subjects matched by gestational age at delivery. The FLP group demonstrated a higher incidence of partial placental infarction than the control group.

Placental pathology and neonatal outcomes in pre-eclampsia with gestational diabetes mellitus

Objective To investigate histopathological placental lesions and adverse neonatal outcomes by Pre-eclampsia (PE) with Gestational Diabetes Mellitus (GDM). Methods This was a retrospective cohort study of pregnancies with PE delivered between 1 January 2012 to 1 January 2014. Pregnant women with PE were recruited, and divided into PE with GDM (PE + GDM) group (n = 278) and PE without GDM (PE − GDM) group (n = 586). We compared the placental pathology and neonatal outcomes between the two groups. Results The (PE + GDM) group was significantly associated with high placenta weight (534.8 ± 124.1 vs 519.3 ± 132.3 g, p = .011), the large diameter of the placenta (17.8 ± 2.2 vs 16.2 ± 2.7 cm, p = .016) than (PE − GDM) group. The incidence of chorioamnionitis in (PE + GDM) group was significantly higher than (PE − GDM) group [48.9% (136/278) vs 41.5% (243/586), p = .028], whereas there were no significant differences in umbilical cord length and infarction between the two groups. The (PE + GDM) group had a higher rate of prematurity [44.9% (125/278) vs 39.9% (234/586), p = .042] than (PE − GDM) group, in (PE + GDM) group the incidence of LGA [15.1% (42/278) vs 1.0% (6/586), p = .034], RDS [18.7% (52/278) vs 9.2% (54/586), p = .011] and hyperbilirubinemia [10.7% (30/278) vs 1.0% (6/586), p = .038] were higher than (PE − GDM) group. Conclusions GDM increased the offspring’s complication in pregnancy with PE, the potential mechanism might be that GDM increased the placenta inflammation.

Perioperative Use of Cefazolin and Indomethacin for Physical Examination-Indicated Cerclages to Improve Gestational Latency.

To evaluate gestational latency in individuals who did and did not receive perioperative cefazolin and indomethacin after physical examination-indicated cerclage. This is a retrospective cohort study of all pregnant women with a singleton gestation who underwent physical examination-indicated cerclage placement and delivered at Northwestern Memorial Hospital from 2009 to 2018. Physical examination-indicated cerclage was performed in the setting of painless cervical dilation of at least 1 cm between 16 0/7 and 23 6/7 weeks of gestation. After 2014, our practice universally implemented perioperative prophylaxis of cefazolin and indomethacin. Individuals were categorized based on exposure to perioperative prophylaxis. The primary outcome was pregnancy latency at least 28 days after cerclage placement. Secondary outcomes included median latency; median gestational age at delivery; preterm birth before 28 weeks of gestation; preterm prelabor rupture of membranes; chorioamnionitis; and median birth weight. Multivariable analyses were performed, as well as a sensitivity analysis using propensity score matching. Cerclages were placed in 142 people: 72 (50.7%) received perioperative prophylaxis. Baseline demographics were not significantly different between groups. On multivariable analyses, individuals who received perioperative prophylaxis had a higher incidence of achieving a pregnancy latency at 28 days or more (adjusted relative risk [aRR] 1.21, 95% CI 1.05-1.40). Individuals who received perioperative prophylaxis had a significant improvement in gestational latency (+17.8 days, 95% CI 1.4-34.2 days) and birth weight (+489.8 g, 95% CI 64.6-915.0 g), with no differences in other outcomes. On sensitivity analysis, individuals receiving perioperative prophylaxis had a higher incidence of achieving a pregnancy latency at 28 days or more, (aRR 1.17, 95% CI 1.01-1.36) with no differences in other outcomes. Perioperative use of cefazolin and indomethacin prophylaxis during physical examination-indicated cerclage placement is associated with a significant prolongation in gestational latency without an increase in incidence of chorioamnionitis.

Features of pregnancy course in women with chemoresistant tuberculosis (a literature review)

Tuberculosis is a global cause of morbidity among women of reproductive age, constituting a serious maternal and perinatal risk in both developed and developing countries. Tuberculosis is the third highest cause of death in women of reproductive age. At the same time, the frequency of diagnosing a specific process in pregnant women and pregnancy in women with tuberculosis is almost the same. Today, against this background, the treatment of chemoresistant tuberculosis (CR-TB) in pregnant women remains controversial. The purpose. To conduct a review of current literature sources in order to determine the characteristics of gestation in women with CR-TB, which will assist clinicians in the management of such patients. Results . In pregnant women, extrapulmonary and pulmonary forms of tuberculosis incidence are almost the same. Chest X-ray examination in pregnant women should not be avoided, since the radiation risk for the fetus is insignificant when the abdominal cavity shielding. In women with tuberculosis, childbirth occurs on average at the 38th week of pregnancy, and premature labor is associated with tuberculosis progression. In pregnant women with tuberculosis, the incidence of chorioamnionitis, gestosis, premature birth, anemia, pneumonia, maternal and perinatal mortality is higher than in pregnant women without tuberculosis. Newborns have an increased risk of a premature birth, congenital tuberculosis, intrauterine growth retardation, congenital abnormalities, and distress syndrome. A high frequency of these pathologies in pregnant women and newborns largely depends on tuberculosis progression, chemoresistance of mycobacterium tuberculosis and the adequacy of anti-mycobacterial therapy. Untreated CR-TB is associated with higher maternal mortality, an increased risk of vertical transmission of tuberculosis, spontaneous miscarriage, intrauterine growth restriction, premature birth, increased neonatal mortality. Breastfeeding is possible if there is a sputum culture conversion in mother. The risk of toxic reactions to anti-tuberculosis drugs in breastfed infants is low and may be minimized if a mother with tuberculosis takes medications immediately after breastfeeding. Medical indications for artificial termination of pregnancy at 12–22 weeks’ gestation are severe forms of tuberculosis: disseminated, progressive, chemoresistant, with severe complications. Conclusions . Considering the analysis of the literature, all pregnant women should be prescribed treatment for CR-TB with second-line anti-tuberculosis drugs based on the drug sensitivity test starting from the second trimester (if a patient is HIV-negative or not in a critical state) with the exception of drugs such as amikacin, streptomycin, prothionamide and ethionamide. A timely and adequate anti-mycobacterial therapy is the key to successful pregnancy outcome. Pregnancy follow-up among women with CR-TB should be based on an interdisciplinary approach including a team of physicians such as a tuberculosis specialist, obstetrician, neonatologist, and public health expert.

A pilot randomized controlled trial of complete bed rest versus activity restriction after preterm premature rupture of the membranes

ObjectiveTo assess the impact of bed rest on maternal and neonatal outcomes in pregnancies complicated by preterm premature rupture of the membranes (PPROM), enabling proper sample size calculation for a powered randomized controlled trial (RCT). Study DesignWe conducted a pilot unblinded randomized controlled trial with a 1:1 allocation ratio (complete bed rest vs activity restriction groups) on singleton pregnancies complicated by PPROM at 24 + 0–33 + 6 weeks. Maternal and neonatal data were compared between groups with an intent-to-treat analysis. The primary outcomes were the latency time to delivery and the incidence of chorioamnionitis. The trial was conducted in a tertiary center of the Portuguese national healthcare system. Patients received standard antibiotic prophylaxis. Delivery was planned for the 34th week of gestation, except in cases of spontaneous labor or another complication. ResultsThirty-two cases were randomized and analyzed, 14 in the complete bed rest group and 18 in the activity restriction group. The median gestational age at PPROM was 30 vs 29 weeks (p = 0.82). In the complete bed rest group, the incidence of chorioamnionitis was nonsignificantly lower (14% vs 28%, p = 0.43). Median latency time was 11.5 days (95% CI, 2–20) in the complete bed rest group and 7.5 days (95% CI, 3–11) in the activity restriction group, lacking statistical significance on univariate (p = 0.6) and survival analyses (log-rank test, p = 0.75). No difference was found between groups regarding indication or type of delivery and maternal or neonatal morbidity. The median gestational age at delivery was 32 weeks for both groups (p = 0.94). A sample size of 2052 participants was calculated for a powered RCT, considering latency as the primary outcome. ConclusionIn this pilot trial, bed rest did not increase latency to delivery and did not improve maternal or neonatal morbidity in the setting of PPROM at 24 + 0–33 + 6 weeks. A sample size calculation is now available for a powered RCT.

Predictive value of procalcitonin, C-reactive protein, and white blood cells for chorioamnionitis among women with preterm premature rupture of membranes.

To determine the predictive value of procalcitonin, C-reactive protein (CRP), and white blood cells (WBC) for chorioamnionitis among women with preterm premature rupture of membranes (PPROM). A prospective cross-sectional study of all women with singleton pregnancy and PPROM admitted to a referral hospital in Shiraz, Iran, from 2016 to 2018. All women were hospitalized until delivery. The incidence of chorioamnionitis was recorded. Maternal serum CRP, procalcitonin, and WBC were measured on the day of admission and the day before termination of pregnancy. The diagnostic accuracy of each test was evaluated by receiver operator characteristic (ROC) curve analysis. Overall, 75 women with PPROM were included in the study. After termination of pregnancy, 34 (45.3%) were diagnosed with clinical chorioamnionitis. Those with chorioamnionitis had significantly higher serum levels of CRP both on admission (P=0.004) and before termination of pregnancy (P<0.001). The area under the curve for last CRP was 0.78 (95% confidence interval, 0.57-0.84), indicating moderate accuracy. Procalcitonin and WBC had low accuracy to predict chorioamnionitis. Among CRP, procalcitonin, and WBC, maternal serum CRP was found to be the most accurate predictor of chorioamnionitis among women with PPROM.

Neurodevelopmental outcomes of extremely preterm infants in southern China: A multicenter study

ObjectiveTo assess treatment outcomes and associated factors of extremely preterm infants (EPIs) in GuangXi, China. MethodsThis was a retrospective study consisting of 131 eligible cases with gestational age (GA) between 22 and 28 weeks, and infants were followed until 18–24 months. Data including clinical characteristics, perinatal factors and after-birth conditions were collected from the neonatal intensive care unit in 10 hospitals in Guangxi from January 1st 2010 until May 31st 2016. ResultsDuring that period, 307 EPIs were born in the hospitals. 137 infants died in hospital after their parents decided to withdraw clinical treatment, and 11 infants died despite full resuscitation was provided. Of the 159 surviving infants, 28 infants were lost to follow-up. In total, 131 infants who survived and were presented to follow-up at 18–24 months of age were enrolled into this study. Of the 131 infants evaluated at 18–24 months follow-up, 47 (35.9%) were diagnosed with neurodevelopmental disability (ND), and 84 (64%) demonstrated on tract motor and language skills. The incidence of chorioamnionitis, early onset sepsis (EOS), bronchopulmonary dysplasia (BPD) were all higher in the group of infants who were diagnosed with ND compared to those with normal motor language development (NML), the duration of mechanical ventilation (MV) was longer in ND group, and the higher incidence of ND was seen in the smaller GA babies (p < 0.05). Adjusted the BPD severity, GA was a protective factor of neurodevelopmental outcome (combined OR = 0.338, 95% CI: 0.145–0.791). In EPIs with moderate BPD and severe BPD, chorioamnionitis was a risk factor of ND (OR = 10.313 and 5.778，respectively, 95% CI: 1.389–6.486 and 1.444–23.119, respectively). The Logistic regression analysis showed that GA (OR = 0.207, 95%CI = 0.047–0.917) was a protective factor for ND, and chorioamnionitis (OR = 6.010, 95%CI: 1.331–27.138), moderate-to-severe BPD (OR = 4.285, 95%CI: 1.495–12.287), the duration of MV (OR = 3.508, 95%CI: 2.077–5.926) were independent risk factors for ND in EPIs. ConclusionsChorioamnionitis, moderate-to-severe BPD, and the duration of MV were associated with neurodevelopmental disability in EPIs. The smaller the GA, the higher incidence of neurodevelopmental disability.

Azithromycin vs erythromycin for the management of preterm premature rupture of membranes

Preterm premature rupture of membranes complicates 2-3% of pregnancies. Many institutions have advocated for the use of azithromycin instead of erythromycin. This is secondary to national shortages of erythromycin, ease of administration, better side effect profile, and decreased cost of azithromycin as compared with erythromycin. The objective of the study was to evaluate whether there are differences in the latency from preterm premature rupture of membranes to delivery in patients treated with different dosing regimens of azithromycin vs erythromycin. This is a multicenter, retrospective cohort of women with singleton pregnancies with confirmed rupture of membranes between 230 and 336 weeks from January 2010 to June 2015. Patients were excluded if there was a contraindication to expectant management of preterm premature rupture of membranes. Patients received 1 of 4 antibiotic regimens: (1) azithromycin 1000 mg per os once (azithromycin 1 day group); (2) azithromycin 500 mg per os once, followed by azithromycin 250 mg per os daily for 4 days (azithromycin 5 day group); (3) azithromycin 500 mg intravenously for 2 days, followed by azithromycin 500 mg per os daily for 5 days (azithromycin 7 day group); or (4) erythromycin intravenously for 2 days followed by erythromycin per os for 5 days (erythromycin group). The choice of macrolide was based on institutional policy and/or availability of antibiotics at the time of admission. In addition, all patients received ampicillin intravenously for 2 days followed by amoxicillin per os for 5 days. Primary outcome was latency from diagnosis of rupture of membranes to delivery. Secondary outcomes included clinical and histopathological chorioamnionitis and neonatal outcomes. Four hundred fifty-three patients who met inclusion criteria were identified. Seventy-eight patients received azithromycin for 1 day, 191 patients received azithromycin for 5 days, 52 patients received azithromycin for 7 days, and 132 patients received erythromycin. Women who received the 5 day regimen were younger and less likely to be non-African American, have hypertension, have sexually transmitted infection, or experienced substance abuse. There was no statistical difference in median latency time of azithromycin 1 day (4.9 days, 95% confidence interval, 3.3-6.4), azithromycin 5 days (5.0, 95% confidence interval, 3.9-6.1), or azithromycin 7 days (4.9 days, 95% confidence interval, 2.8-7.0) when compared with erythromycin (5.1 days, 95% confidence interval, 3.9-6.4) after adjusting for demographic variables (P= .99). Clinical chorioamnionitis was not different between groups in the adjusted model. Respiratory distress syndrome was increased in the azithromycin 5 day group vs azithromycin 1 day vs erythromycin (44% vs. 29% and 29%, P= .005, respectively). There was no difference in latency to delivery, incidence of chorioamnionitis, or neonatal outcomes when comparing different dosing regimens of the azithromycin with erythromycin, with the exception of respiratory distress syndrome being more common in the 5 day azithromycin group. Azithromycin could be considered as an alternative to erythromycin in the expectant management of preterm premature rupture of membranes if erythromycin is unavailable or contraindicated. There appears to be no additional benefit to an extended course of azithromycin beyond the single-day dosing, but final recommendations on dosing strategies should rely on clinical trials.