Maternal Infectious Morbidity Research Articles

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

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 24h vs. 12h. In July 2021, our protocol of induction of labor in term-PROM was extended from 12h to 24h 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. The 24h and 12h ROM-to-induction protocol groups included 962 and 802 women, respectively. In the 24h 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 24h 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. 12h group. 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.

Prevalence of Tuberculosis in HIV- or Tuberculosis-exposed neonates at the University Teaching Hospital in Lusaka over a period of six months

Background: Tuberculosis (TB) is the leading cause of mortality globally and represents a major health problem. The burden of TB in Zambia is among the highest in the African region with a national prevalence estimated at 455/100 000 for all age groups. A large proportion of people with TB are in the reproductive age group as such may either be pregnant or have young children. As at 2014 the prevalence of TB among women attending antenatal care in Zambia was estimated to be 1.5% in HIV infected women and 1.4% in uninfected women. There is a close association between maternal TB and HIV infection and postpartum infant morbidity and mortality. TB in neonates is very rare but a tenfold increase in the risk of acquiring TB in infants born to HIV infected mothers has been documented. Methods: A cross sectional study was conducted to establish the prevalence of tuberculosis in neonates exposed to either HIV or TB, or to both TB and HIV. The study included neonates aged 28 days and below that were admitted to the intensive care unit (NICU) and nurseries on general pediatric wards at the University teaching hospital. Mothers to neonates that had a positive rapid HIV test were approached, made aware of the study and invited to participate by giving consent to have their baby included in the study. When consent was granted, basic demographic details and medical information were collected. One gastric lavage sample was collected before the first feed of the day and analysed using Xpert MTB- RIF test. Results: One hundred forty-nine consecutive neonates that met the inclusion criteria were enrolled in the study. The average age of the neonates was nine days, 49 % had mean birth weight of 2.50kg (0.85 SD), 86 full term delivery and 73 (49%) were male. One hundred, ten (110) were born to multiparous (74%) vs 38 primiparous (26%) mothers. All the neonates enrolled in the study were HIV exposed and only one neonate was exposed to both TB and HIV. Mycobacterium tuberculosis was detected in 2 out 149 samples analysed using the Xpert MTB-RIF test. None were positive for rifampicin resistance Conclusion: The prevalence of TB using Xpert MTB-RIF test performed on gastric aspirates of HIV exposed neonates admitted to the University teaching hospital is 1.3 %.

Synthetic Osmotic Dilators for Pre-Induction Cervical Ripening - an Evidence-Based Review.

Mechanical methods have gained growing interest for pre-induction cervical ripening in women with an unripe cervix, since they have a better safety profile compared to prostaglandins. Balloon catheters have been the gold standard method for decades, while there was a lack of data on synthetic osmotic cervical dilators. Not until 2015, when Dilapan-S was approved by the Food and Drug Administration (FDA) for induction of labor, numerous studies have been published on the use of Dilapan-S in this field. The rate of vaginal deliveries associated with the use of Dilapan-S ranges from 61.6 to 81.7%, and no serious complications needing further interventions have been reported to this date. Dilapan-S was shown to be as effective as the Foley balloon catheter as well as the 10mg PGE 2 vaginal insert and orally applied misoprostol (25µg every 2 hours) in achieving vaginal delivery, but patient's satisfaction during the cervical ripening process was significantly higher compared to the other methods and the rate of uterine hyperstimulation was significantly lower compared to prostaglandins (PGs). Minor complications (e.g. vaginal bleeding) associated with the use of Dilapan-S were <2%, and maternal infectious morbidity was not higher compared to Foley balloon and vaginal PGE 2 or misoprostol. Due to these beneficial properties Dilapan-S might be an ideal option for outpatient cervical ripening, as shown in a recent randomized clinical trial comparing inpatient to outpatient cervical ripening. Furthermore, according to the manufacturers' product information, Dilapan-S is the only cervical ripening method that is not contraindicated for induction of labor in women with a previous cesarean section. Upcoming guidelines should consider synthetic osmotic cervical dilators as an effective and safe method for cervical ripening/induction of labor acknowledging that more evidence-based data are mandatory, particularly in patients with a previous cesarean section.

Association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis among patients undergoing induction of labor at term

Rectovaginal colonization with Group B Streptococcus during pregnancy has historically been shown to be associated with an increased risk of clinical chorioamnionitis and peripartum infectious morbidity. Newer observational data in the era of intrapartum antibiotic prophylaxis suggest a possible reversal of this association; however, it is unclear if this is related to differences in labor management for those with and without Group B Streptococcus colonization. We therefore sought to assess the association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis within the context of a randomized induction of labor trial with a standardized labor protocol. We performed an exploratory secondary analysis of a randomized trial of patients undergoing term induction at a tertiary care center. Patients received third trimester Group B Streptococcus screening and intrapartum antibiotic prophylaxis as routine care. Group B Streptococcus detection was performed using a carrot broth-enhanced subculture to Group B Streptococcus Detect approach (Hardy Diagnostics, Santa Maria, CA). Labor management was protocolized per the trial. Patients with unknown Group B Streptococcus status or who did not receive intrapartum antibiotic prophylaxis, if indicated, were excluded. The primary outcome was diagnosis of clinical chorioamnionitis, compared between patients who received intrapartum antibiotic prophylaxis for known Group B Streptococcus positive status (by culture, history, or Group B Streptococcus bacteriuria) and those who were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis. Secondary outcomes included postpartum endometritis, wound infection, a composite maternal peripartum infectious morbidity, and neonatal outcomes. A total of 491 patients were enrolled in the trial. Of these, 466 had a known Group B Streptococcus status and received or did not receive intrapartum antibiotic prophylaxis accordingly and were included in this analysis: 292 (62.7%) were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis, and 174 (37.3%) were Group B Streptococcus positive and received intrapartum antibiotic prophylaxis. The majority of patients were Non-Hispanic Black (78.1%) and nulliparous (59.7%). There were no differences in demographic, clinical, induction or labor characteristics between groups. Patients who were Group B Streptococcus positive had a 49% lower rate of clinical chorioamnionitis (8.1% vs 14.7%, odds ratio, 0.51; P=.03) and a lower rate of peripartum infectious morbidity (8.1% vs 15.8%, odds ratio, 0.47; P=.02) compared to those who were Group B Streptococcus negative. Infants born to patients who were Group B Streptococcus positive were significantly less likely to be admitted to the neonatal intensive care unit (3.4% vs 15.1%, P<.001). Although Group B Streptococcus colonization has historically been considered a risk factor for clinical chorioamnionitis, in the era of universal antibiotic prophylaxis for Group B Streptococcus positive patients, our findings support the point that intrapartum antibiotic prophylaxis for Group B Streptococcus positivity is associated with lower rates of clinical chorioamnionitis and peripartum infectious morbidity among patients undergoing induction with protocolized labor management. These findings demonstrate that intrapartum antibiotic prophylaxis for Group B Streptococcus may protect against perinatal infectious morbidity, a phenomenon that warrants further investigation.

Single versus dual antibiotic regimen in women with term prolonged rupture of membranes and intrapartum fever: a retrospective study.

The impact ofE. coli in causing peripartum infections has been increasing due to rising ampicillin resistance. In this study, we compared maternal and neonatal outcomes of women with prolonged rupture of membranes (ROM >18h) and intrapartum fever, according to two antibiotic regimens they received, and describe the bacterial distribution focusing on risk factors for Enterobacteriaceae-related infectious morbidity. This 10-year retrospective study of women with ROM >18h and intrapartum fever included 62 women who were treated with ampicillin and gentamicin due to suspected intraamniotic infection and 79 without these signs who were treated with ampicillin alone. The primary outcomes were endometritis and neonatal early-onset sepsis (EOS) rates. Outcomes were compared using univariate and multivariate analyses. Among women who received ampicillin alone compared with dual therapy, rates were higher of endometritis (17% vs. 3%, p<0.001), neonatal early onset sepsis (7.5% vs. 0%, p=0.03), Enterobacteriaceae positive placental swab culture (67.9% vs. 15.7%, p<0.001), and histopathological subchorionitis (25.3% vs. 8.0%, p=0.008). Over 83% of Enterobacteriaceae isolates were ampicillin-resistant. Gestational age at delivery >41 weeks, meconium at delivery, ROM >24h and treatment with a single antibiotic agent were associated with the presence of a positive Enterobacteriaceae placental swab culture. Ampicillin compared to dual treatment in women with prolonged ROM and fever might promote the growth of ampicillin-resistant Enterobacteriaceae (including E.coli) and increase risks of maternal and neonatal infectious morbidity.

Timing of Intravenous Prophylactic Antibiotic Agents for Cesarean Delivery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: Prophylactic antibiotic administration has been used to reduce infectious morbidities in cesarean deliveries. However, no consensus on the timing has been reached. We performed this review to compare maternal and neonatal infectious morbidities of antibiotic administration before skin incision and after cord clamping. Methods: PubMed, EMBASE, MEDLINE, Cochrane Library, and Web of Science databases were searched. Only randomized controlled trials (RCTs) comparing the use of antibiotic agents pre-operatively and after cord clamping were included. Characteristics and results of the included studies were extracted, and risks of bias were assessed. A fixed-effect model was applied to estimate the relative risks (RRs) for outcomes. Results: Sixteen RCTs, including 8,027 women and 7,131 newborns, met the selection criteria. Pre-operative administration of antibiotic agents was associated with a reduction in the risk of endometritis (RR, 0.52; 95% confidence interval [CI], 0.37-0.72) and wound complications (RR, 0.54; 95% CI, 0.42-0.69), compared with administration after cord clamping. No differences were observed in the rate of febrile illness (RR, 0.79; 95% CI, 0.59-1.05), urinary tract infection (RR, 0.92; 95% CI, 0.64-1.32), neonatal intensive care unit (NICU) admission (RR, 0.94; 95% CI, 0.79-1.12), and neonatal sepsis (RR, 0.83; 95% CI, 0.61-1.14). Conclusions: The present study showed that prophylactic antibiotic agent administration before skin incision can reduce the risk of endometritis and wound complications while not increasing that of NICU admission and neonatal sepsis compared with administration after cord clamping.

Compared perinatal outcomes of two prophylactic antibiotic regimens for preterm premature rupture of membranes: a randomized controlled trial

Prophylactic antibiotic use in preterm premature rupture of membranes is associated with significantly reduced intra-amniotic infection and improved neonatal outcome, although data are insufficient to determine the optimal antibiotic regimen. Ampicillin resistance has changed the epidemiology of neonatal sepsis. This study aimed to determine the efficacy of two antibiotic regimens in prolonging the latency period in women with preterm premature rupture of membranes. This randomized-controlled trial was conducted in 3 tertiary university-affiliated hospitals. A total of 124 women with preterm premature rupture of membranes at <37 weeks of gestation were randomized into two antibiotic prophylactic protocols: ampicillin + roxithromycin and cefuroxime + roxithromycin. The latency period length, neonatal adverse outcomes, and maternal infectious morbidity, including intrauterine infection, intrapartum fever, postpartum antibiotic treatment, endometritis, and wound infection, were measured and compared. Maternal infectious morbidity was higher in the ampicillin group than in the cefuroxime group (17.7% vs 6.5%; 1-sided P value =.048). The pathogen distribution among placenta, membrane, cord, and uterine cultures differed between the groups (P=.017). Enterobacteriaceae spp. cultures were identified in 68.6% of the cultures in the ampicillin group and 43.2% in the cefuroxime group (P=.036). The composite neonatal adverse outcome was higher in the ampicillin group than in the cefuroxime group (55 [88.7%] vs 46 [74.2%]; 1-sided P value =.03). The proportion of primiparas with a latency period >4 days was significantly higher in the cefuroxime group than in the ampicillin group (odds ratio, 3.69; 95% confidence interval, 1.175-11.607; P=.025). In combination with roxithromycin, the use of cefuroxime, as a prophylactic in women with premature rupture of membranes at <37 weeks of gestation, showed longer pregnancy in primiparas and less maternal and neonatal morbidity than the use of ampicillin. Further larger studies are needed to support our results.

Association between group B streptococcus positivity and maternal infectious morbidity

Vaginorectal colonization with Group B Streptococcus (GBS) has historically been associated with higher rates of chorioamnionitis and postpartum infection. Data from a recent observational cohort suggests a possible reversal of this association. In order to minimize confounding by differences in labor management, we sought to assess the association between GBS positivity and chorioamnionitis within the context of a randomized induction trial with a standardized labor protocol.

1344. Infectious Morbidity and Mortality of HIV-Exposed, Uninfected Infants Compared with HIV-Unexposed Uninfected Infants in Botswana

Abstract Background Studies have shown increased risk for infection-related hospitalizations among infants HIV-exposed-uninfected (HEU) compared to infants HIV-unexposed-uninfected (HUU). However, limited data exist during an era of expanded antiretroviral therapy (ART) and improved healthcare access in pregnancy. Methods The Tshilo Dikotla study prospectively enrolled pregnant women ≥ 18 years old, both living with HIV (WLHIV) and HIV-seronegative, in Botswana, following mother-infant pairs through 3 years postpartum. Pregnant WLHIV received tenofovir/lamivudine or emtricitabine plus efavirenz or dolutegravir. For this analysis, the primary outcome, infectious morbidity, was hospitalization or death due to an infectious cause for infants in the first 12 months of life. Log-binomial models were fit to assess the association between in utero HIV exposure status and infectious morbidity. Subgroup analysis among infants HEU was performed to assess associations between timing of maternal ART initiation (pre-conception vs. during pregnancy) and infant infectious morbidity. Results Of 464 infants, 314 (67.7%) were HEU. Maternal age was higher among WLHIV (30.3 vs. 24.6 years; p &amp;lt; 0.01), as was gravidity (3.0 vs.1.0; p &amp;lt; 0.01). The proportion of WLHIV reporting senior secondary or tertiary education was lower (43.3% vs 72.0%; p&amp;lt; 0.01). A total of 35 (7.5%) infants were hospitalized/died due to infectious causes [26 (8.3%) HEU vs. 9 (6.0%) HUU (p=0.38)]. The most frequent infections were pneumonia and diarrhea/gastroenteritis. There was no significant difference in infectious morbidity by infant HIV exposure status [adjusted Odds Ratio (aOR), 1.17; 95% Confidence Interval (CI), 0.49, 2.81] after adjusting for maternal age, gravidity, income, and education. No association was found between timing of maternal ART initiation and infectious morbidity (aOR 0.60; 95% CI, 0.25, 1.40) among infants who were HEU, after additionally adjusting for maternal CD4 count and HIV viral load. Characteristics of infants by in utero HIV exposure status Conclusion In this small sub-Saharan African cohort, no detectable associations were observed by infant HIV exposure status or timing of maternal ART initiation and infant infectious morbidity. Larger studies are needed to confirm these findings. Disclosures All Authors: No reported disclosures.

A PROSPECTIVE STUDY ON THE MATERNAL OUTCOME IN CASES OF PREVIOUS ONE CESAREAN SECTION

Background and Objectives:Women with previous cesarean sections constitute a high-risk group in obstetrics. The study was conducted to determine the mode of delivery in a previous cesarean section group and maternalcomplications. Method:The study was a prospective observational study conducted in The NSCB Medical College, Jabalpur from January 2020 to June 2021. Cases with previous one cesarean section for outcome in present pregnancy were taken and Cases with gestation before 28 weeks and previous section &gt; 2 were excluded. Result:A total of 384 cases presented with the previous one CS, TOLAC was given to 109 patients (28.38%) and 51.37% achieved VBAC in the TOLAC group. Women who were selected for repeat CS without a trial of labor were 275 (71.61%)and the most common indication being scar tenderness 28%. Post-op maternal complications and infectious morbidity were significantly higher in the repeat cesarean section group. Conclusion: Women given a trial of labor with careful monitoring and taken for emergency LSCS on minimal indication is the best answer to management with an expectant attitude and individualization of labor in patients who had one cesarean section is not only justifiable but represents a sound and conservative obstetrical practice.

Optimal timing of labor induction after prelabor rupture of membranes at term: a secondary analysis of the TERMPROM study

In the case of prelabor rupture of membranes at term, the risk for neonatal and maternal infectious morbidity increases progressively with time from prelabor rupture of membranes. Although most studies identified a benefit associated with early induction within the first 24 hours following term prelabor rupture of membranes, there is currently no precise data regarding how early should induction be scheduled. This study aimed to identify the optimal timing of labor induction among women with term prelabor rupture of membranes by comparing the maternal and neonatal outcomes associated with labor induction with those of expectant management at any given 1-hour interval following prelabor rupture of membranes. This was a secondary analysis of data from the TERMPROM trial, an international, multicenter, randomized clinical trial on immediate delivery vs expectant management of women with prelaor rupture of membranes at term (≥37+0/7 weeks' gestation). We considered all participants as a single cohort of women with term prelabor rupture of membranes, irrespective of the original randomized study group allocation. For each given 1-hour time interval within the first 36 hours following prelabor rupture of membranes, we compared the outcomes of subjects for whom labor induction was initiated during this interval with those of subjects managed expectantly at the same time interval. The primary neonatal outcome was a composite of neonatal infection and admission to the neonatal intensive care unit. The primary maternal outcomes included maternal infection (clinical chorioamnionitis or postpartum fever) and cesarean delivery. Of the 4742 subjects who met the study criteria, 2622 underwent labor induction, and 2120 experienced a spontaneous onset of labor. The rates of the neonatal composite outcome, neonatal admission to intensive care unit, and maternal infection increased progressively with time after prelabor rupture of membranes. The risk for these outcomes was lower among women who underwent induction when compared with those managed expectantly within the first 15 to 20 hours after prelabor rupture of membranes without affecting the risk for cesarean delivery. In addition, women who underwent labor induction within the first 30 to 36 hours had a shorter prelabor rupture of membranes to delivery time and a shorter total maternal hospital stay when compared with those managed expectantly at the same time interval. Among women managed expectantly, less than two-thirds (64%; 1365/2120) experienced a spontaneous onset of labor within the first 24 hours following prelabor rupture of membranes. These findings suggest that immediate labor induction seems to be the optimal management strategy to minimize neonatal and maternal morbidity in the setting of prelabor rupture of membranes at term gestations. In cases for which immediate induction is not feasible, labor induction remains the preferred option over expectant management if performed within the first 15 to 20 hours after prelabor rupture of membranes.

Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity

A recent study from the United Kingdom suggested that a single dosage of adjunctive amoxicillin/clavulanic acid with operative vaginal delivery reduces maternal infectious morbidity by 40% (from 19% to 11%). However, 89% of their study population received an episiotomy. This study aimed to evaluate whether operative vaginal delivery is an independent risk factor for composite maternal postpartum infectious morbidity in a population with a low episiotomy rate. This was a retrospective cohort study of patients with viable singleton vaginal deliveries after ≥34 weeks gestation at a single perinatal center (2013-2018). The patients were categorized by the mode of delivery: spontaneous vaginal delivery or operative vaginal delivery (forceps or vacuum-assisted). The primary outcome was a composite of maternal infectious morbidity up to 6 weeks after delivery, defined as (1) endometritis, (2) perineal wound morbidity (infection, breakdown, or dehiscence), or (3) culture-proven urinary tract infection. The patient characteristics and outcomes were compared between the groups using appropriate tests. Multivariable models were used to estimate the association between operative vaginal delivery and study outcomes compared with spontaneous vaginal delivery, with adjustment for selected confounders. Of 14,647 deliveries meeting the inclusion criteria, 732 (5.0%) were operative vaginal deliveries: 354 (48%) forceps and 378 (52%) vacuums. Overall, 210 (1.4%) patients developed the morbidity composite. Patients having an operative vaginal delivery were more likely to be nulliparous, have labor inductions, develop intrapartum chorioamnionitis, receive an episiotomy, and sustain a third- or fourth-degree laceration. After adjusting for confounding factors, no significant association was observed between operative vaginal delivery and composite morbidity (adjusted odds ratio, 1.4 [0.8-2.4]) or any of its individual components. Administration of postpartum antibiotics and documented fever were also similar between groups. There was also no significant association between instrument (forceps vs vacuum) and the maternal infection composite. In this single-center US cohort, operative vaginal delivery was not an independent risk factor for maternal composite postpartum infectious morbidity.

Comparative analysis of C-section outcomes with antibiotic prophylaxis and antibiotic therapy in the Regional Perinatal Center

Prophylactic prescription of antibiotics before C-section prevents maternal infectious morbidity in the postoperative period, while irrational prescription leads to the development of adverse outcomes [1]. Postpartum infections are becoming the main cause of prolonged hospital stay and increase the costs of the healthcare system [2]. The aim: to conduct a comparative pharmacoepidemiological analysis of the caesarean section outcomes with antibiotic prophylaxis and antibiotic therapy.

Comparing Infectious Morbidity between Administration of Antibiotic before Skin Incision and after Umbilical Cord Clamping during Elective Cesarean Section

Objective: To assess the differences in maternal infectious morbidity when cefazolin is administered prior to skin incision versus after clamping the umbilical cord in elective caesarean section. Infectious morbidities include febrile morbidity, surgical site infection, endometritis, and urinary tract infection. Materials and Methods: The present study was a prospective double-blind randomized controlled trial of 92 pregnant women who visited Krathumbaen Hospital for antenatal care at 37 weeks of pregnancy, of whom elective cesarean section was indicated, between June and December 2020. The participants were randomly divided into two groups. Group A represented those who receive cefazolin prior to skin incision and Group B represented those received cefazolin after umbilical cord clamping. After the cesarean operation, data were collected from medical records, and each group would be observed for complications. Frequency, percentage frequency distribution, mean and standard deviation, independent t-test, Chi-square, and Fisher exact test were the statistical data utilized. The data were displayed in a descriptive statistical form following the analysis. The define p-value in the present study trial is p=0.05. Results: Demographic variables were not different between groups. Findings revealed that nine (19.57%) pregnant women in group A and ten (21.74%) in group B experienced febrile morbidity, which was not statistically significantly different. Neither group had any postoperative surgical site infection, endometritis, or urinary tract infection. Conclusion: Comparing post-operative infectious morbidity, there was no significant difference in the time when cefazolin was administered before skin incision or after umbilical cord clamping in elective cesarean section. Keywords: Prophylactic antibiotic; Elective cesarean section; Infectious morbidity

Long-term impact of pre-incision antibiotics on children born by caesarean section: a longitudinal study based on UK electronic health records.

Since changes in the national guidance in 2011, prophylactic antibiotics for women undergoing caesarean section are recommended prior to skin incision, rather than after the baby's umbilical cord has been clamped. Evidence from randomised controlled trials conducted outside the UK has shown that this reduces maternal infectious morbidity; however, the prophylactic antibiotics also cross the placenta, meaning that babies are exposed to them around the time of birth. Antibiotics are known to affect the gut microbiota of the babies, but the long-term effects of exposure to high-dose broad-spectrum antibiotics around the time of birth on allergy and immune-related diseases are unknown. We aimed to examine whether or not in-utero exposure to antibiotics immediately prior to birth compared with no pre-incisional antibiotic exposure increases the risk of (1) asthma and (2) eczema in children born by caesarean section. This was a controlled interrupted time series study. The study took place in primary and secondary care. Children born in the UK during 2006-18 delivered by caesarean section were compared with a control cohort delivered vaginally. In-utero exposure to antibiotics immediately prior to birth. Asthma and eczema in children in the first 5 years of life. Additional secondary outcomes, including other allergy-related conditions, autoimmune diseases, infections, other immune system-related diseases and neurodevelopmental conditions, were also assessed. The Health Improvement Network (THIN) and the Clinical Practice Research Datalink (CPRD) primary care databases and the Hospital Episode Statistics (HES) database. Previously published linkage strategies were adapted to link anonymised data on mothers and babies in these databases. Duplicate practices contributing to both THIN and the CPRD databases were removed to create a THIN-CPRD data set. In the THIN-CPRD and HES data sets, records of 515,945 and 3,945,351 mother-baby pairs were analysed, respectively. The risk of asthma was not significantly higher in children born by caesarean section exposed to pre-incision antibiotics than in children whose mothers received post-cord clamping antibiotics, with an incidence rate ratio of 0.91 (95% confidence interval 0.78 to 1.05) for diagnosis of asthma in primary care and an incidence rate ratio of 1.05 (95% confidence interval 0.99 to 1.11) for asthma resulting in a hospital admission. We also did not find an increased risk of eczema, with an incidence rate ratio of 0.98 (95% confidence interval 0.94 to1.03) and an incidence rate ratio of 0.96 (95% confidence interval 0.71 to 1.29) for diagnosis in primary care and hospital admissions, respectively. It was not possible to ascertain the exposure to pre-incision antibiotics at an individual level. The maximum follow-up of children was 5 years. There was no evidence that the policy change from post-cord clamping to pre-incision prophylactic antibiotics for caesarean sections during 2006-18 had an impact on the incidence of asthma and eczema in early childhood in the UK. There is a need for further research to investigate if pre-incision antibiotics have any impact on developing asthma and other allergy and immune-related conditions in older children. This study is registered as researchregistry3736. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 30. See the NIHR Journals Library website for further project information.

Severe maternal infectious morbidity during the second half of pregnancy is an independent risk factor for a small for gestational age neonate

ObjectiveThe effect of severe maternal infectious morbidity on fetal growth during the second half of pregnancy is under debate. Preliminary evidence suggests that such association may be plausible. The objectives of this study were to determine: 1) The association between severe maternal infectious morbidity and adverse pregnancy outcome; and 2) The effect of maternal infection during pregnancy on fetal growth. Study designThis retrospective population – based cohort study included 4771 women who gave birth at our medical center during the study period. Parturients were allocated into two groups: 1) patients with severe maternal infection during the second half of pregnancy (n = 368); and 2) control group comprised of normal pregnant women who were matched to the study group by maternal age, gravidity and parity (n = 4403). ResultsThe severe maternal infection group included women with pneumonia (n = 198), pyelonephritis (n = 131), and viral pneumonitis (n = 39). In comparison to the normal patients group: 1) having had pneumonia during the second half of pregnancy was associated with increased rates of fetal growth restriction, placental abruption, fetal demise (P < 0.001, for all comparisons) and preeclampsia (P = 0.041); 2) Pyelonephritis during the second half of gestation was associated with higher rates of fetal growth restriction (P < 0.001), placental abruption (P = 0.006) and labor induction (P = 0.039). As a group, women with severe maternal infection had higher rates of small for gestational age neonates compared to normal parturients (P < 0.001). Among women with infections, only those who had pyelonephritis (P = 0.032) or pneumonia (P = 0.008), had a higher rate of small for gestational age neonates than those in the control group. After adjustment to confounding factors, maternal infection (OR = 1.42, 95% CI 1.085–1.85) and previous delivery of a small for gestational age neonate (OR = 2.54, 95% CI 2.02–3.19), were independent risk factors for the delivery of a small for gestational age neonate. ConclusionSevere maternal infectious morbidity during the second half of pregnancy is an independent risk factor for the delivery of a small for gestational age neonate and is associated with adverse pregnancy outcomes. Both, pneumonia and pyelonephritis, during the second half of gestation affect fetal growth and are related to higher rates of small for gestational age neonates.

569 Timing of antibiotic prophylaxis in cesarean delivery and the rate of postpartum infections – a cross-over study in a nationwide cohort

Introduction and aims of the study: Current clinical guidelines recommend antibiotic prophylaxis in cesarean delivery before cord clamping. Therefore, most hospitals in Denmark have changed practice since 2010, with only a few hospitals still administering antibiotics after cord clamping. This study evaluates, whether a change in antibiotic timing practice has reduced maternal infectious morbidity among women giving birth by cesarean delivery in Denmark. Methods: A national cohort study, with a cross-over design: eight year periods on either side of the breakpoint on the 1st of January 2010 were evaluated.

62 Single- Versus Double-Layer Uterine Closure After Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Abstract Aim To compare single-layer (SL) with double-layer (DL) uterine closure techniques after caesarean section in terms of ultrasonographic findings and rate of CS complications. Method PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant randomized clinical trials (RCTs). Retrieved articles were screened, and relevant studies were included in a meta-analysis. Continuous data were pooled as mean difference (MD) with 95% confidence interval (CI), and dichotomous data were pooled as relative risk (RR) and 95% CI. Analysis was conducted using RevMan software (Version 5.4). Results Eighteen RCTs were included in our study. Pooled results favoured DL uterine closure in terms of residual myometrial thickness (MD = -1.15, 95% CI [-1.69, -0.60], P &amp;lt; 0.0001) and dysmenorrhea (RR = 1.36, 95% CI [1.02, 1.81], P = 0.04), while SL closure had shorter operation time than DL closure (MD = -2.25, 95% CI [-3.29, -1.21], P &amp;lt; 0.00001). Both techniques had similar results in terms of uterine dehiscence or rupture (RR = 1.88, 95% CI [0.63, 5.62], P = 0.26), healing ratio (MD = -5.00, 95% CI [-12.40, 2.39], P = 0.18), maternal infectious morbidity (RR = 0.94, 95% CI [0.66, 1.34], P = 0.72), hospital stay (MD = -0.12, 95% CI [-0.30, 0.06], P = 0.18), and readmission rate (RR = 0.95, 95% CI [0.64, 1.40], P = 0.78). Conclusions DL closure of caesarean uterine scar is associated with more residual myometrial thickness and less dysmenorrhea compared with SL uterine closure. But SL closure has the advantage of the shorter operation time.

Is amniopatch an effective treatment for spontaneous previable premature rupture of membranes? Analysis of perinatal outcome.

To characterize the perinatal outcomes of pregnancies complicated by spontaneous previable premature rupture of membranes with a therapeutic intervention in the form of amniopatch (AP) at the 2nd Department of Obstetrics and Gynecology (2008‒2019). The retrospective analysis of perinatal markers and early neonatal morbidity of pregnancies treated with amniopatch. Discussion comparison with the published papers of cases of spontaneous previable rupture of membranes managed expectantly. Out of the total number of pregnancies, 53 met the exclusion criteria, of which 35 were terminated by delivering a live newborn, 3 newborns died during the hospitalization. The following incidence of early complications has been reported in live births: 1) Bronchopulmonary dysplasia (10/35-28.57 %), 2) Newborn respiratory distress syndrome (25/35-71.42 %), 3) Neonatal sepsis (15/35-42.85 %), 4) Intraventricular hemorrhage (14/35-40 %), 5) Periventricular leukomalacia (3/35-8.57 %), 6). Necrotizing enterocolitis (2/35-5.71 %), 7) Retinopathy of prematurity (7/35-20 %) and 8) Foetal compression syndrome (16/35-45.71 %). In a discussion comparison with available publications of expectantly managed pregnancies, we observed a statistically significantly lower incidence of respiratory distress syndrome, retinopathy, and chorioamnionitis in our cohort along with a higher incidence of foetal compression defects. Amniopatch can be a therapeutic method for reducing the neonatal mortality associated with RDS, maternal infectious morbidity, and an alternative in patients, who require an active approach to such a compromised pregnancy (Tab. 12, Fig. 1, Ref. 50).

Pre-operative Vs. Post-operative Vaginal Cleansing with Povidone-iodine and Post-caesarean Infectious Morbidity: A Randomized Controlled Study.

Post-caesarean maternal infectious morbidity is still a big challenge despite prophylactic antibiotics use and other modalities adopted to prevent it. Pre-operative or post-operative vaginal cleansing with povidone-iodine may have effect on post-caesarean maternal infectious morbidity. The aim of this study was to compare the effectiveness of pre-operative vs. post-operative vaginal cleansing with povidone-iodine in reducing post-caesarean maternal infectious morbidities in a teaching hospital, South East Nigeria. This was a randomized controlled trial involving 244 pregnant women who underwent elective or emergency lower segment caesarean section at Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria. Recruited patients were randomized into two groups: Group 1 had pre-operative vaginal cleansing with 5% povidone-iodine, whereas group 2 had post-operative vaginal cleansing with 5% povidone-iodine. Post-operatively, patients were monitored for clinical symptoms and signs of endometritis, wound infection, and pyrexia daily till discharge and at 2 weeks post-partum visit. Both groups received same post-operative care. Data were analysed using Statistical Package for Social Sciences (IBM SPSS) software (version 20, Chicago, IL, USA). Continuous variables were presented as mean and standard deviation (mean ± 2SD), whereas categorical variables were presented as numbers, frequencies, and percentages. The t-test was used for comparison between groups for quantitative variables, whereas the χ2 test was used to compare categorical variables. Relative risk and 95% confidence interval were calculated for outcome measures. P-value<0.05 was considered significant. The overall infectious morbidity rate was 14.3% (34/239) in all the study participants. The rate was 1.7% (4/239) among women in the pre-operative vaginal cleansing group and 12.6% (30/239) among women in the post-operative vaginal cleansing group. This was statistically significant [(P < 0.05); relative risk (RR) 0.13, 95% confidence interval (CI) 0.05-0.36]. Endometritis occurred in 13/239 (5.4%) women with 0.8% in the pre-operative group and 4.6% in the post-operative vaginal cleansing group. This was also statistically significant (P = 0.009; RR 0.18, 95% CI 0.04-0.78). Wound infection occurred in 11/239 (4.6%) women with 0.8% in the pre-operative group and 3.8% in the post-operative vaginal cleansing group (P = 0.032; RR 0.22, 95% CI 0.05-0.98). Pyrexia occurred in 10/239 (4.2%) women with 0 (0%) in the pre-operative group and 4.2% in the post-operative vaginal cleansing group. This was also statistically significant (P = 0.0007; RR 0.01, 95% CI 0.007-0.16). These were commoners among women with ruptured foetal membranes (P =0.001; RR 0.22, CI 0.08-0.61) and those who had emergency caesarean delivery (P=0.0001; RR 0.14, CI 0.05-0.37). Pre-operative vaginal cleansing with povidone-iodine is more effective in the reduction of composite post-caesarean maternal infectious morbidity compared with immediate post-operative vaginal cleansing with povidone-iodine, especially in women with ruptured foetal membranes and those who had emergency caesarean section.