Peripartum Infection Research Articles

Does infection with COVID-2019 during labor increase the risk for obstetric anal sphincter injuries?

To investigate the association between coronavirus disease 2019 (COVID-19) infection during the peripartum period and obstetric anal sphincter injuries (OASIS). A retrospective cohort study was conducted, including all singleton vaginal deliveries and cesarean deliveries due to failed vacuum extraction, between June 2020 and January 2022 at a large tertiary medical center. OASIS complication during childbirth was compared between women with and without peripartum diagnosis of COVID-19, defined as a positive polymerase chain reaction test obtained within 1 week before delivery or up to 3 days after delivery. Universal screening for COVID-19 was implemented. A logistic regression model was used to adjust for confounding variables. The study included 22 911 women, among whom 468 (2.0%) tested positive for COVID-19 and 22 443 women had no COVID-19 diagnosis. After adjusting for confounding variables, peripartum infection with COVID-19 was found to be independently associated with OASIS (adjusted odds ratio 4.38, 95% confidence interval 2.00-9.61; P < 0.001). Infection with COVID-19 during the peripartum period significantly increases the risk for OASIS by more than fourfold. These findings emphasize the importance of understanding the impact of COVID-19 on birth complications, such as OASIS, to improve public health measures and enhance obstetric outcomes during pandemics.

Peripartum Infections: A Position Statement of the Indian Society of Critical Care Medicine.

Samavedam S, Sodhi K, Anand P, Bajwa SJS, Karnad DR, Karanth S, et al. Peripartum Infections: A Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2024;28(S2):S92-S103.

Acute febrile illness in pregnancy: Spectrum of disease and impact on maternal and foetal outcome.

Acute febrile illness (AFI) in pregnancy is a neglected cause of maternal and foetal mortality and morbidity in low-and middle-income countries. This prospective cohort studied antenatal and postpartum women admitted with acute fever to a tertiary care university teaching hospital from July 2014 to March 2015 for aetiology, maternal and foetal complications, and the impact on maternal mortality ratio (MMR) and perinatal mortality rate. Among the 180 women admitted with AFI, urinary tract infection 54(30%) was the commonest cause, followed by airborne infections (67; 37.2%), peripartum or wound infections (25; 13.8%) and vector-borne diseases (21; 11.6%). Maternal deaths were 4 (2%) and foetal deaths 9 (5%). Post-operative gram-negative sepsis was the most common cause of maternal mortality. The MMR was ten times higher with AFI 2778 against 197 (p < 0.0001) among the other hospital deliveries during the same period. Screening for asymptomatic bacteriuria , maintaining aseptic precautions, and vaccination may impact maternal and foetal morbidity significantly.

Cesarean Delivery Complicated by Peripartum Infection and Risk of Uterine Rupture During Subsequent Trial of Labor.

Background: Uterine rupture is a rare, but dangerous obstetric complication that can occur during trial of vaginal birth. Methods: The aim of this study was to evaluate the relationship between peripartum infection at the first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. We conducted a retrospective case-control study from March 2014 to October 2020 at a single academic medical center. The study group included women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who went through a successful vaginal birth after cesarean section (VBAC) without evidence of dehiscence or uterine rupture. We compared the rate of peripartum infection during the first cesarean delivery (CD) and other relevant variables, between the two groups. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful VBAC as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p = 0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk factor for uterine rupture at the subsequent trial of labor after CD (95% confidence interval, p = 0.034). Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery.

Group B Streptococcus Infection and Obstetric Hemorrhage Risk.

To elucidate the association between GBS infection and maternal risk for obstetric hemorrhage (OBH) and OBH-related morbidities (OBH-M). This was a retrospective cohort study of all deliveries with a documented GBS status at a single large academic medical center from 2018 to 2019. GBS status was determined by either urine culture or rectovaginal culture collected during the antepartum period. The primary outcomes were quantitative blood loss (QBL), OBH, and a composite of OBH-M. Secondary outcomes were individual components of the OBH-M composite and frequency of hemorrhage-related interventions utilized intrapartum and postpartum. A stratified analysis was conducted examining only patients who were diagnosed intrapartum with an intrapartum intraamniotic infection (III). Of 4679 pregnant individuals who delivered a live infant between January 1, 2018 and January 1,2019 with a documented GBS status, 1,487 were identified as GBS positive (+) and 3192 were identified as GBS negative (-). The GBS + group did not have significantly higher QBL (p = 0.29) or rate of OBH (p = 0.35). There were no significant differences by GBS status in OBH morbidity (p = 0.79) or its individual components or frequency of individual pharmacologic or non-pharmacologic OBHrelated interventions. There were also no significant differences by GBS status among patients with an III. GBS infection at the time of delivery was not associated with increased risk for OBH or OBH-M. Further research is needed to further explore the relationship between peripartum infections and OBH risk.

Applying Tension to the Transcervical Foley Balloon and Delivery Times in Term Nulliparous Women Undergoing Induction of Labor: A Randomized Controlled Trial.

To investigate the effects of applying tension to a transcervical Foley balloon on delivery time in term nulliparous patients undergoing labor induction. This cluster randomized clinical trial included 279 term nulliparous women presenting for labor induction with a plan for cervical ripening through transcervical Foley balloon placement. Participants were assigned to either the tension group (n=138) or the no-tension group (n=141) on the basis of randomized, weekly clusters (26 total clusters). The primary outcome measured was the time from initial Foley balloon insertion to delivery. Secondary outcomes included cesarean delivery rates, peripartum infection, and neonatal intensive care unit (NICU) admission. Our prior data suggested that delivery time in the tension group would be about 1,053 minutes. We estimated a sample size of 260 (130 per group, 26 clusters) on the basis of a 25% difference, power of 80%, and two-sided α of 0.05. A total of 279 term nulliparous patients were included in the analysis. The median time from Foley placement to delivery was 1,596 minutes (range 430-3,438 minutes) for the tension group and 1,621 minutes (range 488-3,323 minutes) for the no-tension group ( P =.8); similar results were noted for time to vaginal delivery. No significant differences were observed in the secondary outcomes, including the rates of cesarean delivery (34.1% vs 29.8%, P =.7), peripartum infection, and NICU admission, between the two groups. Applying tension to a transcervical Foley balloon in term nulliparous women undergoing labor induction did not significantly reduce delivery time or improve secondary outcomes. ClinicalTrials.gov , NCT05404776.

A247 THE IMPACT OF BIOLOGICS ON MATERNAL AND NEONATAL OUTCOMES IN PREGNANT PATIENTS WITH INFLAMMATORY BOWEL DISEASE AND THEIR ASSOCIATION WITH THERAPEUTIC DRUG LEVELS

Abstract Background Biologic therapies are at the backbone of managing moderate to severe IBD and maintaining clinical remission. The data on the effects of biologic therapy on maternal and neonatal outcomes continues to be limited. To our knowledge, there have been no previous studies specifically investigating whether biologic therapeutic drug levels in pregnant patients are related to maternal and neonatal outcomes. Aims The objective of this study is to determine whether biologic use in pregnancy is associated with adverse maternal and fetal outcomes, and if those outcomes correlate to specific therapeutic drug levels. Methods In this study, we retrospectively evaluate patients at a high-volume pregnancy and inflammatory bowel disease centre at Mount Sinai Hospital in Toronto between January 1st, 2017 to December 31st, 2022. Primary outcomes include maternal complications, such as induction of labour, cesarean section, peripartum infections, placental abruption, preterm labour and pre-eclampsia. Secondary outcomes include neonatal complications, such as preterm birth, low birth weight (ampersand:003C2500g), congenital anomalies and the presence of neonatal infection. These outcomes will be compared to therapeutic drug levels measured in preconception, during pregnancy and post-partum. Results A total of 312 patients were included in our study, of which 152 were on biologic treatment for IBD. Of the biologics population, the majority of patients are on Remicade, followed by Humira and Stelara (Table 1). Preliminary data analysis reveals that there was no significant difference in the rate of miscarriages (10% vs. 6%, P= 0.1), cesarean section (44% vs. 38%, P=0.3) and preterm deliveries (12% vs. 14%, P=0.7) between the biologics vs. non-biologics patient groups. Next round of analysis will include secondary outcomes and therapeutic drug levels. Conclusions Through this study, we hope to add to the literature on the possible safety of maintaining biologic therapy during pregnancy in those with inflammatory bowel disease. The data on proactive therapeutic drug monitoring in pregnant patients may bring to light the importance of its inclusion in clinical decision-making algorithms. Breakdown of therapies in the biologic patient group Funding Agencies None

Epidemiology and risk factors for healthcare-associated maternal peripartum infections in Ukraine: results a multicenter study.

Aim: To estimate the frequency of different types of healthcare-associated maternal peripartum infections and their risk factors among women in Ukraine. Materials and Methods: Multicenter prospective cohort study was conducted in nine regional perinatal centers of Ukraine between January 1, 2021, to December 31, 2023. The criteria for specific healthcare-associated maternal peripartum infections (endometritis, episiotomy infection, and maternal sepsis) site were adapted from the CDC/NHSN case definitions. Surveillance was performed during the hospitalization period and up to 30 days after hospital discharge. Results: A total of 3600 deliveries by the vaginal route were performed during the study period, 600 (16.7%) maternal peripartum infections were observed. Of all maternal peripartum infection cases, 79.7% were detected after hospital discharge. The most common maternal peripartum infections include endometritis (54.8%), episiotomy infections (34.4%), and maternal sepsis (10.8%). According to the multivariate logistic regression analysis, the body mass index >25, placenta previa, premature rupture of membrane, prolonged rupture of membranes, manual removal of the placenta, multiple vaginal examinations, bacterial vaginosis, aerobic vaginitis, gestational diabetes mellitus, and anemia during pregnancy were independent risk factors for maternal peripartum infections. Conclusions: Results this study suggest a high prevalence of healthcare-associated maternal peripartum infections in Ukraine. Several factors have been associated with increased risk of maternal peripartum infections, including pre-existing maternal conditions, placenta previa, prolonged rupture of membranes, and spontaneous or provider-initiated conditions during labour and childbirth.

Predicting peripartum infection in laboring patients at high risk in Cameroon, Africa

ObjectiveTo develop a predictive model for peripartum infection among high risk laboring patients in Cameroon, Africa. Study designWe conducted a secondary analysis of the Cameroon Antibiotic Prophylaxis Trial (NCT 3248297), a multicenter 3-arm double-blind randomized controlled trial of oral azithromycin ± amoxicillin among term pregnancies with prolonged labor or rupture of membranes in Cameroon 1/2018–5/2020. Patients with chorioamnionitis prior to randomization, study drug contraindications, or planned cesarean were excluded. The outcome of interest was a composite of maternal peripartum infection (chorioamnionitis, endometritis, sepsis by World Health Organization criteria, wound infection/abscess) diagnosed up to 6 weeks postpartum. Potential predictors were compared between patients with and without the composite outcome, and evaluated at a 0.05 alpha level. Statistically significant exposures were analyzed using multivariable regression (to generate adjusted odds ratios and 95 % confidence intervals) with backwards selection to generate a parsimonious model. Receiver operating characteristic curves with associated area under the curve assessed the model’s predictive ability. A nomogram based on the final best fit multivariable model was constructed. ResultsOf 756 patients in the parent trial, 652 were analyzed: 45 (7 %) had peripartum infection. Those with infection were more likely to be nulliparous, lower education level, higher gestational age, receive antibiotics per hospital protocols, and undergo cesarean. In our best-fit multivariable model, none/primary education (vs university), cesarean birth, and antibiotic receipt per physician discretion (vs for cesarean prophylaxis) were significantly associated with increased infection risk. This model was moderately predictive (AUC = 0.75, 95 % CI 0.67–0.82). When using this 3 factor model, for a patient with a cesarean birth, receipt of antibiotics per physician discretion, and university education, the probability of peripartum infection was 35 % (95 % CI 0.11–0.73). ConclusionsWhile several variables such as parity are associated with infectious morbidity within 6 weeks among high risk laboring patients in Cameroon, only education level, antibiotic indication, and cesarean birth were independently associated, and a model including these 3 factors was moderately predictive. Validation of our findings in a larger population is warranted.

Outcomes of Women with Preeclampsia and Eclampsia Admitted in the Intensive Care Unit at a Tertiary Care Hospital in Mogadishu, Somalia.

Intensive care for a hypertensive mother with preeclampsia or eclampsia is crucial for both maternal and neonatal outcomes. This study highlights the level of morbidity and mortality among women with preeclampsia and eclampsia admitted to the intensive care unit. Methods. This retrospective study was conducted in Mogadishu, Somalia, at the Mogadishu Somali Türkiye Training and Research Hospital from February 2019 to July 2022. The study focused on the different complications, managements, and final outcomes of preeclampsia and eclampsia mothers admitted to the intensive care unit. The data was retrieved from the electronic records of patients admitted to the intensive care unit. Results. During our study period, a total of 237 patients were identified as having preeclampsia/eclampsia, of whom 71 required intensive care admission. The mean age of the studied patients was 25 ± 6 years. The most common reason for being taken to the intensive care unit (ICU) was having a seizure (n = 33, 46.5%), followed by having very high blood pressure (n = 20, 28.2%), and being confused (n = 18, 25.3%). Peripartum infection was the most common maternal complication during ICU admission (66.7%), followed by cardiac-related arrhythmia (66.7%), postpartum bleeding (48%), acute kidney injury (18.4%), HELLP syndrome (16.4%), severe anemia (9.6%), and stroke (8.7%). Among patients, 65 (91.5%) needed mechanical ventilation. About 11.1% of these patients died during hospitalization. There were associations between mortality and some complications, particularly acute kidney injury (p value less than 0.02) and peripartum infection (p value less than 0.003). Conclusion. Hypertensive disease of pregnancy (preeclampsia/eclampsia) requiring intensive care unit admission has a very high morbidity and mortality rate.

Impact of Covid-19 on risk of severe maternal morbidity

BackgroundWe examined the risk of severe life-threatening morbidity in pregnant patients with Covid-19 infection.MethodsWe conducted a population-based study of 162,576 pregnancies between March 2020 and March 2022 in Quebec, Canada. The main exposure was Covid-19 infection, including the severity, period of infection (antepartum, peripartum), and circulating variant (wildtype, alpha, delta, omicron). The outcome was severe maternal morbidity during pregnancy up to 42 days postpartum. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between Covid-19 infection and severe maternal morbidity using adjusted log-binomial regression models.ResultsCovid-19 infection was associated with twice the risk of severe maternal morbidity compared with no infection (RR 2.02, 95% CI 1.76–2.31). Risks were elevated for acute renal failure (RR 3.01, 95% CI 1.79–5.06), embolism, shock, sepsis, and disseminated intravascular coagulation (RR 1.35, 95% CI 0.95–1.93), and severe hemorrhage (RR 1.49, 95% CI 1.09–2.04). Severe antepartum (RR 13.60, 95% CI 10.72–17.26) and peripartum infections (RR 20.93, 95% CI 17.11–25.60) were strongly associated with severe maternal morbidity. Mild antepartum infections also increased the risk, but to a lesser magnitude (RR 3.43, 95% CI 2.42–4.86). Risk of severe maternal morbidity was around 3 times greater during circulation of wildtype and the alpha and delta variants, but only 1.2 times greater during omicron.ConclusionsCovid-19 infection during pregnancy increases risk of life-threatening maternal morbidity, including renal, embolic, and hemorrhagic complications. Severe Covid-19 infection with any variant in the antepartum or peripartum periods all increase the risk of severe maternal morbidity.

Maternal and Cord Anti-SARS-CoV-2-Spike IgG following COVID-19 Vaccination versus Infection during Pregnancy: A Prospective Study, Israel October 2021-March 2022.

Defining how pregnant women respond to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vaccination is critical to optimize vaccination strategies that protect mother and infant at the epidemic. This study aimed to compare anti-SARS-CoV-2-spike immunoglobulin G (IgG) of vaccinated versus infected women and to determine the optimal timing of maternal vaccination during pregnancy at the time of epidemic. We collected maternal/cord blood at delivery (October 2021-March 2022) and measured anti-SARS-CoV-2-spike IgG geometric mean concentrations (IgG-GMCs) using a quantitative immunoassay. We compared groups according to timing and number of doses and correlated maternal and fetal IgG levels. We described the proportion of women with IgG levels above the 150 AU/mL positivity threshold according to the timing of infection/vaccination and performed a subanalysis for maternal IgG-GMC levels pre- and during the Omicron wave. We included 238 vaccinated women, 125 who received two doses and 113 three doses, and 48 unvaccinated infected women. All groups infected/vaccinated in the second or third trimester had an IgG-GMC above the positivity threshold. Third-trimester vaccination (second/third dose) resulted in higher maternal and cord-blood IgG-GMC compared to the second trimester (maternal-IgG: 102,32 vs. 4,325 AU/mL, p < 0.001; cord-IgG: 12,113 vs. 8,112 AU/mL, p < 0.001). Compared with infected-only women, a higher proportion of vaccinated women with ≥2 doses and their newborns had IgG levels above the positivity threshold at all time points. In vaccinated women, there were higher maternal IgG-GMC levels during the Omicron wave than pre-Omicron. At the time of epidemic, receiving an additional COVID-19 vaccine dose in the third trimester resulted in a higher IgG-GMC compared to the second trimester. Relatively higher levels of maternal and cord IgG-GMC were achieved following vaccination than infection. Women infected during or before the first trimester might benefit from an additional third-trimester dose to prevent peripartum infection and to passively immunize their newborn. The higher levels of maternal IgG-GMC in the Omicron period are suggestive of hybrid immunity. · Higher maternal anti-SARS-IgGs in vaccinated → infected.. · Higher cord anti-SARS-IgGs in vaccinated → infected.. · Third-trimester vaccine resulted in high-cord IgG levels..

Time to reconsider antibiotic prophylaxis in women with prolonged rupture of membranes: The trend of Enterobacteriaceae in peripartum infections.

The proportion of neonatal early-onset sepsis (EOS) by gram-negative bacteria has increased. The authors examined bacterial distribution in the amniotic membrane cultures of women with peripartum fever (PPF) and related perinatal outcomes. This retrospective study covered the period 2011 to 2019. The primary outcomes were Enterobacteriaceae-positive birth culture rates in women with PPF and the trend of ampicillin resistance. Maternal and neonatal outcomes were compared between women with group B Streptococcus (GBS) and Enterobacteriaceae-positive isolates. Bacterial distribution was also compared according to rupture of membrane (ROM) duration. Among 621 women with PPF, the positive birth culture rate was 52%. Increasing prevalences of ampicillin-resistant Enterobacteriaceae (81%) were noted. Positive birth cultures were associated with maternal bacteremia (P = 0.017) and neonatal EOS (P = 0.003). Prolonged ROM ≥18 h was associated with increased risk for Enterobacteriaceae-positive cultures, while intrapartum ampicillin and gentamicin were associated with lower risk. Enterobacteriaceae-positive compared with GBS-positive birth cultures were associated with adverse maternal and neonatal outcomes. Positive birth cultures were related to maternal bacteremia and neonatal sepsis. Adverse outcomes were more prevalent among women with Enterobacteriaceae-positive versus GBS-positive birth cultures. Prolonged ROM is a risk factor for Enterobacteriaceae-positive birth cultures among women with PPF. Antibiotic prophylaxis treatment for prolonged ROM should be reconsidered.

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.

Delabeling Penicillin Allergy in Pregnancy Using Innovation and Patient Education

Ten percent of patients report a penicillin (PCN) allergy although <1% have been confirmed. Beta lactam antibiotics are routinely used for peripartum infection prophylaxis, including group B Streptococcus (GBS). Delabeling PCN allergy prenatally improves maternal and neonatal outcomes. We hypothesized that PCN allergy patient education would increase allergy referrals, delabeling rates, and improve clinical outcomes.

Prophylactic antibiotic use during labor and delivery in China: a nationwide, multicenter, hospital-based, cross-sectional study

BackgroundProphylactic antibiotic use during delivery is common in routine obstetric practice to prevent infection globally, especially in low- and middle-income countries. In China, however, little is currently known about the national estimates for prophylactic antibiotic use during delivery. Therefore, we aimed to describe the prevalence of prophylactic antibiotic use and guideline adherence using national data in China.MethodsThis cross-sectional study analyzed a national dataset from the China Labor and Delivery Survey in 2015–2016. The primary outcomes were prophylactic antibiotic use and clinician adherence to WHO recommendations for the prevention and treatment of maternal peripartum infections. We estimated the weighted prevalence of the outcomes with Taylor series linearization and investigated the associated factors of the outcomes with logistic regression.ResultsOf the 72,519 deliveries, the prevalence of antibiotic prophylaxis was 52.0%, varying from 92.8% in Shanxi to 17.3% in Hainan. The prevalence of clinician adherence to the WHO guideline was 79.9%, ranging from 93.4% in Shandong to 50.0% in Shanxi. Prophylactic antibiotic use was associated with cesarean delivery (AOR, 55.77; 95%CI, 25.74–120.86), operative vaginal delivery (AOR, 4.00; 95%CI, 1.64–9.78), preterm (AOR, 1.96; 95%CI, 1.60–2.41), premature rupture of membranes (PROM) (AOR, 2.80; 95%CI, 1.87–4.18), and meconium-stained amniotic fluid (AOR, 1.91; 95%CI, 1.30–2.81) in all deliveries and also episiotomy (AOR, 1.48; 95%CI, 1.02–2.16) in vaginal deliveries. Clinician adherence was positively associated with cesarean delivery (AOR, 5.72; 95%CI, 2.74–11.93) while negatively associated with operative vaginal delivery (AOR, 0.26; 95%CI, 0.11–0.61), PROM (AOR, 0.50; 95%CI, 0.35–0.70), and meconium-stained amniotic fluid (AOR, 0.66; 95%CI, 0.48–0.91) in all deliveries. In vaginal deliveries, clinician adherence was negatively associated with episiotomy (AOR, 0.67; 95%CI, 0.46–0.96) and severe perineal trauma (AOR, 0.09; 95%CI, 0.02–0.44). Besides, clinicians in general hospitals prescribed prophylactic antibiotics more likely (AOR, 2.79; 95%CI, 1.50–5.19) and had a lower adherence (AOR, 0.38; 95%CI, 0.20–0.71) than their peers in maternity hospitals.ConclusionsWe observed that about half of all deliveries in China received antibiotics for prophylaxis, and most deliveries were prescribed according to the WHO guideline. Furthermore, the two prevalence rates for prophylactic antibiotic use and clinician adherence varied widely across provinces of China.

Getting With the Times: A Review of Peripartum Infections and Proposed Modernized Treatment Regimens.

This article provides a review of peripartum infections, including intra-amniotic infection, postpartum endometritis, and postabortal infections. We present a case of postabortal infection to frame the review. The microbiology, pathogenesis, risk factors, diagnosis, and treatment of peripartum infections are reviewed, and a critical appraisal of the literature and available guidelines is provided. There is a focus on discussing optimal antimicrobial therapy for treating these infections.

Peripartum Infections Among Women With Inflammatory Bowel Disease.

Pregnant patients with inflammatory bowel diseases (IBDs) are frequently treated with immunomodulatory agents and may be at increased risk of adverse outcomes, including peripartum infections. We sought to examine the risk for peripartum infections in patients with IBD compared with control subjects and identify potential risk factors associated with peripartum infections in these patients. This retrospective cohort study compared peripartum infection rates and associated risk factors between pregnant women with and without IBD. The study population included women attending a dedicated joint maternal-fetal medicine and gastroenterology clinic for pregnant women with IBD between 2012 and 2019 at the Rabin Medical Center in Israel, a major referral center for patients with IBD. For each patient, 5 women without IBD were matched according to the newborn's birth date (±2 years), age, parity, and body mass index. Peripartum infection was defined as any 1 of the following: chorioamnionitis, maternal fever (>38°C) detected during labor or postpartum hospitalization, and positive culture taken during the hospitalization. Overall, 195 pregnant women with IBD (72 [37%] with ulcerative colitis, 123 [63%] with Crohn's disease) were matched with 888 control subjects. The mean disease duration was 8.4 ± 7.02 years. IBD therapy, used by 81%, included most frequently 5-aminosalicylic acid (44%) and tumor necrosis factor inhibitors (27%). Peripartum infections were observed in 15 (7.7%) patients and 49 (5.5%) control subjects (P = 1.00). No medication significantly increased the likelihood of peripartum infection. Cesarean delivery was more likely among women with IBD but was not associated with an increased risk of peripartum infection. Peripartum infections were comparable in patients with IBD and control subjects. These reassuring data augment existing knowledge of obstetrical outcomes in IBD patients and contribute to the discussion between caregivers and patients.

Factors affecting the use of antibiotics and antiseptics to prevent maternal infection at birth: A global mixed-methods systematic review

Over 10% of maternal deaths annually are due to sepsis. Prophylactic antibiotics and antiseptic agents are critical interventions to prevent maternal peripartum infections. We conducted a mixed-method systematic review to better understand factors affecting the use of prophylactic antibiotics and antiseptic agents to prevent peripartum infections. We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health, Global Index Medicus, and Maternity and Infant Care for studies published between 1 January 1990 and 27 May 2022. We included primary qualitative, quantitative, and mixed-methods studies that focused on women, families, and healthcare providers' perceptions and experiences of prophylactic antibiotic and antiseptics during labour and birth in health facilities. There were no language restrictions. We used a thematic synthesis approach for qualitative evidence and GRADE-CERQual approach for assessing confidence in these review findings. Quantitative study results were mapped to the qualitative findings and reported narratively. We included 19 studies (5 qualitative, 12 quantitative and 2 mixed-methods studies), 16 relating to antibiotics, 2 to antiseptic use, and 1 study to both antibiotic and antiseptic use. Most related to providers' perspectives and were conducted in high-income countries. Key themes on factors affecting antibiotic use were providers' beliefs about benefits and harms, perceptions of women's risk of infection, regimen preferences and clinical decision-making processes. Studies on antiseptic use explored women's perceptions of vaginal cleansing, and provider's beliefs about benefits and the usefulness of guidelines. We identified a range of factors affecting how providers use prophylactic antibiotics at birth, which can undermine implementation of clinical guidelines. There were insufficient data for low-resource settings, women's perspectives, and regarding use of antiseptics, highlighting the need for further research in these areas. Implications for practice include that interventions to improve prophylactic antibiotic use should take account of local environments and perceived infection risk and ensure contextually relevant guidance.

Diagnosis of fetal growth restriction in a cohort of small-for-gestational-age neonates at term: neonatal and maternal outcomes

Small-for-gestational-age neonates (birthweight of <10th percentile for gestational age) are significantly more likely to have multiple adverse outcomes than appropriate-for-gestational-age neonates (birthweight of 10th-90th percentile). Most small-for-gestational-age neonates are undetected during pregnancy (ie, not diagnosed as fetal growth restriction), but the sequela of being undetected remains uncertain. The primary objective of this study was to compare the composite neonatal adverse outcomes among singleton pregnancies that were at least 37 weeks and delivered small-for-gestational-age neonates, which were diagnosed as either fetal growth restriction during pregnancy (detected small for gestational age) or not (undetected small for gestational age). This was a secondary analysis of a retrospective cohort, the Consortium for Safe Labor. Singleton births at 37.0 to 41.6 weeks of gestation without congenital anomalies born small for gestational age were included in the analysis. The primary outcome was the rate of composite neonatal adverse outcome, defined as any of the following: Apgar score of <5 at 5 minutes, cardiopulmonary resuscitation at birth, respiratory distress syndrome, continuous positive airway pressure, mechanical ventilation, neonatal seizures, hypoxic-ischemic encephalopathy or diagnosis of asphyxia, intraventricular hemorrhage, necrotizing enterocolitis, neonatal sepsis, or fetal or neonatal death. The secondary outcome was the rate of composite maternal adverse outcome, which included any of the following: postpartum hemorrhage, peripartum infection, thromboembolism, hysterectomy, uterine rupture, eclampsia, intensive care unit admission, or maternal death. Small for gestational age with a prenatal diagnosis of fetal growth restriction (detected small for gestational age) was compared with small for gestational age without a prenatal diagnosis of fetal growth restriction (undetected small for gestational age). Multivariate logistic regression models were used to compare groups. A P value of <.05 was considered statistically significant. Gestational age-specific risks of composite neonatal adverse outcome and perinatal death were computed for each week of gestation among ongoing pregnancies. Of the 228,438 deliveries in the Consortium for Safe Labor, 18,607 (8.1%) met the inclusion criteria. Among these deliveries, 17,689 (95.0%) were undetected small for gestational age, and 918 (5.0%) were detected small for gestational age. The overall rate of composite neonatal adverse outcome was 3.0%. Moreover, the rate of composite neonatal adverse outcome was similar between undetected small for gestational age and detected small for gestational age (3.0% vs 3.9%, respectively; adjusted odds ratio, 1.33; 95% confidence interval, 0.88-2.00). Some components of the composite-respiratory distress syndrome, mechanical ventilation, and necrotizing enterocolitis-were significantly higher among undetected small for gestational age than among detected small for gestational age. The overall rate of composite maternal adverse outcome was 6.2%. The rate of composite maternal adverse outcome between undetected small for gestational age and detected small for gestational age (6.2% vs 5.1%, respectively; adjusted odds ratio, 0.84; 95% confidence interval, 0.60-1.18) was similar. In gestational age-specific comparisons of composite neonatal adverse outcome, no difference was found between the undetected small-for-gestational-age group and the detected small-for-gestational-age group except for in pregnancies >41 weeks. In pregnancies at 41.0 to 41.6 weeks, the rate of composite neonatal adverse outcome was significantly greater in detected small for gestational age than in undetected small for gestational age (10.0% vs 2.5%, respectively; P=.035). Antenatal detection of small for gestational age was not associated with improved composite neonatal adverse outcomes, although some components of morbidity improved with detection. Maternal outcomes did not differ between detected small for gestational age and undetected small for gestational age.