Postcesarean Endometritis Research Articles

Vaginal preparation with different antiseptic solutions before cesarean section for preventing postoperative infections: A systematic review and network meta-analysis.

We aimed to investigate the effect of various vaginal wash solutions on reducing risks of post-cesarean endometritis, wound infections, fever, and hospital stay duration. Scopus, Web of Science, PubMed, and Cochrane Library were searched for randomized clinical trials that compared different vaginal wash solutions to each other or to "no vaginal cleaning"; without restriction on the age of parturients or site where trials were conducted. We analyzed this frequentist network meta-analysis using the netmeta package in R software version 4.1.2; synthesized data as mean difference or risk ratio with their 95% confidence intervals. Our network meta-analysis included 29 RCTs with a total sample size of 9311 women undergoing CS. Regarding post-cesarean endometritis, we found that povidone-iodine had the highest significant risk reduction compared to "no vaginal cleaning" (RR=0.08, 95% CI [0.01, 0.69]). While regarding post-cesarean reduction of wound infection, fever, and hospital stay duration, we found that chlorhexidine 4% (RR=0.17, 95% CI [0.05, 0.65]), saline 0.9% (RR=0.12, 95% CI [0.03; 0.48]), and saline 0.9% (MD=-1.29, 95% CI [-2.18; -0.39]), respectively, had the highest significant risk reduction compared to "no vaginal cleaning." Vaginal wash solutions were associated with a significant reduction of post-cesarean endometritis, wound infection, fever, and hospital stay duration. Since povidone-iodine had the highest significant reduction of post-cesarean endometritis, we recommend setting povidone-iodine as the standard practice as pre cesarean vaginal wash solution; consistent practice guidelines of Enhanced Recovery After Surgery (ERAS).

Effect of Vaginal Cleansing with Povidone Iodine Solution before Cesarean Section on Postoperative Endometritis Infection

Background: Cesarean section (CS) continues to be the surgical intervention most often performed in obstetrics, with a daily increasing frequency of use. The risk for all postpartum infections is increased in CS compared to vaginal delivery. Infectious complications developing in the aftermath of CS are one of the main causes of maternal morbidity. So, the aim of this study was to investigate the effect of vaginal cleansing with Povidone Iodine solution before cesarean section on postoperative Endometritis Infection . Design: A quasi- experimental design was utilized in this study. Setting: This study was conducted at the operating room of Obstetrics and Gynecologic Department in Beni-Seuf University Hospital from the period of May 2019 until August 2019. The study Subjects included 200 pregnant women undergoing elective cesarean delivery, who were selected by purposive sampling technique. then divided into control and study group 100 per each group. The study group receive vaginal cleansing before cesarean section by antiseptic iodine solution 10% and standard abdominal scrub. Control group receive standard abdominal scrub only. Tools was used of data collection included; 1st tool: Structured interview questionnaire was designed by the researchers and included demographic characteristics and data related to the participants’ clinical profile 2nd tool: Postpartum follow-up checklist to assess presence or absence of the post CS infectious morbidity such as; endometritis (lower abdomen pain and a smelly vaginal discharge), febrile morbidity, and incisional site infection.3rd tool: Numericаl rating scale (NRЅ). Study results: Shows there was statistically significant difference regards fever and a smelly vaginal discharge among both groups, while there was no statistically significant difference was found regards wound infection and lower abdomen pain. Conclusion: Preoperative vaginal cleansing using antiseptic iodine solution 10% was an effective practice for reducing post cesarean endometritis where overall post cesarean infectious morbidity rate was lower among study group compared to control those exposed to routine care alone; supporting the study hypothesis. Recommendations: Physicians and Nurses should be used antiseptic povidone-Iodine 10% or vaginal cleaning as regular practice before cesarean deliveries. Apply vaginal preparation with anti septic solution before C.S operation for high risk group for infection as premature rupture of membranes, diabetes, and anemia.

Decreased Post-Cesarean Endometritis Following Povidone Iodine-Vaginal Preparation

Background: Despite the use of several strategies to prevent post-Cesarean complications including wound infections and endometritis, they remain high morbidities. Objective: To assess the pre-Cesarean preparation of the vagina with povidone iodine as a preventive measure against post-cesarean wound infection and endometritis. Patients and Methods: A case-control study conducted on 200 pregnant women who prepared for elective Cesarean section. The operations were conducted either with standard classical abdominal scrub alone (as control group) or vaginal povidone iodine preparation in addition to the standard abdominal scrub. Each woman was followed up post-operatively for development of fever, endometritis, and wound infection, duration of postoperative antibiotics administration, and postoperative stay. Results: Post-Cesarean endometritis developed in 6% of women who received a vaginal preparation pre-operatively and 15% of the controls. 30% of control women and 20% of women in the treatment group had post-operative febrile illness. Wound infections were uncommon complications that occurred only in two percent of the control patients and one percent of patient in the treatment group. Conclusion: Pre-operative vaginal treatment with povidone iodine decreased the risk of post-Cesarean endometritis. However, this protocol doesn't decrease the whole risk of post-operative wound infection or fever.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. This is an update of a Cochrane Review first published in 2010 and subsequently updated in 2012, twice in 2014, in 2017 and 2018. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We also assessed the side effects of vaginal cleansing solutions to determine adverse events associated with the intervention. We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (7 July 2019), and reference lists of retrieved studies. We included randomized controlled trials (RCTs) and quasi-RCTs assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. Cluster-RCTs were eligible for inclusion, but we did not identify any. We excluded trials that utilized vaginal preparation during labor or that did not use antibiotic surgical prophylaxis. We also excluded any trials using a cross-over design. We included trials published in abstract form only if sufficient information was present in the abstract on methods and outcomes to analyze. At least three of the review authors independently assessed eligibility of the studies. Two review authors were assigned to extract study characteristics, quality assessments, and data from eligible studies. We included 21 trials, reporting results for 7038 women evaluating the effects of vaginal cleansing (17 using povidone-iodine, 3 chlorhexidine, 1 benzalkonium chloride) on post-cesarean infectious morbidity. Trials used vaginal preparations administered by sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (17 trials) or the use of a saline vaginal preparation (4 trials). One trial did not report on any outcomes of interest. Trials were performed in 10 different countries (Saudi Arabia, Pakistan, Iran, Thailand, Turkey, USA, Egypt, UK, Kenya and India). The overall risk of bias was low for areas of attrition, reporting, and other bias. About half of the trials had low risk of selection bias, with most of the remainder rated as unclear. Due to lack of blinding, we rated performance bias as high risk in nearly one-third of the trials, low risk in one-third, and unclear in one-third. Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 7.1% in control groups to 3.1% in vaginal cleansing groups (average risk ratio (aRR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; 20 trials, 6918 women; moderate-certainty evidence). This reduction in endometritis was seen for both iodine-based solutions and chlorhexidine-based solutions. Risks of postoperative fever and postoperative wound infection are also probably reduced by vaginal antiseptic preparation (fever: aRR 0.64, 0.50 to 0.82; 16 trials, 6163 women; and wound infection: RR 0.62, 95% CI 0.50 to 0.77; 18 trials, 6385 women; both moderate-certainty evidence). Two trials found that there may be a lower risk of a composite outcome of wound complication or endometritis in women receiving preoperative vaginal preparation (RR 0.46, 95% CI 0.26 to 0.82; 2 trials, 499 women; low-certainty evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing. Subgroup analysis suggested a greater effect with vaginal preparations for those women in labour versus those not in labour for four out of five outcomes examined (post-cesarean endometritis; postoperative fever; postoperative wound infection; composite wound complication or endometritis). This apparent difference needs to be investigated further in future trials. We did not observe any subgroup differences between women with ruptured membranes and women with intact membranes. Vaginal preparation with povidone-iodine or chlorhexidine solution compared to saline or not cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis, postoperative fever, and postoperative wound infection. Subgroup analysis found that these benefits were typically present whether iodine-based or chlorhexidine-based solutions were used and when women were in labor before the cesarean. The suggested benefit in women in labor needs further investigation in future trials. There was moderate-certainty evidence using GRADE for all reported outcomes, with downgrading decisions based on limitations in study design or imprecision. As a simple intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries. Future research on this intervention being incorporated into bundles of care plans for women receiving cesarean delivery will be needed.

Povidone-iodine 1% is the most effective vaginal antiseptic for preventing post-cesarean endometritis: a systematic review and network meta-analysis

Direct comparison metaanalyses have reported benefits with presurgical vaginal preparation before cesarean delivery for the reduction of endometritis. These reports did not perform a multitreatment comparison of the various antiseptic solutions assessed in previous studies. The purpose of this study was to review the literature systematically and quantitate and summarize indirectly the comparative efficacy of antiseptic formulations and their concentrations that are used for the preparation of the vagina before cesarean delivery in the prevention of endometritis and other infectious complications. We used MEDLINE, EMBASE (from their inception to November 2018) and Cochrane databases, biographies, and conference proceedings. We used randomized clinical trials of patients who underwent surgical preparation of the vagina with antiseptic formulations before cesarean delivery with the aim of reducing the risk of infectious morbidity. Our systematic review was registered and followed the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for network meta-analysis guidelines. Network meta-analysis was performed with computerized software and used user-written programs to assess consistency, inconsistency, ranking probabilities, and graphing results. Direct and indirect pairwise comparisons of the various formulations and their concentrations were performed with the use of multivariate random-effects models and metaregression. A frequentist inference method was employed for the fitted model to estimate the ranking probabilities. Subgroup analyses for patients in labor, not in labor, and with ruptured membranes were conducted. For the prevention of endometritis, we identified 23 studies that comprised 7097 women who were allocated to the following treatments: povidone-iodine (1%, 5%, 10%), chlorhexidine (0.2%, 0.4%), metronidazole gel, cetrimide, or normal saline solution/no treatment. Direct and indirect pairwise comparisons indicated that, when compared with saline solution or no treatment, all antiseptic formulations decreased rates of endometritis (5.2% vs 9.1%; odds ratio, 0.48; 95% confidence interval, 0.35-0.65; 22 studies/6994 women). Individually, povidone-iodine (odds ratio, 0.43; 95% confidence interval, 0.28-0.64; 16 studies/5968 women), cetrimide (odds ratio, 0.34; 95% confidence interval, 0.13-0.90; 1 study/200 women), and metronidazole (odds ratio, 0.38; 95% confidence interval, 0.16-0.90; 1 study/224 women) significantly reduced the risk of endometritis. Rankings of vaginal preparations indicated that povidone-iodine 1% had the highest probability (72.7%) of being the most effective treatment for the prevention of endometritis. For the secondary outcomes of postoperative wound infection and fever, a significant reduction was found only with povidone-iodine (odds ratio, 0.61; 95% confidence interval, 0.48-0.78; 16 studies/5968 women; and odds ratio, 0.58; 95% confidence interval, 0.40-0.83; 12 studies/4667 women). Subgroup analyses also found that povidone-iodine significantly reduced risk of endometritis for women in labor (odds ratio, 0.42; 95% confidence interval, 0.20-0.88; 5 studies/1211 women), with ruptured membranes(odds ratio, 0.21; 95% confidence interval, 0.10-0.44; 4 studies/476 women), and undergoing planned cesarean delivery (odds ratio, 0.39; 95% confidence interval, 0.27-0.57; 8 studies/1825 women). Among patients who underwent cesarean delivery, presurgical vaginal irrigation with povidone-iodine had the highest probability of reducing the risk of endometritis, postoperative wound infections, and fever.

Nosocomial post-cesarean endometritis: a rationalized strategy of antibacterial therapy

The number of patients with nosocomial post-cesarean endometritis is steadily growing. Aim: to study the etiology of nosocomial post-cesarean endometritis and to propose a rationalized antimicrobial therapy. Material and methods. Sixty six puerperas with post-cesarean endometritis were examined. The spectrum of microflora and its resistance to antimicrobial agents were determined using an automatic microbiological analyzer based on mass spectrometry. Results. Enterococci, E. coli, staphylococci and streptococci were the most clinically significant pathogens found in the examined patients with post-cesarean endometritis. The microflora spectrum in the endometrium reflected the previous «antibacterial history»; this association must be taken into account when developing antibacterial therapy. Conclusion. If the new mother was previously treated with antibacterial agents, it is recommended to use a combination of the reserve antibiotics in order to block the entire spectrum of possible multidrug-resistant pathogens. In cases of the resistant Gram-positive microflora (MRSE, MRSA, E. faecium), it is advisable to prescribe vancomycin. For the resistant Gram-negative microflora (Enterobacter spp., Citrobacter spp., E. coli-ESBL+ and Klebsiella spp.-ESBL+), vancomycin should be combined with carbapenems.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. This is an update of a Cochrane review first published in 2010 and subsequently updated in 2012, and twice in 2014. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We also assessed the side effects of vaginal cleansing solutions to determine adverse events associated with the intervention. We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (10 July 2017), and reference lists of retrieved studies. We included randomized trials and one quasi-randomized trial assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. Cluster-randomized trials were eligible for inclusion but none were identified. We excluded trials that utilized vaginal preparation during labor or that did not use antibiotic surgical prophylaxis. We also excluded any trials using a cross-over design. At least three of the review authors independently assessed eligibility of the studies. Two review authors were assigned to extract study characteristics, quality assessments, and data from eligible studies. We included 11 trials reporting results for 3403 women evaluating the effects of vaginal cleansing (eight using povidone-iodine, two chlorhexidine, one benzalkonium chloride) on post-cesarean infectious morbidity. Additionally, some trials used vaginal preparations using sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (eight trials) or the use of a saline vaginal preparation (three trials). The risk of bias in the studies reduced our confidence in the results for endometritis outcomes.Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 8.7% in control groups to 3.8% in vaginal cleansing groups (average risk ratio (RR) 0.36, 95% confidence interval (CI) 0.20 to 0.63, 10 trials, 3283 women, moderate quality of evidence). Subgroup analysis could not rule out larger reductions in endometritis with antiseptics in women who were in labor or in women whose membranes had ruptured when antiseptics were used. Risks of postoperative fever and postoperative wound infection may be slightly lowered by antiseptic preparation, but the confidence intervals around the effects for both outcomes are consistent with a large reduction in risk and no difference between groups (fever: RR 0.87 (0.72 to 1.05; wound infection: RR 0.74 (95% CI 0.49 to 1.11), both moderate-quality evidence). Two trials reported a lower risk of a composite outcome of wound complication or endometritis in women receiving preoperative vaginal preparation (RR 0.46, 95% CI 0.26 to 0.82, two trials, 499 women, moderate-quality evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing. Vaginal preparation with povidone-iodine or chlorhexidine solution compared to saline or not cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis. Subgroup analysis could not rule out larger reductions in endometritis with antiseptics in women who were in labor or in women whose membranes had ruptured when antiseptics were used.The quality of the evidence using GRADE was moderate for all reported outcomes. We downgraded the outcome of post-cesarean endometritis and composite of wound complications or endometritis for risk of bias and postoperative fever and postoperative wound infections for wide CIs.As a simple, generally inexpensive intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries.

Preoperative Vaginal Preparation for Prevention of Post-Cesarean Endometritis [22L

INTRODUCTION: Endometritis complicates 6%–27% cesarean deliveries (CD). A recent meta-analysis showed a reduction in endometritis with vaginal cleansing prior to CD (4.5% versus 8.8%). Our study examines the proportions of endometritis from two time periods–prior to and after the implementation of vaginal preparation prior to CD at one hospital. We aim to see the effect shown in research in clinical practice. METHODS: A retrospective chart review of 356 women undergoing cesarean delivery prior to and after the policy change. After implementation of the vaginal preparation protocol, a policy of administration of 400 μg of buccal misoprostol for postpartum hemorrhage prophylaxis was instituted so this was recorded. Odds ratios (OR) and 95% confidence interval (CI) of endometritis diagnosed by ICD code or 2+ symptoms were calculated. RESULTS: The rate of endometritis was 3.8% in the pre-policy period and 15.2% post-policy, OR 4.5 (95% CI 1.7–11.8). Notably the frequency of fever was 4.5% pre-policy compared with 22.2% post-policy. When the rates of endometritis with those given misoprostol were excluded the rates were 3.8% pre-policy and 6.7% post-policy, OR 1.8 (95% CI 0.5–6.6). CONCLUSION: When comparing rates of endometritis after instituting a vaginal preparation protocol we found a paradoxical increase in the rate of endometritis. However, this could be driven by the increased rate of fevers associated with misoprostol prophylaxis. When this was accounted for, there was a non-significant increase. Confounding factors may lead to important differences from randomized studies and are important to assess when evaluating practice change.

569: Cost-effectiveness analysis of vaginal preparation with antiseptic solution for cesarean infection prophylaxis

Endometritis in women with a previous cesarean delivery is associated with an increased risk of uterine rupture in a subsequent trial of labor. Cleansing the vagina with antiseptic solution before cesarean delivery has been demonstrated to reduce the risk of endometritis. The goal of this study was to investigate whether it is cost-effective to add vaginal preparation to standard regimens of cesarean prophylaxis by considering the maternal outcomes in the current and potential subsequent pregnancy. In particular, we examined the impact of endometritis on future risk of uterine rupture during trial of labor. A cost-effectiveness model was created using TreeAge to compare the outcomes of using vaginal preparation vs. standard of care in a theoretical cohort of 1.2 million women, the approximate the number of annual cesarean deliveries in the US. Outcomes examined included endometritis, sepsis, VTE, and maternal death in current pregnancy and uterine rupture, cesarean hysterectomy, and maternal death in subsequent pregnancy, including cost and quality-adjusted life years (QALY) for both pregnancies. Probabilities, utilities, and costs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. One-way sensitivity analyses were used to determine the robustness of our results. When comparing vaginal antiseptic vs. no vaginal preparation, there were 88,128 fewer cases of endometritis, 641 fewer cases of sepsis, 6 fewer VTEs, and 28 fewer maternal deaths. Additionally, this strategy prevented 95 uterine ruptures, 11 cesarean hysterectomies, and 2 maternal deaths in the subsequent pregnancy. Overall, our model showed that vaginal preparation led to both lower costs and higher QALYs when compared to standard prophylaxis. With sensitivity analysis, we found that as long as the cost of vaginal antiseptic remained below $604 (cost assumption of Povidone-Iodine preparation in our model was $6), then it was cost effective. When compared to standard of care, the addition of vaginal antiseptic preparation to post-cesarean endometritis prophylaxis is less costly and leads to better maternal outcomes in the index delivery and subsequent deliveries.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Retraction notice to “Evaluation of the risk of postcesarean endometritis with preoperative vaginal preparation with povidone–iodine: A randomized controlled study” [Middle East Fertil. Soc. J. 20/4 (2015) 246–250

Retraction notice to “Evaluation of the risk of postcesarean endometritis with preoperative vaginal preparation with povidone–iodine: A randomized controlled study” [Middle East Fertil. Soc. J. 20/4 (2015) 246–250

A comparison of 3 antibiotic regimens for prevention of postcesarean endometritis: an historical cohort study

Prophylactic antibiotics are of proven value in decreasing the frequency of postcesarean endometritis. The beneficial effect of prophylaxis is enhanced when the antibiotics are administered before the surgical incision as opposed to after the clamping of the umbilical cord. However, the optimal antibiotic regimen for prophylaxis has not been established firmly. The purpose of this study was to compare 3 different antibiotic regimens for the prevention of postcesarean endometritis. This retrospective historical cohort study was conducted at the University of Florida, which is a tertiary care facility that serves a predominantly indigent patient population. In the period January 2003 to December 2007, our standard prophylactic antibiotic regimen for all women who had cesarean delivery was cefazolin (1 g) administered immediately after the baby's umbilical cord was clamped. In November 2008, we began to administer the combined regimen of cefazolin (1 g intravenously) plus azithromycin (500 mg intravenously); both were given 30-60 minutes before the skin incision. In the period of January-December 2014, we continued the dual agent regimen but based the dose of cefazolin on the patient's body mass index: 2 g intravenously if the body mass index was <30 kg/m(2) and 3 g if the body mass index was >30 kg/m(2). The surgical technique was consistent throughout all 3 time periods. Our primary endpoint was the frequency of endometritis in each time period. This diagnosis was based on fever ≥37.5°C, lower abdominal pain and tenderness, the exclusion of other localizing signs of infection, and the requirement for administration of therapeutic antibiotics. In the first year after beginning the new antibiotic regimen, we also monitored the frequency of neonatal sepsis evaluations and compared it with the frequency that was recorded during the year immediately preceding the change in antibiotic regimens. During the entire period 2003-2014, 29,633 women delivered at our institution; 6455 women (22%) had a cesarean delivery. In the period January 2003 to December 2007, 1034 women had a primary or repeat cesarean delivery. One hundred seventy women (16.4%; 95% confidence interval, 14.4-18.4%) developed endometritis. In the period November 2008 to December 2013, 4484 women had a primary or repeat cesarean delivery. Fifty-nine patients (1.3%; 95% confidence interval, 1.0-1.7%) developed endometritis (P < .0001 compared with period1). In the year 2014, 937 women had a cesarean delivery; 22 of them (2.3%, 95% confidence interval, 1.3-3.3%) developed endometritis (P< .0001 compared with period 1 and P > .5 and <.10 compared with period 2). The frequency of evaluations for suspected neonatal sepsis in infants who were delivered to mothers who had cesarean delivery was 17.6% in the period January to December 2007 and 19.3% in the period November 2008 to November 2009 (relative risk, 1.1; 95% confidence interval, 0.7-1.9). One infant had proven sepsis in the former period; 2infants had proven sepsis in the latter period (not significant). When administered before skin incision, the combination of cefazolin plus azithromycin was significantly more effective in the prevention of endometritis than the administration of cefazolin after cord clamping; the rate of endometritis was reduced to a very low level without increasing the rate of neonatal sepsis evaluations.

Pelvic Abscess with Uterine Wound Dehiscence Post Cesarean Section, Rare Presentation with Modified Management: Case Report &amp; Literature Review

The rate of caesarean section rate is increasing worldwide, the ideal rate being from 10 to 15% according to WHO. Various complications are associated with this operative procedure, such as intraoperative hemorrhage, wound and chest infections, abdominal wound dehiscence, from anesthesia, deep vein thrombosis, and pulmonary embolism to name a few. Uterine wound dehiscence is a very rare complication of cesarean section that presents with PPH[1]. Postoperative pyrexia may result from various causes, pelvic abscess being a very rare one, occurring in < 1% of patients with post cesarean endometritis[2]. This report describes anunusual cause of fever following cesarean delivery and presentation of its sequelae, our method of management, its outcome with comparison to similar cases presented in the literature. This the first case report in literature of post-operative pelvic abscess with uterine wound dehiscence, a rare presentationthat was managed with radiological intervention and assistance.

RETRACTED: Evaluation of the risk of postcesarean endometritis with preoperative vaginal preparation with povidone–iodine: A randomized controlled study

Objective To investigate the effect of preoperative vaginal preparation with povidone–iodine as a preventive intervention against postcesarean endometritis and wound infection. Design Randomized controlled study. Setting Suzan Mubarak University Hospital, Egypt & Aramco Hospital, Saudia Arabia. Patients 400 women were to undergononemergent cesarean delivery. Subjects received either standard abdominal scrub alone or abdominal scrub with an additional vaginal preparation with povidone–iodine solution. All subjects received prophylactic antibiotic preoperatively. Interventions Each subject’s postoperative course was reviewed for development of febrile morbidity (temperature > 38.0 °C), endometritis (temperature > 38.4 °C accompanied by fundal tenderness occurring beyond the first postoperative day, in the absence of evidence of other infection), and wound infection. Results Postcesarean endometritis occurred in 7.0% of subjects who received a preoperative vaginal preparation and 14.5% of controls (P < .05). There was no measurable effect of a vaginal scrub on the development of postoperative fever or wound infection. The adjusted odds ratio for developing endometritis after a vaginal preparation was 0.44 (95% confidence interval (CI) 0.193–0.997). Multivariate analysis showed an increased risk of developing endometritis in association with severe anemia (adjusted OR 4.26, 95% Cl 1.568–11.582), use of intrapartum internal monitors (adjusted OR 2.84, 95% Cl 1.311–6.136), or history of antenatal genitourinary infection (adjusted OR 2.9, 95% CI 1.265–6.596). Conclusion Preoperative vaginal scrub with povidone–iodine decreases the incidence of postcesarean endometritis. This intervention does not seem to decrease the overall risk of postoperative fever or wound infection.

Vaginal disinfection before cesarean delivery in preventing postoperative infections: a meta-analysis

Objective To analyze the efficacy of vaginal disinfection with povidone-iodine before cesarean delivery in preventing postoperative infections.Methods Randomized controlled trials,identified from a systematic search of relevant databases including PubMed,EMBASE,CBM,CNKI,and CQVIP,were screened and evaluated according to standardized criteria.RevMan 5.2software was used to do the meta-analysis.Results A total of 9randomized controlled trials with 3 024 participants,with 1 508 in the vaginal cleansing group and 1 516 in the control group,were included in this meta-analysis.The analysis result showed that vaginal disinfection with povidone-iodine before cesarean delivery reduced the incidence of postcesarean endometritis(RR=0.55,95% CI 0.36-0.85,P =0.007).The incidence of post-cesarean endometritis was significantly reduced in women with ruptured membranes(RR=0.29,95%CI:0.16-0.52,P0.000 1)and women in labor(RR=0.63,95%CI 0.41-0.96,P=0.03),but not significantly reduced in the women with intact membranes(RR=0.73,95%CI 0.50-1.08,P=0.11)or women not in labor(RR=0.79,95%CI 0.53-1.17,P=0.24).Vaginal disinfection could not help to reduce the incidence of postoperative wound infection(RR=0.80,95%CI 0.53-1.22,P=0.30)or postoperative fever(RR=0.92,95%CI 0.76-1.11,P=0.37).Conclusion Vaginal disinfection with povidone-iodine before cesarean delivery can decrease the risk of post-cesarean endometritis,especially for women undergoing cesarean delivery with ruptured membranes or in labor,but vaginal disinfection do not reduce the risk of postoperative wound infection or fever.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 December 2014). We included randomized and quasi-randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. We independently assessed eligibility and quality of the studies. Seven trials randomizing 2816 women (2635 analyzed) evaluated the effects of vaginal cleansing (all with povidone-iodine) on post-cesarean infectious morbidity. The risk of bias was generally low, with the quality of most of the studies being high. Vaginal preparation immediately before cesarean delivery significantly reduced the incidence of post-cesarean endometritis from 8.3% in control groups to 4.3% in vaginal cleansing groups (average risk ratio (RR) 0.45, 95% confidence interval (CI) 0.25 to 0.81, seven trials, 2635 women). The risk reduction was particularly strong for women who were already in labor at the time of the cesarean delivery (7.4% in the vaginal cleansing group versus 13.0% in the control group; RR 0.56, 95% CI 0.34 to 0.95, three trials, 523 women) and for women with ruptured membranes (4.3% in the vaginal cleansing group versus 17.9% in the control group; RR 0.24, 95% CI 0.10 to 0.55, three trials, 272 women). No other outcomes realized statistically significant differences between the vaginal cleansing and control groups. No adverse effects were reported with the povidone-iodine vaginal cleansing.The quality of the evidence using GRADE was low for post-cesarean endometritis, moderate for postoperative fever, and low for wound infection. Vaginal preparation with povidone-iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis. This benefit is particularly realized for women undergoing cesarean delivery, who are already in labor or who have ruptured membranes. As a simple, generally inexpensive intervention, providers should consider implementing preoperative vaginal cleansing with povidone-iodine before performing cesarean deliveries.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 July 2014). We included randomized and quasi-randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. We independently assessed eligibility and quality of the studies. Five trials randomizing 1946 women (1766 analyzed) evaluated the effects of vaginal cleansing (all with povidone-iodine) on post-cesarean infectious morbidity. The risk of bias was generally low, with the quality of most of the studies being high. Vaginal preparation immediately before cesarean delivery significantly reduced the incidence of post-cesarean endometritis from 7.2% in control groups to 3.6% in vaginal cleansing groups (average risk ratio (RR) 0.39, 95% confidence interval (CI) 0.16 to 0.97, five trials, 1766 women). The risk reduction was particularly strong for women with ruptured membranes (1.4% in the vaginal cleansing group versus 15.4% in the control group; RR 0.13, 95% CI 0.02 to 0.66, two trials, 148 women). No other outcomes realized statistically significant differences between the vaginal cleansing and control groups. No adverse effects were reported with the povidone-iodine vaginal cleansing.The quality of the evidence using GRADE was low for post-cesarean endometritis, moderate for postoperative fever, and low for wound infection. Vaginal preparation with povidone-iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis. This benefit is particularly realized for women undergoing cesarean delivery with ruptured membranes. As a simple, generally inexpensive intervention, providers should consider implementing preoperative vaginal cleansing with povidone-iodine before performing cesarean deliveries.

Comparison between Azithromycin and Cephalexin for Preventing Infection after Cesarean Section in Obese Patient

Introduction: Postcesarean infection can cause maternal mortality and morbidity. Use of prophylactic antibiotics could decrease surgical site infection. Despite using prophylactic antibiotics in obese women, compared to normal weighted women the rate of wound infection is higher in this group. The aim of this study is to compare prophylactic effect of azithromycin and cephalexin on febrile morbidity and postcesarean infection in women with BMI > 30. Methods and Materials: This randomized controlled double blind clinical trial was done on 231 women with BMI > 30 who underwent elective cesarean section. Patients were randomly divided to intervention and control groups. Keflin 2 gr IV was administered 0.5 hr before surgery for both intervention and control groups. Cefalexin (placebo) every 6 hr and azythromycin (placebo) every 12 hr for control group and cephalexin 500 mg every 6 hr and azithromycin 250 mg every 12 hr for intervention group were administered for 48 hrs. Patients were under observation till 1 month after surgery. Fever, wound infection, endometritis and hospitalization were compared between two groups with SPSS v. 18. Results: A total of 231 patients 113 (48.9%) were enrolled in intervention group and 118 (51.1%) in control group with mean age of (28.53 ± 5.51) recruited. BMI distribution did not differ in the two groups. Hospitalization in control group was significantly higher than that in intervention group (2.58 ± 0.99) vs (2.11 ± 0.45) (P value < 0.001). BMI in intervention group with and without fever was (34.62 ± 2.64) and (30.89 ± 2.80), respectively (P value < 0.001). In control group, BMI in patients with and without fever was (38.60 ± 2.80) and (31.29 ± 1.28), respectively (P value = 0.001). Fever and endometritis simultaneously was seen in 3 (2.7%) of intervention group and 8 (6.8%) of control group. In interventions 3 (2.7%) had fever but no endometritis and 2 (1.8%) had endometritis but no fever (P < 0.001). In control group, 23 (19.5%) patients had fever but no endometritis and 4 (3.4%) patients had endometritis but no fever (P value < 0.001). Febrile patients in control group 31 (26.3%) were significantly more than those in intervention group 6 (5.3%) (P value < 0.001). Discussion: Administration of prophylactic azithromycin and cephalexin resulted in a decrease in febrile morbidity and length of hospital stay and is recommended. BMI of patients with fever was significantly higher in both intervention and control groups compared to those who didn’t experience fever. Postcesarean endometritis wasn’t significantly different in two groups. Postcesarean wound infection wasn’t seen in any group.

The effect of placental removal method on perioperative hemorrhage at cesarean delivery; a randomized clinical trial

The aim of this prospective randomized clinical study is to compare whether the removal methods of placenta during cesarean section have an impact on perioperative hemorrhage. One hundred women with singleton term pregnancies undergoing elective cesarean section through lower segment transverse incision under general anesthesia were included in this study. They were randomly allocated to two groups according to the type of removal of the placenta from the uterus after childbirth; manually or spontaneously. The main outcome measures were change in hemoglobin levels after cesarean section. The secondary outcomes were operative time, required transfusions and postcesarean endometritis. Fifty patients were randomized to the manual removal group and 50 to the spontaneous group. The demographic characteristics of the two groups were similar. There were no difference in terms of change in hemoglobin levels after cesarean section between two groups (1.6 ± 1.0 and 1.5 ± 1.0, respectively; P = 0.711). In addition, none of the patients required blood transfusion and showed postpartum infections. There is not an association between the method of removal of the placenta and postpartum blood loss in cesarean section deliveries.

A Simple Checklist for Preventing Major Complications Associated With Cesarean Delivery

I propose a simple, evidence-based, eight-item checklist that, if followed, should reduce the frequency of many of the most serious complications associated with cesarean delivery: endometritis, wound infection, wound disruption, thrombophlebitis, and uterine scar dehiscence in a subsequent pregnancy. The frequency of abdominal wound infections can be reduced significantly by using electric clippers, rather than a razor, to remove the hair at the site of the surgical incision, washing the skin with a chlorhexidine solution, and administering broad-spectrum antibiotic prophylaxis before the start of surgery rather than after the neonate's umbilical cord has been clamped. Administration of broad-spectrum antibiotic prophylaxis and removal of the placenta by traction on the umbilical cord, rather than by manual extraction, will reduce the frequency of postcesarean endometritis. Closure of the uterine incision in two layers rather than one will significantly reduce the frequency of scar dehiscence in a subsequent pregnancy. Closure of the deep subcutaneous layer in patients whose subcutaneous tissue is greater than 2 cm in thickness will significantly reduce the risk of seroma, hematoma, and subsequent wound disruption. Institution of appropriate prophylaxis for deep vein thrombosis in intermediate and high-risk patients will reduce the risk of subsequent thromboembolic events.

Decreasing Incidence of Postcesarean Endometritis With Extended-Spectrum Antibiotic Prophylaxis

To describe the effect of an extended-spectrum prophylactic antibiotic regimen on postcesarean endometritis. This is a cohort study of trends in postcesarean endometritis using data both from prospective surveillance by the infection control unit and from query of our obstetric computerized database to compare three periods of antibiotic prophylaxis: standard narrow-spectrum with intravenous first- or second-generation cephalosporin (1992-1996), clinical trial of extended-spectrum with addition of intravenous doxycycline and oral azithromycin (1997-1999), and routine use of extended-spectrum with addition of intravenous azithromycin (2001-2006) to standard cephalosporin prophylaxis. A total of 48,913 deliveries at 24 weeks or more of gestation occurred from 1992 to 2006, of which 10,966 (22.4%) were cesarean deliveries. Annual cesarean rates increased from 16% to 27.5%. Trends in the incidence of postcesarean endometritis revealed a biphasic decrease consistent with the phased introduction of extended-spectrum prophylaxis. Incidence (95% confidence interval [CI]) of endometritis by prospective surveillance dropped from 19.9% (95% CI 18.6-21.3%) to 15.4% (95% CI 13.2-17.9%) during the clinical trial period: relative risk (RR) 0.77 (95% CI 0.66-0.91), P=.002; and then to 6.3% (95% CI 5.0-7.9%) during routine use of extended-spectrum prophylaxis: RR 0.41 (95% CI 0.31-0.54), P<.001. Corresponding incidence by database query dropped from 23% (95% CI 21.5-24.4%) to 16% (95% CI 14.4-17.9%): RR 0.69 (95% CI 0.61-0.79), P<.001; and then to 2.1% (95% CI 1.8-2.6%): RR 0.13 (95% CI 0.11-0.16), P<.001. These findings were unchanged after adjusting for potential confounders. Extended-spectrum antibiotic prophylaxis involving the addition of azithromycin to standard narrow-spectrum prophylaxis was associated with a significant reduction in postcesarean endometritis. II.