Rate Of Endometritis Research Articles

Comparison of Frequency of Post Caesarean Wound Infection with Amoxicillin Versus Ceftriaxone

Background: Cesarean delivery is a crucial factor in association with postpartum infection, there is a 5 to 20-timesmuch higher risk of getting an infection in contrast with a vaginal delivery. By not having prophylactic antibiotics, the rates of postpartum endometritis can reach 35 to 40%. This study was conducted to contrast the frequency of postoperative wound infection in patients receiving prophylactic amoxicillin vs. ceftriaxone. Methods: This Randomized Controlled Trial was conducted at the Department of Obstetrics & Gynecology, Ayub Teaching Hospital, Abbottabad, from 1st February 2016 to 31st January 2017. 210 patients undergoing cesarean section were included in this study. All the patients who participated in this study were categorized and further divided into two equal groups. Each group comprised 105 patients each through the process of block randomization. Patients in Group A were administered Amoxicillin 1000 mg and patients in group B were administered ceftriaxone 1000 mg for 48 hours following cesarean section patients were followed up on the 8thpost-op day for removal of stitches and wound examination. Results Wound infection was noted in 17 (8.1%) patients. 13 of which belonged to the Amoxicillin category. There was a statistically huge difference between the two groups regarding postoperative wound infection (p=0.023). Upon stratification of outcome variable with age and parity, the results were found to be statistically insignificant (p > 0.05). Conclusion The incidence of post-operative wound infection is minimal with the administration of ceftriaxone following a cesarean section. Keywords: Amoxicillin, Ceftriaxone, Nosocomial infection, Wound infection, cesarean section.

Secondary postpartum hemorrhage: Incidence, etiologies, and clinical courses in the setting of a high cesarean delivery rate.

To evaluate the incidence, etiologies, and clinical outcomes of secondary postpartum hemorrhage in a hospital with a high cesarean section rate and to compare the etiologies of secondary postpartum hemorrhage following cesarean delivery versus vaginal delivery. This retrospective study included 123 women with secondary postpartum hemorrhage who were treated at a tertiary-level hospital between January 2004 and June 2018. Descriptive statistics and the chi-square test were used for data analysis. The incidence of secondary postpartum hemorrhage was 0.21%. The median onset of bleeding was 12 days after delivery. Fifty-two percent of the deliveries were by cesarean section. The most common etiology of secondary postpartum hemorrhage was endometritis (67.5%), followed by retained placental tissue (21.1%). Women who delivered by cesarean section had a higher rate of endometritis (80.0% vs 53.4%) and a lower rate of retained placental tissue (10.8% vs. 32.8%) than those who delivered vaginally. Surgical intervention included uterine evacuation in 29.3% and hysterectomy in 8.1% of the patients. Five percent of women were treated by embolization. Endometritis was the most common cause of secondary postpartum hemorrhage. Women who delivered by cesarean section were less likely to have retained placental tissue but were at higher risk for endometritis and uterine pseudoaneurysm than those who delivered vaginally.

Expanded Risk-Based Strategy for Postpartum Antibiotic Prophylaxis in Deliveries Complicated by Intraamniotic Infection: Results of a Pre- and Post-Intervention Study

Intraamniotic infection (IAI) during labor is a risk factor for postpartum endometritis. Current practice guidelines for IAI support a single dose of prophylactic antibiotics in the postpartum period following cesarean but not vaginal deliveries. This study aimed to determine whether a standardized risk-based strategy of extended antibiotic prophylaxis was associated with a reduced rate of endometritis.

The Cost-Effectiveness of Bacterial Vaginosis Testing Prior to Delivery

Bacterial vaginosis (BV) has been linked to postoperative infections after gynecologic procedures; data regarding obstetrical outcomes after BV are mixed. Currently, screening and treatment of BV is not recommended prior to delivery. We sought to investigate the cost-effectiveness of testing and treating BV to reduce rates of endometritis and surgical site infection (SSI) after delivery.

Reproductive outcomes and reproductive tract microbiota shift in women with moderate-to-severe intrauterine adhesions following 30-day post-hysteroscopic placement of balloon stents or intrauterine contraceptive devices: A randomized controlled trial.

SummaryBackgroundIntrauterine adhesions (IUA) develop in up to 20% of women with a history of abortion. After hysteroscopic adhesiolysis, balloon stents are usually placed for seven days to prevent recurrence. The efficacy of prolonged use (30 days) of balloon stents has not been determined.MethodsThe trial was conducted from June 2019 to March 2021. Ninety-one patients who underwent hysteroscopic adhesiolysis for moderate or severe IUA were randomized to receive a 30-day placement of a balloon stent (n = 44) or an intrauterine device (IUD) (n = 47). The primary outcomes were the ongoing pregnancy and miscarriage rates assessed at 15-19 months. The secondary outcomes were the recurrence of IUA and the American Fertility Society (AFS) intrauterine adhesion scores at the first and second hysteroscopies, the diagnosis of new chronic endometritis at the second-look hysteroscopy, and the vaginal/uterine microbiome assessed using 16S rRNA sequencing. The trial was registered at Chinese Clinical Trial Registry (ChiCTR1900023306).FindingsThe ongoing pregnancy rates (balloon 56·4% versus IUD 57·1%) and miscarriage rates (balloon 10·3% versus IUD 22·9%) were not significantly different between the groups. No differences in the recurrence of IUA, reduction of AFS scores, or new endometritis rates were detected. The bacterial load in the uterus and vagina increased in the IUD group but not in the balloon group.InterpretationBalloon placement has a similar effect on ongoing pregnancy rates as intrauterine device (IUD) placement. Patients who underwent balloon placement had a lower miscarriage rate, although the difference was not significant. There were no differences in the recurrence rate of IUA, reduction of American Fertility Society scores, or rate of new chronic endometritis. The balloon stent has less effects on the uterine microbiota.FundingNational Natural Science Foundation of China (81802593).

The association between chronic endometritis and uterine fibroids.

Background:Some studies reported the association between fibroids with uterine inflammation. By considering this hypothesis, the formation and recurrence of uterine fibroids can be prevented by diagnosis and treatment of inflammation, and complications and costs can be reduced. This study aimed to evaluate the association between chronic endometritis and uterine fibroids in non-menopausal women.Materials and Methods:This prospective case-control study was performed on non-menopausal women referred to Al-Zahra Hospital in Rasht during April 2019-April 2020. Non- menopausal women of reproductive age (20-55 years old) with abnormal uterine bleeding who were candidates for hysteroscopy based on medical history and ultrasound reports were included in this study. The case group with fibroids were divided into two groups of intramural and subserosal myoma group and submucosal group based on the location of fibroids. The control group was patients with abnormal uterine bleeding complaints and no uterine fibroid. Endometrial specimens were examined by a pathologist for histological and immunochemistry assessments. In interpreting the results of endometrial biopsy, a positive result was indicated by the presence of one or more plasma cells per 10 high power field. Data were gathered by a form including age, parity, history of recurrent miscarriage, patient’s complaint (abnormal uterine bleeding), hysteroscopic results (submucosal myoma-polyp-normal), uterine histology (polyp, endometritis, and hyperplasia) and prevalence of chronic endometritis based on plasma cell in the biopsy. Data were analyzed by SPSS software version 21. Data were reported by descriptive statistics including number, percent, mean and standard deviation. The normality of quantitative data was assessed by the Kolmogorov- Smirnov test. Mann-Whitney U test, Chi-square and Fisher exact tests were used to compare groups and logistic regression was used to control the effect of confounders.Results:The incidence of chronic endometritis was 39% (38 out of 97) and a higher incidence of chronic endometritis was noted in the case group than the control group (46% vs. 31%), No significant difference was observed between the two groups (P > 0.05). However, the incidence of chronic endometritis in women with submucosal myoma was higher than the intramural and subserosal groups (64% vs. 37%) (P = 0.04). To control the effect of age on the rate of chronic endometritis in both groups, no significant effect was observed in logistic regression.Conclusions:The results showed the overall incidence of chronic endometritis was higher than previous studies and also the incidence was higher and more significant in women with submucosal myoma than in the intramural and subserosal group. As in this study, authors assessed the association between chronic endometritis and uterine fibroids, further studies assessing the cause and effect relationships are recommended.

Opportunities to improve the diagnosis chronic tndometritis

Goal of the research: optimization of the diagnosis of chronic endometritis.
 Methodology: perspective research.
 Institution: Department of obstetrics and gynecology of the Kursk medical University.
 Material of the research: 67 patients suffering benign diseases of endometrium and myometrium connected with it. 59 patients with the diseases of the uterus of the same пaтe without chronic endometritis.
 Methods of the research: clinico-laboratory, ultrasonography, hysteroscopic, histologic, cytologic, microbiologic examination of the endometrium, PSR, radioimmunological method to determine progesterone rate in the blood plasma.
 Results of the research: the endoscopice variants of chronic endometritis are extreted: hyperplastic and hypoplastic (and also its forms - focal and diffusive). They are necessary stages achieving reliable diagnosis of the inflammatory process of endometrium a differential method of probing of endometrium depending on a variant and damage rate of chronic endometritis is worked out.
 Conclusion: the complex method of the diagnosis chronic endometritis including hysteroscopy with visual biopsy and cytologic-histologic examination of endometrium increases the quality of diagnosis by 64,4% in comparison with the traditional curettement of the endometrium and considerably decreases the number of posttraumatic and inflammatory complications.

Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study

Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management. This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ). From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias. Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19-0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy. Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy.

142. Impact of an Antimicrobial Stewardship Intervention on Antibiotic Prescribing in Patients with Obstetric Infection and Penicillin Allergy

BackgroundAntibiotics are commonly administered in the peripartum period and most patients with penicillin allergy can tolerate beta lactams, which are preferred for the prophylaxis and treatment of several common obstetric infections. The purpose of this study was to evaluate the impact of a stewardship intervention bundle (including updates to institutional antibiotic guidelines, reclassification of severe penicillin allergy, development of order sets, and a physician champion) on the management of obstetric infections in patients with reported penicillin allergy. MethodsThis was a multicenter, retrospective study of adult patients presenting for labor and delivery who received at least one dose of antibiotics for an infectious indication May 1, 2018 to October 31, 2018 (pre-intervention) and May 1 2020 to October 31, 2020 (post-intervention). The primary outcome was the composite rates of patients with a reported penicillin allergy who received a preferred agent for Group B Streptococcus (GBS) prophylaxis, intraamniotic infection, or cesarean surgical site infection (SSI) prophylaxis. ResultsA total of 192 patients with a documented penicillin allergy were evaluated (96 patients each in pre- and post-intervention groups). Hives were the most commonly reported allergy in both groups (40% vs 39%, P=0.883). Following stewardship interventions, there was a significant increase in the rate of preferred antibiotics prescribed to patients with penicillin allergy (34.3% vs 84.3%, P< 0.001), driven mainly by patients with non-severe allergy (18.4% vs 82.9%, P< 0.001). There were non-statistically significant trends toward lower rates of postpartum endometritis, 30-day readmission, 90-day SSI, and neonatal early onset sepsis. Allergic reactions in the post-intervention group were limited to itching and rash in one patient each; both resolved with medical management. ConclusionA comprehensive antibiotic stewardship intervention increased preferred antibiotic prescribing for treatment and prophylaxis of obstetric infections. Pregnant patients with non-severe penicillin allergies, even those reporting hives, can tolerate beta-lactam antibiotics. The potential positive impact on clinical outcomes warrants additional investigation. Disclosures Neil Seligman, MD, Natera (Consultant)UpToDate (Other Financial or Material Support, Author)

Levofloxacin or gonadotropin releasing hormone agonist treatment decreases intrauterine microbial colonization in human endometriosis

ObjectiveWe examined the hypothesis that antibiotic treatment with or without gonadotropin releasing hormone agonist (GnRHa) may decrease intrauterine infection with consequent decrease in tissue inflammation, cell proliferation and angiogenesis in human endometriosis. Study designThis is a prospective non-randomized observational study. Endometrial/endometriotic samples were collected during surgery from 53 women with endometriosis and 47 control women who were treated with levofloxacin (LVFX, 500 mg, once per os) or GnRHa (1.88 mg/IM for 3 months) before surgery. Endometrial samples were analyzed by broad-range polymerase-chain reaction (PCR) amplification of bacteria targeting V5-V6 region of 16S rRNA gene. Immunohistochemical analysis was performed using antibodies against CD138 (Syndecan-1, a marker of plasma cells), CD68 (marker of macrophages), Ki-67 (cell proliferation marker), and CD31 (vascular cells marker). Results16S rDNA metagenome assay indicated that treatment with either of LVFX or GnRHa + LVFX significantly decreased some components of major bacterial genera comparing to untreated group. In women with endometriosis, treatment with either of LVFX or GnRHa + LVFX significantly decreased Gardnerella, Prevotella, Acidibactor, Atopobium, Megasphaera, and Bradyrhizobium (p < 0.05 for each) comparing to untreated group. Cochran-Mantel-Haenszel test indicated that occurrence rate of chronic endometritis was significantly decreased after GnRHa + LVFX treatment comparing to GnRHa treatment group (p = 0.041). These findings were coincided with significantly decreased CD68-stained macrophage infiltration, Ki-67- stained cell proliferation and CD31-stained micro-vessel density in endometria and endometriotic lesions with histology proven improvement in the morphological appearance of ovarian endometrioma. ConclusionsThese findings suggest that clinical administration of a broad-spectrum antibiotic with or without GnRHa may be effective in improving uterine infection with decrease of tissue inflammation, cell proliferation, and angiogenesis in human endometriosis.

Redefining chronic endometritis: the importance of endometrial stromal changes

To develop diagnostic criteria for chronic endometritis and compare the prevalence of chronic endometritis between women with recurrent pregnancy loss (RPL) and controls. Cohort study. Single academic fertility center. Women with unexplained RPL (two or more pregnancy losses) and prospectively recruited controls without a history of RPL or infertility. Endometrial samples were stained with hematoxylin and eosin and CD138. A pathologist blinded to patient history recorded the number of plasma cells per 10 high-power fields (HPFs). In addition, the presence or absence of endometrial stromal changes was documented. Prevalence of chronic endometritis. Endometrial samples from 50 women with unexplained RPL and 26 controls were evaluated. When chronic endometritis was defined as the presence of one or more plasma cells per 10 HPFs, 31% of controls and 56% of women with RPL met the criterion. When both endometrial stromal changes and plasma cells were required for a diagnosis of chronic endometritis, no controls and 30% of women with RPL met the criteria. Although rare plasma cells were found in biopsy samples from controls, the presence of both plasma cells and endometrial stromal changes was limited to the RPL cohort. We propose that chronic endometritis be defined as the presence of one or more plasma cells per 10 HPFs in the setting of endometrial stromal changes. With the use of these strict diagnostic criteria, women with RPL have a significantly higher rate of chronic endometritis, supporting an association between chronic endometritis and RPL.

Effectiveness of Chlamydia trachomatis expedited partner therapy in pregnancy

Expedited partner therapy for Chlamydia trachomatis has had mixed efficacy in different populations, but limited data exist on the efficacy of the therapy in a pregnant population. This study aimed to evaluate the real-world effectiveness of establishing a prenatal expedited partner therapy program in eradicating chlamydia before delivery and to examine the maternal and neonatal outcomes between women who received expedited partner therapy for chlamydia and women who received standard partner referral testing and treatment during pregnancy. An expedited partner therapy program was implemented on August 21, 2019, at a public hospital in a county with high chlamydia prevalence. Pregnant women were provided with single-dose packets of azithromycin to treat partners following a diagnosis of chlamydia infection. We prospectively observed pregnant women treated in the expedited partner therapy program who delivered at our institution in the same year and compared the outcomes with a historic cohort from the previous year that had traditional partner referral testing and treatment. We excluded women with concurrent gonorrhea, HIV, syphilis, or current intimate partner violence. The primary outcome was chlamydia reinfection or no-cure rates at repeat testing in 4 to 6 weeks following treatment or at the 36-week prenatal care screening. Secondary outcomes included obstetrical, maternal, and neonatal outcomes, including premature rupture of membranes, chorioamnionitis, endometritis, neonatal intensive care unit admission, neonatal sepsis, pneumonia, and conjunctivitis. The rate of chlamydia infection was 3.6% over a 2-year period in our delivered population. In the year following the implementation of the expedited partner therapy, compared with 419 women (mean±standard deviation, 23.4±5.5 years) who were diagnosed with chlamydia infection in the previous year, 471 women (mean±standard deviation age, 23.8±5.3 years) who delivered at our institution were diagnosed with chlamydia infection. There was no difference in race, parity, prenatal care attendance, or concomitant sexually transmitted infections. Compared with the pre-expedited partner therapy group, the rate of reinfection in the post-expedited partner therapy group was not statistically different (60/471 [13%] vs 61/419 [15%]; odds ratio, 0.86 [95% confidence interval 0.58-1.26]). In a per-protocol analysis, 72 women (17%) in the pre-expedited partner therapy group and 389 women (83%) in post-expedited partner therapy group received expedited partner therapy; reinfection was not statistically different between groups (P=.47). There was no difference in secondary outcomes, although a trend toward improved rates of endometritis was noted in the post-expedited partner therapy group (odds ratio, 0.13; 95% confidence interval, 0.02-1.02). The implementation of a prenatal expedited partner therapy program did not affect the rate of chlamydia reinfection before delivery. Treatment of chlamydia in an inner-city population has multiple factors that lead to successful treatment. Future efforts to reduce sexually transmitted infection and chlamydia reinfection rates in an at-risk population should include exploring patient education and safe sex practices beyond expedited partner therapy alone during pregnancy.

PREVENTION OF POST OPERATIVE INFECTIONS IN EMERGENCY CAESAREAN SECTIONS: ROLE OF SURGICAL BUNDLE AND VAGINAL CLEANING

Introduction: Caesarean section (CS) is one of the commonest surgical procedures performed in obstetrics. Postoperative infectious complications including surgical site infections (SSI) are a cause of significant morbidity after CS as compared to vaginal delivery. Aim: To assess the role of application of surgical bundle and vaginal cleaning before caesarean section in preventing postoperative infectious complications. Design: Prospective randomised interventional study. Place and duration of study: Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College and hospital,Aligarh from November 2016 to October 2018. Methodology: Total of 216 patients undergoing emergency CS in the hospital was enrolled in the study. Patients were kept in 2 groups. In group 1, women undergoing emergency C-Section whom conventional preoperative preparation was done using savlon-povidone iodine as skin antiseptic and a 7 day postop prophylactic antibiotic regime was administered.In group 2,surgical bundle and vaginal cleaning was done but postop prophylactic antibiotic regime was reduced to 3 day Results:Overall,SSIs were most common infectious morbidity in both groups with highest incidence in group 1(14.7%) and lower in group 2(7.01%), and the difference was statistically significant. Rates of endometritis, UTI and URTI were similar among 2 groups.Duration of hospital stay was lower for group 2 (6.43+_3.29days).No Significant association was noted between haemoglobin levels &lt;8g/dl and number of &gt;4 vaginal examinations with risk of development of SSI (p&lt;0.05). Conclusion:Bundled approach including vaginal cleaning has decreased the incidence of SSIs after emergency CS but larger clinical studies are needed to prove the definite role

Impact of manual removal of the placenta and intrauterine cleaning during elective cesarean delivery on maternal infectious morbidity and blood loss

Objective to assess the impact of manual removal of the placenta and intrauterine cleaning during elective cesarean delivery on maternal infectious morbidity and blood loss. Methods This prospective multicenter trial was conducted on 436 pregnant women at term who were intended for elective cesarean delivery and allocated into four groups; group 1 (n = 110) who underwent manual removal of the placenta with intrauterine cleaning, group 2 (n = 106) who underwent manual removal of the placenta without intrauterine cleaning, group 3 (n = 108) who underwent spontaneous placental delivery with intrauterine cleaning and group 4 (n = 112) who underwent spontaneous placental delivery without intrauterine cleaning. Maternal operative blood loss, the rate of endometritis and surgical site infections (SSIs) was assessed and recorded. Results There was no significant difference between the four groups regarding drop of hemoglobin concentration, drop of hematocrit value, re-operation, re-admission to hospital, duration of hospital stay, the rate of endometritis and SSIs as well as maternal acceptability in terms of overall discomfort, overall satisfaction with delivery and recommendation to other women (p > .05). Intrauterine cleaning was associated with a significantly shorter duration of discharge of lochia and rapid return to daily activity compared to non-intrauterine cleaning (p < .05). Conclusion Manual removal of the placenta and intrauterine cleaning have no deleterious impact on maternal blood loss and infectious morbidity after elective cesarean section. Also, intrauterine cleaning was associated with faster cessation of lochia and faster return to daily activity.

909 Obstetric outcomes among women who underwent TOLAC versus repeat cesarean

Women with a prior cesarean must make an informed choice between a repeat cesarean versus a trial of labor after cesarean (TOLAC). The objective of this study was to determine the differences in maternal and infant outcomes in women who underwent repeat cesarean delivery (CD) without TOLAC versus women who underwent TOLAC. This was a retrospective cohort study of women delivering in California between 2007-2011 who were delivering after a previous cesarean. The study included women with singleton, non-anomalous, multiparous live births between 37- and 41-weeks’ gestation. We examined rates of maternal and infant outcomes. Analyses were conducted using Pearson’s chi-squared test of significance with an alpha of 0.05. In this study, 345,308 women-infant dyads met the inclusion criteria. Of these, 296,457 (85.9%) had a repeat cesarean section without TOLAC and 48,851 (14.1%) underwent TOLAC. Maternal and infant outcomes were significantly different between groups. Rates of endometritis were lower in women with a repeat cesarean without TOLAC than those who had a trial of labor (0.4% vs. 0.6%, p<0.001). Women who did not undergo TOLAC experienced lower rates of postpartum hemorrhage compared to those who did (1.2% vs. 3.1%, p<0.001), though the experienced a higher rate of blood transfusion (1.0% vs. 0.9%, p<0.001). Infants of women in the TOLAC group had higher rates of neonatal intensive care unit admission (7.2% vs. 5.6%, p<0.001) and higher rates of APGAR scores under 7 at five minutes (0.5% vs. 0.3%, p <0.001). Infants of women in the TOLAC group were also more likely to have hypoxic-ischemic encephalopathy (0.1% vs. 0.02%, p<0.001). There was no significant difference in neonatal death. We found that, when comparing undergoing repeat cesarean with and without TOLAC, maternal and infant outcomes were significantly different. Future research should investigate characteristics and management factors contributing to these differences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1164 Maternal and infant outcomes in those undergoing TOLAC by hospital setting

The objective of this study was to assess whether maternal and neonatal outcomes in those undergoing trial of labor after cesarean (TOLAC) differ significantly between hospitals in rural versus urban settings. We conducted a retrospective cohort study of singleton, non-anomalous, term deliveries in California between 2007 and 2011. We compared maternal and neonatal outcomes separately between rural and urban settings. Chi-square and multivariable logistic regression analyses were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance. 45,763 women-infant dyads were included in this study. We found the odds of operative vaginal delivery in women undergoing TOLAC were significantly higher at urban centers compared to rural hospitals (aOR: 1.00% vs 0.46%, p<0.001). In women undergoing TOLAC, rates of endometritis were significantly higher at urban hospitals than rural (0.62% vs. 0.24%, p=0.049). Rates of post-partum hemorrhage was significantly higher at urban hospitals than rural (3.07% vs 1.90%, p=0.006), although maternal transfusion rates were not significantly different. Rates of placental abruption were not significantly different between the two settings. Infants of women undergoing TOLAC were admitted to the neonatal intensive care unit (NICU) at a significantly higher rate in urban hospitals than rural hospitals (7.28% vs 3.90%, p<0.001). The remaining outcomes were not significantly different, including rates of low APGAR scores, brachial plexus injury, HIE, neonatal and infant death. In this study, we found that most outcomes in women undergoing TOLAC did not differ significantly between rural and urban settings. At hospitals in urban settings, women experienced higher rates of endometritis and post-partum hemorrhage. Neonatal outcomes were also generally not significantly different, however, infants of women in urban settings experienced higher rates of NICU admission than rural hospitals. Further research ought to be done to determine whether VBAC success rates contribute to these differences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

933 Maternal and infant outcomes in those undergoing TOLAC by hospital volume

This study assessed whether maternal and neonatal outcomes in those undergoing trial of labor after cesarean (TOLAC) differ significantly between hospitals of different volumes. We conducted a retrospective cohort study of singleton, non-anomalous, term deliveries in California between 2007 and 2011. We studied outcomes stratified by low, medium, and high hospital volume based on previous literature. Chi-square and multivariable logistic regression analyses were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance 45,763 women-infant dyads met our inclusion criteria. The odds of operative vaginal delivery in women undergoing TOLAC were significantly higher at high volume hospitals compared to low and medium volume hospitals (aOR: 1.65 vs 0.94 and 1.00, respectively). Rates of post-partum hemorrhage were significantly different, with highest rates in high volume hospitals (3.24%) compared with medium and low volume centers (2.68% and 2.46%, respectively). Transfusion rates were also significantly different. Rates of severe maternal morbidity, endometritis, and placental abruption were not significantly different. For neonates, rates of neonatal intensive care unit (NICU) admission was highest in medium volume centers (7.8%) compared to low and high (6.56% and 6.91%, respectively). APGAR scores <7 at 5 minutes were significantly different between groups, and highest at medium volume centers (0.63%) when compared to low and high (0.60% and 0.40%, respectively). There was no significant difference in brachial plexus injuries, HIE, neonatal or infant death between groups. In women undergoing TOLAC, most outcomes were not different. However, there was a significantly higher rate of post-partum hemorrhage and maternal blood transfusion between hospital volume categorizations. Of the outcomes studied, NICU admission and low APGAR scores were the only outcomes that were significantly different. Whether or not VBAC success rate is contributing to the lack of complications seen needs to be studied further.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1170 One-step deflation of bakri intrauterine balloon tamponade is not associated with increased blood loss

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality. Bakri intrauterine balloon tamponade (IBT) for refractory hemorrhage decreases morbidity, need for additional surgery, and blood loss; however, the most effective deflation method is unknown. We aimed to determine if 1-step compared to serial deflation of the IBT is associated with less blood loss after removal. Retrospective cohort study of patients with PPH who received IBT from January 2012 to August 2020 at a single institution. Patients were excluded if the IBT remained in place for fewer than 2 hours. The primary exposure was deflation method: 1-step (removed in 1 pass) or serial (in >1 pass). The primary outcome was estimated blood loss (EBL) from the initiation of IBT deflation to discharge. Secondary outcomes included clinically estimable blood loss (≥200 mL) after IBT deflation, need for additional interventions, postpartum fever and endometritis. 279 patients received an IBT which remained in place for ≥2 hours following PPH. The IBT was deflated in a single pass (1-step) in 112 (40%) and serially in 167 (60%). Baseline characteristics and pre-IBT hemorrhage were similar, except the serial group had less pre-existing hypertension, less labor augmentation with oxytocin, more multiple gestations, and higher EBL prior to IBT placement (Table 1). EBL after starting IBT deflation was greater in the 1-step group (42±294 mL 1-step vs 28±48 mL serial, p <0.001). There was no difference in rate of clinically significant EBL (2.7% 1-step vs 2.4% serial, p = 1.0), including after adjusting for pre-IBT EBL and other baseline characteristics. No difference was seen in need for additional interventions. Rates of postpartum fever (29% vs 32%, p=0.57) and endometritis (11% vs 17%, p=0.18) were not different based on 1-step vs serial deflation, respectively (Table 2). Patients with PPH whose IBT was deflated all at once did not have more post-IBT blood loss compared to those deflated serially, nor was there any difference in rate of need for additional interventions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Outcomes of Expectant Management of Term Prelabor Rupture of Membranes

ObjectiveTo assess rates of induction/augmentation of labor, maternal infection, neonatal outcomes, and time to birth when women were expectantly managed after term prelabor rupture of membranes (PROM) at home or in the hospital. DesignRetrospective, descriptive study based on a review of data from a hospital midwifery service database and chart review. SettingA large Midwest hospital with 4,700 births annually. ParticipantsWe used the cases of women who received midwifery care, experienced term PROM, and had singleton fetuses in the vertex position. MethodsWe conducted an analysis of maternal and neonatal outcomes with term PROM using data from a midwifery service quality improvement database. We compared characteristics and outcomes between management plans (immediate induction, expectant hospital, and expectant home) using chi-square, analysis of variance, and independent t-tests. ResultsPROM occurred in 281 (12%) of the 2,357 women cared for by the midwifery service between January 2016 and December 2018. One hundred fifty women (53.3%) opted to wait for labor onset at home, 102 (36.3%) were expectantly managed in the hospital, 21 (7.5%) were admitted for immediate induction of labor, and 8 (2.8%) were admitted for immediate cesarean birth. The rate of spontaneous labor onset was not significantly different between the two expectant management groups or between nulliparous and multiparous women. A total of 88 (34.9%) women who were expectantly managed ultimately had their labors induced. Rates of chorioamnionitis and endometritis were not significantly different between the expectant management groups in this study or compared with national averages. There was no difference in NICU admissions or Apgar scores below 7. The mean time from PROM to birth was significantly shorter in the expectant management in hospital group (27.3 hours) than in the expectant management at home group (33.5 hours). ConclusionExpectant management at home or in the hospital is appropriate for low-risk pregnant women with term PROM. Women for whom this option is appropriate include those with term singleton fetuses in vertex presentation with reassuring fetal heart rates and confirmed clear amniotic fluid. Acceptable time frames for home management include up to 24 hours for women with negative group B streptococcus cultures and up to 12 hours for those with positive cultures.

Postpartum endometritis after uterine cleaning versus no cleaning in cesarean sections: Randomized clinical trial.

The aim of the study was to compare the rates of postpartum endometritis due to uterine cleaning and no cleaning in patients delivered by elective cesarean section. This was a randomized clinical trial conducted at the Obstetrics and Gynecology Department, Suez Canal University Hospital, Ismailia, from June 2019 to November 2019. We recruited patients undergoing cesarean delivery aged 18-45 years with singleton pregnancy, intact membranes, either first or repeated delivery, without labor pains. Patients were allocated into two groups, uterine cleaning (336 patients) and no cleaning (312 patients). The main outcome measure was the occurrence of postpartum endometritis. Both groups were matched in their demographic characters. Twelve patients (3.6%) developed endometritis in the cleaning group versus one patient (0.3%) in the other one. Estimated blood loss was 754.35 ± 247.13 and 730.36 ± 232.77 for the cleaning and no cleaning groups, respectively, with a P value of 0.201. Septic wound infection (21 patients, 6.3%) was predominant in the cleaning group. Uterine cleaning after delivery of the placenta during CS can be omitted as a surgical step during the operation. It was associated with increased rates of postpartum endometritis and blood loss.