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Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment.American Journal of Obstetrics and... Mar 2024Clinical chorioamnionitis, the most common infection-related diagnosis in labor and delivery units, is an antecedent of puerperal infection and neonatal sepsis. The... (Review)
Review
Clinical chorioamnionitis, the most common infection-related diagnosis in labor and delivery units, is an antecedent of puerperal infection and neonatal sepsis. The condition is suspected when intrapartum fever is associated with two other maternal and fetal signs of local or systemic inflammation (eg, maternal tachycardia, uterine tenderness, maternal leukocytosis, malodorous vaginal discharge or amniotic fluid, and fetal tachycardia). Clinical chorioamnionitis is a syndrome caused by intraamniotic infection, sterile intraamniotic inflammation (inflammation without bacteria), or systemic maternal inflammation induced by epidural analgesia. In cases of uncertainty, a definitive diagnosis can be made by analyzing amniotic fluid with methods to detect bacteria (Gram stain, culture, or microbial nucleic acid) and inflammation (white blood cell count, glucose concentration, interleukin-6, interleukin-8, matrix metalloproteinase-8). The most common microorganisms are Ureaplasma species, and polymicrobial infections occur in 70% of cases. The fetal attack rate is low, and the rate of positive neonatal blood cultures ranges between 0.2% and 4%. Intrapartum antibiotic administration is the standard treatment to reduce neonatal sepsis. Treatment with ampicillin and gentamicin have been recommended by professional societies, although other antibiotic regimens, eg, cephalosporins, have been used. Given the importance of Ureaplasma species as a cause of intraamniotic infection, consideration needs to be given to the administration of antimicrobial agents effective against these microorganisms such as azithromycin or clarithromycin. We have used the combination of ceftriaxone, clarithromycin, and metronidazole, which has been shown to eradicate intraamniotic infection with microbiologic studies. Routine testing of neonates born to affected mothers for genital mycoplasmas could improve the detection of neonatal sepsis. Clinical chorioamnionitis is associated with decreased uterine activity, failure to progress in labor, and postpartum hemorrhage; however, clinical chorioamnionitis by itself is not an indication for cesarean delivery. Oxytocin is often administered for labor augmentation, and it is prudent to have uterotonic agents at hand to manage postpartum hemorrhage. Infants born to mothers with clinical chorioamnionitis near term are at risk for early-onset neonatal sepsis and for long-term disability such as cerebral palsy. A frontier is the noninvasive assessment of amniotic fluid to diagnose intraamniotic inflammation with a transcervical amniotic fluid collector and a rapid bedside test for IL-8 for patients with ruptured membranes. This approach promises to improve diagnostic accuracy and to provide a basis for antimicrobial administration.
Topics: Female; Infant, Newborn; Pregnancy; Humans; Chorioamnionitis; Clarithromycin; Postpartum Hemorrhage; Neonatal Sepsis; Anti-Bacterial Agents; Amniotic Fluid; Inflammation; Tachycardia
PubMed: 38233317
DOI: 10.1016/j.ajog.2023.02.002 -
The Journal of Maternal-fetal &... Dec 2023Women's choice of birth following a cesarean delivery either includes a trial of elective repeat cesarean section (ERCS) or a trial of labor after cesarean (TOLAC). No... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Women's choice of birth following a cesarean delivery either includes a trial of elective repeat cesarean section (ERCS) or a trial of labor after cesarean (TOLAC). No comprehensive overview or systematic summary is currently available.
METHODS
EMBASE, PubMed, and the Cochrane Library databases were searched from inception to 1 February 2020. Studies reporting the safety of TOLAC and ERCS in pregnant women with prior cesarean delivery were included. Statistical analysis was performed using RevMan 5.3 and Stata 15.0. Odds ratios (ORs) and 95% confidence intervals (CIs) were adopted as the effective measures.
RESULTS
A total of 13 studies covering 676,532 cases were included in this meta-analysis. The results demonstrated that the rates of uterine rupture (OR = 3.35, 95%CI [1.57, 7.15], = 81%), neonatal asphyxia (OR = 2.32, 95%CI [1.76, 3.08], = 0%) and perinatal death (OR = 1.71, 95%CI [1.29, 2.25], = 0%) were higher in the TOLAC group compared with the ERCS group. The rates of peripartum hysterectomy (OR = 0.70, 95%CI [0.44, 1.11], = 62%), blood transfusion (OR = 1.24, 95%CI [0.72, 2.12], = 95%), and puerperal infection (OR = 1.11, 95%CI [0.77, 1.60], = 95%) showed no significant differences between the two groups.
CONCLUSION
TOLAC is associated with a higher risk of uterine rupture, neonatal asphyxia, and perinatal death compared with ERCS. Nevertheless, it should be noted that the risks of all complications were small in both groups. This information is important for healthcare providers and women choosing the delivery type.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Cesarean Section; Cesarean Section, Repeat; Trial of Labor; Perinatal Death; Uterine Rupture; Asphyxia; Vaginal Birth after Cesarean; Retrospective Studies
PubMed: 37217450
DOI: 10.1080/14767058.2023.2214831 -
BMC Pregnancy and Childbirth Nov 2023Puerperal infection (PI) is a severe threat to maternal health. The incidence and risk of PI should be accurately quantified and conveyed for prior decision-making. This... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Puerperal infection (PI) is a severe threat to maternal health. The incidence and risk of PI should be accurately quantified and conveyed for prior decision-making. This study aims to assess the quality of the published literature on the epidemiology of PI, and synthesize them to identify the temporal trends and risk factors of PI occurring in Mainland China.
METHODS
This review was registered in PROSPERO (CRD42021267399). Putting a time frame on 2010 to March 2022, we searched Cochrane library, Embase, Google Scholar, MEDLINE, Web of Science, China biology medicine, China national knowledge infrastructure and Chinese medical current contents, and performed a meta-analysis and meta-regression to pool the incidence of PI and the effects of risk factors on PI.
RESULTS
A total of 49 eligible studies with 133,938 participants from 17 provinces were included. The pooled incidence of PI was 4.95% (95%CIs, 4.46-5.43), and there was a statistical association between the incidence of PI following caesarean section and the median year of data collection. Gestational hypertension (OR = 2.14), Gestational diabetes mellitus (OR = 1.82), primipara (OR = 0.81), genital tract inflammation (OR = 2.51), anemia during pregnancy (OR = 2.28), caesarean section (OR = 2.03), episiotomy (OR = 2.64), premature rupture of membrane (OR = 2.54), prolonged labor (OR = 1.32), placenta remnant (OR = 2.59) and postpartum hemorrhage (OR = 2.43) have significant association with PI.
CONCLUSIONS
Maternal infection remains a crucial complication during puerperium in Mainland China, which showed a nationwide temporal rising following caesarean section in the past decade. The opportunity to prevent unnecessary PI exists in several simple but necessary measures and it's urgent for clinicians and policymakers to focus joint efforts on promoting the bundle of evidence-based practices.
Topics: Pregnancy; Female; Humans; Cesarean Section; Incidence; Puerperal Infection; China; Risk Factors; Epidemiologic Studies
PubMed: 37996780
DOI: 10.1186/s12884-023-06135-x -
Medicine, Health Care, and Philosophy Dec 2023Semmelweis' discovery of the etiology of childbed fever has long attracted the attention of historians of medicine and biographers. In recent years it has also become of...
Semmelweis' discovery of the etiology of childbed fever has long attracted the attention of historians of medicine and biographers. In recent years it has also become of increasing interest to philosophers. In this paper I discuss the interpretation of Semmelweis' methodology from the viewpoint of the inference to the best explanation and argue that Popperian methodology is better at capturing the dynamics of the growth of knowledge. Furthermore, I criticize the attempts to explain the failure of Semmelweis to have his discovery accepted on the basis of the Kuhnian concept of paradigms, and warn that this view may endorse dogmatism as the norm The Kuhnian position also raises the problem of the authoritarian nature of scientific institutions which defend a paradigm against unorthodox, rebellious views, such as in the case of Semmelweis. Popperian philosophy is seen as a challenge to promote a link between an open society and open science with its main aim being to cherish a free critical spirit.
Topics: Pregnancy; Female; Humans; Puerperal Infection; Medicine; Knowledge
PubMed: 37584837
DOI: 10.1007/s11019-023-10167-7 -
Annals of Global Health 2023In resource-poor settings, perinatal infections contribute significantly to maternal and neonatal deaths, and the use of clean delivery kits (CDKs) has been proposed as... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
In resource-poor settings, perinatal infections contribute significantly to maternal and neonatal deaths, and the use of clean delivery kits (CDKs) has been proposed as a tool to reduce the risk of infection-related deaths. This study aims to assess the acceptability and effectiveness of CDKs in preventing infections in deliveries attended by traditional birth attendants (TBAs) in Abeokuta, Nigeria.
METHODS
The study was a cluster-randomized trial with 67 birth centres/clusters, 453 births/mothers, and 457 babies randomized to intervention or control arms; intervention involved supplementation of delivery with JANMA CDKs. Interviews were conducted at the birth homes, and the primary outcomes were neonatal infection and puerperal fever. The association between infection and perinatal risk factors was tested using the Chi-square and Fisher's exact tests.
RESULTS
CDKs were well accepted by TBAs. The incidence of puerperal fever and neonatal infection was 1.1% and 11.2%, respectively. Concurrent infection was found in 1 (0.22%) of the mother-neonate pair. There was no significant association between any of the sociodemographic factors and infection for both mothers and neonates. PROM and prolonged labour were significantly associated with puerperal infection. All mothers with puerperal fever were from the control group. Compared to the control group, the relative risk of puerperal infection and neonatal infection in the intervention group was 0.08 (0.004 -1.35, p = 0.079) and 0.64 (0.37 to 1.1, p = 0.10), respectively.
CONCLUSION
CDKs hold promising results in attenuating maternal infections in resource-poor settings. Larger studies with greater statistical power are required to establish statistically reliable information.
Topics: Female; Humans; Infant; Infant, Newborn; Pregnancy; Home Childbirth; Midwifery; Nigeria; Parturition; Puerperal Infection
PubMed: 38077261
DOI: 10.5334/aogh.4015 -
Obstetrics and Gynecology Mar 2024To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis.
OBJECTIVE
To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis.
METHODS
We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure.
RESULTS
Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum.
CONCLUSION
Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions.
Topics: Pregnancy; Female; United States; Humans; Puerperal Infection; Patient Readmission; Retrospective Studies; Risk Factors; Hospitalization; Postpartum Period; Sepsis
PubMed: 37944152
DOI: 10.1097/AOG.0000000000005437 -
BMC Pregnancy and Childbirth Mar 2024This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection... (Meta-Analysis)
Meta-Analysis
Can the use of azithromycin during labour reduce the incidence of infection among puerperae and newborns? A systematic review and meta-analysis of randomized controlled trials.
OBJECTIVE
This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns.
DATA SOURCES
We independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024.
METHODS
We included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity.
RESULTS
The pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55-0.77; I, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52-0.74; I, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24-0.78; P < .005); however, there was great heterogeneity among the studies (I, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17-0.52; I, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35-0.65; I, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears.
CONCLUSION
In this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Azithromycin; Neonatal Sepsis; Cesarean Section; Chorioamnionitis; Endometritis; Incidence; Randomized Controlled Trials as Topic; Sepsis; Puerperal Infection; Surgical Wound Infection; Urinary Tract Infections
PubMed: 38486177
DOI: 10.1186/s12884-024-06390-6 -
Cureus Jul 2023Breast abscesses can be a complication of infectious mastitis or the first presentation of a breast infection, presenting as pain, erythema, and a lump. Actinomycosis is...
Breast abscesses can be a complication of infectious mastitis or the first presentation of a breast infection, presenting as pain, erythema, and a lump. Actinomycosis is a rare chronic disease caused by anaerobic branched filamentous gram-positive bacteria belonging to the genus. It is usually found in the human mouth, digestive tract, and genital tract but can also cause breast abscesses. Actinomycosis affecting the breast is a rare condition that typically occurs as a secondary infection resulting from a pulmonary infection. It is primary when inoculation occurs through the nipple. This report describes the case of a 48-year-old institutionalized female with periareolar swelling in the right breast that had been evolving for approximately two months. The abscess was drained, and the aspirated material contained , a gram-positive bacterium. Actinomycosis of the breast can manifest as either a sinus tract or mass-like features that closely resemble malignancy. The clinical presentation can pose challenges in distinguishing between primary actinomycosis, mastitis, and inflammatory carcinoma. Treatment consists of drainage with needle aspiration or surgical drainage and antibiotic therapy.
PubMed: 37602065
DOI: 10.7759/cureus.42092