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Postpartum Endometritis

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401. WITHDRAWN: Manual removal of placenta at caesarean section. (Abstract)

associated with increased post-partum endometritis (odds ratio 5.44, 95% confidence interval 1.25 to 23.75) and a statistically non-significant trend towards an increase in feto maternal haemorrhage (odds ratio 2.19, 95% confidence interval 0.69 to 6.93).The evidence suggests that manual removal of the placenta at caesarean section may do more harm than good, by increasing maternal blood loss and increasing the risk of infection.

2007 Cochrane

402. Are hygroscopic dilators better than vaginal prostaglandins for induction of labour? A systematic review

to 4mg administered as either gel or pessaries. Maternal morbidity was reported at six weeks post partum. Definitions of maternal and neonatal morbidity varied across the studies (where reported). The authors stated neither how the papers were selected for the review nor how many reviewers performed the selection. Assessment of study quality The authors stated that they assessed study validity and mentioned blinding. The authors did not state how the assessment was performed. Data extraction Risk (...) of induction. The primary review outcome was vaginal delivery. Secondary outcomes were maternal morbidity (endometritis or chorioamnionitis), neonatal morbidity (neonatal sepsis, need for assisted ventilation, intensive care admission or death) and rate of emergency caesarean sections due to foetal heart rate change. Participants in the included studies were primiparous women. The studies used laminaria, lamicel or dilapan administered for differing lengths of time. Prostaglandin dose varied from 0.5μg

2008 DARE.

403. Elective Cesarean section to prevent anal incontinence and brachial plexus injuries associated with macrosomia: a decision analysis

crucial to the analysis were brachial plexus injury to the newborn, maternal anal incontinence, maternal urinary incontinence, emergency hysterectomy, blood transfusion due to postpartum haemorrhage, and maternal mortality. The benefits were estimated for two individuals simultaneously (the mother and the baby). Outcomes assessed in the review The outcomes estimated from the literature were the probability estimates associated with specific clinical conditions considered in the model, such as: anal (...) transient conditions (e.g. endometritis or transient tachypnoea of the newborn) were not considered. It was also noted that the model focused on primigravidae and the proposed policy might not be appropriate for women planning large families. Implications of the study The study results supported the proposed policy whereby all primigravidae patients would be offered an ultrasound at 39 weeks' gestation, followed by elective C-section for any estimated foetal weights greater than or equal to 4,500 g

2005 NHS Economic Evaluation Database.

404. Management of bacterial vaginosis

their risk of developing PID subsequently. BV is common in some populations of women undergoing elective termination of pregnancy (TOP), and is associated with post-TOP endometritis and PID (level of evidence Ib)(5). In pregnancy BV is associated with late miscarriage, preterm birth, preterm premature rupture of membranes, and postpartum endometritis (Ib) (6-10). BV has been associated with an increased incidence of vaginal cuff cellulitis and abscess formation following transvaginal hysterectomy (III (...) ):1048-59. 9. Watts DH, Krohn MA, Hillier SL, Eschenbach DA. Bacterial vaginosis as a risk factor for post-cesarean endometritis. Obstet Gynecol 1990;75(1):52- 8. 10. Goldenberg RL, Hauth JC, Andrews WW. Intrauterine infection and preterm delivery. N Engl J Med 2000;342(20):1500-7. 11. Soper DE. Bacterial vaginosis and postoperative infections. Am J Obstet Gynecol 1993;169(2:Pt 2):467-9. 12. Keane FE, Thomas BJ, Whitaker L, Renton A, Taylor-Robinson D. An association between non-gonococcal urethritis

2006 British Association for Sexual Health and HIV

405. Prophylactic versus therapeutic amnioinfusion for oligohydramnios in labour. (Abstract)

arterial pH, oxytocin augmentation, meconium aspiration, neonatal pneumonia or postpartum endometritis. Prophylactic amnioinfusion was associated with increased intrapartum fever (relative risk 3.48, 95% confidence interval 1.21 to 10.05).There appears to be no advantage of prophylactic amnioinfusion over therapeutic amnioinfusion carried out only when fetal heart rate decelerations or thick meconium-staining of the liquor occur.

2000 Cochrane

406. Antibiotic prophylaxis for cesarean section. (Abstract)

Antibiotic prophylaxis for cesarean section. The single most important risk factor for postpartum maternal infection is Cesarean delivery.The objective of this review was to assess the effects of prophylactic antibiotic treatment on infectious complications in women undergoing Cesarean delivery.We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register.Randomised trials comparing antibiotic prophylaxis or no treatment for both elective (...) and non-elective Cesarean section.Two reviewers assessed trial quality and extracted data.Sixty-six trials were included. Use of prophylactic antibiotics in women undergoing Cesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, urinary tract infection and serious infection after Cesarean section. The reduction in the risk of endometritis with antibiotics was similar across different patient groups. The relative risk for elective Cesarean section

2000 Cochrane

407. Manual removal of placenta at caesarean section. (Abstract)

associated with increased post-partum endometritis (odds ratio 5.44, 95% confidence interval 1.25 to 23.75) and a statistically non-significant trend towards an increase in feto maternal haemorrhage (odds ratio 2.19, 95% confidence interval 0.69 to 6.93).The evidence suggests that manual removal of the placenta at caesarean section may do more harm than good, by increasing maternal blood loss and increasing the risk of infection.

2000 Cochrane

408. Canadian consensus guidelines for the management of pregnant HIV-positive women and their offspring

women and their care teams in making decisions regarding optimal manage- ment during pregnancy, delivery and the postpartum period. Benefits of implementing guidelines: Optimal prenatal, intra- partum and postpartum care of the woman and her infant will result in significant reduction in perinatal HIV transmission (from about 25% to less than 1% with optimal care), improve pregnancy outcomes, minimize the risk of toxic effects to the fetus/neonate, and improve short-term and long-term health (...) recommendation] 15. Avoid unnecessary rupture of the membranes. In addi- tion, avoid use of fetal scalp electrodes and fetal scalp sampling. Carefully evaluate the need to use forceps or vacuum, taking into account the entire clinical situation. [Level II D recommendation] Postpartum care of the woman Recommendations 16. Carefully monitor the woman for signs of endometritis or wound infection. [Level III B recommendation] 17. A longer-than-average postpartum hospital stay may be re- quired to ensure

2003 CPG Infobase

409. Intrapartum amnioinfusion for meconium-stained fluid: meta-analysis of prospective clinical trials

of women randomly assigned to amnioinfusion groups ranged from 17 to 323, with control groups generally of a similar size (18 to 329). Outcomes assessed in the review Meconium below the vocal chords, meconium aspiration syndrome, foetal acidaemia (umbilical artery pH below 7.20), Caesarean delivery, and postpartum endometritis. How were decisions on the relevance of primary studies made? All of the trials were reviewed independently by the investigators. It was not reported how many investigators (...) ) without increased postpartum endometritis (OR 0.47, 95% CI: 0.31, 0.72). There were several reports of adverse events associated with amnioinfusion. It increased basal uterine tone even when a small volume (250 mL) of infusate was used. Uterine hypertonus and foetal bradycardia have been associated with specific infusion protocols, although they seem to be eliminated by adjustment of the infusion rate. Statistically significant heterogeneity was found for the outcomes of frequency of meconium

2000 DARE.

410. Concomitant use of glucocorticoids: a comparison of two metaanalyses on antibiotic treatment in preterm premature rupture of membranes

on admission ranged from 29.2 to 30.4 weeks. Most patients remained hospitalised throughout the treatment. Outcomes assessed in the review The neonatal outcomes assessed were: neonatal death, sepsis, hyaline membrane disease, respiratory distress syndrome, intraventricular haemorrhage, and necrotising enterocolitus. The maternal outcomes included chorioamnionitis and postpartum endometritis. The secondary outcomes were mean latency periods, mean birth weights, and mean durations of maternal and neonatal (...) was not violated in any outcome included. Antibiotic treatment had no significant effect on chorioamnionitis, postpartum endometritis, or on any of the neonatal outcomes included. Secondary outcomes: a combined result for secondary outcomes was not calculated because the outcomes were either incomplete or reported inconsistently. Information regarding pregnancy prolongation was available in 4 of the 5 studies. In one study, the mean rupture-to-delivery interval was significantly longer in the antibiotics group

1998 DARE.

411. Prophylactic amnioinfusion for intrapartum oligohydramnios: a meta-analysis of randomized controlled trials

rate for foetal heart rate abnormalities, including intrapartum variable decelerations. Secondary outcomes were overall Caesarean section rate, foetal acidaemia at birth, foetal heart rate abnormalities during labour, Apgar scores under 7 at 5 minutes, and postpartum endometritis. Only studies with clearly documented outcome data were eligible. Acidaemia at birth was defined as an umbilical artery pH of less than 7.20 (most studies) or less than 7.10 (two studies). How were decisions (...) section rate, foetal acidaemia at birth, foetal heart rate abnormalities during labour, and Apgar scores under 7 at 5 minutes. Postpartum endometritis rates were similar among treatment groups. Apart from acidaemia at birth, studies were homogeneous for outcomes. For most outcomes, funnel plots showed no evidence of publication bias. The included studies were of high quality. Caesarean section rate for foetal heart rate abnormalities (12 RCTs with 1,240 women): OR 0.23 (95% CI: 0.15, 0.35

2000 DARE.

412. Intrapartum chemoprophylaxis of perinatal group B streptococcal infections: a critical review of randomized controlled trials

outcomes. One study observed a statistically-significant reduction in postpartum vaginal colonisation with intrapartum chemoprophylaxis in a subset of patients, and also a statistically-significant reduction of postpartum febrile morbidity. No statistically-significant reduction was found in endometritis or sepsis, but these events have a very low incidence and so the sample size is too small to detect such a reduction. Authors' conclusions The use of intrapartum chemoprophylaxis to reduce perinatal (...) . Women had to be treated with antibiotic during, but not before, labour. Outcomes assessed in the review Group B streptococci neonatal outcomes: colonisation, proved early- or late-onset infection, probable infection and proved infection due to organisms other than group B streptococci. Group B streptococci maternal outcomes: sepsis, postpartum febrile morbidity and postpartum vaginal colonisation. How were decisions on the relevance of primary studies made? Two researchers assessed the papers

1994 DARE.

413. Pumps and warmers during amnioinfusion: is either necessary?

of meconium below the vocal cords at delivery, low 5-minute Apgar score and postpartum endometritis. How were decisions on the relevance of primary studies made? The authors do not state how the papers were selected for the review, or how many of the authors performed the selection. Studies in which the primary purpose was other than to compare outcomes in patients who received, or did not receive amnioinfusion, were excluded. Assessment of study quality Studies with less than 40 patients were excluded

1996 DARE.

414. A randomized, prospective study comparing once-daily gentamicin versus thrice-daily gentamicin in the treatment of puerperal infection

intravenously every 24 hours with clindamycin 1,200 mg intravenously every 12 hours. Type of intervention Treatment. Economic study type Cost-effectiveness analysis. Study population Patients with puerperal endometritis or with chorioamnionitis in labour. The patients met the following criteria: two temperatures of 100.4 degree F or higher 6 hours apart excluding the first 12 postpartum hours, a single temperature of 102 degree F or higher in the first 12 postpartum hours, a diagnosis of chorioamnionitis (...) in labour thought to require postpartum prophylactic antibiotic therapy, or a diagnosis of postpartum endometritis after initial discharge from hospital. Additional supporting factors for the diagnosis of postpartum endometritis were uterine tenderness, foul-smelling lochia, an elevated white blood cell count, and maternal tachycardia. Patients were excluded if they had a baseline serum creatinine level greater than 1.5 mg/dl, extrapelvic sources of infection, and allergy or hypersensitivity to either

1997 NHS Economic Evaluation Database.

415. Perinatal screening for group B streptococci: cost-benefit analysis of rapid polymerase chain reaction

evaluation were PCR tests, 35- to 37-week culture, maternal antibiotic prophylaxis, in-hospital care of non-infected infants, NICU care for GBS-infected infants, and the lifetime health care costs for a healthy or disabled infant. The cost/resource boundary of the study was that of society. The costs of treating the maternal outcomes of postpartum bacteraemia and endometritis were excluded since the analysis focused on infant costs. Resource use was mainly estimated from authors' assumptions and some

2002 NHS Economic Evaluation Database.

416. Cost-effective delivery management of the vertex and nonvertex twin gestation

(including intra-amniotic infection, postpartum endometritis, sepsis, or postpartum haemorrhage), maternal length of stay (days); the neonatal rates of pulmonary disease, neonatal infectious disease, the percentage of infants requiring the use of ventilator, the percentage of infants being admitted to the normal newborn nursery, and neonatal length of hospitalisation. The three study groups were found to be comparable in terms of maternal demographics, medical complications, gestational age, birth weight (...) separately. Cost analysis covered the costs of maternal hospitalisation including the delivery and postpartum course, and neonatal hospitalisation. The perspective adopted in the cost analysis was that of the third-party insurer or public payer. The source of the charge data was the study hospital finance office. Charge data from a single institution were judged to be a good proxy for true costs. The date of the price data was 1996. Charge data were inflated to 1996 constant dollars. The cost analysis

1998 NHS Economic Evaluation Database.

417. Performance and cost-effectiveness of selective screening criteria for Chlamydia trachomatis infection in women: implications for a national Chlamydia control strategy

versus prevalent and symptomatic versus asymptomatic infections in the FP and STD settings. Several less common but costly outcomes, in which chlamydia trachomatis may play a causative role, such as low birth weight and post-partum endometritis were not considered. The generalisability of the results to other settings was discussed and adequate comparisons with other relevant studies were made. Implications of the study More data are needed on the various effectiveness measures and other diagnostic

1997 NHS Economic Evaluation Database.

418. Membrane sweeping versus dinoprostone vaginal insert in the management of pregnancies beyond 41 weeks with an unfavourable cervix

. The gestational age on admission, the increase of gestational age from study entrance to admission to labour and delivery, the mode of delivery, the reason for operative delivery, birth weight, Apgar scores, neonatal disposition, and reasons for admission to newborn intensive care unit were similar for both groups. Two patients in the cervidil group and one in the membrane-sweeping group developed postpartum endometritis. All three patients had undergone abdominal delivery, had prolonged rupture of membranes (...) of comparators The author explicitly justified the use of dinoprostone vaginal inserts (Cervidil) as the comparator treatment to dinoprostone gel (Prepidil) by asserting that the vaginal inserts achieve ripening over a shorter period. The author acknowledged that a recent investigation (Doany et al.) suggested that a combined therapy of membrane sweeping and dinoprostone was superior in preventing post-term pregnancies compared to either technique on its own. Validity of estimate of measure of benefit

1999 NHS Economic Evaluation Database.

419. Uncomplicated pregnancy: clinical pathway genesis based on the nursing process

% confidence interval, CI: 2.17 - 6.92; p<0.05). However, these admissions were not clinically significant because they were all for postpartum mastitis or endometritis, and they occurred after 48 hours of hospital discharge. There were 9 newborn hospital readmissions in the control group versus 12 in the intervention group, (p>0.05). The number of maternal unscheduled clinic visits was 123 in the control group and 237 in the intervention group, (p>0.05). The numbers of newborn unscheduled clinic visits (...) the programme. Multiparous patients were discharged within 24 hours and primiparous patients were discharged within 48 hours. Type of intervention Other: Patient care management. Economic study type Cost-effectiveness analysis. Study population The study population comprised gravidas with uncomplicated antepartum, intrapartum and postpartum courses, with a vaginal delivery of the newborn between 38 and 42 weeks' gestation with weight appropriate for gestational age by the appropriate intrauterine growth

2000 NHS Economic Evaluation Database.

420. High-concentration supplemental perioperative oxygen to reduce the incidence of postcesarean surgical site infection: a randomized controlled trial (Abstract)

inspired oxygen decreases the incidence of surgical site infection in women undergoing cesarean delivery.Using a double blind technique, 143 women undergoing cesarean delivery under regional anesthesia after the onset of labor were randomly assigned to receive low- or high-concentration inspired oxygen via nonrebreathing mask during the operation and for 2 hours after. Surgical site infection was defined clinically as administration of antibiotics for postpartum endometritis or wound infection during

2008 EvidenceUpdates Controlled trial quality: predicted high

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