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Postpartum Endometritis

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82. Placenta Praevia and Placenta Accreta: Diagnosis and Management

is not exclusively a consequence of caesarean delivery. Other surgical trauma to the integrity of the uterine endometrium and/or superficial myometrium, such as those following uterine curettage, manual removal of the placenta, postpartum endometritis or myomectomy, has been associated with accreta placentation in subsequent pregnancies. , , Overall, the aOR for placenta accreta spectrum after previous uterine surgery is 3.40 (95% CI 1.30–8.91). Evidence level 2+ The development of placenta accreta spectrum has (...) the placental edge is less than 20 mm from the internal os, and as normal when the placental edge is 20 mm or more from the internal os on TAS or TVS. This new classification could better define the risks of perinatal complications, such as antepartum haemorrhage and major postpartum haemorrhage (PPH), , and has the potential of improving the obstetric management of placenta praevia. Recent articles reviewed in this guideline refer to the AIUM classification. The estimated incidence of placenta praevia

2018 Royal College of Obstetricians and Gynaecologists

83. Intrapartum fever

and/or affected general appearance and/or suspicion of sepsis. o In case of assumed intrauterine infection microbiologic tests from the placenta and amniotic membranes have to be analyzed to confirm diagnosis, preferably biopsies, but as a minimum swab culture. o Urine dip-stick. If positive for leucocytes or nitrite send urine to culture. o Cervix swab and amniotic fluid (intrauterine catheter or during C-section) culture should be considered. o All microbiotic tests may be valuable postpartum, but only (...) prøver fra fosterhinder og placenta, optimalt som vævsprøver i spidsglas, som minimum som podning til D+R. o U-stix. Ved leukocytter og/eller nitrit suppl. med dyrkning. o Cervixpodning og amnionvæske (intrauterint kateter/ved sectio) til D+R kan overvejes. o Samtlig mikrobiologi kan have værdi postpartum, men kun U-stix har relevans i den akutte fase. o Infektionstal kan overvejes. Har begrænset diagnostisk værdi i den akutte fase, men kan evt. bruges i relation til forløbet post partum D Øget

2019 Nordic Federation of Societies of Obstetrics and Gynecology

84. Obstetric anal sphincter injury (OASIS)

be assessed clinically 10-15 days postpartum. The visit should include inspection of the wound to diagnose wound ruptures requiring re-suturing. C Review can be by a trained midwife or nurse, an experienced obstetrician or a uro- gynecologist. v Women who have undergone obstetric anal sphincter repair should be advised to contact the hospital in case of rupture of the wound, infection, fecal incontinence or profound fecal urgency within three weeks of delivery. v Women who have undergone obstetric anal (...) anal sphincter repair should be assessed clinically 10-15 days postpartum. The visit should include inspection of the wound to diagnose wound ruptures requiring re-suturing. C 7 Review can be by a trained midwife or nurse, an experienced obstetrician or a uro- gynecologist. v Women who have undergone obstetric anal sphincter repair should be advised to contact the hospital in case of rupture of the wound, infection, fecal incontinence or profound fecal urgency within three weeks of delivery. v

2019 Nordic Federation of Societies of Obstetrics and Gynecology

85. The Irish Maternity Early Warning System (IMEWS) National Clinical Guideline

are increased, renal clearance is increased and metabolism is altered (Soma-Pillay et al., 2016; Tan and Tan, 2013). Critical illness in pregnancy may be due to conditions specific to or exacerbated by pregnancy, or coincidental conditions. The conditions specific to pregnancy include (but not limited to) obstetric haemorrhage, pre-eclampsia/eclampsia, pulmonary embolism (venous and amniotic fluid), chorioamnionitis/endometritis, uterine rupture, placenta accreta and acute fatty liver (Neligan and Laffey (...) , 2011) . The Confidential Maternal Death Enquiry (MDE) Ireland 2009-2015 reported a total of 54 maternal deaths occurring during pregnancy or up to 42 days postpartum (O’Hare et al., 2017) (Table 2). Causes of death are classified as direct, indirect and coincidental with direct being comparable to those conditions specific to pregnancy (plus suicide). The maternal mortality rate (MMR) for the triennium 2013-2015 was 6.5 per 100,000 maternities (95% CI 3.1 – 11.2) in Ireland. Measuring outcome based

2019 HIQA Guidelines

86. ShortGUIDE: Term prelabour rupture of membranes (PROM)

Caesarean section (RR 0.84; 95% CI 0.69 to 1.04; 23 trials, n=8576) No significant difference Maternal length of stay (MD -0.79 days; 95% CI -1.20 to -0.38; 2 trials, n=748) Decreased Positive maternal experience 19,20 Mixed reports Admission to neonatal/special care (RR 0.75; 95% CI 0.66 to 0.85; 8 trials n= 6179,) Decreased Neonatal sepsis (definite or probable) (RR 0.73; 95% CI 0.58 to 0.92; 16 trials, n=7314) Decreased Postpartum antibiotic use, pyrexia, endometritis, operative vaginal birth (...) , primary postpartum haemorrhage, caesarean section for fetal distress, uterine rupture, epidural analgesia, cord prolapse, stillbirth, Apgar 24 hours o Change in fetal movements o Signs of infection o Change in vaginal loss · Offer information that risk of infection: o Increased with vaginal intercourse o Not affected by showering or bathing · Recommend IOL if: o Woman requests o Concern for maternal or fetal wellbeing Expectant care at home? Recommend expectant care in hospital Indications for active

2019 Queensland Health

87. Antibiotic prophylaxis for operative vaginal delivery. (PubMed)

Antibiotic prophylaxis for operative vaginal delivery. Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear.To assess the effectiveness and safety of antibiotic prophylaxis in reducing (...) endometritis and maternal length of stay.One small trial was identified reporting only two outcomes. Evidence from this single trial suggests that antibiotic prophylaxis may lead to little or no difference in endometritis or maternal length of stay. There were no data on any other outcomes to evaluate the impact of antibiotic prophylaxis after operative vaginal delivery. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing

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2017 Cochrane

88. Interventions for treating genital Chlamydia trachomatis infection in pregnancy. (PubMed)

Interventions for treating genital Chlamydia trachomatis infection in pregnancy. Genital Chlamydia trachomatis (C.trachomatis) infection may lead to pregnancy complications such as miscarriage, preterm labour, low birthweight, preterm rupture of membranes, increased perinatal mortality, postpartum endometritis, chlamydial conjunctivitis and C.trachomatis pneumonia.This review supersedes a previous review on this topic.To establish the most efficacious and best-tolerated therapy for treatment

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2017 Cochrane

89. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). (PubMed)

, 5691 infants). Women in the planned early birth group had more positive experiences compared with women in the expectant management group.No clear differences between groups were observed for endometritis; postpartum pyrexia; postpartum antibiotic usage; caesarean for fetal distress; operative vaginal birth; uterine rupture; epidural analgesia; postpartum haemorrhage; adverse effects; cord prolapse; stillbirth; neonatal mortality; pneumonia; Apgar score less than seven at five minutes; use (...) the other 20 were at unclear or high risk of bias.Primary outcomes: women who had planned early birth were at a reduced risk of maternal infectious morbidity (chorioamnionitis and/or endometritis) than women who had expectant management following term prelabour rupture of membranes (average risk ratio (RR) 0.49; 95% confidence interval (CI) 0.33 to 0.72; eight trials, 6864 women; Tau² = 0.19; I² = 72%; low-quality evidence), and their neonates were less likely to have definite or probable early-onset

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2017 Cochrane

90. Routine antibiotic prophylaxis after normal vaginal birth for reducing maternal infectious morbidity. (PubMed)

of the evidence for application in practice, particularly in settings where women may be at higher risk of developing endometritis. The use of antibiotics did not reduce the incidence of urinary tract infections, wound infection or the length of maternal hospital stay. Antibiotics are not a substitute for infection prevention and control measures around the time of childbirth and the postpartum period. The decision to routinely administer prophylactic antibiotics after normal vaginal births needs (...) administration of prophylactic antibiotics to women after normal (uncomplicated) vaginal birth, compared with placebo or no antibiotic prophylaxis, reduces postpartum maternal infectious morbidities and improves outcomes.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2017), LILACS, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (22 August 2017) and reference lists of retrieved studies.We planned to include randomised or quasi

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2017 Cochrane

91. Antibiotic prophylaxis for episiotomy repair following vaginal birth. (PubMed)

(e.g. endometritis) were reported in either the antibiotic or control group.The trial did not report on any of the secondary outcomes of interest for this review, including severe maternal infectious morbidity, discomfort or pain at the episiotomy wound site, sexual function postpartum, adverse effects of antibiotics, costs of care, women's satisfaction with care, and individual antimicrobial resistance.There was insufficient evidence to assess the clinical benefits or harms of routine antibiotic (...) Antibiotic prophylaxis for episiotomy repair following vaginal birth. Bacterial infections occurring during labour, childbirth, and the puerperium may be associated with considerable maternal and perinatal morbidity and mortality. Antibiotic prophylaxis might reduce wound infection incidence after an episiotomy, particularly in situations associated with a higher risk of postpartum perineal infection, such as midline episiotomy, extension of the incision, or in settings where the baseline risk

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2017 Cochrane

93. CRACKCast E177 – Acute Complications of Pregnancy

. In general, the tetracyclines and quinolones are contraindicated in pregnant patients. Treatment of genital tract infections may be important in preventing preterm labor and decreasing transmission to the infant. Complications: Salpingitis in pregnancy Disseminated gonorrhea in pregnancy Gonococcal arthritis Preterm labour Postpartum endometritis Infant: Conjunctivitis Pneumonitis Neonatal gonococcal ophthalmia Sepsis Chlamydia: Treatment during pregnancy or breast-feeding is azithromycin (single 1-g (...) % of women will have no pain or vaginal bleeding. Assessment is generally based on clinical features, coagulation parameters, and signs of fetal distress. Hypertension in Pregnancy Gestational hypertension occurs during pregnancy (>20wks), resolves during the postpartum period and equals a new blood pressure reading of 140/90 mm Hg or higher. Preeclampsia is gestational hypertension with proteinuria (>300 mg/24 hr); eclampsia is the occurrence of seizures in the patient with signs of preeclampsia

2018 CandiEM

94. CRACKCast E180 – Labor & Delivery

infections. Causative organisms for these infections include gram-positive cocci and gram-negative coliforms and, less commonly Chlamydia and Mycoplasma spp. Endometritis is the most common puerperal infection, usually developing on the second or third day postpartum. Typically, the lochia has a foul odor, and the white blood cell count is elevated. Fever and abdominal pain indicate greater severity of infection, often warranting inpatient care and intravenous antibiotics. A coexistent surgical wound (...) with or without tazobactam, and ampicillin and sulbactam. Most patients with postpartum endometritis require admission. 19) List 5 RFs for post-partum depression Previously diagnosed depression, inadequate spousal support, adverse socioeconomic factors, life stressors, and emergency delivery. Symptoms peak at 10 to 12 weeks postpartum, although some cases are diagnosed up to 1 year after delivery. When postpartum depression is unrecognized, these women are at high risk for suicide and may come to the ED

2018 CandiEM

95. Fever during labor

should be considered. D o All microbiotic tests may be valuable postpartum, but only urine dip-stick is of relevance in the acute phase. o Infection parameters can be considered, but are of limited diagnostic value in the acute phase. They might be valuable when monitoring development post partum. Suspicion on intrauterine infection in case of intrapartum fever and at least one of the folowing: • Fetal tachycardia >160 beats per minute • Foul smelling vaginal discharge/amniotic fluid • Uterine (...) Venyler ved temperatur =39°C og/eller medtaget almentilstand og/eller mistanke om sepsis. o Ved formodet intrauterin infektion skal der mhp. endelig diagnose sendes mikrobiologiske prøver fra fosterhinder og placenta, optimalt som vævsprøver i spidsglas, som minimum som podning til D+R. o U-stix. Ved leukocytter og/eller nitrit suppl. med dyrkning. o Cervixpodning og amnionvæske (intrauterint kateter/ved sectio) til D+R kan overvejes. o Samtlig mikrobiologi kan have værdi postpartum, men kun U-stix

2018 Nordic Federation of Societies of Obstetrics and Gynecology

97. WHO recommendations: intrapartum care for a positive childbirth experience

and Childbirth Group (of the Cochrane Collaboration) PICO population (P), intervention (I), comparator (C), outcome (O) PMNCH The Partnership for Maternal, Newborn & Child HealthWHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE viii PPH postpartum haemorrhage RCOG Royal College of Obstetricians and Gynaecologists RCT randomized controlled trial RHR Department of Reproductive Health and Research (at WHO) RMC respectful maternity care RR risk ratio SMD standardized mean difference TWG (...) of recommendation Third stage of labour Prophylactic uterotonics 41. The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births. a 42. Oxytocin (10 IU, IM/IV) is the recommended uterotonic drug for the prevention of postpartum haemorrhage (PPH). a 43. In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate, ergometrine/ methylergometrine, or the fixed drug combination of oxytocin

2018 World Health Organisation Guidelines

98. Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section

canal injury was reported in 1 woman and 5 women respectively in the DBC and prostaglandin gel groups (p=0.10) in the RCT of 126 pregnant women. 5.7 Intrapartum fever was reported in 8 and 2 women respectively in the DBC and SBC groups (p=0.10) in the RCT of 302 pregnant women comparing DBC (n=148) against SBC (n=145). 5.8 Postpartum endometritis after caesarean section occurred in 1 woman in the DBC plus oral misoprostol group (n=59) and in no women in the oral misoprostol alone group (n=63 (...) arterial pH: prostaglandin gel group 7.25, DBC group 7.26, SBC group 7.26; a single p value of 0.05 was cited) in an RCT of 330 nulliparous pregnant women. 5.5 There was no statistically significant difference in the incidence of postpartum haemorrhage (that is, more than 1000 ml blood loss) between the DBC, SBC and prostaglandin gel groups (DBC 5% [5/107], SBC 5% [5/110], prostaglandin gel group 11% [12/113]; a single p value of 0.143 was cited) in the RCT of 330 nulliparous pregnant women. 5.6 Birth

2015 National Institute for Health and Clinical Excellence - Interventional Procedures

99. Postplacental insertion of intrauterine devices

%). This risk was not greater than the risk of insertionmorethan6monthsafterdelivery[28]. Infection Risk of infection after postplacental insertion is low, and randomized trials have not demonstrated a difference in infectionbasedoninsertiontiming[25,29–31].Welkovicet al. assessed infection at 10 days postpartum in 145 women who chose a postplacental CuT380A after vaginal delivery and 157 who did not choose an IUD. They found no difference in clinical signs of endometritis between IUD acceptorsandnon (...) 2), for use in any postpartum time frame, regardlessofbreastfeedingstatusandmodeofdelivery[20]. Almost all research involving postplacental IUD insertion excludedwomenwithriskfactors for postpartum infection, including rupture of membranes more than 18–24hbefore delivery or chorioamnionitis prior to delivery, so safety of placement in these situations has not been demonstrated. Clinicaljudgmentshouldbeusedtoassessriskofpostpartum endometritis. In addition, many studies have excluded women

2017 Society of Family Planning

100. Early pregnancy loss

antibiotic prophylaxis prior to surgery 53 o Consider based on individual clinical indications (e.g. endometritis) • If clinically indicated, consider USS at time of suction curettage Follow-up • Refer to Section 1.2 for information/advice requirements • Advise GP follow-up if ongoing clinical concerns • ß-hCG not routinely indicated • USS not routinely recommended Repeat curettage • If repeat curettage is required (experienced operator required): o Consider initial hysteroscopy to facilitate uterine

2017 Queensland Health

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