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Postpartum Endometritis

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101. WHO recommendations on maternal health

PERIPARTUM INFECTIONS NEW ¦ ¦ A simple regimen such as ampicillin and once-daily gentamicin is recommended as first- line antibiotics for the treatment of chorioamnionitis. (Conditional recommendation based on very low-quality evidence). Source ¦ ¦ A combination of clindamycin and gentamicin is recommended as first-line antibiotics for the treatment of postpartum endometritis. (Conditional recommendation based on very low- quality evidence). Source 12. HIV INFECTION DURING PREGNANCY HIV diagnosis (...) 14 Augmentation of labour 15 6. Prevention of postpartum haemorrhage 15 7. Postnatal care 16 8 . Health promotion for maternal and newborn health 19 Management of maternal conditions 22 9. Postpartum haemorrhage 22 10. Pre-eclampsia and eclampsia 23 11. Peripartum infections 24 12. HIV infection 24 13. Malaria 27 14. Tuberculosis 27iv Abbreviations AIDS acquired immunodeficiency syndrome ANC antenatal care ART antiretroviral therapy ARV antiretroviral AZT zidovudine CCT controlled cord traction

2017 World Health Organisation Guidelines

102. Vaginal cleansing before caesarean delivery reduces risk of infections

views on the research. Why was this study needed? A womb infection (postpartum endometritis) occurs after about 27% of caesarean deliveries. This is five to 20 times more common than after vaginal delivery. There are about 167,000 planned and emergency caesarean deliveries each year in English NHS hospitals. Womb infections are often caused by vaginal bacteria that migrate to the womb. These infections need prompt antibiotic treatment to avoid sepsis, complications of the reproductive system (...) Excellence; 2011 (updated 2012). Patient. . Leeds: Patient; 2017. The Maternal, Newborn and Infant Clinical Outcome Review Programme. . Oxford: The Maternal, Newborn and Infant Clinical Outcome Review Programme; 2016. WHO. . Geneva: World Health Organization; 2015. Why was this study needed? A womb infection (postpartum endometritis) occurs after about 27% of caesarean deliveries. This is five to 20 times more common than after vaginal delivery. There are about 167,000 planned and emergency caesarean

2019 NIHR Dissemination Centre

103. Induction of labour within 24 hours, if waters break at 37 weeks of pregnancy, can reduce womb infection

; 95% CI 0.61 to 0.85; four trials, 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 (...) was better at reducing the risk of maternal infection in the lining of the uterus (endometritis) and/or the fetal membranes (chorioamnionitis) or the need for caesarean section. Researchers also looked for stillbirths or complications for the baby recorded in the trials. For some outcomes, the quality of the evidence was downgraded to low due to a high risk of bias and large differences between the studies. However, the maternal infection and caesarean section outcomes are objective so we are moderately

2019 NIHR Dissemination Centre

105. 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

106. 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

107. Long-Acting Reversible Contraception: Implants and Intrauterine Devices

Category 1 (47). Immediate postpartum insertion is contraindicated for women in whom uterine infection (ie, peripartum chorioamnionitis, endometritis, or puerperal sepsis) or ongoing postpartum hemorrhage are diagnosed (US MEC Category 4) (47). Expulsion rates for immediate postpartum IUD insertion are higher than for interval or postabortion insertion, vary by study, and may be as high as 10–27% ( ). Differences in expulsion rates are similar with manual insertion versus use of ring forceps, but may (...) these contraceptive methods are made readily available (51). Adolescents aged 14–17 years who chose a LARC method were more likely to use the contraceptive implant (51). Contraceptive acceptability and continuation rates were studied in a group of 137 postpartum adolescents ( ). At 24 months, continuation rates were higher in contraceptive implant users compared with contraceptive injection and combined contraceptive pill users ( P <.001) (64). In another study of 116 adolescents, continuation rates

2017 American College of Obstetricians and Gynecologists

108. Approaches to Limit Intervention During Labor and Birth

hours; 95% had delivered by 94–107 hours after rupture of membranes ( ). A 2017 Cochrane review that compared immediate induction with expectant management did not find a difference in cesarean delivery or definite early-onset neonatal sepsis, but did find a decreased risk of chorioamnionitis or endometritis, or both (relative risk [RR], 0.49; 95% CI, 0.33–0.72), decreased risk of definite or probable early-onset neonatal sepsis (RR, 0.73; 95% CI, 0.58–0.92), and a decreased risk of neonatal (...) was restricted to high quality RCTs (RR, 1.07; 95% CI, 0.98–1.16.) (55). However, a recent large retrospective analysis found that delaying pushing by 60 minutes or more was associated with modest increases in cesarean delivery (adjusted odds ratio [AOR], 1.86; 95% CI, 1.63–2.12) and operative vaginal delivery (AOR, 1.26; 95% CI, 1.14–1.40), postpartum hemorrhage (AOR, 1.43; 95% CI, 1.05–1.95), and transfusion (AOR, 1.51; 95% CI, 1.04–2.17), but no increase in adverse neonatal outcomes ( ). The study design

2017 American College of Obstetricians and Gynecologists

109. Intrapartum Management of Intraamniotic Infection

and managed by obstetrician–gynecologists or other obstetric care providers will be noted among term patients in labor. Intraamniotic infection can be associated with acute neonatal morbidity, including neonatal pneumonia, meningitis, sepsis, and death. Maternal morbidity from intraamniotic infection also can be significant, and may include dysfunctional labor requiring increased intervention, postpartum uterine atony with hemorrhage, endometritis, peritonitis, sepsis, adult respiratory distress syndrome (...) –3.84) (13). It is nonetheless important to acknowledge that the overall absolute risk of cerebral palsy remains quite low (approximately 2 per 1,000 live births) ( ). Maternal morbidity from intraamniotic infection also can be significant, and may include dysfunctional labor requiring increased intervention, postpartum uterine atony with hemorrhage, endometritis, peritonitis, sepsis, adult respiratory distress syndrome and, rarely, death ( , ). Obstetric risk factors for intraamniotic infection

2017 American College of Obstetricians and Gynecologists

110. Vaginal cleansing before caesarean delivery reduces risk of infections

views on the research. Why was this study needed? A womb infection (postpartum endometritis) occurs after about 27% of caesarean deliveries. This is five to 20 times more common than after vaginal delivery. There are about 167,000 planned and emergency caesarean deliveries each year in English NHS hospitals. Womb infections are often caused by vaginal bacteria that migrate to the womb. These infections need prompt antibiotic treatment to avoid sepsis, complications of the reproductive system (...) Excellence; 2011 (updated 2012). Patient. . Leeds: Patient; 2017. The Maternal, Newborn and Infant Clinical Outcome Review Programme. . Oxford: The Maternal, Newborn and Infant Clinical Outcome Review Programme; 2016. WHO. . Geneva: World Health Organization; 2015. Why was this study needed? A womb infection (postpartum endometritis) occurs after about 27% of caesarean deliveries. This is five to 20 times more common than after vaginal delivery. There are about 167,000 planned and emergency caesarean

2018 NIHR Dissemination Centre

111. Induction of labour within 24 hours, if waters break at 37 weeks of pregnancy, can reduce womb infection

; 95% CI 0.61 to 0.85; four trials, 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 (...) was better at reducing the risk of maternal infection in the lining of the uterus (endometritis) and/or the fetal membranes (chorioamnionitis) or the need for caesarean section. Researchers also looked for stillbirths or complications for the baby recorded in the trials. For some outcomes, the quality of the evidence was downgraded to low due to a high risk of bias and large differences between the studies. However, the maternal infection and caesarean section outcomes are objective so we are moderately

2018 NIHR Dissemination Centre

112. WHO guidelines for the treatment of Neisseria gonorrhoeae

. Pharyngeal infections are mainly asymptomatic, but mild sore throat and pharyngitis may occur. In the majority of women with gonorrhoea, the lack of discernible symptoms results in unrecognized and untreated infections. Untreated infections usually resolve spontaneously but may lead to serious complications such as pelvic inflammatory disease, including endometritis, salpingitis and tubo-ovarian abscess, which can lead to ectopic pregnancy and infertility. Untreated urethral infection in men can lead

2016 World Health Organisation Guidelines

114. Prevalence, risk factors and molecular characterization of Chlamydia trachomatis in pregnant women from Córdoba, Argentina: A prospective study. (PubMed)

Prevalence, risk factors and molecular characterization of Chlamydia trachomatis in pregnant women from Córdoba, Argentina: A prospective study. Chlamydia trachomatis causes the most prevalent bacterial Sexual Transmitted Infection. In pregnant women, untreated chlamydial infections are associated with abortions, premature rupture of membranes, postpartum endometritis, low birth weight and transmission to the newborn. In Córdoba, Argentina, there is little knowledge about the prevalence

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2019 PLoS ONE

115. Antibiotic prophylaxis during the second and third trimester to reduce adverse pregnancy outcomes and morbidity. (PubMed)

pregnancy (RR 0.64; 95% CI 0.47 to 0.88 (one trial, 258 women)), but there was no reduction in the subgroup of pregnant women with previous preterm birth without BV during the pregnancy (RR 1.08; 95% CI 0.66 to 1.77 (two trials, 500 women)). A reduction in the risk of postpartum endometritis (RR 0.55; 95% CI 0.33 to 0.92 (one trial, 196 women)) was observed in high-risk pregnant women (women with a history of preterm birth, low birthweight, stillbirth or early perinatal death) and in all women (RR 0.53 (...) of bias was low, except that incomplete outcome data produced high risk of bias in some studies. The quality of the evidence using GRADE was assessed as low for preterm prelabour rupture of membranes, high for preterm delivery, moderate for postpartum endometritis, low for prelabour rupture of membranes, and very low for chorioamnionitis. Intrapartum fever needing treatment with antibiotics was not reported in any of the included studies.Antibiotic prophylaxis did not reduce the risk of preterm

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2015 Cochrane

116. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. (PubMed)

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries.To (...) determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 July 2014).We included randomized and quasi-randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean

2014 Cochrane

117. Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV). (PubMed)

Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV). The incidence of chorioamnionitis occurs in between eight and 12 women for every 1000 live births and 96% of cases of chorioamnionitis are due to ascending infection. Following spontaneous vaginal delivery, 1% to 4% of women develop postpartum endometritis. The incidence of neonatal sepsis is 0.5% to 1% of all infants born. Maternal vaginal bacteria are the main agents (...) authors independently assessed trial eligibility and quality, extracted and interpreted the data. A third review author analyzed and interpreted the data. The fourth author also interpreted the data.We included three studies (3012 participants). There was no evidence of an effect of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. Although the data suggest a trend in reducing postpartum endometritis, the difference was not statistically significant (three trials

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2014 Cochrane

118. Antibiotic regimens for management of intra-amniotic infection. (PubMed)

placebo after vaginal delivery showed no significant differences between groups in rates of treatment failure or postpartum endometritis. No significant differences were found in rates of neonatal death and postpartum endometritis when use of antibiotics was compared with no treatment. Four trials assessing two different dosages/regimens of gentamicin or dual-agent therapy versus triple-agent therapy, or comparing antibiotics, found no significant differences in most reported neonatal or maternal (...) in nearly 20% of term births and in 50% of preterm births. Women with chorioamnionitis have a two to three times higher risk for cesarean delivery and a three to four times greater risk for endomyometritis, wound infection, pelvic abscess, bacteremia, and postpartum hemorrhage.To assess the effects of administering antibiotic regimens for intra-amniotic infection on maternal and perinatal morbidity and mortality and on infection-related complications.We searched the Cochrane Pregnancy and Childbirth

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2014 Cochrane

119. Antibiotics for meconium-stained amniotic fluid in labour for preventing maternal and neonatal infections. (PubMed)

) and postpartum endometritis (RR 0.50, 95% CI 0.18 to 1.38). However, there was a significant decrease in the risk of chorioamnionitis (RR 0.36, 95% CI 0.21 to 0.62). No serious adverse effects were reported. Drug resistance, duration of mechanical ventilation and duration of admission to NICU/hospital were not reported. Most of the domains for risk of bias were at low risk of bias for one study and at unclear risk of bias for the other study. The quality of the evidence using GRADE was low for neonatal (...) sepsis, postpartum endometritis, and neonatal mortality and morbidity prior to discharge (Neonatal intensive care admissions) and of moderate quality for chorioamnionitis.Current evidence indicates that compared to placebo, antibiotics for MSAF in labour may reduce chorioamnionitis. There was no evidence that antibiotics could reduce postpartum endometritis, neonatal sepsis and NICU admission. This systematic review identifies the need for more well-designed, adequately powered RCTs to assess

2014 Cochrane

120. High-dose versus low-dose oxytocin infusion regimens for induction of labour at term. (PubMed)

0.84, 95% CI 0.23 to 3.12; two trials), postpartum haemorrhage (RR 1.08, 95% CI 0.87 to 1.34; five trials), or endometritis (RR 1.35, 95% CI 0.53 to 3.43; three trials). Removal of high bias studies reveals a significant reduction of induction to delivery interval (MD -1.94 hours, 95% CI -0.99 to -2.89 hours, 489 women). A significant increase in hyperstimulation without specifying fetal heart rate changes was found in the high-dose group (RR 1.86, 95% CI 1.55 to 2.25).No other secondary outcomes

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2014 Cochrane

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