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To estimate the association between timing of administration of adjunctive azithromycin for prophylaxis at unscheduled cesarean delivery and maternal infection and neonatal morbidity.We conducted a secondary analysis of a randomized trial of adjunctive azithromycin prophylaxis in patients with singleton gestations who were undergoing unscheduled cesarean delivery. The primary exposure was the timing of initiation of the study drug (after skin incision or 0-30 minutes, more than 30-60 minutes, or more than 60 minutes before skin incision). The primary outcome was a composite of endometritis, wound infection, and other maternal infections occurring up to 6 weeks after cesarean delivery. Secondary outcomes included composite neonatal morbidity, neonatal intensive care unit admission for longer than 72 hours, and neonatal sepsis. The association of azithromycin with outcomes was compared within each antibiotic timing group and presented as risk ratios (RRs) with 95% CIs. A Breslow-Day homogeneity test was applied to assess differences in association by antibiotic timing.Of 2,013 participants, antibiotics were initiated after skin incision (median 3 minutes, range 0-229 minutes) in 269 (13.4%), 0-30 minutes before skin incision in 1,378 (68.5%), more than 30-60 minutes before skin incision in 270 (13.4%), and more than 60 minutes before skin incision (median 85 minutes, range 61-218 minutes) in 96 (4.8%). The RRs (95% CIs) of the infectious composite outcome for azithromycin compared with placebo were significantly lower for groups that initiated azithromycin after skin incision or within 1 hour before skin incision (after skin incision: RR 0.31, 95% CI 0.13-0.76; 0-30 minutes before: RR 0.62, 95% CI 0.44-0.89; more than 30-60 minutes before: 0.31, 95% CI 0.13-0.66). Risks were not significantly different in patients who received azithromycin more than 60 minutes before skin incision (RR 0.59, 95% CI 0.10-3.36). Results were similar when endometritis and wound infections were analyzed separately. Neonatal outcomes were not significantly different for azithromycin compared with placebo across all timing groups.Adjunctive azithromycin administration up to 60 minutes before or at a median of 3 minutes after skin incision was associated with reduced risks of maternal composite postoperative infection in unscheduled cesarean deliveries.ClinicalTrials.gov, NCT01235546.

Objectives: To identify characteristics associated with spontaneous labor onset in pregnant patients undergoing expectant management at greater than 39 weeks’ gestation and delineate perinatal outcomes associated with spontaneous labor compared with labor induction. Study design: This was a retrospective cohort study of singleton pregnancies ≥390/7 weeks gestation delivered at a single center in 2013. Exclusion criteria were elective induction, cesarean delivery or presence of a medical indication for delivery at 39weeks, more than one prior cesarean delivery, fetal anomaly or demise. We evaluated prenatally available maternal characteristics as potential predictors of the primary outcome-spontaneous labor onset. Multivariable logistic regression was used to generate two parsimonious models – one with and one without third trimester cervical dilation. We also performed sensitivity analysis by parity and timing of cervical examination, and compared mode of delivery and other secondary outcomes between patients who spontaneous labored and those who did not. Results: Of 707 eligible patients, 536(75.8%) attained spontaneous labor and 171(24.2%) did not. In the first model, maternal BMI, parity and substance use were identified as the most predictive factors. Overall, the model did not predict spontaneous labor(AUC 0.65, 95% CI 0.61-0.70) with high accuracy. The addition of third trimester cervical dilation in the second model did not significantly improve labor prediction(AUC 0.66, 95% CI: 0.61-0.70; p=0.76). These results did not differ by timing of cervical examination or parity. Patients admitted in spontaneous labor had lower odds of cesarean delivery(OR 0.33, 95% CI 0.21-0.53) and NICU admission(OR 0.38, 95% CI 0.15-0.94). Other perinatal outcomes were similar between groups. Conclusions : Maternal characteristics did not predict spontaneous labor onset ≥39 weeks’ gestation with high accuracy. Patients should be counseled on challenges of labor prediction regardless of parity and cervical examination, outcomes if spontaneous labor does not occur and benefits of elective labor induction discussed.

Background We conducted a cross-sectional study of pregnant women with acute respiratory illness during delivery hospitalizations during influenza season to describe clinical testing for respiratory viruses and infection prevention practices. Methods Women had nasal swabs tested for influenza and other respiratory viruses. Among 91 enrolled women, 22 (24%) had clinical testing for influenza. Results Based on clinical and study testing combined, 41 of 91 (45%) women had samples positive for respiratory viruses. The most common virus was influenza (17 of 91, 19%); 53% (9 of 17) of influenza virus infections were identified through study testing alone. Only 16% of women were on droplet precautions. Conclusions Peripartum respiratory infections may be underrecognized.

The prevalence of opioid use disorder and medication-assisted treatment in pregnancy is increasing. Compared with term infants, preterm infants have a lower incidence of neonatal opioid withdrawal syndrome. It is unknown whether early term delivery compared with full or late-term delivery decreases the risk of neonatal opioid withdrawal syndrome.This study aimed to compare the neonatal outcomes among opioid-exposed infants born in the early, full, and late-term periods.This was a retrospective cohort study of opioid-exposed pregnancies delivering at a single center from 2010 to 2017 at ≥37 weeks gestation. Participants with multiple gestations or fetal anomalies were excluded. Maternal opioid exposure was defined as prescription (including medication-assisted treatment) or nonprescription opioid use or a positive urine drug screen in pregnancy for opiates. The primary outcome was a neonatal composite of respiratory distress syndrome, neonatal sepsis, neonatal seizures, hypoxic ischemic encephalopathy, jaundice requiring treatment, 5-minute Apgar5, neonatal intensive care unit admission, neonatal opioid withdrawal syndrome, or neonatal death. The secondary outcomes included individual components of the primary outcome, birthweight, need for and length of neonatal opioid withdrawal syndrome treatment, length of hospital admission, and maximum Finnegan scores. Early (37-39), full (39-41), and late (41-42 weeks) term groups were defined by the American College of Obstetricians and Gynecologists.Of 399 infants, 136 (34.1%), 229 (57.4%), and 34 (8.5%) were born in the early, full, and late-term periods, respectively. Two hundred and seventy patients (67.7%) received medication-assisted treatment for opioid use disorder, and the baseline characteristics were similar in all the groups except for history of intranasal heroin use, positive urine toxicology screen for heroin or any opiates, and delivery indication (P.05). The primary composite outcome occurred in 313 (78.4%) neonates, and 296 (74.2%) neonates had neonatal opioid withdrawal syndrome. More than half (219 [54.9%]) of opioid-exposed neonates were admitted to the neonatal intensive care unit, and 160 (40.1%) required pharmacologic neonatal opioid withdrawal syndrome treatment for a mean duration of almost 3 weeks (19.0±16.1 days). There were no significant differences in the primary composite outcome, incidence of neonatal opioid withdrawal syndrome, or other secondary outcomes (except birthweight) between neonates born in the early, full, or late-term periods.Although neonatal morbidity was frequent among opioid-exposed neonates, the incidence and severity of neonatal opioid withdrawal syndrome or other neonatal outcomes were not different between neonates delivered in the early, full, and late-term periods, suggesting that opioid-exposed infants may not benefit from early term delivery.

Introduction: Chronic hyperglycaemia is associated with subfertility and infertility in male diabetic subjects, possible as a result of perturbed testicular antioxidant defence system. Recent evidence however shows that some testicular cells produce insulin and this raises the possibility of a role for this hormone in spermatogenesis. Moreover, isoforms of the nuclear peroxisome proliferator activated receptor (PPAR) have been detected in testicular tissue, suggesting a role for insulin sensitization in testicular function. Materials and Methods: In this study, we report the ameliorative effects of the PPAR γ agonist pioglitazone on testicular morphologic aberrations and impaired semen profile induced by diabetes in rats treated with intraperitoneal alloxan (150 mg/kg). Diabetic rats were randomly assigned to receive oral pioglitazone at 10 or 30 mg/kg once daily for 6 weeks. Weekly blood glucose measurement using the glucometer showed weak effect of pioglitazone on hyperglycaemia in our model. Results: Nonetheless, findings from caudal epididymal sperm analysis showed significantly high sperm density in the pioglitazone-treated rats at the two doses tested (P < 0.05 compared with diabetic controls). Moreover, pioglitazone at 10 mg/kg improved sperm motility and lowered the percentages of deformed and dead sperm cells in the treated diabetic rats. Haematoxylin and eosin (H&E) sections of the testes showed signiicantly reduced seminiferous tubule diameter and lumen size, as well as diminished height of the germinal epithelium in the untreated diabetic rats, but not in rats on pioglitazone intervention. Furthermore, Gordon and Sweet section of the testes showed thickened interstitial compartment only in the untreated diabetic group. Meanwhile, interstitial cells of Leydig appeared undisturbed in testicular sections of all the groups, while intratesticular testosterone levels measured by the enzyme immunoassay technique were not significantly different between the treated and control rats (P > 0.05). These findings show that increased sensitization of testicular cells to insulin signalling mediated by the PPAR γ agonist pioglitazone restores testicular histomorphometry and improves semen quality in diabetic rats, despite the weak effect of this drug on blood glucose. Conclusion: This suggests a role for insulin sensitizers and improved insulin signalling in the amelioration of testicular lesions and regulation of spermatogenesis in the diabetic state; and lends support for insulin at promoting testicular functions.

A systematic review of the literature was conducted to determine the estimates of and definitions for human papillomavirus (HPV) persistence in women following treatment of cervical intra-epithelial neoplasia (CIN). A total of 45 studies presented data on post-treatment HPV persistence among 6,106 women. Most studies assessed HPV persistence after loop excision (42%), followed by conization (7%), cryotherapy (11%), laser treatment (4%), interferon-alpha, therapeutic vaccination, and photodynamic therapy (2% each) and mixed treatment (38%). Baseline HPV testing was conducted before or at treatment for most studies (96%). Follow-up HPV testing ranged from 1.5 to 80 months after baseline. Median HPV persistence tended to decrease with increasing follow-up time, declining from 27% at 3 months after treatment to 21% at 6 months, 15% at 12 months, and 10% at 24 months. Post-treatment HPV persistence estimates varied widely and were influenced by patient age, HPV-type, detection method, treatment method, and minimum HPV post-treatment testing interval. Loop excision and conization appeared to outperform cryotherapy procedures in terms of their ability to clear HPV infection. This systematic review provides evidence for the substantial heterogeneity in post-treatment HPV DNA testing practices and persistence estimates.