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Objective To decrease the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the Mount Sinai Hospital's obstetric service, additional contact and respiratory precautions for patients and staff were implemented. Patients were allowed only one support person, SARS-CoV-2 tested on admission, and required to mask during hospitalization. Staff were required to wear masks and eye shields, gloves for all patient care, and gowns for care with SARS-CoV-2-infected patients. This study determined if the risk of endometritis/intra-amniotic infection (IAI) changed under the new pandemic precautions. Study Design A single-center, historical cohort study via electronic medical record review compared singleton deliveries among patients who labored during the "pandemic period" (from March 1 through May 31, 2020) with those who labored during the "prepandemic period" (March 1 through May 31, 2019) to determine if the risk of endometritis/IAI differed. The analysis was done using logistic regression with inverse probability of treatment weighting (IPTW) to adjust for possible differences in obstetric practice and patient population between the two periods. Results Four percent (53/1,318) of patients in the pandemic period and 5.1% (82/1,596) of patients in the prepandemic period were diagnosed with endometritis/IAI (p = 0.15). Compared with patients who delivered in the prepandemic period, those who delivered during the pandemic period had a higher body mass index at delivery (median: 28.36 [interquartile range, IQR: 25.70, 32.07] vs. 28.00 [IQR: 25.23, 31.50], p = 0.01) and experienced fewer digital exams (median: 4 [range: 1, 10] vs. 4 (range: 1, 19], p = 0.004), a practice not included in the SARS-CoV-2 prevention strategy. In multivariable logistic regression with IPTW adjusting for risk factors for endometritis/IAI, period of delivery was not associated with endometritis/IAI (odds ratio = 0.76, 95% confidence interval [0.52, 1.11], p = 0.15). Conclusion The use of respiratory and contact precautions to limit the spread of SARS-CoV-2 was not associated with risk of endometritis/IAI. Key Points Pandemic infection control precautions were not associated with a decrease in endometritis/IAIs. The early months of the pandemic were associated with the performance of fewer digital cervical exams. The early months of the pandemic were associated with a higher BMI at delivery. [ABSTRACT FROM AUTHOR]

Objective This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States. Study Design The 2000–2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association. Results An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection. Conclusion Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity. Key Points Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Endometritis and wound infection decreased over the study period. Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes. [ABSTRACT FROM AUTHOR]

Objective To evaluate whether use of both preoperative 2% chlorhexidine gluconate abdominal cloth and 4% chlorhexidine gluconate vaginal scrub is effective in reducing surgical site infections (SSIs) in patients undergoing cesarean delivery after labor. Study Design This is a single-center, randomized clinical trial in which patients were randomized 1:1 to receive 2% chlorhexidine gluconate cloth applied to the abdomen in addition to the application of 4% chlorhexidine gluconate vaginal scrub versus standard of care. The primary outcome was rate of SSIs, including endometritis, by 6 weeks postdelivery. The secondary outcomes were other wound complications (erythema at the operative site, skin separation, drainage, fever, hematoma, seroma) by 6 weeks postdelivery, hospital readmission for wound complications, and day of discharge after cesarean delivery. Results A total of 319 patients between September 2018 and February 2021 met eligibility criteria: 160 were randomized to the chlorhexidine gluconate abdominal cloth and vaginal scrub group and 159 were randomized to the standard of care group. The groups did not have significant differences in maternal demographic characteristics. Of the 302 (95%) individuals included in primary analysis, there was no statistically significant difference in SSI and endometritis rate by 6 weeks postdelivery (6.6% in chlorhexidine vs. 5.3% standard of care, p = 0.65). Secondary outcomes were also similar among the two groups. Conclusion The combination of preoperative 2% chlorhexidine gluconate abdominal cloth and 4% chlorhexidine gluconate vaginal scrub does not appear to reduce the risk of SSI with cesarean delivery after trial of labor when compared with standard of care. Key Points Preoperative chlorhexidine abdominal cloth/vaginal scrub does not decrease SSI in cesarean after labor. Preoperative chlorhexidine abdominal cloth/vaginal scrub does not decrease other wound complications in cesarean after labor. There was no difference in discharge day, 2-week or 6-week SSI rates. [ABSTRACT FROM AUTHOR]

Objective As body mass index increases, the risk of postpartum infections has been shown to increase. However, most studies lump women with a body mass index (BMI) of above 40 kg/m 2 together, making risk assessment for women in higher BMI categories challenging. The objective of this study was to evaluate the impact of extreme obesity on postpartum infectious morbidity and wound complications during the postpartum period. Study Design The present study is a secondary analysis of women who underwent cesarean delivery and had BMI ≥ 40 kg/m 2 in the Maternal-Fetal Medicine Units Cesarean Registry. The primary outcome was a composite of postpartum infectious morbidity including endometritis, wound infection, inpatient wound complication prior to discharge, and readmission due to wound complications. Appropriate statistics used to compare baseline demographics, pregnancy complications, and primary outcomes among women by increasing BMI groups (40–49.9, 50–59.9, 60–69.9, and >70 kg/m 2). Results Rates of postpartum infectious morbidity increased with BMI category (11.7% BMI: 50–59.9 kg/m 2 ; 13.7% BMI: 60–69.9 kg/m 2 ; and 21.9% BMI >70+ kg/m 2 ; p = 0.001). Readmission for wound complications also increased with BMI (3.1% for BMI: 50–59.9 kg/m 2 ; 6.2% for BMI: 60–69.9 kg/m 2 ; and 9.4% for BMI >70+ kg/m 2 ; p = 0.001). After adjusting for confounders, increased BMI of 70+ kg/m 2 category remained the most significant predictor of postpartum infectious complications compared with women with BMI of 40 to 49.9 kg/m 2 (adjusted odds ratio [aOR] = 6.38; 95% confidence interval [CI]: 1.37–29.7). The adjusted odds of readmission also increased with BMI (aOR = 2.33, 95% CI: 1.35–4.02 for BMI 50–59.9 kg/m 2 ; aOR = 4.91, 95% CI: 2.07–11.7 for BMI of 60–69.9 kg/m 2 ; and aOR = 36.2, 95% CI: 7.45–176 for BMI >70 kg/m 2). Conclusion Women with BMI 50 to 70+ kg/m 2 are at an increased risk of postpartum wound infections and complications compared with women with BMI 40 to 49.9 kg/m 2. These data provide increased guidance for counseling women with an extremely elevated BMI and highlight the importance of postpartum wound prevention bundles. Key Points Women with super obesity have higher rates of wound complications. Women at extremes of obesity experience worse postpartum infectious morbidity. More research is needed on effective strategies to minimize morbidity in this population. [ABSTRACT FROM AUTHOR]

Objective Urinary tract infections are among the most common infections during pregnancy. The association between symptomatic lower urinary tract infections during pregnancy and fetal and maternal complications such as preterm birth and low birthweight remains unclear. The aim of this research is to evaluate the association between urinary tract infections during pregnancy and maternal and neonatal outcomes, especially preterm birth. Study Design This study is a secondary analysis of a multicenter prospective cohort study, which included patients between October 2011 and June 2013. The population consists of women with low risk singleton pregnancies. We divided the cohort into women with and without a symptomatic lower urinary tract infection after 20 weeks of gestation. Baseline characteristics and maternal and neonatal outcomes were compared between the two groups. Multivariable logistic regression analysis was used to correct for confounders. The main outcome was spontaneous preterm birth at <37 weeks. Results We identified 4,918 pregnant women eligible for enrollment, of whom 9.4% had a symptomatic lower urinary tract infection during their pregnancy. Women with symptomatic lower urinary tract infections were at increased risk for both preterm birth in general (12 vs. 5.1%, adjusted OR 2.5; 95% CI 1.7–3.5) as well as a spontaneous preterm birth at <37 weeks (8.2 vs. 3.7%, adjusted OR 2.3; 95% CI 1.5–3.5). This association was also present for early preterm birth at <34 weeks. Women with symptomatic lower urinary tract infections during pregnancy are also at increased risk of endometritis (8.9 vs. 1.8%, adjusted OR 5.3; 95% CI 1.4–20) and mastitis (7.8 vs. 1.8%, adjusted OR 4.0; 95% CI 1.6–10) postpartum. Conclusion Low risk women with symptomatic lower urinary tract infections during pregnancy are at increased risk of spontaneous preterm birth. In addition, an increased risk for endometritis and mastitis postpartum was found in women with symptomatic lower urinary tract infection during pregnancy. Key Points UTIs increase the risk of preterm birth. UTIs increase the risk of endometritis postpartum. UTIs increase the risk of mastitis postpartum. [ABSTRACT FROM AUTHOR]

Objective The aim of the study is to evaluate differences in maternal and neonatal outcomes based on updated criteria for defining active labor at 6 cm of cervical dilation and to determine if these recommendations are cost-effective. Study Design A decision-analytic model was built using TreeAge Pro 2020 software. We included maternal outcomes of mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and death. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. Costs and quality-adjusted life years (QALYs) were included from the maternal and infant perspectives. We used a willingness-to-pay threshold of $100,000 per QALY and all model inputs were subjected to sensitivity analysis. Results In a theoretical cohort of 1.4 million women, a threshold of 6 cm to define active labor resulted in 373,668 fewer cesarean deliveries, 33,181 fewer cases of endometritis, 143 fewer postpartum hemorrhages requiring transfusions, and seven fewer maternal deaths when compared with a threshold of 4 cm. However, there were higher rates of adverse neonatal outcomes, including 484 more cases of shoulder dystocia and 17 more instances of permanent brachial plexus injury. Using 6 cm as the threshold resulted in lower costs and greater effectiveness, making it a dominant strategy. Multivariate sensitivity analysis demonstrated the model was robust over a wide range of assumptions. Conclusion In this model, considering 6 cm of cervical dilation as the threshold for the active phase of labor compared with 4 cm was a cost-effective strategy to prevent primary cesarean deliveries, lower costs, and improve maternal outcomes, despite associated increased adverse neonatal outcomes. Key Pointsg Cervical dilation of 6 cm should be considered the threshold for the active phase of labor. This is a change from the prior definition of 4 cm. We built a theoretical model to compare outcomes and costs associated with the new active phase definition of 6 cm. Using a 6-cm threshold is a cost-effective strategy for decreasing primary cesarean deliveries. [ABSTRACT FROM AUTHOR]

Objective  We sought to characterize the incidence and risk factors associated with developing maternal morbidity following preterm prelabor rupture of membranes. Study Design  Retrospective case–control study of patients with preterm prelabor rupture of membranes at a single institution from 2013 to 2019 admitted at ≥23 weeks gestational age. The primary outcome was a composite of maternal morbidity which included: death, sepsis, intensive care unit (ICU) admission, acute kidney injury, postpartum dilation and curettage, postpartum hysterectomy, venous thromboembolism, postpartum hemorrhage, postpartum wound complication, postpartum endometritis, pelvic abscess, postpartum pneumonia, readmission, and/or need for blood transfusion were compared with patients without above morbidities. Severe morbidity was defined as: death, ICU admission, venous thromboembolism, acute kidney injury, postpartum hysterectomy, sepsis, and/or transfusion >2 units. Demographics, antenatal, and delivery characteristics were compared between patients with and without maternal morbidity. Bivariate statistics and regression models were used to compare outcomes and calculate adjusted odd ratios. Results  Of 361 included patients, 64 patients (17.7%) experienced maternal morbidity and nine (2.5%) had severe morbidity. Patients who experienced maternal morbidity were significantly (p  < 0.05) more likely to be older, have private insurance, have BMI ≥40, have chorioamnionitis at delivery, and undergo cesarean or operative vaginal delivery when compared with patients who did not experience morbidity. After controlling for confounders, cesarean delivery (aOR 2.38, 95% CI[1.30,4.39]), body mass index ≥40 at admission (aOR 2.54, 95% CI[1.12,5.79]), private insurance (aOR 3.08, 95% CI[1.54,6.16]), and tobacco use (aOR 3.43, 95% CI[1.58,7.48]) were associated with increased odds of maternal morbidity. Conclusion  In this cohort, maternal morbidity occurred in 17.7% of patients with preterm prelabor rupture of membranes. Private insurance, body mass index ≥40, tobacco use, and cesarean delivery were associated with higher odds of morbidity. These data can be used in counseling and to advocate for smoking cessation. Key Points 17.7% of patients with PPROM experienced maternal morbidity. BMI ≥40 was associated with higher odds of maternal morbidity. Tobacco use and cesarean delivery were associated with higher odds of maternal morbidity. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to assess whether colonization with group B streptococcus (GBS) is associated with maternal peripartum infection in an era of routine prophylaxis. Study Design  This study presented a secondary analysis of women delivering ≥37 weeks who underwent a trial of labor from the U.S. Consortium on Safe Labor (CSL) study. The exposure was maternal GBS colonization and the outcome was a diagnosis of chorioamnionitis, and secondarily, analyses were restricted to deliveries not admitted in labor and measures of postpartum infection (postpartum fever, endometritis, and surgical site infection). Logistic regression with generalized estimating equations was used accounting for within-woman correlations. Models adjusted for maternal age, parity, race, prepregnancy body mass index, pregestational diabetes, insurance status, study site/region, year of delivery, number of vaginal exams from admission to delivery, and time (in hours) from admission to delivery. Results  Among 170,804 assessed women, 33,877 (19.8%) were colonized with GBS and 5,172 (3.0%) were diagnosed with chorioamnionitis. While the frequency of GBS colonization did not vary by chorioamnionitis status (3.0% in both groups), in multivariable analyses, GBS colonization was associated with slightly lower odds of chorioamnionitis (adjusted odds ratio [AOR]: 0.89; 95% confidence interval [CI]: 0.83–0.96). In secondary analyses, this association held regardless of spontaneous labor on admission; and the odds of postpartum infectious outcomes were not higher with GBS colonization. Conclusion  In contrast to historical data, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis. Key Points Data in an era prior to routine group B streptococcus (GBS) screening and prophylaxis showed that maternal GBS colonization was associated with a higher frequency of maternal peripartum infection. In the current study, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis. The results highlight potential benefits of GBS screening and intrapartum antibiotic prophylaxis beyond neonatal disease prevention, including mitigating the risk of maternal infectious morbidity. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to examine the rates of intraamniotic infection between intrauterine pressure catheter with amnioinfusion and intrauterine pressure catheter alone. Study Design  This was a retrospective cohort study of all women who had an intrauterine pressure catheter placement during labor at a tertiary referral hospital from January 2016 to June 2018. Outcomes were compared between women who had an intrauterine pressure catheter with amnioinfusion and intrauterine pressure catheter placement alone. The primary outcome was the rate of intraamniotic infection. Secondary outcomes included postpartum endometritis, postpartum hemorrhage (blood loss of ≥1,000 mL), quantitative blood loss (mL), and cesarean delivery. Multivariable logistic regression analysis was performed to calculate adjusted odds ratios (aOR) and 95% confidence interval (95% CI), controlling for age, race, body mass index, gestational age, and length of time of rupture of membranes. Results  Of 1,268 women with an intrauterine pressure catheter, 298 (23.5%) also had an amnioinfusion. Women who had amnioinfusion through an intrauterine pressure catheter compared with those who had intrauterine pressure catheter alone had similar rates of intraamniotic infection (5.4 vs. 8.0%, crude p  = 0.12, aOR 0.69; 95% CI 0.39–1.21), as well as secondary outcomes such as postpartum endometritis (3.0 vs. 2.5%, crude p  = 0.61, aOR 1.12; 95% CI 0.49–2.53), postpartum hemorrhage (16.1 vs. 15.8%, crude p  = 0.89, aOR 1.07; 95% CI 0.75–1.54), blood loss (479.5 vs. 500 mL, adjusted p  = 0.89), and cesarean delivery (40.6 vs. 43.1%, crude p  = 0.45, aOR 0.90; 95% CI 0.68–1.19). Conclusion  Amnioinfusion was not associated with increased odds of intraamniotic infection compared with intrauterine pressure catheter placement alone. Key Points Amnioinfusion involves instilling fluid into the amniotic cavity to relieve variable decelerations. Amnioinfusion is not associated with increased odds of chorioamnionitis compared to IUPC alone. Amnioinfusion is not associated with increased odds of PPH compared to IUPC placement alone. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to examine maternal outcomes of ongoing pregnancies complicated by fetal life-limiting conditions. Study design  This was a retrospective matched cohort study of women with a diagnosis of fetal life-limiting condition between 2010 and 2018 in a single academic center. Cases were matched to controls (women who had normal fetal anatomic survey) according to year of delivery, body mass index, and parity in a 1:4 ratio. Bivariable and multivariable analyses were performed to compare the prevalence of the primary composite outcome, which included any one of the following: preeclampsia, gestational diabetes, cesarean delivery, third and fourth degree laceration, postpartum hemorrhage, blood transfusion, endometritis or wound infection, maternal intensive care unit admission, hysterectomy and maternal death, between cases and controls. Results  During the study period, we found 101 cases that met inclusion criteria, matched to 404 controls. The rate of the composite maternal outcome did not differ between the two groups (39.6 vs. 38.9%, p  = 0.948). For individual outcomes, women with diagnosis of fetal life-limiting condition had higher rates of blood transfusion (2.0 vs. 0%, p  = 0.005) and longer length of the first stage of labor (median of 12 [6.8–22.0] hours vs. 6.6 [3.9–11.0] hours; p  < 0.001). In a multivariable analysis, first stage of labor continued to be longer by an average of 6.48 hours among women with a diagnosis of fetal life-limiting condition compared with controls. Conclusion  After controlling for confounding factors, except a longer first stage of labor, women diagnosed with fetal life-limiting conditions who continued the pregnancy did not have a higher rate of adverse maternal outcomes. Key Points The rates of ongoing pregnancies with fetal life-limiting conditions are increasing. Women with ongoing pregnancies with fetal life-limiting conditions had longer first stage of labor. The rest of the adverse maternal outcomes were not increased in this obstetric population. [ABSTRACT FROM AUTHOR]

Objective  Chorioamnionitis (CAM) is associated with postcesarean (CS) infectious morbidity (IM). Beta-lactam antibiotics (BLA) are used to treat CAM. It is uncertain if women who cannot receive BLA attain similar benefit from treatment of CAM with non-BLA. Study Design  Retrospective cohort of women with CAM is delivered by CS in the maternal-fetal medicine units CS registry. We compared IM in women who received BLA versus women who received non-BLA. The primary outcome was a composite of endometritis, wound complication, necrotizing fasciitis, septic pelvic thrombophlebitis, and pelvic abscess. Multivariable logistic regression estimated odds ratios for the association of non-BLA treatment with IM outcomes. Results  A total of 3,063 (93%) women received BLA, and 232 (7%) received non-BLA. Groups had similar rates of composite post-CS IM (10.6 vs. 12.1%, p  = 0.5). After adjusting for confounders, treatment of CAM with non-BLA was not associated with post-CS IM (adjusted odds ratio [AOR] 1.1, 95% confidence interval [CI] 0.6–1.7), endometritis (AOR 1.1, 95% CI 0.7–1.8), or wound complications (AOR 1.2, 95% CI 0.5–3.2). Conclusion  Women with CAM who receive non-BLA and require CS may not be at increased risk of postoperative infections complications, compared to women who receive BLA. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to develop a core outcome set of primary outcomes for studies involving cesarean deliveries with infectious morbidity outcomes. Study Design  Authors reported primary outcomes from 11 Cochrane systematic reviews (SRs), 12 other SRs, and 327 randomized controlled trials (RCTs). These outcomes were condensed into 20 primary outcome groups. Next, a modified Delphi technique was used to gain consensus on key outcomes. Authors from included SRs were sent a questionnaire consisting of a free response and multiple-choice questions. These data were used to propose a set of core outcomes. Results  The most frequent outcomes in RCTs were composite "infectious outcomes" (24%) with the second most common being endometritis (12%). The most common reported SR outcomes were wound infection (21%) and endometritis (16%). For the Delphi survey free response portion, wound infection (88%) and endometritis (79%) were the most commonly endorsed outcomes. Chosen list outcomes were maternal mortality (83%), wound infection (83%), wound complications (86%), and postpartum endometritis (80%). The proposed final core outcome set for cesarean trials was endometritis (primary outcome), maternal mortality, wound infection, wound complications, febrile morbidity, and neonatal morbidity. Conclusion  Utilizing defined core outcomes in all studies of cesarean section can harmonize trial reports and allow data synthesis for meta-analyses. [ABSTRACT FROM AUTHOR]

Objective  To estimate the incidence of and define risk factors for postpartum infectious complications after vaginal birth after cesarean (VBAC) complicated by chorioamnionitis. Study Design  A secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Unit Cesarean Registry was performed. The primary outcome was a composite of postpartum infection: endometritis, sepsis, pelvic abscess, urinary tract infection, necrotizing fasciitis, and septic pelvic thrombophlebitis. Peripartum predictors were compared using parametric and nonparametric tests, as appropriate, and multivariate predictors assessed using logistic regression. Results  A total of 559 subjects had chorioamnionitis in labor and a successful VBAC. Twenty-four (4.3%) subjects experienced the primary outcome, mainly due to endometritis (19/24). Significant factors included preterm delivery <32 weeks (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.32–7.06) and body mass index (BMI) ≥40 (OR: 4.63, 95% CI: 1.25–17.14). Receipt of postpartum antibiotics was protective against postpartum infection (OR: 0.28, 95% CI: 0.12–0.65). In multivariate analysis, preterm delivery <32 weeks, BMI ≥40, and receipt of postpartum antibiotics remained associated with postpartum infection. Conclusion  Nearly 5% of women with chorioamnionitis had a postpartum infectious complication after vaginal delivery, with higher rates in those delivering at <32 weeks and with prepregnancy BMI ≥40. Receipt of postpartum antibiotics decreased the odds of postpartum infection markedly. [ABSTRACT FROM AUTHOR]

Objective  To evaluate whether prophylactic antibiotics at the time of placement of an intrauterine balloon tamponade (IBT) is associated with a reduction in postpartum endometritis. Study Design  Retrospective cohort study of patients who received an IBT from January 1, 2012, to December 12, 2016. Patients were included if the IBT remained in place at least 2 hours and excluded if chorioamnionitis was present. Patients who received prophylactic antibiotics at the time of IBT placement were compared with those who did not. Results  A total of 149 subjects received an IBT; 36 were excluded due to early removal or chorioamnionitis. Of the remaining, 59 received prophylactic antibiotics and 54 did not. Baseline characteristics were similar between the groups except mode of delivery. The majority (65%) of those who did not receive prophylactic antibiotics had a cesarean delivery (p  = 0.03). The overall incidence of endometritis was 15%. The incidence of endometritis was greater among those patients who did not receive prophylactic antibiotics compared with those who did (5 vs. 26%; p  < 0.002; odds ratio [OR]: 6.53; 95% confidence interval [CI]: 1.76–24.25). This association remained after adjustment for mode of delivery and receiving group B Streptococcus antibiotics prior to delivery (adjusted OR: 5.9; 95% CI: 1.58–22.35). Conclusion  Prophylactic antibiotics were associated with a reduction in postpartum endometritis among patients receiving an IBT. [ABSTRACT FROM AUTHOR]

Objective  To explore whether the effect of azithromycin (AZI) on postcesarean infections varied by the presence/absence of genital mycoplasmataceae placental colonization. Study Design  This was a single-center substudy of multicenter double-blind C/SOAP (Cesarean Section Optimal Antibiotic Prophylaxis) trial of women randomized to AZI or placebo (+cefazolin) antibiotic prophylaxis at cesarean. Chorioamnion/placenta specimens were tested for genital mycoplasmataceae colonization by polymerase chain reaction. Primary outcome was a composite of endometritis, wound infection, or other infections up to 6 weeks postpartum. Analysis was intent-to-treat; logistic regression was used to evaluate interactions between treatment assignment (AZI/placebo) and the presence/absence of mycoplasmataceae and to quantify effects of AZI in analyses stratified by the presence/absence of these microorganisms. Results  Specimens from 613 women (303 AZI and 310 placebo) were evaluated. Baseline characteristics were similar between groups, and approximately 1/3 (30.3%) had mycoplasmataceae placental/chorioamnion colonization. There was no evidence of effect modification (p interaction  = 0.79) between treatment assignment and the presence/absence of organisms. Stratified analyses showed fewer events in the AZI group in the presence (odds ratio [OR]: 0.42; 95% confidence interval [CI]: 0.17–1.01) and absence (OR: 0.49; 95% CI: 0.24–1) of mycoplasmataceae. Results were similar with endometritis/wound infections and with ureaplasmas/mycoplasmas considered separately. Conclusion  The reduction in postcesarean infection with AZI does not vary based on the presence or absence of genital mycoplasmataceae placental colonization. [ABSTRACT FROM AUTHOR]

Objective  We sought to compare adverse maternal outcomes between women with and without a uterine extension at the time of cesarean. Study Design  We conducted a retrospective cohort study of women with and without a uterine extension during a primary low transverse cesarean of a full-term singleton gestation. The primary outcomes were (1) estimated blood loss (EBL) and (2) composite maternal morbidity (defined as ≥ 1 of the following: blood transfusion, endometritis, or readmission). Pearson's chi-square or Fisher's exact test was used to compare categorical data; Student's t -test or Mann–Whitney's U -tests was used for continuous data. Linear and logistic regressions were used to adjust for confounding factors. Results  There were 252 women included (126 with extension and 126 without an extension). Women with extensions had a higher EBL (1,038 vs. 832 mL, p  < 0.001) and higher rate of the composite maternal morbidity (19.1 vs. 5.6%, p  = 0.001). Additionally, women with extensions had an increased risk of postpartum hemorrhage ≥ 1 L (53.2 vs. 23.8%, p  < 0.001) and 1.5 L (12.7 vs. 0%, p  < 0.001) and were associated with prolonged length of hospital stay (29 vs. 17%, p  = 0.04). Conclusion  Uterine extensions are associated with adverse maternal outcomes including higher EBL and increase in maternal morbidity. [ABSTRACT FROM AUTHOR]

Objective  To evaluate outcomes with expectant management of preterm prelabor rupture of membranes (PROM) until 35 weeks versus immediate delivery at ≥34 weeks. Study Design  This was a multicenter retrospective cohort study of singletons with preterm PROM at >20 weeks from 2011 through 2017. Groups were defined as expectant management until 35 weeks versus immediate delivery at ≥34 weeks. Primary outcome was composite neonatal morbidity: need for respiratory support, culture positive neonatal sepsis, or antibiotic administration for >72 hours. Univariate and general estimating equation models were used with p  < 0.05 considered significant. Results  A total of 280 mother–infant dyads were included. There was no difference in composite neonatal outcome in pregnancies managed with expectant management compared with immediate delivery (43.4 vs. 37.5%; p  = 0.32). Those with expectant management had shorter length of neonatal intensive care unit (NICU) admission but higher rates of neonatal antibiotics for > 72 hours, endometritis, and histological chorioamnionitis. There were no cases of fetal demise, neonatal death, or maternal sepsis, and only three cases of neonatal sepsis. Conclusion  There is no difference in composite neonatal morbidity in pregnancies with preterm PROM managed with expectant management until 35 weeks as compared with immediate delivery at 34 weeks. Expectant management is associated with a decreased length of NICU admission but increased short-term infectious morbidity. [ABSTRACT FROM AUTHOR]

Objective  To determine if increasing predicted risk of cesarean was associated with longer labor length and increased morbidity among women undergoing induction with an unfavorable cervix. Study Design  Using a publically available database, we evaluated whether a previously validated prediction model for cesarean delivery after induction was associated with labor length, maternal morbidity (third-/fourth-degree lacerations, endometritis, blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and death), and neonatal morbidity (blood transfusion, encephalopathy, intraventricular hemorrhage, severe respiratory distress syndrome, necrotizing enterocolitis, and sepsis). Full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix (Bishop score ≤6 and dilation ≤2 cm) undergoing induction of labor were included. Results  A total of 8,466 women met the inclusion criteria. Each category increase in cesarean probability (<20, 20–39.9, 40–59.9, ≥60%) was associated with an increase in labor length (9.6, 10.8, 11.7, and 11.9 hours, respectively; p  < 0.001). With increasing predicted probability of cesarean there, was also a significant increase in maternal morbidity with each category (2.6, 4.7, 5.1, 6.1%; p  = 0.001) and increase in neonatal morbidity (0.9, 1.5, 2, 2.2%; p  = 0.002). Conclusion  Using a validated prediction model for cesarean delivery among women induced with an unfavorable cervix, increasing predicted probability of cesarean is associated with longer labor length and increased maternal and neonatal morbidity. [ABSTRACT FROM AUTHOR]

Objective  To assess whether prolonged induction of labor was associated with increased maternal or neonatal morbidity. Study Design  We performed a retrospective cohort study of women undergoing induction of labor at a single institution. We included women with singletons ≥ 36 weeks with initial cervical dilation ≤4 cm. Prolonged induction of labor was defined as lasting > 36 hours from the time of initial method to delivery. A 2-to-1 propensity score-matched analysis was performed between women with and those without prolonged induction of labor. Maternal outcomes were cesarean delivery, chorioamnionitis, endometritis, postpartum hemorrhage, severe perineal laceration, and length of postpartum admission. Neonatal outcomes included Apgar scores, umbilical artery pH, and neonatal intensive care admission. Results  Among 2,021 women, 407 (20.1%) had a prolonged induction. In unadjusted analyses, prolonged induction of labor was associated with increased cesarean delivery and chorioamnionitis. After 2-to-1 propensity score matching, there were 267 women with prolonged induction and 424 controls. Women with prolonged induction of labor had higher rates of cesarean delivery (35.6 vs. 16%, p  < 0.001), chorioamnionitis (14.2 vs. 4.7%, p  < 0.001), endometritis (6.4 vs. 1.9%, p  = 0.002), and postpartum hemorrhage (18.8 vs. 11.9%, p  = 0.008). There were no significant differences in neonatal outcomes. Conclusion  Overall length of induction impacts maternal outcome. [ABSTRACT FROM AUTHOR]

Objective  Given that recent consensus guidelines established to decrease cesarean delivery (CD) rates use 6 cm to define the onset of the active phase of labor, our objective was to evaluate maternal and neonatal outcomes after CD for the indication of arrest of dilation at 4 to 5 cm compared with ≥ 6 cm. Study Design  We performed a secondary analysis using data from the Maternal Fetal-Medicine Units Network Cesarean Registry. We included nulliparous women with term, singleton, vertex gestations who underwent primary CD for arrest of dilation. We compared those who reached a maximum cervical dilation of 4 to 5 cm with those of ≥6 cm. Our primary outcome was composite maternal morbidity that included chorioamnionitis, endometritis, transfusion, wound complication, operative injury, intensive care unit admission, or death. Results  Of the 73,257 women in the dataset, 5,681 met the inclusion criteria. After adjusting for confounders, there was no difference in composite maternal (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 0.94–1.52) or neonatal morbidity (aOR: 0.94; 95% CI: 0.79–1.10) between the groups. Conclusion  In this historical cohort, maternal and neonatal outcomes after CD for arrest of dilation ≥ 6 cm were comparable to those performed at 4 to 5 cm and support recent labor management guidelines. [ABSTRACT FROM AUTHOR]

Objective This article aims to compare the composite maternal and neonatal morbidities (CMM and CNM, respectively) between macrosomic (≥4,000 g) and nonmacrosomic (<4,000 g) newborns among women with diabetes mellitus (DM). Methods Maternal demographic and peripartum outcome data (N = 1,260) were collected from a retrospective cohort. CMM included chorioamnionitis/endometritis, wound infection, shoulder dystocia, eclampsia, pulmonary edema, admission for hypoglycemia, 3rd/4th degree perineal laceration, and death.CNMincluded 5-minute Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score of <4, neonatal intensive care unit (NICU) admission, respiratory distress syndrome, mechanical ventilation, intraventricular hemorrhage grade III/IV, necrotizing enterocolitis stage II/III, hypoglycemia, hypocalcemia, bronchopulmonary dysplasia, sepsis, seizures, hyperbilirubinemia, and death.Multivariable Poisson regression models with robust error variance were used to calculate adjusted relative risk (aRR) and 95% confidence interval (CI). Results The study population consisted of 967 subjects, including 854 (88.3%) nonmacrosomic and 113 (11.7%) macrosomic infants. After adjustment, the risk of CMMwas higher amongmacrosomic deliveries (aRR = 4.08, 95% CI = 2.45-6.80). The risk of CNM was also higher among macrosomic deliveries (aRR = 1.77, 95% CI = 1.39-2.24). Macrosomia was associated with an increased risk in NICU admission, hypoglycemia, and hyperbilirubinemia. Conclusion Among DM deliveries, macrosomia was associated with a fourfold higher risk of CMM and almost twofold higher risk of CNM. [ABSTRACT FROM AUTHOR]

Objective This study aims to estimate postcesarean infectious morbidity in women receiving perioperative β-lactam versus non-β-lactam antibiotics. Methods We conducted a retrospective cohort analysis of the Maternal-Fetal Medicine Unit Cesarean Registry. The exposure was β-lactam perioperative antibiotics versus non-β-lactam regimens at cesarean delivery (CD). We stratified by labored versus unlabored CD. The primary composite outcome included wound infection, seroma, hematoma, endometritis, readmission due to wound complication, or debridement. Multivariable logistic regression estimated odds of wound complication by antibiotic regimen after adjusting for relevant confounders. Results Our analysis included 43,735 women who delivered via CD, 48% following labor. In both groups, 95% of women received β-lactam antibiotics. In the labored CD group (n = 20,860), there was no significant difference in primary outcome by β-lactam versus non-β-lactam antibiotics (10.5 vs. 9.9%, p = 0.53). In the unlabored CD group (n = 22,875), women receiving non-β-lactam antibiotics were more likely to experience a wound complication compared with those in the β-lactam group (6.2 vs. 4.7%, p = 0.02, adjusted odds ratio: 1.39, 95% confidence interval: 1.08-1.80) after adjustment for clinical confounders. Conclusion In unlabored CD, non-β-lactam antibiotics have a higher risk of wound complications compared with β-lactam regimens. Further study to optimize antibiotic prophylaxis for β-lactam allergic women undergoing unlabored CD is warranted. [ABSTRACT FROM AUTHOR]

Objective To determine if postpartum antibiotics are necessary for patients with chorioamnionitis after a cesarean delivery (CD). Study Design Multicenter randomized controlled trial. Laboring patients with singleton gestations and chorioamnionitis who underwent CD were eligible. Patients were treated with ampicillin and gentamicin per standard protocol, then given clindamycin prior to skin incision. Patients were randomized to either postpartum antibiotic prophylaxis or no treatment following delivery. The primary outcome was the rate of endometritis. Assuming a 30% risk of endometritis in patients with chorioamnionitis who undergo CD, 119 patients per arm would be required to detect a 50% decrease in endometritis. Results The trial was stopped for futility following a planned interim analysis after 80 patients were randomized. There was no difference in the rate of the primary outcome between the two groups (9.8 vs. 7.7%, relative risk [RR]: 1.27; 95% confidence interval [CI]: 0.30, 5.31). Ameta-analysis comparing post-CD antibiotics versus no treatment did not find a statistically significant difference between the groups (16.7 vs. 12.0%, pooled RR: 1.43; 95% CI: 0.72, 2.84). Conclusion Additional postpartum antibiotics do not decrease the rate of endometritis in patients with chorioamnionitis who undergo CD. The current preoperative antibiotic regimen including clindamycin should remain the standard of care in these patients. [ABSTRACT FROM AUTHOR]