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Objective: To determine whether prophylactic antibiotics reduce the frequency of postpartum endometritis after manual removal of the placenta., Methods: A retrospective cohort study was conducted using data for all women who underwent manual removal of the placenta after vaginal delivery at a tertiary medical center in Jerusalem, Israel, between January 1, 2010, and December 31, 2015. The study group comprised women who had not received prophylactic antibiotic treatment, whereas the control group comprised women who had received prophylactic antibiotic treatment. The primary outcome measure was the frequency of postpartum endometritis., Results: Of the 407 women included in the analysis, 7 (1.7%) developed postpartum endometritis. Six of the women with postpartum endometritis had received prophylactic treatment with antibiotics, whereas one woman had not (odds ratio 0.555, 95% confidence interval 0.065-4.630)., Conclusion: Prophylactic antibiotics before manual removal of the placenta did not decrease the odds of postpartum endometritis., (© 2017 International Federation of Gynecology and Obstetrics.)

A transient uterine inflammation post-breeding is a normal physiological reaction in the mare, and it is believed that the inflammatory response is necessary to eliminate bacteria and excess spermatozoa introduced into the uterine lumen. A tight balance between multiple pro- and anti-inflammatory factors is required for resolving the breeding-induced inflammation within 24-36 hr in the reproductively healthy mare, whereas a subpopulation of mares is susceptible to development of a persistent infection that can interfere with fertility. The aetiology of persistent endometritis can be either bacterial or semen-induced and both scenarios can threaten the establishment of pregnancy. Several factors associated with susceptibility to persistent endometritis have been identified including altered innate immune response in the early inflammatory process, reduced myometrial contractions and impaired opsonization; however, the pathogenesis to susceptibility has not been fully elucidated. Current research focuses on the initial hours of uterine inflammatory responses to semen and bacteria, and potential treatments to modify this altered innate immune response. An increased understanding of the mechanisms involved in the disease progression is necessary to improve the treatment and management of these mares. This review attempts to summarize the current knowledge of the uterine inflammatory and immunological responses to breeding-induced endometritis, persistent breeding-induced endometritis (PBIE) and bacterial endometritis in the mare., (© 2017 Blackwell Verlag GmbH.)

Purpose: The purpose of this study was to perform a meta-analysis comparing the rates of uterine rupture, and other maternal and neonatal complications, between women who undergo a trial of labour (TOL) after a prior Cesarean delivery and those to undergo elective repeat Cesarean delivery (ERCD)., Source: Medline, Cochrane, EMBASE and Google Scholar were searched until May 6, 2015 using the keywords/phrases: trial of labour, Cesarean section, elective, repeat, pregnancy and vaginal birth. Randomized controlled trials (RCTs), two-arm prospective studies, one-arm studies and retrospective studies were included. The primary outcome was uterine rupture., Principal Findings: Sixteen studies were included in the meta-analysis. TOL after prior Cesarean delivery was associated with higher odds of uterine rupture as compared with ERCD (Peto odds ratio [OR] = 4.685, 95% confidence interval [CI]: 3.077 to 7.133, p < 0.001). TOL was associated with a higher rate of endometritis, a lower rate of hysterectomy, and a lower rate of respiratory problems in newborns. There were no differences between the groups with respect to neonatal intensive care unit admissions, postpartum hemorrhage, thromboembolic disease, sepsis and neonatal mortality., Conclusions: TOL may be associated with a higher risk of uterine rupture and endometritis, but lower risk of hysterectomy and neonatal respiratory problems than ERCD.

Objective: To identify maternal clinical risk factors for postcesarean maternal infection in a randomized clinical trial of preincision extended-spectrum antibiotic prophylaxis., Methods: We conducted a planned secondary analysis of a randomized clinical trial. Patients were 24 weeks of gestation or greater and delivered by cesarean after a minimum of 4 hours of ruptured membranes or labor. All participants received standard preincision prophylaxis and were randomized to receive azithromycin or placebo. The primary outcome for this analysis is maternal infection: a composite outcome of endometritis, wound infection (superficial or deep), or other infections occurring up to 6 weeks postpartum. Maternal clinical characteristics associated with maternal infection, after controlling for azithromycin assignment, were identified. These maternal factors were included in a multivariable logistic regression model for maternal infection., Results: Of 2,013 patients, 1,019 were randomized to azithromycin. Overall, 177 (8.8%) had postcesarean maternal infection. In the final adjusted model, compared with the reference groups, women of black race-ethnicity, with a nontransverse uterine incision, with duration of membrane rupture greater than 6 hours, and surgery duration greater than 49 minutes, were associated higher odds of maternal infection (all with adjusted odds ratios [ORs] of approximately 2); azithromycin was associated with lower odds of maternal infection (adjusted OR 0.4, 95% confidence interval 0.3-0.6)., Conclusion: Despite preincision azithromycin-based extended-spectrum antibiotic prophylaxis, postcesarean maternal infection remains a significant source of morbidity. Recognition of risk factors may help guide innovative prevention strategies., Clinical Trial Registration: ClinicalTrials.gov, https://clinicaltrials.gov, NCT012235546.

Nitric oxide (NO) may have a role in persistent breeding-induced endometritis in mares through an inhibitory effect on uterine contractility. The objectives of this study were to test the effect of NO on spontaneous uterine contractility in-vitro and to evaluate whether this effect varied between the longitudinal and circular muscle layers of the uterus. Reproductive tracts were collected from eight euthanized non-pregnant mares (age 4-19 years; body weight 405-530 kg). Transrectal examination of the reproductive tract was performed before euthanasia to evaluate stage of the estrous cycle and presence of any apparent abnormality. After euthanasia, one uterine tissue sample was collected for histological evaluation and four full-thickness uterine tissue strips (10-12 mm × 2 mm), two parallel to each muscle layer, were excised for in-vitro contractility evaluation. Strips were suspended in tissue chambers containing Krebs-Henseleit solution, with continuous aeration (95% O 2 -5% CO 2 ; pH 7.4) at 37 °C. After equilibration, spontaneous contractility was recorded (pre-treatment) and strips excised in each direction were randomly allocated to each of two groups: 1) SNAP (S-nitroso-N-acetylpenicillamine, an NO donor); or 2) NAP (N-acetyl-d-penicillamine, vehicle and time-matched control). These were treated at 15 min intervals with increasing concentrations (10 -7  M to 10 -3  M) of SNAP and NAP, respectively. Contractility data was recorded throughout the experiment. An interaction effect of group-by-concentration was observed (P < 0.0001). The mean contractility after treatment with 10 -4  M and 10 -3  M SNAP were significantly lower than the pre-treatment contractility and the mean contractility after treatment with lower SNAP concentrations. In contrast, contractility did not change significantly in the NAP treated controls. The effect of treatment on uterine contractility was not influenced by age or weight of the mare, stage of estrous cycle, uterine histology grade, or muscle layer. Secondary findings included significant main effects of stage of estrous cycle (increased contractility in estrus compared to diestrus), uterine histology grade (decreased contractility in grade IIB compared to grade I) and age (decreased contractility in mares aged > 8 years compared to mares aged ≤ 8 years). In conclusion, results of this study indicate that NO has a dose-dependent inhibitory effect on spontaneous uterine contractility irrespective of the muscle layer in the mare., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Arterial embolisation (AE) plays a major role in current practice in the management of postpartum haemorrhage (PPH) that fails to respond to conservative treatment. While its benefit is well known, long-term outcomes of AE have been poorly investigated. The objective of this review is to assess its potential complications and long-term effects on the patients' quality of life., Methods: Using the terms "embolisation" and "postpartum haemorrhage", we searched the Cochrane Central Register of Controlled Trials, Medline and PubMed for published studies. We limited the search to articles in English and French reporting "complications", "fertility", "menstruation" or "menstrual cycle" in humans. To ensure completeness, the references of extracted articles and review articles were also searched., Results: The fertility rate in patients attempting another pregnancy reaches 70-80 %. Pregnancies following AE for PPH are not associated with a higher rate of intrauterine growth restriction. Pathological placentation (placenta accreta/increta/percreta) occurs more frequently after AE than in the general population. Psychological wellbeing, post-traumatic stress and sexual dysfunction after a life-threatening PPH requiring AE will require further investigation., Conclusion: AE does not appear to adversely affect menstrual cycle, fertility and subsequent pregnancies, but may affect placentation. The experience of a life-threatening PPH, however, might prevent couples from pursuing another pregnancy., Key Points: • Embolisation for PPH does not adversely affect menstrual cycle and fertility • Experience of life-threatening PPH might prevent couples from pursuing another pregnancy • Pathological placentation seems to occur more frequently after embolisation for PPH.

Background: The objective of this study is to evaluate 'near miss' and mortality in women with postpartum infections., Methods: We performed a retrospective review of all patients referred to the University Teaching Hospital of Kigali (CHUK) between January 2012 and December 2013. We identified 117 patients with postpartum infections. Demographic data, length of admission, location of referral, initial surgery and subsequent treatment modalities including antibiotic administration and secondary surgery were recorded. The primary outcome of interest was a composite of maternal mortality and "near miss" defined as more than one laparotomy with/without hysterectomy and prolonged hospitalization., Results: Diagnoses at CHUK were: pelvic peritonitis (56 %), deep surgical site infection including fasciitis (17 %), and endometritis (15 %). The primary procedures performed prior to transfer were: cesarean section (81 %), septic abortion management (12 %), and vaginal delivery (7 %). Antibiotics were initiated prior to transfer in 66 % of women. Surgery was required in 73 % of patients. Hysterectomies were performed in 22 % of patients. Maternal death occurred in 5 % of the patient population. The primary outcome of severe maternal morbidity and mortality occurred in 90 patients (77 %)., Conclusion: Peritonitis-primarily as a result of cesarean deliveries-is associated with significant morbidity and mortality in our population.

The main objective was to evaluate the association between vulvovaginal laceration and uterine diseases in dairy cows. The secondary objectives were to evaluate the association between vulvovaginal laceration and cyclicity, and reproductive performance. The vulvovaginal region of 660 Holstein cows from a 5,000 lactating-cows herd was inspected at 4d in milk (DIM) for the presence of lacerations, and scored (VLS) as follows: 0=no laceration; 1=laceration <2cm at the dorsal commissure of the vulva or lateral walls of the vulva/vagina; 2=laceration ≥2cm at the dorsal commissure of the vulva or at the lateral walls of the vulva/vagina, or both. Vaginal discharge was scored at 4, 6, and 8 DIM for diagnosis of metritis, and then at 32 DIM for diagnosis of purulent vaginal discharge (PVD). Data were analyzed using LOGISTIC and PHREG procedures of SAS. Cows with VLS 2 had greater incidence of metritis than cows with VLS 0 (69.1 vs. 42.4%), and cows with VLS 1 tended to have greater incidence of metritis than cows with VLS 0 (52.0 vs. 42.4%). Cows with VLS 2 had greater incidence of PVD than cows with VLS 0 (56.5 vs. 43.1%). A lower proportion of cows with VLS 2 than VLS 0 were cyclic by 64 DIM (70.0 vs. 86.8%). A lower proportion of cows with VLS 2 than VLS 0 were pregnant at 60 d after first AI (28.7 vs. 33.6%). Proportion of pregnant cows at 60d after AI tended to be lower for VLS 1 than VLS 0 (28.4 vs. 33.6%). Hazard of pregnancy by 300 DIM was not affected by VLS. Hazard of pregnancy was decreased for cows with metritis, PVD, and anovular cows. In summary, vulvovaginal laceration was associated with uterine disease and cyclicity, which were negatively associated with reproductive performance. Vulvovaginal laceration was recognized as a risk factor for postpartum uterine disease., (Copyright © 2016 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Background: Prophylactic antibiotics are of proven value in decreasing the frequency of postcesarean endometritis. The beneficial effect of prophylaxis is enhanced when the antibiotics are administered before the surgical incision as opposed to after the clamping of the umbilical cord. However, the optimal antibiotic regimen for prophylaxis has not been established firmly., Objective: The purpose of this study was to compare 3 different antibiotic regimens for the prevention of postcesarean endometritis., Study Design: This retrospective historical cohort study was conducted at the University of Florida, which is a tertiary care facility that serves a predominantly indigent patient population. In the period January 2003 to December 2007, our standard prophylactic antibiotic regimen for all women who had cesarean delivery was cefazolin (1 g) administered immediately after the baby's umbilical cord was clamped. In November 2008, we began to administer the combined regimen of cefazolin (1 g intravenously) plus azithromycin (500 mg intravenously); both were given 30-60 minutes before the skin incision. In the period of January-December 2014, we continued the dual agent regimen but based the dose of cefazolin on the patient's body mass index: 2 g intravenously if the body mass index was <30 kg/m(2) and 3 g if the body mass index was >30 kg/m(2). The surgical technique was consistent throughout all 3 time periods. Our primary endpoint was the frequency of endometritis in each time period. This diagnosis was based on fever ≥37.5°C, lower abdominal pain and tenderness, the exclusion of other localizing signs of infection, and the requirement for administration of therapeutic antibiotics. In the first year after beginning the new antibiotic regimen, we also monitored the frequency of neonatal sepsis evaluations and compared it with the frequency that was recorded during the year immediately preceding the change in antibiotic regimens., Results: During the entire period 2003-2014, 29,633 women delivered at our institution; 6455 women (22%) had a cesarean delivery. In the period January 2003 to December 2007, 1034 women had a primary or repeat cesarean delivery. One hundred seventy women (16.4%; 95% confidence interval, 14.4-18.4%) developed endometritis. In the period November 2008 to December 2013, 4484 women had a primary or repeat cesarean delivery. Fifty-nine patients (1.3%; 95% confidence interval, 1.0-1.7%) developed endometritis (P < .0001 compared with period 1). In the year 2014, 937 women had a cesarean delivery; 22 of them (2.3%, 95% confidence interval, 1.3-3.3%) developed endometritis (P < .0001 compared with period 1 and P > .5 and <.10 compared with period 2). The frequency of evaluations for suspected neonatal sepsis in infants who were delivered to mothers who had cesarean delivery was 17.6% in the period January to December 2007 and 19.3% in the period November 2008 to November 2009 (relative risk, 1.1; 95% confidence interval, 0.7-1.9). One infant had proven sepsis in the former period; 2 infants had proven sepsis in the latter period (not significant)., Conclusions: When administered before skin incision, the combination of cefazolin plus azithromycin was significantly more effective in the prevention of endometritis than the administration of cefazolin after cord clamping; the rate of endometritis was reduced to a very low level without increasing the rate of neonatal sepsis evaluations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine the effectiveness and cost of antibiotic chemoprophylaxis in reducing infectious morbidity in low-risk women undergoing elective cesarean delivery., Methods: A prospective randomized clinical trial was performed at a single tertiary care center in Jinan, China between November 2012 and December 2013. Women were randomized to receive either antibiotic prophylaxis or no antibiotics prior to elective cesarean delivery at term. The infectious morbidity (fever, surgical site infection - SSI, endometritis and urinary tract infection), routine blood tests and hospital costs were measured., Results: Total of 414 women were enrolled into the study; and 202 women received antibiotic chemoprophylaxis and 212 women received no antibiotics. Demographic and clinical characteristics were similar between the two groups. Total of one case in the treatment group and four case in the non-treatment group developed endometritis, giving the postoperative infection rate of 1.2%, which was not statistically significant between the two groups (χ(2) = 1.679, p = 0.195). The secondary outcomes were also not different between the two groups, except the costs of hospitalization, which was significantly higher in the treatment group (p < 0.001)., Conclusions: In low-risk women undergoing elective cesarean delivery at term, prophylactic antibiotics did not reduce the risk of postoperative infection, but significantly increased the cost of hospitalization.

Mastitis-Metritis-Agalactia (MMA), also known as postpartum dysgalactia syndrome (PPDS) is the most important disease complex in sows after birth. The present study compared 30 MMA problem herds (over 12% of farrowing sows affected) with 30 control farms (less than 10% of farrowing sows affected) to identify risk factors and treatment incidence. Important risk factors identified were in gilts the integration into the herd after the first farrowing, in gestating sows firm fecal consistency as well as in lactating sows soiled troughs, a low flow rate (<2 liters per minute) in drinking nipples and a high prevalence of lameness. The treatment incidence was also significantly different between the two groups. The MMA prevalence could be reduced through optimization of husbandry, feeding and management, which could essentially diminish the use of antibiotics.

Objective: In women with multiple prior cesarean deliveries (CDs), vertical skin incisions are thought by some to result in better outcomes. The objective of this study was to compare maternal and neonatal outcomes according to the type of skin incisions among women with multiple prior CDs., Study Design: This was a secondary analysis of MFMU Cesarean Registry data. Women undergoing repeat CD with a viable singleton gestation and history of ≥2 prior CDs were included in this analysis. Women who had indications for urgent CD (e.g., cord prolapse) or suspected placenta accreta were excluded. Maternal and neonatal outcomes of women with 2, 3 and ≥4 prior CDs were compared by skin-incision type (transverse vs. vertical) using univariable and multivariable analyses., Results: 5007 women met the inclusion criteria. In univariable analysis, women with 2 prior CDs who had a vertical skin incision had shorter incision-to-delivery intervals (12.9 min vs. 14.1 min, p<0.001) but also higher rates of endometritis and composite adverse maternal outcomes (4.9% vs. 2.7%, p=0.001, 16.1% vs. 13.4%, p=0.026, respectively). Women with 3 prior CDs also had higher rates of composite adverse maternal outcomes (21.2% vs. 15.8%, p=0.042). In women with ≥4 prior CDs, prolonged hospitalization, composite adverse maternal outcomes, NICU admission and composite adverse neonatal outcomes also were higher with vertical skin incision (23.2% vs. 9.3%, p=0.005, 32.9% vs. 13.7%, p=0.001, 32.1% vs.19.6%, p=0.045, 32.9% vs.19.4%, p=0.024, respectively). In multivariable analyses, vertical skin incision remained associated with prolonged hospitalization and composite adverse maternal outcome among women with ≥4 prior CDs (aOR 3.40, CI 1.11-10.38, aOR=2.37, CI 1.02-5.55, respectively)., Conclusion: Vertical skin incision at the time of multiple repeat CD was not associated with better obstetric or perinatal outcomes and was associated among women with ≥4 prior CDs with a higher frequency of prolonged hospitalization and adverse maternal outcomes., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Cesarean section (CS) is one of the most common obstetric procedures worldwide and an increased rate of cesarean section has been observed in recent studies. Maternal and fetal mortality and morbidity associated with cesarean section is an important health problem worldwide. This requires the evaluation of the effect of repeated cesarean delivery on maternal morbidity., Material/methods: A total of 2460 patients who underwent delivery by CS at a center in southeast Turkey between January 2012 and January 2014 (24 months) were included in the study. The patients were divided into 5 groups according to the number of CSs, and the maternal and neonatal outcomes of the groups were retrospectively evaluated., Results: A statistically significant difference was found between the groups in terms of maternal age, education level, time of hospitalization, operating time, the presence of dense adhesions, bowel and bladder injury, the presence of placenta previa, hysterectomy, blood transfusion requirements, and need for intensive care (p<0.05). Placenta previa (OR, 11.7; 95% CI, 2.6-53.2) and placenta accreta (OR, 12.2; 95% CI, 3.9-37.8) were found to be important risk factors in terms of the need for hysterectomy. No statistically significant difference was found between the groups for gestational age at birth, birth weight, fifth-minute APGAR score, preoperative and postoperative hemoglobin levels, uterine rupture, wound infection, wound dehiscence, placenta accreta, maternal death, and endometritis (p>0.05). A total of 4 or more CSs was identified as the critical level for most of the major complications., Conclusions: An increasing number of CSs is accompanied by serious maternal complications. Four or more CSs are of especially critical importance. Decreasing the number of cesarean sections is required to decrease relevant complications. Vaginal birth after CS is an option that should be recommended to the patient.

Study Question: What is the prevalence of chronic endometritis (CE) in women with repeated unexplained implantation failure (RIF) at IVF, and how does antibiotic treatment affect the reproductive outcome?, Summary Answer: Chronic endometritis, associated with infection with common bacteria or mycoplasma, is common in women complaining of RIF and antibiotic treatment significantly improves the reproductive outcome at a subsequent IVF cycle., What Is Known Already: We have reported that CE is a frequent finding in women with repeated pregnancy loss and a significantly higher rate of successful pregnancies was achieved after adequate antibiotic treatment. Moreover, CE was identified in 30.3% of patients with repeated implantation failure at IVF and women diagnosed with CE had lower implantation rates (11.5%) after IVF cycles. In contrast, other authors reported that the clinical implication of CE should be considered minimal and that the reproductive outcome at IVF/ICSI cycles was not negatively affected by CE., Study Design, Size, Duration: A retrospective study was performed from January 2009 through June 2012 on 106 women with unexplained infertility and a history of RIF., Participants/materials, Setting, Methods: All patients underwent hysteroscopy and endometrial sampling for histology and microbiological investigations. Women diagnosed with CE underwent antibiotic treatment and the effect of treatment was confirmed by hysteroscopy with biopsy. Within 6 months after treatment all women had a further IVF attempt. The IVF outcomes were compared in women without signs of CE (Group 1) and persistent CE (Group 2) after antibiotic treatment. Clinical pregnancy rate (PR), and live birth rate (LBR) were compared at post-treatment IVF attempt., Main Results and the Role of Chance: Seventy (66.0%) women were diagnosed with CE at hysteroscopy. In 61 (57.5%) CE was confirmed by histology and 48 (45.0%) by cultures. Common bacteria and mycoplasma were the most prevalent agents. In 46 (75.4%) out of 61 women, with diagnosis of CE at hysteroscopy and histology, examinations were normal after appropriate antibiotic treatment control (Group 1) while in 15 (24.6%) cases signs of CE were still present (Group 2). At IVF attempt after treatment, a significantly higher PR and LBR was reported in women from Group 1 compared with women from Group 2 (65.2 versus 33.0% P = 0.039; 60.8 versus 13.3%, P = 0.02, respectively)., Limitations, Reasons for Caution: Possible biases related to retrospective studies and to preferential referral of patients with CE, and limited number of cases., Wider Implications of the Findings: A prospective randomized clinical trial is needed to confirm our findings but in women with RIF a hysteroscopic evaluation of the uterine cavity to exclude CE should be considered and appropriate antibiotic treatment should be given before submitting the patient to a further IVF attempt., (© The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Chorioamnionitis is a common infection that affects both mother and infant. Infant complications associated with chorioamnionitis include early neonatal sepsis, pneumonia, and meningitis. Chorioamnionitis can also result in maternal morbidity such as pelvic infection and septic shock.Clinical chorioamnionitis is estimated to occur in 1% to 2% of term births and in 5% to 10% of preterm births; histologic chorioamnionitis is found 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., Objectives: To assess the effects of administering antibiotic regimens for intra-amniotic infection on maternal and perinatal morbidity and mortality and on infection-related complications., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 October 2014), CENTRAL, MEDLINE, Embase, LILACS, and the WHO ICTRP (September 2014). We also searched reference lists of retrieved studies and contacted experts in the field., Selection Criteria: Randomized controlled trials (RCTs) that included women who experienced intra-amniotic infection. Trials were included if they compared antibiotic treatment with placebo or no treatment (if applicable), treatment with different antibiotic regimens, or timing of antibiotic therapy (intrapartum and/or postpartum). Therefore, this review assesses trials evaluating intrapartum antibiotics, intrapartum and postpartum antibiotic regimens, and postpartum antibiotics. Diagnosis of intra-amniotic infection was based on standard criteria (clinical/test), and no limit was placed on gestational age., Data Collection and Analysis: Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and checked them for accuracy. We assessed the quality of the evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach and included a 'Summary of findings' table., Main Results: Our prespecified primary outcomes were maternal and neonatal mortality, maternal and neonatal severe infection, and duration of maternal and neonatal hospital stay.We included 11 studies (involving 1296 women) and assessed them as having low to moderate risk of bias - mainly because allocation concealment methods were not adequately reported, most studies were open, and outcome reporting was incomplete. The quality of the evidence was low to very low for most outcomes, as per the GRADE approach. The following antibiotics were assessed in the included trials: ampicillin, ampicillin/sulbactam, gentamicin, clindamycin, and cefotetan. During labor: meta-analysis of two studies found no clear differences in rates of neonatal sepsis (163 neonates; risk ratio (RR) 1.07, 95% confidence interval (CI) 0.40 to 2.86; I² = 9%; low quality of evidence), treatment failure (endometritis) (163 participants; RR 0.86, 95% CI 0.27 to 2.70; I² = 0%; low quality of evidence), and postpartum hemorrhage (RR 1.39, 95% CI 0.76 to 2.56; I² = 0%; low quality of evidence) when two different dosages/regimens of gentamicin were assessed. No clear differences between groups were found for any reported maternal or neonatal outcomes. The review did not identify data for a comparison of antibiotics versus no treatment/placebo. Postpartum: meta-analysis of two studies that evaluated use of antibiotics versus 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 outcomes; the duration of hospital stay showed a difference in favor of the group of women who received short-duration antibiotics (one study, 292 women; mean difference (MD) -0.90 days, 95% CI -1.64 to -0.16; moderate quality of evidence). Intrapartum versus postpartum: one small study (45 women) evaluating use of ampicillin/gentamicin during intrapartum versus immediate postpartum treatment found significant differences favoring the intrapartum group in the mean number of days of maternal postpartum hospital stay (one trial, 45 women; MD -1.00 days, 95% CI -1.94 to - 0.06; very low quality of evidence) and the mean number of neonatal hospital stay days (one trial, 45 neonates; MD -1.90 days, 95% CI -3.91 to -0.49; very low quality of evidence). Although no significant differences were found in the rate of maternal bacteremia or early neonatal sepsis, for the outcome of neonatal pneumonia or sepsis we observed a significant difference favoring intrapartum treatment (one trial, 45 neonates; RR 0.06, 95% CI 0.00 to 0.95; very low quality of evidence)., Authors' Conclusions: This review included 11 studies (having low to moderate risk of bias). The quality of the evidence was low to very low for most outcomes, as per the GRADE approach. Only one outcome (duration of hospital stay) was considered to provide moderate quality of evidence when antibiotics (short duration) were compared with antibiotics (long duration) during postpartum management of intra-amniotic infection. Our main reasons for downgrading the quality of evidence were limitations in study design or execution (risk of bias), imprecision, and inconsistency of results.Currently, limited evidence is available to reveal the most appropriate antimicrobial regimen for the treatment of patients with intra-amniotic infection; whether antibiotics should be continued during the postpartum period; and which antibiotic regimen or what treatment duration should be used. Also, no evidence was found on adverse effects of the intervention (not reported in any of the included studies). One small RCT showed that use of antibiotics during the intrapartum period is superior to their use during the postpartum period in reducing the number of days of maternal and neonatal hospital stay.

Endometrosis is a degenerative chronic process, characterized by paramount fibrosis development in mare endometrium. This condition is one of the major causes of subfertility/infertility in mares. As in other organs, fibrosis might be a pathologic sequel of many chronic inflammatory diseases. However, aetiology and physiopathologic mechanisms involved in endometrial fibrosis are still controversial. This review presents new hypotheses based on our newest data. As the first line of innate immune defence, systemic neutrophils arrive in the uterus at mating or in the presence of pathogens. A novel paradigm is that neutrophils cast out their DNA in response to infectious stimuli and form neutrophil extracellular traps (NETs). We have shown that bacterial strains of Streptococcus zooepidemicus, Escherichia coli or Staphylococcus capitis, known to cause endometritis in mares were able to induce NETs release in vitro by equine PMN to different extents. An intriguing dilemma is the dual action of NETs. While NETs play a desirable role fighting micro-organisms in mare uterus, they may also contribute to endometrial fibrosis. A long-term in vitro exposure of mare endometrium explants to NETs components (myeloperoxidase, elastase and cathepsin G) up-regulated fibrosis markers TGFβ and Tissue inhibitor of metalloproteinase (TIMP-1). Also, pro-fibrotic cytokines regulated collagen deposition and fibrosis. Changes in expression of connective tissue growth factor (CTGF), interleukins (IL)1-α, IL-1β, IL-6 and receptors in endometrium with different degrees of fibrosis and/or inflammation were observed. A putative role of CTGF, IL and NETs components in endometrosis development should be considered. Additionally, we speculate that in sustained endometritis in mares, prostaglandins may not only cause early luteolysis or early pregnancy loss, but may also be related to endometrial fibrosis pathogenesis by stimulating collagen deposition., (© 2014 Blackwell Verlag GmbH.)

Objective: The objective of the study was to compare maternal and neonatal infectious morbidity following cesareans performed in the second and first stages of labor., Study Design: We conducted a retropective cohort study of all consecutive, singleton, term, cesarean deliveries in laboring women in a single institution from 2005 to 2012. Second-stage cesareans were defined as those performed at complete cervical dilation (10 cm), and first-stage cesareans were those performed before 10 cm cervical dilation. The primary outcome was endometritis. Rates of infectious morbidity were compared in the 2 groups. Multivariable logistic regression was used to calculate adjusted risk estimates., Results: Of 2505 cesareans meeting inclusion criteria, 400 (16.0%) were performed in the second stage, whereas 2105 (84.0%) were performed in the first stage of labor. The risk of endometritis was nearly 3-fold higher in second- compared with first-stage cesareans (4.25% vs 1.52%; crude odds ratio, 2.88; 95% confidence interval, 1.58-5.23). The risk remained significantly higher after controlling for confounders (adjusted odds ratio, 2.78; 95% confidence interval, 1.51-5.09)., Conclusion: Second-stage cesarean is associated with an increased risk of endometritis compared with first-stage cesarean. Further studies will determine whether different infection preventive strategies are needed at second-stage cesareans to reduce endometritis., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To estimate the association of obesity and extreme obesity with maternal complications after cesarean delivery., Methods: This was a secondary cohort analysis of a randomized controlled trial. The parent study was designed to estimate the effect of supplemental oxygen on postcesarean infectious morbidity. Because the study intervention had no effect, study groups were combined as a cohort. For this secondary analysis, the exposure was obesity, stratified as normal or overweight (body mass index [BMI] less than 30), obese (BMI 30-45), or extremely obese (BMI higher than 45). The primary outcome was a composite of wound infection and endometritis. Secondary outcomes included wound infection, endometritis, wound opening, hematoma or seroma, and emergency department visit. We performed unadjusted and multivariable logistic regression analyses. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported., Results: We included 585 women in the analysis. Eighty-five patients (14.5%) had BMIs higher than 45. Rates of black race, chronic hypertension, diabetes, and gestational diabetes increased and operative duration increased with increasing obesity severity. Obese patients were more likely to have a cesarean delivery after labor and have a vertical skin incision or classical uterine incision. After controlling for confounders, extremely obese patients had a twofold to fourfold increase in postoperative complications, including the primary infectious outcome (18.8%, adjusted OR 2.7, CI 1.2-6.1), wound infection (18.8%, adjusted OR 3.4, CI 1.4-8.0), and emergency department visit (23.1%, adjusted OR 2.2, CI 1.03-4.9)., Conclusion: Maternal extreme obesity is associated with a considerable increase in postcesarean wound complications., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00603603., Level of Evidence: II.

In the treatment of postpartum haemorrhage from uterine atony, uterine compression sutures, such as the B-Lynch suture and its modifications have a role with the advantage of preservation of the uterus for fertility. There is however, a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in undesirable complications. We undertook a five-year retrospective study of all women who underwent uterine compression sutures at the KK Women's and Children's Hospital, between 2008 and 2012. In total, 23 women had uterine compression sutures during the study period, of which, nineteen women managed to conserve their uterus. Our complication rate was 25%, which included persistent vaginal discharge, pyometra and endometritis. There were three conceptions, with two successful pregnancies. Our study shows uterine compression suture to be a safe and effective alternative to avoid hysterectomy with preservation of fertility at the time of major postpartum haemorrhage. The outcome of subsequent pregnancies is reassuring.

Introduction: Colouterine fistula is a very rare condition; most cases described in the literature are secondary to complications of diverticulitis in elderly patients., Case Presentation: We report the case of a 34-year-old African woman who presented with a colouterine fistula secondary to polymyomectomy, which was diagnosed in the setting of severe endometritis. She had a Hartmann procedure and abundant irrigation of her abdominal and uterine cavities followed by placement of a double drainage in order to preserve fertility. This is the first case of a conservative management of the uterus in such conditions., Conclusion: Conservative surgery in colouterine fistula should be discussed as an alternative to hysterectomy in young infertile women.

Uterine leiomyomas (fibroids) are the most common benign tumor of the female reproductive system. Fibroids can become symptomatic with symptoms such as menorrhagia and menometrorrhagia, pelvic pain, and reproductive dysfunction. Hysterectomy, myomectomy, and the less invasive uterine artery embolization are now commonly performed if conservative management of symptomatic fibroids fails. Moreover, uterine artery embolization (UAE) is the preferred minimally invasive procedure for the treatment of symptomatic fibroids. Major complications of UAE are extremely rare but well known. Additionally, there is a risk of undiagnosed uterine sarcoma found post embolization, which has been reported in literature during the past 12 years. Herein, we describe a case of an incidentally discovered uterine sarcoma in a premenopausal female after hysterectomy for post uterine artery embolization endometritis and sepsis.

Multiparous Holstein cows (n=60) were used to determine effects of supplementing hydroxy forms of Zn, Cu, and Mn compared with 2 other common supplementation strategies on oxidative metabolism, cytological endometritis, and performance of transition cows. After a 1-wk pretreatment period, cows were assigned randomly to 1 of 3 dietary treatments from 21 d before expected calving through 84 d postcalving. Dietary treatments administered by daily top-dressing included (1) inorganic sulfate forms of Zn, Cu, and Mn (ITM); (2) a blend (75:25) of sulfates and organic complexes of Zn, Cu, and Mn (ITM/OTM); and (3) hydroxy trace minerals (HTM) of Zn, Cu, and Mn. The resulting dietary concentrations of supplemental Zn, Cu, and Mn were similar among treatments and averaged 40, 10, and 27 mg/kg, respectively, before calving and 59, 15, and 40 mg/kg, respectively, after calving. Total concentrations of Zn, Cu, and Mn averaged 80, 16, and 62 mg/kg during the prepartum period and 102, 23, and 75 mg/kg, respectively, during the postpartum period. Overall, effects of treatment on milk yield and milk composition were not significant. Cows fed HTM during the prepartum period had higher body weight (BW) than those fed ITM during the prepartum period and had higher BW during the postpartum period than those fed the other treatments; however, BW change, body condition score, and body condition score change were not affected by treatment. Plasma total antioxidant capacity was lower in cows fed HTM than ITM but was not different from cows fed ITM/OTM. Cows fed HTM tended to have lower concentrations of plasma thiobarbituric acid reactive substances than those fed ITM during the whole study period, but plasma thiobarbituric acid reactive substances were not different between HTM and ITM/OTM. Plasma haptoglobin was lower in cows fed HTM than ITM/OTM at 1 wk postpartum. Endometrial cytology 7d postcalving and cytological endometritis as assessed on 1d between 40 and 60 d postcalving was not affected by treatment. In conclusion, supplementation with HTM sources of Zn, Cu, and Mn modulated plasma variables related to oxidative metabolism compared with supplementation with ITM; however, HTM and ITM/OTM resulted in similar responses. Furthermore, the source of trace minerals did not affect performance or uterine health in this experiment., (Copyright © 2014 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose was to determine the effect of the timing of prophylactic antibiotics for cesarean section on post-operative infectious complications., Study Design: This was a prospective, double-blinded, randomized controlled trial in which patients were randomized to receive cefazolin or clindamycin either before skin incision or after cord clamp. The primary outcome was maternal infectious morbidity at 6 weeks postpartum, a composite infectious outcome, which included endometritis, urinary tract infection, wound infection and pneumonia., Result: Data on 896 women were analyzed; 449 randomized to skin incision, 447 to cord clamp. Postpartum infections were seen in a total of 8.4% of patients. Timing of antibiotic administration did not significantly affect any maternal postpartum infection rates or selected neonatal outcomes., Conclusion: Our results suggest that, in a largely non-laboring population, the timing of prophylactic antibiotic administration does not impact post-operative infectious complications of the mother. Despite being one of the largest randomized controlled trials to address this question, our study still lacked sufficient power to make definitive conclusions.

Persistence of free fluid in the uterine lumen of bitches with endometrial hyperplasia appears to be diagnostic for mating-induced endometritis and is associated with reduced chances of pregnancy. This study investigated the possibility that reduced fertility might be associated with an effect of uterine fluid on sperm. Uterine lavage fluid was collected pre- and post-insemination from normal bitches without ultrasonographically-detectable luminal fluid (n=4), and previously non-pregnant bitches with endometrial hyperplasia and luminal fluid (n=4). Concentrations of polymorphonuclear neutrophils (PMNs) were measured and the effect of the fluid on the attachment of spermatozoa to the uterine epithelium was studied using medium (M) 199 as a control. To elucidate whether any effect was accounted for by the presence of PMNs, attachment was also measured in M199 with PMNs added at the concentration found in lavage fluid. Pre-insemination lavage fluid from both groups contained low concentrations of PMNs which increased post-insemination; the increase was larger for bitches with uterine fluid. Compared with M199 controls, lavage fluid reduced the attachment of spermatozoa; fluid from bitches with endometrial hyperplasia and uterine fluid had a greater effect than normal bitches, and post-insemination fluid had a greater effect than pre-insemination fluid. Spermatozoal attachment was reduced by a similar magnitude for M199 with added PMNs, although post-insemination fluid from bitches with endometrial hyperplasia reduced attachment more than M199 with added PMNs. Poor fertility in bitches with uterine luminal fluid might be partially associated with impaired attachment of spermatozoa to uterine epithelium, mediated principally, but not solely, by PMN influx into the uterine lumen., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The first objective of this study was to evaluate intrauterine nitric oxide (NO) and endometrial inducible NO synthase (iNOS) in mares susceptible or resistant to persistent breeding-induced endometritis (PBIE) within 24 h after breeding. Mares susceptible (n = 6) or resistant (n = 6) to PBIE were inseminated over five cycles, and uterine secretions and endometrial biopsies were collected before and 2, 6, 12 and 24 h after insemination. Uterine secretions were analysed for NO and biopsies were analyzed for iNOS expression. A second experiment evaluated the effect of treatment with dexamethasone or mycobacterial cell wall extract (MCWE) on uterine NO production and endometrial iNOS mRNA expression. Six susceptible mares were inseminated over three cycles with (i) killed spermatozoa without treatment (control), (ii) killed spermatozoa with 50 mg of dexamethasone IV or (iii) MCWE IV 24 h prior to insemination with killed spermatozoa. Six resistant mares were inseminated with killed spermatozoa as a control. Six hours after breeding, uterine biopsies and secretions were collected and evaluated for NO and iNOS mRNA. In Experiment 1, resistant mares had an increase in iNOS mRNA expression 2 h post-breeding compared to baseline (p = 0.045), 12 h (p = 0.014) and 24 h (p = 0.001). Susceptible mares had higher expression 2 h compared to 6 h (p = 0.046). No differences were observed in mRNA or protein expression of iNOS between resistant and susceptible mares. Resistant mares had a relatively steady amount of total intrauterine NO over 24 h, while susceptible mares had an increase over time, with a significantly higher increase in total NO than resistant mares at 6 (p = 0.04) and 12 h (p = 0.032). In Experiment 2, no differences were observed for iNOS mRNA expression. Susceptible mares had increased NO when compared to resistant mares (p = 0.008) and MCWE decreased NO (p = 0.047)., (© 2012 Blackwell Verlag GmbH.)

Objective: To analyze the clinical situations that leads us to carry out curettage after cesarean section, the ultrasound prior surgery, intraoperative, and pathological findings., Methods: A retrospective study of all cases of postpartum curettage after cesarean section in a level 3 maternity unit., Results: There were 42 curettages to women with cesarean sections (1.6% of all cesarean sections). The indications for curettage were: fever: 21, methrorraghia: 11, and residual trophoblastic tissue: 10. In the previous ultrasound, all indicated curettages for retained trophoblastic tissue showed it, and in a lower proportion those indicated for fever (66.6%) or methrorraghia (22.2%). A total of fourteen curettages (35%) were performed without suspect image of retained tissue, and in all cases the surgeon described to obtain small amount of tissue. From material submitted to pathologic evaluation trophoblastic tissue was found in 64.7%, and there were no differences as curettage indication., Conclusions: When the previous ultrasound do not showed retained tissue, the surgeon did not remove retained material. When extracted there were always in small amounts. Therefore, it could be concluded that after cesarean section the curettage should be indicated only in the presence of evident ultrasound image of retained products.

Uterine inflammation occurs after calving in association with extensive endometrial remodelling and bacterial contamination. If the inflammation persists, it leads to reduced fertility. Chronic endometritis is highly prevalent in high-yielding cows that experience negative energy balance (NEB) in early lactation. This study investigated the effect of NEB on the antimicrobial peptides S100A8 and S100A9 in involuting uteri collected 2 weeks post partum. Holstein-Friesian cows (six per treatment) were randomly allocated to two interventions designed to produce mild or severe NEB (MNEB and SNEB) status. Endometrial samples were examined histologically, and the presence of neutrophils, macrophages, lymphocytes and natural killer cells was confirmed using haematoxylin and eosin and immunostaining. SNEB cows had greater signs of uterine inflammation. Samples of previously gravid uterine horn were used to localise S100A8 and S100A9 by immunohistochemistry. Both S100 proteins were present in bovine endometrium with strong staining in epithelial and stromal cells and in infiltrated leucocytes. Immunostaining was significantly higher in SNEB cows along with increased numbers of segmented neutrophils. These results suggest that the metabolic changes of a post-partum cow suffering from NEB delay uterine involution and promote a chronic state of inflammation. We show that upregulation of S100A8 and S100A9 is clearly a key component of the early endometrial response to uterine infection. Further studies are warranted to link the extent of this response after calving to the likelihood of cows developing endometritis and to their subsequent fertility.

Background: To report the outcomes of women admitted following preterm pre-labour rupture of membranes (pPROM) and to determine whether the location of care (hospital vs outpatient) influences maternal and perinatal outcomes., Methods: A retrospective cohort study was performed using routinely collected de-identified data of 144 women (between June 2007 and June 2011) who presented to the Mater Mother's Hospital, Brisbane, Australia, with pPROM (prior to 34 weeks 0 days gestation) and who remained undelivered after 72 h from the time of ruptured membranes. Outcomes were compared for women who were subsequently managed as an outpatient (n = 53) versus those who were managed in hospital (n = 91). The two primary outcome measures were composite outcomes of (i) maternal morbidity and (ii) perinatal morbidity/mortality. The composite outcome of maternal morbidity comprised one or more of antepartum haemorrhage, clinical chorioamnionitis and/or endometritis, cord prolapse, blood transfusion, wound infection/haematoma/dehiscence/seroma. The composite outcome of perinatal morbidity/mortality comprised one or more of stillbirth, neonatal death, respiratory distress syndrome, neonatal infection, chronic neonatal lung disease, intraventricular haemorrhage, periventricular leukomalacia and necrotising enterocolitis., Results: When adjusted for confounders, there was no difference between hospital care and outpatient care in the composite outcome measure of perinatal morbidity/mortality (aOR 1.37; 95%CI 0.55-3.47) or the composite outcome measure of maternal morbidity (aOR 1.62; 95%CI 0.67-3.89)., Conclusions: Women with pPROM who remain undelivered after 72 h and are managed out of hospital do not appear to have significant differences in major adverse maternal or perinatal outcomes compared with those managed as inpatients., (© 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

In this cohort study, our objective was to identify potentially modifiable risk factors and causes for febrile morbidity in teenage mothers. We identified all cases of febrile morbidity using the United States Joint Commission on Maternal Welfare definition in a cohort of teenage deliveries over a 4-year period at one institution. Of the 730 included teenage deliveries, 49 (7%) women suffered postpartum febrile morbidity. Higher maternal pre-pregnancy body mass index (BMI: 34.0 ± 8.6 vs 30.3 ± 6.0 kg/m(2), p = 0.0001), caesarean delivery (RR 21.3, 95% CU 8.9-54.9) and postpartum haemorrhage (RR 3.0, 95% CI 1.1-6.7) were associated with postpartum febrile morbidity. Risk factors for febrile morbidity in the teenage parturient include obesity, caesarean delivery and postpartum haemorrhage. Considering the increasing rates of teenage obesity and overall caesarean delivery rates, attention must be focused on these modifiable risk factors to avoid this complication during a tenuous time for the teenage parent.

This study investigated the incidence of mycoplasma infection in the uterus of postpartum Holstein dairy cows and its relationship to the occurrence of endometritis. The genital tracts of 209 cows from three dairy farms in the Iwate Prefecture, Japan, were examined at Weeks 5 and 7 postpartum. The condition of the cervicovaginal mucus was assessed using a Metricheck device and assigned a score from 0 (clear mucus) to 4 (purulent material with fetid odor). Intrauterine samples (N = 418) were collected at Weeks 5 and 7 postpartum using a cytobrush. After its withdrawal, swab samples were placed in mycoplasma culture broth at 37 °C for 72 hours. A novel and rapid polymerase chain reaction was used to detect seven mycoplasma species (Mycoplasma bovis, M. arginini, M. bovigenitalium, M. californicum, M. bovirhinis, M. alkalescens, and M. canadense). The cytobrush was also rolled gently along the length of a glass slide for subsequent polymorphonuclear neutrophil count. The diagnostic criteria for cytological endometritis were 6% or more and 4% or more polymorphonuclear neutrophils at Weeks 5 and 7, respectively. From a subset of cows, additional swabs were rolled against the cytobrush and then placed in transport medium. These samples were then plated on specific agar plates and cultured under aerobic and anaerobic conditions to identify other bacteria present. The incidence of dystocia at the last calving was compared in mycoplasma positive and negative cows. Of the seven mycoplasma species, only M. bovigenitalium was detected; it was detected in 31 of the 418 uterine swabs (7.4%). Twenty-four cows were positive for M. bovigenitalium (eight cows at Week 5, nine cows at Week 7, and seven cows at both Weeks 5 and 7). The incidence of dystocia was higher (P < 0.0001) in mycoplasma positive (7/24; 29.2%) compared with mycoplasma negative (4/185; 2.2%) cows. However, there was no significant association between dystocia at last calving and subsequent uterine infection with other bacteria. In addition, the incidence of cytologic endometritis was higher (P < 0.05) in mycoplasma positive (8/16; 50%) than in mycoplasma negative (47/193; 24.4%) cows at Week 7. Therefore, we concluded that M. bovigenitalium infection in the uterus might be associated with recent dystocia and with cytologic endometritis in postpartum dairy cows., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The objectives of this study were to assess the clinical and metabolic risk factors for clinical endometritis, the likelihood for having a normal vaginal discharge during postpartum, and the effects of endometritis on milk yield, reproductive efficiency, and metabolic status in Holstein cows. The study was conducted in a commercial dairy herd (Cordoba, Argentina) where 303 Holstein cows were enrolled. Cows were body condition scored (1 to 5) and tail bled on -14, 7, 21, 31, 41, and 50 d relative to parturition. Cows having a vaginal discharge with presence of pus between 21 and 41 d postpartum (dpp) were diagnosed as having clinical endometritis. Plasma blood samples were analyzed for nonesterified fatty acids (NEFA), β-hydroxybutyrate (BHBA), and blood urea nitrogen using commercial kits and insulin-like growth factor 1, insulin, and leptin by RIA. Data were analyzed with PROC MIXED, PROC GENMOD, and PROC PHREG of SAS (SAS Institute Inc., Cary, NC). Abnormal calving and puerperal metritis increased the risk for endometritis [adjusted odds ratio (AOR)=2.21 for both]. High prepartum NEFA and high postpartum BHBA increased the risk for endometritis (AOR=1.003 and 1.001, respectively), whereas high prepartum blood urea nitrogen reduced it (AOR=0.853). Cut-offs of 456.6 μM NEFA and 402.5 μM BHBA had sensitivities of 0.69 and 0.58, and specificities of 0.88 and 0.86, respectively. The likelihood for having normal vaginal discharge increased with time (∼1% × dpp) and with normal calving. Cows with endometritis had higher milk yield than normal herdmates (27.8±0.9 vs. 25.7±0.4 kg/d), lower risk for pregnancy by 100 dpp (AOR=0.10), higher nonpregnancy risk by 200 dpp (AOR=2.87), and higher risk for culling than normal cows (AOR=2.28). Cows with endometritis had a lower hazard rate (0.44) for pregnancy and had approximately 70 d longer calving-to-conception intervals. Finally, endometritis had no effect on metabolic hormones. In conclusion, the risk for clinical endometritis increases with abnormal calving and puerperal metritis, as prepartum NEFA and postpartum BHBA concentrations increase. Prepartum NEFA and postpartum BHBA could be useful for the prediction of endometritis. Last, clinical endometritis has detrimental effects on reproductive efficiency, as affected cows take longer to get pregnant and are at higher risk for culling., (Copyright © 2013 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Postoperative infection is the most commonly seen complication of surgery in obstetrics and gynecology. The use of antibiotic prophylaxis has greatly decreased though not completely eliminated this adverse outcome. Postoperative infections include wound cellulitis, wound abscess, endomyometritis, pelvic cellulitis, and pelvic abscess. Infections usually manifest as fever and greater than normal postoperative pain. Refractory fevers maybe because of septic pelvic vein thrombophlebitis or maybe noninfectious in origin. Broad-spectrum antibiotics should be initiated as soon as possible when diagnosis of postoperative infection is made; most patients will respond to treatment within 24 to 48 hours when appropriate antibiotics are selected.

Objective: The purpose of the present study was to determine whether the vaginal preparation with povidone-iodine prior to caesarean delivery decreased the incidence of postpartum endometritis., Methods: The present study was a prospective randomized controlled trial in which subjects received a vaginal preparation with povidone-iodine solution immediately prior to caesarean delivery or received no vaginal preparation. The primary outcome measure was the rate of postpartum endometritis., Results: A significant decrease in post-caesarean endometritis was noted in the group that received the povidone-iodine vaginal preparation (n = 334) compared with the control group (n = 336) [6.9 vs. 11.6%; RR = 1.69; 95% CI = 1.03-2.76]. No statistically significant differences in the incidence of endometritis were noted between the experimental and control groups among women who were not in labor at the time of the caesarean delivery [9.2 vs. 8.6%; RR = 1.05; 95% CI = 0.58-1.90], and no differences were found between groups when women with ruptured membranes were excluded from the analysis [9.6 vs. 6.7%; RR = 1.39; 95% CI = 0.78-2.47]., Conclusions: Vaginal preparation with povidone-iodine solution immediately prior to a caesarean delivery reduces the risk of post-operative endometritis. This preemptive measure was only found to be beneficial in women whose membranes had ruptured and those who were in labor prior to caesarean surgery.

Background: There are only few studies concerning the usage of antibiotics in preventing endometritis after uterine curettage for spontaneous first trimester incomplete abortion and no conclusion can be demonstrated, Objective: To investigate the effectiveness of prophylactic cefoxitin in preventing endometritis after uterine curettage for spontaneous first trimester incomplete abortion., Material and Method: Eighty-four women with spontaneous first trimester incomplete abortion were randomly allocated into two groups using a computer-generated random number list and the allocation concealment was maintained using a sealed opaque envelope. The patients in the study group were given 1 g of cefoxitin while the patients in the control group were given 0.1 ml of vitamin B complex intravenously 20 minutes prior to curettage. Uterine curettage was performed after intravenous sedation and analgesic drugs were administered. The patients were evaluated on the first, third and seventh day after uterine curettage., Results: Seventy-nine cases had completed the study protocol. There were no statistically significant differences in demographic data and details of uterine curettage between both groups. Two cases of endometritis were found in the control group but none in the study group. However the difference did not reach the statistical significance (p = 0.241)., Conclusion: Prophylactic cefoxitin is not effective in preventing endometritis after uterine curettage for spontaneous first trimester incomplete abortion.

Low-dose insemination has been proposed to reduce persistent breeding-induced endometritis (PBIE) in mares with delayed uterine clearance (DUC). Others proposed that hysteroscopic insemination induces an exaggerated inflammatory response and should be avoided in DUC mares. The objectives here were to evaluate presence and severity of PBIE in normal and DUC mares after hysteroscopic insemination with fresh semen, and to determine if hysteroscopy could be used in DUC mares without inducing excessive inflammation. Reproductively normal (n = 4) and DUC (n = 5) mares received four treatments in random order: uterine body insemination (UB, 1 × 10(9) spermatozoa, 20 ml), hysteroscopic insemination (HYST, 5 × 10(6) spermatozoa, 0.5 ml), sham hysteroscopic insemination (SHAM, semen extender, 0.5 ml) and hysteroscopic infusion of seminal plasma (SP, 0.5 ml). Significantly more DUC (50%) mares than normal (14%) mares accumulated intrauterine fluid 24 h post-treatment. The difference in fluid accumulation between DUC (40%) mares and normal (7%) mares was also significant 48 h post-treatment. Fluid scores were not significantly different between treatments in normal mares. However, treatments HYST and SHAM resulted in significantly higher fluid scores 24 h but not 48 h post-treatment in DUC mares. There was no effect of treatment or mare group on the percentage and total number of neutrophils in uterine fluid 48 h post-treatment. Percentage of neutrophils was correlated with duration of hysteroscopy in normal mares, with procedures lasting ≥ 9 min associated with PBIE. There was no effect of mare group, treatment or duration of hysteroscopy on pregnancy rate. Hysteroscopy induces a transient inflammation that is not more severe than that after conventional artificial insemination, suggesting no contraindication to its use in DUC mares., (© 2011 Blackwell Verlag GmbH.)

Persistent breeding-induced endometritis is ranked as the third most common medical problem in the adult mare and leads to enormous economic loss in horse breeding. In mares suffering from persistent breeding-induced endometritis, increased amounts of intrauterine (i.u.) fluid or viscous mucus in estrus or after breeding may act as a barrier for sperm and can contribute to low fertility. Current therapies of these mares aim to eliminate i.u. fluid and mucus by uterine lavage and/or administration of ecbolic drugs. Recently, i.u. administration of N-acetylcysteine (NAC) has been shown to support therapy in mares with endometritis. It was the objective of the present study to investigate effects of an oral administration of NAC on the viscosity of i.u. fluid in estrous mares. It was hypothesized that oral treatment with NAC reduces the viscosity of i.u. fluid and has a positive effect on the inflammatory response of the endometrium. Mares (n = 12) were included in the study as soon as estrus was detected (ovarian follicle >3.0 cm and endometrial edema), which was defined as Day 1. They were randomly assigned to a treatment (10 mg/kg NAC on Days 1-4) or a control group (no treatment). On days 1 and 5 i.u. mucus was collected and its rheologic properties were accessed. On Day 5, endometrial biopsies were obtained and evaluated for integrity of the luminal epithelium, number of polymorphonuclear neutrophils (PMN), staining for cyclooxygenase 2 (COX2), staining with Kiel 67 antigen (Ki-67), lectins and periodic acid Schiff (PAS). In the treatment group, viscosity of i.u. mucus increased significantly between Days 1 and 5 (P < 0.05), while no differences were found in control mares (n.s.). At no time were significant differences between treated and control mares seen. Integrity of epithelium was not affected. After NAC treatment the mean number of PMN in endometrial biopsies was significantly lower compared to mares of the control group (1.9 ± 0.3 vs. 4.8 ± 0.4; P < 0.05). Nuclear immunostaining for COX2 was significantly lower after NAC treatment compared to control mares (P < 0.05). Score for PAS and Alcain staining of mucus in deep uterine glands differed significantly between groups (both P < 0.05). We conclude that oral NAC treatment does not reduce viscosity of uterine mucus but has an antiinflammatory effect on the equine endometrium., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The objectives were to: (1) investigate the associations of age and endometrial biopsy score with uterine fluid retention after insemination; and (2) determine if a strict classification of susceptibility to persistent breeding-induced endometritis (PBIE) based on biopsy score, endometrial cytology, and fluid retention after inseminations, is consistent over subsequent breeding seasons. In Experiment 1, 57 mares were inseminated with 10(9) freeze-killed sperm during estrus and evaluated for uterine fluid retention 48 h and 96 h after insemination. Comparisons were made between fluid retention and biopsy score or age. In Experiment 2, a subset of 14 mares was classified for susceptibility to persistent breeding-induced endometritis in two subsequent breeding seasons. Biopsy score and age were associated with fluid retention (P < 0.001). In addition, age was related to biopsy score (P < 0.001). Of the mares examined for susceptibility, 36% (5 of 14) changed status during subsequent seasons. Three mares changed to a more severe classification (intermediate to susceptible, or resistant to intermediate), whereas two mares changed to a less severe classification (susceptible to intermediate)., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This review attempts to summarize the current knowledge on uterine inflammatory response after mating in horses, pigs and cattle. Post-mating endometritis has been extensively studied in horses as it has been considered to cause infertility. The inflammation is known to occur also in cattle, but it has not been investigated to a similar extent. There are a number of publications about mechanisms of post-mating uterine inflammation in pigs, which seem to resemble those in horses. The major focus of this review is the horse, but relevant literature is presented also on swine and cattle. Spermatozoa, seminal plasma and semen extenders play roles in the induction of inflammation. In addition, sperm numbers, concentration and viability, as well as the site of semen deposition may modulate the inflammatory response. Cytokines, polymorphonuclear leucocytes (PMN) and mononuclear cells represent the uterine inflammatory response to mating. Inflammation is the first line of defence against invasion and eliminates excess spermatozoa and bacteria. Semen deposition elicits a massive PMN invasion, followed by phagocytosis of sperm aided by the formation of neutrophil extracellular traps. Exposure of the female genital tract to semen is important also for endometrial receptivity and pre-implantation embryo development. Seminal plasma (SP) and inflammation elicit transient immune tolerance to antigens present in semen. SP contains immune-regulatory molecules that activate and control immune responses to antigens by stimulating expression of cytokines and growth factors and by initiating tissue remodelling. SP also regulates ovarian function. Effective elimination of excess sperm and inflammatory by-products and subsequent rapid return of the endometrium to the normal state is a prerequisite for pregnancy. Uterine backflow, driven by myometrial contractions and requiring a patent cervix, is an important physical tool in uterine drainage., (© 2012 Blackwell Verlag GmbH.)

Objective: Ertapenem is a broad spectrum carbapenem approved for the treatment of postpartum endometritis. Data regarding clinical outcomes after treatment with ertapenem for endometritis after cesarean delivery are limited. Our objectives were to compare clinical outcomes and cost of ertapenem versus a multi-drug regimen for treatment of endometritis after cesarean delivery., Methods: Retrospectively, patients with endometritis after cesarean delivery who were treated with ertapenem (group A) were compared to those treated with a combination regimen (group B). Mann-Whitney U and Fisher's Exact were used for statistical analysis with p value <0.05 considered statistically significant., Results: Sixty-three patients were included: 31 in group A and 32 in group B. Demographics and intrapartum characteristics did not differ. Number of administered doses (A: 3, B: 11.5 p < 0.0001), cost (A: $156.63, B: $54.48 p < 0.0001) and nursing time in minutes (A: 6.6, B: 25.3 p < 0.0001) were different between both groups. Wound complications were higher in group A, occurring in 7 patients compared to 1 patient in group B (p = 0.024)., Conclusion: Although time and number of administered doses were less in group A, given the high wound complication rate in patients treated with ertapenem, this drug may not be appropriate for all patients with endometritis after CD.

Inversion of uterus is a rare complication of vaginal delivery. The reported incidence of puerperal inversion varies from approximately 1 in 550 to 1 in several thousand normal deliveries. Maternal mortality has been reported to be as high as 15%, mainly because of associated life threatening blood loss and shock. Early diagnosis, prompt and aggressive management decrease the morbidity and mortality to minimal. We report a case of 21 year old primi, who presented to us with uterine inversion after delivery at a rural set up by untrained birth attendant ("Dai"). She was managed surgically with Haultain's operation and discharged after 5 days. She didn't turn up for follow up and was readmitted after 4 weeks with uterine reinversion associated with endometritis. A recent case is described, followed by a short review of literature.

The ovarian remnant syndrome arises as a consequence of incomplete ovariectomy or ovariohysterectomy. Remnant ovarian tissue which has been left mostly unintentionally in the bitch may show endocrine activity a few weeks to several years after surgery, provoking a variety of clinical signs. The majority of affected bitches return to heat, in other cases signs of pseudopregnancy and endometritis may be observed. Occasionally, bitches with unclear clinical signs are presented with the suspicion of an inactive ovarian remnant. The following article intends to place the origin of the ovarian remnant syndrome into a factual context regarding the responsibility of the veterinarian and to demonstrate a reasonable diagnostic procedure according to the respective clinical signs. In this regard, the clinical-gynaecological examination, including vaginal cytology, must receive high priority, with the addition of progesterone analysis in peripheral blood plasma or serum if required. Using these combined diagnostic tools, ovarian remnants in stages of endocrine activity (follicular and luteal phases as well as cystic or tumourous ovarian tissue) can be easily unequivocally diagnosed. The application of a GnRH-stimulation test is only reasonable in bitches in which clinical signs are missing. In this context, the usefulness of semi-quantitative LH-assays is also discussed.

The infiltration of human myometrium and cervix with leukocytes and the formation of a pro-inflammatory environment within the uterus have been associated with the initiation of both term and preterm parturition. The mechanism regulating the onset of this pro-inflammatory cascade is not fully elucidated. We demonstrate that prokineticin 1 (PROK1) is up-regulated in human myometrium and placenta during labor. The expression of PROK1 receptor remains unchanged during labor and is abundantly expressed in the myometrium. Gene array analysis identified 65 genes up-regulated by PROK1 in human myometrium, mainly cytokines and chemokines, including IL-1β, chemokine C-C motif ligand 3, and colony-stimulating factor 3. In addition, we demonstrate that PROK1 increases the expression of chemokine C-C motif ligand 20, IL-6, IL-8, prostaglandin synthase 2, and prostaglandin E(2) and F(2α) secretion. The treatment of myometrial explants with 100 ng/mL of lipopolysaccharide up-regulates the expression of PROK1, PROK1 receptor, and inflammatory mediators. The infection of myometrial explants with lentiviral microRNA targeting PROK1, preceding treatment with lipopolysaccharide, reduces the expression of inflammatory genes. We propose that PROK1 is a novel inflammatory mediator that can contribute to the onset of human parturition at term and partially mediate premature onset of inflammatory pathways during bacterial infection., (Copyright © 2011 American Society for Investigative Pathology. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine if the best predictor of pregnancy complications is pre-pregnancy body mass index (BMI) alone or in combination with other factors., Methods: BMI and peripartum outcomes of singleton pregnancies were evaluated. Recursive partitioning and logistic regression modeling was used., Results: Of the 4,286 cohorts, 26% were obese (BMI >30 kg/m(2)) and, compared to cohorts with normal weight, at risk for wound infections (P < 0.001), and shoulder dystocia (P < 0.001). High-risk patients (15%; BMI >32.5, parity, pregnancy weight gain of 28 lb by 28 weeks) were at increased risk for wound infection (P < 0.001), endometritis (P < 0.001), shoulder dystocia (P = 0.001) and 5 min Apgar score <4 (P < 0.041) and at lower risk for pre-term delivery (P = 0.007)., Conclusions: Since BMI, parity, and weight gain until 28 weeks together provide better prediction of peripartum complications than BMI alone, these characteristics can be used to triage and refer patients.

Objective: The purpose of this study was to investigate whether supplemental oxygen during and for 2 hours after cesarean delivery reduces the incidence of postcesarean infectious morbidity., Study Design: We conducted a randomized, controlled trial from 2008-2010. Women who underwent cesarean delivery were randomly assigned to receive either 2 L of oxygen by nasal cannula during cesarean delivery only (standard care) or 10 L of oxygen by nonrebreather mask (intervention group) during and for 2 hours after cesarean delivery. Women who underwent scheduled or intrapartum cesarean delivery were eligible and were observed for 1 month after the procedure. The primary composite outcome was maternal infectious morbidity, which included endometritis and wound infection., Results: Five hundred eighty-five women were included in the final analysis. Infectious morbidity occurred in 8.8% of patients in the standard care group and in 12.2% of patients in the supplemental oxygen group. There was no significant difference in the rate of infectious morbidity between the standard care and intervention groups (relative risk, 1.4; 95% confidence interval, 0.9-2.3)., Conclusion: Supplemental oxygen does not reduce the rate of postcesarean delivery infectious morbidity, including endometritis and wound infection., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: premature rupture of membranes occurs between 5 and 15% of pregnancies, of these, 10% occurs at term and preterm 2 to 3.5%., Objective: To compare maternal and perinatal outcomes from the use of erythromycin or clindamycin in women with preterm premature rupture of membranes with conservative treatment at the Regional General Hospital No. 36., Patients and Methods: comparative, prospective, randomized study conducted at the Regional General Hospital No. 36 of the Instituto Mexicano del Seguro Social, Puebla. The most common risk factors were cervical infections (55%) and urinary tract infection (55%). A history of premature rupture of membranes in pregnancy was reported in 12.5% of patients. Group A was prescribed erythromycin and group B, standard-dose clindamycin, these were the independent variables. Maternal outcomes (deciduoendometritis and chorioamnionitis) and perinatal (respiratory distress syndrome, necrotizing enterocolitis and sepsis) were the dependent variables. Fisher exact test was applied to the results of the study., Results: about perinatal outcome, sepsis was expressed more frequently in the clindamycin group (60%) compared with erythromycin (35%). The occurrence of respiratory distress syndrome was similar in both groups, 70 and 75% respectively. For necrotizing enterocolitis, 25 and 5%. Maternal alterations as chorioamnionitis occurred in 20% of patients in group A and 5% in group B. Endometritis results were similar in both groups., Conclusions: comparing the maternal and perinatal outcomes with conservative management of premature rupture of membranes, results were better in the group treated with erythromycin. It is not possible to prove it statistically because of the sample size.