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PubMed1988

Comparison of ticarcillin plus clavulanic acid with clindamycin and gentamicin in the treatment of postcesarean endomyometritis.

The efficacy of a single antibiotic--Timentin (ticarcillin with clavulanic acid)--was compared with a standard two antibiotic regimen (clindamycin and gentamicin) for the treatment of endomyometritis after cesarean delivery. The regimens were 3 grams of ticarcillin plus 100 milligrams of clavulanic acid given intravenously every four hours, or 600 milligrams of clindamycin given intravenously every six hours plus 3 to 5 milligrams per kilogram per day of gentamicin given intramuscularly. The diagnosis of endomyometritis was based upon an oral temperature of 100.4 degrees F. or higher on any two occasions, excluding the first 24 hours post partum, uterine tenderness and the absence of another focus of infection. Ninety-one patients were treated. Treatment failure rates were three of 49 in the clindamycin and gentamicin group and four of 42 of the ticarcillin plus clavulanic acid group. Treatment failures did not appear to be different from successes demographically or in risk factors for endomyometritis. The results of this study suggest that ticarcillin with clavulanic acid is as effective in the treatment of postcesarean endomyometritis as the standard regimen of clindamycin and gentamicin.

Adult↗
PubMed2002

Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery.

OBJECTIVE: Our purpose was to evaluate obesity (body mass index greater than 30.0) as an independent risk factor for infectious morbidity in women having elective or nonelective cesarean deliveries. METHODS: Charts of 611 patients undergoing cesarean were reviewed. After exclusion of those with pre-existing chorioamnionitis, 574 cases were separated into two groups (elective or nonelective cesarean) and then subdivided based on the presence or not of postdelivery infectious morbidity. Estimated blood loss, operative time, number of vaginal examinations, labor length, use of internal monitors, body mass index (BMI), and obesity (BMI greater than 30.0) were then recorded. Student t test, chi(2), multivariate analysis, and receiver operating characteristics curves were used where appropriate (significance: P <.05). RESULTS: The mean gestational age at delivery was 38.3 weeks. Three hundred sixty patients had nonelective cesareans, and 214 had elective cesareans. Prophylactic antibiotics were used for 86.6% of the nonelective group and 75.2% of the elective group. In the nonelective group and after multivariate analysis, significant risk factors for postoperative infections were as follows: labor length (18.4 hours versus 10.9, P <.003), number of vaginal examinations (6.1 versus 4.5, P <.001), BMI (36.6 versus 32.3, P <.001), and obesity (81.8% versus 57.3%, P <.001). For the elective group, a higher BMI (38.9 versus 32.2, P <.003), and black race (63.2% versus 11.5%, P <.001) were found to be significant. CONCLUSION: Our data suggest that obesity is a independent risk factor for postcesarean infectious morbidity and endomyometritis, even if the cesarean is elective and prophylactic antibiotics are given.

Adult↗
PubMed1999

Uterine flora at cesarean and its relationship to postpartum endometritis.

OBJECTIVE: To evaluate the relationship between the presence of microorganisms at the time of cesarean at different sites of the genital tract and the development of postpartum endometritus. METHODS: One-hundred thirty-three healthy women who delivered by cesarean were enrolled in this prospective study. Cultures were obtained during the surgery and on days 3-5 postoperatively. Gram staining of uterine cavity fluid was done on days 3-5. Gram stains were examined under a high-power microscope for the presence of polymorphonuclear leukocytes. RESULTS: Twenty patients (15.0%) met the criteria for postpartum endometritis. Forty-five patients (33.8%) had one or more positive cultures (n = 133) at the time of surgery, resulting in 93 positive cultures and 123 bacterial isolates. Forty-four patients had positive postoperative uterine cavity cultures at days 3-5 postpartum, resulting in 65 isolates. Of 44 patients with a positive postoperative culture, 26 (59.1%) also had Gram stain positive for polymorphonuclear leukocytes in the uterine cavity fluid, whereas only six of 89 patients (6.7%) with negative postoperative culture had a positive Gram stain (P < .05). The relative risk of having a positive culture on postoperative day 3-5 if the culture at surgery was positive at any site was 15.6 (95% confidence interval [CI] 5.9, 42.2), and it was 19.5 (95% CI 6.8, 57.8) if the culture was positive at the lower uterine segment. CONCLUSION: The presence of bacteria in the lower uterine segment at the time of the surgery predicts their presence in the uterine cavity during puerperium. The Gram stain of uterine cavity fluid on postcesarean days 3-5 is another quick tool that can expedite the diagnosis of postpartum endometritis.

Adult↗
PubMed1986

Pathophysiology and management of postcesarean endomyometritis.

Endomyometritis is the most common complication associated with cesarean delivery. The incidence varies from 5 to 85%, depending upon the patient population surveyed. The major risk factors for postcesarean endomyometritis are young age, low socioeconomic status, and extended duration of labor and ruptured membranes. The principal microorganisms responsible for infection are group B streptococci, aerobic gram-negative bacilli, anaerobic gram-positive cocci, and anaerobic gram-negative bacilli. The mean incidence of bacteremia in patients with endomyometritis is 10%. Less than 2% of infected patients develop life-threatening complications such as septic shock, pelvic abscess, or septic pelvic thrombophlebitis. Antibiotics of proved value in treatment of postcesarean endomyometritis include the newer broad-spectrum cephalosporins and ureidopenicillins and the combination regimen of clindamycin plus aminoglycoside.

Adult↗
PubMed2005

Thromboprophylaxis after cesarean delivery: a decision analysis.

OBJECTIVE: To compare 4 strategies for managing patients after cesarean delivery. METHODS: Using decision analysis, we compared universal subcutaneous (SC) heparin prophylaxis, heparin prophylaxis only for patients with a genetic thrombophilia, use of pneumatic compression stockings (PCS), and no thromboprophylaxis. Outcomes included heparin-induced thrombocytopenia (HIT), HIT-related thrombosis, major maternal bleeding, and venous thromboembolism (VTE). RESULTS: Use of PCS was the strategy with the lowest number of adverse events. With heparin prophylaxis, 13 cases of HIT-induced thrombosis and hemorrhage would occur per VTE prevented. When heparin prophylaxis is administered only to thrombophilia-positive women, 1.2 cases of HIT-induced thrombosis and bleeding would occur per VTE prevented. In sensitivity analyses, the model was stable across virtually all variable ranges. CONCLUSION: Use of PCS after cesarean delivery is the strategy with the lowest number of adverse events. Universal prophylaxis with SC heparin is associated with an excess risk of HIT-induced thrombosis and bleeding per VTE prevented compared with PCS use. Until future studies are completed, postcesarean thromboprophylaxis with PCS should be used if the clinician elects to provide prophylaxis.

Bandages↗
PubMed2005

Preoperative vaginal preparation with povidone-iodine and the risk of postcesarean endometritis.

OBJECTIVE: Postcesarean endometritis and wound infection remain significant morbidities, despite use of strategies to prevent these complications. We investigated the effect of preoperative vaginal preparation with povidone-iodine as a preventive intervention against postcesarean endometritis and wound infection. METHODS: A randomized controlled study was performed in 308 women undergoing nonemergent cesarean delivery. Subjects received either standard abdominal scrub alone or abdominal scrub with an additional vaginal preparation with povidone-iodine solution. All subjects received prophylactic antibiotic at the time of umbilical cord clamping. Each subject's postoperative course was reviewed for development of febrile morbidity (temperature > 38.0 degrees C), endometritis (temperature > 38.4 degrees C accompanied by fundal tenderness occurring beyond the first postoperative day, in the absence of evidence of other infection), and wound infection. RESULTS: Postcesarean endometritis occurred in 7.0% of subjects who received a preoperative vaginal preparation and 14.5% of controls (P < .05). There was no measurable effect of a vaginal scrub on the development of postoperative fever or wound infection. The adjusted odds ratio for developing endometritis after a vaginal preparation was 0.44 (95% confidence interval [CI] 0.193-0.997). Multivariate analysis showed an increased risk of developing endometritis in association with severe anemia (adjusted OR 4.26, 95% CI 1.568-11.582), use of intrapartum internal monitors (adjusted OR 2.84, 95% CI 1.311-6.136), or history of antenatal genitourinary infection (adjusted OR 2.9, 95% CI 1.265-6.596). CONCLUSION: Preoperative vaginal scrub with povidone-iodine decreases the incidence of postcesarean endometritis. This intervention does not seem to decrease the overall risk of postoperative fever or wound infection.

Adult↗
PubMed1993

Opioid antagonist adjuncts to epidural morphine for postcesarean analgesia: maternal outcomes.

This prospective, randomized, controlled investigation compared the effects of three prophylactic mu-opioid antagonists, epidural butorphanol (BU) 3 mg, epidural nalbuphine (NB) 10 mg, and oral naltrexone (NX) 6 mg, on postcesarean epidural morphine analgesia. After randomization, 102 term parturients underwent cesarean delivery with epidural anesthesia, 2% lidocaine and epinephrine 1:200,000. When the umbilical cord was clamped, each patient received one epidural solution (containing morphine 4 mg plus either saline or treatment drug), and one oral capsule (containing either placebo or treatment drug) in a double-blind manner. Maternal outcomes included pain and satisfaction [assessed with 100-mm visual analog scales (VAS)], and the incidence and severity of respiratory depression, somnolence, pruritus, nausea, and emesis. Through the first 12 h postpartum, the BU group achieved significantly greater analgesia than the morphine sulfate (control) (MS), NB, and NX groups, a significantly lower incidence of severe pruritus than the MS group, and significantly greater satisfaction than MS and NX groups. Epidural morphine and BU promoted better analgesia and satisfaction than any previously documented postcesarean regimen.

Adult↗
PubMed2001

Endometriosis arises from implant of endometriotic cells outside the uterus: a report of active vesicouterine centrifugal fistula.

Vesicouterine fistula is rare, accounting for nearly 4% of all urogenital fistulas. Lower segment cesarean delivery is the main predisposing event but in the last few years other possible predisposing factors have been pointed out. Clinically, it can show itself in different forms and the diagnosis is often delayed although it is not difficult. We report our experience about a case of postcesarean vesicouterine fistula arising on a focus of vesical endometriosis and we discuss an eventual hypothetical pathogenetic correlation between bladder endometriosis and uterovesical fistula.

Adult↗
PubMed2005

Diagnostic imaging in uterine incisional necrosis/dehiscence complicating cesarean section.

OBJECTIVE: To review the diagnostic imaging studies in patients with surgically proven uterine incisional necrosis/dehiscence complicating cesarean section and to compare these studies with the findings at surgery. STUDY DESIGN: Over a 6-year period, the records of 7 patients with imaging studies prior to surgery for uterine incisional necrosis/dehiscence complicating cesarean delivery were reviewed and compared with the findings at surgery. RESULTS: Four cases underwent computed tomography (CT) and sonography, 1 underwent CT only, and 2 underwent sonography only. Abnormal findings included abdominal free fluid in 4, pleural effusions in 3, dilated bowel in 3, possible bladder flap hematoma in 2 and single instances of liver abscess and retained products of conception. In no cases were all the studies normal, and necrosis/dehiscence was not demonstrated in any patient. CONCLUSION: Abdominal free fluid, bowel distension, pleural effusion and bladder flap hematoma seen on CT or sonogram in the postcesarean context suggest the possibility of uterine incisional necrosis/dehiscence. Magnetic resonance imaging (MRI) might then be indicated since MRI may be superior to CT in evaluating complications at the incisional site because of its multiplanar capability and greater degree of soft tissue contrast.

Ascitic Fluid↗
PubMed2001

[Vesicouterine fistula and bladder endometriosis. A case report].

Vesicouterine fistula is rare, accounting nearly 4% of all urogenital fistulas. Cesarean delivery through uterine lower segment is the main predisposing event but in the last years other possible predisposing factors have been pointed out. Clinically, it can occur in different forms and the diagnosis is often delayed although it is not difficult. In this study personal experience in a case of postcesarean vesicouterine fistula arisen on a focus of bladder endometriosis is reported and an eventual hypothetical pathogenetic correlation between bladder endometriosis and vesicouterine fistula is discussed.

Adult↗
PubMed1988

Treatment of postcesarean endomyometritis.

Improved understanding of the microbiology of postcesarean endometritis has dramatically changed the approach to its antibiotic therapy. Initial therapy should include broad-spectrum anaerobic coverage, including against all Bacteroides species, as well as gram-positive and gram-negative aerobic coverage. Moreover, ideally initial therapy should also include coverage of Chlamydia trachomatis. Furthermore, although the use of antibiotic prophylaxis for high-risk patients undergoing cesarean section has significantly decreased their incidence of febrile morbidity, one must remember that prophylactic antibiotics have important bacteriologic effects that may limit the efficacy of monotherapy for the treatment of endometritis in prophylaxis failures.

Cesarean Section↗
PubMed2000

Clinical usefulness of white blood cell count after cesarean delivery.

OBJECTIVE: To examine changes in white blood cell (WBC) count after cesarean and estimate risk of postoperative infection. METHODS: We measured complete blood cell counts at admission and on postoperative day 1 for 458 women who had cesareans. Information from charts was abstracted, and definitions of infectious outcomes and fever were applied by three physicians masked to laboratory results. We examined changes in absolute and relative WBC counts by labor status. Likelihood ratios for postoperative infection were calculated for statistically distinct categories of percentage changes. RESULTS: We excluded 60 women with chorioamnionitis. Of the remainder, 34 (8.5%) developed endometritis and three (0.8%) pneumonia. Women who labored before cesarean (n = 198) had higher antepartum (P <.001) and postoperative day 1 (P <.001) WBC counts than those who did not (n = 200). However, change in WBC count after cesarean relative to antepartum was similar for both groups (P =.41), averaging a 22% increase. We grouped percentage changes into the following three levels: up to 24%, 25-99%, and at least 100%. The lowest level (n = 246) corresponded to a category-specific likelihood ratio for diagnosis of serious postpartum infection of 0. 5 (95% confidence interval [CI] 0.3, 0.8), the midlevel (n = 141) to a category-specific likelihood ratio of 1.7 (95% CI 1.2, 2.3), and the highest level (n = 11) to a category-specific likelihood ratio of 5.8 (95% CI 1.8, 18.7). CONCLUSION: Labor influenced postcesarean WBC counts but did not obscure changes associated with infection. Information gained from changes in WBC counts can be used to assess risk of infection.

Adult↗
PubMed2000

Prophylactic intravenous ondansetron reduces the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery.

UNLABELLED: Pruritus is a common side effect of intrathecal morphine injection for postoperative pain control. Its incidence is especially high in patients undergoing cesarean delivery. We investigated the effectiveness of ondansetron in preventing intrathecal morphine-induced pruritus in such patients. We included 60 consecutive nonbreastfeeding women who were scheduled for elective cesarean delivery. After the administration of spinal anesthesia with bupivacaine and intrathecal morphine 0.15 mg injection, the patients were randomly divided into three groups. Group 1 received placebo (normal saline) IV injection, Group 2 diphenhydramine 30 mg IV injection, and Group 3 ondansetron 0.1 mg/kg IV injection. The incidence of pruritus was significantly lower in the ondansetron group (25%) when compared with that in the placebo group (85%) and in the diphenhydramine group (80%) (both P < 0.05). The postoperative pain score and time to flatus passage were not significantly different among the three groups. There were no headache or extrapyramidal signs associated with ondansetron use. In conclusion, ondansetron prophylaxis significantly reduced the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery. IMPLICATIONS: Ondansetron prophylaxis significantly decreases the incidence of pruritus, a common side effect of intrathecal morphine used to treat postcesarean delivery pain.

Adolescent↗
PubMedDate not supplied

Single dose cefazolin prophylaxis for postcesarean infections: before vs. after cord clamping.

The objective of this study was to test the hypothesis that 1 g of cefazolin administered preoperatively is no more effective than the same dose administered after cord clamping in preventing postcesarean infectious morbidity. Ninety consecutive laboring subjects undergoing cesarean delivery at > or = 37 weeks gestation were randomized by computer to receive 1 g of cefazolin intravenously preoperatively or after cord clamping in a double-blinded, placebo-controlled study. The 2 groups were compared for differences in maternal and neonatal demographics, and intrapartum and operative characteristics associated with postcesarean infection. Primary maternal outcome variables were endometritis or wound infection. Secondary outcomes included intra-abdominal abscess formation, septic pelvic thrombophlebitis, pneumonia, or urinary tract infection. Neonatal outcomes included sepsis screens, sepsis, pneumonia, and meningitis. Subjects were followed 6 weeks postoperatively for late complications. Subjects receiving cefazolin preoperatively or after cord clamping had similar maternal and neonatal demographics, and intrapartum and operative characteristics. One patient in the former group experienced both endometritis and wound infection. In the latter group, 2 wound infections and 1 case of endometritis occurred (P = 0.35). There were no secondary maternal infections. Two infants treated for pneumonia and 2 other infants readmitted with febrile illnesses were born to mothers receiving cefazolin preoperatively. Overall, 8 neonates were evaluated for suspected sepsis and all had negative studies. Six of these infants' mothers received cefazolin preoperatively (P = 0.28). In conclusion, 1 gram of cefazolin preoperatively is no more effective than the same dose administered after cord clamping in preventing postcesarean infectious morbidity, but is associated with a trend toward increased suspected sepsis in the newborn. However, this trend may be related to differences between the study groups' risk factors for infection.

Bacterial Infections↗
PubMed2005

Postcesarean pulmonary embolism, sustained cardiopulmonary resuscitation, embolectomy, and near-death experience.

BACKGROUND: Survival after surgical embolectomy for massive postcesarean pulmonary embolism causing sustained cardiac arrest is rare. CASE: One day after an uneventful cesarean delivery, a woman developed cardiac asystole and apnea due to pulmonary embolism. Femoral-femoral cardiopulmonary bypass performed during continuous cardiopulmonary resuscitation allowed a successful embolectomy. Upon awakening, the patient reported a near-death experience. Pulmonary embolism causes approximately 2 deaths per 100,000 live births per year in the United States, and postcesarean pulmonary embolism is probably more common than pulmonary embolism after vaginal delivery. CONCLUSION: Massive pulmonary embolism is a potentially treatable catastrophic event after cesarean delivery, even if continuous cardiopulmonary resuscitation is required until life-saving embolectomy is done.

Acute Disease↗
PubMed1993

Trichomonas vaginalis: a reemerging pathogen.

Infestation with T. vaginalis is a common and potentially morbid infection. In addition to reproductive tract discharge and irritation, infection with this protozoa is increasingly recognized to be associated with reproductive tract complications, including postabortal infection, postcesarean infection, preterm birth, and PROM. Clinical diagnosis is often difficult and newer approaches using specific antigen and nucleic acid technologies will probably replace "wet prep" microscopic techniques. Effective treatments continue to depend on oral metronidazole treatment. Cure of resistant strains, which remain rare, depends on administration of higher, more prolonged doses of metronidazole. Improved understanding of the natural history, pathobiology, diagnosis, and treatment of this common protozoa is urgently needed. Practitioners should consider routinely screening and treating women for trichomoniasis before any reproductive tract surgery (chorionic villi sampling, hysterectomy, cesarean section, dilatation and curettage, therapeutic abortion, and so on), after changing sexual partners, and during pregnancy. Both symptomatic and asymptomatic patients and their sexual contacts should be treated.

Diagnosis, Differential↗
PubMed2003

Prevention of urinary and anal incontinence: role of elective cesarean delivery.

PURPOSE OF REVIEW: Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it, this has created confusion among health personnel [corrected]. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking. RECENT FINDINGS: Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor. SUMMARY: Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.

Cesarean Section↗
PubMed1987

Surgical birth: interpretations of cesarean delivery among private hospital patients and nursing staff.

Cesarean delivery, although classified by medical practitioners as major surgery, is simultaneously defined as childbirth by both specialists and laypeople. Women experiencing cesarean delivery, therefore, confront a contradiction which affects postpartum treatment by nursing staff and expectations by family and the postcesarean patient regarding appropriate responses to delivery. Elicitation of the explanatory models of cesarean patients in a private Dallas hospital indicates the ambiguity in the definition of the cesarean reflecting more general trends in American obstetrics. Further, the data demonstrate the limited influence of the natural childbirth movement and the acceptance of technological intervention at birth in this population.

Adolescent↗