Risk factors for postcesarean surgical site infection

Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty?

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

Obstetric outcomes during delivery hospitalizations among obese pregnant women in the United States

The rates of both maternal and fetal adverse outcomes increase significantly with higher body mass index. The aim of this study was to calculate national estimates of adverse maternal and fetal outcomes and associated hospitalization cost among obese pregnant women using a national database. This study was a retrospective analysis of data retrieved from Nationwide Inpatient Sample database, collected during 2010–2014. The primary outcomes of this study were adverse maternal and fetal outcomes, hospital length of stay, and hospitalization cost. There was a total of 18,687,217 delivery-related hospitalizations, of which 1,048,323 were among obese women. Obese women were more likely to have cesarean deliveries (aOR 1.70, 95% CI 1.62–1.79) and labor inductions (aOR 1.51, 95% CI 1.42–1.60), greater length of stay after cesarean deliveries (aOR 1.14, 95% CI 1.08–1.36) and vaginal deliveries (aOR 1.48, 95% CI 1.23–1.77). They were also more likely to have pregnancy-related hypertension, preeclampsia, gestational diabetes, premature rupture of membranes, chorioamnionitis, venous thromboembolism, excessive fetal growth, and fetal distress. Obese pregnant women had significantly greater risk for adverse obstetrical outcomes, which substantially increased the hospital and economic burden. Risk stratification of pregnant patients based on obesity could also help obstetricians to make better clinical decisions and improve patient outcomes.

Post-cesarean section surgical site infection and associated factors in East Gojjam zone primary hospitals, Amhara region, North West Ethiopia, 2020

PURPOSE

Maternal surgical site infection after cesarean delivery is a clinical problem which contributes to significant morbidity and mortality. In Ethiopia admissions following cesarean section due to surgical site infection have been routine activities of health care institutions but there is limited scientific evidence on both the magnitude of the problem and factors associated with it making prevention mechanisms less effective. Therefore, this study aimed to assess magnitude and risk factors of post-cesarean section surgical site infection at primary hospitals of East Gojjam Zone, Northwest Ethiopia.

METHODS

Institution-based cross sectional study with retrospective chart review was conducted from September 10-30 /2020 at 3 randomly selected primary hospitals of east Gojjam zone. The data were entered in Epi data version 3.1 and exported to Statistical Package for Social Science Software version 26. Post-cesarean section surgical site infection was measured based on disease classification and definition of the term by Center for Disease Control and Prevention. After checking for presence of multicollinarity, presence and degree of association of factors with outcome variable were computed through logistic regression analysis. Factors with P value ≤ 0.2 in bi-variable logistic regression analysis were included in the multivariable logistic regression analysis and those variables with P-value of <0.05 in multivariable analysis were considered statistically significant.

RESULT

From 622 medical records of women who underwent cesarean section, 77 (12.4%) of them developed surgical site infection. Rural residence [(AOR = 2.30, 95%CI: (1.29, 4.09)], duration of labor greater than 24hrs [(AOR = 3.48, 95%CI: (1.49, 8.09)], rupture of membrane>12hrs[(AOR = 4.61,95%CI:(2.34,9.09)], hypertension[(AOR = 3.14,95%CI:(1.29,7.59)] and preoperative Hematocrit ≤30%[(AOR = 3.22,95%CI:(1.25,8.31)] were factors significantly associated with post-cesarean section surgical site infections.

CONCLUSION

Magnitude of post-cesarean section surgical site infection was a significant problem in primary hospitals. Minimizing prolonged labor; minimize early rupture of membrane, properly managing patients with comorbidities like hypertension, strengthen prophylaxis and treatment for anemia during antenatal care and raising awareness for rural residents can reduce the problem. Zonal police makers should give emphasis to reduce its burden.

Chlorhexidine-alcohol versus povidone-iodine as preoperative skin antisepsis for prevention of surgical site infection in cesarean delivery-a pilot randomized control trial

Objectives

To compare the efficacy of chlorhexidine–alcohol and povidone–iodine as preoperative antiseptic skin preparation for prevention of surgical site infection (SSI) after cesarean delivery (CD).

Materials and methods

A total of 311 eligible women who underwent CS were recruited in the study after fulfilling all the eligibility and exclusion criteria. Patients were randomized into two groups (153 in chlorhexidine–alcohol group and 158 in povidone–iodine group) by a computer-generated randomization table. Patients were followed for a period of 30 days in postoperative period to monitor for SSI.

Results

The rate of SSI in the chlorhexidine–alcohol group is 5.4% and that of the povidone–iodine group is 8.6%. E. coli, K. pneumoniae, and Acinetobacter baumannii were the most common organisms isolated. E. coli was found in 9.5% of the total SSI cases.

Conclusions

The study found that the patients who received chlorhexidine–alcohol as skin antiseptic had less chance of developing SSI than those who received povidone–iodine; however, it did not reach a statistical significance.

Trial registration

Clinical Trials Registry of India CTRI/2018/05/014294. Registered on May 31, 2018

Delivery method of the placenta in cesarean deliveries and the effect of uterine incision repair area on morbidity: A randomized controlled study

Objective

We evaluated the effects of spontaneous or manual delivery of the placenta and repair of uterine incision inside or outside the abdomen on intraoperative blood loss, postoperative infection morbidity, and postoperative hospitalization time.

Materials and Methods

We conducted a prospective randomized controlled study with 150 patients among 160 patients who were indicated to undergo emergency cesarean procedures in our tertiary hospital. We divided the patient population into four groups. These four groups were formed by comparing the way the placenta was delivered manually and by spontaneous traction with the repair of the uterus inside and outside the abdomen. Blood loss was determined using quantitative and gravimetric methods. A numeric rating scale was used, which is a one-dimensional method used for uterine sensitivity distribution and pain measurement.

Results

The amount of bleeding was 339 mL in group 1, 237 mL in group 2, 470 mL in group 3, and 490 mL in group 4, which were significantly different (p<0.001). The mean surgical time was 30.8±5.5 minutes in group 1, 30.7±4.4 minutes in group 2, 38.5±6.9 minutes in group 3, and 43.9 minutes in group 4 (p<0.001). When the distribution of uterine tenderness among the groups was examined in the fundus examinations performed on the postpartum 1^st day of the patients, we found a significant difference (p<0.001). When all groups were compared, there was a significant difference between group 1 and group 4 in terms of hospital stay (p<0.004). Among the contributing factors were endometritis, maternal body weight (p<0.053), advanced gestational week (p<0.004), prolonged surgical time (p<0.009), and the presence of meconium.

Conclusion

Manual removal of the placenta resulted in higher blood loss, increased uterine tenderness, and longer hospitalization compared with the spontaneous separation method. The uterine incision repair site did not affect morbidity.

Peripartum infectious morbidity in women with preeclampsia

BACKGROUND

Dysregulated maternal systemic inflammatory response is a commonly accepted component in the pathogenesis of preeclampsia. Chronic inflammation then occurs characterized by oxidative stress, proinflammatory cytokine production, and abnormal T-cell function. Infection results in similar physiologic changes.

OBJECTIVE

The objective of this study was to examine the association between the diagnosis of preeclampsia and the development of chorioamnionitis, postpartum fever, endometritis and wound infection. We hypothesize that the heightened chronic inflammatory state of preeclampsia increases the risk for maternal peripartum infection.

STUDY DESIGN

This was a retrospective cohort study from the Consortium on Safe Labor (CSL). In the present analysis, we included all women from the CSL database and compared their characteristics and pregnancy outcomes between those with and without a diagnosis of preeclampsia prior to labor. Women presenting with preterm prelabor rupture of membranes or were diagnosed with preeclampsia during labor or postpartum were excluded. The primary outcome was a composite of maternal peripartum infections including intrapartum chorioamnionitis, postpartum fever, endometritis, and wound infection. This outcome was compared between women with and without a diagnosis of preeclampsia prior to labor using univariable and multivariable analyses.

RESULTS

A total of 227,052 women were eligible for the analysis, of these 14,268 (6.3%) were diagnosed with preeclampsia. In univariable analysis, the rate of composite maternal peripartum infection was higher among women with preeclampsia (4.2 versus 3.8%, p = .026). When looking at each individual component, that rates of wound infection (1.0 versus 0.5%, p < .001) and postpartum fever (8.2 versus 4.4%, p < .001) were higher among women with diagnosis of preeclampsia, whereas the rate of intrapartum chorioamnionitis was lower among women with preeclampsia (1.3 versus 1.7% p = .004). Endometritis rates did not differ between the two groups. In multivariable logistic regression, adjusted for confounding variables, including maternal race, insurance status, prepregnancy BMI, maternal age, number of fetuses, number of vaginal exams, intrauterine pressure catheter and fetal scalp electrode placement, mode of delivery, group B streptococcus positivity, maternal education level, induction of labor, prelabor rupture of membranes, tobacco use, presence of diabetes (pregestational and gestational), gestational age at delivery, and chronic hypertension, the association between preeclampsia and composite maternal peripartum infection did not persist. In fact, after controlling for these influences, women with preeclampsia showed lower rates of intrapartum chorioamnionitis (aOR 0.83, 95% CI 0.70-0.99). The rest of the individual component of the primary composite outcome, postpartum fever, endometritis, and wound infection, were not associated with the diagnosis of preeclampsia.

CONCLUSIONS

In this large cohort of women diagnosed with preeclampsia prior to labor, the rate of intrapartum chorioamnionitis was decreased and the rate of postpartum infectious morbidity was not higher compared to women without a diagnosis of preeclampsia.

RNA Sequencing Reveals Diverse Functions of Amniotic Fluid Neutrophils and Monocytes/Macrophages in Intra-Amniotic Infection

Intra-amniotic infection, the invasion of microbes into the amniotic cavity resulting in inflammation, is a clinical condition that can lead to adverse pregnancy outcomes for the mother and fetus as well as severe long-term neonatal morbidities. Despite much research focused on the consequences of intra-amniotic infection, there remains little knowledge about the innate immune cells that respond to invading microbes. We performed RNA-seq of sorted amniotic fluid neutrophils and monocytes/macrophages from women with intra-amniotic infection to determine the transcriptomic differences between these innate immune cells. Further, we sought to identify specific transcriptomic pathways that were significantly altered by the maternal or fetal origin of amniotic fluid neutrophils and monocytes/macrophages, the presence of a severe fetal inflammatory response, and pregnancy outcome (i.e., preterm or term delivery). We show that significant transcriptomic differences exist between amniotic fluid neutrophils and monocytes/macrophages from women with intra-amniotic infection, indicating the distinct roles these cells play. The transcriptome of amniotic fluid immune cells varies based on their maternal or fetal origin, and the significant transcriptomic differences between fetal and maternal monocytes/macrophages imply that those of fetal origin exhibit impaired functions. Notably, transcriptomic changes in amniotic fluid monocytes/macrophages suggest that these immune cells collaborate with neutrophils in the trafficking of fetal leukocytes throughout the umbilical cord (i.e., funisitis). Finally, amniotic fluid neutrophils and monocytes/macrophages from preterm deliveries display enhanced transcriptional activity compared to those from term deliveries, highlighting the protective role of these cells during this vulnerable period. Collectively, these findings demonstrate the underlying complexity of local innate immune responses in women with intra-amniotic infection and provide new insights into the functions of neutrophils and monocytes/macrophages in the amniotic cavity.

Risk Factors for Postcesarean Wound Infection in a Tertiary Hospital in Lagos, Nigeria

Background:

There has been a global increase in cesarean section rates. While this has improved perinatal outcome, it is associated with complications such as wound infection. We determined risk factors for cesarean section wound infection in a tertiary hospital in Lagos, Nigeria.

Materials and Methods:

We prospectively studied a cohort of 906 women who had cesarean section at the Obstetrics Unit of the Lagos State University Teaching Hospital between January 1, 2011, and December 31, 2011. A comparison was made between 176 women who had wound infection and 730 women who did not using logistic regression.

Results:

Of the 2134 deliveries during the study, 906 (42.5%) had cesarean section and of which 176 (19.4%) had wound infection. Independent risk factors for wound infection were: preoperative anemia (adjusted odds ratio [aOR] = 1.88; 95% confidence intervals [CI] = 1.03–3.41; P = 0.0396), presence of diabetes mellitus (aOR = 7.94; 95% CI = 1.60–39.27; P = 0.0111), HIV infection (aOR = 6.34; 95% CI = 1.74–23.06; P = 0.0051), prolonged operation time (aOR = 2.30; 95% CI = 1.19–4.42; P = 0.0127), excessive blood loss at surgery (aOR = 5.05; 95% CI = 2.18–11.66; P = 0.0002), and chorioamnionitis (aOR = 9.00; 95% CI = 1.37–59.32; P = 0.0224).

Conclusions:

Patients with HIV infection, diabetes mellitus, preoperative anemia and chorioamnionitis have an increased risk of postcesarean wound infection as is when surgical time exceeds 1 h or when associated with blood loss >11.

Skin and subcutaneous fascia closure at caesarean section to reduce wound complications: the closure randomised trial

BACKGROUND

Wound infection is a common complication following caesarean section. Factors influencing the risk of infection may include the suture material for skin closure, and closure of the subcutaneous fascia. We assessed the effect of skin closure with absorbable versus non-absorbable suture, and closure versus non-closure of the subcutaneous fascia on risk of wound infection following Caesarean section.

METHODS

Women undergoing caesarean birth at an Adelaide maternity hospital were eligible for recruitment to a randomised trial using a 2 × 2 factorial design. Women were randomised to either closure or non-closure of the subcutaneous fascia and to subcuticular skin closure with an absorbable or non-absorbable suture. Participants were randomised to each of the two interventions into one of 4 possible groups: Group 1 - non-absorbable skin suture and non-closure of the subcutaneous fascia; Group 2 - absorbable skin suture and non-closure of the subcutaneous fascia; Group 3 - non-absorbable skin suture and closure of the subcutaneous fascia; and Group 4 - absorbable skin suture and closure of the subcutaneous fascia. The primary outcomes were reported wound infection and wound haematoma or seroma within the first 30 days after birth.

RESULTS

A total of 851 women were recruited and randomised, with 849 women included in the analyses (Group 1: 216 women; Group 2: 212 women; Group 3: 212 women; Group 4: 211 women). In women who underwent fascia closure, there was a statistically significant increase in risk of wound infection within 30 days post-operatively for those who had skin closure with an absorbable suture (Group 4), compared with women who had skin closure with a non-absorbable suture (Group 3) (adjusted RR 2.17; 95% CI 1.05, 4.45; p = 0.035). There was no significant difference in risk of wound infection for absorbable vs non-absorbable sutures in women who did not undergo fascia closure.

CONCLUSION

The combination of subcutaneous fascia closure and skin closure with an absorbable suture may be associated with an increased risk of reported wound infection after caesarean section.

TRIAL REGISTRATION

Prospectively registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12608000143325 , on the 20th March, 2008.

Evidence that intra-amniotic infections are often the result of an ascending invasion - a molecular microbiological study

Background Microbial invasion of the amniotic cavity resulting in intra-amniotic infection is associated with obstetrical complications such as preterm labor with intact or ruptured membranes, cervical insufficiency, as well as clinical and histological chorioamnionitis. The most widely accepted pathway for intra-amniotic infection is the ascension of microorganisms from the lower genital tract. However, hematogenous dissemination of microorganisms from the oral cavity or intestine, retrograde seeding from the peritoneal cavity through the fallopian tubes, and introduction through invasive medical procedures have also been suggested as potential pathways for intra-amniotic infection. The primary reason that an ascending pathway is viewed as most common is that the microorganisms most often detected in the amniotic fluid are those that are typical inhabitants of the vagina. However, thus far, no studies have shown that microorganisms in the amniotic cavity are simultaneously present in the vagina of the woman from which they were isolated. The objective of the study was to determine the frequency with which microorganisms isolated from women with intra-amniotic infection are also present in the lower genital tract. Methods This was a cross-sectional study of women with intra-amniotic infection with intact membranes. Intra-amniotic infection was defined as a positive culture and elevated concentrations of interleukin-6 (IL-6) (>2.6 ng/mL) in amniotic fluid and/or acute histologic chorioamnionitis and funisitis. Microorganisms isolated from bacterial cultures of amniotic fluid were taxonomically identified through matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) and 16S ribosomal RNA (rRNA) gene sequencing. Vaginal swabs were obtained at the time of amniocentesis for the identification of microorganisms in the lower genital tract. The overall bacterial profiles of amniotic fluids and vaginal swabs were characterized through 16S rRNA gene sequencing. The bacterial profiles of vaginal swabs were interrogated for the presence of bacteria cultured from amniotic fluid and for the presence of prominent (>1% average relative abundance) operational taxonomic units (OTUs) within the overall 16S rRNA gene bacterial profiles of amniotic fluid. Results (1) A total of 75% (6/8) of women had bacteria cultured from their amniotic fluid that are typical residents of the vaginal ecosystem. (2) A total of 62.5% (5/8) of women with bacteria cultured from their amniotic fluid also had these bacteria present in their vagina. (3) The microorganisms cultured from amniotic fluid and also detected in the vagina were Ureaplasma urealyticum, Escherichia coli, and Streptococcus agalactiae. (4) 16S rRNA gene sequencing revealed that the amniotic fluid of women with intra-amniotic infection had bacterial profiles dominated by Sneathia, Ureaplasma, Prevotella, Lactobacillus, Escherichia, Gardnerella, Peptostreptococcus, Peptoniphilus, and Streptococcus, many of which had not been cultured from the amniotic fluid samples. (5) Seventy percent (7/10) of the prominent (>1% average relative abundance) OTUs found in amniotic fluid were also prominent in the vagina. Conclusion The majority of women with intra-amniotic infection had bacteria cultured from their amniotic fluid that were typical vaginal commensals, and these bacteria were detected within the vagina at the time of amniocentesis. Molecular microbiological interrogation of amniotic fluid from women with intra-amniotic infection revealed that the bacterial profiles of amniotic fluid were largely consistent with those of the vagina. These findings indicate that ascension from the lower genital tract is the primary pathway for intra-amniotic infection.

Intra-abdominal infection (IAI) following cesarean section: a retrospective study in a tertiary referral hospital in Egypt

BACKGROUND

The incidence of post cesarean intra-abdominal infection (IAI) and the independent risk factors associated with it were retrospectively studied at a tertiary referral hospital in Egypt.

METHODS

The study targeted the period between January 2014 and December 2017 (4 years) at Minia University Hospital for Obstetrics and Gynecology (a tertiary referral hospital), Minia Governorate, Egypt. All cases that developed IAI following cesarean section (CS) during the study period were included (408 cases, which served as the case group); in addition, 1300 cases that underwent CS during the study period and were not complicated by IAI or surgical site Infection (SSI) were randomly chosen from the records (control group). The records of cases and controls were compared and bivariate analysis and multivariate logistic regression were used to identify risk factors for IAI.

RESULTS

During the studied period, there were 35,500 deliveries in the hospital, and 14200 cases (40%) of these were by cesarean section, producing a rate of 40%. The incidence of IAI post CS was 2.87%, and the mortality rate was 1.2% (due to septicemia). The most identifiable risk factors for IAI were chorioamnionitis (AOR 9.54; 95% CI =6.15-16.2; p ≤ 0.001) and premature rupture of membranes (PROM) (AOR 7.54; 95% CI =5.69-10.24; p ≤ 0.001). Risk factors also included: prolonged duration of CS >  1 h (AOR 3.42; 95% CI =2.45-5.23; p = 0.005), no antenatal care (ANC) visits (AOR 3.14; 95% CI =2.14-4.26; p = 0.003), blood loss > 1000 ml (AOR 2.86; 95% CI =2.04-3.92; p = 0.011), emergency CS (AOR 2.24; 95% CI =1.78-3.29; p = 0.016), prolonged labor ≥24 h. (AOR 1.76; 95% CI =1.26-2.27; p = 0.034) and diabetes mellitus (AOR 1.68; 95% CI =1.11-2.39; p = 0.021).

CONCLUSIONS

The incidence of IAI post CS in our hospital was 2.87%. Identification of predictors and risk factors for IAI is an important preventive measure.

Predictors of surgical site skin infection and clinical outcome at caesarean section in the very severely obese: A retrospective cohort study

INTRODUCTION

The optimal surgical approach for caesarean section is uncertain in women with very severe obesity (body mass index (BMI) >40kg/m2). We aimed to assess maternal and surgical predictors of surgical site skin infection (SSSI) in very severely obese women and to undertake an exploratory evaluation of clinical outcomes in women with a supra-panniculus transverse compared to an infra-panniculus transverse skin incision.

MATERIAL AND METHODS

Using a retrospective cohort design, case-records were reviewed of very severely obese women with a singleton pregnancy delivered by caesarean between August 2011 and December 2015 (n = 453) in two maternity hospitals in Scotland. Logistic regression analysis was used to determine predictors for SSSI. Outcomes were compared between women who had a supra-panniculus transverse compared to infra-panniculus transverse skin incision.

RESULTS

Lower maternal age was predictive of SSSI, with current smoking status and longer wound open times being marginally significant. Maternal BMI, suture method and material demonstrated univariate associations with SSSI but were not independent predictors. Women with a supra-panniculus transverse skin incision were older (32.9 (4.4), vs. 30.6 (5.7), p = 0.002), had higher BMI (49.2 (7.1), vs. 43.3 (3.3), p<0.001), shorter gestation at delivery (days) (267.7 (14.9), vs. 274.8 (14.5), p<0.001) and higher prevalence of gestational diabetes mellitus (42.6% vs. 21.9%, p = 0.002). SSSI rates did not differ between supra-panniculus transverse (13/47; 27.7%) and infra-panniculus transverse (90/406; 22.2%; p = 0.395) skin incisions.

CONCLUSION

SSSI rates are high in very severely obese women following caesarean section, regardless of location of skin incision.

The surgical wound in infrared: thermographic profiles and early stage test-accuracy to predict surgical site infection in obese women during the first 30 days after caesarean section

Background

Prophylactic antibiotics are commonly prescribed intra-operatively after caesarean section birth, often at high doses. Even so, wound infections are not uncommon and obesity increases the risk. Currently, no independent wound assessment technology is available to stratify women to low or high risk of surgical site infection (SSI).Study Aim: to investigate the potential of non-invasive infrared thermography (IRT), performed at short times after surgery, to predict later SSI.

Methods

IRT was undertaken in hospital on day 2 with community follow up (days 7, 15, 30) after surgery. Thermal maps of wound site and abdomen were accompanied by digital photographs, the latter used for wound assessment by six experienced healthcare professionals. Confirmatory diagnosis of SSI was made on the basis of antibiotic prescribing by the woman's community physician with logistic regression models derived to model dichotomous outcomes.

Results

Fifty-three women aged 21-44 years with BMI 30.1-43.9 Kg.m- 2 were recruited. SSI rate (within 30 days) was 28%. Inter-rater variability for 'professional' opinion of wound appearance showed poor levels of agreement. Two regions of interest were interrogated; wound site and abdomen. Wound site temperature was consistently elevated (1.5 °C) above abdominal temperature with similar values at days 2,7,15 in those who did and did not, develop SSI. Mean abdominal temperature was lower in women who subsequently developed SSI; significantly so at day 7. A unit (1 °C) reduction in abdominal temperature was associated with a 3-fold raised odds of infection. The difference between the sites (wound minus abdomen temperature) was significantly associated with odds of infection; with a 1 °C widening in temperature associated with an odds ratio for SSI of 2.25 (day 2) and 2.5 (day 7). Correct predictions for wound outcome using logistic regression models ranged from 70 to 79%.

Conclusions

IRT imaging of wound and abdomen in obese women undergoing c-section improves upon visual (subjective) wound assessment. The proportion of cases correctly classified using the wound-abdominal temperature differences holds promise for precision and performance of IRT as an independent SSI prognostic tool and future technology to aid decision making in antibiotic prescribing.

Early preterm preeclampsia outcomes by intended mode of delivery

BACKGROUND

The optimal route of delivery in early-onset preeclampsia before 34 weeks is debated because many clinicians are reluctant to proceed with induction for perceived high risk of failure.

OBJECTIVE

Our objective was to investigate labor induction success rates and compare maternal and neonatal outcomes by intended mode of delivery in women with early preterm preeclampsia.

STUDY DESIGN

We identified 914 singleton pregnancies with preeclampsia in the Consortium on Safe Labor study for analysis who delivered between 24 0/7 and 33 6/7 weeks. We excluded fetal anomalies, antepartum stillbirth, or spontaneous preterm labor. Maternal and neonatal outcomes were compared between women undergoing induction of labor (n = 460) and planned cesarean delivery (n = 454) and women with successful induction of labor (n = 214) and unsuccessful induction of labor (n = 246). We calculated relative risks and 95% confidence intervals to determine outcomes by Poisson regression model with propensity score adjustment. The calculation of propensity scores considered covariates such as maternal age, gestational age, parity, body mass index, tobacco use, diabetes mellitus, chronic hypertension, hospital type and site, birthweight, history of cesarean delivery, malpresentation/breech, simplified Bishop score, insurance, marital status, and steroid use.

RESULTS

Among the 460 women with induction (50%), 47% of deliveries were vaginal. By gestational age, 24 to 27 6/7, 28 to 31 6/7, and 32 to 33 6/7, the induction of labor success rates were 38% (12 of 32), 39% (70 of 180), and 54% (132 of 248), respectively. Induction of labor compared with planned cesarean delivery was less likely to be associated with placental abruption (adjusted relative risk, 0.33; 95% confidence interval, 0.16-0.67), wound infection or separation (adjusted relative risk, 0.23; 95% confidence interval, 0.06-0.85), and neonatal asphyxia (0.12; 95% confidence interval, 0.02-0.78). Women with vaginal delivery compared with those with failed induction of labor had decreased maternal morbidity (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.82) and no difference in neonatal outcomes.

CONCLUSION

About half of women with preterm preeclampsia who attempted an induction had a successful vaginal delivery. The rate of successful vaginal delivery increases with gestational age. Successful induction has the benefit of preventing maternal and fetal comorbidities associated with previous cesarean deliveries in subsequent pregnancies. While overall rates of a composite of serious maternal and neonatal morbidity/mortality did not differ between induction of labor and planned cesarean delivery groups, women with failed induction of labor had increased maternal morbidity highlighting the complex route of delivery counseling required in this high-risk population of women.

An Assessment Scale for Patients with Postoperative Superficial Incisional Surgical Site Infection: a Cross-Sectional Study

Superficial incisional surgical site infection (SSI) is a common postoperative complication in surgical patients. The aim of this study was to assess the predictive power of an assessment scale for identifying patients at risk of superficial incisional SSI. A cross-sectional survey was conducted at the Department of Surgery at the Medical Research Institute Hospital, Alexandria University. A sample of 150 adult patients aged from 18 to 65 years, who undergoing general surgeries that had clean sutured surgical wounds, was randomly selected. Forty-six patients (30.7%) had SSI. The total score can significantly discriminate between positive and negative superficial incisional SSI patients with diagnostic accuracy of AUC (SE) = 0.66 (0.048). Each score more than the cutoff point (11.5) will increase the risk of surgical site infection development by 2.5 times (OR (95% CI) = 2.5 (1.26-3.1)). The developed assessment scale can discriminate between patients who are at risk of superficial incisional SSI and those who are not. It can be used as a preliminary screening tool for subsequent investigation for the presence of infection.

Surgical Site Infections in Emergency Abdominal Surgery at Tamale Teaching Hospital, Ghana

BACKGROUND

Surgical site infections (SSIs) result in delayed wound healing, increased use of antibiotics and increased length of hospital stay, putting remarkable physical and financial burden on patients, their relatives and the healthcare facilities. Patient-related factors, such as pre-existing colonization with antibiotic-resistant bacteria, and clinical-related factors, such as adherence to sterile techniques, contribute to the development of SSIs. The objective of this study, therefore, was to determine the SSI rate and risk factors for emergency abdominal surgeries at Tamale Teaching Hospital, Ghana.

METHODS

The study population was composed of patients undergoing emergency abdominal surgery at the Tamale Teaching Hospital between June 2010 and June 2015. Demographic and clinical data were collected and included, but was not limited to, patient age and sex, type of procedure performed, wound class (dirty or contaminated), receipt of perioperative blood transfusion, American Society of Anesthesiologists (ASA) score, presence of SSI, length of hospital stay and outcome of surgery. Standard multiple regression was used to statistically assess the independent variables for their association with SSI, and Pearson correlation coefficient was used to determine the strength of association. The beta (β) values, which had the greatest influence on the overall SSI, indicated the relative influence of the entered variable(s).

RESULTS

A total of 1011 patients underwent various emergency abdominal surgical procedures during the period of study. The β values were 0.008 for perioperative blood transfusion, 0.050 for sex, - 0.048 for ASA risk, - 0.001 for having health insurance, 0.037 for being referred from another health facility and 0.034 for age. Sex was the most distinctive contributor to SSI, while perioperative blood transfusion showed the least influence. Sex and ASA score were the best predictors of SSI occurrence. The coefficients of the P values for wound class and serum haemoglobin level (g/dL) were 0.000 and 0.032, respectively. The outcome of surgery was significantly and strongly associated with overall SSI and vice versa (r = 0.088, P < 0.01 two-tailed).

CONCLUSION

Sex, ASA score, perioperative blood transfusion, wound class and haemoglobin level can predispose to SSI.

Surgical site infections after cesarean delivery: epidemiology, prevention and treatment

Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries. Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and poses a burden to the health care system. SSIs complicate a significant number of patients who undergo CD - 2-7% will experience sound infections and 2-16% will develop endometritis. Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples. Implementation of surgical bundles in non-obstetric patients has been promising., Creating a similar patient care bundle comprised evidence-based elements in patients who undergo CD may decrease the incidence of this major complication. Each hospital has the opportunity to create its own CD surgical bundle to decrease surgical site infection.

Postcesarean wound infection: prevalence, impact, prevention, and management challenges

Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%-15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI.

Independent risk factors for surgical site infection after cesarean delivery in a rural tertiary care medical center

BACKGROUND

We aimed to determine the incidence of surgical site infection (SSI) after cesarean delivery (CD) and identify the risk factors in a rural population.

METHODS

We identified 218 SSI patients by International Classification of Disease codes and matched them with 3131 parturients (control) from the electronic record database in a time-matched retrospective quality assurance analysis.

RESULTS AND DISCUSSION

The incidence of SSI after CD was 7.0 %. Risk factors included higher body mass index (BMI) [40.30 ± 10.60 kg/m² SSI (95 % CI 38.73-41.87) vs 34.05 ± 8.24 kg/m² control (95 % CI 33.75-34.35, P < 0.001)], years of education [13.28 ± 2.44 years SSI (95 % CI 12.9-13.66) vs 14.07 ± 2.81 years control (95 % CI 13.96-14.18, P < 0.001)], number of prior births [2 (1-9) SSI vs 1 (1-11) control (P < 0.001)], tobacco use (OR 1.49; 95 % CI 1.06-2.09, P = 0.03), prior diagnosis of hypertension (OR 1.80; 95 % CI 1.34-2.42, P < 0.001), gestational diabetes (OR 1.59; 95 % CI 1.18-2.13, P = 0.003), and an emergency/STAT CD (OR 1.6; 95 % CI 1.1-2.3, P = 0.01).

CONCLUSIONS

Risk factors for SSI after CD included higher BMI, less years of education, higher prior births, tobacco use, prior diagnosis of hypertension, gestational diabetes, and emergency/STAT CD. The presence of ruptured membranes was protective against SSI.

Effectiveness and short-term safety of modified sodium hyaluronic acid-carboxymethylcellulose at cesarean delivery: a randomized trial

BACKGROUND

The rising cesarean birth rate has drawn attention to risks associated with repeat cesarean birth. Prevention of adhesions with adhesion barriers has been promoted as a way to decrease operative difficulty. However, robust data demonstrating effectiveness of such interventions are lacking.

OBJECTIVE

We report data from a multicenter trial designed to evaluate the short-term safety and effectiveness of a modified sodium hyaluronic acid (HA)-carboxymethylcellulose (CMC) absorbable adhesion barrier for reduction of adhesions following cesarean delivery.

STUDY DESIGN

Patients who underwent primary or repeat cesarean delivery were included in this multicenter, single-blinded (patient), randomized controlled trial. Patients were randomized into either HA-CMC (N = 380) or no treatment (N = 373). No other modifications to their treatment were part of the protocol. Short-term safety data were collected following randomization. The location and density of adhesions (primary outcome) were assessed at their subsequent delivery using a validated tool, which can also be used to derive an adhesion score that ranges from 0-12.

RESULTS

No differences in baseline characteristics, postoperative course, or incidence of complications between the groups following randomization were noted. Eighty patients from the HA-CMC group and 92 controls returned for subsequent deliveries. Adhesions in any location were reported in 75.6% of the HA-CMC group and 75.9% of the controls (P = .99). There was no significant difference in the median adhesion score; 2 (range 0-10) for the HA-CMC group vs 2 (range 0-8) for the control group (P = .65). One third of the HA-CMC patients met the definition for severe adhesions (adhesion score >4) compared to 15.5% in the control group (P = .052). There were no significant differences in the time from incision to delivery (P = .56). Uterine dehiscence in the next pregnancy was reported in 2 patients in HA-CMC group vs 1 in the control group (P = .60).

CONCLUSION

Although we did not identify any short-term safety concerns, HA-CMC adhesion barrier applied at cesarean delivery did not reduce adhesion formation at the subsequent cesarean delivery.

Surgical Site Infection following Cesarean Delivery: Patient, Provider, and Procedure-Specific Risk Factors

OBJECTIVE

This study aims to identify risk factors for cesarean delivery (CD) surgical site infection (SSI). study design: Retrospective analysis of 2,739 CDs performed at the University of Pittsburgh in 2011. CD SSIs were defined using National Healthcare Safety Network (NHSN) criteria. Chi-square test and t-test were used for bivariate analyses and multivariate logistic regression was used to identify SSI risk factors.

RESULTS

Of 2,739 CDs, 178 (6.5%) were complicated by SSI. Patients with a SSI were more likely to have Medicaid, have resident physicians perform the CD, an American Society of Anesthesiologists (ASA) class of ≥ 3, chorioamnionitis, tobacco use, and labor before CD. In multivariable analysis, labor (odds ratio [OR], 2.35; 95% confidence interval [95% CI], 1.65-3.38), chorioamnionitis (OR, 2.24; 95% CI, 1.25-3.83), resident teaching service (OR, 2.15; 95% CI, 1.54-3.00), tobacco use (OR, 1.70; 95% CI, 1.04-2.70), ASA class ≥ 3 (OR, 1.61; 95% CI, 1.06-2.39), and CDs performed for nonreassuring fetal status (OR, 0.43; 95% CI, 0.26-0.67) were significantly associated with CD SSI.

CONCLUSION

Multiple patient, provider, and procedure-specific risk factors contribute to CD SSI risk which may be targeted in infection-control efforts.

Risk factors for surgical site infection following cesarean section in a Brazilian Women's Hospital: a case-control study

The present study evaluated patients with diagnosis of surgical site infection (SSI) following cesarean section and their controls to determinate risk factors and impact of antibiotic prophylaxis on this condition.

Methods

All cesareans performed from January 2009 to December 2012 were evaluated for SSI, based on criteria established by CDC/NHSN. Control patients were determined after inclusion of case patients. Medical records of case and control patients were reviewed and compared regarding sociodemographic and clinical characteristics.

Results

Our study demonstrated an association following univariate analysis between post-cesarean SSI and number of internal vaginal examinations, time of membrane rupture, emergency cesarean and improper use of antibiotic prophylaxis. This same situation did not repeat itself in multivariate analysis with adjustment for risk factors, especially with regard to antibiotic prophylaxis, considering the emergency cesarean factor only.

Conclusion

The authors of the present study not only question surgical antimicrobial prophylaxis use based on data presented here and in literature, but suggest that the prophylaxis is perhaps indicated primarily in selected groups of patients undergoing cesarean section. Further research with greater number of patients and evaluated risk factors are fundamental for better understanding of the causes and evolution of surgical site infection after cesarean delivery.

Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania

Background

Surgical site infection (SSI) is the second most common infectious complication after urinary tract infection following a delivery by caesarean section (CS). At Bugando Medical Centre there has no study documenting the epidemiology of SSI after CS despite the large number of CSs performed and the relatively common occurrence of SSIs.

Methods

This was a prospective cohort study involving pregnant women who underwent a CS between October 2011 and February 2012 at Bugando Medical Centre. A total of 345 pregnant women were enrolled. Preoperative, intraoperative and postoperative data were collected using a standardized questionnaire. Wound specimens were collected and processed as per standard operative procedures; and susceptibility testing was carried out using a disc diffusion technique. Data was analyzed using STATA version 11.

Results

The overall cumulative incidence of SSI was 10.9% with an incidence rate of 37.5 per 10,000 people/day (95% CI, 26.8-52.4). The median time from CS to the development of SSI was 7 days (interquartile range [IQR] = 6–9 days). Six independent risk factors for post caesarean SSI as identified in this study by multivariate analysis are: hypertensive disorders of pregnancy (HR: 2.5; 95% CI, 1.1-5.6; P = 0.021), severe anaemia (HR: 3.8; 95% CI, 1.2-12.4, P = 0.028), surgical wound class III (HR: 2.4; 95% CI, 1.1-5.0; P = 0.021), multiple vaginal examinations (HR: 2.5; 95% CI, 1.2-5.1; P = 0.011), prolonged duration of operation (HR: 2.6; 95% CI, 1.2-5.5; P = 0.015) and an operation performed by an intern or junior doctor (HR: 4.0; 95% CI, 1.7-9.2; P = 0.001). Staphylococcus aureus was the most common organism (27.3%), followed by Klebsiella pneumoniae (22.7%). Patients with a SSI had a longer average hospital stay than those without a SSI (12.7 ± 6.9 vs. 4 ± 1.7; P < 0.0001) and the case fatality rate among patients with a SSI was 2.9%.

Conclusion

SSIs are common among women undergoing CSs at Bugando Medical Centre. SSIs were commonly associated with multiple factors. Strategies to control these factors are urgently needed to control SSIs post CS at Bugando Medical Centre and other centres in developing countries.

REMOVED: The relationship between primary cesarean delivery skin incision type and wound complications in women with morbid obesity

This article has been removed: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been removed at the request of the Editors-in-Chief and Authors. The original publication reported that univariate analysis showed that a vertical skin incision in obese women undergoing Cesarean delivery was associated with a higher odds ratio for wound complications than a transverse skin incision. Multivariable analyses showed a reversal of the association (i.e. the odds of wound complications were lower in women with a vertical skin incision). However, there was an error in the way the variable was entered in the logistic analysis. Re-analysis with the correct coding of the variable indicates that a transverse skin incision is associated with decreased odds of wound complication compared to a vertical skin incision.

Maternal obesity and risk of postcesarean wound complications

OBJECTIVE

To estimate the effect of increasing severity of obesity on postcesarean wound complications and surgical characteristics.

STUDY DESIGN

We performed a retrospective cohort study of consecutive cesarean deliveries at a tertiary care facility from 2004 to 2008. Four comparison groups were defined by body mass index (BMI; kg/cm2): < 30 (n = 728), 30 to 39.9 (n = 1,087), 40 to 49.9 (n = 428), or ≥ 50 (n = 201). The primary outcome was wound complication, defined as wound disruption or infection within 6 weeks postoperatively. Surgical characteristics were compared between groups including administration of preoperative antibiotics, type of skin incision, estimated blood loss (EBL), operative time, and type of skin closure.

RESULTS

Of the 2,444 women with complete follow-up data, 266 (10.9%) developed a wound complication. Compared with nonobese women (6.6%), increasing BMI was associated with an increased risk of wound complications: BMI 30.0 to 39.9, 9.2%, adjusted odds ratio (aOR) 1.4 (95% confidence interval [CI] 0.99 to 2.0); BMI 40.0 to 49.9, 16.8%, aOR 2.6 (95% CI 1.7 to 3.8); BMI ≥ 50, 22.9%, aOR 3.0 (95% CI 1.9 to 4.9). Increasing BMI was also associated with increased rates of midline vertical incision, longer operative time, higher EBL, and lower rates of subcuticular skin closure.

CONCLUSION

A dose-response relationship exists between increasing BMI and risk of postcesarean wound complications. Increasing obesity also significantly influences operative outcomes.

Risk factors for wound infection after lower segment cesarean section

The incidence of post caesarean wound infection and independent risk factors associated with wound infection were retrospectively studied at a tertiary care hospital. A retrospective case controlled study of 107 patients with wound infection after lower segment caesarean section (LSCS) was undertaken between January 1998 and December 2007. The control group comprised of 340 patients selected randomly from among those who had LSCS during the study period with no wound infection. Chart reviews of patients with wound infection were identified using the definitions from the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance Systems. Comparisons for categorical variables were performed using the X (2) or Fisher exact test. Continuous variables were compared using the 2-tailed Student t test. P < 0.05 was considered significant. Logistic regression determined the independent risk factors. The overall wound infection rate in the study was 4.2% among 2 541 lower transverse CS. The independent risk factors identified for wound infection were, obesity, duration of labor >12 hours, and no antenatal care. Patients' age and parity, diabetes mellitus, premature rupture of membranes (PROM) >8 hours and elective vs. emergency surgery was not found to be significantly associated with wound infection.

CONCLUSION

The independent risk factors could be incorporated into the policies for surveillance and prevention of wound infection. Antibiotic prophylaxis may be utilized in high risk patients such as PROM, obese patients and prolonged labor.

Abdominal surgical site infections: a prospective study of determinant factors in Harare, Zimbabwe

Surgical site infections (SSIs) are reported in lower frequencies in the developed countries than in the developing world. A prospective evaluation of risk factors in 285 patients undergoing abdominal surgery procedures in Zimbabwe was therefore undertaken. Overall infection rate was 26%. The age group 30-39 years had the highest number of dirty wounds and the highest rate of human immunodeficiency virus (HIV) infection. Multivariate regression analysis showed a correlation between wound class and SSI (P < 0·05). This was also noted for American Society of Anesthesiologists (ASA) score (P < 0·05). HIV-infected patients had 52% SSIs and non-infected patients had 26% (P < 0·05). Patients receiving blood transfusion had 51% SSIs and those not transfused had 17% (P < 0·01). Patients receiving pre- and intra-operative prophylactic antibiotics had 18% SSIs and those receiving postoperative administration had 37% (P < 0·01). Treatment ranged from dressings only in 11% to surgical intervention in 30% resulting in prolongation of median hospital stay from 8 to 18 days (P < 0·001). Mortality was 7%. High wound class, high ASA score, blood transfusion, HIV infection and delayed use of prophylactic antibiotics were risk factors for SSIs, resulting in surgical interventions, prolonged hospital stay and mortality.

Postpartum wound and bleeding complications in women who received peripartum anticoagulation

INTRODUCTION

The objective of this study was to compare wound and bleeding complications between women who received anticoagulation after cesarean delivery due to history of prior venous thromboembolic disease, arterial disease, or being a thrombophilia carrier with adverse pregnancy outcome, to women not receiving anticoagulation.

METHODS

Women in the Duke Thrombosis Center Registry who underwent cesarean delivery during 2003-2011 and received postpartum anticoagulation (anticoagulation group, n=77), were compared with a subset of women who delivered during the same time period, but did not receive anticoagulation (no anticoagulation group, n=77). The no anticoagulation group comprised women who were matched to the anticoagulation group by age, body mass index, type of cesarean (no labor vs. labor), and date of delivery. Bleeding and wound complications were compared between the two groups. A multivariable logistic regression model was constructed to determine if anticoagulation was an independent predictor of wound complication.

RESULTS

Women who received anticoagulation during pregnancy had a greater incidence of wound complications compared to those who did not (30% vs. 8%, p<0.001). Using multivariable logistic regression, while controlling for race, diabetes, chorioamnionitis, and aspirin use, anticoagulation predicted the development of any wound complication (OR 5.8, 95% CI 2.2, 17.6), but there were no differences in the mean estimated blood loss at delivery (782 vs. 778 ml, p=0.91), change in postpartum hematocrit (5.4 vs. 5.2%, p=0.772), or percent of women receiving blood products (6.5 vs. 1.3%, p=0.209) between the two groups.

CONCLUSIONS

Anticoagulation following cesarean delivery is associated with an increased risk of post-cesarean wound complications, but not other postpartum bleeding complications.

Association of smoking with wound complications after cesarean delivery

OBJECTIVE

To determine whether smoking is an independent risk factor for wound dehiscence after cesarean delivery.

METHODS

In this case-control study, medical records were reviewed for all patients with wound dehiscence after cesarean delivery during a 7-month period. Wound dehiscence was defined as separation of wound edges requiring treatment. Three control patients without such complications were randomly selected for each case patient. Univariate associations were assessed using t test or Fisher's exact test; univariate odds ratios (OR) and 95% confidence intervals (CI) were calculated with logistic regression. Multivariate associations were assessed with logistic regression on variables with a univariate association significant at p ≤ 0.10.

RESULTS

Of 597 cesarean deliveries, 30 cases (5 %) with wound dehiscence were identified. As individual variables, smoking (46.7 vs. 21.1%, p < 0.01, cases vs. controls), histological chorioamnionitis (27.6 vs. 6.7%, p < 0.01) and preoperative hematocrit (34.0 ± 3.2 vs. 35.4 ± 3.4, p < 0.05) were significantly associated with wound complications. In a multivariate logistic regression model, only smoking (OR 5.32; 95% CI 1.77-15.97, p < 0.01) and histological chorioamnionitis (OR 5.62; 95% CI 1.43-22.11, p < 0.01) were independently associated with wound dehiscence.

CONCLUSIONS

Smoking and histological chorioamnionitis are independently associated with wound dehiscence after cesarean delivery.

Cesarean section in morbidly obese parturients: practical implications and complications

The prevalence of obesity has reached pandemic proportions across nations. Morbid obesity has a dramatic impact on pregnancy outcome. Cesarean section in these women poses many surgical, anesthetic, and logistical challenges. In view of the increased risk of cesarean delivery in morbidly obese women, the practical implications and complications are reviewed in this article. A Medline search was conducted to review the recent relevant articles in english literature on cesarean section in morbidly obese women. The types of incisions and techniques used during cesarean delivery, intra-operative and postpartum complications, anesthetic and logistical issues, maternal morbidity and mortality were reviewed. Morbidly obese women with a body mass index (BMI >40 kg/m(2) are at increased risk of pregnancy complications and a significantly increased rate of cesarean delivery. Low transverse skin incisions and transverse uterine incisions are definitely superior and must be the first option. Closure of the subcutaneous layer is recommended, but the placement of subcutaneous drains remains controversial. Thromboprophylaxis adjusted to body weight and prophylactic antibiotics help in reducing postpartum morbidity. Morbidly obese women are at increased risk of postpartum infectious morbidity. Weight reduction in the postpartum period and thereafter must be strongly encouraged for optimal future pregnancy outcomes and well-being.

Wound infection in the obese pregnant woman

Obesity has been linked as a risk factor for wound complications and is becoming a more common occurrence. We reviewed the risk factors, preventive strategies, and recommended management of wound complications in obese women undergoing cesarean delivery. The limited available data support the use of prophylactic antibiotic before cesarean delivery, closure of subcutaneous space >2 cm, and maintaining normothermia intraoperatively to help reduce the incidence of postoperative wound complications. Data regarding management of cesarean wound complications in the obese patient are sparse, but they do suggest either primary or secondary closure of wounds is preferred to healing by secondary intention. Antibiotics should be administered in the presence of cellulitis or systemic toxicity. Use of vacuum-assisted wound closure devices may be useful in wound management. There is a need for randomized controlled trials which evaluate the prevention and management of wound complications in obese women undergoing cesarean delivery.

Obesity, diabetes, and the risk of infections diagnosed in hospital and post-discharge infections after cesarean section: a prospective cohort study

OBJECTIVE

To assess the impact of obesity and diabetes on the risk of post-cesarean infections.

DESIGN

Prospective cohort study.

SETTING

Obstetric departments at three hospitals in Denmark.

POPULATION

2,492 consecutive women having cesarean section (CS) from February 2007 to August 2008.

METHODS

We collected complete data from medical records and databases on CS, body mass index, diabetes (type 1, type 2, and gestational), and post-cesarean infections. Post-discharge infections diagnosed by general practitioners were ascertained through positive microbiological cultures and antibiotic prescriptions.

MAIN OUTCOME MEASURES

Cumulative incidences of infections within 30 days after CS.

RESULTS

Of 2,492 women having CS, 373 (15.2%) were obese and 123 (4.9%) had diabetes. Overall, 458 women (18.4%) had a post-cesarean infection within 30 days and 174 (7.0%) were diagnosed in-hospital. The risk of post-cesarean infections was higher among obese than non-obese women: adjusted (for diabetes and emergency/elective CS) odds ratio (OR)=1.43; 95% confidence interval (CI): 1.09-1.88, particularly for in-hospital infections (OR=1.86; 95%CI: 1.28-2.72). After controlling for obesity and mode of CS, type 2 or gestational diabetes were weak predictors of infection risk (OR=1.18; 95%CI: 0.72-1.93), whereas the adjusted OR in women with type 1 diabetes was 1.65 (95%CI: 0.64-4.25). Among diabetic women, obesity increased the risk of post-cesarean infections more than twofold; the adjusted ORs were 2.06 (95%CI: 1.13-3.75) for infections overall and 2.74 (95%CI: 1.25-6.01) for in-hospital infections.

CONCLUSION

Obesity increases the risk of post-cesarean infections and diabetes further strengthens this association.

Preoperative infliximab is not associated with an increased risk of short-term postoperative complications after restorative proctocolectomy and ileal pouch-anal anastomosis

INTRODUCTION

Considerable controversy exists over whether the preoperative use of infliximab (IFX) for refractory ulcerative colitis (UC) increases the risk for surgical complications after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this study was to assess the association between preoperative IFX use and short-term surgical complications in a single-surgeon cohort at a tertiary care academic center.

METHODS

UC patients who underwent IPAA from September 2005 through May 2009 were retrospectively identified. Twenty-nine patients treated with IFX within 12 weeks of surgery and 52 non-IFX control subjects were identified. Short-term postoperative outcomes were compared between groups occurring within 30 days of loop ileostomy closure.

RESULTS

Patients were similar with respect to demographics, co-morbidities, rate of emergency surgery, hand-sewn anastomosis, and preoperative use of cyclosporine, azathioprine, and high-dose steroids. IFX patients were more likely to have received a laparoscopic hand-assisted IPAA, low-, medium-, and any-dose steroids, 6-mercaptopurine (6-MP), methotrexate, and to have failed medical therapy. There was no short-term mortality. Overall postoperative and infectious complications were similar between IFX and non-IFX groups. Multivariate regression models revealed no independent predictors for postoperative complications when including IFX [odds ratio (OR) 0.78, p = 0.67], laparoscopic hand-assisted IPAA, 6-MP, methotrexate, steroids, failure of medical therapy, and body mass index.

CONCLUSIONS

Preoperative IFX use was not associated with an increased risk of short-term postoperative complications after IPAA.

Current debate on the use of antibiotic prophylaxis for caesarean section

Caesarean delivery is frequently complicated by surgical site infections, endometritis and urinary tract infection. Most surgical site infections occur after discharge from the hospital, and are increasingly being used as performance indicators. Worldwide, the rate of caesarean delivery is increasing. Evidence-based guidelines recommended the use of prophylactic antibiotics before surgical incision. An exception is made for caesarean delivery, where narrow-range antibiotics are administered after umbilical cord clamping because of putative neonatal benefit. However, recent evidence supports the use of pre-incision, broad-spectrum antibiotics, which result in a lower rate of maternal morbidity with no disadvantage to the neonate.

Obstetrical and neonatal outcomes in obese parturients

OBJECTIVE

Obstetrical risk is increased with maternal obesity. This prospective study was designed to simultaneously evaluate the outcomes in obese parturients and their newborns.

METHODS

Patients with a body mass index (BMI) > or =35 were prospectively identified and compared to an equal number of normal weight parturients. Maternal and neonatal outcome measures were compared for the peripartum and neonatal period.

RESULTS

We identified 580 obese parturients over a 6 month period and compared them to an equal number of normal weight parturients. The incidence of obesity in this population was 23%. Obesity was associated with increased rates of hypertension, diabetes, and cesarean section. Obese patients were more likely to develop postpartum complications. Neonatal outcomes were compared for infants > or =37 weeks gestation excluding multiple births (496 neonates in the obese group and 520 in the control group). The neonates of obese parturients were more likely to be macrosomic, have 1-minute Apgar scores of < or =7.0 and require admission to a special care unit. Sub-group analysis showed that negative outcomes for parturients and their neonates correlated with increasing BMI. Neonates born to obese diabetic parturients had the highest risk of poor outcomes.

CONCLUSIONS

Maternal obesity confers increased risks for both the parturient and their newborn.

Complications of cesarean delivery in the massively obese parturient

OBJECTIVE

The objective of the study was to determine predictors of cesarean delivery morbidity associated with massive obesity.

STUDY DESIGN

This was an institutional review board-approved retrospective study of massively obese women (body mass index, > or = 50 kg/m(2)) undergoing cesarean delivery. Bivariable and multivariable analyses were used to assess the strength of association between wound complication and various predictors.

RESULTS

Fifty-eight of 194 patients (30%) had a wound complication. Most (90%) were wound disruptions, and 86% were diagnosed after hospital discharge (median postoperative day, 8.5; interquartile range, 6-12). Subcutaneous drains and smoking, but not labor or ruptured membranes, were independently associated with wound complication after controlling for various confounders. Vertical abdominal incisions were associated with increased operative time, blood loss, and vertical hysterotomy.

CONCLUSION

Women with a body mass index > or = 50 kg/m(2) have a much greater risk for cesarean wound complications than previously reported. Avoidance of subcutaneous drains and increased use of transverse abdominal wall incisions should be considered in massively obese parturients to reduce operative morbidity.

Educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduce cesarean section surgical site infections

BACKGROUND

In 2005, of the approximately 4 million births in the United States, 30% were by cesarean section (C-section) delivery, which translates to roughly over 1 million C-sections in 2005 alone. C-section is associated with higher morbidity than vaginal delivery. Women who undergo C-section are 5 times more likely to develop a postpartum infection after delivery than women who undergo vaginal delivery.

OBJECTIVE

Estimates of surgical site infection (SSI) after C-section range from 1.50 to 2.64. A quality improvement initiative was implemented at the University of Minnesota Medical School to reduce rates of SSI using changes based on recommended care initiatives.

METHODS

The multidisciplinary team developed a comprehensive staff education and training program, added a preoperative skin preparation protocol using chlorhexidine gluconate (CHG) no-rinse cloths, added CHG with alcohol for interoperative skin preparation, and modified instrument sterilization techniques.

RESULTS

Data analysis revealed a statistically significant reduction in the overall SSI rate from 7.5% (33/441) in January-July 2006 to 1.2% (5/436) in January-July 2007 (chi(2) test statistic, 21.2; P < .001; relative reduction of 84%).

CONCLUSION

Interventions, including staff education, use of CHG no-rinse cloths for preoperative skin prep, CHG with alcohol for intraoperative skin prep, and appropriate instrument sterilization management led to reductions in SSI rates in patients undergoing C-section at our institution. Rates of endometritis were also noted to be lower after implementation of the interventions.