- Email: [email protected]
228: Impact of extended-spectrum antibiotic prophylaxis on incidence of post-cesarean surgical wound infection
SMFM Abstracts
www.AJOG.org 225
DELIVERING TERM BREECH VAGINALLY BY STRICT PROTOCOL: COMPARABLE TO CESAREAN FOR NEONATE; SUPERIOR TO CESAREAN FOR MOTHER RACHEL MICHAELSON-COHEN1, SORINA GRISARU-GRANOVSKY1, TAMAR HALEVY-SHALEM1, AHARON TEVET1, ARNON SAMUELOFF1, 1Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel OBJECTIVE: Planned cesarean section (CS) has become the customary approach for delivery of the fetus in breech presentation at term. We aimed to assess whether the increase in the CS rate has improved neonatal outcome without compromising maternal outcome. STUDY DESIGN: We compared breech delivery prior to and after the Term Breech Trial (1996, 2005 respectively). During both periods vaginal delivery (VD) was managed by our strict dynamic protocol, which includes selection criteria (EFW 2500-3800g, flexion of fetal head, frank/complete breech presentation, adequate maternal pelvis, cooperative patient, lack of perinatal complications) with reevaluation during each stage (adequate labor progression, normal fetal monitoring). Primary outcomes were perinatal mortality or serious morbidity, and maternal mortality or serious morbidity. Analysis was by intention to treat. RESULTS: In our tertiary center there were 5,814 deliveries in 1996, 178 (3.1%) breech presentation; 115 (64.6%) were planned CS and 63 (35.4%) were planned VD. There were 10,621 deliveries in 2005, 292 (2.7%) were breech presentation; 264(90.4%) were planned CS; 28(9.6%) were planned VD. Thus, planned VD decreased from 35.4% to 9.6%. 98.3% vs. 98.9% of planned CS were delivered by CS in 1996 and 2005, respectively. 68.3% vs. 32.1% of those with planned VD were delivered vaginally in the first and second study period, respectively. Perinatal outcome did not differ between the two periods. There were no low Apgar scores, major perinatal trauma cases, extended NICU admissions or perinatal deaths. Maternal morbidity was significantly higher in the later period, with an overall 16.4% increase in any adverse outcome (extended hospitalization length, postpartum fever, wound infection, blood transfusion, pneumonia, deep vein thrombosis and intestinal obstruction increased by 7.1%, 5.0%, 1.5%, 1.2%, 0.8%, 0.4% and 0.4%, respectively, P⬍0.05 ). CONCLUSION: The maternal risks of planned CS for breech presentation at term are unwarranted given comparable neonatal outcome when delivering vaginally by a strict protocol.
227
EFFECT OF TWO VS ONE STITCH ON THE PREVENTION OF PRETERM BIRTH IN WOMEN WITH SINGLETON PREGNANCIES UNDERGOING ELECTIVE CERVICAL CERCLAGE PLACEMENT KARLIJN WOENSDREGT1, ERROL NORWITZ1, MICHAEL CACKOVIC1, MICHAEL PAIDAS1, JESSICA ILLUZZI1, 1Yale University, New Haven, Connecticut OBJECTIVE: Cervical cerclage remains the treatment of choice for women with cervical insufficiency, but the ideal technique has yet to be established. This study investigates whether placement of two stitches is more effective than a single stitch in preventing preterm birth in singleton pregnancies undergoing elective cerclage placement. STUDY DESIGN: We conducted a retrospective review of all women with singleton pregnancies who received an elective cerclage for a history of cervical insufficiency or sonographic cervical shortening at Yale-New Haven Hospital from Jan 1995 to Dec 2005. If more than one pregnancy per patient was identified, the first pregnancy was selected. The primary outcome of interest was gestational age (GA) at delivery. Secondary outcomes included complications of placement, indication for cerclage removal, GA at removal, GA at rupture of membranes (ROM), type of delivery, and neonatal outcome. Statistical analysis was performed using Student’s t test, Chi-square, Mann-Whitney-Wilcoxon test, and logistic regression. p⬍0.05 defined statistical significance. RESULTS: Of the 150 patients who met inclusion for analysis, 112 (74.7%) received one stitch and 38 (25.3%) received 2 stitches. There were no demographic differences between the two groups as regards maternal age, parity, prior obstetric history, prior cervical surgery, and indications for cerclage. Data analysis showed no significant difference in GA at delivery between the 1 vs 2 cerclage groups overall (38.0 vs 38.3 weeks, respectively [median; p⫽0.356]) or for a given GA cut-off (⬍37 weeks: 37.4% vs 34.2% [p⫽0.727]; ⬍34 weeks: 16.8% vs 18.4% [p⫽0.823]; ⬍28 weeks: 9.4% vs 2.6% [p⫽0.179]). Analysis of secondary outcomes demonstrated no significant difference between the number of stitches and complications of placement, indications for cerclage removal, GA at removal, GA at ROM, route of delivery, and neonatal outcome. CONCLUSION: This study shows no benefit to the placement of two stitches over one stitch at the time of elective cervical cerclage placement in women with a singleton pregnancy. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.241
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.239 228 226
INTRAFETAL RADIOFREQUENCY ABLATION IN PREGNANCIES COMPLICATED BY SEVERE TWIN TWIN TRANSFUSION SYNDROME JEFFREY LIVINGSTON1, MOUNIRA HABLI2, FOONG.YEN LIM3, ANNETTE BOMBRYS2, WILLIAM POLZIN4, TIMOTHY CROMBLEHOLME3, 1University of Cincinnati, Fetal Care Center, Cincinnati, Ohio, 2 University of Cincinnati, Maternal Fetal Medicine, Cincinnati, Ohio, 3Cincinnati Children’s Hospital Medical Center, Fetal Care Center, Cincinnati, Ohio, 4Good Samaritan Hospital, Maternal Fetal Medicine, Cincinnati, Ohio OBJECTIVE: To evaluate perinatal survival in pregnancies treated with intrafetal radiofrequency ablation (RFA) for severe twin twin transfusion syndrome (TTTS) STUDY DESIGN: A retrospective chart review was conducted on pregnancies treated with RFA for severe TTTS between 2005-2007. All were evaluated with ultrasound, ultrafast MRI, and echocardiogram. Staging and severity of recipient twin cardiomyopathy was by the Cincinnati modification of the Quintero system. Placental insufficiency was defined as growth ⬍5% with increased head to abdominal circumference. RESULTS: Fourteen (twin n⫽13, triplet n⫽1) pregnancies were treated with RFA. Indications for treatment in 7 were stage IV TTTS ( hydrops fetalis in donor n⫽2, in recipient n⫽5), ishemic / hemorrrhagic brain injury in a recipient with stage IIIC (n⫽2), severe donor growth restriction (n⫽4), and 1 donor with hindbrain herniation into a large encephalocele with stage IIIC. Overall co-twin survival at 30 days postnatal was high [14/15(93%)]. Intraoperative co-twin demise occured in 1 recipient immediately after the donor RFA for IUGR. Median delivery was at 33 wks (range 24-39). Only 1 early preterm birth occurred at ⬍ 28 wks. Route of delivery was vaginal in 8/14 (57%). CONCLUSION: RFA for severe TTTS has high rates of co-twin survival.
IMPACT OF EXTENDED-SPECTRUM ANTIBIOTIC PROPHYLAXIS ON INCIDENCE OF POST-CESAREAN SURGICAL WOUND INFECTION ALAN TITA1, JOHN OWEN1, A. STAMM2, JOHN HAUTH1, WILLIAM ANDREWS1, 1University of Alabama at Birmingham, Obstetrics and Gynecology, Birmingham, Alabama, 2University of Alabama at Birmingham, Internal Medicine, Birmingham, Alabama OBJECTIVE: Ureaplasma is disproportionately isolated in post-cesarean endometritis and wound infections. Extended-spectrum antibiotic prophylaxis to cover for Ureaplasma reduced rates of both endometritis and surgical wound infections (SWIs) in a published trial. Herein we describe the institutional impact of extended-spectrum prophylaxis on postcesarean SWIs. STUDY DESIGN: Incidence of post-cesarean SWIs, ascertained at our institution by prospective infection control surveillance following CDC protocols, was compared for 3 periods of cesarean antibiotic prophylaxis: 1). narrow-spectrum with 1st or 2nd generation cephalosporin (1992-96), 2). clinical trial of extended-spectrum with addition of intravenous doxycycline and oral azithromycin (1997-99), and 3). routine use of extended-spectrum with addition of intravenous azithromycin (2001-2006). Year 2000 marked the period between the end of the trial and the introduction of routine extended prophylaxis. Infection surveillance was performed year-round until 1997, for 6 months in 1999 and for 3 months/year since 2000. For logistic reasons surveillance was not performed in 1998 and 2001. RESULTS: Post-cesarean SWIs decreased from ⬃4% in 1992 to ⬃0% (3-month surveillance) in 2006 (Figure). Cumulative incidence of SWIs decreased from 3.1% (102/3292) during the period of narrow-spectrum prophylaxis to 2.4% (22/926) during the clinical trial, and to 1.3% (15/10292) with routine use of extendedspectrum prophylaxis; p-value for trend test ⬍ 0.002.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.240
CONCLUSION: There was a significant decreasing trend in post-cesarean SWIs coincident with the introduction of extended-spectrum prophylaxis. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.242
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S75
www.AJOG.org 225
DELIVERING TERM BREECH VAGINALLY BY STRICT PROTOCOL: COMPARABLE TO CESAREAN FOR NEONATE; SUPERIOR TO CESAREAN FOR MOTHER RACHEL MICHAELSON-COHEN1, SORINA GRISARU-GRANOVSKY1, TAMAR HALEVY-SHALEM1, AHARON TEVET1, ARNON SAMUELOFF1, 1Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel OBJECTIVE: Planned cesarean section (CS) has become the customary approach for delivery of the fetus in breech presentation at term. We aimed to assess whether the increase in the CS rate has improved neonatal outcome without compromising maternal outcome. STUDY DESIGN: We compared breech delivery prior to and after the Term Breech Trial (1996, 2005 respectively). During both periods vaginal delivery (VD) was managed by our strict dynamic protocol, which includes selection criteria (EFW 2500-3800g, flexion of fetal head, frank/complete breech presentation, adequate maternal pelvis, cooperative patient, lack of perinatal complications) with reevaluation during each stage (adequate labor progression, normal fetal monitoring). Primary outcomes were perinatal mortality or serious morbidity, and maternal mortality or serious morbidity. Analysis was by intention to treat. RESULTS: In our tertiary center there were 5,814 deliveries in 1996, 178 (3.1%) breech presentation; 115 (64.6%) were planned CS and 63 (35.4%) were planned VD. There were 10,621 deliveries in 2005, 292 (2.7%) were breech presentation; 264(90.4%) were planned CS; 28(9.6%) were planned VD. Thus, planned VD decreased from 35.4% to 9.6%. 98.3% vs. 98.9% of planned CS were delivered by CS in 1996 and 2005, respectively. 68.3% vs. 32.1% of those with planned VD were delivered vaginally in the first and second study period, respectively. Perinatal outcome did not differ between the two periods. There were no low Apgar scores, major perinatal trauma cases, extended NICU admissions or perinatal deaths. Maternal morbidity was significantly higher in the later period, with an overall 16.4% increase in any adverse outcome (extended hospitalization length, postpartum fever, wound infection, blood transfusion, pneumonia, deep vein thrombosis and intestinal obstruction increased by 7.1%, 5.0%, 1.5%, 1.2%, 0.8%, 0.4% and 0.4%, respectively, P⬍0.05 ). CONCLUSION: The maternal risks of planned CS for breech presentation at term are unwarranted given comparable neonatal outcome when delivering vaginally by a strict protocol.
227
EFFECT OF TWO VS ONE STITCH ON THE PREVENTION OF PRETERM BIRTH IN WOMEN WITH SINGLETON PREGNANCIES UNDERGOING ELECTIVE CERVICAL CERCLAGE PLACEMENT KARLIJN WOENSDREGT1, ERROL NORWITZ1, MICHAEL CACKOVIC1, MICHAEL PAIDAS1, JESSICA ILLUZZI1, 1Yale University, New Haven, Connecticut OBJECTIVE: Cervical cerclage remains the treatment of choice for women with cervical insufficiency, but the ideal technique has yet to be established. This study investigates whether placement of two stitches is more effective than a single stitch in preventing preterm birth in singleton pregnancies undergoing elective cerclage placement. STUDY DESIGN: We conducted a retrospective review of all women with singleton pregnancies who received an elective cerclage for a history of cervical insufficiency or sonographic cervical shortening at Yale-New Haven Hospital from Jan 1995 to Dec 2005. If more than one pregnancy per patient was identified, the first pregnancy was selected. The primary outcome of interest was gestational age (GA) at delivery. Secondary outcomes included complications of placement, indication for cerclage removal, GA at removal, GA at rupture of membranes (ROM), type of delivery, and neonatal outcome. Statistical analysis was performed using Student’s t test, Chi-square, Mann-Whitney-Wilcoxon test, and logistic regression. p⬍0.05 defined statistical significance. RESULTS: Of the 150 patients who met inclusion for analysis, 112 (74.7%) received one stitch and 38 (25.3%) received 2 stitches. There were no demographic differences between the two groups as regards maternal age, parity, prior obstetric history, prior cervical surgery, and indications for cerclage. Data analysis showed no significant difference in GA at delivery between the 1 vs 2 cerclage groups overall (38.0 vs 38.3 weeks, respectively [median; p⫽0.356]) or for a given GA cut-off (⬍37 weeks: 37.4% vs 34.2% [p⫽0.727]; ⬍34 weeks: 16.8% vs 18.4% [p⫽0.823]; ⬍28 weeks: 9.4% vs 2.6% [p⫽0.179]). Analysis of secondary outcomes demonstrated no significant difference between the number of stitches and complications of placement, indications for cerclage removal, GA at removal, GA at ROM, route of delivery, and neonatal outcome. CONCLUSION: This study shows no benefit to the placement of two stitches over one stitch at the time of elective cervical cerclage placement in women with a singleton pregnancy. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.241
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.239 228 226
INTRAFETAL RADIOFREQUENCY ABLATION IN PREGNANCIES COMPLICATED BY SEVERE TWIN TWIN TRANSFUSION SYNDROME JEFFREY LIVINGSTON1, MOUNIRA HABLI2, FOONG.YEN LIM3, ANNETTE BOMBRYS2, WILLIAM POLZIN4, TIMOTHY CROMBLEHOLME3, 1University of Cincinnati, Fetal Care Center, Cincinnati, Ohio, 2 University of Cincinnati, Maternal Fetal Medicine, Cincinnati, Ohio, 3Cincinnati Children’s Hospital Medical Center, Fetal Care Center, Cincinnati, Ohio, 4Good Samaritan Hospital, Maternal Fetal Medicine, Cincinnati, Ohio OBJECTIVE: To evaluate perinatal survival in pregnancies treated with intrafetal radiofrequency ablation (RFA) for severe twin twin transfusion syndrome (TTTS) STUDY DESIGN: A retrospective chart review was conducted on pregnancies treated with RFA for severe TTTS between 2005-2007. All were evaluated with ultrasound, ultrafast MRI, and echocardiogram. Staging and severity of recipient twin cardiomyopathy was by the Cincinnati modification of the Quintero system. Placental insufficiency was defined as growth ⬍5% with increased head to abdominal circumference. RESULTS: Fourteen (twin n⫽13, triplet n⫽1) pregnancies were treated with RFA. Indications for treatment in 7 were stage IV TTTS ( hydrops fetalis in donor n⫽2, in recipient n⫽5), ishemic / hemorrrhagic brain injury in a recipient with stage IIIC (n⫽2), severe donor growth restriction (n⫽4), and 1 donor with hindbrain herniation into a large encephalocele with stage IIIC. Overall co-twin survival at 30 days postnatal was high [14/15(93%)]. Intraoperative co-twin demise occured in 1 recipient immediately after the donor RFA for IUGR. Median delivery was at 33 wks (range 24-39). Only 1 early preterm birth occurred at ⬍ 28 wks. Route of delivery was vaginal in 8/14 (57%). CONCLUSION: RFA for severe TTTS has high rates of co-twin survival.
IMPACT OF EXTENDED-SPECTRUM ANTIBIOTIC PROPHYLAXIS ON INCIDENCE OF POST-CESAREAN SURGICAL WOUND INFECTION ALAN TITA1, JOHN OWEN1, A. STAMM2, JOHN HAUTH1, WILLIAM ANDREWS1, 1University of Alabama at Birmingham, Obstetrics and Gynecology, Birmingham, Alabama, 2University of Alabama at Birmingham, Internal Medicine, Birmingham, Alabama OBJECTIVE: Ureaplasma is disproportionately isolated in post-cesarean endometritis and wound infections. Extended-spectrum antibiotic prophylaxis to cover for Ureaplasma reduced rates of both endometritis and surgical wound infections (SWIs) in a published trial. Herein we describe the institutional impact of extended-spectrum prophylaxis on postcesarean SWIs. STUDY DESIGN: Incidence of post-cesarean SWIs, ascertained at our institution by prospective infection control surveillance following CDC protocols, was compared for 3 periods of cesarean antibiotic prophylaxis: 1). narrow-spectrum with 1st or 2nd generation cephalosporin (1992-96), 2). clinical trial of extended-spectrum with addition of intravenous doxycycline and oral azithromycin (1997-99), and 3). routine use of extended-spectrum with addition of intravenous azithromycin (2001-2006). Year 2000 marked the period between the end of the trial and the introduction of routine extended prophylaxis. Infection surveillance was performed year-round until 1997, for 6 months in 1999 and for 3 months/year since 2000. For logistic reasons surveillance was not performed in 1998 and 2001. RESULTS: Post-cesarean SWIs decreased from ⬃4% in 1992 to ⬃0% (3-month surveillance) in 2006 (Figure). Cumulative incidence of SWIs decreased from 3.1% (102/3292) during the period of narrow-spectrum prophylaxis to 2.4% (22/926) during the clinical trial, and to 1.3% (15/10292) with routine use of extendedspectrum prophylaxis; p-value for trend test ⬍ 0.002.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.240
CONCLUSION: There was a significant decreasing trend in post-cesarean SWIs coincident with the introduction of extended-spectrum prophylaxis. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.242
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S75