Fetal and maternal inflammatory response in the setting of maternal intrapartum fever with and without clinical and histologic chorioamnionitis.

BACKGROUND: Both infectious and noninfectious causes of maternal fever have been linked to adverse neonatal outcomes including low Apg0ar scores, respiratory distress, hypotonia, and neonatal seizures. Even in the absence of infection, the occurrence of intrapartum fever is a strong risk factor for poor long-term neonatal developmental outcomes, including encephalopathy, cerebral palsy, and neonatal death. OBJECTIVE: The primary objective of this study was to compare intrapartum and postpartum maternal and fetal umbilical cord serum levels of cytokines RANTES, interferon-É£, interleukin-1ß, interleukin-2, interleukin-4, interleukin-6, interleukin-8, interleukin-10, interleukin-13, and tumor necrosis factor-α among nonfebrile patients, febrile patients without clinical chorioamnionitis, and febrile patient with clinical chorioamnionitis. STUDY DESIGN: This study was conducted at the Richmond University Medical Center from May 15, 2020 to July 16, 2019. During this time, we recruited 30 nonfebrile patients at >36 gestational weeks who were in labor and collected umbilical cord and pre- and postdelivery maternal serum samples to evaluate the cytokine levels. Placentas were collected for pathologic review and to evaluate the histopathologic findings. These results were compared with 121 patients who developed a fever of >38°C during labor. The febrile patients were further divided based on the presence or absence of clinical chorioamnionitis. A secondary analysis was performed based on the presence of absence of histologic chorioamnionitis. Statistical analysis was performed using IBM Statistical Package for the Social Sciences version 25.0. For the 3 group comparisons, a P value of <.017 was considered statistically significant after application of a Bonferroni correction. RESULTS: A total of 151 patients were included in the study; 30 were nonfebrile patients, 46 were febrile patients with a diagnosis of clinical chorioamnionitis, and 75 were febrile patients without clinical chorioamnionitis. Compared with nonfebrile patients, umbilical cord serum interferon-É£, interleukin-1ß, interleukin-6, interleukin-8, RANTES, and tumor necrosis factor-α levels were elevated in the presence of maternal hyperthermia irrespective of the diagnosis of clinical chorioamnionitis. Interleukin-6 umbilical cord levels were more than doubled from 63.60 pg/mL (6.09-1769.03 pg/mL) in febrile patients with no clinical chorioamnionitis to 135.77 pg/mL (1.86-6004.78 pg/mL) in febrile patients with clinical chorioamnionitis, making it the only cytokine that was significantly different between these 2 groups. When comparing the intrapartum maternal serum, we found a significant elevation in the interleukin-10, RANTES, and tumor necrosis factor-α levels in the febrile group irrespective of the presence of clinical chorioamnionitis when compared with the nonfebrile group. In the postpartum maternal blood evaluations, tumor necrosis factor-α was the only cytokine that was significantly higher in febrile patients than in nonfebrile controls. CONCLUSION: In the setting of intrapartum fever, maternal cytokine profiles were similar irrespective of the diagnosis of clinical chorioamnionitis. Even in the absence of clinical or histologic chorioamnionitis, maternal hyperthermia induced elevations in fetal cytokines.

Autoimmune progesterone dermatitis following vaginal progesterone exposure in pregnancy.

In the non-pregnant state, exogenous as well as endogenous fluctuations of progesterone have been demonstrated to cause a rare delayed hypersensitivity reaction known as autoimmune progesterone dermatitis. We describe the case of a 20-year-old woman in her second pregnancy who presented to our delivery unit at 31 weeks and 3 days gestation for a cutaneous breakout with pruritic pustules, blisters, and crusts across her chest back and extremities 23 days after the initiation of vaginal progesterone. After suspension of the vaginal progesterone, the patient's cutaneous lesions resolved. Differential diagnosis and management strategies are discussed. With the increased use of progesterone during pregnancy, complications arising from their use will rise. Clinicians should be aware of their potential adverse effects and consider autoimmune progesterone dermatitis in the differential diagnosis of patients presenting with pruritic lesion in pregnancy.

Vaginal cleansing with chlorhexidine gluconate or povidone-iodine prior to cesarean delivery: a randomized comparator-controlled trial.

BACKGROUND: Several randomized controlled trials have demonstrated that preoperative abdominal skin preparation with chlorhexidine gluconate is superior to povidone-iodine for the prevention of surgical site infections. Despite these results, povidone-iodine is still the most commonly used agent for vaginal preparation, even though it may not be ideal. OBJECTIVES: The objectives of the study were as follows: (1) to determine whether vaginal cleansing with a 4% chlorhexidine gluconate solution results in fewer wound infections as compared with povidone-iodine when used for vaginal antisepsis prior to cesarean delivery and (2) to compare rates of patient reported side-effects associated with vaginal application of 4% chlorhexidine gluconate solution and 10% povidone-iodine. STUDY DESIGN: This is a block randomized, comparator-controlled, open-label trial. Women undergoing nonemergent cesarean delivery were randomized to receive vaginal cleansing with either 4% chlorhexidine solution or 10% povidone-iodine solution prior to skin incision. The primary outcome was wound site infection occurring within 14 days of cesarean delivery including superficial or deep surgical site infection. Secondary outcomes included rates of endometritis, postoperative fever, and side effects (vaginal dryness, irritation, and desquamitization) occurring within 14 days of cesarean delivery. Risks were reported as odds ratios with 95% confidence intervals, with P < .05 considered as significant. RESULTS: From Dec. 1, 2016, through Feb. 28, 2018, a total of 1,114 patients met the inclusion criteria: 524 were randomized to the chlorhexidine gluconate arm and 590 to the povidone-iodine arm. Both arms were similar with regard to age, parity, body mass index, gestational age at delivery, indication for cesarean delivery, and incidence of membrane rupture. The rate of wound infection was significantly lower in the chlorhexidine arm as compared with povidone-iodine (0.6% vs 2.0%; P = .039, odds ratio, 0.28, 95% confidence interval, 0.08-0.98). Rates of endometritis (0.4% vs 0.5%, P = 1.000) and postoperative fever (2.5% and 2.7%, P = 0.892) were similar for the chlorhexidine and povidone-iodine groups, respectively. No adverse effects on the vaginal mucosa were noted for either solution. CONCLUSION: Vaginal cleansing with a 4% chlorhexidine solution prior to cesarean delivery resulted in fewer overall wound infections when compared with povidone-iodine solution with no patient-reported adverse reactions.

An Original Suprapannicular Incision Technique for Cesarean Delivery in the Morbidly Obese Parturient.

BACKGROUND: Obese patients are at an increased risk of cesarean delivery and its associated wound complications. We present an alternative incision technique for obese parturients that avoids making a Pfannenstiel incision under the panniculus while still providing access to the lower uterine segment. TECHNIQUE: For our technique, an assistant uses Allis clamps to exert caudal traction on the patient's panniculus and a transverse skin incision is made under the umbilicus, 3 cm below the line joining the anterosuperior iliac crests. On entry to the abdominal cavity, a wound retractor is placed to optimize access to the lower uterine segment so that a low transverse uterine incision can be made. EXPERIENCE: We have used this incision technique on 17 obese patients with no incidence of intraoperative complications, no requirement to perform a vertical hysterotomy incision, and no postoperative wound infections. CONCLUSION: Our technique is a feasible alternative incision for obese parturients that avoids making a subpannicular Pfannenstiel incision and still allows for good access to the lower uterine segment.