Perioperative Antibiotics and Other Factors Associated with Postcesarean Infections: A Case-Control Study.

OBJECTIVE: Our objective was to determine modifiable risk factors associated with surgical site infection (SSI) and postpartum endometritis. We hypothesized that inappropriate surgical antibiotic prophylaxis would be a risk factor for both types of infections. STUDY DESIGN: This was a single-center case-control study of SSI and endometritis after cesarean delivery over a 2-year period from 2016 to 2017. Cases were identified by International Classification of Diseases, 10th Revision diagnosis codes, infection control surveillance, and electronic medical records search and were subsequently confirmed by chart review. Three controls were randomly selected for each case from all cesareans ± 48 hours from case delivery. Demographic, pregnancy, and delivery characteristics were abstracted. Separate multivariable logistic regression models were used to assess factors associated with SSI and endometritis. Postpartum outcomes, including length of stay and readmission, were also compared. RESULTS: We identified 141 cases of SSI and endometritis with an overall postpartum infection rate of 4.0% among all cesarean deliveries. In adjusted analysis, factors associated with both SSI and endometritis were intrapartum delivery, classical or other (non-low-transverse) uterine incision, and blood transfusion. Factors associated with SSI only included inadequate antibiotic prophylaxis, public insurance, hypertensive disorder of pregnancy, and nonchlorhexidine abdominal preparation; factors only associated with endometritis included ß-lactam allergy, anticoagulation therapy, and chorioamnionitis. Among cases, 34% of those with SSI and 25% of those with endometritis did not receive adequate antibiotic prophylaxis, compared with 12.9 and 13.5% in control groups, respectively. Failure to receive appropriate antibiotic prophylaxis was associated with an increased risk of SSI (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 1.3-15.6) but not endometritis (aOR 0.9, 95% CI 0.4-2.0). CONCLUSION: Inadequate surgical antibiotic prophylaxis was associated with an increased risk of SSI but not postpartum endometritis, highlighting the different mechanisms of these infections and the importance of prioritizing adequate surgical prophylaxis. Additional potentially modifiable factors which emerged included blood transfusion and chlorhexidine skin preparation. KEY POINTS: · Inadequate antibiotic prophylaxis is associated with a four-fold risk in surgical site infections.. · The most common cause for failure to achieve adequate surgical prophylaxis was inappropriate timing of antibiotics at or after skin incision.. · Blood transfusions are strongly associated (>10-fold risk) with both SSI and endometritis..

History of respiratory problems in prior infant and respiratory morbidity in subsequent pregnancy.

OBJECTIVE: Respiratory distress syndrome (RDS) is a common cause of morbidity in preterm neonates. Late preterm births (34 0/7 to 36 6/7 weeks of gestation) account for three-quarters of preterm births. Delivery in the late preterm period is a well-established risk factor for RDS.1 Whether history of a neonate with respiratory morbidity at birth relates to respiratory morbidity in a subsequent pregnancy is not well characterized. In this research letter, we have described how maternally reported respiratory morbidity in a neonate in a previous pregnancy is associated with respiratory morbidity in a neonate in a subsequent pregnancy. STUDY DESIGN: This was a secondary analysis of a randomized controlled study of antenatal corticosteroids in the late preterm period (antenatal betamethasone for women at risk for late preterm delivery).2 Multiparous patients with a singleton pregnancy were included. The institutional review board at The University of Chicago (approval number IRB 21-0141) deemed this study exempt. Respiratory morbidity of a previous infant was maternally reported in a questionnaire specifying any "respiratory problems at birth" in their live neonates (yes or no). Major respiratory morbidity (MRM) in the current pregnancy was defined as any of the following: continuous positive airway pressure or high-flow nasal cannula for ≥12 hours in the first 72 hours of life, ventilator use in the first 72 hours of life, extracorporeal membrane oxygenation, oxygen requirement of FiO2 of ≥0.3 for ≥24 total hours in the first 72 hours of life, or stillbirth or neonatal death at <72 hours of age. This was abstracted from maternal and neonatal medical records. The presence of any respiratory morbidity (MRM, RDS, or transient tachypnea of the newborn [TTN]) was compared by history of a previous infant with any respiratory morbidity. Chi-square and Wilcoxon rank-sum tests were used for bivariable analyses, and logistic regression was performed to adjust for confounders. The analysis was repeated, stratified by any betamethasone use. RESULTS: We included 1412 multiparous patients, 195 with a previous infant with maternally reported respiratory morbidity and 1217 without. RDS, MRM, and a composite of RDS, TTN, and apnea were more likely among those who had a sibling with respiratory morbidity, per maternal report (adjusted odds ratio [aOR] of RDS, 2.17 [95% confidence interval (CI), 1.28-3.70]; aOR of MRM, 1.9 [95% CI, 1.20-3.02]; aOR of RDS, TTN, and apnea, 1.85 [95% CI, 1.22-2.70]). When stratified by administration of betamethasone, the risk of MRM was only persistent in those without betamethasone use (aOR, 1.84; 95% CI, 1.00-3.39). Similarly, the risk of RDS and a composite risk of RDS, TTN, and apnea were only persistent in those without betamethasone use (aOR, 2.37 [95% CI, 1.16-4.84]; aOR, 1.82 [95% CI, 1.05-3.17]) Tables 1 and 2. CONCLUSION: A maternally reported history of respiratory morbidity in a previous late preterm or term infant was independently associated with respiratory morbidity, including RDS, in a subsequent infant. When stratified by betamethasone use, the risk of respiratory morbidity was only persistent in those neonates without betamethasone exposure during the late preterm period.

Fetal brain ultrasound measures and maternal nutrition: A feasibility study in Ecuador.

OBJECTIVE: Nutrition during pregnancy is an important modifiable determinant of fetal growth and development. This pilot study aimed to characterize the association between fetal anthropometry, fetal brain development, and maternal diet among women in Ecuador using portable ultrasound in resource-limited clinics, including measurements of brain structures not typically imaged in this setting. METHODS: Pregnant women (n = 47) from four resource-limited health centers were surveyed on demographic, socioeconomic, morbidity, and dietary information. Maternal height, weight, and blood pressure were taken. A sonographer took 15 images per participant, including those standardly assessed during the fetal survey and additional brain structures identified as potentially responsive to maternal nutrition, but not part of the standard fetal survey. RESULTS: Mean percentiles for all standard fetal survey measurements generated from WHO Fetal Growth Curves fell below 50%, and negative mean Z scores were found for biparietal diameter (-0.95 ± 1.11) and femur length (-0.22 ± 1.10). Generalized linear modeling adjusting for gestational age and other covariates showed frequency of seafood consumption was positively associated with fetal biparietal diameter Z score (P = 0.005), beans and legumes positively associated with femur length (P = 0.006), and a negative association was found for soda consumption and fetal head circumference (P = 0.013). CONCLUSIONS: This pilot study demonstrated the feasibility of capturing images of nutrition-relevant fetal brain structures not part of the standard fetal survey in resource-limited settings using portable ultrasound. Our study revealed associations between anthropometry, brain structure size, and maternal diet demonstrating potential for prenatal nutrition research using ultrasound in the field.

Insulin Sensitivity and Inflammation Mediate the Impact of Fitness on Cerebrovascular Health in Adolescents.

BACKGROUND/OBJECTIVES: To investigate in adolescents the relationships between retinal vessel diameter, physical fitness, insulin sensitivity, and systemic inflammation. METHODS: We evaluated 157 adolescents, 112 with excessive weight and 45 lean, all without type 2 diabetes mellitus. All received detailed evaluations, including measurements of retinal vessel diameter, insulin sensitivity, levels of inflammation, and physical fitness. RESULTS: Overweight/obese adolescents had significantly narrower retinal arteriolar and wider venular diameters, significantly lower insulin sensitivity, and physical fitness. They also had decreased levels of anti-inflammatory and increased levels of proinflammatory markers as well as an overall higher inflammation balance score. Fitness was associated with larger retinal arteriolar and narrower venular diameters and these relationships were mediated by insulin sensitivity. We demonstrate that inflammation also mediates the relationship between fitness and retinal venular, but not arterial diameter; insulin sensitivity and inflammation balance score jointly mediate this relationship with little overlap in their effects. CONCLUSIONS: Increasing fitness and insulin sensitivity and reducing inflammation among adolescents carrying excess weight may improve microvascular integrity. Interventions to improve physical fitness and insulin function and reduce inflammation in adolescents, a group likely to benefit from such interventions, may reduce not only cardiovascular disease in middle age, but also improve cerebrovascular function later in life.

Obesity, fitness, and brain integrity in adolescence.

OBJECTIVE: We set out to ascertain the relationship between insulin resistance, fitness, and brain structure and function in adolescents. DESIGN AND METHODS: We studied 79 obese and 51 non-obese participants who were recruited from the community, all without type 2 diabetes mellitus. All participants received medical, endocrine, neuropsychological, and MRI evaluations as well as a 6-minute walk test that was used to estimate fitness (maximal oxygen consumption). RESULTS: Obese adolescents had significantly thinner orbitofrontal cortices and performed significantly worse on Visual Working Memory tasks and the Digit Vigilance task. Insulin sensitivity and maximal oxygen consumption (VO2 max) were both highly correlated with central obesity and orbitofrontal cortical thickness, although insulin sensitivity was the stronger predictor for orbitofrontal cortical thickness. We also found that VO2 max was the only significant physiological variable related to visual working memory. CONCLUSIONS: This is the first study to report positive associations between insulin resistance, VO2 max, and frontal lobe brain integrity in adolescents. Given the importance of brain health for learning and school performance, we conclude that schools should also emphasize physical fitness in order to maintain structural and functional brain integrity and facilitate academic achievement.