Reducing Cesarean Delivery Surgical Site Complications.

Cesarean delivery (CD) wound complications disrupt the time a mother spends with her newborn. Surgical site infections (SSI) may result in unplanned office visits, emergency room visits, and hospital readmissions. Despite increasing attention to preoperative preparation, the CD SSI rate remains high. Local practices must be evaluated, and new methods to reduce CD SSI must be used.

Efficacy of Non-Beta-lactam Antibiotics for Prevention of Cesarean Delivery Surgical Site Infections.

Objective To examine the association between perioperative Beta ( ß ))-lactam versus non- ß -lactam antibiotics and cesarean delivery surgical site infection (SSI). Study Design Retrospective cohort of women undergoing cesarean delivery from January 1 to December 31, 2014. All women undergoing cesarean after 34 weeks with a postpartum visit were included. Prevalence of SSI was compared between women receiving ß -lactam versus non- ß -lactam antibiotics. Bivariate analyses were performed using Pearson's Chi-square, Fisher's exact, or Wilcoxon's rank-sum tests. Logistic regression models were fit controlling for possible confounders. Results Of the 929 women included, 826 (89%) received ß -lactam prophylaxis and 103 (11%) received a non- ß -lactam. Among the 893 women who reported a non-type I (low risk) allergy, 819 (92%) received ß -lactam prophylaxis. SSI occurred in 7% of women who received ß -lactam antibiotics versus 15% of women who received a non- ß -lactam ( p = 0.004). ß -Lactam prophylaxis was associated with lower odds of SSI compared with non- ß -lactam antibiotics (odds ratio [OR] = 0.43; 95% confidence interval [CI] = 0.22-0.83; p = 0.01) after controlling for chorioamnionitis in labor, postlabor cesarean, endometritis, tobacco use, and body mass index (BMI). Conclusion ß -Lactam perioperative prophylaxis is associated with lower odds of a cesarean delivery surgical site infection compared with non- ß -lactam antibiotics.

Prophylactic Negative Pressure Wound Therapy for Obese Women After Cesarean Delivery: A Systematic Review and Meta-analysis.

OBJECTIVE: To summarize available studies on wound complication outcomes after prophylactic negative pressure wound therapy for obese women (body mass index 30 or greater). DATA SOURCES: We conducted a systematic review and meta-analysis using electronic database search (PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Google scholar, and Web of Science), Cochrane, and trial registries including ClinicalTrials.gov. METHODS OF STUDY SELECTION: We conducted an electronic search of research articles from 1966 to January 2017 for randomized controlled trials (RCTs), prospective cohort, and retrospective cohort studies of negative pressure wound therapy compared with standard dressing after cesarean delivery among obese women. Our primary outcome was defined as a composite of wound complication, including wound or surgical site infection, cellulitis, seroma, hematoma, wound disruption, or dehiscence. For cohort studies and RCTs, we performed a descriptive systematic review. For available RCTs, we performed a meta-analysis and pooled risk ratios using a random-effects model. We assessed for heterogeneity using χ test for heterogeneity and I test. We assessed for publication bias using a funnel plot. TABULATION, INTEGRATION, AND RESULTS: Of 10 studies meeting eligibility criteria, five were RCTs and five were cohort studies. Results of cohort studies were varied; however, all had a high potential for selection bias. In the meta-analysis, there was no difference in primary composite outcome among those women with negative pressure wound therapy (16.8%) compared with those who had standard dressing (17.8%) (risk ratio 0.97, 95% CI 0.63-1.49). There was no statistically significant heterogeneity (χ test 4.80, P=.31, I=17%). CONCLUSION: Currently available evidence does not support negative pressure wound therapy use among obese women for cesarean wound complication prevention. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: International prospective register of systematic reviews, 42016033948.

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.

Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis.

OBJECTIVE: The purpose of this investigation was to examine the economic impact of performing elective repeat cesarean during 37 or 38 weeks of gestation relative to the American College of Obstetricians and Gynecologists recommendation of a 39-week delivery. STUDY DESIGN: Decision analysis modeling was used to estimate economic outcomes for a hypothetical cohort of neonates using data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network study of "Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes." Costs and charges were estimated using the Florida Healthcare Cost and Utilization Project. RESULTS: A total of 82,541 deliveries occurring between 37-39 completed weeks of gestation were analyzed for the incidence of adverse outcomes and their hospital costs and charges. The model demonstrated increased costs through increasing adverse outcomes among elective repeat cesarean deliveries performed <39 weeks of gestation. CONCLUSION: Our findings suggest that there are benefits to waiting until 39 weeks of gestation to perform an elective repeat cesarean delivery.

Maternal super-obesity (body mass index > or = 50) and adverse pregnancy outcomes.

OBJECTIVE: To determine if pregnancy complications are increased in super-obese (a body mass index (BMI) of 50 or more) compared to other, less obese parturients. DESIGN: Cross-sectional study. SETTING AND POPULATION: All 19,700 eligible women, including 425 (2.2%) super-obese women with singleton births between 1996 and 2007 delivering at a tertiary referral center, identified using a perinatal research database. METHODS: Bivariate and trend analyses were used to assess the relation between super-obesity and various pregnancy complications compared to other well-established BMI categories. Adjusted odds ratios (ORs) were calculated using multivariable logistic regression techniques. MAIN OUTCOME MEASURES: Outcomes for adjusted and unadjusted analyses were small-for-gestational age (SGA) birth, large-for-gestational age (LGA) birth, preeclampsia, gestational diabetes mellitus (GDM), fetal death, preterm birth, placental abruption, cesarean delivery, and Apgar scores < 7. RESULTS: Compared to all other obese and non-obese women, super-obese women had the highest rates of preeclampsia, GDM, LGA, and cesarean delivery (all p < 0.05 for trend test). Super-obesity was also associated with a 44% reduction in SGA compared to all other women (OR 0.55, 95% confidence interval (CI) 0.40-0.76) and a 25% reduction compared to other, less obese women (OR 0.75, 95% CI 0.54-1.03). Super-obesity was positively associated with LGA, GDM, preeclampsia, cesarean delivery, and a 5-minute Apgar score < 7 compared to all other women after controlling for important confounders. CONCLUSION: Super-obesity is associated with higher rates of pregnancy complications compared to women of all other BMI classes, including other obese women.

Morbidity associated with sickle cell disease in pregnancy.

OBJECTIVE: The purpose of this study was to identify morbidity that is associated with sickle cell disease (SCD) in pregnancy. STUDY DESIGN: The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 2000-2003 was queried for all pregnancy-related discharges with a diagnosis of SCD. RESULTS: There were 17,952 deliveries (0.1% of the total) to women with SCD. There were 10 deaths (72.4 per 100,000 deliveries). Cerebral vein thrombosis, pneumonia, pyelonephritis, deep venous thrombosis, transfusion, postpartum infection, sepsis, and systemic inflammatory response syndrome were much more common among women with SCD. They were more likely to undergo cesarean delivery, to experience pregnancy-related complications (such as gestational hypertension/preeclampsia, eclampsia, abruption, antepartum bleeding, preterm labor, and fetal growth restriction), and to have cardiomyopathy or pulmonary hypertension at the time of delivery. CONCLUSION: Women with sickle cell disease are at greater risk for morbidity in pregnancy than previously estimated.