Sivan Zuarez-Easton

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.

Are there modifiable risk factors that may predict the occurrence of brachial plexus injury

Objective:To identify risk factors, particularly modifiable, associated with brachial plexus injury.Study Design:A retrospective case–control study conducted at a single hospital between the years 1993 and 2012. All neonates who were diagnosed of brachial plexus injury were included. A control group matched at a ratio of 1:2 was randomly selected. Demographic and obstetric data were obtained from the hospital discharge register with ICD-9 codes and crosschecked with the labor medical records. All medical files were manually checked and validated. A stepwise logistic regression model was performed to identify independent predictors for brachial plexus injury before delivery among those found significant in the univariate analysis.Results:Of all 83 806 deliveries that took place during this period, 144 cases of brachial plexus injury were identified (1.7/1000 deliveries). Overall, 142 cases and 286 controls had available data. Among the study group, 41 (28.9%) had documented shoulder dystocia compared with 1 (0.4%) among the controls (P<0.0001). Logistic regression analysis revealed that maternal age above 35 years (P=0.01; odds ratio (OR) 2.7; 95% confidence interval (CI) 1.3 to 5.7), estimated fetal weight before delivery (P<0.0001; OR 2.5; 95% CI 1.7 to 3.8, for each 500 g increase), vaginal birth after cesarean (P=0.02; OR 3.3; 95% CI 1.2 to 8.8) and vacuum extraction (P=0.02; OR 3.6; 95% CI 1.2 to 10.3) were all found to be independent predictors for developing brachial plexus injury. When stratifying the analysis according to parity, vacuum delivery was found to be an independent risk factor only among primiparous women (OR 6.0; 95% CI 1.7 to 21.6).Conclusions:The findings suggest that very few factors contributing to brachial plexus injury are modifiable. For that reason, it remains an unpredictable and probably an unavoidable event.

Trend in major neonatal and maternal morbidities accompanying the rise in the cesarean delivery rate

The aim of the study was to explore a cesarean delivery rate (CDR) beyond which major neonatal and maternal morbidities may outweigh the benefits of the procedure itself. A retrospective population-based cohort study was conducted at a single university teaching hospital between 1993 and 2012. Pregnant women who delivered at a gestational age of 23 weeks or more were included. Data including delivery mode, brachial plexus injury (BPI), neonatal encephalopathy (NE), placenta accreta (PA), blood transfusion (BT), and cesarean hysterectomy (CH) for each year were extracted, plotted, and trends analyzed. The Cochran-Armitage Trend Test was used to identify trends and correlations. Overall, 83,806 deliveries took place during this period. CDR increased from 10.9% to 21.7% (p < 0.001). Significant decreases in the incidence of BPI (p < 0.001) and NE (p = 0.006) were observed. At CDRs of 13.6% and 20%, there was no further significant decrease in the incidence of BPI and NE, respectively. The incidence of BT increased significantly (p < 0.001) while the increase in the incidence of PA was not significant (p = 0.06) nor the change in the incidence of CH (p = 0.4). A CDR of 20% may still confirm additional beneficial effect on major perinatal morbidities without a significant increase in the incidence of PA.

Comparison of single- and double-balloon catheters for labor induction: a systematic review and meta-analysis of randomized controlled trials

ObjectiveThere is a paucity of head-to-head randomized trials that compare single- and double-balloon catheters, and the results of the available data in terms of time from catheter insertion to delivery and delivery mode are mixed. This meta-analysis of randomized controlled trials compares the efficacy of single- and double-balloon catheters in women undergoing labor induction.Study designSearches were made in MEDLINE, EMBASE, PubMed, ClinicalTrials.gov, and the Cochrane Library from inception through June 2016. Peer-reviewed randomized and quasi-randomized trials that compared single- and double-balloon catheters head-to-head for cervical ripening or labor induction were identified. Eligible study populations consisted of women with singleton pregnancies that had any indication for labor induction and were randomly assigned to undergo induction with a single- or a double-balloon catheter. The primary outcome was time from catheter insertion to delivery and delivery mode. The secondary outcomes were intrapartum fever or chorioamnionitis, woman’s satisfaction, and neonatal Apgar score.ResultsOf the 520 records identified, five randomized trials (996 women; 491 with single-balloon and 505 with double-balloon catheters) were considered eligible and included in the meta-analysis. Time from catheter insertion to delivery did not differ between the two types of catheter (p = 0.527; WMD −0.87; 95% CI: −3.55, 1.82). The incidence of cesarean delivery also did not differ (p = 0.844; RR 0.97; 95% CI: 0.69, 1.35). Delivery within 24 h, delivery mode, incidences of intrapartum fever or chorioamnionitis, and neonatal Apgar score <7 at 5 min did not differ between the two types of catheter as well. Women who were induced with the single-balloon catheter were more satisfied (p = 0.029; WMD 0.56; 95% CI: 0.06, 1.06).ConclusionTime from catheter insertion to delivery and delivery mode were comparable between the two types of catheter.

Cervical ripening with the balloon catheter and the risk of subsequent preterm birth

Objective:To examine the risk of subsequent preterm birth after cervical ripening using a balloon catheter.Study Design:A retrospective study was held at a university teaching hospital between January 2007 and June 2013. The study group included women who underwent cervical ripening using a balloon (single or double) catheter in the previous pregnancy followed by a subsequent singleton delivery (balloon catheter group). Two control groups were included. The first was similar to the study group except that ripening was achieved in the previous pregnancy with vaginal prostaglandin E2 (PGE2 group). The second control group had a previous pregnancy that resulted in spontaneous onset of labor at term (unexposed group). The primary outcome was the incidence of spontaneous preterm birth (before 37 weeks) in the index pregnancy.Result:Overall, 558 women were included; each group consisted of 186 women. The incidence of spontaneous preterm birth in the index pregnancy did not differ between the groups (0.5, 1.6 and 2.7% in the balloon catheter, PGE2 and in the unexposed groups, respectively, P=0.31). Among the balloon catheter group, 58 (31.2%) women had the ripening performed with a single-balloon catheter and 128 (68.8%) women with a double-balloon catheter. The rate of the spontaneous preterm birth in the index pregnancy did not differ between the two groups (P=1.0).Conclusion:Cervical ripening with a balloon catheter does not increase the rate of subsequent spontaneous preterm birth.

Risk factors for persistent disability in children with obstetric brachial plexus palsy

Objective:Obstetric brachial plexus palsy (OBPP) at birth, is a serious neurologic injury that may lead to a long lasting disability. We aimed to examine the occurrence and risk factors associated with disability lasting >1 year.Study Design:A retrospective cohort study conducted between 1993 and 2012 included individuals with diagnosis of OBPP at birth. Affected individual’s motor function was evaluated by a direct physical exam based on a muscle grading system of the limb, shoulder, elbow and hand. When not feasible a telephone questionnaire was used. Participants reported on activities of daily living, disability duration and any type of intervention. Stepwise logistic regression model was used to identify demographic and obstetric risk factors for disability lasting >1 year.Results:Of all 83 806 deliveries during this period, 144 OBPP cases were identified (1.7/1000). Of the 91 (63.2%) individuals located 42 (46.2%) were evaluated by a physical exam and 49 (53.8%) answered a telephone questionnaire. In 12 (13.2%) disability lasted >1 year. Significant predictors for disability lasting >1 year included birthweight >4 kg (P=0.02; odds ratio (OR) 6.17; 95% confidence interval (CI) 1.33–28.65) and younger maternal age (P=0.02; OR 0.84; 95% CI: 0.73–0.97). OBPP decreased 16% per 1 year increase in maternal age.Conclusions:OBPP is a transient injury in most cases. Birthweight over 4 kg and younger maternal age maybe associated with disability lasting >1 year.