Tony Wen

Timing of perioperative antibiotics for cesarean delivery: a metaanalysis

OBJECTIVE The purpose of this study was to summarize the available evidence on timing of perioperative antibiotics for cesarean delivery. STUDY DESIGN We searched the literature for studies that compare prophylactic antibiotics for cesarean delivery that are given before the procedure vs at cord clamping. Only randomized controlled trials were included. RESULTS Preoperative administration significantly reduced the risk of postpartum endometritis (relative risk [RR], 0.47; 95% CI, 0.26-0.85; P = .012) and total infectious morbidity (RR, 0.50; 95% CI, 0.33-0.78; P = .002). There was a trend toward lower risk of wound infection (RR, 0.60; 95% CI, 0.30-1.21; P = .15). Preoperative administration of antibiotics did not significantly affect suspected neonatal sepsis that requires a workup (RR, 1; 95% CI, 0.70-1.42), proven sepsis (RR, 0.93; 95% CI, 0.45-1.96), or neonatal intensive care unit admissions (RR, 1.07 95% CI, 0.51-2.24). There was no significant heterogeneity between the randomized controlled trials. CONCLUSION There is strong evidence that antibiotic prophylaxis for cesarean delivery that is given before skin incision, rather than after cord clamping, decreases the incidence of postpartum endometritis and total infectious morbidities, without affecting neonatal outcomes.

Pregnancy outcome after ultrasound diagnosis of fetal intra-abdominal umbilical vein varix

Fetal intra‐abdominal umbilical vein (FIUV) varix is a focal dilatation of the intra‐abdominal portion of the umbilical vein, which has been reported to be associated with intrauterine death and other anomalies. Our aim was to examine our experience with this diagnosis at a single tertiary‐care center and to correlate it with clinical outcome.

Zika Virus and Pregnancy: A Review of the Literature and Clinical Considerations.

The latest Zika virus (ZIKV) outbreak has reached epidemic proportions as it spreads throughout South and Central America. In November 2015, the Brazilian Ministry of Health reported a 20-fold increase in the number of cases of neonatal microcephaly, which corresponds geographically and temporally to the ZIKV outbreak. Case reports have provided some evidence of a causal link between maternal ZIKV infection, fetal microcephaly, and intracranial calcifications. The sparse data regarding ZIKV in pregnancy come solely from case reports and personal communications, and recommendations for management of ZIKV exposure during pregnancy are rapidly evolving. Our objective is to review and synthesize the current literature regarding ZIKV as it pertains to pregnancy and provide some assistance to clinicians who may have to manage a pregnant patient with potential exposure to ZIKV. We will also explore certain aspects of related viruses in pregnancy in hopes to shed light on this little-known topic.

Interferon therapy in primary care

Interferons are proteins produced by human blood cells in response to stimulation (viral infection). The natural roles of interferons are host defense and modulation of the immune system. Therapeutic uses are based on these roles. Interferon-alpha has been widely used for malignancies, skin conditions, viral infections, and myeloproliferative disorders. Interferon-beta is a standard treatment for relapsing multiple sclerosis. Interferon-gamma therapy is currently used for chronic granulomatous disease and skin lesions (human papilloma virus related and keloids), but further research is ongoing. Side effects of interferon therapy are common and limit utility. Flulike symptoms are reported by more than 75% and depression by 10-40% of interferon users. Severe adverse effects are less common but may be life threatening, including autoimmune diseases, thrombotic-thrombocytopenic purpura, and acute renal failure. Limited use of interferon therapy during pregnancy has been described, with successful maternal and neonatal outcomes. Use of interferon therapy during early pregnancy is not an indication for termination.

Analysis of bioplex syphilis IgG quantitative results in different patient populations

Because of the need to reduce labor costs, many laboratories are replacing the traditional syphilis testing algorithm—screening with a manual nontreponemal test, followed by an anti-Treponema pallidum antibody test—with a “reverse” algorithm that uses an automated immunoassay to screen for

The effect of 17β-estradiol on isolated omental arteries from preeclamptic women

OBJECTIVE To study the effect of 17beta-estradiol on isolated omental arteries from preeclamptic women. STUDY DESIGN Rings of omental artery with intact endothelium were mounted in organ chambers for isometric tension recording. We studied the effect of pharmacological concentrations of 17beta-estradiol on potassium chloride-induced tension and the concentration-contraction relationships for norepinephrine and calcium. RESULTS Cumulative application of 17beta-estradiol, in a concentration-dependent manner, relaxed potassium chloride contracted rings. Sixty minutes of incubation with 17beta-estradiol (10(-5)mol/l) attenuated the tension developed in response to potassium chloride, norepinephrine and calcium. Tamoxifen (10(-6)mol/l) did not antagonize the inhibitory actions of 17beta-estradiol. CONCLUSIONS Pharmacological concentrations of 17beta-estradiol retain the capability for relaxing omental artery rings from preeclamptic women. The loss of refractoriness to norepinephrine, increased responsiveness to calcium ions and decreased ability of 17beta-estradiol to inhibit calcium-induced tension may be responsible for increased vascular reactivity in preeclampsia.

Early versus Late Feeding after Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE This study aims to evaluate whether early feeding after cesarean delivery (CD) shortens the time to pass flatus and bowel movement. METHODS Women at term undergoing CD were randomly assigned to start oral intake either within 6 hours (early feeding) or after 12 hours (late feeding) from surgery completion. Women with preeclampsia, or requiring emergent CD, additional bowel surgery, or the use of general anesthesia were excluded. Our primary outcome was time of passing first flatus following surgery completion. Secondary outcomes included time of first bowel sounds, time of first bowel movement, nausea/vomiting, and length of maternal hospital stay (clinicaltrials.gov identifier NCT02396485). RESULTS A total of 177 women were randomized to early (n  =  85) or late feeding (n  =  82). There was no loss to follow-up, and outcomes were available for all patients. There were no differences in baseline characteristics between the two groups. Early feeding resulted in shorter time to pass flatus (median [interquartile range], 715 [485-1,208] minutes vs. 1,300 [820-1,760] minutes; p < 0.001) and to have bowel sounds (232 [168-537.8] minutes vs. 554.5 [202-706] minutes; p = 0.001). Time to pass bowel movement was shorter in the early-feeding group, but did not reach significance. The groups did not differ in length of stay or in rates of nausea, vomiting, or ileus. CONCLUSION In women undergoing CD, early oral intake is well tolerated and results in earlier return of bowel function.

Fetal assessment near the limits of viability

Assessments of gestational age are critical in dealing with the pregnancy at the limits of viability, 22-25-weeks gestation, where neonatal outcomes reveal very significant differences from week to week. The obstetrical team can estimate gestational age within a window of 7-10 days during this critical threshold at the window of viability via determination of last menstrual period, bimanual exam, early pregnancy test, and/or ultrasound. One must also take into account the impact of maternal disease processes, congenital abnormalities, number of fetus(es), and/or fetal growth restriction, along with ongoing evaluation and parental involvement in this decision-making process during the peri-viability period.