Vaginal cleaning before cesarean delivery significantly reduces infection: A Systematic Review and Meta-analysis.

A simple and inexpensive intervention of vaginal cleaning with an antiseptic solution before cesarean delivery brings down the rate of endometritis note the results of a Systematic Review and Meta-analysis published August 4 in Journal of Obstetrics and Gynecology.

The effect was significantly more in patients in labor or with ruptured membranes at the time of the procedure.

Claudia Caissutti, MD, from the Department of Experimental Clinical and Medical Science, Clinic of Obstetrics and Gynecology, University of Udine, Italy, and colleagues searched MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library from their inception to January 2017.

They included randomized trials comparing vaginal cleaning with any antiseptic against placebo or no cleaning at all. The final data for review came from 16 RCTs, with a total of 4,837 women in whom vaginal preparation was done immediately before the start of cesarean section.

Most of the trials used povidone–iodine (n = 11) as the cleaning agent, while rest used chlorhexidine diacetate solution n = 3) , metronidazole vaginal gel prep ( n =1), and Cetrimide ( n =1) .

The observed incidence of endometritis in women who received preoperative vaginal cleansing was nearly 50% less as compared to women with placebo or no cleaning (4.5% vs 8.7%; relative risk [RR], 0.52; 95% confidence interval [CI], 0.37 - 0.72). These group also had significantly lower incidence of postoperative fever (9.4% compared with 14.9%; RR, 0.65).

No significant difference was observed in postoperative wound infection among the groups.

In a separate planned subgroup analysis, the observed difference in rates of endometritis was only seen in women who were in active labor and for patients with rupture of membranes. Four trials stratified the data according to women were in labor or not and three trials looked into women with and without ruptured membranes.

When the data was stratified according to type of cleaning agent and prophylactic antibiotics, the results were in according to the overall analysis.

Women who received prophylactic antibiotics had a 67% decrease in endometritis incidence. The authors opined, "Surgical prophylaxis with intravenous antibiotics before cesarean delivery has been clearly demonstrated as beneficial in reducing postoperative infection morbidity, Thus, it is the standard of care and these findings could translate to current practice."

The results of study have confirmed the findings of earlier Cochrane database systematic review published in 2013.

Data is needed to assess the effect of vaginal cleaning in women not in labor and without ruptured membranes.

The authors concluded that, “Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. We recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds.”

Maternal clinical risk factors for increased rate of post cesarean infection identified.

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Preincisional extended antibiotic prophylaxis does not prevent occurrence of maternal infections that significantly contributes to increased maternal morbidity in cesarean sections.

Maternal BMI, rupture of membranes to delivery interval, race and duration of surgery are important contributing factors towards maternal infection even after prophylactic antibiotics were given according to a study published online ahead of print in Journal of obstetrics and gynecology.

This was a secondary analysis Cesarean Section Optimal Antibiotic Prophylaxis trial (C/SOAP),that concluded that pairing Azithromycin with standard pre-incisional prophylaxis reduced the surgical site infection by nearly 50%.  Dr. Alan Tita presented the paper  at the 36^th Annual Pregnancy Meeting 2016 sponsored by the Society for Maternal-Fetal Medicine.

The secondary analysis of the data was done in an effort to further identify maternal clinical risk factors that can further reduce the risk of maternal infections.

The primary outcome studied was maternal infection and consists of  a composite of endometritis, wound infection (superficial or deep), or other infections occurring up to 6 weeks postpartum.

Data from all 2013 patients in the primary study was included in the secondary analysis.

After controlling for Azithromycin: maternal age, duration of ROM, duration of surgery, vertical or non-transverse skin incision, staple skin closure, BMI and labor induction significantly influenced the incidence of maternal morbidity.

After parsimonious regression model, in which those variables that were statistically non-significant were removed from the analysis, showed that black race, duration of rupture of membranes more than 6 hours and duration of surgery more than 49 minutes were significantly associated with increased maternal infection.

If duration of rupture of membrane exceeds 6 hours than the rate of maternal infection increases by 1.9 to 3.4-fold.

In addition, in unadjusted analysis patients with BMI more than 30 had 2.5 times higher risk of infection as compared to those with BMI< 25 in whom the risk of infection  was minimal.

The researchers advocate need of additional studies in patients with these risk factors to formulate guidelines for further reduction in infectious morbidity.