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.”
