Azithromycin Prophylaxis for Cesarean Delivery

Rothaus, C. The New England Journal of Medicine. Published online: September 29th 2016

Cesarean delivery is the most common major surgical procedure and is associated with a rate of surgical-site infection (including endometritis and wound infection) that is 5 to 10 times the rate for vaginal delivery. Tita et al. assessed whether the addition of azithromycin to standard antibiotic prophylaxis before skin incision would reduce the incidence of infection after cesarean section among women who were undergoing nonelective cesarean delivery during labor or after membrane rupture. In this new Original Article involving women who received standard antibiotic prophylaxis for nonelective cesarean section, the risk of infection after surgery was lower with the addition of azithromycin than with placebo.

Clinical Pearl

• How does pregnancy-associated infection rank as a cause of maternal death in the United States?

Globally, pregnancy-associated infection is a major cause of maternal death and is the fourth most common cause in the United States.

Clinical Pearl

• How often do postoperative infections occur after nonelective cesarean delivery?

Despite routine use of antibiotic prophylaxis (commonly, a cephalosporin given before skin incision), infection after cesarean section remains an important concern, particularly among women who undergo nonelective procedures (i.e., unscheduled cesarean section during labor, after membrane rupture, or for maternal or fetal emergencies). As many as 60 to 70% of all cesarean deliveries are nonelective; postoperative infections occur in up to 12% of women undergoing nonelective cesarean delivery with standard preincision prophylaxis.#

Read the full Now@NEJM Blog post here

Read the original research article here

Measuring standards and improving neonatal care

Following the publication yesterday of the ‘Neonatal audit programme 2016 annual report’,the Royal College of Paediatrics and Child Health has published a leaflet Your baby’s care: measuring standards and improving neonatal care.

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This leaflet for parents has been designed to help parents and clinicians to work together to achieve the best outcomes for preterm and sick babies who require care.

It is intended that readers will gain a fuller understanding of the audit measures used, the questions the National Neonatal Audit Programme (NNAP) asks and why it asks them, thereby helping parents to comprehend and confidently discuss aspects of their baby’s care.


National neonatal audit programme: 2016 annual report

Royal College of Paediatrics and Child Health (RCPCH)


This report outlines the result of a national audit of neonatal services and finds an improvement in rates of two year follow-up for premature babies but that there was an increase in risk of illness and that some units were still failing to record timely consultation with parents.

The report urges neonatal units to form partnerships with neighbouring hospitals in order to reduce variation and drive up standards of care for very sick babies.

Report    Press release

Making the most of the single-family-room NICU

Steinhorn, R.H. (2016) The Journal of Pediatrics. Volume 177. pp. 1–2

A major change in neonatal intensive care unit (NICU) design has been the replacement of open wards with private or single-family-rooms (SFR). The anticipated advantages of family privacy, lower light and noise levels, and improved infection control seemed to merit this switch despite the drawbacks of higher construction costs and staffing inefficiencies.

To add to these potential concerns, Pineda et al reported that neonates cared for in SFR had more abnormal brain structure and lower cerebral maturation scores at the time of discharge, as well as lower Bayley-III language and motor scores at age 2 years than their counterparts cared for in open wards (J Pediatr 2014;164:52-60).

Read the full article here

Maternal vitamin D deficiency and fetal distress/birth asphyxia: a population-based nested case–control study

Lindqvist, P.G. et al. BMJ Open. Published online: 22 September 2016


Objective: Vitamin D deficiency causes not only skeletal problems but also muscle weakness, including heart muscle. If the fetal heart is also affected, it might be more susceptible to fetal distress and birth asphyxia. In this pilot study, we hypothesised that low maternal vitamin D levels are over-represented in pregnancies with fetal distress/birth asphyxia.

Design and setting: A population-based nested case–control study.

Patients: Banked sera of 2496 women from the 12th week of pregnancy.

Outcome measures: Vitamin D levels were analysed using a direct competitive chemiluminescence immunoassay. Vitamin D levels in early gestation in women delivered by emergency caesarean section due to suspected fetal distress were compared to those in controls. Birth asphyxia was defined as Apgar <7 at 5 min and/or umbilical cord pH≤7.15.

Results: Vitamin D levels were significantly lower in mothers delivered by emergency caesarean section due to suspected fetal distress (n=53, 43.6±18 nmol/L) compared to controls (n=120, 48.6±19 nmol/L, p=0.04). Birth asphyxia was more common in women with vitamin D deficiency (n=95) in early pregnancy (OR 2.4, 95% CI 1.1 to 5.7).

Conclusions: Low vitamin D levels in early pregnancy may be associated with emergency caesarean section due to suspected fetal distress and birth asphyxia. If our findings are supported by further studies, preferably on severe birth asphyxia, vitamin D supplementation/sun exposure in pregnancy may lower the risk of subsequent birth asphyxia.

Read the article here

Behavioral, Social, and Emotional Symptom Comorbidities and Profiles in Adolescent Survivors of Childhood Cancer

Brinkman, T.M. et al. (2016) Journal of Clinical Oncology. 34(28) pp. 3417-342


Purpose: In the general population, psychological symptoms frequently co-occur; however, profiles of symptom comorbidities have not been examined among adolescent survivors of childhood cancer.

Patients and Methods: Parents of 3,893 5-year survivors of childhood cancer who were treated between 1970 and 1999 and who were assessed in adolescence (age 12 to 17 years) completed the Behavior Problems Index. Age- and sex-standardizedz scores were calculated for symptom domains by using the Childhood Cancer Survivor Study sibling cohort. Latent profile analysis identified profiles of comorbid symptoms, and multivariable multinomial logistic regression modeling examined associations between cancer treatment exposures and physical late effects and identified symptom profiles. Odds ratios (ORs) and 95% CIs for latent class membership were estimated and analyses were stratified by cranial radiation therapy (CRT; CRT or no CRT).

Results: Four symptoms profiles were identified: no significant symptoms (CRT, 63%; no CRT, 70%); elevated anxiety and/or depression, social withdrawal, and attention problems (internalizing; CRT, 31%; no CRT, 16%); elevated headstrong behavior and attention problems (externalizing; CRT, no observed; no CRT, 9%); and elevated internalizing and externalizing symptoms (global symptoms; CRT, 6%; no CRT, 5%). Treatment with ≥ 30 Gy CRT conferred greater risk of internalizing (OR, 1.7; 95% CI, 1.0 to 2.8) and global symptoms (OR, 3.2; 95% CI, 1.2 to 8.4). Among the no CRT group, corticosteroid treatment was associated with externalizing symptoms (OR, 1.9; 95% CI, 1.2 to 2.8) and ≥ 4.3 g/m2 intravenous methotrexate exposure was associated with global symptoms (OR, 1.5; 95% CI, 0.9 to 2.4). Treatment late effects, including obesity, cancer-related pain, and sensory impairments, were significantly associated with increased risk of comorbid symptoms.

Conclusion: Behavioral, emotional, and social symptoms frequently co-occur in adolescent survivors of childhood cancer and are associated with treatment exposures and physical late effects. Assessment and consideration of symptom profiles are essential for directing appropriate mental health treatment for adolescent survivors.

Read the abstract here

Investment in new units for mums with mental ill health

NHS England is preparing to invest in three new inpatient units for mums with serious mental ill health to help them to stay with their babies.

The new Mother and Baby Units (MBUs) will be in East Anglia: Cambridgeshire, Norfolk and Suffolk; the North West: Cumbria and Lancashire; and the South West: Cornwall, Devon and Somerset.


The services will provide in-patient support for women and their babies with the most complex and severe needs who require hospital care who are experiencing severe mental health crisis including very serious conditions like post-partum psychosis.

Expanding capacity in mother and baby units is a key element of NHS England’s transformation programme for perinatal mental health services as part of integrated pathways of care. This covers both the creation of new units in areas with the most severe access issues, as well as reviewing capacity in existing units, with funding across the five-year period – estimated £10m in 2017/18 and £15m in 2018/19 as outlined in the Implementation Plan.

The perinatal mental health programme also supports the ambitions of the widerMaternity Transformation Programme, which seeks to deliver the vision set out in Better Births, the report of the National Maternity Review to improve maternity outcomes for women and their babies.

Read more via NHS England