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Postpartum infections; prevalence, associated obstetric factors and the role of vitamin D
Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences. Department of Obstetrics and Gynecology, Ryhov County Hospital, Jönköping.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Postpartum infections are a major cause of maternal mortality and morbidity worldwide. Breast infection, endometritis, urinary tract infection and wound infections are the most common postpartum infections and together they affect almost 20% of women after childbirth. Some risk factors for postpartum infections, for example cesarean section, have been relatively well studied, but other presumable risk factors are yet to be confirmed.

The proportion of pregnant women who are overweight or obese is increasing in most parts of the world. Increased maternal body mass index (BMI) is associated with maternal and infant morbidity. The association between overweight / obesity and postpartum infections is incompletely understood. Vitamin D deficiency has in epidemiological studies been shown to increase the risk of various infections. Furthermore, vitamin D is an important factor in the human immune system. Concomitantly, vitamin D supplementation seems protective against some types of infections. Whether vitamin D deficiency is a risk factor for postpartum infections has not been studied.

Material and Methods: In a population-based observational study using questionnaires, the prevalences of postpartum wound infections, endometritis, urinary tract infections and mastitis in the southeast region of Sweden were estimated (Paper I). All women giving birth in the region during one year (n=11 124) were asked to participate. Papers II and III were cohort studies based on all deliveries in Sweden during eight years (2005-2012). Data sources were the Swedish Medical Birth Register, the Swedish National Patient Register and the Swedish Prescribed Drugs Register. In paper II all term deliveries were included (n=795 072). Risk factors for postpartum wound infections, endometritis and urinary tract infection were evaluated. Paper III included all deliveries (n=841 780) and examined the impact of BMI on the risk of postpartum wound infections, endometritis and breast abscess after different modes of delivery. Infections were defined as the presence of applicable ICD-10 codes. The Mantel-Haenszel technique was used to calculate adjusted odds ratios. In paper IV the association between vitamin D deficiency and overall postpartum infectious morbidity was analyzed. Serum samples from the Pregnancy Biobank in Linköping, drawn at the time of delivery, were used to determine concentrations of 25-hydroxyvitamin D in 1397 women. ICD-10 codes were extracted from the women’s medical records. The prevalence of vitamin D deficiency was calculated and adjusted odds ratios for postpartum infections were estimated with multivariable logistic regression analysis.

Results: More than one out of ten women in southeast Sweden reported wound infections; endometritis, urinary tract infection or mastitis postpartum and 7.5% reported antibiotic treatment for infection. Cesarean section was the strongest risk factor for wound infection, followed by obstetric anal sphincter injuries and episiotomy. For endometritis, the strongest risk factors were anemia, manual placental removal and emergency cesarean section. Urinary tract infection was associated with anemia, instrumental vaginal delivery and emergency cesarean section. There was a dose-dependent increased risk of postpartum infection with higher BMI. For morbidly obese women the risk of infection was over 50% higher than for normal weight women. The risk of endometritis after normal vaginal delivery increased the higher the BMI, as did the risk of wound infection after cesarean section, regardless of the type of cesarean section. For breast abscess, there was an inverse association with BMI.

Vitamin D deficiency was present among almost 60% of pregnant women at the time of delivery. No association between vitamin D deficiency and postpartum infections was found.

Conclusions: Every tenth Swedish woman acquired an infection postpartum and three quarters of them received antibiotics for infection. Anemia was an important risk factor for postpartum infection, and the strongest risk factor for endometritis and urinary tract infection. Strong efforts should be made to reduce blood loss during and after childbirth. This thesis confirmed cesarean section as a major risk factor for postpartum infection, especially wound infection. The risk increased if the woman was overweight or obese, regardless of whether it was a planned or an emergency cesarean section.

Vitamin D deficiency was common among Swedish pregnant women, but it was not found to be associated with postpartum infections.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 62
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1686
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:liu:diva-156877DOI: 10.3384/diss.diva-156877ISBN: 9789176850541 (print)OAI: oai:DiVA.org:liu-156877DiVA, id: diva2:1315838
Public defence
2019-06-07, Originalet, Qulturum, Länssjukhuset Ryhov, Jönköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-05-15 Created: 2019-05-15 Last updated: 2019-05-15Bibliographically approved
List of papers
1. Prevalence of postpartum infections: a population-based observational study
Open this publication in new window or tab >>Prevalence of postpartum infections: a population-based observational study
2014 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 93, no 10, p. 1065-1068Article in journal (Refereed) Published
Abstract [en]

We investigated the prevalence of postpartum infections among women giving birth during 1year in a population-based observational/questionnaire study at seven hospitals in the southeast region of Sweden. Of the women greater than99% (n=11124) received a questionnaire to inquire if they had endometritis, mastitis, or wound, urinary tract or any other infection within 2months postpartum and whether they received antibiotics for this. Prevalence rates for infections and antibiotic treatment were estimated. The response rate was 60.1%. At least one infectious episode was reported by 10.3% of the women and 7.5% had received antibiotics. The prevalence for infections with and without antibiotics were, respectively, mastitis 4.7% and 2.9%, urinary tract infection 3.0% and 2.4%, endometritis 2.0% and 1.7%, wound infection 1.8% and 1.2%. There was no inter-county difference in infection prevalence. Clinical postpartum infections in a high-resource setting are relatively common.

Place, publisher, year, edition, pages
Informa Healthcare / Wiley: 12 months, 2014
Keywords
Infections; postpartum; mastitis; urinary tract infection; endometritis; wound infection
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-111744 (URN)10.1111/aogs.12455 (DOI)000342582800016 ()25132521 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden

Available from: 2014-10-31 Created: 2014-10-31 Last updated: 2019-05-15
2. Postpartum infection in relation to maternal characteristics, obstetric interventions and complications
Open this publication in new window or tab >>Postpartum infection in relation to maternal characteristics, obstetric interventions and complications
2018 (English)In: Journal of Perinatal Medicine, ISSN 0300-5577, E-ISSN 1619-3997, Vol. 46, no 3, p. 271-278Article in journal (Refereed) Published
Abstract [en]

The purpose was to evaluate the association between maternal characteristics, obstetrical interventions/complications and postpartum wound infections (WI), urinary tract infection (UTI) and endometritis. Furthermore, this study aimed to determine the time from delivery to onset of infections after discharge from the hospital. Three large Swedish Medical Health Registers were scrutinized for the period 2005-2012. A total of 582,576 women had 795,072 deliveries. Women with diagnosis codes for WIs, UTIs or endometritis, from delivery to 8 weeks postpartum, were compared to non-infected women. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Increasing age and body mass index (BMI) were both associated with increasing prevalence of postpartum infections. WIs were most strongly associated with cesarean section (CS) (OR 17.2; 95% CI 16.1-18.3), 3rd and 4th degree tears (OR 10.7%; 95% CI 9.80-11.9) and episiotomy (OR 10.2; 95% CI 8.94-11.5). Endometritis was associated with anemia (OR 3.16; 95% CI 3.01-3.31) and manual placental removal (OR 2.72; 95% CI 2.51-2.95). UTI was associated with emergency CS (OR 3.46; 95% CI 3.07-3.89) and instrumental delivery (OR 3.70; 95% CI 3.29-4.16). For women discharged from the delivery hospital the peak occurrence of UTI was 6 days postpartum, while for WIs and endometritis it was 7 days postpartum.

Place, publisher, year, edition, pages
WALTER DE GRUYTER GMBH, 2018
Keywords
Anemia; cesarean; endometritis; postpartum infection; urinary tract infection; wound infection
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-147575 (URN)10.1515/jpm-2016-0389 (DOI)000429429900006 ()28672754 (PubMedID)
Note

Funding Agencies|Futurum - the academy for healthcare, Region Jonkoping County, Sweden

Available from: 2018-04-26 Created: 2018-04-26 Last updated: 2019-05-15

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