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Haider Fa’akAbd-El-Kareem¹ , Aseel Dawood Salman² , Barakat majeed Hameed³

¹F.I.C.O.G.Consultant Obstetrician and Gynecologist / Al Yarmouk Teaching Hospital, Baghdad/ Iraq

²Residant doctor in Obstetrics and gynecology department/ Al Yarmouk teaching hospital, Baghdad/ Iraq

³M.B.Ch.B ,C.A.B.O.G/ Senior specialist / Obstetrics and gynecology department /Al Yarmoukteaching hospital/ Al-Karkh Health Directorate/ Ministry of Health/ Baghdad/ Iraq

Corresponding Author Email: drnihadkhalawe@gmail.com

DOI :

Abstract

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Introduction :

Birth of a fetus through incision in the abdominal wall and uterine wall.This definition is not applied to the removal of the fetus from the abdominal cavity in the case of uterine rupture or abdominal pregnancy. Rarely, hysterotomy is performed on a woman who has just died or in whom death is expected soon⁽¹⁾.Primitive cesarean sections also occurred spontaneously during difficult labor or accidentally, asignored lacerations of a woman by horned animals for example. Interestingly, some women reportedly survived .The documented history of CS extends well over four centuries. The Prevalence of cesareansection in a tertiary care hospital is high compared to WHO data. The most spread indications of cesarean section are fetal distress and previous cesarean section^(2). TheincidenceofSSIfollowingCSaccordingtopostdischargesurveillancewas 9.9%, which is higher than expected for a low-risk procedure. Because follow- up was difficult for all cases, this incidence may be underrated. Underuse of antimicrobial prophylaxis may also be a contributing factor, because prophylactic antibiotics were administered in less than 25% of cases⁽³⁾.

Among obese women undergoing cesarean section who received standard preoperative cephalosporin prophylaxis, a postoperative 48-hour course of cephalexin-metronidazole, compared with placebo, presented with a reduced rate ofSSI within 30 days of delivery. For prevention of SSI among obese women after cesareansection,prophylacticoralcephalexinandmetronidazolemaybeindicated^(4).

Theaimofthestudy:toinvestigatetheassociationbetweenpostcesareansurgicalsiteinfectionand meconium stained amniotic fluid.

Patients and methods :

Studydesignandstudy setting:This study is a Prospective observational study was conducted in Al-Yarmuk Teaching Hospital carried out between January 2022 to December 2022 in the obstetrics and gynecology department.

Patientselection:This study involved 200 pregnant women with either singleton or Multiple pregnancies between 37 Completed weeks to 42 Completed weeks.The women were recruited from in patients department as they admitted for either elective or emergency CS , subsequently divided in two groups according to intraoperative findingsgroup A meconium Stained liquor which included l00 women and group B included 100 women clean liquors.

Inclusioncriteria:Womenwithasingletonpregnancyormultipleattemptinglaborwho ultimately had a cesarean delivery; Nonrupturemembranepreoperative; Takeantibioticpreoperative. Exclusion criteria: WomenwithRupturemembrane; DM; IUD and Patientwithsystemicinfection(sepsis).Clinicalassessment.

Statisticalanalysis:The collected data were introduced into Microsoft Excel sheet 2016 and loadedinto SPSS-V24 statistical software. Tables and graphs were used to display descriptive statistics. Independent two sample t-test was used to find out the thesignificance of thedifference between measured continuous numerical variables and Chi-square tests were used to find out significances of association between related categorical variables. P-values less than 0.05 were considered a discriminative point of significance.

Results:

The total study samples were 200 pregnant women. One hundred of them with clear liquor and one hundred of them with meconium. The highest proportion of pregnant women with clear liquor among the age group (>35 years) were 15 (53.6%). The highest proportion of pregnant with meconium among the age group (≤ 18 years) was 10 (71.4%). Living in urban or rural areas was without significant difference (P=0.317). Obese pregnant with meconium was 38 (67.9%), while normal weight pregnant with clear liquorwas 35 (63.6%) and this difference was significant (P=0.003). Pregnant with meconium with higher BMI (28.08 ± 3.914 Kg/m²) were (P<0.001). The highest distribution of smokers 6 (66.7%) were distributed among meconium without significant differences (P=0. 489).As shown in table (1).

The highest proportion of pregnant women wasgravida<5 with clear liquor 83 (56.5%), while the highest proportion of pregnant women wasgravida ≥ 5 with meconium 36 (67.9%) with (P=0.002) the difference was statically significant between two groups. Primgravida was significant (P=0.001) with the highest distribution of 33 (75.0%) among clear liquor. The groups with difference between history of abortion and meconium show no significant difference (P=0.721). As shown in table (2).

The highest proportion of preterm pregnant women with clear liquor were 50 (65.8%), while the highest distribution of postdate pregnant women withmeconium was 9 (75.0%) was significant (P=0.001). Number of births and presence of hypertension were without significant differences in distribution among study groups (P=0.683, and 0.274 respectively). As shown in table (3).

The obese patient with wound infection was statically significant (P<0.001) and were distributed among was the highest proportion of pregnant women with wound infection 18 (32.1%). Also, a higher mean of BMI among pregnant women who developed wound infection was (28.96 ± 4.974 Kg/m²) with a highly significant difference (P<0.001). As shown in table (4).

Multivariate analysis for the possible factors associated with wound infection shows that there was 1.880 odd radio for awound infection to be among pregnant with meconium (95% C.I. = 1.3906 to 2.9859), with failure to achieve statistical significance (P=0.7594).There was 0.861 odds radio for not having wound infection to be among those pregnant with clear liquor (95% C.I. = 0.4040 to 0.8374), achieving statistical significance (P<0.001). When the odds ratio was adjusted with BMI, there were 1.155 odds for wound infection among pregnant with meconium and higher BMI (95% C.I. = 1.0415 to 1.2822) with a high significance (P=0.0064). When the odds ratio was adjusted with smoking, there were 1.643 odds for wound infectiontobeamongpregnantwithmeconiumandsmoking(95%C.I.= 0.3093to 8.7298) with failure to achieve statistical significantly (P=0.5599).When the odds ratio was adjusted with the type of C/S, there were 0.818 odds for a wound infection to be among pregnant with meconium and emergency C/S (95% C.I. = 0.3699 to 1.8121) with failure to achieve statistical significance (P=0.6217). When the odds ratio was adjusted with obesity, there were 2.398 odds for wound infection to be among pregnant with meconium and obesity (95% C.I. = 1.6300 to 2.8720) with statistical significance (P<0.001).As shown in table (5).

Discussion :

There are several known risk factors for cesarean SSIs. The cesarean section alone has a significant risk of developing cesarean endometritis^(5,6,7).

This study suggests that meconium-stained amniotic fluid (MSAF) may be an independent risk factor for surgical site infection (SSI) in pregnant women undergoing cesarean delivery, even when accounting for confounding factors like preoperative antibiotic use.

The highest proportion of women with clear liquor were aged >35 years (15, 53.6%), while those with meconium were aged ≤18 years (10, 71.4%) (P=0.245). The mean age for women with MSAF was 29.20 ± 6.353 years, showing significance (P=0.0158). Age-related vascular changes may contribute to MSAF development.

Urban versus rural residence showed no significant difference (P=0.317), unlike other studies linking rural living to higher risks of anemia and preterm birth. In our study, 38 obese women (67.9%) had meconium, while 35 normal-weight women (63.6%) had clear liquor (P=0.003). Higher BMI (28.08 ± 3.914 Kg/m²) was significant for meconium (P<0.001), aligning with findings that obesity increases surgical risks.

Smokers showed no significant difference in meconium presence (P=0.489). The majority of women were gravida<5 with clear liquor (83, 56.5%), while those gravida ≥5 had meconium (36, 67.9%) (P=0.002). Primigravidawas significant (P=0.001) with clear liquor. No significant difference was found regarding the history of abortion (P=0.721).

Preterm women with clear liquor numbered 50 (65.8%), while postdate women with meconium were 9 (75.0%) (P=0.001). No significant differences were noted for the number of births or hypertension (P=0.683, P=0.274). Our findings indicate that 58% of women had thick meconium, 7% moderate, and 35% thin.

Emergency C/S was more common in meconium cases (59, 57.8%), while elective C/S with clear liquor was 57 (58.2%) (P=0.034). Previous scars were more common in clear liquor cases (83, 55.3%) compared to meconium (33, 66.0%) (P=0.007). Surgical factors showed no significant differences (P=0.061, 0.329, P=0.370).Wound infections were significantly higher in obese women (18, 32.1%) with a higher mean BMI (28.96 ± 4.974 Kg/m²) (P<0.001). No significant difference was seen between clear liquor and meconium in obese women (P=0.896). Preoperative antibiotics likely reduced infection rates, aligning with findings that prophylactic antibiotics significantly lower SSI rates.Exclusion of diabetes and premature rupture of membranes in our study may have reduced SSI risk. Our small sample size might limit the statistical significance of our findings on SSI^(8&9).

Conclusion:ThisstudyhasshownnosignificanteffectofMSAFonSSI,andconcludedthatthe risk factors (obesity, age, D.M., emergency CS…) and the sample size may affectthe result on SSI.

Reference

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