PHILADELPHIA -- Menopause-related depression was mitigated with transdermal estradiol (E2) plus progesterone in a randomized trial reported here.

One year of treatment with 0.1 mg of E2 added to 200 mg micronized intramuscular progesterone significantly decreased incidence of clinically significant depressive symptoms compared to those assigned to placebo (17.3% versus 32.3%, P<0.05), according to Jennifer L. Gordon, PhD, of the University of Regina in Saskatchewan, Canada, and colleagues.

Women who were not on hormonal treatment were also more likely to report a score of 16 or greater on the CES-D scale at least once during treatment compared to women on estradiol treatment (OR 5.3, 95% CI 1.8-15.8, P<0.01), presented at the annual meeting of The North American Menopause Society.

A total of 172 perimenopausal or early postmenopausal women, who were medically healthy and without a diagnosis of major depressive disorders, bipolar, or any other psychotic disorder at time of enrollment, were randomized 1:1 to active treatment or placebo. All participants were community-dwelling women ages 45-60 and were not taking any medications to confound cardiovascular or endocrine profiles.

Transdermal estradiol was dosed at 0.025 mg for 2 weeks, then increased to 0.05 mg for 4 weeks, and then remained at 0.1 mg for the rest of the study. This was paired with micronized progesterone at 200 mg, which was administered for 12 days, every 2 to 3 months. The control group was provided placebo patches and pills.

Participants were evaluated seven times during the 12-month study. Depressive symptoms were defined at a rate score of 16 or higher on the Center for Epidemiologist Studies-Depression Scale, and bothersome level of vasomotor symptoms were measured according to the Greene Climacteric Scale.

Beneficial treatment effects of E2 and IMP therapy compared to placebo were seen among early perimenopausal women, but were not seen among postmenopausal women. The authors suggested that one possible underlying mechanism to explain this finding might be attributed to the stabilization of fluctuating estradiol levels.

A significant interaction between treatment and recent stressful life events on depressive symptoms reported by the CES-D scale was also noted. Among women who reported high amounts of stressful life events prior to study inception, CES-D score was significantly lower among the TE+IMP group compared to placebo.

Gordon's group also found that prior history of depression, physical or sexual abuse, and baseline vasomotor symptoms and E2 levels were not significant moderators of the treatment effects.

"If confirmed in future research, clinicians may consider using transdermal estradiol as a prophylactic treatment for depressive symptoms in the menopause transition," Gordon stated during an oral presentation of the findings.

During a Q&A following the presentation, a member of the audience inquired as to why the research group chose such a high dose of estradiol. Gordon replied that 0.1 mg has been found to decrease ovulation in the menopause transition and stabilize the hormonal environment compared to lower doses, and the group aimed to find if stabilization of the environment was tied to improved mood.

The research was supported by two NIH grants.

Gordon reported no conflicts of interest.

• Primary Source

  North American Menopause Society

  Source Reference: Gordon J, et al "Antidepressant effects of transdermal estradiol in the menopause transition are moderated by stressful life events" NAMS 2017; Abstract S-23.

FRIDAY, Oct. 6, 2017 (HealthDay News) -- In a move that could affect millions of American women, the Trump Administration is poised to roll back a federal mandate requiring that birth control be available as part of employer-based health plans.

Instead, new rules -- expected as early as Friday -- would give employers much wider leeway to declare themselves exempt from providing contraception due to moral or religious objections, The New York Times reported.

More than 55 million women currently have access to free birth control due to the contraceptive coverage mandate, according to data compiled under the Obama administration. The new rules would also affect hundreds of thousands of women who get free contraception under the Affordable Care Act.

The expected action from the White House fulfills a promise President Donald Trump made to voters during the 2016 election campaign.

According to the Times, wording in the new rules offers an exemption to any employer based on "moral convictions" or because it objects to covering birth control services "based on its sincerely held religious beliefs."

The Trump administration wording says that expanding exemptions was needed so that all religious objections to contraceptive coverage could be accommodated. "Application of the mandate to entities with sincerely held religious objections to it does not serve a compelling governmental interest," it says.

The birth control mandate was the focus of intense litigation during the Obama Administration, as companies, hospitals, charitable groups and other organizations with moral objections sought to distance themselves from providing birth control to female employees. In one such case, an order of nuns called the Little Sisters of the Poor said the mandate would make them "morally complicit in grave sin," the Times reported.

On the campaign trail, Trump told voters that he would "make absolutely certain religious orders like the Little Sisters of the Poor are not bullied by the federal government because of their religious beliefs."

But the new move is expected to prompt even more legal battles -- this time from groups advocating for women and public health.

In a statement, Dr. Anne Davis, consulting medical director for Physicians for Reproductive Health, said the rollback could send many American women "back to the days when patients couldn't afford the birth control that helps them live healthier lives."

"No matter where they work, women need and deserve birth control access," Davis said. "An employer's beliefs have no place in these private decisions, just as they would not in any other conversation about a patient's health care. It's a dangerous intrusion into a woman's privacy and her ability to get the care she needs."

Dana Singiser, Planned Parenthood's vice president of public policy and government affairs, agreed.

"Let's be clear: this rule has nothing to do with religion. Under the Affordable Care Act religious organizations already have an accommodation that still ensures their employees get coverage through other means," she said. "This rule is about taking away women's fundamental health care, plain and simple."

But the Trump administration said that in expanding exemptions, it is honoring objections to contraceptive coverage on moral as well as purely religious grounds.

"Congress has a consistent history of supporting conscience protections for moral convictions alongside protections for religious beliefs," the administration said.

Companies that now decide to opt out of contraceptive coverage are required to notify employees, the new rules state.

The new rules are to take effect immediately, the Trump administration said, because "it would be impracticable and contrary to the public interest to engage in full notice and comment rule-making." Public comments are being accepted, however.

More information

There's more on contraception at the American College of Obstetricians and Gynecologists.

SOURCES: The New York Times; Oct. 5, 2017, news releases, Planned Parenthood Federation of America, Physicians for Reproductive Health

-- E. J. Mundell

Last Updated: Oct 6, 2017

Copyright © 2017 HealthDay. All rights reserved.

SAN DIEGO -- A few extra glasses of water a day could cut the risk of urinary tract infections for women plagued with recurrent episodes, a researcher said here.

In a randomized trial, drinking about three extra pints of water a day cut the risk of uncomplicated acute cystitis (AUC) by about half, according to Thomas Hooton, MD, of the University of Miami School of Medicine.

The extra water was also associated with fewer courses of antibiotics during the year-long study, Hooton told reporters here at the annual IDWeek meeting, sponsored jointly by the Infectious Diseases Society of American (IDSA), the Pediatric Infectious Diseases Society (PIDS), the Society for Healthcare Epidemiology of America (SHEA), and the HIV Medicine Association (HIVMA).

The finding is not really a surprise, Hooton said -- doctors have long been telling women to drink more water to prevent or help treat recurring AUC.

The idea makes sense, he said, because the conventional wisdom has been that disease-causing bacteria make their way from the vagina up the urethra to the bladder. Frequent flushing with urine can prevent the bacteria from sticking to bladder cells, growing, and causing disease.

But while that's a good story, he said, there had been no real study of the issue. "You always want to have confirmatory data," Hooton said. "It helps to be able to say there's a well-done study that looked at this question very carefully and showed the risk was pretty dramatically reduced."

To obtain that data, he and colleagues enrolled 140 premenopausal women whose self-reported fluid intake was low -- less than 1.5 liters of total fluid a day -- and who had had at least three episodes of AUC in the previous year.

They were randomly assigned 1:1 to increase their water intake by 1.5 L a day or to make no change in their habits.

The investigators had monthly telephone calls with all participants as well as regular clinic visits in which such things as urine volume and osmolality -- a measure of the concentration of the fluid -- were tested.

Women in the intervention group were given 500 mL bottles of water and urged to begin drinking one at the start of each meal and to finish it before the next meal, Hooton said.

Over the study period, the 70 women in the intervention group:

• Increased their water intake significantly compared with the control group -- an increase of 1.15 L on average versus an average drop of 0.01 L
• Raised their average total fluid intake by 1.65 L versus 0.03 L among the control group
• Upped average urine volume and number of urine voids -- 1.40 L versus 0.04 L and 2.2 a day versus a decrease of 0.2, respectively
• Saw a decrease in urine osmolality of 408 mOsm/kg versus 35 in controls

But the key finding, Hooton said, was that the average number of recurrent AUC episodes in the water group over the year was 1.6, compared with 3.1 among the control women. Those number yielded an odds ratio for AUC of 0.52, which was highly significant, he said.

As might be expected, the average number of antimicrobial regimens used to treat AUC was 1.8 in the water group and 3.5 in the control group, which was again significant. As well, he noted, the average number of days to first AUC after the start of the study and the mean number of days between episodes was longer for those in the water group.

The findings are important because many women suffer recurrent AUC and most are treated with antibiotics, commented Susan Bleasdale, MD, of the University of Illinois at Chicago, who moderated a media briefing on the trial.

The study, she told reporters, "may be a game-changer" in the way antibiotics are used.

The usual advice doctors give women to keep hydrated often comes when they are already in the throes of an infection -- advice often given along with a prescription for antibiotics. The point of the study, she said, is that increased water intake appears to prevent the infections in the first place -- and therefore the need for scripts.

While the study took place among premenopausal women at risk for recurrent AUC, Hooton said he sees no reason it would not apply to those past the menopause, as well as to women of all ages who suffer less frequent attacks. But he added that hasn't yet been demonstrated.

Hooton said he had no disclosures to make.

The study had support from Danone Research.

Bleasdale made no disclosures.

• Reviewed by Henry A. Solomon, MD, FACP, FACCClinical Associate Professor, Weill Cornell Medical College and Dorothy Caputo, MA, BSN, RN, Nurse Planner

• Primary Source

  IDWeek 2017

  Source Reference: Hooton T, et al "Prevention of recurrent acute uncomplicated cystitis by increasing daily water in premenopausal women : A prospective randomized controlled study" IDWeek 2017; abstract LB-7.

Julia Haskins

Exposure to extreme heat may lead to problems with pregnancy and birth outcomes, a recent study finds.

According to the study, published in July in the International Journal of Environmental Research and Public Health, exposing pregnant women to extreme temperatures can lead to problems related to length of gestation and birthweight, neonatal stress and stillbirth.

Study researchers conducted a literature review of the effect on climate change on maternal, fetal and neonatal health. They found evidence of adverse outcomes across studies, with preterm birth being the most common.

Exceeding a heat threshold was found to be a bigger driver of adverse outcomes than duration of heat exposure. According to the study, “data show that surpassing historical temperature percentiles in each city resulted in an adverse birth outcome of some kind across all studies.”

Pregnant women need to be concerned about heat exposure, said study author Sabrina McCormick, PhD, associate professor of environmental and occupational health at the Milken Institute School of Public Health at the George Washington University.

“We often normalize the heat...but when it comes to pregnant women, it may be that we need to be more cautious than we have to date,” McCormick told The Nation’s Health. “(We need) to reconceptualize heat as another risk that pregnant women have to consider as they go about their day-to-day activities.”

Climate change has been linked to increasing temperatures around the globe, and 2016 was the warmest year ever recorded.

McCormick said she would like to see health care providers become more educated about extreme heat linked to climate change and communicate the dangers of extreme heat exposure with pregnant patients in regular conversations.

Environmental policy also has the potential to influence the health outcomes of pregnant women, particularly in terms of reducing the urban heat island effect, McCormick said. The urban heat island effect refers to metropolitan areas that are much warmer than surrounding rural areas due to human activity and the absence of green spaces.

“It’s extremely important that both policymakers and individual cities...attempt to reduce the urban heat island effect through increasing access to green space and green coverage in general,” she said.

Public health has an equally important role in communicating the importance of staying cool in high temperatures. McCormick noted that while heat advisories are often geared toward at-risk groups such as children and elderly people, pregnant women are rarely included in such messaging. She said she would like to see public health warnings about extreme heat specifically target pregnant women, who are also at high risk for heat-related illness.

In addition, because pregnancy is often a time for women to reconsider their health behaviors, being more environmentally conscious can also be part of making good prenatal health decisions, according to McCormick.

“When we think about the transgenerational effects of climate change — which there are and there will be more of — this kind of research shows how (what) we’re doing today will affect our children (and) our children’s children,” she said. “It’s an important reflection on why we need to be taking action.”

For more information, visit http://www.mdpi.com/1660-4601/14/8/853/htm.

• Copyright The Nation’s Health, American Public Health Association

Women: Take five! Or less! Learn about five things you can do that can go a long way to improve or maintain good health.

In Five Minutes or Less, You Can:

1. Learn about the number one killer of women.
   Heart disease is the leading cause of death for women in the United States. Learn the symptoms of a heart attack and stroke. You can save a life by knowing the signs and symptoms!
2. Schedule a check-up. 
   Regular check-ups are important. Schedule an appointment with your health care provider to discuss what screenings and exams you need and when you need them.
3. Protect your skin from the sun. 
   Skin cancer is one of the most common cancers among women in the United States. In just minutes you can protect your skin and put on broad spectrum sunscreen with at least SPF 15 before you go outside, even on slightly cloudy or cool days.
4. Find an HIV, STD, and Hepatitis testing site near you. 
   Untreated sexually transmitted diseases (STDs) can have long-term consequences [221 KB] for women, such as infertility. Find testing near you to know your status.
5. Take folic acid before and during pregnancy.
   The B vitamin folic acid can help prevent certain birth defects. If a woman has enough folic acid in her body before and during pregnancy, her baby may be less likely to be born with certain birth defects of the brain or spine. All women who could possibly get pregnant should take 400 micrograms of folic acid every day in a vitamin or in foods that have been enriched with it.

These tips are just a few of the many things you can do in five minutes or less. Learn more small steps you can take to improve your health.

Annual report shows more than 2 million cases of chlamydia, gonorrhea and syphilis reported in 2016

En Español

TUESDAY, Sept. 26, 2017 (HealthDay News) -- New cases of sexually transmitted diseases in the United States reached an all-time high in 2016, federal health officials reported Tuesday.

There were 1.6 million cases of chlamydia, 470,000 cases of gonorrhea and 28,000 of syphilis reported that year, the U.S. Centers for Disease Control and Prevention announced in its annual report on STDs.

And the diseases are on the rise in a number of groups, including women, infants, and gay and bisexual men.

"Increases in STDs are a clear warning of a growing threat," said Dr. Jonathan Mermin, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

"STDs are a persistent enemy, growing in number, and outpacing our ability to respond," he said in an agency news release.

Young women account for nearly half of all diagnosed chlamydia infections, but syphilis and gonorrhea are increasingly affecting new groups of people.

Between 2015 and 2016, syphilis rates rose nearly 18 percent. Most cases occurred among men, especially gays and bisexuals. Half of the men in those two groups also had HIV, according to the report.

But syphilis rates rose 36 percent among women and 28 percent among newborns between 2015 and 2016. In 2016, there were more than 600 cases of syphilis-infected newborns, resulting in more than 40 deaths and severe health complications, the CDC said.

"Every baby born with syphilis represents a tragic systems failure," said Gail Bolan, director of CDC's Division of STD Prevention. "All it takes is a simple STD test and antibiotic treatment to prevent this enormous heartache and help assure a healthy start for the next generation of Americans."

Gonorrhea rates rose among both men and women in 2016, but the largest increase (22 percent) was among men, and a large number of new gonorrhea cases were among gay and bisexual men. The report also noted the growing threat of drug resistance to the last remaining recommended gonorrhea treatment.

In order to stem the rise in STD rates, the CDC said:

• State and local health departments need to refocus on preventing and treating these diseases.
• Doctors need to make STD screening and treatment a standard part of medical care, especially for pregnant women and gay and bisexual men.
• People need to talk openly about STDs, get tested regularly, and reduce risk by using condoms or being monogamous.

Antibiotics can cure all three diseases. But if undiagnosed and untreated, STDs can lead to serious health problems such as infertility, life-threatening ectopic pregnancy, stillbirth, and increased risk of HIV infection, according to the CDC.

More information

The U.S. National Institute of Allergy and Infectious Diseases has more on STDs.

SOURCE: U.S. Centers for Disease Control and Prevention, news release, Sept. 26, 2017

-- Robert Preidt

Last Updated: Sep 26, 2017

Copyright © 2017 HealthDay. All rights reserved.

Mood disorder seen in 1 in 200 new moms with no psychiatric history

En Español

By Dennis Thompson
HealthDay Reporter

TUESDAY, Sept. 26, 2017 (HealthDay News) -- Women who have suffered from postpartum depression are more likely to go through it again after subsequent pregnancies, a new Danish study shows.

Postpartum depression occurs 27 to 46 times more frequently during subsequent pregnancies for mothers who experienced it after their first birth, researchers report.

These results show that women who have had postpartum depression in the past should prepare themselves if they get pregnant again, said lead researcher Marie-Louise Rasmussen, an epidemiologist with Statens Serum Institut in Copenhagen.

Antidepressants or psychotherapy could help cushion the blow or even head off postpartum depression, Rasmussen said.

"In theory, psychotherapy is preferred but not always sufficient and not always available. Often, the general practitioner has to add antidepressant medication," Rasmussen said. "Social support from the spouse and surroundings is also very important."

In most cases, women can expect to shake off their postpartum depression within a year, the researchers found.

"Based on this data, we would think for most women who receive treatment, their depression should be treated and resolved in six months or less," said Dr. James Murrough. He's director of the mood and anxiety disorders program at the Icahn School of Medicine at Mount Sinai in New York City.

Postpartum depression generally takes hold of a new mother within days of delivery, although sometimes depression develops during pregnancy, according to the U.S. National Institute of Mental Health.

Brain chemistry changes caused by post-delivery hormone fluctuations are a contributing cause of postpartum depression, along with the sleep deprivation experienced by most new parents, NIMH says.

Signs of postpartum depression can include feelings of sadness and hopelessness, frequent crying, anxiety or moodiness, changes in sleeping or eating patterns, difficulty with concentration, anger or rage, and loss of interest in activities that are usually enjoyable, according to the mental health institute.

A new mother with postpartum depression also might withdraw from friends or family and have difficulty forming an emotional attachment to her baby.

Rasmussen and her colleagues undertook this study to provide women facing pregnancy with better estimates of their overall risk of postpartum depression.

"Postpartum depression is a disease depriving families of a time period that should be filled with affinity, love and bonding," Rasmussen said. "Especially for women with no prior experience with psychiatric disease, this must come as a bolt out of the blue."

The researchers analyzed data from Danish national registries on more than 457,000 women who delivered their first child between 1996 and 2013 and had no prior medical history of depression.

They reviewed medical records for signs of postpartum depression -- specifically whether these women filled an antidepressant prescription or sought treatment for depression within six months after giving birth.

About 1 in every 200 women experienced postpartum depression, the researchers found.

But within a year of seeking care, only 28 percent of these women were still being treated for depression, the results showed. And four years later, that number was 5 percent.

The risk of postpartum depression in subsequent births was 15 percent for women who took antidepressants following their first birth and 21 percent for women who sought depression treatment at a hospital. That amounts to a 27 and 46 times higher risk than for women who didn't experience depression during their first pregnancy, the researchers said.

"The episodes were characterized by a relatively short treatment duration, yet a notably higher rate of later depression and recurrent episodes of postpartum depression," Rasmussen said.

The higher risk for women who've already experienced postpartum depression "suggests that there's some underlying vulnerability to develop depression in these particular individuals," Murrough said. "Basically, it's not random. If you had it before, you could have it again."

Murrough and Rasmussen urged pregnant women to discuss the risk of postpartum depression with their doctor, particularly if they suffered it before.

"It's not clear that's discussed often in standard practice, amazingly," Murrough said.

The new study was published Sept. 26 in the journal PLOS Medicine.

More information

For more on postpartum depression, visit the U.S. National Institute of Mental Health.

SOURCES: Marie-Louise Rasmussen, epidemiologist, Statens Serum Institut, Copenhagen, Denmark; James Murrough, M.D., director, Mood and Anxiety Disorders Program, Icahn School of Medicine at Mount Sinai, New York City; Sept. 26, 2017, PLOS Medicine

Last Updated: Sep 26, 2017

Copyright © 2017 HealthDay. All rights reserved.

Action Points

A prophylactic, postoperative course of antibiotics with cephalexin (Keflex) and metronidazole (Flagyl) reduced rates of surgical site infection (SSI) in obese women undergoing cesarean delivery, a randomized clinical trial found.

Thirty days after C-section delivery, the rate of SSI was 6.4% in the treatment group versus 15.4% in the placebo group (between group difference 9%, 95% CI 2.9%-15%, P=0.01), reported Carri Warshak, MD, of the University of Cincinnati College of Medicine in Ohio, and colleagues.

The relative risk of SSI was reduced by 59% in the treatment group versus the placebo group (RR 0.41, 95% CI 0.22-0.77, P=0.01), they wrote in the Journal of the American Medical Association.

C-section deliveries are the most frequently performed surgeries in the U.S., Warshak's group said. Approximately 1.3 million were performed in 2010. Previous research has shown that 3% to 12% of all C-section deliveries are complicated by surgical site infections, and that infection risk increases with increasing maternal weight, they said.

"Obesity is an independent risk factor for SSI despite recommended preoperative antibiotic regimens. Limited studies have addressed optimal antibiotic regimens for the prevention of SSI among obese women," the investigators wrote. "Various postpartum antibiotic combinations and durations have been studied with conflicting benefit, but no studies have specifically addressed the obese population.

"This study was the first to our knowledge to evaluate the use of a prophylactic postcesarean course of cephalexin-metronidazole for prevention of SSI in an obese population," they said. "Cephalexin and metronidazole have high oral bioavailability and pharmacoeconomic advantages and are generally well tolerated, supporting the drug combination as a choice for postpartum prophylactic coverage."

Anatomic factors associated with obesity, such as skin folds and increased tissue pressure, or the bioactive qualities of adipose tissue, which secretes hormones, chemokines, and cytokines, may be why obesity increases SSI risk, the investigators said.

The single-center, double-blind study enrolled 403 pregnant women with a BMI≥ 30 and a final plan for C-section delivery. They were enrolled from October 2010 through December 2015 and followed through February 2016. Their mean age was 28 and mean BMI was 39.7.

Study participants were randomly assigned to receive oral cephalexin, 500mg, and metronidazole, 500mg (n=202), versus an identical-appearing placebo (n=201) every 8 hours for a total of 48 hours following C-section delivery. The primary outcome was SSI, defined as any superficial incisional, deep incisional, or organ/space infections within 30 days after C-section delivery.

All participants received 2 g of intravenous cefazolin (Ancef, Kefzol) prior to surgery, which was the standard of care at the time of the study. The overall SSI rate in the study was 10.9% (95% CI 7.9%-14%). No serious adverse events were reported in the treatment or placebo groups, the investigators said.

Cellulitis was the only secondary outcome significantly reduced with prophylactic antibiotics, Warshak's group reported. Cellulitis occurred in 12 participants in the treatment group (5.9%, 95% CI 2.7%-9.2%) versus 27 in the placebo group (13.4%, 95% CI 8.9%-18.2%). The mean difference was 7.5% (95% CI 1.7%-13.0%). The relative risk was 0.44 (95% CI 0.23-0.84). There were no significant differences between treatment and placebo for other secondary outcomes, including rates of incisional morbidity, fever of unknown etiology, wound separation, or endometritis.

In an accompanying editorial, David Calfee, MD, and Amos Grünebaum, MD, both of Weill Cornell Medicine in New York City, agreed with the authors' conclusions. "The results of this study suggest that a 2-day course of oral cephalexin and metronidazole after cesarean delivery may be an effective strategy to prevent postcesarean SSI among obese women," they wrote.

However, Calfee and Grünebaum added several caveats. "When determining if and how the results of this study should alter current clinical practice, it is important to recognize that the results of this study are quite different from those of several previous studies conducted in other surgical patient populations in which no benefit from postoperative antimicrobial prophylaxis was found and on which current clinical guidelines for antimicrobial prophylaxis are based," they wrote. "The explanation for this difference may be as simple as the identification in the current study of a very specific, high-risk group of patients for which the intervention is effective."

"However, several questions are worthy of additional consideration and study," they said. "For example, were glycemic control, maintenance of normothermia, and preoperative bathing routinely implemented? Would the same benefit be seen among obese women who receive a higher preoperative dose of cefazolin (ie, 3 g), as recommended in current clinical practice guidelines?"

Both the editorialists and the authors said a chief study limitation was its single-center design, which raises the possibility of site-specific confounders, so that the results might not be generalizable to other obstetric practices.

The study was funded by the University of Cincinnati Department of Obstetrics and Gynecology.

Warshak and co-authors disclosed no relevant relationships with industry.

Calfee disclosed support from Merck, Sharpe, and Dohme.

• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

• Primary Source

  Journal of the American Medical Association

  Source Reference: Valent AM, et al "Effect of post-cesarean delivery oral cephalexin and metronidazole on surgical site infection among obese women: a randomized clinical trial" JAMA 2017;318:1026-1034; DOI:10.1001/jama.2017.10567.

• Secondary Source

  Journal of the American Medical Association

  Source Reference: Calfee DP and Grünebaum A "Postoperative antimicrobial prophylaxis following cesarean delivery in obese women: An exception to the rule?" JAMA 2017; 318:1012-1013.

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