Evaluating the Clinical Utility of Cervical Cultures in Postpartum Endometritis Management

Evaluating the Clinical Utility of Cervical Cultures in Postpartum Endometritis Management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating the Clinical Utility of Cervical Cultures in Postpartum Endometritis Management Nir Meller, Ronen Fluss, Sharon Amit This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4687919/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Aug, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 6 You are reading this latest preprint version Abstract Purpose To evaluate the utility of cervical cultures in the diagnosis and management of postpartum endometritis. Methods A retrospective study was conducted on 1069 cervical cultures collected from postpartum women with suspected endometritis between 2011 and 2021. Patient demographics, obstetric history, clinical parameters, and culture results were analyzed. Microorganisms were categorized into five groups based on species and virulence. Statistical analysis was performed to identify associations between risk factors, pathogens, and disease severity. Results The positivity rate for distinct microorganisms in cervical cultures was 33.1%. Escherichia coli (10.8%) and Group B Streptococcus (7.5%) were the most common isolates. Prolonged labor duration and prolonged rupture of membranes were associated with Enterobacterales infections. Elevated white blood cell count was linked to Enterobacterales and Beta-hemolytic Streptococci, whilst the former were also associated with higher rate of postpartum clinic visit. No significant differences in disease severity were found between other microorganism groups. Conclusion The study suggests that while cervical cultures can identify potential pathogens in postpartum endometritis, their clinical utility is questionable due to the polymicrobial nature of the disease and the isolation of commensal microorganisms. The lack of significant differences in disease severity across various microorganism groups raises questions regarding the contribution of distinct bacterial identification in endometritis management. Endometritis Microbiology Postpartum Infections What does this study adds to the clinical work? The study questions the utility of cervical cultures in the management of postpartum endometritis, and improve the understanding of their results. The study presents associations between specific microorganisms and severity of disease. INTRODUCTION Endometritis is a term that applies to an infection of the endometrial lining, the myometrium, and the parametrium ( 1 ). Endometritis is the most common febrile complication after delivery ( 2 ). It occurs in 1–3% of vaginal births, and is significantly more common after caesarean delivery ( 3 ). Endometritis leads to prolonged postpartum hospital stays and stands as one of the most common reasons for postpartum readmissions, thus posing a substantial burden on the healthcare system ( 4 – 6 ). The diagnosis of postpartum endometritis is based on the presence of fever in the absence of any other obvious cause. Tachycardia, uterine tenderness, foul-smelling lochia or purulent vaginal discharge and elevated white blood cells are common clinical findings used to support the diagnosis of endometritis ( 3 , 7 ). The pathogenesis of endometritis is related to contamination of the uterine cavity with vaginal microorganisms during labor ( 3 ), and it is usually a polymicrobial infection associated with mixed aerobic and anaerobic flora ( 8 ). According to previous publications related micro-organisms include facultative anaerobes such as Escherichia coli, Group B streptococcus (GBS), and Enterococcus spp., and typical obligate anaerobes such as Peptostreptococcus, Bacteriodes, and Clostridium spp. Nevertheless, more virulent bacteria, such as Group A Streptococcus or Staphylococcus aureus, may be involved ( 7 , 9 ). The utility of endometrial, cervical and vaginal cultures as part of the management of endometritis is controversial. Proponents of the usage of microbiological cultures state that patients with suspected endometritis should have an endometrial aspirate and cervical swab sent for aerobic and anaerobic culture ( 10 ). Cultures will allegedly detect the distinct microorganism, and administration of the right antibiotic regimen will be ensured ( 9 , 11 – 13 ). Past publication stated that “A vaginal swab should be submitted specifically for the detection of Group A streptococcus (GAS) and Staphylococcus aureus” ( 11 ). Another explanation for the purpose of endometrial and cervical cultures is that identification of GBS or Neisseria gonorrhoeae would affect paediatrician care ( 14 ). Nevertheless, the opponents of the usage of microbiological cultures doubt the clinical relevance of the cultures, as obtaining an endometrial or cervical culture without microbiological contamination from the vagina during sampling is challenging ( 3 ). The clinical significance of cervical cultures is further questioned due to studies indicating no significant difference in the rate of positive results between patients with and without postpartum febrile illness ( 15 ). Our research focuses on evaluating the utility of cervical cultures in diagnosing and managing postpartum endometritis. In this study, we aim to establish the prevalence of distinct microorganism isolated from cervical cultures of affected patients, identify risk factors linked to particular pathogens, and assess the correlation between these pathogens and disease severity. METHODS In this retrospective study from a single tertiary referral center, we reviewed all cases in which cervical cultures were collected in the puerperium period (0–6 weeks postpartum) between 2011–2021. Our protocol screened cervical cultures sampled from every case of suspected postpartum endometritis, providing comprehensive bacteriological data of all endometritis cases within the study timeframe. Specimen collection was carried out in the maternity ward if the suspicion of endometritis was raised during the hospitalization following labor, or in the emergency gynecology department if the patient was re-admitted. Samples were collected from uterus cervix after visualization with speculum, using a sterile swab. Swabs were placed in a solid AMIES transport media and shipped to the lab, located on campus. Samples were processed according to relevant standard microbiological guidelines ( 16 ). A distinct microorganism was identified if it predominantly grew in culture or if it was a consensual virulent species if isolated from the vagina/cervix (e.g. Streptococcus pyogenes/agalactiae (Group A and B streptococci, respectively), Neisseria gonorrhea, etc.). Empirical antimicrobial treatment was commenced immediately upon diagnosis, and was modified only if needed clinically, regardless of cultures’ results. Pediatricians were noticed of isolated microorganisms in order to confirm compatible antibiotic coverage for newborns. We included all patients who had cervical culture obtained within the first six weeks postpartum. Patients with alternative etiology for puerperal fever (e.g. pyelonephritis, surgical site infection, mastitis etc.) are not included in our cohort. We extracted data from medical records including demographic characteristics, obstetrical history, pregnancy and labor characteristics and clinical parameters regarding the concurrent endometritis. Data extraction and exploration were done with MDClone big data platform. We included known risk factors for endometritis and parameters related to infection severity as follows: "Intrapartum fever" (manually added to the patient record when a fever of 38°C is measured during labor); Length of stay (LOS); “Re-admission” means subsequent admission to our gynecologic emergency department during the puerperium period; “Fever” in the severity of disease table is the maximal temperature measured during the time period between two days prior to the cervical swab collection and seven days afterwards; Laboratory results are the maximal or minimal values during the time period between two days prior to the cervical swab collection and seven days afterwards; “Blood culture” relates to any positive blood culture from the date of cervical swab collection to 6 weeks afterwards; “Diagnosis of sepsis” relates to suspected sepsis during the fourteen days following the cervical swab collection; “ICU admission” relates to admission to intensive care unit during the first week after cervical swab collection; “Postpartum clinic visit” is any visit in our institution designated clinic for follow-up after complicated postpartum cases, during the six weeks following labor; Pelvic/abdominal CT scan is any examination that was conducted following the 6 weeks postpartum. We reviewed cultures’ results and extracted the data of microorganisms’ growth. In order to perform statistical analysis, we divided the microorganisms which were cultured into five categories according to their species nature and known virulence. The five groups are: Non-virulent species, Enterobacterales, beta-hemolytic Streptococci, Staphylococcus aureus, Candida species, alongside negative results. A list of all microorganisms included in each group appears in Appendix 1 . For each risk factor, we examined association with the groups of microorganisms by testing the difference of its distribution between the groups. For approximately normal (bell-shaped) distributed factors, possibly after log-transformation, we used an ANOVA model. For non-normal distributed ordered valued factors, we used the Kruskal Wallis test (rank-based ANOVA), and for nominal factors we used the Chi-squared test using simulated based p-values due to several low frequencies. We did not correct for inflation of type 1 error due to multiple testing of many risk factors. For risk factors found with a significant (5% level) association further post-hoc comparisons were conducted in order to detect the individual group differences. The post-hoc p-values of pairwise comparisons were corrected for multiple comparisons. Similar methods were carried to evaluate association between groups of microorganisms and severity of disease. RESULTS The overall cohort of deliveries in our institution during the study period included 83,791 deliveries. Our study included 1069 cervical cultures results of postpartum women with clinical suspicion of endometritis. A total of 538 (50.3%) of the deliveries cases were following a cesarean section and the rest (49.7%) were following a vaginal delivery. Distinct microorganism was cultured in 354 samples, yielding a positivity rate of 33.12%. The most common bacterium was Escherichia coli (10.8% of all cultures), followed by Group B streptococcus (Streptococcus agalactiae) (7.5%). All other microorganisms and their occurrences are detailed in Appendix 1 . The distribution of culture results between the microorganisms’ groups is listed in Table 1 . Table 1 Distribution of culture results to micro-organisms’ groups. Group Microorganism Group Frequency (%) A Enterobacterales 142 (13.3%) B Beta-hemolytic-Streptococci 107 (10.0%) C Staphylococcus aureus 16 (1.5%) D Candida species 21 (2.0%) E Non-virulent species 68 (6.4%) O No distinct microorganism 715 (66.9%) Table 2 demonstrates demographic and obstetric characteristic of endometritis cases that have compared according to microorganisms groups. Five different risk factors showed a significant difference across pathogen groups: duration of the 2nd stage of labor, time from rupture of membrane (ROM) to labor, cesarean section rate, length of hospital stay (LOS) and usage of antibiotics before culture collection. Table 2. Major demographic and obstetric characteristics of endometritis cases, by groups of microorganisms. Characteristics n Enterobacterales ß -hemolytic-Streptococci Staph. aureus Candida species Non-virulent species No distinct microorganism P-value Age M 1069 31 32 34 33 32 32 0. 84 BMI > 35 rate 955 0.1 0.1 0.1 0.1 0.1 0.1 0.87 Parity M 1069 1 1 1 2 1 1 0.08 Spontaneous Labor Onset rate 1069 0.3 0.4 0.2 0.4 0.3 0.4 0. 45 Duration of 2 nd Stage of Labor (h) C 457 3.0 1.4 2.1 1.8 2.2 2.1 0. 02 Artificial Membranes Rupture rate 996 0. 5 0. 5 0. 3 0. 6 0. 5 0. 5 0.22 Meconium stained Amniotic Fluid rate 998 0. 1 0. 1 0. 1 0. 2 0. 2 0. 1 0. 70 Time from ROM to Labor (h) C 998 7.3 3.4 0.2 1.5 2.3 4.2 0.002 Cesarean Delivery rate 1062 0.5 0.4 0.6 0.5 0.6 0. 5 0.04 Duration of 3rd Stage of Labor (h) C 340 0.3 0.2 0.3 0.2 0.3 0.2 0.46 Twin Pregnancy rate 1069 0.1 0.1 0.3 0.1 0.1 0.1 0.19 Birth Weight (kg) C 1062 2. 9 3. 1 3.0 3.3 3.1 3.1 0. 18 Length of Stay (d) C 822 5.2 3.7 10.0 4.0 4.7 4.2 0.02 Table 2 presents the distribution of each characteristics between the various microorganisms groups. M values are presented as medians; Χ values are presented as means; p-value represents the difference between the groups. BMI – body mass index; h – hours; ROM – rupture of membrane; d – days; In post-hoc analysis we have found significant differences between specific microorganisms groups in duration of the 2nd stage of labor and in the time from ROM to labor. The duration of the 2nd stage of labor was significantly longer in the Enterobacterales group in comparison to group the Beta-hemolytic streptococci group. The time from ROM to labor was significantly longer in the Enterobacterales group in comparison to Beta-hemolytic Streptococci, Staphylococcus aureus groups and the no distinct organism group. The entire post-hoc analysis results can be found in Appendix 2 . Table 3 compares various parameters of disease severity between the microorganisms groups. Five risk factors showed a significant difference across pathogen groups: Re-admission rate, maximal white blood cell (WBC) count, rate of positive blood culture, length of stay after re-admission and postpartum clinic visits. Table 3 . Measures of severity of disease by groups of microorganisms. Measure n Enterobacterales ß -hemolytic-Streptococci Staph. aureus Candida species Non-virulent species No distinct microorganism P- value Re-admission rate 1069 0.3 0.5 0.3 0.2 0.3 0.4 0.03 Fever (Celsius) 1057 38.1 38.1 37.8 38.0 38.1 38.0 0.50 Maximal CRP (mg/l) 578 100.0 118.0 107.2 128.1 102.2 103.5 0.886 Maximal Platelet (K/mcl) 1057 314.0 300.1 291.0 289.0 288.0 304.0 0.291 Minimal Hemoglobin (g/dl) 1057 10.6 11.2 10.9 10.0 10.6 10.8 0.321 Maximal WBC (K/microL) 1057 13.3 15.7 13.9 10.4 13.9 12.7 0.000 Maximal Fibrinogen (mg/dl) 684 468.0 438.5 547.0 424.0 476.0 457.0 0.297 Maximal Creatinine (mg/dl) 1021 0.7 0.7 0.7 0.7 0.7 0.7 0.150 Positive blood culture rate 783 0.09 0.02 0.23 0.06 0.11 0.05 0.030 Pelvic/abdominal CT rate 1069 0.15 0.09 0.19 0.05 0.09 0.12 0.517 Sepsis diagnosis rate 1069 0.02 0.01 0.00 0.00 0.02 0.00 0.142 ICU admission rate 1069 0.00 0.01 0.00 0.00 0.02 0.00 0.507 Postpartum clinic visit rate 1069 0.3 0.2 0.3 0.1 0.3 0.2 0.005 Normal distributed factors are presented as means. CRP - C-reactive protein; WBC - white blood cell; CT - computed tomography; ICU - intensive care unit; LOT - length of stay. Significant differences between specific microorganism groups were found in the re-admission rate, the maximal WBC value and in the postpartum clinic visit. In post-hoc analysis we have found that the maximal WBC count was significantly higher among the Enterobacterales and Beta-hemolytic Streptococci groups than the no distinct organism group. Postpartum clinic visit rate was significantly higher in the Enterobacterales group in comparison to the Beta-hemolytic Streptococci and the no distinct organism group. The entire post-hoc analysis results can be found in Appendix 2 . DISCUSSION Postpartum endometritis is the most common obstetric infection ( 2 ). It leads to prolonged postpartum hospital stays, thus imposing a considerable strain on healthcare resources. Nevertheless, data regarding the association between distinct risk factors, causative pathogens and the severity of the condition are sparse and not consistent. This research outlines our decade-long practice of obtaining cervical swabs for microbiological assessment in managing postpartum endometritis patients. Our objective was to assess the utility of cervical cultures in diagnosing and treating postpartum endometritis by identifying specific risk factors associated with particular pathogens and evaluating the relationship between these pathogens and the severity of the disease severity. Our cohort included 1069 patients who underwent cervical swab collection for microbiologic cultures following a diagnosis of suspected endometritis. Our cohort represents 1.2% of the total number of deliveries in our institution, which is not different than published rates of postpartum endometritis after vaginal delivery but probably lower than the published rate of endometritis following cesarean deliveries ( 2 , 5 , 12 ). Endometritis is considered to be a polymicrobial infection ( 3 , 9 ). Clearly, cervical swabs are prone to vaginal microbiota contamination ( 3 ). Nevertheless, even studies in which protected culture methods were used found high prevalence of polymicrobial infections ( 9 ). The fact that most microorganisms isolated in cervical cultures from patients with endometritis are part of the normal genital microbiota, makes the task of identifying the causative pathogen even more challenging. For example, Gibbs et al. compared the endometrial microbiota of 74 postpartum patients with and without clinical endometritis, and found no difference between groups. Although they admitted that their finding cannot exclude ‘superabundance’ of pathogens, they postulated that at least some afebrile postpartum women harbour abundant pathogens in the endometrial cavities ( 17 ). In conclusion, a definite laboratory confirmation of the microbiological etiology of endometritis is difficult if not impossible. Conversely, despite limitations, pointing at a distinct microorganism in cervical cultures is a standard procedure in clinical microbiology ( 16 ). In our cohort of cervical cultures, single distinct microorganism positivity rate was 33%. It should be emphasized that this rate represents only the probability of a microbiological identification of a single distinct bacteria rather than its true causal role, or the accuracy of endometritis diagnosis. Moreover, another 8% of cultures (Non-virulent and Candida species groups), are of non-virulent microorganisms, which are not considered to be pathogens associated with endometritis but rather represents vaginal microbiota. In accordance with previous old studies ( 4 , 18 ), Escherichia coli was the most common distinct organism in endometritis patients, with similar reported incidence ( 19 ). The second most common distinct organism in our study was Streptococcus agalactiae (GBS). In our analysis, we tried to identify association between specific risk factors and particular pathogens. Both prolonged 2nd stage of labor and prolonged rupture of membranes are well known risk factors of postpartum endometritis ( 1 , 14 , 20 ). We found that Enterobacterales are associated with significantly longer 2nd stage of labor, in comparison with Beta-hemolytic Streptococci. This finding might be related to multiple vaginal examinations ( 1 ), leading to disruption of vaginal microbiome and iatrogenic introduction of colonic microorganisms in the genital tract. Similarly, Enterobacterales are associated with significantly longer duration of ROP, and again might reflect the tendency of microorganisms to migrate from the lower gastrointestinal tract to the genital tract and/or to flourish in the genital tract during to iatrogenic interventions. Lastly, we examined the correlation between these pathogens and the disease's severity. Although there are no specific parameters for disease severity in cases of endometritis, we examined a variety of parameters that are linked to the severity of illness. We found that WBC count is significantly higher in patients with endometritis and isolated Enterobacterales and Beta-hemolytic Streptococci in comparison to cases where no distinct microorganism was isolated. This finding is concordant to previous studies that state that endometritis caused by Beta-hemolytic Streptococcus, especially S. pyogenes (Group A Streptococcus), are associated with significant morbidity and mortality ( 1 , 21 ). Nevertheless, WBC elevation is sometimes physiologic and not pathological, and might be related to longer duration of labor ( 21 ). In addition, we found a higher rate of postpartum clinic visit among patients who had isolated Enterobacterales in comparison to patients with either Beta-hemolytic Streptococcus or no distinct microorganisms. This finding is also consistent with the illness severity among patients whose disease is liked to Enterobacterales. Beside mild differences between the groups of microorganisms as described above, we did not find any other significant association between particular group of microorganisms and disease severity. It is plausible that such differences exist between specific pathogens, and could have been abundant if we focus on the most virulent species (e.g. S. pyogenes). This assumption correlates with studies that suggested that cervical cultures are needed as part of the assessment of patients with endometritis only for finding the specific cases of such high virulent pathogens ( 11 ). We believe that the lack of robust differences in disease severity between the groups of microorganisms isolated from cervical cultures questions the added value of this procedure, which due to its technical limitation and lack of standardization does not necessarily point at the culprit organism. It is worth emphasizing that the adequacy of the antibiotic treatment to the isolated microorganisms was not addressed in this study. Furthermore, we did not asses the contribution of cultures’ results to the clinical management and outcome of newborns to the mothers in our cohort. The study's principal strength lies in its large sample size, comprising a thorough review of 1069 cervical cultures collected during the puerperium period, yielding a substantial dataset for analyzing endometritis genital microbiology. Covering a period from 2011 to 2021, the study provides a longitudinal outlook, mitigating confounding factors arising from shifts in clinical protocols and laboratory techniques. However, it has limitations: its retrospective nature may compromise data integrity; its single-center context (both clinically- and laboratory- wise) may limit broader applicability. Additionally, the inherent risk of contamination in cervical cultures, the polymicrobial nature of most endometritis infections, and the statistical necessity to aggregate diverse pathogens into categories may have obscured more nuanced differences in pathogen-specific diseases. Moreover, microbiological sampling and processing technics are not standardized locally or globally. For example, the use of speculum, cervical vs. vaginal sampling, swab type, culture media type, etc. are not universal and may have a dramatic effect on the yield and results of the culture. Likewise, anaerobic cultures are not consistent in its methodology in our study and worldwide, thus it is difficult to estimate the true contribution of obligate anaerobes (some are vaginal microbiota) to endometritis cases. In conclusion , this study presents valuable insights into the role of cervical cultures in diagnosing and managing postpartum endometritis. We analyzed 1069 cervical cultures from a single tertiary referral center, revealing a 33% positivity rate for single distinct microorganism, with Escherichia coli and Streptococcus agalactiae being the most commonly isolated organisms. Although we did find association between few consensual risk factors and measures of disease severity with specific pathogens, the differences between the groups of microorganisms are subtle. The lack of significant differences in disease severity across various microorganism groups raises questions pertaining to the contribution of distinct bacterial identification in endometritis management. Further investigation is needed in order to define whether there is a correlation between the adequacy of antibiotic treatment based on the microorganism’s antibiogram and the maternal clinical outcome, and whether there is any relation between the microorganism to the perinatal outcome. Declarations The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by Nir Meller. Analysis was performed by Nir Meller and Ronen Fluss. The first draft of the manuscript was written by Nir Meller and Sharon Amit. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University B (January 10 th 2023 / 9065-22-SMC). References Faro S. Postpartum endometritis. Clin Perinatol. 2005 Sep;32(3):803–14. Chaim W, Bashiri A, Bar-David J, Shoham-Vardi I, Mazor M. Prevalence and Clinical Significance of Postpartum Endometritis and Wound Infection. 2000. French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001067. Salmanov AG, Vitiuk AD, Zhelezov D, Bilokon O, Kornatska AG, Dyndar OA, et al. Prevalence of postpartum endometritis and antimicrobial resistance of responsible pathogens in ukraine: results a multicenter study (2015-2017). 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Supplementary Files APPENDICES.docx Cite Share Download PDF Status: Published Journal Publication published 23 Aug, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Editorial decision: Accept as is 09 Aug, 2024 Reviewers agreed at journal 08 Jul, 2024 Reviewers invited by journal 08 Jul, 2024 Editor invited by journal 08 Jul, 2024 Editor assigned by journal 05 Jul, 2024 First submitted to journal 04 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4687919","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":324045254,"identity":"820c64b5-649d-42fd-8f83-f323dce2c74b","order_by":0,"name":"Nir Meller","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYDACZhBRYAFkMB8AsiRkiNRiIMHAwM6WANLCQ6RVIC38PAYgJmEt5uy8Tzd8MJCQM2/m+fzqRo0FDwP74aMb8GmxbGY3uznDQMJY5jDvNuucY0CH8aSl3cDrpMNsbLd5DCQSZzDzbjPOYQNqkeAxI6zlj4FE/QxmnmfGOf+I1QL0foIEMw/z49w2IrXc7DGQMJzBzGbGnNsnwcNG0C/nj7Hd+FFhIy/Bf/jx55xvdXL87IeP4dWCDNgkwCSxykGA+QMpqkfBKBgFo2DkAACReju8CP+PGAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-6250-4202","institution":"Sheba Medical Center at Tel Hashomer","correspondingAuthor":true,"prefix":"","firstName":"Nir","middleName":"","lastName":"Meller","suffix":""},{"id":324045255,"identity":"783a27fa-8d64-4dff-879f-8b3c89074225","order_by":1,"name":"Ronen Fluss","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ronen","middleName":"","lastName":"Fluss","suffix":""},{"id":324045256,"identity":"00186508-a8a7-44d8-9616-b0736df0b7d4","order_by":2,"name":"Sharon Amit","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Amit","suffix":""}],"badges":[],"createdAt":"2024-07-04 16:59:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4687919/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4687919/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-024-07696-8","type":"published","date":"2024-08-23T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63300626,"identity":"a014ea49-9f47-470b-a42d-2f0f5ca2f876","added_by":"auto","created_at":"2024-08-26 16:15:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":733220,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4687919/v1/448d6468-4cdf-47cb-ac21-2139a488907e.pdf"},{"id":61471223,"identity":"20eabcac-6cdb-4c57-be67-d3dcc05cfebe","added_by":"auto","created_at":"2024-07-31 06:48:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34421,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDICES.docx","url":"https://assets-eu.researchsquare.com/files/rs-4687919/v1/e7afa4239db950060f458fdb.docx"}],"financialInterests":"","formattedTitle":"Evaluating the Clinical Utility of Cervical Cultures in Postpartum Endometritis Management","fulltext":[{"header":"What does this study adds to the clinical work?","content":"\u003cp\u003eThe study questions the utility of cervical cultures in the management of postpartum endometritis, and improve the understanding of their results. The study presents associations between specific microorganisms and severity of disease.\u0026nbsp;\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eEndometritis is a term that applies to an infection of the endometrial lining, the myometrium, and the parametrium (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Endometritis is the most common febrile complication after delivery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It occurs in 1\u0026ndash;3% of vaginal births, and is significantly more common after caesarean delivery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Endometritis leads to prolonged postpartum hospital stays and stands as one of the most common reasons for postpartum readmissions, thus posing a substantial burden on the healthcare system (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe diagnosis of postpartum endometritis is based on the presence of fever in the absence of any other obvious cause. Tachycardia, uterine tenderness, foul-smelling lochia or purulent vaginal discharge and elevated white blood cells are common clinical findings used to support the diagnosis of endometritis (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe pathogenesis of endometritis is related to contamination of the uterine cavity with vaginal microorganisms during labor (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and it is usually a polymicrobial infection associated with mixed aerobic and anaerobic flora (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). According to previous publications related micro-organisms include facultative anaerobes such as Escherichia coli, Group B streptococcus (GBS), and Enterococcus spp., and typical obligate anaerobes such as Peptostreptococcus, Bacteriodes, and Clostridium spp. Nevertheless, more virulent bacteria, such as Group A Streptococcus or Staphylococcus aureus, may be involved (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe utility of endometrial, cervical and vaginal cultures as part of the management of endometritis is controversial. Proponents of the usage of microbiological cultures state that patients with suspected endometritis should have an endometrial aspirate and cervical swab sent for aerobic and anaerobic culture (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Cultures will allegedly detect the distinct microorganism, and administration of the right antibiotic regimen will be ensured (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Past publication stated that \u0026ldquo;A vaginal swab should be submitted specifically for the detection of Group A streptococcus (GAS) and Staphylococcus aureus\u0026rdquo; (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Another explanation for the purpose of endometrial and cervical cultures is that identification of GBS or Neisseria gonorrhoeae would affect paediatrician care (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Nevertheless, the opponents of the usage of microbiological cultures doubt the clinical relevance of the cultures, as obtaining an endometrial or cervical culture without microbiological contamination from the vagina during sampling is challenging (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The clinical significance of cervical cultures is further questioned due to studies indicating no significant difference in the rate of positive results between patients with and without postpartum febrile illness (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur research focuses on evaluating the utility of cervical cultures in diagnosing and managing postpartum endometritis. In this study, we aim to establish the prevalence of distinct microorganism isolated from cervical cultures of affected patients, identify risk factors linked to particular pathogens, and assess the correlation between these pathogens and disease severity.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eIn this retrospective study from a single tertiary referral center, we reviewed all cases in which cervical cultures were collected in the puerperium period (0\u0026ndash;6 weeks postpartum) between 2011\u0026ndash;2021. Our protocol screened cervical cultures sampled from every case of suspected postpartum endometritis, providing comprehensive bacteriological data of all endometritis cases within the study timeframe. Specimen collection was carried out in the maternity ward if the suspicion of endometritis was raised during the hospitalization following labor, or in the emergency gynecology department if the patient was re-admitted. Samples were collected from uterus cervix after visualization with speculum, using a sterile swab. Swabs were placed in a solid AMIES transport media and shipped to the lab, located on campus. Samples were processed according to relevant standard microbiological guidelines (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). A distinct microorganism was identified if it predominantly grew in culture or if it was a consensual virulent species if isolated from the vagina/cervix (e.g. Streptococcus pyogenes/agalactiae (Group A and B streptococci, respectively), Neisseria gonorrhea, etc.). Empirical antimicrobial treatment was commenced immediately upon diagnosis, and was modified only if needed clinically, regardless of cultures\u0026rsquo; results. Pediatricians were noticed of isolated microorganisms in order to confirm compatible antibiotic coverage for newborns.\u003c/p\u003e \u003cp\u003eWe included all patients who had cervical culture obtained within the first six weeks postpartum. Patients with alternative etiology for puerperal fever (e.g. pyelonephritis, surgical site infection, mastitis etc.) are not included in our cohort.\u003c/p\u003e \u003cp\u003eWe extracted data from medical records including demographic characteristics, obstetrical history, pregnancy and labor characteristics and clinical parameters regarding the concurrent endometritis. Data extraction and exploration were done with MDClone big data platform. We included known risk factors for endometritis and parameters related to infection severity as follows: \"Intrapartum fever\" (manually added to the patient record when a fever of 38\u0026deg;C is measured during labor); Length of stay (LOS); \u0026ldquo;Re-admission\u0026rdquo; means subsequent admission to our gynecologic emergency department during the puerperium period; \u0026ldquo;Fever\u0026rdquo; in the severity of disease table is the maximal temperature measured during the time period between two days prior to the cervical swab collection and seven days afterwards; Laboratory results are the maximal or minimal values during the time period between two days prior to the cervical swab collection and seven days afterwards; \u0026ldquo;Blood culture\u0026rdquo; relates to any positive blood culture from the date of cervical swab collection to 6 weeks afterwards; \u0026ldquo;Diagnosis of sepsis\u0026rdquo; relates to suspected sepsis during the fourteen days following the cervical swab collection; \u0026ldquo;ICU admission\u0026rdquo; relates to admission to intensive care unit during the first week after cervical swab collection; \u0026ldquo;Postpartum clinic visit\u0026rdquo; is any visit in our institution designated clinic for follow-up after complicated postpartum cases, during the six weeks following labor; Pelvic/abdominal CT scan is any examination that was conducted following the 6 weeks postpartum.\u003c/p\u003e \u003cp\u003eWe reviewed cultures\u0026rsquo; results and extracted the data of microorganisms\u0026rsquo; growth. In order to perform statistical analysis, we divided the microorganisms which were cultured into five categories according to their species nature and known virulence. The five groups are: Non-virulent species, Enterobacterales, beta-hemolytic Streptococci, Staphylococcus aureus, Candida species, alongside negative results. A list of all microorganisms included in each group appears in \u003cspan refid=\"Sec5\" class=\"InternalRef\"\u003e\u003cb\u003eAppendix 1\u003c/b\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFor each risk factor, we examined association with the groups of microorganisms by testing the difference of its distribution between the groups. For approximately normal (bell-shaped) distributed factors, possibly after log-transformation, we used an ANOVA model. For non-normal distributed ordered valued factors, we used the Kruskal Wallis test (rank-based ANOVA), and for nominal factors we used the Chi-squared test using simulated based p-values due to several low frequencies. We did not correct for inflation of type 1 error due to multiple testing of many risk factors. For risk factors found with a significant (5% level) association further post-hoc comparisons were conducted in order to detect the individual group differences. The post-hoc p-values of pairwise comparisons were corrected for multiple comparisons. Similar methods were carried to evaluate association between groups of microorganisms and severity of disease.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe overall cohort of deliveries in our institution during the study period included 83,791 deliveries. Our study included 1069 cervical cultures results of postpartum women with clinical suspicion of endometritis. A total of 538 (50.3%) of the deliveries cases were following a cesarean section and the rest (49.7%) were following a vaginal delivery. Distinct microorganism was cultured in 354 samples, yielding a positivity rate of 33.12%. The most common bacterium was Escherichia coli (10.8% of all cultures), followed by Group B streptococcus (Streptococcus agalactiae) (7.5%). All other microorganisms and their occurrences are detailed in \u003cspan refid=\"Sec5\" class=\"InternalRef\"\u003e\u003cb\u003eAppendix 1\u003c/b\u003e\u003c/span\u003e. The distribution of culture results between the microorganisms\u0026rsquo; groups is listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of culture results to micro-organisms\u0026rsquo; groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicroorganism Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnterobacterales\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e142 (13.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeta-hemolytic-Streptococci\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaphylococcus aureus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCandida species\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-virulent species\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eO\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo distinct microorganism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e715 (66.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates demographic and obstetric characteristic of endometritis cases that have compared according to microorganisms groups. Five different risk factors showed a significant difference across pathogen groups: duration of the 2nd stage of labor, time from rupture of membrane (ROM) to labor, cesarean section rate, length of hospital stay (LOS) and usage of antibiotics before culture collection.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e \u003cstrong\u003eMajor demographic and obstetric characteristics of endometritis cases, by groups of microorganisms.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable style=\"float: left;width: 5.2e+2pt;border: none;border-collapse:collapse;margin-left:6.75pt;margin-right:6.75pt;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:91.75pt;border:solid black 1.0pt;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:13px;line-height:200%;color:#222222;\"\u003eCharacteristics\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:42.55pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003en\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:70.85pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eEnterobacterales\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;background: rgb(176, 179, 178);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e\u0026szlig;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e-hemolytic-Streptococci\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:49.6pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eStaph. aureus\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:42.55pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eCandida species\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:63.8pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eNon-virulent species\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:63.75pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eNo distinct microorganism\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eP-value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eAge\u003csup\u003eM\u003c/sup\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e31\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e34\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e33\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e32\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e84\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eBMI \u0026gt; 35 rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e955\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.87\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eParity\u003csup\u003eM\u003c/sup\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.08\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eSpontaneous Labor Onset\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e\u0026nbsp;\u003cstrong\u003erate\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e45\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eDuration of 2\u003csup\u003end\u003c/sup\u003e Stage of Labor\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:9px;line-height:200%;color:black;\"\u003e(h)\u003c/span\u003e\u003csup\u003e\u003cspan style=\"font-size:9px;line-height:200%;font-family:Symbol;color:black;\"\u003eC\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e457\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e2.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e2.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e2.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(247, 202, 172);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e02\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eArtificial Membranes Rupture rate\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e996\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0. 6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.22\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eMeconium stained Amniotic Fluid rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e998\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e70\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eTime from ROM to Labor\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:9px;line-height:200%;color:black;\"\u003e(h)\u003c/span\u003e\u003csup\u003e\u003cspan style=\"font-size:9px;line-height:200%;font-family:Symbol;color:black;\"\u003eC\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e998\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e7.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e1.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e2.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e4.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(247, 202, 172);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.002\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eCesarean Delivery rate\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1062\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(247, 202, 172);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.04\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eDuration of 3rd Stage of Labor\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:9px;line-height:200%;color:black;\"\u003e(h)\u003c/span\u003e\u003csup\u003e\u003cspan style=\"font-size:9px;line-height:200%;font-family:Symbol;color:black;\"\u003eC\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e340\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.46\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eTwin Pregnancy rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.19\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eBirth Weight\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:9px;line-height:200%;color:black;\"\u003e(kg)\u003c/span\u003e\u003csup\u003e\u003cspan style=\"font-size:9px;line-height:200%;font-family:Symbol;color:black;\"\u003eC\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1062\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e2.\u003cspan dir=\"RTL\"\u003e9\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.\u003cspan dir=\"RTL\"\u003e18\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(217, 217, 217);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eLength of Stay\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:9px;line-height:200%;color:black;\"\u003e(d)\u003c/span\u003e\u003csup\u003e\u003cspan style=\"font-size:9px;line-height:200%;font-family:Symbol;color:black;\"\u003eC\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e822\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e5.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.7pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e3.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.6pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e10.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42.55pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e4.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e4.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan dir=\"RTL\" style=\"font-size:11px;line-height:200%;color:black;\"\u003e4.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.45pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(247, 202, 172);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the distribution of each characteristics between the various microorganisms groups.\u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cb\u003eM\u003c/b\u003e \u003c/sup\u003e values are presented as medians; \u003csup\u003eΧ\u003c/sup\u003e values are presented as means; p-value represents the difference between the groups.\u003c/p\u003e \u003cp\u003eBMI \u0026ndash; body mass index; h \u0026ndash; hours; ROM \u0026ndash; rupture of membrane; d \u0026ndash; days;\u003c/p\u003e \u003cp\u003eIn post-hoc analysis we have found significant differences between specific microorganisms groups in duration of the 2nd stage of labor and in the time from ROM to labor. The duration of the 2nd stage of labor was significantly longer in the Enterobacterales group in comparison to group the Beta-hemolytic streptococci group. The time from ROM to labor was significantly longer in the Enterobacterales group in comparison to Beta-hemolytic Streptococci, Staphylococcus aureus groups and the no distinct organism group. The entire post-hoc analysis results can be found in \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003e\u003cb\u003eAppendix 2\u003c/b\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e compares various parameters of disease severity between the microorganisms groups. Five risk factors showed a significant difference across pathogen groups: Re-admission rate, maximal white blood cell (WBC) count, rate of positive blood culture, length of stay after re-admission and postpartum clinic visits.\u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eTable \u003cspan dir=\"RTL\"\u003e3\u003c/span\u003e\u003c/strong\u003e. \u003cstrong\u003eMeasures of severity of disease by groups of microorganisms.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable style=\"width: 5.2e+2pt;border: none;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:110.25pt;border:solid black 1.0pt;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eMeasure\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003en\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eEnterobacterales\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.8pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;background: rgb(176, 179, 178);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e\u0026szlig;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e-hemolytic-Streptococci\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eStaph. aureus\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eCandida species\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eNon-virulent species\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eNo distinct\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003emicroorganism\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border:solid black 1.0pt;border-left:none;background:#B0B3B2;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eP- value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 9pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eRe-admission rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:9.0pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:9.0pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New 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3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1057\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e38.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp 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1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e100.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e118.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n 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solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e300.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e291.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e289.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e288.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e304.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.291\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eMinimal Hemoglobin\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e(g/dl)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1057\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e10.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e11.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e10.9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e10.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e10.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e10.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.321\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eMaximal WBC\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e(K/microL)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1057\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e13.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e15.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e13.9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e10.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e13.9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e12.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;background:#F7CAAC;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eMaximal Fibrinogen\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e(mg/dl)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e684\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e468.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e438.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e547.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e424.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e476.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e457.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.297\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eMaximal Creatinine\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e(mg/dl)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1021\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.150\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003ePositive blood culture rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e783\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.09\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.23\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.06\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.11\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;background:#F7CAAC;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.030\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003ePelvic/abdominal CT\u0026nbsp;rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.15\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.09\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.19\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.09\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.12\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.517\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eSepsis diagnosis rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.142\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003eICU admission rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.507\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: rgb(212, 212, 212);padding: 3pt;height: 8.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;line-height:200%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003ePostpartum clinic visit rate\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:31.1pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height: 200%;color:black;\"\u003e1069\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:66.2pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:54.8pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 0in 0in 0in;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:61.9pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:35.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;background:#F7CAAC;padding:3.0pt 3.0pt 3.0pt 3.0pt;height:8.25pt;\"\u003e\n \u003cp style='margin-right:0in;margin-left:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin:0in;text-align:center;line-height:200%;'\u003e\u003cspan style=\"font-size:11px;line-height:200%;color:black;\"\u003e0.005\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003eNormal distributed factors are presented as means.\u003c/p\u003e \u003cp\u003eCRP - C-reactive protein; WBC - white blood cell; CT - computed tomography; ICU - intensive care unit; LOT - length of stay.\u003c/p\u003e \u003cp\u003eSignificant differences between specific microorganism groups were found in the re-admission rate, the maximal WBC value and in the postpartum clinic visit. In post-hoc analysis we have found that the maximal WBC count was significantly higher among the Enterobacterales and Beta-hemolytic Streptococci groups than the no distinct organism group. Postpartum clinic visit rate was significantly higher in the Enterobacterales group in comparison to the Beta-hemolytic Streptococci and the no distinct organism group. The entire post-hoc analysis results can be found in \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003e\u003cb\u003eAppendix 2\u003c/b\u003e\u003c/span\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003ePostpartum endometritis is the most common obstetric infection (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It leads to prolonged postpartum hospital stays, thus imposing a considerable strain on healthcare resources. Nevertheless, data regarding the association between distinct risk factors, causative pathogens and the severity of the condition are sparse and not consistent. This research outlines our decade-long practice of obtaining cervical swabs for microbiological assessment in managing postpartum endometritis patients. Our objective was to assess the utility of cervical cultures in diagnosing and treating postpartum endometritis by identifying specific risk factors associated with particular pathogens and evaluating the relationship between these pathogens and the severity of the disease severity. Our cohort included 1069 patients who underwent cervical swab collection for microbiologic cultures following a diagnosis of suspected endometritis. Our cohort represents 1.2% of the total number of deliveries in our institution, which is not different than published rates of postpartum endometritis after vaginal delivery but probably lower than the published rate of endometritis following cesarean deliveries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEndometritis is considered to be a polymicrobial infection (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Clearly, cervical swabs are prone to vaginal microbiota contamination (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Nevertheless, even studies in which protected culture methods were used found high prevalence of polymicrobial infections (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe fact that most microorganisms isolated in cervical cultures from patients with endometritis are part of the normal genital microbiota, makes the task of identifying the causative pathogen even more challenging. For example, Gibbs et al. compared the endometrial microbiota of 74 postpartum patients with and without clinical endometritis, and found no difference between groups. Although they admitted that their finding cannot exclude \u0026lsquo;superabundance\u0026rsquo; of pathogens, they postulated that at least some afebrile postpartum women harbour abundant pathogens in the endometrial cavities (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In conclusion, a definite laboratory confirmation of the microbiological etiology of endometritis is difficult if not impossible. Conversely, despite limitations, pointing at a distinct microorganism in cervical cultures is a standard procedure in clinical microbiology (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our cohort of cervical cultures, single distinct microorganism positivity rate was 33%. It should be emphasized that this rate represents only the probability of a microbiological identification of a single distinct bacteria rather than its true causal role, or the accuracy of endometritis diagnosis. Moreover, another 8% of cultures (Non-virulent and Candida species groups), are of non-virulent microorganisms, which are not considered to be pathogens associated with endometritis but rather represents vaginal microbiota.\u003c/p\u003e \u003cp\u003eIn accordance with previous old studies (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), Escherichia coli was the most common distinct organism in endometritis patients, with similar reported incidence (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The second most common distinct organism in our study was Streptococcus agalactiae (GBS).\u003c/p\u003e \u003cp\u003eIn our analysis, we tried to identify association between specific risk factors and particular pathogens. Both prolonged 2nd stage of labor and prolonged rupture of membranes are well known risk factors of postpartum endometritis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). We found that Enterobacterales are associated with significantly longer 2nd stage of labor, in comparison with Beta-hemolytic Streptococci. This finding might be related to multiple vaginal examinations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), leading to disruption of vaginal microbiome and iatrogenic introduction of colonic microorganisms in the genital tract. Similarly, Enterobacterales are associated with significantly longer duration of ROP, and again might reflect the tendency of microorganisms to migrate from the lower gastrointestinal tract to the genital tract and/or to flourish in the genital tract during to iatrogenic interventions.\u003c/p\u003e \u003cp\u003eLastly, we examined the correlation between these pathogens and the disease's severity. Although there are no specific parameters for disease severity in cases of endometritis, we examined a variety of parameters that are linked to the severity of illness. We found that WBC count is significantly higher in patients with endometritis and isolated Enterobacterales and Beta-hemolytic Streptococci in comparison to cases where no distinct microorganism was isolated. This finding is concordant to previous studies that state that endometritis caused by Beta-hemolytic Streptococcus, especially S. pyogenes (Group A Streptococcus), are associated with significant morbidity and mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Nevertheless, WBC elevation is sometimes physiologic and not pathological, and might be related to longer duration of labor (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In addition, we found a higher rate of postpartum clinic visit among patients who had isolated Enterobacterales in comparison to patients with either Beta-hemolytic Streptococcus or no distinct microorganisms. This finding is also consistent with the illness severity among patients whose disease is liked to Enterobacterales.\u003c/p\u003e \u003cp\u003eBeside mild differences between the groups of microorganisms as described above, we did not find any other significant association between particular group of microorganisms and disease severity. It is plausible that such differences exist between specific pathogens, and could have been abundant if we focus on the most virulent species (e.g. S. pyogenes). This assumption correlates with studies that suggested that cervical cultures are needed as part of the assessment of patients with endometritis only for finding the specific cases of such high virulent pathogens (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). We believe that the lack of robust differences in disease severity between the groups of microorganisms isolated from cervical cultures questions the added value of this procedure, which due to its technical limitation and lack of standardization does not necessarily point at the culprit organism. It is worth emphasizing that the adequacy of the antibiotic treatment to the isolated microorganisms was not addressed in this study. Furthermore, we did not asses the contribution of cultures\u0026rsquo; results to the clinical management and outcome of newborns to the mothers in our cohort.\u003c/p\u003e \u003cp\u003eThe study's principal strength lies in its large sample size, comprising a thorough review of 1069 cervical cultures collected during the puerperium period, yielding a substantial dataset for analyzing endometritis genital microbiology. Covering a period from 2011 to 2021, the study provides a longitudinal outlook, mitigating confounding factors arising from shifts in clinical protocols and laboratory techniques. However, it has limitations: its retrospective nature may compromise data integrity; its single-center context (both clinically- and laboratory- wise) may limit broader applicability. Additionally, the inherent risk of contamination in cervical cultures, the polymicrobial nature of most endometritis infections, and the statistical necessity to aggregate diverse pathogens into categories may have obscured more nuanced differences in pathogen-specific diseases. Moreover, microbiological sampling and processing technics are not standardized locally or globally. For example, the use of speculum, cervical vs. vaginal sampling, swab type, culture media type, etc. are not universal and may have a dramatic effect on the yield and results of the culture. Likewise, anaerobic cultures are not consistent in its methodology in our study and worldwide, thus it is difficult to estimate the true contribution of obligate anaerobes (some are vaginal microbiota) to endometritis cases.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIn conclusion\u003c/span\u003e, this study presents valuable insights into the role of cervical cultures in diagnosing and managing postpartum endometritis. We analyzed 1069 cervical cultures from a single tertiary referral center, revealing a 33% positivity rate for single distinct microorganism, with Escherichia coli and Streptococcus agalactiae being the most commonly isolated organisms. Although we did find association between few consensual risk factors and measures of disease severity with specific pathogens, the differences between the groups of microorganisms are subtle. The lack of significant differences in disease severity across various microorganism groups raises questions pertaining to the contribution of distinct bacterial identification in endometritis management. Further investigation is needed in order to define whether there is a correlation between the adequacy of antibiotic treatment based on the microorganism\u0026rsquo;s antibiogram and the maternal clinical outcome, and whether there is any relation between the microorganism to the perinatal outcome.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by Nir Meller. Analysis was performed by Nir Meller and Ronen Fluss. The first draft of the manuscript was written by Nir Meller and Sharon Amit. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University B (January 10\u003csup\u003eth\u003c/sup\u003e 2023 / 9065-22-SMC).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFaro S. Postpartum endometritis. Clin Perinatol. 2005 Sep;32(3):803\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eChaim W, Bashiri A, Bar-David J, Shoham-Vardi I, Mazor M. Prevalence and Clinical Significance of Postpartum Endometritis and Wound Infection. 2000. \u003c/li\u003e\n\u003cli\u003eFrench LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001067. \u003c/li\u003e\n\u003cli\u003eSalmanov AG, Vitiuk AD, Zhelezov D, Bilokon O, Kornatska AG, Dyndar OA, et al. Prevalence of postpartum endometritis and antimicrobial resistance of responsible pathogens in ukraine: results a multicenter study (2015-2017). Wiad Lek. 2020;73(6):1177\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eBelfort MA, Clark SL, Saade GR, Kleja K, Dildy GA, Van Veen TR, et al. Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period. Am J Obstet Gynecol. 2010 Jan;202(1):35.e1-35.e7. \u003c/li\u003e\n\u003cli\u003eBlumenfeld Y, El-Sayed Y, Lyell D, Nelson L, Butwick A. Risk Factors for Prolonged Postpartum Length of Stay Following Cesarean Delivery. Am J Perinatol. 2015 Jan 16;32(09):825\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eMorgan J, Roberts S. Maternal sepsis. Obstet Gynecol Clin North Am. 2013 Mar;40(1):69\u0026ndash;87. \u003c/li\u003e\n\u003cli\u003eMackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015 Feb 2;2015(2):CD001067. \u003c/li\u003e\n\u003cli\u003eRosene K, Eschenbach DA, Tompkins LS, Kenny GE, Watkins H. Polymicrobial early postpartum endometritis with facultative and anaerobic bacteria, genital mycoplasmas, and Chlamydia trachomatis: treatment with piperacillin or cefoxitin. J Infect Dis. 1986 Jun;153(6):1028\u0026ndash;37. \u003c/li\u003e\n\u003cli\u003eSingh N, Sethi A. Endometritis - Diagnosis,Treatment and its impact on fertility - A Scoping Review. JBRA Assist Reprod. 2022 Aug 4;26(3):538\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eSoper DE. Early recognition of serious infections in obstetrics and gynecology. Clin Obstet Gynecol. 2012 Dec;55(4):858\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eTaylor M, Jenkins SM, Pillarisetty LS. Endometritis. 2024. \u003c/li\u003e\n\u003cli\u003eLedger WJ. Post-partum endomyometritis diagnosis and treatment: a review. J Obstet Gynaecol Res. 2003 Dec;29(6):364\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eKarsnitz DB. Puerperal infections of the genital tract: A clinical review. Vol. 58, Journal of Midwifery and Women\u0026rsquo;s Health. John Wiley and Sons Inc.; 2013. p. 632\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eEschenbach DA, Rosene K, Tompkins LS, Watkins H, Gravett MG. Endometrial Cultures Obtained by a Triple-Lumen Method from Afebrile and Febrile Postpartum Women. Journal of Infectious Diseases. 1986 Jun 1;153(6):1038\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eAmy L. Leber, Carey-Ann D. Burnham. Clinical Microbiology Procedures Handbook . 5th ed. 2023 (Or the latest edition for the time of executing the lab procedure). \u003c/li\u003e\n\u003cli\u003eGibbs RS, O\u0026rsquo;Dell TN, MacGregor RR, Schwarz RH, Morton H. Puerperal endometritis: a prospective microbiologic study. Am J Obstet Gynecol. 1975;121(7):919\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eSweet RL, Ledger WJ. Puerperal infectious morbidity. Am J Obstet Gynecol. 1973 Dec;117(8):1093\u0026ndash;100. \u003c/li\u003e\n\u003cli\u003eGibbs RS, Blanco JD, Bernstein S. Role of Aerobic Gram-Negative Bacilli in Endometritis After Cesarean Section. Clinical Infectious Diseases. 1985 Nov 1;7(Supplement_4):S690\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eMaharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007 Jun;62(6):393\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eAcker DB, Johnson MP, Sachs BP, Friedman EA. The leukocyte count in labor. Am J Obstet Gynecol. 1985 Dec;153(7):737\u0026ndash;9. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Endometritis, Microbiology, Postpartum, Infections","lastPublishedDoi":"10.21203/rs.3.rs-4687919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4687919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the utility of cervical cultures in the diagnosis and management of postpartum endometritis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted on 1069 cervical cultures collected from postpartum women with suspected endometritis between 2011 and 2021. Patient demographics, obstetric history, clinical parameters, and culture results were analyzed. Microorganisms were categorized into five groups based on species and virulence. Statistical analysis was performed to identify associations between risk factors, pathogens, and disease severity.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe positivity rate for distinct microorganisms in cervical cultures was 33.1%. Escherichia coli (10.8%) and Group B Streptococcus (7.5%) were the most common isolates. Prolonged labor duration and prolonged rupture of membranes were associated with Enterobacterales infections. Elevated white blood cell count was linked to Enterobacterales and Beta-hemolytic Streptococci, whilst the former were also associated with higher rate of postpartum clinic visit. No significant differences in disease severity were found between other microorganism groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study suggests that while cervical cultures can identify potential pathogens in postpartum endometritis, their clinical utility is questionable due to the polymicrobial nature of the disease and the isolation of commensal microorganisms. The lack of significant differences in disease severity across various microorganism groups raises questions regarding the contribution of distinct bacterial identification in endometritis management.\u003c/p\u003e","manuscriptTitle":"Evaluating the Clinical Utility of Cervical Cultures in Postpartum Endometritis Management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-31 06:48:09","doi":"10.21203/rs.3.rs-4687919/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept as is","date":"2024-08-09T05:10:47+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-07-08T19:19:06+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-08T09:09:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2024-07-08T08:12:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-05T14:01:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2024-07-04T12:59:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"44db8eb5-29e5-49d9-9f3d-17140e078a69","owner":[],"postedDate":"July 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-26T16:09:00+00:00","versionOfRecord":{"articleIdentity":"rs-4687919","link":"https://doi.org/10.1007/s00404-024-07696-8","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2024-08-23 15:57:30","publishedOnDateReadable":"August 23rd, 2024"},"versionCreatedAt":"2024-07-31 06:48:09","video":"","vorDoi":"10.1007/s00404-024-07696-8","vorDoiUrl":"https://doi.org/10.1007/s00404-024-07696-8","workflowStages":[]},"version":"v1","identity":"rs-4687919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4687919","identity":"rs-4687919","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}