intrauterine infections justin sanders md dept. family and social medicine albert einstein college...
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Intrauterine Infections
Justin Sanders MD
Dept. Family and Social MedicineAlbert Einstein College of Medicine
June 25, 2009
Case
34 G6P1041 GBS+ at 40 1/7 weeks Pt receiving intrapartum PCN Prolonged labor augmented with Pitocin Pain control with epidural MD notices pt feels warm at the time of
delivery Temp 101.5 F
Objectives
Define Intrauterine Infection Diagnosis Differential Diagnosis for peripartum fever Epidemiology Risk factors Etiology/Pathophysiology Sequelae Prevention Management
Intrauterine Infection
Puerperal infection – can be defined clinically or histopathologically.
Can be found in subclinical form Includes infection of amniotic fluid, fetal
membranes, placenta and/or decidua Often referred to generally as chorioamnionitis
or “chorio” Also includes deciduitis, villitis (placental villi),
and funisitis (umbilical cord)
Goldenberg R et al. N Engl J Med 2000;342:1500-1507
Potential Sites of Bacterial Infection within the Uterus
Intrauterine Infection
DiagnosisClinical
– Temp ≥ 38°C (100.4°F)
– ≥ 2 of: maternal tachycardia, fetal tachycardia, uterine tenderness, foul odor of the amniotic fluid, maternal leukocytosis
Histopathologic– Inspection of placenta and fetal membranes
• Identification of polymorphonuclear lympocytes in tissue
– Amniocentesis
– Occurs with much higher incidence than clinical intrauterine infection
Differential Diagnosis
• Epidural anesthesia
– Strongly associated with intrapartum maternal fever (RR 5.6, 95%CI, 4.0-7.8, p<.001), neonatal sepsis workup, and neonatal antibiotics – but not with neonatal sepsis
• Dehydration
• Urinary tract infection
• Genital tract infection
• Malignant Hypertension (theoretical, Ψ assoc.)
Epidemiology
Clinical
– Term: 0.5-2%; Preterm 0.5-10%
– Determined mostly by older studies
Histological
– 2-3 x incidence of clinical infection
– 5-30% > 34wks; 40-50% 29-34 wks;
– Nearly all fetal membranes of preterm labors <28 weeks (60-80%)
Risk Factors• Independent Risk Factors
– Nulliparity
– (P)PROM / Preterm Labor
– Duration of Labor
– Duration of ROM
– Internal fetal monitors
– Number of vaginal examinations ! ! !
• Others– Young age
– Low SocioEconomic Status
– BV
– GBS +
– Meconium-stained amniotic fluid
Pathogenesis
• Most common: ascending bacteria from lower genital tract.
• Polymicrobial – usually a combination of anaerobic and aerobic organisms.
• Pathogens most frequently isolated from amniotic fluid of pts with “chorio” are found in vaginal flora:
– Gardnerella, Ureaplasma, Bacteroidies, Mycoplasma, group A, B, C strep, Peptococcus, Peptostreptococcus, E. Coli.
Pathogenesis
• Other (rare) routes of infection: hematogenous, transplacental, retrograde from pelvis, transuterine infection from medical procedures (CVS, amniocentesis)
• Believed to be endotoxin mediated effect that may initiate maternal/fetal inflammatory response → PROM, PTL, neurologic damage in fetus
Sequelae: Labor– (P)PROM – subclinical infection
– Decreased uterine contractility• C-Section for FTP despite Oxytocin AOL
• Satin et al: – pts w/ chorio dx'd prior to Pit AOL had shorter
intervals from start Pit to delivery– Pts w/ chorio dx'd after Pit AOL, interval to delivery
significantly prolonged
– Postpartum hemorrhage• 50% greater after C-section; 80% greater after
SVD
Bottom Line: Increased Labor Abnormalities
Goldenberg R et al. N Engl J Med 2000;342:1500-1507
Potential Pathways from Choriodecidual Bacterial Colonization to Preterm Delivery
IUI and PTL
Sequelae: Newborn
• Complications of Preterm delivery
– Fetal lung immaturity, IVH, PVL, seizures (3-fold risk in one study)
• Low Apgars, hypotension, need for resuscitation at time of delivery.
• Bacteremia and Sepsis
• Cerebral Palsy (independent RF, pre + term)
– OR 9.3 in one study
– Assoc. w/ PVL (in turn assoc. w/ high IA cytokine levels)
Sequelae: Newborns• Wendel et al, 1994: Chorioamnionitis, Non-
reassuring FHT, Neonatal outcome
– Background: Nonreassuring FHT, e.g. tachycardia and dec. variability, common in presence of acute chorio
– 217 pts with chorio; analyzed FHT, compared with duration of time from dx to delivery, neonatal outcomes
– No diff. In cord pH, Apgar scores, sepsis, admission to special-care nursery, O2 req in neonates, especially under 12 hours
Prevention
• Treat BV?
– Cochrane review: no improvement in outcomes
– ? benefit to early (<20wks) treatment
– Nevertheless, CDC recommends
• Treat Trichomoniasis?
– RF for (P)PROM, PTL/PTB
– No recommendation
• Treat GBS!
– Leading cause of neonatal sepsis
Prevention
• Avoid digital vaginal examination if possible in patients with PPROM and PROM
– ACOG advises against DVE during intial eval unless prompt labor/delivery anticipated.
– Visual estimation with sterile speculum is recommended to assess cervical status
• Minimize DVE in labor, esp in latent phase labor and/or ROM
• Avoid IUPC's unless needed to dx arrest disorders
Management
• Centers on effective delivery and administration of broad-spectrum abx
• Gentamycin 1.5mg/kg q8h, plus Ampicillin 2G q6h or penG 5mU q6
• Anaerobic coverage for C-section – Clindamycin or Metronidazole
• Other (context dependent) choices: • Ext-spectrum penicillins (eg.
Pipercillin/Tazobactam)
• Cephalosporins (e.g. cefotetan)
• Vancomycin for PCN allergy
Management
• Start abx ASAP after diagnosis
– Longer dx to delivery interval (p<.001)
– Decreased neonatal sepsis (p<.001)
– Lower neonatal sepsis related mortality (p<.15)
• Duration of tx
– Traditionally 48-72h
– Short course appears to be sufficient• One study studied intrapartum plus one
postpartum dose of each agent = abx tx until 24hours afebrile
Management
• Antipyretics
– Advisible for fetal indications
– Maternal temp related to fetal acid-base balance
• Delivery indicated, not necessarily C-section
• Placenta to path, cord gasses sent (and followed up on)
Case
• Amp 2g and Gent 80mg initiated immediately
• Clinical suspicion low after delivery
• Abx held after one dose post-partum
• Mom and baby did well
Summary
• More than a fever
• Remember the epidural
• Fairly common
• Don't touch too much
• Prevention is better than treatment
• Treat early (but not necessarily long)
• Placenta to path
References• Churgay C, Smith M, Blok B. Maternal Fever During Labor – What does it mean? J Am Board Fam Pract
1994;7:14-24
• Edwards R. Chorioamnionitis and Labor. Obstetrics and Gynecology Clinics of N America 2005;32:287-96
• Fahey J. Clinical management of Intra-amniotic Infection and Chorioamnionitis: A Review of the Literature. J Midwifery Womens Health 2008;53:227–235
• Goldenberg R, Hauth J, Andrews W. Intrauterine Infection and Preterm Delivery. N .Engl J Med 2000;342:1500-1507
• Lieberman E. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics 1997;99:415-19
• Marowitz A. Midwifery Management of Premature Rupture of Membranes at Term. J Midwifery Womens Health 2007;52:199–206
• Satin A et al. Chorioamnionitis: a harbinger of dystocia. Obstet Gynecol 1992;79:913-5
• Simhan H, Canavan T. Preterm Premature Rupture of Membranes: diagnosis, evaluation and management strategies. BJOG: Int J Obstetrics and Gynaecology 2005;112(S1):32-37
• Snyder M, Crawford P, Jamieson B. What treatment approach to intrapartum maternal fever has the best fetal outcomes? J Fam Pract 2007;56(5)
• Wendel P et al. Chorioamnionitis: Associations of Nonreassuring Fetal Heart-Rate Patterns and Interval From Diagnosis to Delivery on Neonatal Outcome. Infectious Disease in Obstetrics and Gynecology 1994;2:162-166