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Intrauterine Infections

Justin Sanders MD Dept. Family and Social Medicine Albert Einstein College of Medicine June 25, 2009. Intrauterine Infections. Case. 34 G6P1041 GBS+ at 40 1/7 weeks Pt receiving intrapartum PCN Prolonged labor augmented with Pitocin Pain control with epidural

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Intrauterine Infections

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  1. Justin Sanders MD Dept. Family and Social Medicine Albert Einstein College of Medicine June 25, 2009 Intrauterine Infections

  2. 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

  3. Objectives • Define Intrauterine Infection • Diagnosis • Differential Diagnosis for peripartum fever • Epidemiology • Risk factors • Etiology/Pathophysiology • Sequelae • Prevention • Management

  4. 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)

  5. Intrauterine Infection Potential Sites of Bacterial Infection within the Uterus Goldenberg R et al. N Engl J Med 2000;342:1500-1507

  6. Diagnosis • Clinical • 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

  7. 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.)

  8. 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%)

  9. 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

  10. 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.

  11. 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

  12. 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

  13. Potential Pathways from Choriodecidual Bacterial Colonization to Preterm Delivery IUI and PTL Goldenberg R et al. N Engl J Med 2000;342:1500-1507

  14. 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)

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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)

  21. 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

  22. 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

  23. 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

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