justin sanders md dept family and social medicine albert einstein college of medicine june 25 2009
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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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justin sanders md dept family and social medicine albert einstein college of medicine june 25 2009
Justin Sanders MD

Dept. Family and Social Medicine

Albert Einstein College of Medicine

June 25, 2009

Intrauterine Infections
slide2
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
Objectives
  • Define Intrauterine Infection
  • Diagnosis
  • Differential Diagnosis for peripartum fever
  • Epidemiology
  • Risk factors
  • Etiology/Pathophysiology
  • Sequelae
  • Prevention
  • Management
intrauterine infection
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)
intrauterine infection1
Intrauterine Infection

Potential Sites of Bacterial Infection within the Uterus

Goldenberg R et al. N Engl J Med 2000;342:1500-1507

diagnosis
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
differential diagnosis
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
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
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
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.
pathogenesis1
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
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

iui and ptl
Potential Pathways from Choriodecidual Bacterial Colonization to Preterm DeliveryIUI and PTL

Goldenberg R et al. N Engl J Med 2000;342:1500-1507

sequelae newborn
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
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
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
prevention1
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
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
management1
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
management2
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)
slide22
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
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
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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