intrauterine infections justin sanders md dept. family and social medicine albert einstein college...

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