Intrauterine Infections

Justin Sanders MD Dept. Family and Social Medicine Albert 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)

Potential Sites of Bacterial Infection within the Uterus

Intrauterine Infection

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

Diagnosis
Clinical
Temp 38C (100.4F) 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, assoc.)

Epidemiology
Clinical
Term: 0.5-2%; Preterm 0.5-10% Determined mostly by older studies 2-3 x incidence of clinical infection

Histological

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

Potential Pathways from Choriodecidual Bacterial Colonization to Preterm Delivery

IUI and PTL

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

Sequelae: Newborn
Complications of Preterm delivery
Fetal lung immaturity, IVH, PVL, seizures (3fold 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, Nonreassuring 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 RF for (P)PROM, PTL/PTB No recommendation Leading cause of neonatal sepsis

Treat Trichomoniasis?

Treat GBS!

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) 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

Duration of tx

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;53:227235 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;52:199206 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