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Intrauterine Infections
Justin Sanders MD
Dept. Family and Social Medicine
Albert Einstein College of Medicine
June 25, 2009
Case
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34 G6P1041 GBS+ at 40 1/7 weeks
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Pt receiving intrapartum PCN
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Prolonged labor augmented with Pitocin
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Pain control with epidural
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MD notices pt feels warm at the time of
delivery
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Temp 101.5 F
Objectives
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Define Intrauterine Infection
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Diagnosis
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Differential Diagnosis for peripartum fever
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Epidemiology
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Risk factors
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Etiology/Pathophysiology
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Sequelae
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Prevention

Management
Intrauterine Infection
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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
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Temp ≥ 38°C (100.4°F)
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≥ 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
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Term: 0.5-2%; Preterm 0.5-10%
–
Determined mostly by older studies
Histological
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2-3 x incidence of clinical infection
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5-30% > 34wks; 40-50% 29-34 wks;
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Nearly all fetal membranes of preterm labors
<28 weeks (60-80%)
Risk Factors
•
•
Independent Risk Factors
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Nulliparity
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(P)PROM / Preterm Labor
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Duration of Labor
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Duration of ROM
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Internal fetal monitors
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Number of vaginal examinations ! ! !
Others
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Young age
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Low SocioEconomic Status
–
BV
–
GBS +
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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
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Decreased uterine contractility
•
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C-Section for FTP despite Oxytocin AOL
Satin et al:
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–
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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
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Fetal lung immaturity, IVH, PVL, seizures (3fold risk in one study)
•
Low Apgars, hypotension, need for
resuscitation at time of delivery.
•
Bacteremia and Sepsis
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Cerebral Palsy (independent RF, pre + term)
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OR 9.3 in one study
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Assoc. w/ PVL (in turn assoc. w/ high IA
cytokine levels)
Sequelae: Newborns
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Wendel et al, 1994: Chorioamnionitis, Nonreassuring FHT, Neonatal outcome
–
Background: Nonreassuring FHT, e.g.
tachycardia and dec. variability, common in
presence of acute chorio
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217 pts with chorio; analyzed FHT, compared
with duration of time from dx to delivery,
neonatal outcomes
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No diff. In cord pH, Apgar scores, sepsis,
admission to special-care nursery, O2 req in
neonates, especially under 12 hours
Prevention
•
•
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Treat BV?
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Cochrane review: no improvement in
outcomes
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? benefit to early (<20wks) treatment
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Nevertheless, CDC recommends
Treat Trichomoniasis?
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RF for (P)PROM, PTL/PTB
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No recommendation
Treat GBS!
–
Leading cause of neonatal sepsis
Prevention
•
Avoid digital vaginal examination if possible
in patients with PPROM and PROM
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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:
•
•
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Ext-spectrum penicillins (eg.
Pipercillin/Tazobactam)
Cephalosporins (e.g. cefotetan)
Vancomycin for PCN allergy
Management
•
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Start abx ASAP after diagnosis
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Longer dx to delivery interval (p<.001)
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Decreased neonatal sepsis (p<.001)
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Lower neonatal sepsis related mortality
(p<.15)
Duration of tx
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Traditionally 48-72h
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Short course appears to be sufficient
•
One study studied intrapartum plus one
postpartum dose of each agent = abx tx until
24hours afebrile
Management
•
Antipyretics
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Advisible for fetal indications
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Maternal temp related to fetal acid-base
balance
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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
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Mom and baby did well
Summary
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More than a fever
•
Remember the epidural
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Fairly common
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Don't touch too much
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Prevention is better than treatment
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Treat early (but not necessarily long)
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Placenta to path
References
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Churgay C, Smith M, Blok B. Maternal Fever During Labor – What does it mean? J Am Board Fam Pract
1994;7:14-24
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Edwards R. Chorioamnionitis and Labor. Obstetrics and Gynecology Clinics of N America 2005;32:287-96
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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