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Intrauterine Infections

Justin Sanders MD

Dept. Family and Social MedicineAlbert Einstein College of Medicine

June 25, 2009


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Objectives

Define Intrauterine Infection

Diagnosis

Differential Diagnosis for peripartum fever Epidemiology

Risk factors

Etiology/Pathophysiology

Sequelae

Prevention

Management


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Intrauterine Infection

Puerperal infection can be defined clinicallyor histopathologically.

Can be found in subclinical form

Includes infection of amniotic fluid, fetalmembranes, placenta and/or decidua

Often referred to generally as chorioamnionitisor chorio

Also includes deciduitis, villitis (placental villi),and funisitis (umbilical cord)


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

Potential Sites of Bacterial Infection within the Uterus

Intrauterine Infection


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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 intissue

Amniocentesis

Occurs with much higher incidence than clinicalintrauterine infection


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Differential Diagnosis

Epidural anesthesia

Strongly associated with intrapartum maternalfever (RR 5.6, 95%CI, 4.0-7.8, p


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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


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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


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Pathogenesis

Most common: ascending bacteria fromlower genital tract.

Polymicrobial usually a combination ofanaerobic and aerobic organisms.

Pathogens most frequently isolated fromamniotic fluid of pts with chorio are found in

vaginal flora: Gardnerella, Ureaplasma, Bacteroidies,

Mycoplasma, group A, B, C strep,Peptococcus, Peptostreptococcus, E. Coli.


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Pathogenesis

Other (rare) routes of infection:hematogenous, transplacental, retrogradefrom pelvis, transuterine infection from

medical procedures (CVS, amniocentesis) Believed to be endotoxin mediated effect that

may initiate maternal/fetal inflammatoryresponse PROM, PTL, neurologic damagein fetus


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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 deliverysignificantly prolonged

Postpartum hemorrhage 50% greater after C-section; 80% greater after

SVD

Bottom Line: Increased Labor Abnormalities


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

Potential Pathways from Choriodecidual Bacterial Colonization to Preterm Delivery

IUI and PTL


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Sequelae: Newborn

Complications of Preterm delivery

Fetal lung immaturity, IVH, PVL, seizures (3-fold risk in one study)

Low Apgars, hypotension, need forresuscitation 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)


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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, comparedwith duration of time from dx to delivery,neonatal outcomes

No diff. In cord pH, Apgar scores, sepsis,admission to special-care nursery, O2 req inneonates, especially under 12 hours


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Prevention

Treat BV?

Cochrane review: no improvement inoutcomes

? benefit to early (


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Prevention

Avoid digital vaginal examination if possiblein patients with PPROM and PROM

ACOG advises against DVE during intial eval

unless prompt labor/delivery anticipated.

Visual estimation with sterile speculum isrecommended to assess cervical status

Minimize DVE in labor, esp in latent phaselabor and/or ROM

Avoid IUPC's unless needed to dx arrestdisorders


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Management

Centers on effective delivery andadministration 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


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Management

Start abx ASAP after diagnosis

Longer dx to delivery interval (p


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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)


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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


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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


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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 Med2000;342:1500-1507

Lieberman E. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics1997;99:415-19

Marowitz A. Midwifery Management of Premature Rupture of Membranes at Term. J Midwifery WomensHealth 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 andmanagement 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 bestfetal outcomes? J Fam Pract 2007;56(5)

Wendel P et al. Chorioamnionitis: Associations of Nonreassuring Fetal Heart-Rate Patterns and IntervalFrom Diagnosis to Delivery on Neonatal Outcome. Infectious Disease in Obstetrics and Gynecology1994;2:162-166

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