Today, I reviewed, link to, and excerpt from REBELEM‘s REBEL CAST, REBEL Core Cast 117.0 – Infections of Pregnancy*.
*Jenny Beck-Esmay, MD, “REBEL Core Cast 117.0 – Infections of Pregnancy”, REBEL EM blog, February 7, 2024. Available at: https://rebelem.com/rebel-core-cast-117-0-infections-of-pregnancy/.
All that follows is from the above outstanding resource.
REBEL Core Cast 117.0 – Infections of Pregnancy
- Written by Jenny Beck-Esmay, MD
- REBEL Cast, REBEL Core
- Medical Category: Obstetrics and Gynecology
Take Home Points
- Infections are a leading cause of maternal mortality worldwide.
- Prompt recognition is critical in management.
- Most infectious processes will require admission and close observation for improvement or decompensation.
Click here for the direct link to the podcast.
Urinary Tract Infection/Pyelonephritis
Epidemiology:
- Occurs in as many as 15% of pregnant women and between 20-40% of pregnant women with asymptomatic bacteriuria will progress to pyelonephritis (Gorgas 2008)
Management:
- Uncomplicated UTI
- Suggested antibiotics include:
- Nitrofurantoin 100mg PO BID x7 days OR
- Cephalexin 500mg PO BID x7 days
- Pyelonephritis
- Hospital admission
- Suggested antibiotics include:
- Ceftriaxone 1g IV Q24H OR
- Aztreonam 2g IV Q8H for beta-lactam allergy
Complications:
- Maternal sepsis
- Maternal renal injury
- Congenital abnormalities of the fetus
- Premature rupture of membranes
- Low birth weight
Chorioamnionitis
Definition: Also known as intraamniotic infection. Chorioamnionitis is a bacterial infection of fetal amnion and chorion membranes.
Epidemiology:
- Occurs in 1 to 10% of all pregnancies (Gorgas 2008)
- Incidence increases significantly with preterm labor
Diagnosis:
- Chorioamnionitis is defined as maternal fever >38°C and at least two of the following (Apantaku and Mulik 2007):
- Maternal tachycardia >100 beats/min for five minutes
- Fetal tachycardia >160 beats/min for five minutes
- Purulent or foul-smelling amniotic fluid or vaginal discharge
- Uterine tenderness
- Maternal leukocytosis
Evaluation (Abbrescia 2003):
- CBC
- Blood cultures
- Vaginal fluid for phosphatidylglycerol
- Tests for fetal lung maturity
- Cervical AND vaginal cultures
- Physical Exam
- Avoid digital cervical exam
- Speculum exam should be done with sterile speculum
- Ultrasonography for fetal well being
Management:
- Given concern for neonatal sepsis, patients should be admitted for IV antibiotics, supportive cares, and possible early delivery
- Most commonly an ascending infection from normal vaginal flora, so antibiotics must be chosen to cover polymicrobial infections
- Ex. Ampicillin IV 2g Q6H AND Gentamicin IV 1.5mg/kg Q8H
- In PCN allergic patient substitute vancomycin 1 g IV Q12H for ampicillin
- Can only be considered cured with delivery of infected products of conception
Complications:
- Placental abruption
- Premature birth
- Neonatal sepsis
- Neonatal death
- Cerebral palsy
- Maternal sepsis
- Need for cesarean delivery
- Postpartum hemorrhage
Postpartum Endometritis
Definition: Generalized uterine infection
Epidemiology:
- Sepsis results in 15% of maternal deaths worldwide (Houry 2014)
- More common in surgical than vaginal deliveries
- May co-exist with surgical site infection
Diagnosis:
- Classic triad includes: fever, lower abdominal pain and uterine tenderness, and foul smelling lochia
Management:
- Hospital admission
- Cover for polymicrobial infection, including anaerobes
- Ex. Clindamycin 900 mg IV Q8H AND Gentamicin 5-7 mg/kg IV Q24H
Septic Abortion
Epidemiology:
- The World Health Organization estimates that one in eight pregnancy related deaths worldwide can be directly attributed to unsafe abortion procedures (Gorgas 2008)
Diagnosis:
- Clinical presentation includes fever, abdominal pain and uterine tenderness in setting of recent abortion
- Presentation can vary from mild infection to septic shock
Evaluation:
- Lactate
- Cultures of cervix, blood and urine
- Coagulation panel to screen for DIC
- Abdominal X-ray to evaluate for free air or retained surgical foreign bodies
- Pelvic ultrasound to evaluate for retained products of conception or surgical foreign bodies
Management:
- Hospital admission may be indicated as infection can progress to septic shock, organ failure, DIC and cardiovascular collapse
- Broad-spectrum antibiotics are indicated. Triple antibiotic coverage is recommended. Suggested regimens include:
- Ampicillin AND
- Gentamicin AND
- Clindamycin OR Metronidazole
- Update tetanus vaccination
- Usually requires dilation and curettage to remove any retained products of conception or foreign bodies.
References:
- Abbrescia, K. and B. Sheridan (2003). “Complications of second and third trimester pregnancies.” Emerg Med Clin North Am 21(3): 695-710, vii. PMID: 12962354
- Apantaku, O. and V. Mulik (2007). “Maternal intra-partum fever.” J Obstet Gynaecol 27(1): 12-15. PMID: 17365450
- Desai, S. and S. Henderson. Labor and Delivery and Their Complications. In: Marx, J et al, ed. Rosen’s Emergency Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:2331-2350.
- Gorgas, D. L. (2008). “Infections related to pregnancy.” Emerg Med Clin North Am 26(2): 345-366, viii. PMID: 18406978
- Houry, D and B. Salhi. Acute Complications of Pregnancy. In: Marx, J et al, ed. Rosen’s Emergency Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014: 2282-2299.
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)
