February 07, 2024

REBEL Core Cast 117.0 – Infections of Pregnancy

5 minutes

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.

REBEL Core Cast 117.0 – Infections of Pregnancy

Click here for Direct Download of 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)

The post REBEL Core Cast 117.0 – Infections of Pregnancy appeared first on REBEL EM - Emergency Medicine Blog.

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By Salim R. Rezaie, MD

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160160 ratings

February 07, 2024

REBEL Core Cast 117.0 – Infections of Pregnancy

5 minutes

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.

REBEL Core Cast 117.0 – Infections of Pregnancy

Click here for Direct Download of 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)

The post REBEL Core Cast 117.0 – Infections of Pregnancy appeared first on REBEL EM - Emergency Medicine Blog.

...more