To treat or not to treat? Infants born with maternal chorioamnionitis Mary Angela Woodward,MD April 29,2015

Outline Maternal chorioamnionitis – Definitions – Risk factors – Diagnosis – Outcomes Identifying the ‘high risk neonate’ – Diagnostic challenges

Maternal Chorioamnionitis Inflammation or infection of the placenta, chorion, amnion Histologic chorioamnionitis: – Infiltration with polymorphonuclear leukocytes – Most cases no clinical signs/symptoms infection – 20% term, 50% preterm Clin Perinat, 2010

Risk Factors

Pathogenesis

Diagnosis Maternal fever (oral temp >/= 38.0 C) *all cases At least 2 of the following: – WBC >15000/cumm (70-90%) – Maternal tachycardia (>100/min) (50-80% cases) – Fetal tachycardia (>160/min) (50-80% cases) – Uterine tenderness or foul amniotic fluid (4-25% cases) Clin Perinatol,2010

Management Intrapartum treatment is superior – Decrease neonatal sepsis – Decrease maternal fever and hospitalization Administer broad spectrum antibiotics to cover Beta Lactamase producing aerobes and anaerobes – Goal to target GBS and E. coli – Ampicillin/Gentamycin/Clindamycin/Flagyl

Maternal Outcomes Maternal bacteremia – 3-12% patients Cesarean delivery required – 8% develop wound infection – 1% develop pelvic abscess – Increased risk endometritis and venous thromboembolism Uterine atony Need for blood transfusion Gabbe 6thEdition 2012

What are the fetal implications?

Fetal-newborn implications Spontaneous intestinal perforation Preterm birth Early onset sepsis Obstet Gynecol, 1999; Pediatrics, 2000 N Engl J Med,2000, Neonatology 2011 Pediatrics, 2013

The Clinical Conundrum Term,clinically well infant History of maternal chorioamnionitis How do we identify and manage the ‘high risk neonate’

Case scenario – Babyboy A 37 weeks gestation, 28 year old primigravida Risk factors? – ROM x 24 hours, – Maternal temp of 38 C at delivery (epidural catheter) – “foul smelling liquor at delivery” SVD & vigorous at delivery Apgars 9,9 Initial screening labs: – White cell count ) – Left shift of 27% – CRP was 35 mg/dl Admit & Rx? Investigations LP? Length of treatment? Length of treatment?

Neonatal admission Pros Close monitoring Early signs of sepsis: – Temperature instability – Lethargy – Tachycardia – Respiratory distress – Poor feeding Cons Separation (mother/baby dyad) Breastfeeding? Exposure to intensive care environment Any other predictors to help guide investigations? Therapy?

CRP as a marker of Neonatal Sepsis

The Lumbar puncture The Concern: missed meningitis in early onset sepsis Meningitis: 15% percent of bacteremia GBS: 5 to 10% with early-onset vs 25% with late-onset Mortality: meningitis vs sepsis (no meningitis) 16% vs 5%

LP: Is there a consensus ? GuidelinesBlood cultureCRPWBC NICE 18-24h (2 nd value) COFN (US)Positive CPS (Canada)WBC<5000/cumm “LP required in frankly symptomatic EOS with positive blood culture. Not indicated in asymptomatic babies even if risk factors are present.” Eldalah 1985, Weiss 1987,Visser 1980, Hendricks 1990,Johnson 1997, May 2005

Blood cultures sent, started on antibiotics At 48 hours: – baby is clinically well, – blood culture is negative, – CRP is 34 mg/dl, – White cell count is 30000, left shift 20 % – No LP done Day 5: – histopathology report: high grade chorioamnionitis Case scenario – Babyboy A

Histopathology? To date: “no role of histological diagnosis of chorioamnionitis in the diagnosis and management of neonatal sepsis”

Duration of antibiotic therapy Canadian guidelines – Reassess at 48 hours: blood culture, clinical status – Blood culture positive: 7-14 days NICE guidelines (UK) – Reassess at 36 hours – 7 days for culture proven sepsis or clinically suspected sepsis with negative blood culture

Evaluation of asymptomatic infants (any gestational age). Richard A. Polin et al. Pediatrics 2014;133: ©2014 by American Academy of Pediatrics

Concerns Diagnosis of chorioamnionitis? Clinical symptoms =?= sepsis Antibiotic overuse Longer length of treatment and hospital stay Increased need for central lines and invasive procedures Rates of lumbar punctures Impact on workload and parental experience in the first few days of life Increase in cost and resource utilization

Refining our approach to risk Vs Normal newborn care Full septic Antibiotics 7+d Observation Investigation Limited treatment

The more I learn, the more I learn how little I know. -- Socrates Thank you!