1. Maternal Fever & What it Means for Baby: A Changing Definition
Andrew M. Ellefson, MD
Neonatologist
Christiana Care Health System
Edited by Cem Soykan, MD
Pediatric Hospitalist at CCHS

2. Background & Definitions
Maternal Chorioamnionitis
A sometimes vague term with flexible definitions that is applied
fairly inconsistently to mother’s with varying degrees of fever
during the peripartum period.
“Triple I” = Intrauterine Inflammation and/or Infection
“Triple I” is diagnosed when fever (≥38 C) is present with one or
more of the following:
Fetal Tachycardia (> 160 bpm > 10 min.)
Maternal WBC > 15,000
Purulent fluid from the cervical os
+ Biochemical or microbiologic amniotic fluid results
T.I.M.E. = Triple I to Manage Early-onset Sepsis:
*** Our new protocol for these babies ***

3. Issues with Current CDC/COFN Guidelines
Many of the references supporting IV abx for all infants of mothers with chorioamnionitis include data before widespread GBS screening implementation1
GBS screening has reduced incidence of Early Onset Sepsis (EOS) due to GBS by 80% to rate of /1000 term newborns2
Early Onset Sepsis due to E.coli estimated at 0.07/1000 newborns3
In these studies, I don’t want to overlook the impact of a maternal diagnosis of chorioamnionitis. The CDC guidelines highlight this risk as a 6 fold increase in the risk for early onset sepsis. However, when you look at the already low rate of early onset GBS and Ecoli disease, the increased risk from “chorio” gives you an estimate 0.42 to 2.2 per 1000 incidence; a number that is still fairly low. All of this without taking into account the clinical status of the newborn or the receipt of intrapartum antibiotics to the mother; both factors that further reduce the incidence or likelihood of early on set sepsis.
Taylor JA, Opel DJ. Choriophobia: a 1-act play. Pediatrics Aug;130(2):342-6.
Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease—revised guidelines from CDC, MMWR Recomm Rep. 2010;59(RR-10):1–36.
Stoll BJ et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Early onset neonatal sepsis: the burden of group B Streptococcal and E. coli disease continues. Pediatrics May;127(5):

4. Impact of “R/O Sepsis - Chorio” Admissions
Asymptomatic Infant admitted for 48 hrs to NICU:
Mother/baby separation
Reduction in bonding
Increased parental stress/anxiety
Reduction in maternal breast milk production and feeding
Increased exposure to formula and IV fluids
Unnecessary lab draws
Risk for extended hospitalization
prolonged antibiotic use due to “culture negative sepsis” 2nd to non-specific CBC lab abnormalities
Weaning off of IVF’s
Adverse Events -
IV infiltrates
Dollars
$500/patient hospital day compared to admission to term nursery
Based on CCHS 2015 “chorio admission” data, this would be
~ $86, ,000/year
For adverse events, a study by researchers at Johns Hopkins in 1983 found that 20% of febrile neonates less than 60 days old who were admitted for rule out sepsis experienced a medical error, including gentamicin overdosing or IV fluid infiltration.
So you can see, the treatment for “chorio” is not necessarily a benign path to pursue. As mentioned, the CDC and COFN guidelines don’t distinguish between well or ill appearing when the decision is made to rule out sepsis and start antibiotics.

5. Click Link Below for OB’s “Triple-I” reference
Bottom Line
Evidence strongly supports modifying how we manage babies born to mothers with “chorioamnionitis” by using a more EBM approach.
Emphasis should be on:
Neonatal clinical exam
Maternal risk factors
NOT isolated factors taken separately.
Recommend:
Discontinue use of the term chorioamnionitis
Start using the term “intrauterine inflammation or infection or both” (A.K.A. “Triple I”)
*A detailed list of references, slides, and segments from Dr. Ellefson’s Peds Grand Rounds on this topic are included at end of this presentation.
Click Link Below for OB’s “Triple-I” reference
Higgins RD, Saade G, Polin RA, et al. Evaluation and Management of Women and Newborns With a Maternal Diagnosis of Chorioamnionitis: Summary of a Workshop. Obstet Gynecol 2016; 127:426.

6. The Newborn Sepsis Calculator
Kaiser Permanente study looked at the genuine need for antibiotics in setting of maternal fever
They found the following things were most crucial in determining risk
Gestational Age
Tmax of the fever
Duration of ROM
GBS status
Antibiotic treatment

7. The Newborn Sepsis Calculator: Results / Output
Kaiser Permanente then found a way to risk stratify the kids.
Based on the clinical exams, there were 3 different potential courses of action to be pursued:
No additional care (= q4h VS CCHS)
CBC, Blood culture & VS q4 hours x48 hours
Admit to NICU for empiric Antibiotics

8. Newborn Clinical Exam – Definitions
Well Appearing
No persistent physiologic abnormalities
Equivocal Exam
Any ONE Persistent Physiologic Abnormalities for ≥4 hours
Tachycardia (≥160)
Tachypnea (≥60)
Temperature Instability - Fever (≥100.4°F [≥ 38°C])
Temperature Instability – Hypothermia (< 97.5°F [<36.3°C])
Respiratory Distress (grunting, flaring, retracting) without O2 needs OR
Any TWO or MORE Physiologic Abnormality Lasting ≥2 hours
See above list again
Note physiologic abnormalities can be intermittent & still count

9. Newborn Clinical Exam – Definitions
Clinical Illness
Simply PUT = Everything worse than Equivocal Exam, but defined below:
O2 Supplementation (outside of the delivery room)
Need for supplemental O2 for ≥2 hours to maintain oxygen saturation >90%
Respiratory Support (outside of the delivery room)
Persistent need for Nasal CPAP
Persistent need for High Flow Nasal Canula or
Persistent need for mechanical ventilation
Blood Pressure Support
Hemodynamic instability requiring vasoactive drugs
Neonatal encephalopathy/ Perinatal depression
Apgar Score of 5 minutes
Seizure

10. Triple I to Manage Early-Onset Sepsis T.I.M.E. The New Process at CCHS
Andrew M. Ellefson, MD
Neonatologist
Christiana Care Health System
Edited by Cem Soykan, MD
Pediatric Hospitalist at CCHS

11. L&D Nurse Responsibilities
The Powerform: Neonatal Sepsis Calculator
A mother with fever ≥38˚ C delivers a baby.
L&D Nurse gets a notification in PowerChart when she opens the baby’s chart.
L&D Nurse must complete the “Neonatal Sepsis Calculator” Powerform
L&D Nurse must notify Pediatric DR provider

12. DR Provider Responsibilities
The Alerts we will get
Open Baby’s Chart
Review Nursing portion & complete their portion of the “Neonatal Sepsis Calculator” Powerform
Call/Notify PMD of baby’s status
Does NOT have to examine the baby, but may be asked to if any other concerns
Peds/DR Provider clicks on Neonatal Sepsis Calculator Form
Should already be filled in by L&D Nurse

13. Scenario Questions & IMPORTANT Points
Stable baby (even with normal transitional physiology - comfortable tachypnea) may remain with the mother per routine in L&D.
The baby can always be brought to the NICU for OBS if indicated.
“Equivocal” exam babies, by definition, require 2-4 hours of persistent symptoms.
Therefore, a comfortably tachypneic baby at 1 HOL may simply be demonstrating transitional physiology
When the mother is ready for transfer to Well Baby floor, only “Well Appearing” babies are cleared for co-transfer to Well Baby floor.
At the time of maternal transfer, any baby with ongoing transitional physiologic abnormalities, or any sign of distress must go to the NICU (Equivocal & Clinical Illness Babies)
If a baby goes to NICU for OBS and then has complete resolution of symptoms, clinical discretion can be used to allow this baby to return to Well Baby Floor with mother.
The Peds/DR provider must notify the Well Baby attending about the baby’s Sepsis Calculator recommendations & disposition.
Ensure proper provider-physician hand off.
The L&D nurse must also report this information in their handoff to post-partum nursing.

14. Newborn Physician & Postpartum Nurse Alerts
Occurs the 1st time each & every Nurse or Provider opens the baby’s chart on the Well Baby unit
Reminds Well Baby Nurse and Physician Providers to review the Neonate Sepsis Calculator Form document.

15. Where to Find the Sepsis Calculator Recommendations in Baby’s Chart

16. Well Baby Floor: Process Flow
Vitals signs on admission.
Vital signs 1 hour after admission to floor, and then Q4hr until 48 hours of life.
Nurse gets alert to review Neonatal Sepsis Calculator Form on baby Daily until 48 HOL
Well Baby/Newborn Physician gets alert to review Neonatal Sepsis Calculator Form on baby Daily until 48 HOL

17. Key Issues to Remember
The goal is to reduce unnecessary admissions to the NICU.
Any Well Baby/Floor newborn with any possible sign of distress needs to be discussed with NICU team & the covering well baby doctor.
Don’t delay in transferring a baby who has abnormal vitals or signs of distress to the NICU.