1. Maternal and Neonatal Sepsis
Allana Oak, D.O. & John Morrison, M.D.
Kentucky Perinatal Association
June 5, 2017

2. Objectives
Describe maternal and newborn sepsis risk factors and pathogens
Review signs and symptoms, antibiotic coverage and optimal treatment of sepsis.

3. Disclosure No financial disclosures but......
I sometimes throw in random pictures to:
Avert boredom
Make sure you are awake
I like to laugh

4. Disclosure

5. Disclosure

6. Final Disclosure

7. Maternal Sepsis 3rd most common direct cause of maternal mortality
Global Maternal and Neonatal Sepsis Initiative

8. WHO definition of Maternal Sepsis
Maternal sepsis is a life threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or postpartum period

9. Maternal Sepsis
More prevalent in developing nations (HIV, malaria, lack of access to care)
In US usually due to puerperal sepsis and UTI
Pyelonephritis
Chorioamnionitis
Septic Abortion
Pneumonia

11. Chorioamnionitis Intra-Amniotic Infection (IAI)
Intraamniotic Infection or Inflammation (Triple I)
Amniotic Fluid
Fetus
Umbilical Cord
Placenta
Fetal membranes

12. Pathogenesis - IAI Migration of cervical flora Hematogenous spread
Invasive procedure
Infection from peritoneum via Fallopian tube

13. Incidence of IAI Varies widely across US
Multifactorial (study type, diagnostic criteria used)
Increased in preterm infants (5-10%)
Decreases as patient approaches term (1-4%)
7% with PROM
12% primary Cesarean delivery
20% > 8 digital vaginal exams

14. Risk Factors – Maternal Sepsis
Longer labor
Length of ROM
Multiple digital vaginal exams
Cervical insufficiency
Nulliparity
MSAF
Internal fetal or uterine monitoring
Presence of genital tract infections/pathogens
ETOH and tobacco abuse
Previous IAI

16. Microbiology - IAI POLYMICROBIAL Genital mycoplasms Anaerobes
Ureaplasma
Mycoplasma
Anaerobes
Garnderella vaginalis
preterm
Enteric Gram negative bacilli
Group B Streptococcus

17. Clinical Findings - IAI
Fever (100%)
Maternal leukocytosis ( WBC > 15,000; %)
Maternal tachycardia ( > 100/min; 50-80%)
Fetal tachycardia (> 160/min; 40-70%)
Uterine tenderness (4-25%)
Bacteremia (5-10%)
Group B strep
E. Coli
Purulent or malodorous amniotic fluid
IAI may be subclinical – preterm labor, PPROM

18. Maternal Sequelae - IAI
Dysfunctional labor
Dysfunctional myometrial contractility due to inflammation
Increase risk of Cesarean
Uterine atony – postpartum hemorrhage – transfusion
Localized infection
Wound infection
Endomyometritis
Septic pelvic thrombophlebitis
Pelvic abscess

19. Sepsis - IAI 18% of maternal sepsis due to IAI Coagulopathy
Adult Respiratory Distress Syndrome
Multisystem organ failure
Elevated lactic acid associated with adverse outcomes
Good news!
Morbidity/mortality low if broad spectrum antibiotics initiated

21. Differential Diagnosis
Most s/s nonspecific
Maternal tachycardia – infection or pain?
Maternal fever – infection or epidural?
Maternal leukocytosis – infection? Labor? Steroids?
Fetal tachycardia – infection? Hypoxemia? Maternal fever?

22. Differential Diagnosis
Labor
Fever, maternal tachycardia, leukocytosis, uterine tenderness
Placental abruption
Uterine tenderness, maternal tachycardia
Usually have vaginal bleeding, absence of fever
Other infections
Pyelonephritis, influenza, appendicitis, pneumonia
Maternal tachycardia, fever, fetal tachycardia

23. Diagnostic Criteria - Presumptive
Fever
>102.2
> two occasions, 30 min apart
PLUS
Fetal tachycardia
>160/min for > 10 min
Maternal WBC
>15,000, bandemia
Purulent fluid
Cervical os, spec exam

24. Diagnostic Criteria - Confirmed
Positive Gram stain of amniotic fluid
Low glucose level in amniotic fluid
Positive amniotic fluid culture
High WBC in amniotic fluid
In the absence of a bloody tap
Histopathologic evidence
Infection
inflammation

25. Amniotic Fluid Analysis
Gold standard is culture
Most specific
Disadvantage – days to get results
Gram stain
6 WBCs/hpf
Glucose concentration
< 14 mg/dl
WBC concentration
>30 cells/mm3
Leukocyte esterase activity
Chemstrip 9

26. Amniocentesis - IAI Preterm labor eval
Initial tests with 67% false positive rate
Proceed with caution if acting prior to culture results
Traumatic tap

27. Future tests...... Interleukin – 6 (IL-6) Proteomic biomarkers
Cervicovaginal fluid
Predictive of microbial invasion of amniotic cavity
Preterm labor and intact membranes
Proteomic biomarkers
Amniotic fluid
Maternal serum
C – reactive protein
Not useful for prediction of IAI

28. Maternal Management
Antibiotics
Delivery

29. Delivery! Delivery is the cure! Induction of Labor
Cesarean if indiciated
Wound infection
Endomyometritis
Venous thrombosis

30. Broad Spectrum Antibiotics
Vaginal delivery
Ampicillin 2g IV every 6 hours PLUS
Gentamicin 5mg/kg once daily
Amp/Sulbactam 3g every 6 hours
Ticarcillin-clavulanate 3.1 g every 4 hours
Cefoxitin 2g every 6 hours

31. Broad Spectrum Antibiotics
Cesarean delivery
Add anaerobic coverage
Ampicillin 2g every 6 hours PLUS
Gentamicin 5 mg/kg once daily PLUS
Clindamycin 900mg or metronidazole 500mg
Amp/Sulbactam 3g every 6 hours
Ticarcillin-clavulanate 3.1 g every 4 hours
Cefoxitin 2g every 6 hours PLUS

32. Antibiotics - IAI Penicillin – allergic patients
Vancomycin 1g IV every 12 hours
Group B Streptococcus carriers
Already receiving intrapartum Pen G
Need to broaden coverage in presence of IAI
Duration of therapy unclear
Intrapartum plus one additional postpartum dose?
Afebrile and symptomatic x 24 hours?
No oral antibiotics after parenteral therapy

33. Intrapartum Management - IAI
Fetal monitoring
Antipyretics
Maternal fever and fetal acidosis = 12.5% risk of neonatal encephalopathy
Reduces fetal tachycardia
Reduces need for Cesarean
Postpartum care

34. Fetal and Neonatal Outcome
Adverse effects of IAI
Perinatal death, asphyxia, early-onset neonatal sepsis, septic shock, pneumonia, meninigitis, IVH, cerebral white matter damage, long term disability i.e. Cerebral palsy, pretem birth morbidity/mortality
40% cases of early- onset neonatal sepsis
Get ready
Dr. Morrision......

35. Prevention - IAI Educate L&D staff on signs and symptoms of IAI
Prompt administration of broad spectrum antibiotics
Modifiable risk factors
Conduct of labor
Minimize # of vaginal exams
Screen and treat for GBS
Prenatal counseling
Discussion of PROM
Substance abuse counseling

36. Conclusion
Intra-amniotic infection refers to infection of the amniotic fluid, membranes, placenta, umbilical cord and/or decidua
IAI is polymicrobial
Presumptive diagnosis
Maternal fever plus, FHR, maternal WBC, purulent fluid
Confirmed diagnosis
Amniotic fluid analysis and culture; histopath
May result in labor abnormalities
Dysfunctional labor
Postpartum hemorrhage
Broad spectrum antibiotics
Delivery is the cure!

38. Questions?

40. Neonatal Sepsis
Take it away
Dr. Morrison!!!