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

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:

Chorioamnionitis

Definition: Also known as intraamniotic infection. Chorioamnionitis is a bacterial infection of fetal amnion and chorion membranes.

Epidemiology:

Diagnosis:

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:

Postpartum Endometritis

Definition: Generalized uterine infection

Epidemiology:

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. 8^th 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. 8^th ed. Philadelphia, PA: Elsevier Saunders; 2014: 2282-2299.

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

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