Chorioamnionitis and GBS NUHS-Evanston General Care Nursery Rotation

Chorioamnionitis and GBS
NUHS-Evanston
General Care Nursery Rotation
What would you do in this scenario?
• A newborn infant is born to a G1P0 mom at 39 2/7
week by SVD
• Mom: GBS + at 34 weeks
• Labor complicated by maternal fever to 103 and fetal
tachycardia.
• Mother received 3 doses of penicillin prior to delivery
• Rupture of membranes was 6 hours prior to the
infant's delivery.
• What treatment and/or evaluation would you
complete for the infant?
Choose the best answer
A. CBC, Blood culture and observe in the
hospital for 48 hours
B. CBC, Blood culture and antibiotics for 48
hours while cultures are pending
C. CBC, Blood culture, and antibiotics for 7
days
D. NO laboratory work but observe for 48 hours
in the hospital
E. No laboratory work and discharge after 24
hours of hospital observations
Case 2
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A newborn infant is born to a G1P0 mom at 38 4/7
week by SVD
Mother GBS+ at 37 weeks gestation
Mom received 2 doses of penicillin, >4 hours before
delivery
Rupture of membranes was 3 hours prior to delivery,
there were no signs of maternal chorioamnionitis
What treatment and/or evaluation would you
complete for the infant?
Choose the best answers
A. CBC, Blood culture and observe in the
hospital for 48 hours
B. CBC, Blood culture and antibiotics for 48
hours while cultures are pending
C. CBC, Blood culture, and antibiotics for 7
days
D. NO laboratory work but observe for 48 hours
in the hospital
E. No laboratory work and discharge after 24
hours of hospital observations
ACOG Definition
• Chorioamnionitis:
– Acute inflammation of membranes and chorion of
the placenta.
– Typically polymicrobial bacterial infection with
rupture of membranes
– 1-4% of all births
– 40-70% of preterm
Risk factors
• Colonization of
Group B strep:
11% risk of
infection
• PROM
• Nulliparity
• African American
• Multiple vaginal
exams
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Prolong labor
Epidural
Meconium staining
Drug or alcohol
abuse
• Immune
compromised
• STDs
• Ureaplasma
Clinical diagnosis during labor or delivery
• Tachycardia
– Maternal HR > 100 ( 30-80% sensitive)
– Fetal HR > 160 ( 40-70% sensitive)
• Uterine fundal tenderness ( 4-25% sensitive)
• Fever:
– > 100.4 X2 or 101 X1 (95-100% sensitive)
• Foul odor to amniotic fluid ( 5-22% sensitive)
• Epidural can confuse the picture as it can
cause similar symptoms
Maternal Complications of
Chorioamnionitis
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Endomyometritis
Wound infection
Pelvic abscess
Bacteremia
Post partum hemorrhage
• Treatment Ampicillin q6hr
Fetal Complication of Chorioamnionitis
• Fetal inflammatory Response with release of
cytokines
• Fetal death
• Neonatal sepsis
Neonatal Complications
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Perinatal death
Asphyxia
Early onset sepsis
Septic shock
Pneumonia
Intraventricular Hemorrhage
Cerebral Palsy
Since GBS causes >11% of early
neonatal infections prevention has
improved outcomes:
Go to :
http://www.cdc.gov/groupbstrep/guidelines/sli
desets.html
Review the slide set: Early-onset Group B
Streptococcal Disease Prevention: For
Clinicians
CDC Algorithm for prevention
Neonatal Sepsis Workups in Infants>=
2000g at birth: A Population-Based Study
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Large population based study performed at Kaiser Permanente by
Escobar
Looked at 2785 of 18,299 infants were evaluated for infection with CBC
+/- blood culture.
62/2785(2.2%) met criteria for infection and were 100% symptomatic by
10 hours of life.
Initial asymptomatic status was associated with decreased risk of
infection
Infants whose mother’s did not receive intrapartum antibiotics had
increase risk if:
– Maternal chorioamnionitis
– Low ANC
– Meconium stained fluid
Study Conclusions
• The risk of bacterial infection in asymptomatic
newborns is low ~ 1%
• Infants of Mothers who are treated with
intrapartum antibioitcs specifically: penicillin,
ampicillin or cefazolin are more likely to be
asymptomatic
Data on Antibiotics for Intrapartum
GBS Prophylaxis
• Penicillin and ampicillin given as intrapartum
prophylaxis are effective in preventing earlyonset GBS disease.
• Cefazolin is probably effective as GBS
intrapartum prophylaxis.
• No similar data available for clindamycin,
erythromycin, or vancomycin.
NorthShore Guidelines:
• If Signs of Neonatal Sepsis:
– Call the ISCU and the pediatrician
– CBC w/dif, Blood Culture, LP, CXR if respiratory distress
– Start antibiotics: IV ampicillin and cefotaxime
• If Maternal Chorioamnionitis:
– CBC w/dif, Blood Culture, vitals every 4 hours.
– Did mother receive IV Pencillin/Ampicillin/Cefazolin
>= 4 hours prior to delivery?
» Yes: Call pediatrician with CBC results, they may or may not
decide to start antibiotics
» No: start IV Ampicillin and Cefotaxime and call pediatrician with
CBC results
GBS prophylaxis indications:
• GBS prophylaxis is not indicated in C-section
with intact membranes at time of delivery
• GBS prophylaxis indications:
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Previous infant with invasive GBS disease
GBS bacteriuria during the current pregnancy
+ GBS screening in late gestation
Unknown GBS status at onset of labor plus any of
the following:
» < 37 wg
» ROM > 18 hours
» Intrapartum temp > 100.3
Is GBS prophylaxis indicated for
mother?
– No: routine care
– Yes: Did mother receive IV Penicillin, Ampicillin,
or Cefotaxime > = 4 hours prior to delivery?
» No: Call the pediatrician.
– Baby > 37 wg and ROM < 18 hours: observe with q4 hour
vitals for 48 hrs. May leave at 24 hours if has good follow
up
– Baby < 37 wg or ROM >= 18 hours: CBC with dif, Blood
Culture, observe with q4 hour vitals for 48 hours.
» Yes: observation with q4 hour vitals for 48 hours. May
leave at 24 hours if has good follow up.
Case 3
• A newborn infant is born to a G3P2 mom at
38 5/7 week by SVD. Maternal screen was
positive for GBS at 34 weeks. Mom received
one dose of penicillin 2 hours prior to a
precipitous delivery. There were no signs of
chorioamnionitis. Rupture of membranes was
4 hours prior to delivery. The infant is
admitted to the newborn nursery at 2 hours of
age and appears well. What treatment and/or
evaluation would you complete for the infant?
Please select the best answer
A. CBC, Blood culture and observe in the
hospital for 48 hours
B. CBC, Blood culture and antibiotics for 48
hours while cultures are pending
C. CBC, Blood culture, and antibiotics for 7
days
D. NO laboratory work but observe for 48 hours
in the hospital
E. No laboratory work and discharge after 24
hours of hospital observations
Case 4
• A newborn infant is born to a G1P0 mom at
36 2/7 week by SVD. The mother presented
in active labor and rupture of membranes was
2 hours prior to delivery. Maternal screen was
positive for group B streptococcus at 34
weeks. She received one dose of penicillin 3
hours prior to delivery. The infant appears
well shortly after birth. What treatment and/or
evaluation would you complete for this infant?
Please select the best answer
A. CBC, Blood culture and observe in the
hospital for 48 hours
B. CBC, Blood culture and antibiotics for 48
hours while cultures are pending
C. CBC, Blood culture, and antibiotics for 7
days
D. NO laboratory work but observe for 48 hours
in the hospital
E. No laboratory work and discharge after 24
hours of hospital observations
Case 5
• A newborn infant is born to a G2P1 mom at
37 2/7 week by SVD. The mother presented
in active labor and rupture of membranes was
20 hours prior to delivery. Maternal screen
was positive for group B streptococcus at 34
weeks. Mom has a history of anaphylaxis
reaction to penicillin so one dose of
vancomycin was given prior to delivery. The
infant appears well. What treatment and/or
evaluation would you complete for this infant?
Please select the best answer
A. CBC, Blood culture and observe in the
hospital for 48 hours
B. CBC, Blood culture and antibiotics for 48
hours while cultures are pending
C. CBC, Blood culture, and antibiotics for 7
days
D. NO laboratory work but observe for 48 hours
in the hospital
E. No laboratory work and discharge after 24
hours of hospital observations
References
• http://www.cdc.gov/groupbstrep/index.html
• Tita A, Andrews W. Diagnosis and
Management of Clinical Chorioamnionitis.
Clinical Perinatol. 2010 June 37(2): 339-354.
• Escobar et al. Neonatal Sepsis Workups in
Infants>= 2000 Grams at Birth: A PopulationBased Study. Pediatrics. 2000
Aug106(2):256-263.
References continued
• Neuman Thomas et al. Interpreting Complete
Blood Counts Soon After Birth in Newborns at
Risk for Sepsis. Pediatrics 2010 November;
126(5): 903-909.