Take Home PointsInfections 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 PregnancyClick here for Direct Download of the PodcastUrinary Tract Infection/PyelonephritisEpidemiology: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 UTISuggested antibiotics include:Nitrofurantoin 100mg PO BID x7 days ORCephalexin 500mg PO BID x7 daysPyelonephritisHospital admissionSuggested antibiotics include:Ceftriaxone 1g IV Q24H ORAztreonam 2g IV Q8H for beta-lactam allergyComplications:Maternal sepsisMaternal renal injuryCongenital abnormalities of the fetusPremature rupture of membranesLow birth weightChorioamnionitisDefinition: Also known as intraamniotic infection.  Chorioamnionitis is a bacterial infection of fetal amnion and chorion membranes.Epidemiology:Occurs in 1 to 10% of all pregnancies (Gorgas 2008)Incidence increases significantly with preterm laborDiagnosis:Chorioamnionitis is defined as maternal fever >38°C and at least two of the following (Apantaku and Mulik 2007):Maternal tachycardia >100 beats/min for five minutesFetal tachycardia >160 beats/min for five minutesPurulent or foul-smelling amniotic fluid or vaginal dischargeUterine tendernessMaternal leukocytosisEvaluation (Abbrescia 2003):CBCBlood culturesVaginal fluid for phosphatidylglycerolTests for fetal lung maturityCervical AND vaginal culturesPhysical ExamAvoid digital cervical examSpeculum exam should be done with sterile speculumUltrasonography for fetal well beingManagement:Given concern for neonatal sepsis, patients should be admitted for IV antibiotics, supportive cares, and possible early deliveryMost commonly an ascending infection from normal vaginal flora, so antibiotics must be chosen to cover polymicrobial infectionsEx. Ampicillin IV 2g Q6H AND Gentamicin IV 1.5mg/kg Q8HIn PCN allergic patient substitute vancomycin 1 g IV Q12H for ampicillinCan only be considered cured with delivery of infected products of conceptionComplications:Placental abruptionPremature birthNeonatal sepsisNeonatal deathCerebral palsyMaternal sepsisNeed for cesarean deliveryPostpartum hemorrhagePostpartum EndometritisDefinition: Generalized uterine infectionEpidemiology:Sepsis results in 15% of maternal deaths worldwide (Houry 2014)More common in surgical than vaginal deliveriesMay co-exist with surgical site infectionDiagnosis:Classic triad includes: fever, lower abdominal pain and uterine tenderness, and foul smelling lochiaManagement:Hospital admissionCover for polymicrobial infection, including anaerobesEx. Clindamycin 900 mg IV Q8H AND Gentamicin 5-7 mg/kg IV Q24HSeptic AbortionEpidemiology: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 abortionPresentation can vary from mild infection to septic shockEvaluation:LactateCultures of cervix, blood and urineCoagulation panel to screen for DICAbdominal X-ray to evaluate for free air or retained surgical foreign bodiesPelvic ultrasound to evaluate for retained products of conception or surgical foreign bodiesManagement:Hospital admission may be indicated as infection can progress to septic shock, organ failure, DIC and cardiovascular collapseBroad-spectrum antibiotics are indicated.  Triple antibiotic coverage is recommended.  Suggested regimens include:Ampicillin ANDGentamicin ANDClindamycin OR MetronidazoleUpdate tetanus vaccinationUsually 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: 12962354Apantaku, O. and V. Mulik (2007). “Maternal intra-partum fever.” J Obstet Gynaecol 27(1): 12-15. PMID: 17365450Desai, S. and S. Henderson. Labor and Delivery and Their Complications. In: Marx, J et al, ed. Rosen’s Emergency Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; Gorgas, D. L. (2008). “Infections related to pregnancy.” Emerg Med Clin North Am 26(2): 345-366, viii. PMID: 18406978Houry, D and B. Salhi. Acute Complications of Pregnancy. In: Marx, J et al, ed. Rosen’s Emergency Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014: 2282-2299.Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)The post REBEL Core Cast 117.0 – Infections of Pregnancy appeared first on REBEL EM - Emergency Medicine Blog.