Transcription:
Management of Newborn with Maternal IAI

Dr. Jyoti Sharma: Hello, everyone. And welcome back to another edition of Neonatology Review: Isolette To Crib. I'm Dr. Jyoti Sharma, and I will be your host for this episode of our podcast. The purpose of this podcast is to review high-yield common topics in neonatology. While our focus is geared towards the perinatal and neonatal boards, anyone learning or studying neonatology will find this podcast useful.

Yes. So for this episode, our guest is Dr. Sanjay Akangire. He is a neonatologist here with us at Children's Mercy Hospital in Kansas City. Tell everyone hi, Dr. Akangire.

Dr. Sanjay Akangire: Hi, everyone. This is Dr. Akangire. And it's a pleasure to be here, Dr. Sharma.

Dr. Jyoti Sharma: Thank you. So he's joining us today to talk about the management of newborns with maternal intraamniotic infections, IAI or chorioamnionitis. In this episode, we'll cover the epidemiology, pathogenesis and management of neonates born to a mother with chorioamnionitis. So Dr. Akangire, to start off, for the sake of our listeners, how would you define chorioamnionitis or intraamniotic infection?

Dr. Sanjay Akangire: Sure. Intraamniotic infection also known as chorioamnionitis is an infection with inflammation of the amniotic fluid, placenta, fetus, fetal membranes or decidua. Commonly, it is caused by anaerobic or aerobic bacteria ascending from vaginal flora and usually it's a polymicrobial infection. Some of the common organisms are mycoplasma, ureaplasma, group B streptococci or GBS, Gram-negative bacilli, Listeria monocytogenes and Staphylococcus aureus.

Dr. Jyoti Sharma: So Dr. Akangire, I think one of the things that we in clinical practice have to deal with is, is there a true infection or true chorioamnionitis or not? So can you go over the criteria for the diagnosis of intraamniotic infections?

Dr. Sanjay Akangire: So criteria for suspected intraamniotic infection is if the maternal temperature is greater than or equal to 39 degrees Celsius or maternal temperature between 38 to 39 degrees Celsius with one additional risk factor. And the risk factors could be maternal leukocytosis, purulent cervical drainage, or fetal tachycardia. And criteria for isolated maternal fever is maternal temperature between 38 to 39 degrees Celsius with no additional risk factors.

Dr. Jyoti Sharma: So now let's discuss the incidence of chorioamnionitis.

Dr. Sanjay Akangire: Yes, chorioamnionitis or intraamniotic infection is the most common cause of peripartum infection. And incidence is approximately 4% of all women giving birth. Incidence is variable and is also different in term and preterm pregnancies.

Dr. Jyoti Sharma: So you just mentioned that the incidence is variable between the pre-term and term pregnancies. You want to talk a little bit more about that?

Dr. Sanjay Akangire: In preterm pregnancies, reported range for intraamniotic infection is about 40 to 70%. The rate is high due to preterm labor in term pregnancies, the incidence is much lower and it's approximately 1% to 4% of all deliveries and 7% if rupture of membranes is prior to labor initiation and 25% if rupture of membranes is for greater than 24 hours, approximately 12% in mothers undergoing primary cesarean section and approximately 1% to 3% in mothers delivering with intact membranes. One important point to mention that the risk of intraamniotic and neonatal infection increases after 40 weeks of gestation.

Dr. Jyoti Sharma: So let's move on to the risk factors for chorioamnionitis. I'm sure there are several risk factors. Do you mind going over some of them?

Dr. Sanjay Akangire: Prolonged rupture of membranes or rupture of membranes for greater than 18 hours is a very important risk factor. Multiple digital vaginal exams, especially with rupture of membranes, cervical insufficiency, nulliparity, meconium-stained amniotic fluid, internal fetal monitoring, presence of genital tract pathogens, especially pathogens causing sexually transmitted infections and group B streptococcus.

Alcohol and tobacco usage is also a risk factor and previous intraamniotic infection. There is increased risk of intraamniotic infection in pregnancies exposed to mechanical methods of cervical ripening compared to prostaglandins.

And Dr. Sharma, it is important to note that these risk factors may not be individually significant, but important in the setting of prolonged rupture of membranes.

Dr. Jyoti Sharma: So that is a great summary of the risk factors. Given the risk factors, can you discuss what are the complications that may occur? And I'm sure you will discuss both neonatal and maternal complications, but can we first discuss the neonatal complications associated with chorioamnionitis?

Dr. Sanjay Akangire: So intraamniotic infection is associated with morbidities like neonatal pneumonia, meningitis, sepsis and even death. Intraamniotic infection infection can be associated with up to 40% of cases of early-onset sepsis.

Dr. Jyoti Sharma: So Dr. Akangire, we are neonotologists and when it comes to neonates, we are not only concerned about the short-term complications, but we always are also concerned about the long-term complications in our patients. So with regards to chorioamnionitis, do we need to be concerned about any long-term complications for infants who have had chorioamnionitis or intraamniotic infection?

Dr. Sanjay Akangire: That's a great question, Dr. Sharma. Intraamniotic infection can be associated with long-term complications like bronchopulmonary dysplasia or BPD and cerebral palsy. And this is potentially due to the effect of inflammation alone.

Dr. Jyoti Sharma: So this, again, points out how important the intrauterine environment is for even long-term outcome of our patient. So moving on, how about the maternal complications? Are there maternal complications that can arise from intrauterine infection?

Dr. Sanjay Akangire: Yes, there are maternal complications as well. Maternal morbidity from Intermatic infection may also be significant. That includes dysfunctional labor, requiring increased intervention, sepsis, peritonitis, adult respiratory distress syndrome, postpartum uterine atony with hemorrhage and endometritis, but rarely death occurs.

Dr. Jyoti Sharma: That is good information. Now, how about the management? So can you review the management of infants exposed to maternal chorioamnionitis or intraamniotic infection?

Dr. Sanjay Akangire: Yes. So management of these infant starts with intrapartum broad-spectrum antibiotics to cover for most common cervicovaginal fluid.. Ampicillin and gentamicin are the preferred antibiotics in this situation.

Dr. Jyoti Sharma: Are there any antibiotic guidelines that are out there?

Dr. Sanjay Akangire: Yes. The CDC and AAP guidelines recommend laboratory studies and empiric antibiotic therapy for all newborns delivered from mothers with a suspected or confirmed intraamniotic infection. These guidelines are being evaluated and various models are being utilized to avoid excess antibiotic exposure in the newborns.

Dr. Jyoti Sharma: So Dr. Akangire, whenever we talk about it especially empiric antibiotics, we always have to think about concern for overuse in the early neonatal period. So can you talk about some of the concerns with use of empiric antibiotics in the early neonatal period?

Dr. Sanjay Akangire: That's a very good question, Dr. Sharma. Early antibiotics disturb the microbiome and increase the risk of asthma, allergies, obesity, inflammatory bowel disease in children, and obviously antibiotic resistance. This also separates the mother from baby shortly after birth if infant is admitted to the NICU, that further increases maternal anxiety and can also affect breastfeeding.

Dr. Jyoti Sharma: So Dr. Akangire, as you have mentioned, given the concerns, what is being done to reduce empiric antibiotic use in the newborn period?

Dr. Sanjay Akangire: So more and more NICUs are using multivariate risk assessment models and close clinical observation models without antibiotics. And this is to safely decrease the number of well-appearing term newborns treated empirically with antibiotics. In our practice, as you know, if the infant is symptomatic, we recommend admission to the NICU and start empiric antibiotics to treat for at least 48 hours until the blood culture is negative.

Dr. Jyoti Sharma: So you just talked about if the baby is symptomatic. Are there any guidelines for asymptomatic infants? My understanding is that more and more the sepsis calculator is being utilized. Can you first talk a little bit about the sepsis calculator?

Dr. Sanjay Akangire: This is a very important question and hot topic in current era. Neonatal sepsis calculator is a free online tool that was developed based on a large multicenter study to evaluate the risk factors for early-onset sepsis for infants born at greater than 30 weeks' gestation. This calculator is a proven tool to stratify the EOS risk based on maternal risk factors and neonatal data and has been utilized widely to decrease antibiotic usage. This calculator utilizes maternal data and provides EOS risk score based on gestational age, time of rupture of membranes prior to delivery, highest intrapartum maternal temperature, maternal GBS status and intrapartum antibiotics.

Infants are further divided into well-appearing, equivocal, clinical illness category based on the clinical presentation and recommendations are based on EOS risk score and infant's signs and symptoms. And that includes observation only, observation and labs with blood culture, and observation with labs and empiric antibiotics. We have developed some local guidelines that utilize neonatal sepsis calculator for management of infants exposed to maternal intraamniotic infection.

Dr. Jyoti Sharma: Dr. Akangire, thanks for that information about the utilization of the sepsis calculator. And my understanding is that more and more data is coming out that with this thoughtful use of a clinical guideline while antibiotic use has decreased, it has not compromised the patient outcomes. Correct? And if I remember correctly, I think one of the publications is from your team also.

Dr. Sanjay Akangire: Yes, absolutely. We had some guidelines published at our institution as you know, and the paper has been published.

Dr. Jyoti Sharma: To summarize, do you mind just going over the important points or take-home points?

Dr. Sanjay Akangire: So infants exposed to intraamniotic infection are at increased risk of infection leading to higher neonatal morbidity. Symptomatic infants should be treated empirically with antibiotics for at least 48 hours if blood culture remained negative. Asymptomatic infants should be monitored very closely for at least 48 hours and may need antibiotics if becomes symptomatic.

Dr. Jyoti Sharma: So Dr. Akangire, to finish off this episode, at the end of our episodes, we like to have at least a question regarding the topic. Do you have a question for us today that you might want to go over?

Dr. Sanjay Akangire: Yes, I do have one question for this. So the question is: A 29-year-old mother had a temperature of 39 degrees Celsius during labor, and she was diagnosed with intraamniotic infection and was started on intrapartum antibiotics. Infant is well-appearing after birth. And based on the CDC guidelines, what would you do? So the choices are: A, infant should be watched in the nursery and no further workup is necessary. Second choice, infant should be admitted to the NICU and worked up with CBC and blood culture. Third choice, infant should be admitted to the NICU and worked up with CBC, blood culture and empiric antibiotics. Forth choice, infants should be watched in the nursery with CBC and blood culture.

Dr. Jyoti Sharma: Okay. So let me look at this. So this is a mother who had all the clinical signs of chorioamnionitis. So she did have intraamniotic infection. So the answer, I think, should be C, infants should be admitted to the NICU and worked up with a CBC, blood culture and empiric antibiotic pending 48 hours of blood culture. Is that correct?

Dr. Sanjay Akangire: That is correct, Dr. Sharma. So CDC recommendation is to do workup and treat with antibiotics for at least 48 hours. Although CDC has above recommendation, several institutions, as we talked earlier, have local guidelines and using models that include EOS calculator to monitor asymptomatic newborns without antibiotics initiation.

Dr. Jyoti Sharma: That was a very good question. I think very relevant for our clinical practice.

Thank you, Dr. Akangire. Hopefully, this information will give you a better understanding of management of the newborn with intraamniotic infection. This is Neonatology Review: isolette To Crib. And I'm Dr. Jyoti Sharma. Thank you for listening and please join us on our next podcast where we will discuss GBS sepsis.