2. PROLONGED RUPTURE OF MEMBRANES AND NEONATAL INFECTION Ayman Abou Mehrem, MD, CABP Staff Physician Department of Pediatrics King Abdulaziz National Guard Hospital
4. In most cases the fetus or neonate is not exposed to potentially pathogenic bacteria until the membranes rupture and the infant passes through the birth canal and/or enters the extra uterine environment
5. The human birth canal is colonized with aerobic and anaerobic organisms that may result in ascending amniotic infection and/or colonization of the infant at birth
6. VERTICAL TRANSMISSION of bacterial agents that infect the amniotic fluid and/or vaginal canal may occur in utero or more commonly during labor and/or delivery
7. CHORIOAMNIONITIS results from microbial invasion of amniotic fluid as a result of prolonged rupture of the chorioamniotic membrane
8. On occasion , amniotic infection occurs with apparently intact membranes or with a relatively brief duration of membrane rupture
9. Amniotic fluid infection may be asymptomatic or may produce maternal fever with or without local or systemic signs of chorioamnionitis
10. THE DURATION OF MEMBRANE RUPTURE is directly correlated with the development of chorioamnionitis LONGER THAN 18 HOURS is the current cut off for increased risk of neonatal infection
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12. In most cases , bacterial colonization of the newborn does not result in disease
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14. Aspiration or ingestion of bacteria in amniotic fluid may lead to congenital pneumonia or systemic infection, with manifestations become apparent before delivery or after a latent period of a few hours. Aspiration or ingestion of bacteria during the birth process may lead to infection after an interval of 1-2 days.
16. Preterm infants have 3- to 10-fold higher incidence of infection than full term, normal birth weight infants do
17. is considered to be an important cause of preterm labor with an increased risk of vertical transmission to the newborn Maternal genital tract infection
18. gestational age The frequency of intra-amniotic infection is inversely related to
20. Premature infants often require prolonged intravenous access, endotracheal intubation or other invasive procedures that provide a portal of entry or impair clearance mechanisms
35. IAP is continued from hospital admission through delivery The greatest efficacy is achieved if penicillin G, ampicillin, or theoretically cefazolin is administered ≥4 hours before delivery
38. Any gestational age If the infant is ill-appearing or sepsis is otherwise strongly suspected, a full diagnostic evaluation including a CBC with differential, a blood culture, and a lumbar puncture (unless the clinical status dictates otherwise) should be done and empiric antibiotic treatment initiated using ampicillin and gentamicin until laboratory results are known. A chest radiograph should be obtained if respiratory symptoms are present
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42. Maternal IAP for GBS? Maternal antibiotics for suspected chorioamnionitis? Limited evaluation Observe ≥48hrs If sepsis is suspected, full diagnostic evaluation and empiric therapy Full diagnostic evaluation Empiric therapy Signs of neonatal sepsis? GA <35 weeks? No evaluation No therapy Observe ≥48 hrs Duration of IAP before delivery <4 hrs? Yes Yes Yes Yes Yes No No No Management of the infant whose mother has received IAP
43. Management of the infant whose mother has prolonged rupture of membranes Rupture of Membranes ≥ 18 hrs Mother has Chorioamnionitis? Sings of Neonatal Sepsis? GBS Screening at 35-37 wks gestation Negative No Evaluation No Therapy Observe ≥ 48 hrs Positive or Unknown Mother received IAP ≥ 4 hrs prior to delivery GA < 35 wks Limited Evaluation (CBC with differential, and blood culture) Observe ≥ 48 hrs Full Septic Screen and Start I.V. Antibiotics if: 1- Change in clinical status 2- Blood culture yields GBS GA < 35 wks Full Septic Screen: CBC with differential, blood culture, LP, and chest X-ray (if indicated). Start I.V. Antibiotics Yes Yes Yes Yes Yes No No No No No Prepared by: Dr. Ayman Abu Mehrem Approved by: Dr. Hesham Al-Girim Reference:
