The document discusses neonatal infection risks associated with prolonged rupture of membranes and strategies for prevention and management. Key points: - Rupture of membranes for longer than 18 hours increases the risk of chorioamnionitis and neonatal infection due to ascending bacterial infection from the birth canal. - Preterm infants have higher infection risks due to immune dysfunction and invasive procedures. - Guidelines recommend screening all pregnant women for Group B Streptococcus (GBS) at 35-37 weeks and administering intrapartum antibiotics (IAP) for those who test positive or have other risk factors. - Management of infants involves observation and/or limited evaluation and empiric antibiotics depending on gestational age,

1. بسم الله الرحمن الرحيم

2. PROLONGED RUPTURE OF MEMBRANES AND NEONATAL INFECTION Ayman Abou Mehrem, MD, CABP Staff Physician Department of Pediatrics King Abdulaziz National Guard Hospital

3. Pathogenesis of Ascending Bacterial Infection

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

11. OTHER FACTORS that associated with increased frequency of NEONATAL INFECTION Difficult Delivery Traumatic Delivery Preterm Delivery Resuscitation at Birth

12. In most cases , bacterial colonization of the newborn does not result in disease

13. What are the factors influencing which colonized infant will develop disease? These are not well understood, but include: Prematurity Underlying illness Invasive procedures Inoculum size Virulence of infecting organism Transplacental maternal antibodies

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.

15. Prematurity and Infection

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

19. immune dysfunction Premature infants have documented

20. Premature infants often require prolonged intravenous access, endotracheal intubation or other invasive procedures that provide a portal of entry or impair clearance mechanisms

21. The most common bacterial organisms causing neonatal infection are: Group B streptococcus (Streptococcus agalactiae) Enteric organisms Listeria monocytogenes Gonococci Chlamydia

22. Group B Streptococcus GBS

23. GBS is encapsulated Gram positive coccus colonizes the gastrointestinal and genital tracts in the humans Approximately 25% of pregnant women carried this organism in their genital and/or gastrointestinal tracts and this carriage was the most critical determinant of risk for early onset GBS infection in their offspring

24. Approaches for GBS Prevention in the Newborn Eradication of colonization in pregnant women with antibiotics given during pregnancy Active screening of pregnant women with antibiotics during labor only for those with positive screening cultures Antibiotics during labor for all pregnant women with one or more factors leading to an increased risk for GBS infection in their offspring Development of vaccines which could be administered to women before pregnancy

25. The first guidelines for Intrapartum Antibiotic Prophylaxis (IAP) were published by the AAP in 1992 A CDC survey of a population of almost 30 million documented a significant decrease in early onset infection (i.e. < 7 days of age) between 1993 and 1998 (1.7 to 0.6 cases per 1000 births)

26. 2002 Revised IAP Guidelines

27. All pregnant women should be screened for GBS colonization with swabs of both the lower vagina and rectum at 35 to 37 weeks of gestation. The only patients who are excluded from screening are those with GBS bacteriuria earlier in the current pregnancy or those who gave birth to a previous infant with invasive GBS disease. These are not included in the screening recommendation because they should receive IAP regardless of the colonization status

28. Swabs should be obtained from the lower vagina (not cervix) and rectum (not anal orifice) and should be promptly placed into non-nutrient transport media Susceptibility testing to erythromycin and clindamycin, if feasible, should be performed for GBS isolates

29. Patients recommended for IAP

30. Pregnant women with a positive screening culture from either vagina or rectum unless a planned cesarean delivery is performed in the absence of labor or membrane rupture Pregnant women who gave birth to a previous infant with invasive GBS disease Pregnant women with documented bacteriuria during the current pregnancy Pregnant women whose culture status is unknown (culture not performed or results not available) and who have any of the following: Delivery at <37 weeks of gestation Amniotic membrane rupture for ≥18 hours Intrapartum temperature ≥38°C

31. Patients not recommended for IAP

32. Positive GBS screening culture in a previous pregnancy (unless the infant had invasive GBS disease or the screening culture is also positive in the current pregnancy) Patient who undergoes a planned cesarean delivery without labor or rupture of membranes Pregnant women with negative GBS screening culture at 35 to 37 weeks of gestation even if they have one or more of the above intrapartum risk factors. The use of broad spectrum intrapartum antibiotics for the treatment of presumed chorioamnionitis in febrile women in labor is left to the discretion of the obstetrician

33. IAP regimens Penicillin G (5 million units IV initial dose, then 2.5 million units IV Q4h) Ampicillin (2 g IV initial dose, then 1 g IV Q4h). Penicillin is preferred based upon its narrower spectrum of activity and theoretical reduced opportunity for development of ampicillin-resistant organisms Cefazolin (2 g initial dose, then 1 g Q8h) is recommended for women with a history of non-immediate-type penicillin-allergy, i.e. at low risk for anaphylaxis

34. Clindamycin (900 mg IV Q8h) or Erythromycin (500 mg IV Q6h) are recommended for patients at high risk for anaphylaxis to penicillins only if their GBS culture screening isolate is documented to be susceptible to one of them Vancomycin (1 g Q12h) is recommended for patients at high risk for anaphylaxis and a GBS isolate resistant to clindamycin or erythromycin; or with unknown susceptibility

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

36. Approach to Threatened Preterm Delivery No GBS culture Onset of labor or rupture of membranes at <37 weeks gestation with significant risk for imminent preterm delivery GBS + GBS - Penicillin IV for >=48 hrs (during tocolysis) Obtain vaginal and rectal GBS culture and initiate IV penicillin No GBS prophylaxis IAP at delivery Stop penicillin GBS + No growth at 48 hrs

37. Management of the infant whose mother has received IAP

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

39. Infants born at <35 wks of gestation there is a clinical suspicion for sepsis a change occurs in clinical status the blood culture yields GBS IAP administered <4 hrs prior to delivery If the infant is healthy-appearing and IAP with penicillin, ampicillin, or cefazolin was administered to the mother at least 4 hrs prior to delivery, a CBC with diff. and blood culture should be obtained and the infant observed without antibiotic treatment for at least 48 hrs Empiric antibiotics are initiated if:

40. Infants born at ≥35 wks of gestation a change occurs in clinical status the blood culture yields GBS If the infant is healthy-appearing and IAP with penicillin, ampicillin, or cefazolin was administered to the mother at less than 4 hrs prior to delivery, a CBC with diff. and blood culture should be obtained and the infant observed without antibiotic treatment for at least 48 hrs Empiric antibiotics are initiated if:

41. If the infant is healthy-appearing and IAP with penicillin, ampicillin, or cefazolin was administered to the mother at least 4 hrs prior to delivery, the infant does not need further evaluation but should be observed in the hospital without antibiotic treatment for at least 48 hrs

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:

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