Urinary Tract Infections/Pyelonephritis


  • 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)


  • Uncomplicated UTI
    • Suggested antibiotics include:
      • Nitrofurantoin 100mg PO BID x7 days OR
      • Cephalexin 500mg PO BID x7 days
    • Pyelonephritis
      • Hospital admission
      • Suggested antibiotics include:
        • Ceftriaxone 1g IV Q24H OR
        • Aztreonam 2g IV Q8H for beta-lactam allergy


  • Maternal sepsis
  • Maternal renal injury
  • Congenital abnormalities of the fetus
  • Premature rupture of membranes
  • Low birth weight


Chorioamnionitis (pregmed.org)

Chorioamnionitis (pregmed.org)

Definition: Also known as intraamniotic infection. Chorioamnionitis is a bacterial infection of fetal amnion and chorion membranes.


  • Occurs in 1 to 10% of all pregnancies (Gorgas 2008)
  • Incidence increases significantly with preterm labor


  • 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 minutes
    • Fetal tachycardia >160 beats/min for five minutes
    • Purulent or foul-smelling amniotic fluid or vaginal discharge
    • Uterine tenderness
    • Maternal leukocytosis

Evaluation (Abbrescia 2003)

  • CBC
  • Blood cultures
  • Vaginal fluid for phosphatidylglycerol
    • Tests for fetal lung maturity
  • Cervical AND vaginal cultures
  • Physical Exam
    • Avoid digital cervical exam
    • Speculum exam should be done with sterile speculum
  • Ultrasonography for fetal well being


  • Given concern for neonatal sepsis, patients should be admitted for IV antibiotics, supportive cares, and possible early delivery
  • Most commonly an ascending infection from normal vaginal flora, so antibiotics must be chosen to cover polymicrobial infections
  • Ampicillin IV 2g Q6H AND Gentamicin IV 1.5mg/kg Q8H
    • In PCN allergic patient substitute vancomycin 1 g IV Q12H for ampicillin
  • Can only be considered cured with delivery of infected products of conception


  • Placental abruption
  • Premature birth
  • Neonatal sepsis
  • Neonatal death
  • Cerebral palsy
  • Maternal sepsis
  • Need for cesarean delivery
  • Postpartum hemorrhage

Postpartum Endometritis

Definition: Generalized uterine infection


  • Sepsis results in 15% of maternal deaths worldwide (Houry 2014)
  • More common in surgical than vaginal deliveries
  • May co-exist with surgical site infection


  • Classic triad includes: fever, lower abdominal pain and uterine tenderness, and foul smelling lochia


  • Hospital admission
  • Cover for polymicrobial infection, including anaerobes
    • Clindamycin 900 mg IV Q8H AND Gentamicin 5-7 mg/kg IV Q24H

Septic Abortion


  • The World Health Organization estimates that one in eight pregnancy related deaths worldwide can be directly attributed to unsafe abortion procedures (Gorgas 2008)


  • Clinical presentation includes fever, abdominal pain and uterine tenderness in setting of recent abortion
  • Presentation can vary from mild infection to septic shock


  • Lactate
  • Cultures of cervix, blood and urine
  • Coagulation panel to screen for DIC
  • Abdominal X-ray to evaluate for free air or retained surgical foreign bodies
  • Pelvic ultrasound to evaluate for retained products of conception or surgical foreign bodies


  • Hospital admission may be indicated as infection can progress to septic shock, organ failure, DIC and cardiovascular collapse
  • Broad-spectrum antibiotics are indicated. Triple antibiotic coverage is recommended. Suggested regimens include:
    • Ampicillin AND
    • Gentamicin AND
    • Clindamycin OR Metronidazole
  • Update tetanus vaccination
  • Usually requires dilation and curettage to remove any retained products of conception or foreign bodies.


Abbrescia, K. and B. Sheridan (2003). “Complications of second and third trimester pregnancies.” Emerg Med Clin North Am 21(3): 695-710, vii. PMID: 12962354

Apantaku, O. and V. Mulik (2007). “Maternal intra-partum fever.” J Obstet Gynaecol 27(1): 12-15. PMID: 17365450

Desai, 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; 2014:2331-2350.

Gorgas, D. L. (2008). “Infections related to pregnancy.” Emerg Med Clin North Am 26(2): 345-366, viii. PMID: 18406978

Houry, 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.