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A5199 - Listeria Chorioamnionitis Sepsis Treated with Delayed Delivery
Author Block: R. Wilson1, S. Sudholt2, J. A. Greenberg3; 1Internal Medicine, Rush University Medical Center, Chicago, IL, United States, 2Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States, 3Pulmonary- Critical Care, Rush University Medical Center, Chicago, IL, United States.
Introduction- Septic shock in a pregnant patient increases the risk for preterm delivery, fetal death, and maternal death. Pregnant women are often excluded from studies of septic patients. Chorioamnionitis is a potential source of sepsis that is unique to a pregnant patient. Although chorioamnionitis is typically polymicrobial, caused by ascending migration of cervicovaginal flora through the cervical canal rarely Listeria Monocytogenes may cause chorioamnionitis via maternal bacteremia and hematogenous spread. Historically, chorioamnionitis is managed with prompt delivery. However, this approach may be problematic if the fetus is extremely premature. We present a case of Listeria chorioamnionitis in which delivery was delayed in order to allow for an improved chance of fetal survival.
Case- A 34-year-old primiparous woman with dichorionic-diamniotic twin pregnancy and past medical history of diffuse large B cell lymphoma (in remission), splenectomy, and gestational diabetes presented at 23 weeks 3 days gestational age with fevers and back pain. She was empirically started on ceftriaxone for presumed pyelonephritis. However, workup for source of infection revealed a negative urinalysis, urine cultures, chest x ray and abdominal ultrasound. On hospital day #2 she was diagnosed with intrauterine fetal demise of twin B. Later that day, she clinically decompensated, her antibiotics were broadened and she was transferred to the ICU for fluids and vasopressors. Blood cultures turned positive for Listeria Monocytogenes. An amniocentesis was performed which was consistent with chorioamnionitis. The patient was able to be weaned off vasopressors and developed no additional organ failure. Given patient’s clinical improvement and reassuring fetal surveillance of surviving twin, the decision was for prolonged IV antibiotics and to delay delivery until at least after 24 weeks gestation to decrease morbidity associated with extremes of prematurity. The patient subsequently went into preterm labor and successfully delivered an extremely premature infant at 24 6/7 weeks gestation. Both the patient and her daughter survived.
Discussion- The case describes a rare cause of septic shock and demonstrates the importance of early identification of sepsis in the pregnant patient. The case highlights how sepsis may present insidiously in pregnant patient and progress rapidly. Delaying delivery with close monitoring in Listeria Monocytogenes chorioamnionitis for a week was done safely. Ultimately, the decision for delivery in the setting of antepartum severe sepsis or septic shock can be challenging but must be based on gestational age, multiple gestations, maternal status, and fetal status.