What is the management for a pregnant woman with diarrhea on the day of delivery with concern for causing neonatal sepsis?

Management of Pregnant Women with Diarrhea on Day of Delivery to Prevent Neonatal Sepsis

Pregnant women with diarrhea on the day of delivery should receive intrapartum antibiotic prophylaxis with ampicillin or penicillin to prevent neonatal sepsis, regardless of GBS colonization status. This approach is essential as diarrhea may indicate potential infectious processes that could increase the risk of neonatal sepsis 1.

Risk Assessment and Initial Management

Maternal Evaluation

• Assess severity of diarrhea (frequency, consistency, presence of blood)
• Check for fever, abdominal pain, or other signs of chorioamnionitis
• Obtain stool cultures if clinically indicated
• Evaluate for dehydration and provide appropriate fluid resuscitation

Antibiotic Prophylaxis Protocol

• First-line therapy: Intravenous penicillin G (5 million units initially, then 2.5-3.0 million units every 4 hours until delivery) OR ampicillin (2g initial dose, then 1g every 4 hours until delivery) 1
• For penicillin-allergic patients:
  • Low risk for anaphylaxis: Cefazolin (2g initial dose, then 1g every 8 hours until delivery)
  • High risk for anaphylaxis: Clindamycin (900mg every 8 hours) or vancomycin (20mg/kg every 8 hours) 1

Timing Considerations

• Optimal protection requires antibiotics to be administered ≥4 hours before delivery 1
• Even if delivery is imminent, initiate antibiotics immediately as any duration provides some protection
• Continue antibiotics until delivery is complete

Special Considerations

Cesarean Delivery

• If cesarean delivery is planned without labor or membrane rupture, routine intrapartum antibiotic prophylaxis is not recommended solely based on GBS status 1
• However, with active diarrhea, prophylaxis should be administered regardless of delivery mode due to increased risk of bacterial translocation

Preterm Labor

• Diarrhea in the setting of preterm labor significantly increases risk for neonatal sepsis 2
• Obtain vaginal and rectal GBS cultures if not already done and time permits
• Initiate broad-spectrum antibiotics pending culture results 1

Neonatal Management After Delivery

If Mother Received Adequate Prophylaxis (≥4 hours)

• Well-appearing infant: Observation for ≥48 hours without routine diagnostic testing
• May discharge after 24 hours if other discharge criteria met, access to medical care is available, and a reliable caregiver is present 1

If Mother Received Inadequate or No Prophylaxis

• Well-appearing infant ≥37 weeks with membrane rupture <18 hours: Observation for ≥48 hours
• Well-appearing infant <37 weeks OR membrane rupture ≥18 hours: Limited evaluation (blood culture, CBC with differential) and observation for ≥48 hours 1
• Signs of sepsis or maternal chorioamnionitis: Full diagnostic evaluation and empiric antibiotic therapy 1

Pitfalls and Caveats

• Diarrhea may increase risk of E. coli and other gram-negative pathogens, not just GBS
• Ampicillin resistance is increasingly common in E. coli infections, particularly in preterm infants 1
• Multiple vaginal examinations (≥3) in the presence of diarrhea significantly increases sepsis risk (OR 9.5) 2
• Maternal diarrhea may lead to dehydration, which can complicate labor management and increase risk of adverse outcomes
• Do not delay antibiotic administration while waiting for culture results if sepsis is suspected

By following this algorithm, the risk of neonatal sepsis can be significantly reduced in the setting of maternal diarrhea on the day of delivery.