The Effect of Clostridium difficile Infection on Pregnancy and Neonatal Outcomes: An Observational Study

Abstract

Introduction: There are limited data on Clostridium difficile infection (CDI) in pregnancy.We did a retrospective study to identify the risk factors and management of CDI in pregnant women and assess the effect of CDI on pregnancy and neonatal outcomes. Methods: Cases were identified using diagnostic codes and confirmed by manual chart review. Cases with CDI within 12 weeks prior to pregnancy, throughout pregnancy, or during 6 weeks postpartum were included. Descriptive statistics were performed to evaluate outcomes. Results: Overall, 31 patients [median age 29 (IQR 26-32) years] were included. Commonest risk factors were outpatient or emergency room visit (90.0%) and antibiotic use (51.6%). Two patients had prior CDI. 22.6% (7) had CDI pre-pregnancy; 16.1% (5) in 1st trimester; 29% (9) in 2nd trimester; 19.3% (6) in 3rd trimester and 12.9% (4) postpartum. 67.7% (21) received metronidazole (MET) initially [4 pre-pregnancy, 15 while pregnant (3 in 1st, 7 in 2nd, 5 in 3rd trimester), 2 postpartum], 29.0% (9) vancomycin (VAN) standard regimen, and 3.2% (1) VAN taper. Treatment response data was available in 30; 14 needed change in treatment (11 were on MET, 2 on VAN, 1 on VAN taper): due to non-resolution of symptoms in 11, adverse events (AEs) in 3. Among those with AEs, 2 on MET switched to VAN, 1 on VAN switched to MET. Subsequent treatment for the rest: MET (2), VAN standard regimen (6), combination of both (1), VAN taper (1), fecal microbiota transplantation (FMT) (1). Overall, 23.3% (7/30) had adverse events (AEs); due to MET in 6, VAN in 4 (Figure 1). 6.8% (2/29) had treatment failure; 1 had FMT after fidaxomicin, 1 had colectomy. Two patients had complications from CDI [shock, sepsis, and colectomy (1); shock (1)]. 20.7% (6/29) had CDI recurrence; median 2 episodes (range 1-3).214_A Figure 1. Adverse events (AEs) experiencedDelivery outcomes were available in 26; 15.4% (4) aborted (3 with CDI preceding event, all treated with MET), 84.6% (22) had live births [59.0% vaginal; 40.9% cesarean]. Excluding post-partum CDI (4), 22.7% births were preterm, 9.0% post-term; 88.5% (23/26) had complications in pregnancy (Figure 2). Among neonates, 10.5% (2/19) were low birth weight; 10.5% (2/19) had macrosomia, 50% (7/14) had complications (3 respiratory distress; 4 hypoglycemia; 5 neonatal jaundice; 2 intrauterine growth restriction; 2 fever). None had AEs due to CDI treatment in mother.214_B Figure 2. Complications and outcomes in pregnancy, puerperium, and neonatal periodConclusion: Pregnant women with CDI have high rates of treatment failure and AEs, and higher rates of adverse outcomes when compared with national data.