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OB
CMECNE

Chorioamnionitis: ACOG Committee Opinion on Diagnosis and Management

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Recall the three categories in the ACOG guideline on intraamniotic infection
2. Select the correct post delivery antibiotic

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

The NICHD conducted a workshop in January 2015 to review evidence, with special consideration to avoid unnecessary treatment with antimicrobials and imprecise terminology. ACOG released a committee opinion, endorsed by SMFM, that agrees with 3 categories proposed by the workshop but differs regarding a single temperature of 39.0˚C.  While the workshop included this finding under ‘isolated maternal fever’, ACOG recommends that a single temperature of 39.0˚C be placed in the ‘suspected intraamniotic infection’ category to maximize sensitivity.

Categories

  • Isolated maternal fever
    • Between 38.0˚C and 38.9˚C
    • With or without persistent temperature elavation
    • no other clinical criteria indicating intraamniotic infection
  • Suspected intraamniotic infection
    • Fever of 39.0˚C or greater on any one occasion
    • Fever between 38.0˚C and 38.9˚C and at least one of the following clinical findings
      • Fetal tachycardia
      • Maternal leukocytosis
      • Definite purulent fluid from the cervical os
  • Confirmed intraamniotic infection
    • Amniocentesis-proven infection through
      • Positive Gram stain, low glucose or positive amniotic fluid (AF) culture
    • Placental pathology revealing infection and/or inflammation of placenta, fetal membranes or cord (funisitis)

SYNOPSIS:

Intrauterine infection can have serious complications and include sepsis, prolonged labor, PPH, hysterectomy, endometritis, ICU admission and rarely maternal mortality. Communication with neonatology team is essential. The workshop determined that research is needed in almost all aspects, including biomarkers in AF and maternal and cord blood to aid in diagnosis and treatment.

KEY POINTS:

Overall Management

  • Intraamniotic infection alone is rarely if ever a reason for immediate cesarean section
    • However, progress of labor should be monitored
    • Augmentation of protracted labor “appears prudent”
    • Base route of delivery on standard obstetric indications
  • Antibiotics and antipyretics should be administered for suspected or confirmed intraamniotic infection
  • Isolated maternal fever may be caused by epidural anesthesia, prostaglandin use, dehydration, hyperthyroidism or excess ambient heat
    • Antibiotics should be considered unless a secondary cause is apparent
    • Monitor closely for additional signs and/or symptoms of infection
  • Postcesarean delivery: One additional dose of chosen antibiotic regimen is indicated
    • Recommended antibiotics: One additional dose is indicated
      • Add clindamycin 900 mg IV or metronidazole 500 mg IV for at least one additional dose
    • Alternative antibiotic regimen: One additional dose is indicated
      • Additional clindamycin is not required
  • Postvaginal delivery: No additional doses required
    • If given, additional clindamycin is not required
  • Consider other risk factors for postpartum endometritis such as bacteremia or persistent fever when deciding whether to continue antibiotics post delivery
    • Women who delivery vaginally are at a lower risk for endometritis
  • Use vancomycin if the patient is colonized with group B strep that is resistant to clindamycin or erythromycin or if colonized and antibiotic sensitivities are unavailable

Recommended Antibiotics

Recommended

  • Ampicillin 2 g IV q6hr

and

  • Gentamicin
    • 2 mg/kg IV load followed by 1.5 mg/kg q8hr or
    • 5 mg/kg IV q24hr

Mild Penicillin Allergy

  • Cefazolin 2 g IV q8hr

and

  • Gentamicin
    • 2 mg/kg IV load followed by 1.5 mg/kg q8hr or
    • 5 mg/kg IV q24hr

Severe Penicillin Allergy

  • Clindamycin 900 mg IV q8hr or Vancomycin 1 g IV q12 hours

and

  • Gentamicin
    • 2 mg/kg IV load followed by 1.5 mg/kg q8hr or
    • 5 mg/kg IV q24hr

Alternative Regimens

  • Ampicillin-sulbactam 3 g IV q6hr
  • Piperacillin-tazobactam 3.375 g IV q6hr or 4.5 g IV q8hr
  • Cefotetan 2 g IV q12hr
  • Cefoxitin 2 g IV q8hr
  • Ertapenem 1 g IV q24hr

Learn More – Primary Sources:

ACOG Committee Opinion 712: Intrapartum Management of Intraamniotic Infection

Evaluation and Management of Women and Newborns With a Maternal Diagnosis of Chorioamnionitis: Summary of a Workshop

Current Management and Long-term Outcomes Following Chorioamnionitis

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Related ObG Topics:

Updated Guidance on GBS Screening and Prophylaxis
‘Chorioamnionitis or Triple I’ – How Valid is the NICHD Guideline for the Diagnosis of Intrauterine Infection?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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