Chorioamnionitis: ACOG Committee Opinion on Diagnosis and Management

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 additional risk factor such as
    • Fetal tachycardia
    • Maternal leukocytosis
    • Definite purulent fluid from the cervical os
  • No maternal fever but other associated clinical signs and symptoms are present
• 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

ACOG Clinical Practice Update: Criteria for Suspected Diagnosis 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

Maternal fever in labor: etiologies, consequences, and clinical management