Chorioamnionitis
Background
- Also known as intra-amniotic infection[1]
- Bacterial infection of fetal amnion and chorion membranes
- Most commonly an ascending infection from normal vaginal flora
Risk Factors
- Young age
- Low socioeconomic status
- Multiple vaginal examinations
- Nulliparity
- Extended duration of labor and ruptured membranes
- Pre-existing genital tract infections
Microbiology
- Polymicrobial
- Genital mycoplasmas, anaerobes, enteric gram-negative bacilli and group B strep
Clinical Features
Signs and Symptoms
- Maternal fever (intra-partum temperature >100.4 °F or >37.8 °C)[2]
- Significant maternal tachycardia (>120 beats/min)
- Fetal tachycardia (>160-180 beats/min)
- Purulent or foul-smelling amniotic fluid or vaginal discharge
- Uterine tenderness
- Maternal leukocytosis (total blood leukocyte count >15,000-18,000 cell/µL)
Presentation
- Severity of presentation is broad. Patient may appear toxic or may have silent chorioamnionitis, which still puts fetus at risk for neonatal sepsis.
Differential Diagnosis
<20 Weeks
- Ectopic pregnancy
- First trimester abortion
- Complete abortion
- Threatened abortion
- Inevitable abortion
- Incomplete abortion
- Missed abortion
- Septic abortion
- Round ligament stretching
- Incarcerated uterus
- Malposition of the uterus
>20 Weeks
- Labor/Preterm labor
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Vaginal trauma
- HELLP syndrome
- Cholestasis of pregnancy
- Chorioamnionitis
- Incarcerated uterus
- Acute fatty liver of pregnancy
- Malposition of the uterus
- Placenta accreta
- Placenta increta
- Placenta percreta
Any time
- Hemorrhagic ovarian cyst
- Fibroid degeneration or torsion
- Ovarian torsion
- Constipation
- Extra-amniotic infections such as pyelonephritis, appendicitis, pneumonia
Workup
- CBC
- Blood cultures
- Vaginal fluid for phosphatidylglycerol
- Tests for fetal lung maturity
- Cervical cultures
- Vaginal cultures
- Ultrasonography for fetal well-being
Exam
- Avoid digital cervical exam
- Speculum exam should be done with sterile speculum
Management
- Ampicillin IV 2g Q6H AND Gentamicin IV 1.5mg/kg Q8H[3]
- Alternative antibiotic regimens:
- Ampicillin-sulbactam IV 2g Q6H
- Ticarcillin-clavulanate IV 3.1g Q4H
- Cefoxitin IV 2g Q4H
- Can only be considered cured with delivery of infected products of conception
- After delivery, treat like postpartum endometritis with clindamycin plus gentamycin
Disposition
Given concern for neonatal sepsis, patients should be admitted for IV antibiotics, supportive care, and possible early delivery[4]
Complications
- Placental abruption
- Premature birth
- Neonatal sepsis
- Neonatal death
- Cerebral palsy
- Maternal sepsis
- Need for cesarean delivery
- Postpartum hemorrhage
See Also
External Links
References
- Abbrescia K, Sheridan B. Complications of second and third trimester pregnancies. Emerg Med Clin N Am 21 (2003): 695-710.
- Apantaku O, Mulik V. Maternal intra-partum fever. J Obstet Gynaecol. 2007 Jan; 27(1):12-5.
- Snyder M. et al. Clinical inquiries. What treatment approach to intrapartum maternal fever has the best fetal outcomes?. J Fam Pract. May 2007;56(5):401-2
- Driscoll SG. Chorioamnionitis: perinatal morbidity and mortality. Pediatr Infect Dis. 1986;5
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