Back to Search Results

6/1/2018

Evaluation and Management of Ruptured Membranes with Amnionitis at Term

Intraamniotic infection (IAI), or amnionitis, is an inflammatory or infectious disorder involving any combination of amniotic fluid, placenta, fetus, fetal membranes, or decidua.   IAI complicates approximately 2-5% of term deliveries and is often a polymicrobial infection ascending from the lower genital tract. 

The greatest risk factor for developing IAI is prolonged labor with ruptured membranes.  Other associated factors include multiple vaginal exams, meconium, group B streptococcus, and sexually transmitted infections.

Potential maternal consequences of IAI include dysfunctional labor, postpartum hemorrhage due to atony, endometritis, sepsis, and rarely death.   Neonates can suffer acute events such as pneumonia, meningitis, sepsis, and death, as well as long-term sequelae of bronchopulmonary dysplasia and cerebral palsy. 

Establishing concern for IAI is key to initiating appropriate treatment and minimizing adverse outcomes.  IAI should be suspected in the setting of maternal fever 38-38.9 C without a clear source AND at least one of the following clinical findings: baseline fetal tachycardia (>160 bpm for at least 10 min), maternal leukocytosis (>15,000 per mm2 in the absence of corticosteroids), and purulent cervical discharge.  Additionally, ACOG recommends that IAI be suspected in patients with an isolated fever of 39 C or greater.   Fundal tenderness and maternal tachycardia are no longer considered among diagnostic criteria as these features may be altered by labor and analgesia or anesthesia.  IAI can be confirmed after delivery by placental pathology findings of chorioamnionitis or growth of bacteria in culture.

Isolated fever between 38C and 39C warrants an evaluation for extra-uterine infections (e.g. pyelonephritis or pneumonia), as well as for non-infectious causes (e.g. epidural anesthesia, dehydration, and prostaglandin induction agents).   Once IAI is preliminarily diagnosed, antibiotic therapy is recommended.  Antibiotics should be considered in the setting of isolated maternal fever unless another source is identified.  Ampicillin and gentamicin are standard treatment for IAI to decrease the risk of neonatal sepsis and maternal morbidity.  In patients with a mild penicillin allergy, cefazolin and gentamicin are recommended and in patients with a severe penicillin allergy gentamycin and either clindamycin or vancomycin are recommended. Alternative regimens include ampicillin-sulbactam or piperacillin-tazobactam.   Appropriate hydration and antipyretics should also be given.  Amnionitis alone is not an indication for immediate cesarean, and labor should be actively managed following standard guidelines.  The decision to proceed with cesarean delivery should be based on maternal or fetal indications.

Regardless of whether or not antibiotics are initiated, it is essential to notify the pediatric care team of the maternal fever, as this greatly impacts the evaluation and treatment of the neonate, who may warrant additional laboratory analysis, antimicrobial treatment, and hospitalization in the intensive care unit. 

Postpartum management should be individualized based on route of delivery. Continuation of antibiotics is not required after vaginal delivery, as risk of endometritis is low.  Patient’s undergoing cesarean should receive at least one additional dose of the antimicrobial therapy they received intra-partum, with the addition of clindamycin or metronidazole to cover intraabdominal anaerobes.  Duration of therapy and antimicrobial regimen should be based upon clinical risk factors including persistent maternal fever and bacteremia. 

Further Reading:

Committee on Obstetric Practice. Committee Opinion No. 712: Intrapartum Management of Intraamniotic Infection. Obstet Gynecol. 2017 Aug;130(2):e95-e101. doi: 10.1097/AOG.0000000000002236.

Higgins RD, Saade G, Polin RA, et al. Evaluation and Management of Women and Newborns with a Maternal Diagnosis of Chorioamnionitis: Summary of a Workshop. Obstet Gynecol. 2016 Mar;127(3):426-36. doi: 10.1097/AOG.0000000000001246.

Initial approval March 2018; Revised November 2019; Revised July 2021. Minor Revision March 2023.

 

********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2023 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved. No re-print, duplication or posting allowed without prior written consent.

 

Back to Search Results