Evaluation and Management of Ruptured Membranes with Amnionitis at Term
6/1/2018 - Katie Shvartsman, MD
Mentor: Paula J. Hilliard, MD
Editor: Julie DeCesare, MD
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 contributing 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 without a clear source AND at least one of the following: 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 patients with an isolated fever of 39o C or greater be included to increase sensitivity and optimize outcomes. Fundal tenderness and maternal tachycardia are no longer supported as these features may be altered by labor and anesthesia. IAI can be confirmed after delivery by placental pathology or culture.
Isolated fever between 38oC and 39oC 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). 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 Clindamycin or Vancomycin and Gentamycin are recommended. Alternative regiments include Ampicillin-sulbactam or Piperacillin-tazobactam. Appropriate hydration and antipyretics should also be given. Labor should be actively managed following standard guidelines. Amnionitis is not an indication for immediate cesarean. The decision to proceed with cesarean delivery should be based on obstetric indications.
There is little data to guide management of isolated maternal fever in the absence of other clinical signs suggesting a source. Maternal fever has been associated with poor neonatal outcomes, therefore it is prudent to consider antimicrobial therapy. Regardless of whether or not antibiotics are initiated, it is essential to notify the pediatric care team, 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 risk for developing endometritis. Antibiotics are not required after vaginal delivery as risk of endometritis is low. Women 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.
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
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