What is the treatment for chorioamnionitis?

Treatment of Chorioamnionitis

For chorioamnionitis, prompt administration of broad-spectrum intravenous antibiotics is essential and should be initiated immediately upon diagnosis, followed by delivery of the fetus regardless of gestational age. 1

Diagnosis

Chorioamnionitis is typically diagnosed clinically based on:

• Maternal fever (≥100.4°F/38.0°C) plus at least one of the following 2, 3:
  • Maternal tachycardia
  • Fetal tachycardia
  • Uterine tenderness
  • Foul-smelling amniotic fluid
  • Maternal leukocytosis

Maternal Treatment Algorithm

First-line Antibiotic Regimen

• Intrapartum antibiotics should be initiated promptly upon diagnosis 1:
  • Ampicillin (2g IV initial dose, then 1g IV every 4 hours until delivery) PLUS
  • Gentamicin (loading dose followed by maintenance dosing based on weight)

For Penicillin-Allergic Patients

• For patients with non-severe allergies:
  • Cefazolin (2g IV initial dose, then 1g IV every 8 hours until delivery) 2
• For patients with severe allergies (anaphylaxis, angioedema):
  • Clindamycin (900 mg IV every 8 hours until delivery) OR
  • Vancomycin (1g IV every 12 hours until delivery) 2

Additional Considerations for Cesarean Delivery

• Add clindamycin at the time of umbilical cord clamping to provide anaerobic coverage 1
• Consider vaginal cleansing with antiseptic solutions before cesarean delivery to reduce risk of endometritis 1

Postpartum Antibiotics

• After vaginal delivery: Additional antibiotics are generally not necessary 1
• After cesarean delivery: Consider one additional dose of antibiotics 1

Delivery Considerations

• Once chorioamnionitis is diagnosed, delivery should be initiated regardless of gestational age 1
• Vaginal delivery is preferred when feasible 1
• Cesarean delivery should be reserved for standard obstetrical indications 1, 4
• Higher doses of oxytocin may be required to achieve adequate uterine activity 1
• No critical time interval between diagnosis and delivery has been identified that significantly impacts neonatal infectious morbidity (within 0-10 hours) 5

Neonatal Management

• All newborns with signs of sepsis should receive:

  • Full diagnostic evaluation (blood culture, CBC with differential, chest radiograph if respiratory symptoms, and lumbar puncture if stable) 2
  • Empirical antibiotic therapy including agents active against GBS (IV ampicillin) and E. coli 2

• Well-appearing newborns whose mothers had chorioamnionitis should receive:

  • Limited evaluation (blood culture and CBC with differential) 2, 6
  • Empirical antibiotic therapy pending culture results 2
  • Consultation with obstetric providers to confirm chorioamnionitis diagnosis 2

Special Considerations

• For preterm pregnancies (24-33 6/7 weeks), consider:
  • Administration of antenatal corticosteroids for fetal lung maturation 1
  • Magnesium sulfate for fetal neuroprotection 1
  • However, delivery should not be delayed to complete the full course of these medications 1

Common Pitfalls and Caveats

• Isolated maternal fever does not automatically equate to chorioamnionitis 7
• Epidural analgesia can cause maternal fever and may lead to overdiagnosis of chorioamnionitis 2
• The sensitivity of neonatal CBC is lowest immediately after birth and improves if delayed for 6-12 hours 2
• Clinical signs of sepsis are more sensitive indicators of neonatal sepsis than hematologic tests 2
• Empirical antibiotic therapy in neonates should be discontinued as soon as clinical course and laboratory evaluation exclude sepsis 2