What is the management of chorioamnionitis before delivery?

Management of Chorioamnionitis Before Delivery

For women diagnosed with chorioamnionitis before delivery, prompt initiation of broad-spectrum intravenous antibiotics and consideration of delivery are the cornerstones of management. 1, 2

Antibiotic Therapy

• First-line antimicrobial regimen consists of ampicillin (2g IV every 6 hours) plus gentamicin (1.5 mg/kg IV every 8 hours), which should be initiated immediately upon diagnosis of chorioamnionitis 1, 2
• For penicillin-allergic patients without history of anaphylaxis, angioedema, respiratory distress, or urticaria, cefazolin is the preferred agent 3
• For penicillin-allergic patients with history of severe allergic reactions, alternative regimens such as clindamycin or vancomycin should be considered 4, 3
• Daily dosing of gentamicin may be preferable to three-times-daily dosing for greater efficacy and decreased fetal toxicity 5

Delivery Considerations

• Once chorioamnionitis is diagnosed, delivery should be considered regardless of gestational age 1
• Vaginal delivery is the preferred route and cesarean delivery should be reserved for standard obstetrical indications 1, 5
• The time interval between diagnosis of chorioamnionitis and delivery is not significantly related to most adverse maternal and neonatal outcomes 1
• Patients with chorioamnionitis may require higher doses of oxytocin to achieve adequate uterine activity 1

Special Considerations for Preterm Pregnancies

• For women with chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation (and possibly between 23 0/7 and 23 6/7 weeks), administration of antenatal corticosteroids for fetal lung maturation and magnesium sulfate for fetal neuroprotection has overall beneficial effects 1
• However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate 1

Intrapartum Antibiotic Prophylaxis (IAP) Considerations

• Chorioamnionitis is a significant risk factor for early-onset Group B Streptococcal (GBS) sepsis in infants 3
• If GBS status is unknown with intrapartum risk factors (including temperature of 100.4°F/38.0°C), IAP is indicated 3
• For women receiving IAP, penicillin is preferred, with ampicillin or cefazolin as alternatives 3

Postpartum Management

• If cesarean delivery is performed, clindamycin (900 mg IV) should be administered at the time of umbilical cord clamping 1, 6
• Evidence suggests that after vaginal delivery, only one additional dose of antibiotics postpartum is sufficient therapy for immunocompetent women with chorioamnionitis 6
• For cesarean delivery, continuing antibiotics until the patient is afebrile and asymptomatic for 24 hours has been traditional practice, though shorter courses may be adequate 7, 6

Neonatal Implications

• All well-appearing newborn infants born to women diagnosed with chorioamnionitis should undergo a "limited evaluation" including blood culture and complete blood count with differential and platelet count 3, 8
• Empirical antimicrobial therapy should be initiated for these neonates pending culture results 8, 4
• The sensitivity of the CBC count is improved if delayed for 6-12 hours after birth 3

Monitoring During Management

• Continuous electronic fetal heart rate monitoring should be used, though its benefit in these patients is not clearly established 1
• Maternal vital signs should be monitored closely for signs of sepsis or clinical deterioration 2
• Antipyretic agents, mainly acetaminophen, may be administered for maternal comfort, though evidence for their benefits is limited 1

Pitfalls and Caveats

• Chorioamnionitis cannot be cured by antibiotic therapy alone without delivery 2
• Broader spectrum agents might be necessary in certain clinical scenarios based on local antimicrobial resistance patterns 4, 2
• Consultation with obstetric providers is important to determine the level of clinical suspicion for chorioamnionitis, as some signs are nonspecific 3
• Local antimicrobial resistance patterns, maternal allergies, and drug availability should be considered when selecting antibiotic regimens 2