What is the treatment for chorioamnionitis in a 28-week pregnant woman?

From the Guidelines

Chorioamnionitis at 28 weeks of pregnancy requires prompt treatment with intravenous broad-spectrum antibiotics, such as ampicillin 2g IV every 6 hours plus gentamicin 5mg/kg IV every 24 hours, and consideration of delivery. The treatment should begin immediately upon diagnosis and continue until at least 24-48 hours after delivery and resolution of maternal fever 1. Some providers add clindamycin 900mg IV every 8 hours if cesarean delivery is anticipated to provide additional anaerobic coverage. Antipyretics such as acetaminophen 650mg every 6 hours should be given for maternal fever. Corticosteroids (betamethasone 12mg IM, two doses 24 hours apart) should be administered to accelerate fetal lung maturity if not previously given. Magnesium sulfate for neuroprotection should be considered with a 4-6g loading dose followed by 1-2g/hour maintenance. Close maternal and fetal monitoring is essential, including vital signs every 2-4 hours, continuous fetal heart rate monitoring, and laboratory tests (complete blood count, C-reactive protein) 1.

Key considerations in the management of chorioamnionitis include:

• Prompt initiation of broad-spectrum antibiotics
• Consideration of delivery regardless of gestational age
• Administration of antipyretics and corticosteroids as needed
• Close monitoring of maternal and fetal status
• Potential addition of clindamycin for anaerobic coverage in cases of cesarean delivery

The diagnosis of chorioamnionitis is typically made clinically, based on signs and symptoms such as fever, uterine tenderness, fetal tachycardia, maternal tachycardia, and foul-smelling or purulent amniotic fluid 1. Intrapartum treatment of chorioamnionitis can prevent neonatal sepsis, and the diagnosis of chorioamnionitis is an important risk factor for early-onset GBS disease in women with GBS colonization 1.

In terms of specific antibiotic regimens, the choice of antibiotics may depend on various factors, including the presence of any maternal allergies or resistance patterns. However, the recommended regimen of ampicillin and gentamicin is generally considered effective for the treatment of chorioamnionitis 1.

Overall, the management of chorioamnionitis at 28 weeks of pregnancy requires a prompt and aggressive approach to prevent maternal and neonatal complications.

From the Research

Treatment of Chorioamnionitis in 28-Week Pregnant Women

• The treatment of chorioamnionitis in pregnant women, including those at 28 weeks of gestation, typically involves the administration of antibiotics to prevent further complications for both the mother and the fetus 2.
• The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period 2.
• In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping 2.
• Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant 2.
• Delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate, and once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age 2.

Antibiotic Regimens

• A review of antibiotic regimens for the management of intra-amniotic infection found that the quality of the evidence was low to very low for most outcomes, and limited evidence is available to reveal the most appropriate antimicrobial regimen for the treatment of patients with intra-amniotic infection 3.
• A study comparing daily gentamicin with 8-hour gentamicin for the treatment of intrapartum chorioamnionitis found that daily gentamicin appears to be as effective as 8-hour gentamicin for the treatment of intrapartum chorioamnionitis 4.
• A retrospective review of patients treated for chorioamnionitis found that a limited course of antibiotics was sufficient for virtually all patients (99%) with chorioamnionitis who had a vaginal delivery, but a subset of patients who delivered by cesarean may have benefited from a more extended course of antibiotic therapy 5.

Implications for Practice

• Clinical chorioamnionitis requires a high index of suspicion, timely diagnosis, prompt antibiotic treatment, and delivery, which may help reduce the potentially devastating outcome of maternal and neonatal infections 6.
• The clinical criteria for chorioamnionitis include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid 6.
• Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications 2.