What is the recommended treatment for a pregnant woman suspected of having chorioamnionitis?

Treatment of Suspected Chorioamnionitis in Pregnancy

For a pregnant woman with suspected chorioamnionitis, immediately initiate intravenous ampicillin plus gentamicin, proceed with delivery regardless of gestational age, and add clindamycin at cord clamping if cesarean delivery is performed. 1, 2

Antibiotic Regimen

First-Line Treatment

• Ampicillin combined with gentamicin is the standard first-line regimen and should be started immediately upon diagnosis during the intrapartum period 1, 2, 3
• Gentamicin should be dosed once daily rather than three times daily for greater efficacy and decreased fetal toxicity 2
• This regimen provides broad-spectrum coverage against Group B Streptococcus and Escherichia coli, the most commonly isolated organisms 4

Cesarean Delivery Modification

• Add clindamycin at the time of umbilical cord clamping if cesarean delivery is performed to reduce postoperative infectious morbidity 1
• This additional anaerobic coverage is critical given the increased risk of endometritis following cesarean section in the setting of chorioamnionitis 1

Penicillin Allergy Alternatives

• For patients without history of anaphylaxis, angioedema, respiratory distress, or urticaria: use cefazolin as the preferred agent 5, 4
• For patients with severe penicillin allergy history: use clindamycin or vancomycin 5, 4
• Broader spectrum agents may be necessary in certain clinical scenarios 5

Delivery Management

Timing and Route

• Delivery should be pursued immediately once chorioamnionitis is diagnosed, regardless of gestational age 1, 3
• Do not delay delivery to complete corticosteroids or magnesium sulfate courses 1
• Vaginal delivery is the safer option; reserve cesarean delivery for standard obstetric indications only 1, 2, 6
• The time interval between diagnosis and delivery is not related to most adverse maternal and neonatal outcomes 1

Labor Considerations

• Patients may require higher doses of oxytocin to achieve adequate uterine activity 1
• Greater uterine activity may be needed to effect cervical dilation changes 1
• Over 90% of patients can be delivered within 12 hours of diagnosis 6

Postpartum Antibiotic Management

• Additional antibiotic therapy after delivery does not appear necessary following vaginal or cesarean delivery 1
• If postdelivery antibiotics are prescribed, there is support for administering one additional dose 1

Adjunctive Therapies

Antipyretics

• Acetaminophen may be administered, though clear evidence of benefit is lacking 1

Antenatal Corticosteroids and Magnesium Sulfate

• Administer antenatal corticosteroids for fetal lung maturation between 24 0/7 and 33 6/7 weeks gestation (possibly 23 0/7 to 23 6/7 weeks) despite chorioamnionitis diagnosis 1
• Administer magnesium sulfate for fetal neuroprotection in the same gestational age range 1
• Current evidence suggests overall beneficial effects on the infant outweigh theoretical risks 1
• However, do not delay delivery to complete these courses 1

Neonatal Implications

Immediate Neonatal Management

• All well-appearing newborns born to mothers with suspected chorioamnionitis should undergo a limited evaluation: blood culture and CBC with differential and platelet count 5, 4, 7
• Delay the CBC for 6-12 hours after birth to improve sensitivity 5, 4
• Initiate antibiotic therapy pending culture results with intravenous ampicillin for GBS plus coverage for E. coli and other gram-negative pathogens 4

Important Caveats

• Consultation with obstetric providers is important as chorioamnionitis is diagnosed clinically and some signs are nonspecific 8, 7
• The diagnosis requires maternal fever plus at least one additional criterion: maternal or fetal tachycardia, maternal leukocytosis, uterine tenderness, or foul amniotic fluid odor 2
• Maternal outcome is usually good following vaginal delivery but more complicated following cesarean delivery 6