What is the management of chorioamnionitis based on its grade stage?

Management of Chorioamnionitis

Chorioamnionitis does not have formal grade or stage classifications that guide management—instead, treatment is uniform once the clinical diagnosis is established, consisting of immediate broad-spectrum intrapartum antibiotics and expedited delivery regardless of gestational age. 1, 2

Clinical Diagnosis

Chorioamnionitis is diagnosed clinically based on:

• Maternal fever ≥100.4°F (38.0°C) PLUS at least one of the following 1, 2:
  • Maternal tachycardia
  • Fetal tachycardia
  • Uterine tenderness
  • Foul-smelling amniotic fluid
  • Maternal leukocytosis

Do not withhold antibiotics pending amniocentesis results or wait for additional fever development if clinical suspicion exists. 1

Immediate Antibiotic Management

First-Line Regimen

Initiate antibiotics within 3 hours of fever recognition (within 1 hour if septic shock suspected): 1

• Ampicillin: 2g IV initial dose, then 1g IV every 4 hours until delivery 1
• Gentamicin: Loading dose followed by weight-based maintenance dosing until delivery 1

Penicillin Allergy Alternatives

• Non-severe allergy: Cefazolin 2g IV initial dose, then 1g IV every 8 hours until delivery 1, 2
• Severe allergy: Clindamycin 900mg IV every 8 hours OR vancomycin 1g IV every 12 hours until delivery 1, 2

Cesarean Delivery Addition

Add clindamycin at umbilical cord clamping if cesarean delivery is performed to provide anaerobic coverage. 3

Postpartum Antibiotic Considerations

Additional postpartum antibiotics are generally not necessary after vaginal or cesarean delivery. 3 If prescribed, limit to a single additional dose rather than extended courses. 3

Delivery Management

Once chorioamnionitis is diagnosed, proceed with delivery regardless of gestational age: 3

• Vaginal delivery is the safer option and should be pursued when feasible 3, 4
• Cesarean section should be reserved for standard obstetric indications only 5, 3, 4
• The diagnosis-to-delivery interval is not related to most adverse maternal and neonatal outcomes, so do not rush to cesarean delivery 3, 6

Labor Augmentation Considerations

Patients with chorioamnionitis may require:

• Higher oxytocin doses to achieve adequate uterine activity 3
• Greater uterine activity to effect cervical dilation changes 3

Adjunctive Maternal Measures

• Obtain blood cultures before antibiotic administration when feasible 1
• Administer acetaminophen for fever control to maintain normothermia, as hyperthermia adversely impacts uterine contractility and may lower the threshold for fetal hypoxic brain injury 1

Antenatal Corticosteroids and Magnesium Sulfate

For gestational ages 24 0/7 to 33 6/7 weeks (possibly 23 0/7 to 23 6/7 weeks): 3

• Administer antenatal corticosteroids for fetal lung maturation despite chorioamnionitis diagnosis 3
• Administer magnesium sulfate for fetal neuroprotection 3
• Do not delay delivery to complete full courses of either medication 3

Neonatal Management

Well-Appearing Newborns

Perform limited evaluation and initiate empirical antibiotics pending culture results: 1, 2

• Blood culture 1, 2
• CBC with differential 1, 2
• Empirical antibiotic therapy (IV ampicillin for GBS and E. coli coverage) 1, 2

Newborns with Signs of Sepsis

Perform full diagnostic evaluation: 1

• Blood culture 1
• CBC with differential 1
• Chest radiograph if respiratory symptoms present 1
• Lumbar puncture if infant is stable 1
• Empirical IV ampicillin and additional agents active against E. coli 1

Common Pitfalls to Avoid

• Do not delay antibiotics waiting for confirmatory testing or additional clinical signs 1
• Do not perform cesarean delivery solely for chorioamnionitis diagnosis—this increases maternal morbidity without neonatal benefit 5, 3
• Recognize that epidural analgesia can cause fever, potentially leading to overdiagnosis, but err on the side of treatment when clinical suspicion exists 2
• Do not withhold corticosteroids or magnesium sulfate in preterm gestations due to chorioamnionitis diagnosis 3