What is the recommended management, including antibiotic therapy and delivery approach, for a pregnant woman with suspected chorioamnionitis (fever ≥38 °C, maternal leukocytosis, uterine tenderness, fetal tachycardia)?

Management of Chorioamnionitis

Immediate Actions

Start broad-spectrum intravenous antibiotics immediately upon clinical diagnosis and proceed to delivery without delay—chorioamnionitis cannot be cured by antibiotics alone and maternal sepsis can progress to death within 18 hours. 1

Antibiotic Regimen

• Administer ampicillin 2g IV initial dose, then 1g IV every 4 hours until delivery, combined with gentamicin (loading dose followed by weight-based maintenance dosing). 1, 2 This regimen covers the polymicrobial nature of intraamniotic infection. 1

• For non-severe penicillin allergies: Use cefazolin 2g IV initial dose, then 1g IV every 8 hours until delivery. 1, 2

• For severe penicillin allergies: Use clindamycin 900mg IV every 8 hours or vancomycin 1g IV every 12 hours until delivery. 1, 2

• If cesarean delivery is performed: Add clindamycin at the time of umbilical cord clamping. 3

Critical Timing Considerations

• Do not wait for maternal fever to initiate treatment—chorioamnionitis can present without fever, especially at earlier gestational ages, and treatment should begin with any sign of infection (maternal tachycardia, purulent discharge, uterine tenderness). 1

• Do not delay antibiotics for amniocentesis results—clinical management proceeds based on bedside assessment. 1

• Initiate antibiotics within 3 hours of fever recognition, or within 1 hour if septic shock is suspected. 1

Delivery Approach

Proceed to delivery once antibiotics are started, regardless of gestational age. 1, 3 The time interval between diagnosis and delivery is not related to most adverse maternal and neonatal outcomes. 3

Route of Delivery

• Vaginal delivery is the safer option—the route is dictated by standard obstetric indications, not by the infection itself. 1, 3

• Cesarean delivery offers no fetal advantage and may increase maternal morbidity. 1

• Reserve cesarean delivery for standard obstetric indications only. 1, 4

Labor Management Considerations

• Patients may require higher doses of oxytocin to achieve adequate uterine activity. 3

• Maintain normothermia with antipyretics (acetaminophen), as hyperthermia adversely impacts uterine contractility and may lower the threshold for fetal hypoxic brain injury. 1

Neonatal Management

Well-Appearing Newborns

Obtain limited evaluation (blood culture and CBC with differential) and begin empirical IV antibiotics (ampicillin for GBS coverage plus an agent active against E. coli). 1, 2

• CBC sensitivity improves when sampled 6–12 hours after birth, but antibiotic therapy must not be delayed awaiting results. 1

• Discontinue empirical antibiotics once clinical course and laboratory data exclude sepsis. 1

Newborns with Any Sign of Sepsis

Perform full diagnostic work-up immediately: 1, 5

• Blood culture
• CBC with differential
• Chest radiograph if respiratory symptoms present
• Lumbar puncture if infant is stable (blood cultures can be sterile in 15–33% of newborns with meningitis) 5

Start empirical broad-spectrum antibiotics immediately with IV ampicillin plus gentamicin or cefotaxime for gram-negative coverage. 1, 5

Special Populations

Preterm Gestations (24–34 weeks)

• Administer antenatal corticosteroids for fetal lung maturation and magnesium sulfate for fetal neuroprotection between 24 0/7 and 33 6/7 weeks, and possibly 23 0/7 to 23 6/7 weeks—overall beneficial effect on the infant. 3

• Do not delay delivery to complete the full course of corticosteroids or magnesium sulfate. 3

Preterm Premature Rupture of Membranes (PPROM)

• Maintain high clinical suspicion—intraamniotic infection occurs in 58.1% of PPROM cases managed expectantly. 1

Common Pitfalls to Avoid

• Do not be falsely reassured by negative maternal GBS screening—more than 60% of early-onset GBS cases occur in infants born to women with negative prenatal cultures at 35–37 weeks. 5

• Do not withhold antibiotics pending amniocentesis results or wait for maternal fever to develop. 1

• Do not assume intrapartum antibiotics mask or delay clinical presentation of neonatal sepsis—signs will still appear within the first 24 hours in most cases. 5

• Epidural analgesia can cause fever and potentially lead to overdiagnosis, but true chorioamnionitis remains a serious condition requiring treatment. 2

Postpartum Antibiotic Management

Additional postdelivery antibiotics are generally not necessary after vaginal or cesarean delivery. 3 If prescribed, there is support for administering one additional dose. 3