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6/1/2018

Evaluation and Management of Ruptured Membranes with Amnionitis at Term

Intraamniotic infection (IAI), or chorioamnionitis, is an inflammatory or infectious disorder involving any combination of amniotic fluid, placenta, fetus, fetal membranes, or decidua.   IAI complicates approximately 2-5% of term deliveries and is often a polymicrobial infection ascending from the lower genital tract. 

The greatest risk factor for developing IAI is prolonged labor with ruptured membranes.  Other associated factors include multiple vaginal exams, meconium, group B streptococcus, and sexually transmitted infections.

Potential maternal consequences of IAI include dysfunctional labor, postpartum hemorrhage due to atony, postpartum endometritis, sepsis, and rarely death.  Affected neonates can develop serious sequelae such as cerebral palsy in addition to other multiorgan diseases including  necrotizing enterocolitis, respiratory distress syndrome, bronchopulmonary dysplasia, thymic involution, cardiac concentric hypertrophy and retinopathy of prematurity.

A high index of suspicion and surveillance for IAI is essential to ensure timely initiation of appropriate medical treatment.  IAI should be suspected in the setting of maternal fever 38-38.9  °C without a clear source AND at least one of the following clinical findings:

• baseline fetal tachycardia (>160 bpm for at least 10 min)
• maternal leukocytosis (>15,000 per mm2 in the absence of corticosteroids)
• purulent cervical discharge.

Fundal tenderness and maternal tachycardia are no longer considered among diagnostic criteria. IAI can be confirmed after delivery by placental pathology findings of chorioamnionitis and/or growth of bacteria in culture.

Isolated maternal fever between 38°C and 39°C warrants an evaluation for extra-uterine infections (e.g. pyelonephritis or pneumonia), as well as for non-infectious causes (e.g. epidural anesthesia, dehydration, and prostaglandin induction agents).

Once IAI is diagnosed, IV antibiotic therapy is recommended.  Ampicillin and gentamicin are standard treatment for IAI to decrease the risk of neonatal sepsis and maternal morbidity.  In patients with a mild penicillin allergy, cefazolin and gentamicin are recommended and in patients with a severe penicillin allergy gentamycin and either clindamycin or vancomycin are recommended. Alternative regimens include piperacillin-tazobactam.  

IAI alone is not an indication for immediate cesarean delivery, and labor should be actively managed following standard guidelines to expedite delivery.  The decision to proceed with cesarean delivery should be based on additional maternal or fetal indications.

In tandem with antibiotic therapy, it is essential to notify the pediatric care team of the maternal fever, as this greatly impacts the evaluation and treatment of the neonate following delivery, who will make necessary preparations for any additional laboratory analysis, antimicrobial treatment, and other potential treatments required in the intensive care unit setting. 

Maternal postpartum management should be individualized based on route of delivery. Limited dosing of antibiotics is acceptable following vaginal deliveries, wherein patients receive only one additional dose of antibiotics after delivery is complete.  Patients undergoing cesarean deliveries, however, benefit from continuation of intrapartum antibiotics, with the addition of clindamycin at time of surgery, for at least 24 hours after delivery to prevent development of postpartum endometritis. Duration of therapy and antimicrobial regimen beyond these recommendations should be based upon clinical risk factors including persistent maternal fever and bacteremia. 

Further Reading:

Committee on Obstetric Practice. Committee Opinion No. 712: Intrapartum Management of Intraamniotic Infection. Obstet Gynecol. 2017 Aug;130(2):e95-e101. doi: 10.1097/AOG.0000000000002236.

Higgins RD, Saade G, Polin RA, et al. Evaluation and Management of Women and Newborns with a Maternal Diagnosis of Chorioamnionitis: Summary of a Workshop. Obstet Gynecol. 2016 Mar;127(3):426-36. doi: 10.1097/AOG.0000000000001246.

Martingano D, Renson A, Rogoff S, Singh S, et al. Daily gentamicin using ideal body weight demonstrates lower risk of postpartum endometritis and increased chance of successful outcome compared with traditional 8-hour dosing for the treatment of intrapartum chorioamnionitis. J Matern Fetal Neonatal Med. 2019 Oct;32(19):3204-3208. doi: 10.1080/14767058.2018.1460348. Epub 2018 Apr 12. PMID: 29642754.

Hood K, Ulfers A, Mersch M, Martingano D et al. Limited Postpartum Versus 24-Hour Antibiotic Dosing Regimens Following Intrapartum Chorioamnionitis. Obstetrics & Gynecology. 2020 May 1;135:11S.

 

Initial approval March 2018; Revised November 2019; Revised July 2021. Minor Revision March 2023.Revised January 2025.

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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