Chorioamnionitis

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Chapter 204 Chorioamnionitis

INTRODUCTION

Description: Chorioamnionitis is inflammation of the fetal membranes. This may be associated with prolonged or premature rupture of the membranes or a primary cause of premature labor.
Prevalence: 50% of premature deliveries.
Predominant age: Reproductive.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Infection by organisms ascending from the vaginal canal, most often when the membranes have been ruptured. Studies indicate that bacteria (specifically Escherichia coli) can permeate intact chorioamnionic membranes. Infection may also occur by hematogenous, transabdominal, or transfallopian routes.
Risk factors: Prolonged rupture of the membranes, frequent pelvic examinations, bacterial or trichomonas vaginitis, vaginal or cervical infection with Chlamydia trachomatis, smoking, anemia, vaginal bleeding.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• May be asymptomatic
• Fever (>100.5°F, 38°C)
• Tachycardia (maternal and fetal)
• Uterine irritability and tenderness
• May result in premature rupture of the membranes or preterm labor
• Maternal signs of infection (elevated white blood count and sedimentation rate)
• Purulent cervical discharge (late)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Placental abruption
• Intra-abdominal infection (e.g., appendicitis)
• Pyelonephritis
• Pneumonia
• Pulmonary embolism
• Wound infection (episiotomy, abdominal incision following cesarean delivery or tubal ligation)
• Breast engorgement
• Drug fever

Associated Conditions: Endometritis, fetal infections (pneumonia, skin infections), and oligohydramnios have been linked to clinical chorioamnionitis. Dysfunctional labor and postpartum hemorrhage are more common. Cerebral palsy has been linked to intrauterine infection.

Workup and Evaluation

Laboratory: White blood count and red cell sedimentation rate. Gram stain of amniotic fluid (a negative test carries a 99% specificity). Cultures may be obtained and may be of assistance in management, but the diagnosis is often made on clinical grounds. (Amniocentesis for culture has not been shown to improve pregnancy outcome. There is no clear evidence to support the use of C-reactive protein for the early diagnosis of chorioamnionitis.)
Imaging: No imaging indicated.
Special Tests: A biophysical profile of the fetus may be of assistance in planning management (if time and maternal condition permit).
Diagnostic Procedures: Physical examination, cultures.

Pathologic Findings

Invasion of the chorion by mononuclear and polymorphonuclear leukocytes (nonspecific).

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation and antibiosis.
Specific Measures: Expedited delivery (induction of labor, augmentation of labor).
Diet: No specific dietary changes indicated except as dictated by obstetric management.
Activity: No restriction except as dictated by obstetric management.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Booklet AP087 (Preterm Labor)

Drug(s) of Choice

Broad-spectrum antibiotic coverage based on organism suspected or detected by culture.
Cefoxitin (2 g IV every 6 to 8 hours)

or

Ticarcillin/clavulanate (Timentin, 3.1 g IV every 6 hours)

or

Imipenem cilastatin (Primaxin, 0.5 g IV every 6 hours)

or

Ampicillin/sulbactam (Unasyn, 3.0 g IV every 6 hours)
Contraindications: Known or suspected allergy. See individual agents for additional considerations.
Precautions: See individual agents.
Interactions: See individual agents.

Alternative Drugs

Mezlocillin 4 g IV every 4 to 6 hours; piperacillin 3 to 4 g IV every 4 hours.

FOLLOW-UP

Patient Monitoring: Increased need for fetal and maternal monitoring for the effects of infection (maternal and fetal) and for the associated labor.
Prevention/Avoidance: Restricted vaginal examinations in labor after rupture of the membranes.
Possible Complications: Significant sepsis may occur, in rare cases to the extent that hysterectomy may be required. There is an increased risk for dysfunctional labor and postpartum hemorrhage. If antibiotic therapy does not provide improvement in 24 to 48 hours, consider the possibility of abscess or septic pelvic thrombophlebitis.
Expected Outcome: With early recognition, aggressive antibiosis, and expedited delivery, maternal response should be expected to be good. Fetal outcome is based on gestational age at delivery.

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MISCELLANEOUS

Pregnancy Considerations: When chorioamnionitis is present, delivery generally must be expedited.
Other Notes: Up to 20% of women with preterm labor can have bacteria recovered by amniocentesis without evidence of overt clinical infection. Chorioamnionitis is not an indication for cesarean delivery.
ICD-9-CM Code: 658.4.

REFERENCES

Level I

Chapman SJ, Owen J. Randomized trial of single-dose versus multiple-dose cefotetan for the postpartum treatment of intrapartum chorioamnionitis. Am J Obstet Gynecol. 1997;177:831.

Grable IA, Garcia PM, Perry D, Socol ML. Group B Streptococcus and preterm premature rupture of membranes: a randomized, double-blind clinical trial of antepartum ampicillin. Am J Obstet Gynecol. 1996;175:1036.

Locksmith GJ, Chin A, Vu T, et al. High compared with standard gentamicin dosing for chorioamnionitis: a comparison of maternal and fetal serum drug levels. Obstet Gynecol. 2005;105:473.

Mitra AG, Whitten MK, Laurent SL, Anderson WE. A randomized, prospective study comparing once-daily gentamicin versus thrice-daily gentamicin in the treatment of puerperal infection. Am J Obstet Gynecol. 1997;177:786.

Owen J, Groome LJ, Hauth JC. Randomized trial of prophylactic antibiotic therapy after preterm amnion rupture. Am J Obstet Gynecol. 1993;169:976.

Turnquest MA, How HY, Cook CR, et al. Chorioamnionitis: is continuation of antibiotic therapy necessary after cesarean section? Am J Obstet Gynecol. 1998;179:1261.

Level II

Chi BH, Mudenda V, Levy J, et al. Acute and chronic chorioamnionitis and the risk of perinatal human immunodeficiency virus-1 transmission. Am J Obstet Gynecol. 2006;194:174.

Edwards RK, Duff P. Single additional dose postpartum therapy for women with chorioamnionitis. Obstet Gynecol. 2003;102:957.

Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol. 2004;104:1051.

Livingston JC, Llata E, Rinehart E, et al. Gentamicin and clindamycin therapy in postpartum endometritis: the efficacy of daily dosing versus dosing every 8 hours. Am J Obstet Gynecol. 2003;188:149.

Mozurkewich EL, Wolf FM. Premature rupture of membranes at term: a meta-analysis of three management schemes. Obstet Gynecol. 1997;89:1035.

Rouse DJ, Landon M, Leveno KJ, et alNational Institute of Child Health And Human Development, Maternal-Fetal Medicine Units Network. The Maternal-Fetal Medicine Units cesarean registry: Chorioamnionitis at term and its duration-relationship to outcomes. Am J Obstet Gynecol. 2004;191:211.

Segel SY, Miles AM, Clothier B, et al. Duration of antibiotic therapy after preterm premature rupture of fetal membranes. Am J Obstet Gynecol. 2003;189:799.

Trochez-Martinez RD, Smith P, Lamont RF. Use of C-reactive protein as a predictor of chorioamnionitis in preterm prelabour rupture of membranes: a systematic review. BJOG. 2007;114:796.

Ugwumadu A, Reid F, Hay P, et al. Oral clindamycin and histologic chorioamnionitis in women with abnormal vaginal flora. Obstet Gynecol. 2006;107:863.

Wu YW, Colford JMJr. Chorioamnionitis as a risk factor for cerebral palsy: a meta-analysis. JAMA. 2000;284:1417.

Level III

American College of Obstetricians and Gynecologists. Prevention of early-onset group B streptococcal disease in newborns. ACOG Committee Opinion 279. Obstet Gynecol. 2002;100:1405.

American College of Obstetricians and Gynecologists. Prophylactic antibiotics in labor and delivery. ACOG Practice Bulletin 47. Obstet Gynecol. 2003;102:875.

American College of Obstetricians and Gynecologists. Premature rupture of membranes. ACOG Practice Bulletin 80. Obstet Gynecol. 2007;109:1007.

Gibbs RS. Chorioamnionitis and bacterial vaginosis. Am J Obstet Gynecol. 1993;169:460.

Gibbs RS, Romero R, Hillier SL, et al. A review of premature birth and subclinical infection. Am J Obstet Gynecol. 1992;166:1515.

Gibbs RS, Schrag S, Schuchat A. Perinatal infections due to group B streptococci. Obstet Gynecol. 2004;104:1062.

Mercer BM, Arheart KL. Antimicrobial therapy in expectant management of preterm premature rupture of the membranes. Lancet. 1995;346:1271.

Simhan HN, Canavan TP. Preterm premature rupture of membranes: diagnosis, evaluation and management strategies. BJOG. 2005;112:32.

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