Intraamniotic infection, or chorioamnionitis, is defined as infection and subsequent inflammation of the amniotic fluid, placenta, decidua, fetus, or fetal membranes (American College of Obstetricians and Gynecologists [ACOG], 2017). It is associated with neonatal and maternal morbidity; much of which can be prevented with prompt recognition and treatment during labor. Babies may suffer acute and long-term complications including sepsis, pneumonia, meningitis, bronchopulmonary dysplasia, cerebral palsy, and even death. Maternal morbidity from chorioamnionitis includes dysfunctional labor, postpartum hemorrhage, infection (endometritis, peritonitis, sepsis), and respiratory distress syndrome. The following is a summary of ACOG's recent committee opinion outlining recommendations for appropriate diagnosis, treatment, and care coordination for intrapartum intraamniotic infection.
Diagnosis
As laboratory or histologic confirmation of intraamniotic infection is often delayed until after birth, most cases are diagnosed using clinical criteria. A panel of experts representing stakeholders from maternal-fetal medicine, obstetrics, and pediatrics recommend separating chorioamnionitis into three categories. These include isolated maternal fever, and either suspected or confirmed intraamniotic infection (Higgins et al., 2016). Isolated maternal fever is described as either one oral temperature >=39 [degrees]C (102.2 [degrees]F) or an oral temperature of 38-38.9 [degrees]C (100.4-102 [degrees]F) that persists longer than 30 minutes. Suspected infection is based on the combination of maternal fever and one or more fetal or maternal clinical findings, including fetal tachycardia, maternal leukocytosis, or purulent cervical drainage. Confirmed infection can be determined by positive gram stain, glucose level, or culture of amniotic fluid or via placental histologic findings consistent with inflammation or infection (ACOG, 2017).
Intrapartum Treatment
Prompt initiation of an antibiotic regimen is recommended for suspected or confirmed chorioamnionitis and should be considered in cases of isolated maternal fever when another cause cannot be identified. As these infections are typically caused by more than one type of bacteria, accepted regimens include gentamicin combined with ampicillin in women not allergic to penicillin, with cefazolin in women with mild penicillin allergy, and with vancomycin or clindamycin in the presence of severe penicillin allergy. Alternate regimens may be considered based on local antibiotic resistance. When the woman is also group B streptococcus positive, appropriate antibiotic regimens should target that infection and be based on antibiotic sensitivity testing (Centers for Disease Control and Prevention, 2010). Other treatment considerations include use of antipyretics and interventions aimed at adequate labor progress. Cesarean birth is not recommended based on the diagnosis of chorioamnionitis alone (ACOG, 2017).
Postpartum and Neonatal Care
Following vaginal birth, continued antibiotic treatment should be considered based on the risk of postpartum endometritis, or when risk factors such as bacteremia or persistent fever are present. At least one additional dose of an antibiotic regimen is recommended following cesarean birth (ACOG, 2017). Treatment guidelines on antibiotic therapy for newborns exposed to suspected or confirmed chorioamnionitis are currently under revision; however, existing guidance recommends laboratory studies and antibiotic treatment. Care coordination and early communication with the neonatal team are essential to provide prompt treatment following birth and heightened surveillance to detect emerging complications (ACOG, 2017).
Perinatal nurses are likely to be the first to detect a developing intraamniotic infection in laboring women or postpartum endometritis after birth. Knowledge of criteria for diagnosis and treatment of these infections is important for protecting women and their babies from associated morbidity and mortality. The full ACOG guideline with details on antibiotic treatment regimens can be found online at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-O
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