1. Michael McNamara, DO Sanford Maternal Fetal Medicine
Chorioamnionitis
Michael McNamara, DO
Sanford Maternal Fetal Medicine

2. No Disclosures

4. Infections in Pregnancy
Chorioamnionitis
Historical term
Infection of the chorion, amnion or both
Intra amniotic infections (AIA)
More common term
Infection of chorion, amnion
Infection also to include amniotic fluid, fetus, umbilical cord, placenta
Intra amniotic infection or inflammation (Triple I)
2015 National Institute of Child Health and Human Development Workshop
Intrauterine infection or inflammation or both
Strict diagnostic criteria

5. Chorioamnionitis Incidence 1– 4% of all deliveries
7 % of premature rupture of membranes (PROM) at term
40% of those patients with rupture of membranes (ROM) > 24 hours
40-70% of pregnancies delivered preterm due to preterm labor (PTL) or preterm premature rupture of membranes (PPROM)
12% undergoing cesarean after going through labor
20% of those patient having > 8 digital exams

7. Protection Against Infection
Mucus plug
Membranes
Placenta

8. Placenta
Normal
Infection

9. Risk Factors Length of labor Duration of ruptured membranes
Number of digital exams following rupture of membranes
Nulliparity
Meconium stained amniotic fluid
Internal monitoring
Presence of bacterial pathogens
Alcohol and tobacco use
Previous pregnancy with same

10. Diagnosis Presumptive
Fever – F (38 C) or greater x 2 or F (39 C) one time
Fetal tachycardia (baseline > 160 bpm)
Maternal leukocytosis (WBC > 15,000) absence of steroids, presence of left shift
Purulent appearing amniotic fluid

11. Fetal tracings
Normal
Fetal Tachycardia

12. Diagnosis Confirmed Positive gram stain of amniotic fluid
Fever – F (38 C) or greater x 2 or F (39 C) one time
Fetal tachycardia (baseline > 160 bpm)
Maternal leukocytosis (WBC > 15,000) absence of steroids, presence of left shift
Purulent appearing amniotic fluid
Positive gram stain of amniotic fluid
Low glucose in amniotic fluid (< 15)
Positive amniotic fluid culture
High white count in amniotic fluid
Pathology evidence of infection or inflammation (or both) of placenta, membranes or umbilical cord

13. Etiology Usually polymicrobial
Genital mycoplasmas (Mycoplasma or Ureaplasma)
Anaerobes (Gardnerella vaginalis)
Enteric gram negative bacteria (E coli)
Group B streptococcus
Listeria monocytogenes

14. Treatment Intrapartum Delivery (except special circumstances)
Antipyretics
Antibiotics (remember the organisms)
Gentamicin
Ampicillin (switch from penicillin if that is being used for GBS prophylaxis)
Penicillin allergy – vancomycin

15. Treatment Post partum Vaginal delivery – Not clear Cesarean
Continue antibiotics for short course, afebrile
No antibiotics
Cesarean
Add clindamycin or flagyl at time of surgery for anaerobic coverage
Continue antibiotics post partum for at least 24 hours post op without fever
No need for oral medications after intravenous course

16. Complications Maternal Dysfunctional labor Sepsis
Cesarean
Post partum hemorrhage and transfusion
Uterine atony
Sepsis
18% of maternal sepsis due to AIA
Post operative complications to include wound infections, endometritis, septic pelvic thrombophlebitis, pelvic abscess

17. Endometritis JH 36 y/o G2, P0 admitted for induction at 38+2 weeks
Type 2 DM, gestational hypertension
GBS +, penicillin allergy (anaphylaxis), clindamycin resistant
Ripened day #1, begun on vancomycin on admission
Day #2, after misoprostol and Cook’s catheter, begun on Pitocin
Spontaneous rupture membranes as 1440 (day #2)
Inadequate labor pattern at 6 cm, unable to obtain adequate contractions due to fetal intolerance
Cesarean at 2213, Gentamicin and Clindamycin for prophylaxis

18. Endometritis
Routine post op course, scheduled to be discharged POD#2 though baby with elevated bilirubin so stayed an extra day
46 hours post op, fever F, tender uterus, otherwise non focal exam
WBC 15.2k with left shift
Begun on Gentamicin, Clindamycin, Vancomycin
Blood cultures positive for E. coli, pan sensitive at 11 hours (Infectious Disease Consult)
After afebrile x 48 hours, home on ciprofloxacin to complete 10 day course

19. Endometritis Post delivery (cesarean or vaginal)
Most common cause for post partum febrile morbidity
Temp 38 C or higher day 2-10 post partum
Polymicrobial

20. Endometritis Examination (excluding other sources)
CBC, serum creatinine, cultures
Chest radiograph
Antibiotics
Gentamicin, clindamycin most common
Enterococcus coverage
Evaluation for abscess, septic pelvic thrombosis, retained products
Drug fever
Treat until hours afebrile

21. Endometritis Risk Factors Cesarean delivery Chorioamnionitis
Prolonged labor, prolonged rupture of membranes
Multiple cervical exams, internal monitoring
Meconium
Manual removal of placenta
Maternal diabetes, anemia, preterm birth
Low socioeconomic state
GBS, heavy strep or E coli vaginal colonization

22. Chorioamnionitis
JW is 39 y/o G6, P3, 38+2 weeks, presented in labor at 5 cm dilation
GDM, previous cesarean x 2 followed by a successful VBAC
Received epidural
AROM, clear fluid
Delivery about 2 ½ hours later
Neonatal Nurse Practitioner at delivery due to bradycardia during second stage (pushing)
Mom with fever of after delivery and begun on antibiotics (24 hours), NICU notified
Mom then afebrile and had uncomplicated post partum course

23. Complications
Fetal / Neonatal