Chorioamnionitis Treatment & Management
- Author: Michael P Sherman, MD, FAAP; Chief Editor: Ted Rosenkrantz, MD more...
This section addresses 2 topics. The first topic includes maternal interventions to treat suspected chorioamnionitis and protect the fetus from infection. The second topic includes the diagnostic approach and the appropriate treatment of neonates born to mothers with suspected chorioamnionitis.
The observation that epidural anesthesia during labor may create findings suggestive of maternal chorioamnionitis is discussed. A maternal fever that occurs when epidural anesthesia is administered during the intrapartum period has often been interpreted as chorioamnionitis. This may not be the case, and the neonate is needlessly treated after birth.
Using ampicillin as the chemoprophylactic agent to prevent group B streptococcal (GBS) disease in the neonate is associated with other issues. Ampicillin-resistant E coli infections in the mother and her infant are reported as an increasing problem. The use of penicillin rather than ampicillin as the chemotherapeutic agent to prevent GBS infections of the newborn is encouraged. The effectiveness of erythromycin, clindamycin, and vancomycin for prevention of neonatal GBS disease requires additional study. These antibiotics are often applied when a mother gives a history of penicillin allergy. Frequently, the maternal history of penicillin allergy is poorly documented.
Obstetric management influencing neonatal outcome
When acute chorioamnionitis is evident, delivery must be expedited. Upon signs of serious fetal distress, delivery must be emergent. Withholding maternal antibiotics to obtain postnatal cultures from the neonate is no longer appropriate. This strategy was once an accepted practice based on the assumption that waiting to obtain cultures from the newborn helps to determine the cause of infection. The morbidity and mortality in the mother and newborn may actually increase because of a delay in administering antibiotics. Studies suggest that obtaining cultures from the mother and beginning antibiotics before delivery probably improves the outcome for the neonate.
The postnatal physician must decide whether the fetus was infected and whether antibiotics given before birth should be continued in the neonate. Those antibiotics may differ from those administered to the mother. The history, physical findings, and findings of certain laboratory studies can assist the physician in deciding whether to continue antibiotics started during the intrapartum period. Because antibiotic chemoprophylaxis reduces the risk of GBS infection in neonates, the physician must always consider beginning penicillin during the intrapartum period when a mother has defined risk factors for GBS disease.[176, 177] The physician for the infant must judge whether the chemoprophylaxis was sufficient to prevent infection (especially in a healthy, full-term neonate) or whether the infant must continue antibiotic therapy after birth.
The US Centers for Disease Control and Prevention (CDC) guidelines outline the strategies for screening and treatment to prevent neonatal disease caused byGBS.[146, 178] New CDC guidelines for the prevention and treatment of neonatal GBS disease were published in 2010.
Determining the appropriate procedures to prevent fetal infection in the setting of premature, prelabor, rupture of membranes is more complex. The mother who has preterm labor or premature rupture of membranes at less than 34 weeks' gestation and no clinical signs or symptoms of chorioamnionitis should receive corticosteroid therapy.
Attitudes towards antibiotic use have changed. If GBS colonization of the mother is not present, and signs and symptoms of chorioamnionitis are absent, pregnant women with preterm labor or premature rupture of membranes at more than 36 weeks' gestation should be observed for infection. Thus, prophylactic antibiotics are not given in these circumstances. Mothers at term gestation with accepted risk factors for GBS infection in their fetus should also receive chemoprophylaxis. Infants at risk of preterm birth, and in whom GBS status is unknown, receive antibiotics during latency until GBS screening is completed. A period of observation for maternal and/or fetal infection is also required after admission, although signs and symptoms may not be evident (ie, silent disease).
Planned early birth versus expectant management for women with premature, prelabor rupture of membranes prior to 37 weeks' gestation and planned home versus hospital care for women with premature, prelabor rupture of membranes prior to 37 weeks' gestation have been reviewed.[179, 180] The preexisting studies were judged inadequate for clinical decision-making on these two topics.
Some obstetricians have observed little effect of corticosteroids on lung maturity after 32 weeks' gestation, whereas others have extended the use of corticosteroids to 34 weeks' gestation. Studies have not clearly demonstrated that the use of corticosteroids increases the risk of bacterial infection in the fetus.
The use of intrapartum penicillin or ampicillin is now a recognized therapy to prevent fetal infection or early onset neonatal infections associated with urogenital colonization by GBS. Amstey and Gibbs recommended that penicillin G rather than ampicillin be administered to the mother for the prevention of early-onset neonatal GBS disease.[176, 182] Their rationale was that penicillin G chemoprophylaxis does not increase colonization of the urogenital tract with ampicillin-resistant gram-negative bacteria. This assumption now seems correct, based on a report showing intrapartum ampicillin did not increase neonatal infections caused by ampicillin-resistant E coli.
Conversely, reports showed an increased occurrence of infections caused by ampicillin-resistant E coli in premature neonates.[183, 184] These mothers had received ampicillin for chemoprophylaxis rather than penicillin, and these authors again recommended use of intrapartum penicillin to prevent fetal or early onset neonatal infections caused by GBS.
Neonatal immunology and the risks created by maternal chorioamnionitis
Newborns are vulnerable to infection because of an immature immune system. Factors that render neonates susceptible to bacterial infections include reduced numbers and/or function of macrophages and dendritic cells in peripheral tissues (eg, lung); lower numbers of neutrophils in the bone marrow storage pool ; decreased immunoglobulin G (IgG) and complement levels, especially in prematurely born infants; an inability to respond to bacterial carbohydrate antigens; an increased percentage of T cells bearing naïve cell surfaces and correspondingly underdeveloped functional behaviors related to foreign antigens; and anatomic and biochemical immaturity of skin and mucosal barriers (eg, lung and gut epithelia) as they relate to local host defenses.
Emerging treatments, such as the use of intravenous immunoglobulins and hematopoietic growth factors, may correct deficiencies of the neonatal immune system. The use of immunotherapy still requires more investigation before these treatments become a standard of care. Specifically, the routine use of intravenous immunoglobins to treat neonatal sepsis is not established, but may be evident in the near future. The mainstays of current neonatal intensive care for bacterial sepsis in neonates are prompt recognition of bacterial infection, antimicrobial therapy, and supportive care. In this review, supportive care is only briefly discussed below. See the Medscape Reference article Neonatal Sepsis for a more in-depth care of these critically-ill neonates.
Treatment of the neonate
Communication between obstetric and pediatric caregivers is essential to recognize neonatal infection.
Recognition or suspicion of maternal chorioamnionitis is essential to reducing neonatal morbidity and mortality caused by early-onset bacterial infections in the neonate. Nurses and physicians who care for the mother must communicate their concerns about maternal infection to the nurses and physicians who care for the newborn after birth. Caregivers in the nursery must be critically aware of a neonate's signs and symptoms in relationship to the antepartum and intrapartum history.
Signs and symptoms in the mother that suggest chorioamnionitis and increase the risk of fetal or neonatal infection are described in Physical. Although numerous ways to approach the diagnosis and treatment of neonatal sepsis are recognized, a hands-on assessment is the main key to recognition. The experienced physician or nurse in the nursery may indicate to fellow caregivers that the newborn has a septic appearance.
Surgical interventions are infrequently required in early onset bacterial infections of the neonate. The conditions that may require intervention include epidural or brain abscess, subcutaneous abscesses, infections localized to the pleural space, certain intra-abdominal infections (especially if intestinal perforation is present), and bone or joint infections.
Depending on the hospital setting and the status of the neonate, a family physician may seek pediatric consultation. Depending on the severity or nature of infection in a hospital setting, the pediatrician may seek consultation with a neonatologist, a pediatric infectious disease subspecialist, or both. If organ system failure is present or impending organ system failure (eg, respiratory, cardiovascular, renal) secondary to infection is a concern, the infant should be transferred to an appropriate level 3 or level 4 neonatal intensive care unit (NICU). Transportation to a level 3 or 4 NICU is clearly indicated for extremely premature infants requiring high-frequency oscillatory ventilation or near-term or term neonates (≥ 35 weeks' gestation) who are close to meeting criteria for extracorporeal membrane oxygenation (ECMO).
Seriously or critically-ill newborns with early-onset bacterial infections often require parenteral nutrition until the condition improves. The use of intravenous lipids during proven bacteremia is the subject of controversy. The fear is that lipid inclusions may interfere with phagocytosis of microbes by hepatic, splenic, or pulmonary macrophages. Infections involving the GI tract may need a special approach to enteral nutrition when the feedings are reinstituted.
Activity and illness is generally related to adults because neonates are typically at rest and are not stressed when seriously or critically ill.
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