Intra-amniotic infection typically results from an infection that ascends through the genital tract.
Risk factors
Risk factors for intra-amniotic infection include the following:
Meconium-stained amniotic fluid
Internal fetal or uterine monitoring
Presence of genital tract pathogens (eg, group B streptococci)
Multiple digital examinations during labor in women with ruptured membranes
Prolonged rupture of membranes (a delay of ≥ 18 to 24 hours between rupture and delivery)
Complications
Intra-amniotic infection can cause as well as result from preterm PROM or preterm delivery. This infection accounts for 50% of deliveries before 30 weeks gestation. It occurs in 33% of women who have preterm labor with intact membranes, 40% who have PROM and are having contractions when admitted, and 75% who go into labor after admission for PROM.
Fetal complications include increased risk of the following:
Preterm delivery
Apgar score < 3
Neonatal infection (eg, sepsis Neonatal Sepsis Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period. Signs are multiple, nonspecific, and include diminished spontaneous activity, less vigorous sucking... read more , pneumonia Neonatal Pneumonia Neonatal pneumonia is lung infection in a neonate. Onset may be within hours of birth and part of a generalized sepsis syndrome or after 7 days and confined to the lungs. Signs may be limited... read more , meningitis Neonatal Bacterial Meningitis Neonatal bacterial meningitis is inflammation of the meninges due to bacterial invasion. Signs are those of sepsis, central nervous system irritation (eg, lethargy, seizures, vomiting, irritability... read more )
Seizures
Death
Maternal complications include increased risk of the following:
Bacteremia
Need for cesarean delivery
Uterine atony
Pelvic abscess
Thromboembolism
Wound complications
Septic shock, coagulopathy, and acute respiratory distress syndrome Acute Hypoxemic Respiratory Failure (AHRF, ARDS) Acute hypoxemic respiratory failure is severe arterial hypoxemia that is refractory to supplemental oxygen. It is caused by intrapulmonary shunting of blood resulting from airspace filling or... read more 
are also risks but are uncommon if infection is treated.
Symptoms and Signs of Intra-Amniotic Infection
Intra-amniotic infection typically causes fever. Other findings include maternal tachycardia, fetal tachycardia, uterine tenderness, foul-smelling amniotic fluid, and/or purulent cervical discharge. However, infection may not cause typical symptoms (ie, subclinical infection).
Diagnosis of Intra-Amniotic Infection
Clinical criteria
Amniocentesis for suspected subclinical infection
(See also American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice: Committee Opinion No. 712: Intrapartum management of intraamniotic infection.)
Intra-amniotic infection is suspected and diagnosed based on clinical and sometimes laboratory criteria. Findings may be categorized as follows (1 Diagnosis reference Intra-amniotic infection is infection of the chorion, amnion, amniotic fluid, placenta, or a combination. Infection increases risk of obstetric complications and problems in the fetus and neonate... read more ):
Isolated maternal fever: A single oral temperature of ≥ 39° C or an oral temperature of ≥ 38 to 39° C that is still present when the temperature is measured after 30 minutes (isolated maternal fever does not automatically lead to a diagnosis of infection)
Suspected intra-amniotic infection based on maternal fever and clinical criteria (elevated maternal white blood cell [WBC] count, fetal tachycardia, purulent cervical discharge)
Confirmed intra-amniotic infection: Suspected intra-amniotic infection that is confirmed by results of amniotic fluid tests (Gram staining, culture, glucose level—see below) or histologic evidence of placental infection or inflammation
Presence of a single symptom or sign, which may have other causes, is less reliable. For example, fetal tachycardia may be due to maternal use of drugs or fetal arrhythmia. However, if intra-amniotic infection is absent, heart rate returns to baseline as these conditions resolve.
Intra-amniotic infection is usually confirmed after delivery.
Subclinical infection
Refractory preterm labor (persisting despite tocolysis) may suggest subclinical infection. If membranes rupture prematurely before term, clinicians should also consider subclinical infection so that they can determine whether induction of labor is indicated.
Amniocentesis with culture of amniotic fluid can help diagnose subclinical infection. The following fluid findings suggest infection:
Presence of any bacteria or leukocytes using Gram staining
Positive culture
Glucose level < 15 mg/dL
WBC count > 30 cells/mcL
Other diagnostic tests for subclinical infection are under study.
Diagnosis reference
1. 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 127 (3):426–436, 2016. doi: 10.1097/AOG.0000000000001246
Treatment of Intra-Amniotic Infection
Broad-spectrum antibiotics, antipyretics, plus delivery
(See also American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice: Committee Opinion No. 712: Intrapartum management of intraamniotic infection.)
Treatment of intra-amniotic infection is recommended when
Intra-amniotic infection is suspected or confirmed.
Women in labor have an isolated temperature of ≥ 39° C and no other clinical risk factors for fever.
If women have a temperature of 38 to 39° C and no risk factors for fever, treatment can be considered.
Appropriate antibiotic treatment reduces morbidity in the mother and neonate.
As soon as intra-amniotic infection is diagnosed, it is treated with broad-spectrum IV antibiotics plus delivery.
A typical intrapartum antibiotic regimen consists of both of the following:
Ampicillin 2 g IV every 6 hours
Gentamicin 2 mg/kg IV (loading dose) followed by 1.5 mg/kg IV every 8 hours or gentamicin 5 mg/kg IV every 24 hours
In addition, if delivery is cesarean, one additional dose of the chosen regimen plus a dose of clindamycin 900 mg IV or metronidazole 500 mg IV can be given after the umbilical cord is clamped.
Women with a mild penicillin allergy can be given
Cefazolin plus gentamicin
Women with a severe penicillin allergy can be given one of the following:
Clindamycin plus gentamicin
Vancomycin plus gentamicin
Vancomycin should be used in women who are colonized with group B streptococci (GBS) if
GBS is resistant to clindamycin or erythromycin unless clindamycin-inducible resistance testing is negative.
Antibiotic sensitivities are not available.
How long antibiotics are given varies, depending on individual circumstances (eg, how high the fever was, when the fever last spiked in relation to delivery).
Antibiotics should not automatically be continued after delivery; use should be based on clinical findings (eg, bacteremia, prolonged fever) and on risk factors for postpartum endometritis, regardless of the delivery route. Women who have a vaginal delivery are less likely to develop endometritis and may not require postpartum antibiotics. After cesarean delivery, at least one additional dose of antibiotics is recommended.
Antipyretics, preferably acetaminophen before delivery, should be given in addition to antibiotics.
Intra-amniotic infection alone is rarely an indication for cesarean delivery. Informing the neonatal care team when intra-amniotic infection is suspected or confirmed and what risk factors are present is essential to optimize evaluation and treatment of the neonate.
Prevention of Intra-Amniotic Infection
Risk of intra-amniotic infection is decreased by avoiding or minimizing digital pelvic examinations in women with preterm PROM Prelabor Rupture of Membranes (PROM) Prelabor rupture of membranes is leakage of amniotic fluid before onset of labor. Diagnosis is clinical. Delivery is recommended when gestational age is ≥ 34 weeks and is generally indicated... read more .
Broad-spectrum antibiotics are given to women with preterm PROM to prolong latency until delivery and decrease risk of infant morbidity and mortality.
Key Points
Intra-amniotic infection can be subclinical and relatively asymptomatic.
Consider the diagnosis when fetal or maternal tachycardia or refractory preterm labor is present, as well as when women have the more classic symptoms of infection (eg, fever, discharge, pain, tenderness).
Consider analyzing and culturing amniotic fluid if women have refractory preterm labor or preterm PROM.
Treat suspected or confirmed intra-amniotic infection with broad-spectrum antibiotics, antipyretics, and delivery.
Also treat women in labor if they have an isolated temperature of ≥ 39° C and no other clinical risk factors for fever.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
magnesium sulfate |
No US brand name |
immune globulin |
Gammagard S/D |
methotrexate |
OTREXUP |
triamcinolone |
KENALOG |
prednisone |
RAYOS |
clindamycin |
CLEOCIN |
gentamicin |
GENOPTIC |
ampicillin |
No US brand name |
metronidazole |
FLAGYL |
oxytocin |
PITOCIN |
misoprostol |
CYTOTEC |
doxylamine |
UNISOM |
promethazine |
PROMETHEGAN |
metoclopramide |
REGLAN |
ondansetron |
ZOFRAN |
prochlorperazine |
COMPRO |
methylprednisolone |
MEDROL |
betamethasone |
CELESTONE SOLUSPAN, DIPROLENE, LUXIQ |
cefazolin |
ANCEF, KEFZOL |
vancomycin |
VANCOCIN |
erythromycin |
ERY-TAB, ERYTHROCIN |
acetaminophen |
TYLENOL |
mifepristone |
MIFEPREX |
