ESSENTIALS OF DIAGNOSIS
Fever not attributable to another source.
Tachycardia in the mother, fetus, or both.
Pelvic infections are relatively common problems encountered during the peripartum period. Chorioamnionitis is an infection of the amnion and chorion (fetal parts), usually occurring during labor. Uterine infection after delivery is often called endometritis or endomyometritis, but the term “metritis” is probably most accurate to emphasize that the infection extends throughout the uterine tissue. These infections are polymicrobial and are most commonly attributed to urogenital pathogens. The single most important risk factor for puerperal infection is cesarean delivery, which increases the risk from 5- to 20-fold. Other recognized risk factors include prolonged labor, use of internal monitors, nulliparity, multiple pelvic examinations, prolonged rupture of membranes, and lower genital tract infections. Although maternal complications such as dysfunctional labor and postpartum hemorrhage are increased with clinical chorioamnionitis, the principal reason to initiate treatment is to prevent morbidity in the offspring. Neonatal complications such as sepsis, pneumonia, intraventricular hemorrhage, and cerebral palsy are increased in the setting of chorioamnionitis. Intrapartum initiation of antibiotics, however, significantly reduces neonatal morbidity.
Puerperal infections are diagnosed principally by the presence of fever (38°C or higher) in the absence of any other source and one or more of the following signs: maternal or fetal tachycardia (or both), and uterine tenderness. Foul-smelling lochia may be present, but is an insensitive marker of infection as many women without infection also experience an unpleasant odor. Likewise, some life-threatening infections such as necrotizing fasciitis are typically odorless. Cultures are typically not done because of the polymicrobial nature of the infection.
Treatment is empiric with broad-spectrum antibiotics that will cover gram-positive and gram-negative organisms if still pregnant and gram-negative organisms and anaerobes if postpartum. A common regimen for chorioamnionitis is ampicillin, 2 g intravenously every 6 hours, and gentamicin, 2 mg/kg intravenous load then 1.5 mg/kg intravenously every 8 hours. A common regimen for metritis is gentamicin, 2 mg/kg intravenous load then 1.5 mg/kg intravenously every 8 hours, and clindamycin, 900 mg intravenously every 8 hours. Antibiotics are stopped in the mother when she has been afebrile (and asymptomatic) for 24 hours. No oral antibiotics are subsequently needed. Patients with metritis who do not respond in the first 24–48 hours may have an enterococcal component of metritis and require additional gram-positive coverage (such as ampicillin) to the regimen.
et al; Chorioamnionitis Workshop Participants. Evaluation and management of women and newborns with a maternal diagnosis of chorioamnionitis: summary of a workshop. Obstet Gynecol. 2016 Mar;127(3):426–36.
et al. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015 Feb 2;(2):CD001067.