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Obstetrics

Chorioamnionitis

Infection of the chorion, amnion, amniotic fluid, and potentially the fetus, usually resulting from ascending bacteria after rupture of membranes or during labour.

Also known as: Intra-amniotic Infection, Amnionitis

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Referral and warning signs

When to refer

Requires management in hospital (HC4/H/RR) capable of IV antibiotics, monitoring, C/S, and neonatal care.

Red flags

  • High fever / Signs of maternal sepsis
  • Signs of fetal distress
  • Failure to progress in labour
  • Purulent amniotic fluid

Signs and symptoms

  • Maternal Fever (>38°C) during labour or after ROM.
  • Maternal Tachycardia (>100 bpm).
  • Fetal Tachycardia (>160 bpm).
  • Uterine tenderness.
  • Foul-smelling or purulent amniotic fluid/vaginal discharge.
  • Maternal leucocytosis (elevated WBC count).

Risk factors

  • Prolonged rupture of membranes (>18-24 hours).
  • Prolonged labour.
  • Multiple vaginal examinations.
  • Internal fetal monitoring.
  • Untreated lower genital tract infections (BV, GBS, STIs).
  • Preterm labour/PPROM.

Diagnosis

Clinical assessment

Diagnosis usually based on clinical signs: Maternal Fever PLUS >=1 of: Maternal tachycardia, Fetal tachycardia, Uterine tenderness, Foul/purulent amniotic fluid.

Investigations

  • Maternal temperature, pulse.
  • Fetal heart rate.
  • Assess uterine tenderness.
  • Observe amniotic fluid character.
  • FBC (maternal leucocytosis).
  • Amniotic fluid analysis (rare).
  • Blood cultures (if sepsis suspected).

Diagnostic criteria

Clinical diagnosis based on fever plus other associated signs.

Management

Non-pharmacological management

  • Expedite delivery (vaginal preferred if safe/progressing, C/S for standard indications).
  • Supportive care (hydration).

Pharmacological treatment

  • Broad-Spectrum IV Antibiotics IMMEDIATELY: Ampicillin 2g IV Q6H PLUS Gentamicin 5 mg/kg IV Q24H. ADD Metronidazole 500mg IV Q8H (or Clindamycin 900mg IV Q8H) if Caesarean Section. Continue until afebrile 24-48h.
  • Antipyretics (Paracetamol).

Monitoring

Monitor maternal vitals, FHR, labour progress. Monitor neonate closely for sepsis postpartum.

Complications

  • Maternal: Puerperal sepsis, Bacteraemia/Shock, PPH, Abscess, Wound infection, Thrombophlebitis.
  • Fetal/Neonatal: Neonatal sepsis, Meningitis, Pneumonia, Preterm birth complications, Cerebral palsy, Stillbirth/Death.

Prevention

  • Limit duration of ROM (induce term PROM).
  • Minimize vaginal exams.
  • Treat genital infections.
  • Prophylactic antibiotics (GBS, prolonged ROM).

Patient education

  • Explanation of infection and risks.
  • Need for IV antibiotics and delivery.
  • Potential need for C/S.
  • Need for neonatal assessment/antibiotics.

Uganda-specific notes

Significant cause of maternal/neonatal sepsis. Prompt recognition and antibiotics (Amp/Gent standard) crucial. Plan for neonatal management.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.3.5

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