The following is a summary of “Antibiotic treatment of women with isolated intrapartum fever vs clinical chorioamnionitis: maternal and neonatal outcomes,” published in the NOVEMBER 2023 issue of Obstetrics and Gynecology by Shqara, et al.

Clinical chorioamnionitis, defined by maternal fever and specific clinical signs during labor, presents challenges with inappropriate management. However, there needed to be more comprehensive data guiding the management of women exhibiting isolated intrapartum fever without other clinical indications of chorioamnionitis. For a study, researchers sought to compare infectious outcomes in mothers and neonates, along with microbiological findings, between two groups: women experiencing isolated intrapartum fever and those diagnosed with clinical chorioamnionitis.

The retrospective study spanned a decade and encompassed all laboring women at our institution with a gestational age of ≥34 weeks, singleton pregnancy, and a body temperature of ≥38.0°C, irrespective of other infection evidence. The department’s protocol dictated that women with isolated intrapartum fever received intravenous ampicillin, while those diagnosed with clinical chorioamnionitis received a combination of intravenous ampicillin and gentamicin. The primary focus was on puerperal endometritis, comparing its occurrence between women with isolated intrapartum fever (ampicillin-treated) and those with clinical chorioamnionitis (ampicillin plus gentamicin-treated). Secondary maternal outcomes included clinical parameters such as cesarean delivery, surgical site infection, postpartum hemorrhage, and postpartum length of stay. Microbiological investigations involved assessing positive chorioamniotic membrane swabs and blood cultures. Secondary neonatal outcomes comprised early-onset sepsis, neonatal intensive care unit admission, and length of stay. Additionally, two multivariate logistic regression models were developed: one predicting puerperal endometritis and the other predicting neonatal early-onset sepsis. These models considered various factors such as gestational age, diabetes mellitus, obesity, positive group B streptococcus status, rupture of membrane ≥18 hours, meconium staining, positive chorioamniotic membrane swabs, cesarean delivery, and empiric postdelivery antibiotic administration. Another model focused on predicting neonatal early-onset sepsis, considering gestational age of 34 to 37 weeks, positive group B streptococcus status, rupture of membrane ≥18 hours, and positive chorioamniotic membrane swabs.

Out of the 458 women meeting the inclusion criteria, those with isolated intrapartum fever (n=227) were compared to women with clinical chorioamnionitis (n=231). Women in the isolated intrapartum fever group exhibited higher rates of puerperal endometritis (3.9% vs 8.8%; P=.03), early-onset sepsis (0.4% vs 4.4%; P=.005), positive chorioamniotic membrane swabs (46.3% vs 63.9%; P<.001), and ampicillin-resistant Escherichia coli (35.5% vs 48.9%; P=.033). The incidence of group B streptococcus–positive chorioamniotic membrane swabs was similar between the groups. In a subanalysis of women with negative or unknown group B streptococcus status, those with isolated intrapartum fever had higher rates of puerperal endometritis and neonatal early-onset sepsis compared to women with suspected chorioamnionitis (8.7% vs 3.3% [P=.041] and 4.1% vs 0% [P<.001], respectively). In two multivariate analysis models, among women with isolated intrapartum fever treated with ampicillin, the odds ratio for antibiotic treatment of endometritis was 2.65 (95% confidence interval, 1.06–6.62; P=.036), and the odds ratio for neonatal early-onset sepsis was 8.33 (95% CI, 1.04–60.60; P=.045).

Women experiencing intrapartum fever, with or without other signs of infection, faced an elevated risk of maternal and neonatal complications. Sole reliance on ampicillin in cases of isolated intrapartum fever might encourage the growth of ampicillin-resistant E. coli in chorioamniotic membranes, potentially leading to puerperal endometritis and early-onset sepsis. In such instances, the consideration of broad-range antibiotics is advisable.

Source: ajog.org/article/S0002-9378(23)00321-6/fulltext