A 34-year-old woman, gravida 2 para 1, at 26 weeks gestation comes to the emergency department due to intermittent leakage of fluid for the past 6 hours. She has had no vaginal bleeding or contractions. The patient's previous pregnancy was complicated by preterm prelabor rupture of membranes at 29 weeks gestation; she delivered at 34 weeks gestation after inpatient management with corticosteroids and latency antibiotics. Temperature is 39.4 C (103 F), blood pressure is 100/70 mm Hg, and pulse is 114/min. Fetal heart rate is 170/min. The uterus is tender to palpation. On speculum examination, purulent amniotic fluid emerges from the cervix with Valsalva and turns the nitrazine paper blue. The cervix is visibly closed. Transabdominal ultrasound shows a vertex fetus consistent with gestational age. The amniotic fluid index is 8 cm. In addition to antibiotics, which of the following is the best next step in management of this patient?
Intraamniotic infection (chorioamnionitis) | |
Risk factors |
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Diagnosis | Maternal fever PLUS ≥1 of the following:
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Management |
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Complications |
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This patient at 26 weeks gestation has preterm prelabor rupture of membranes (PPROM) based on leakage of nitrazine-positive fluid (ie, alkaline amniotic fluid) emerging from the cervix. Risk factors for PPROM include prior PPROM (as in this patient), genitourinary infection, and antepartum bleeding. Uncomplicated cases of PPROM are managed expectantly with inpatient monitoring (eg, serial fetal ultrasounds), prophylactic latency antibiotics, corticosteroids, and delivery at 34 weeks gestation (Choices B, D, and E).
However, patients who develop complications (eg, placental abruption, cord prolapse) do not meet criteria for expectant management. This patient has fever and fetal tachycardia consistent with an intraamniotic infection (IAI) (ie, chorioamnionitis), a fulminant polymicrobial infection of the amniotic sac, fetus, cord, and placenta from ascending vaginal flora. Additional signs may include maternal tachycardia, uterine tenderness, and malodorous or purulent amniotic fluid. IAI has an increased risk of maternal morbidity (eg, sepsis, disseminated intravascular coagulation) and mortality that outweighs the fetal benefit gained by prolonging pregnancy. Therefore, patients with PPROM complicated by IAI require therapeutic antibiotics and immediate delivery (eg, induction of labor), regardless of gestational age.
(Choice A) Fetal fibronectin is used to identify patients with preterm contractions who are at high risk for preterm delivery. It is not performed in PPROM because the risk of preterm delivery is high and, therefore, does not change management. Fetal lung maturity testing is performed in patients with uncertain gestational dating to determine timing of delivery (ie, prolong pregnancy for fetal benefit). Neither of these tests is indicated because this patient requires immediate delivery.
Educational objective:
Intraamniotic infection (chorioamnionitis) is a complication of preterm prelabor rupture of membranes. Due to the increased risk of maternal morbidity and mortality, patients with intraamniotic infection require therapeutic antibiotics and immediate delivery, regardless of gestational age.