C Chorioam mnionit is

Transcription

C Chorioam mnionit is
 Perinattal Joint P
Practice C
Chorioam
mnionitis
O
Original App
proval: 11//06
Type:
T
Cliniical Guidelin
ne
R
Revision/Re
eview Approval: 04.2
23.12
Key
K
words : chorioamnionitis, ele
evated temp
perature,
maternal
m
fev
ver
S
Supersedes
s: n/a
P
Posted date
e: 09.27.12
2
Retire
R
date
e: n/a
able 1. Rec
commended antibiotic regimens
r
forr treatment of chorio-a
amnionitis
Ta
Ta
able 2. Alte
ernative trea
atment options for penicillin allergy
y
Ta
able 3. Pos
stpartum tre
eatment guid
delines after diagnosis of chorio-am
mnionitis Ta
able 4. Rec
commended antibiotics for post-partum treatm
ment after cchorio-amnio
onitis
Ta
able 5. Pos
stpartum tre
eatment guid
delines after diagnosis of endomettritis
Ta
able 6. Rec
commended treatment of post-parttum endom etritis
A
Applicability
y
All patients for whom a diagnosis of cho
orioamnionittis may be m
made
P
Purpose
arify the und
derstanding of a diagno
osis of chorio
oamnionitis
To cla
B
Background
d
Epidural anesthes
sia has been
n shown to alter mater nal tempera
ature regula
ation. There
efore,
nts with mild
d temperatu
ure elevations may not have chorio
oamnionitis.. When we currently
patien
diagnose chorioamnionitis ba
ased solely on a matern
nal tempera
ature of ≥ 38 degrees C
Celsius
nd up treatin
ng a larger then
t
necess
sary group o
of patients a
and their ne
ewborn infan
nts.
we en
D
Definition
o-amnionitis
s is a clinica
al diagnosis based on in
ndividual or multiple sig
gns and sym
mptoms,
Chorio
includ
ding but not limited to:
 Maternal fever
f
define
ed as ≥ 38.4
4 degrees C
Celsius or ≥ 100.4 degrrees Fahrenheit
 Abdomina
al tenderness usually in the setting of ruptured
d membrane
es and no otther
obvious ex
xplanation
 New onsett maternal tachycardia
t
> 100 bea
ats per minu
ute
 New onsett fetal tachy
ycardia > 16
60 beats pe r minute
 Foul smellling amniotic fluid
Pagge 1 of 6 Chorioamnionitis, April 2012 Maternal and fetal baseline heart rates are defined as lasting at least 10 minutes.
When the diagnosis of chorioamnionitis is made, the appropriate antibiotic coverage should
be initiated.
If the patient has an isolated elevated temperature of ≥ 38.0 but < 38.4 degrees Celsius,
without any of the above listed signs or symptoms, then the diagnostic criteria are not met
and antibiotics do not need to be initiated. In this scenario, the >24 hour neonatal
observation is also not indicated.
If the medical staff by clinical judgment initiates antibiotic therapy, then a >24 hour postdelivery stay for the newborn is part of the management.
Table 1. Recommended antibiotic regimens for treatment of chorio-amnionitis
Regimens Dosing 1st choice regimen combination
Ampicillin
2 grams IV q6 hours and
Gentamycin*
1.5 mg/kg IV q8 hours
Alternate regimen combination (for penicillin allergy)
Clindamycin+ 900mg IV q8 hours and
Gentamycin*
1.5 mg/kg IV q8 hours
+
For patients with known GBS and PCN allergy, please check their GBS culture and
make sure it is sensitive to Clindamycin.
*Gentamycin may also be dosed as 5mg/kg IV q24 hours
Page 2 of 6 Chorioamnionitis, April 2012 Table 2. Alternative treatment options for penicillin allergy
Alternative Regimens Dosing Group B strep is a common pathogen in chorio-amnionitis. If the patient is
PCN allergic and the allergic reaction is mild (rash, hives) cephalosporins may
be appropriate. If the allergic reaction is severe, cephalosporins are not
recommended and a combination of Vancomycin and Gentamycin should be
used
1st choice regimen (mild penicillin allergy)
Cefotetan
2 grams IV q 12 hours
Alternate regimen combination (severe penicillin allergy)
Vancomycin
15mg/kg IV q 12 hours and
Gentamycin*
1.5 mg/kg IV q8 hours
*Gentamycin may also be dosed as 5mg/kg IV q24 hours
Table 3. Postpartum treatment guidelines after diagnosis of chorio-amnionitis Treatment completed
Postpartum treatment needed
Chorio-amnionitis, adequate
antibiotic treatment and vaginal
delivery
No post-partum antibiotics indicated
Chorio-amnionitis, adequate
antibiotic treatment and Cesarean
delivery
Post-partum IV antibiotics x 24-48 hours
afebrile. (See suggested regimen below in
Table 4))
Chorio-amnionitis, no antibiotic
treatment prior to vaginal delivery
Post-partum antibiotics either 1 dose or 24
hours afebrile
Chorio-amnionitis, no antibiotic
treatment and Cesarean delivery
Post-partum IV antibiotics x 48 hours
afebrile
Page 3 of 6 Chorioamnionitis, April 2012 Table 4. Recommended antibiotics for post-partum treatment after chorio-amnionitis
Regimens
Dosing
1st choice regimen combination
Clindamycin 900mg IV q8 hours and
Gentamycin
5mg/kg IV q12 hours
Alternate regimen combination
Clindamycin 900mg IV q8 hours and
Flagyl
1 gram loading dose, followed by 500mg IV q6 hours
Alternate regimen
Zosyn
3.375grams IV q6 hours
If patient remains febrile after 24-36 hours, add to cover Enterococcus
(the most likely pathogen):
Ampicillin
2 grams IV q6 hours
If PCN allergy, consider Cephalosporin or Vancomycin
(see Table 2 above for dosing)
Table 5. Postpartum treatment guidelines after diagnosis of endometritis
Delivery Type Postpartum Treatment Needed Vaginal delivery IV antibiotics x 24 hours afebrile Cesarean Delivery
IV antibiotics x 48 hours afebrile
Page 4 of 6 Chorioamnionitis, April 2012 Table 6. Recommended treatment of post-partum endometritis
Regimens
Dosing
1st choice regimen combination
Clindamycin 900mg IV q8 hours and
Gentamycin
5mg/kg IV q12 hours
Alternate regimen combination
Clindamycin 900mg IV q8 hours and
Flagyl
1 gram loading dose, followed by 500mg IV q6 hours
Alternate regimen
Zosyn
3.375grams IV q6 hours
If patient remains febrile after 24-36 hours, add to cover Enterococcus
(the most likely pathogen):
Ampicillin
2 grams IV q6 hours
If PCN allergy, consider Cephalosporin or Vancomycin
(see Table 2 above for dosing)
Exhibits
None
References
None
Related Policies/Guidelines/Procedures/Standards
None
Author
Author: C. van de Ven, MD
Page 5 of 6 Chorioamnionitis, April 2012 Reviewed and Approved By
Perinatal Joint Practice Committee: November 2006; April 23, 2012
Next Review
April 2015
Disclaimer: These are general guidelines not based on specific medical diagnosis. Any medical case
depends on specific medical diagnosis. The guidelines do not constitute medical advice and should
not be used for specific cases. Our goal is to provide general information that may assist in the care
of patients. General guidelines can never replace the expertise and clinical judgment of the treating
physician. Each patient’s situation must be evaluated individually.
©2012 The Regents of the University of Michigan
Author: UMHS Perinatal Joint Practice Committee
Last Revised 04/2012
Page 6 of 6