A 29-year-old woman, gravida 2, para 1, at 31 weeks gestation is evaluated in the antepart… — USMLE Step 2 CK

A $29$ -year-old woman, gravida $2$ , para $1$ , at $31$ weeks gestation is evaluated in the antepartum unit. She was admitted $2$ days ago after a sudden gush of vaginal fluid, and evaluation confirmed preterm premature rupture of membranes (PPROM). At admission, she was started on expectant management with a course of betamethasone and prophylactic ampicillin and erythromycin. She now reports chills and lower abdominal pain. Her temperature is $39.1^\circ\text{C}$ ( $102.4^\circ\text{F}$ ), blood pressure is $105/65\text{ mmHg}$ , and heart rate is $116\text{/min}$ . Physical examination reveals a uterus that is exquisitely tender to palpation. The fetal heart rate tracing demonstrates a baseline of $175\text{/min}$ , minimal variability, and no decelerations. The cervix is $2\text{ cm}$ dilated and $70\%$ effaced. Which of the following is the most appropriate next step in the management of this patient?

Administration of therapeutic intravenous antibiotics and induction of laborAnswer
B
Administration of therapeutic intravenous antibiotics and continuation of expectant management
C
Immediate cesarean delivery
D
Administration of indomethacin and a rescue dose of betamethasone
E
Performance of an amnioinfusion

Answer

Administration of therapeutic intravenous antibiotics and induction of labor

This patient has developed clinical chorioamnionitis, a severe complication of preterm premature rupture of membranes (PPROM), indicated by her fever, significant uterine tenderness, and fetal tachycardia. When an intra-amniotic infection occurs, expectant management must be abandoned regardless of the gestational age. The standard of care mandates the immediate administration of broad-spectrum therapeutic intravenous antibiotics (e.g., ampicillin and gentamicin) and prompt delivery. Induction of labor is the appropriate method to achieve delivery, as chorioamnionitis is not an independent indication for a cesarean section.

Step-by-Step Solution

Evaluate the new clinical findings in a patient with a history of PPROM.

The patient now exhibits a high fever (

39.1^\circ\text{C}

), uterine tenderness, maternal tachycardia (

116\text{/min}

), and fetal tachycardia (

175\text{/min}

These combined signs represent the classic diagnostic criteria for clinical chorioamnionitis (intra-amniotic infection).

Determine the optimal management pathway for clinical chorioamnionitis.

The management must immediately shift from expectant to active intervention with therapeutic broad-spectrum intravenous antibiotics and prompt delivery.

Continuing expectant management in the presence of infection carries an unacceptably high risk of severe maternal morbidity (sepsis) and fetal mortality, which outweighs the risks of prematurity.

Select the appropriate route of delivery.

Induction of labor for a vaginal delivery is indicated.

Cesarean delivery is not indicated solely for chorioamnionitis and should only be performed for standard obstetric indications (e.g., malpresentation, nonreassuring fetal status refractory to resuscitation).

Key Concept

Management of clinical chorioamnionitis complicating preterm premature rupture of membranes (PPROM)

Estimated Time:1m 30s

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