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Question

Difficulty: MediumObstetric Complications

A 27-year-old woman, G1P0, is evaluated in the obstetric triage area at 31 weeks gestation. She reports a sudden gush of clear vaginal fluid that occurred 48 hours ago. Since this morning, she has developed chills and diffuse abdominal discomfort. Her temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 115/min. Physical examination reveals a tender uterine fundus. Speculum examination shows a pool of purulent fluid in the posterior vaginal fornix. Fetal monitoring demonstrates a baseline heart rate of 175/min with moderate variability and no decelerations. Tocodynamometry shows irregular uterine contractions occurring every 8 to 10 minutes. Which of the following is the most appropriate next step in management?

  1. Administration of broad-spectrum intravenous antibiotics and induction of laborAnswer
  2. B
    Administration of broad-spectrum intravenous antibiotics and emergent cesarean delivery
  3. C
    Administration of intramuscular corticosteroids, prophylactic antibiotics, and expectant management
  4. D
    Administration of intravenous magnesium sulfate and intramuscular corticosteroids
  5. E
    Perform amniocentesis to assess for fetal lung maturity before deciding on delivery

Answer

Administration of broad-spectrum intravenous antibiotics and induction of labor
The correct management for intra-amniotic infection (chorioamnionitis) is the administration of broad-spectrum intravenous antibiotics (e.g., ampicillin and gentamicin) and immediate delivery, typically via induction of labor. This patient has classic signs of infection: maternal fever, uterine tenderness, purulent fluid, and fetal tachycardia. In this setting, the risks of maternal sepsis and neonatal morbidity far outweigh the risks of prematurity at 31 weeks. Because the fetal heart rate tracing is reassuring (moderate variability, no decelerations), an induction of labor is safe and preferred over surgical delivery.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation.
The patient has preterm premature rupture of membranes (PPROM) complicated by intra-amniotic infection (chorioamnionitis), evidenced by maternal fever (39.2°C), fundal tenderness, purulent vaginal fluid, and fetal tachycardia.
Recognizing the transition from uncomplicated PPROM to an active intra-amniotic infection dictates a shift from conservative to active management.
2
Determine the definitive treatment requirement for the complication.
Intra-amniotic infection requires prompt delivery regardless of gestational age, alongside maternal broad-spectrum intravenous antibiotics to prevent maternal sepsis and treat fetal infection.
Continuing the pregnancy in the setting of an infected intrauterine environment drastically increases the risk of maternal and fetal mortality.
3
Select the optimal mode of delivery based on maternal and fetal status.
Vaginal delivery via induction of labor is preferred. Despite the fetal tachycardia (175/min), the presence of moderate variability and absence of decelerations indicates a reassuring fetal status.
Fetal tachycardia is a common, expected response to maternal fever. Without signs of acute hypoxic distress, there is no indication to expose the mother to the risks of an emergent cesarean delivery.

Key Concept

Intra-amniotic infection (chorioamnionitis) complicating preterm premature rupture of membranes (PPROM)
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Topics

Obstetric Complications

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