OBSTETRICS  OBSTETRIQUE

A Survey on Variation in Diagnosis and

Treatment of Chorioamnionitis in
Tertiary Centres in Canada
Clara Charpentier, BSc;1 Sarah McDonald, BA, MD, MSc;2
Chealsea Elwood, BMScH, MSc, MD;3,4 Joseph Ting, MBBS, MPH;4,5
Adriana Grigoriu, MD;6,7 Christy Pylypjuk, BSc, MD, MSc;8,9
Mark Yudin, MD, MSc;10 Julianne Van Schalkwyk, MD, MSc;3,4
Isabelle Boucoiran, MSc, MD11,12,13
1

de Montre
Faculty of Medicine, Universite
al, Montre

al, QC
2
Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiology and Health Research
Methods, Evidence and Impact, McMaster University, Hamilton, ON
C. Charpentier 3
Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, BC
4
Women’s Health Research Institute, Vancouver, BC
5
Divison of Neonatalogy, Department of Pediatrics, University of British Columbia, Vancouver, BC
6
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Moncton Hospital, Moncton, NB
7
Faculty of Medicine, Dalhousie University, Halifax, NS
8
Department of Obstetrics, Gynecology and Reproductive Sciences, Faculty of Health Sciences, University of Manitoba,
Winnipeg, MB
9
Children’s Hospital Research Institute of Manitoba, Winnipeg, MB
10
Obstetrics, Gynecology & Reproductive Infectious Diseases, University of Toronto, St. Michael's Hospital, Toronto, ON
11

de Montre
Department of Obstetrics and Gynecology, Faculty of Medicine, Universite
al, Montre

al, QC
12

de Montre
School of Public Health, Universite
al, Montre

al, QC
13

al, QC
Mother and Children Infectious Disease Center, CHU Sainte-Justine Research Center, Montre

Moreover, recommended diagnostic criteria for clinical

ABSTRACT
Objective: Clinical detection and management of chorioamnionitis is
challenging given the gold-standard for diagnosis remains placental
pathology, the results of which are only available after delivery.
Keywords: chorioamnionitis; antibacterial agents; obstetrics;
health care surveys
Corresponding author: Isabelle Boucoiran,
isabelle.boucoiran@umontreal.ca
Disclosures: Organizational support for the Canadian Preterm
Birth Network is provided by the Maternal-Infant Care Research
Centre. The Canadian Preterm Birth Network is supported by Team
Grant PBN150642 from the Canadian Institutes of Health Research
(CIHR). Sarah McDonald is supported by a Tier II Canada
Research Chair. Isabelle Boucoiran is supported by a salary award
from the fonds de recherche du Que
bec-Sante
.
All authors have indicated they meet the journal's requirements for
authorship.
Received on January 22, 2021
Accepted on June 3, 2021
Available online on June 29, 2021
chorioamnionitis have evolved over time. The goal of this study was
to describe trends and differences in chorioamnionitis diagnostic
and management practices in Canada.
Methods: We surveyed obstetric care providers participating
in the Canadian Preterm Birth Network. Questionnaires
were distributed electronically to all 29 sites and
completed by 1 maternal−fetal medicine investigator at each site.
Results: The response rate was 82.8% (n = 24). There was
considerable variation in the clinical criteria used to diagnose
chorioamnionitis with 9 of 22 sites stating this occurs “frequently” or
“very frequently.” Isolated fever was “always” or “most of the time”
used as an indication to start empiric antibiotic therapy in 14 of 24
sites, and 21 of 23 sites used the same diagnostic criteria for term
and preterm deliveries. Placental histology (15 sites) and white
blood cell count (14 sites) were the most common clinical tests
performed to confirm chorioamnionitis. A combination of ampicillin
and aminoglycoside antibiotics was used at 12 sites. Another
frequently used antibiotic therapy was cefazolin and metronidazole
(4 sites).
Conclusion: There is a wide variation in practices for the diagnosis
and management of chorioamnionitis across Canada. The results of
this study will guide efforts to improve and standardize the
management of this condition.

28  JANUARY JOGC JANVIER 2022

 A Survey on Variation in Diagnosis and Treatment of Chorioamnionitis in Tertiary Centres in Canada

RÉSUMÉ microbial investigations. Moreover, fever is frequently

present in labour among women without chorioamnionitis,
Objectif : La de
tection et la prise en charge cliniques de la
chorioamnionite s’ave rent difficiles e

tant donne
que l’examen de in the context of epidural analgesia or prolonged labour.4−6
re
fe

rence pour le diagnostic demeure l’analyse
anatomopathologique du placenta, dont les re
sultats ne sont The recommended diagnostic criteria for chorioamnionitis
disponibles qu’apre  s l’accouchement. De plus, les crite res have evolved over time. The most recent were established
diagnostiques recommande
s pour la chorioamnionite clinique ont
e
volue
au fil du temps. L’objectif de cette e

tude e
tait de de

crire les in the 2015 Workshop of the National Institute for Child
tendances et les diffe
rences dans les pratiques de diagnostic et de and Human Development (NICHD), which was co-
prise en charge de la chorioamnionite au Canada. funded by the American College of Obstetrics and Gyne-
Méthodologie : Nous avons sonde
les fournisseurs de soins cology (ACOG), the American Academy of Pediatrics, and

tricaux ayant adhe
obste
re

au re

seau pancanadien sur les the Society for Maternal-Fetal Medicine (Table 1).1 These
naissances pre
mature
es. Les questionnaires ont e
te

distribue

s par
criteria were based on expert consensus and have not been

lectronique a
voie e  l’ensemble des 29 e
tablissements et remplis par
un chercheur en me
decine fœto-maternelle par e
tablissement. validated in clinical trials. For term deliveries, the Canadian
Paediatric Society (CPS)3 endorses the use of the Gibbs cri-
Résultats : Le taux de re
ponse a e
te

de 82,8 % (n = 24). Les re
sultats

ve
re lent une variation conside
rable dans les criteres cliniques
teria, the first published diagnostic criteria for clinical cho-

s pour diagnostiquer la chorioamnionite, ou
utilise 9e
tablissements rioamnionitis (Table 1).7,8
sur 22 ont indique
une variation « fre
quente » ou « tre  s fre

quente ».
La fie vre isole
e est « toujours » ou « la plupart du temps » utilise
e Antibiotic therapy initiated before delivery has been shown
comme indication pour amorcer une antibiothe
rapie empirique dans

tablissements sur 24, et 21 e
tablissements sur 23 utilisent les
to reduce adverse maternal and neonatal outcomes associ-
14 e
me^ mes crite res diagnostiques pour les accouchements a  terme et ated with chorioamnionitis.9 In 2017, ACOG issued specific
pre
mature
s. L’histologie placentaire (15 e
tablissements) et la recommendations, endorsed by NICHD, for antibiotic ther-

mie (14 e
tablissements) sont les analyses cliniques les
leucocyte apy for clinical chorioamnionitis.1,10 However, several alter-
plus couramment effectue
es pour confirmer la chorioamnionite.
L’antibiothe
rapie combine
e (ampicilline et aminosides) est utilise
e native regimens have also been proposed.11
dans 12 e
tablissements. Une autre antibiothe
rapie fre
quemment

e est la ce
utilise
fazoline-me
tronidazole (4 e
tablissements). Despite the existence of diagnostic and treatment guide-
Conclusion : Les pratiques de diagnostic et de prise en charge de la
lines, we hypothesize that the practices for diagnosis and
chorioamnionite varient grandement au Canada. Les re
sultats de management of intrapartum chorioamnionitis are heterog-
cette e
tude orienteront les efforts visant a
 ame

liorer et a
 normaliser enous. The objective of this study was to describe the diag-
la prise en charge de cette pathologie.
nostic criteria and antibiotics employed in Canada when
intrapartum chorioamnionitis is suspected.
© 2021 The Society of Obstetricians and Gynaecologists of Canada/La
Société des obstétriciens et gynécologues du Canada. Published by
Elsevier Inc. This is an open access article under the CC BY-NC-ND METHODS
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
This study used the Canadian Preterm Birth Network
J Obstet Gynaecol Can 2022;44(1):28−33 (CPTBN) and addressed maternal-fetal medicine (MFM)
https://doi.org/10.1016/j.jogc.2021.06.003
investigators at each site.12 The CPTBN was funded by the
Canadian Institutes of Health Research and consists of a
Canadian network of health care professionals with expertise
INTRODUCTION in MFM, obstetrics, neonatology, pediatrics, neonatal follow-
up, epidemiology, health economics, and health informatics.
horioamnionitis or intra-amniotic infection is an The principal goal of the CPTBN is to develop optimal pre-
C infection and inflammatory condition of the fetal
membranes, amniotic fluid, placental tissues, and decidua,
term birth care practices and protocols.12

caused by polymicrobial organisms ascending from the
maternal genital tract.1 Chorioamnionitis affects approxi-
mately 10% of all women in labour, with a markedly higher
incidence when delivery is before term.2
Chorioamnionitis is associated with increased maternal and
neonatal morbidity and mortality, and its diagnosis is criti-
cal to prevent early-onset sepsis in newborns.3 However,
chorioamnionitis is a tentative diagnosis that is usually con-
firmed after delivery based on placental pathology or
Between December 2019 and November 2020, one MFM
investigator at each site was invited to complete a 15-ques-
tion online survey that was designed by MFM specialists
using ACOG and CPS guideline information.1,3,7,8
Answers were dichotomous or Likert scalable in nature.
The questionnaire addressed (1) the practices used to man-
age fever in labour and to diagnose chorioamnionitis
(7 questions) and (2) the antibiotic therapy prescribed
for clinical chorioamnionitis (6 questions; see
online Appendix). The remaining questions were

JANUARY JOGC JANVIER 2022  29

OBSTETRICS  OBSTÉTRIQUE

Table 1. Diagnostic criteria for clinical chorioamnionitis according to current guidelines

Signs or symptoms NICHD/AGOG criteria1,10 Canadian Paediatric Society criteria8
Fever >38.0°C twice 30 min apart or ≥39°C at least >38.0°C
oncea + 2 other signs
+ 1 other sign
Fetal tachycardia >160 beats/min for ≥10 min No specific criteria
Leukocytosis >15 000 WBCs/mm3 in absence of No specific criteria
corticosteroids
Amniotic fluid Purulent fluid from cervical os Foul/purulent
Fundal tenderness — No specific criteria
Maternal tachycardia — No specific criteria
Biochemical or microbiological amniotic Positive Gram stain for bacteria, low glucose, —
fluid results consistent with microbial high WBC count in absence of a bloody tap,
invasion of the amniotic cavity or positive culture
a
As per ACOG 2017 committee opinion, a temperature ≥39°C with no other clinical signs or symptoms should be considered clinical chorioamnionitis.
ACOG: American College of Obstetrics and Gynecology; NICHD: National Institute for Child and Human Development; WBC: white blood cell.

administrative. “Reference” antibiotics were those recom-
mended by ACOG: ampicillin and gentamicin for patients
not allergic to penicillin, cefazolin and gentamicin for
patients mildly allergic to penicillin, and clindamycin or
vancomycin in combination with gentamicin for patients
with severe penicillin allergy.10 If gentamicin was unavail-
able, it was replaced with tobramycin.
The online survey was hosted by the Maternal-Infant Care
Research Center (Ontario; http://www.micare.ca). Each
site investigator received by email an internet link to access
the informed consent form and the survey questionnaire.
Respondents could review and change their answers before
submitting them.
Descriptive statistics used to summarize the survey find-
ings were calculated using a Microsoft Excel spread-
sheet. Categorical variables were presented as
proportions, including the percentage of sites using diag-
nostic criteria and antibiotics as per current ACOG/
CPS guidelines compared to other cirteria and antibiotics
(Table 1).
The research ethics board of the CHU Sainte-Justine
approved the survey and its distribution.
RESULTS
Twenty-four of the 29 sites (82.8%) completed and
returned the questionnaire. Four participating sites were in
the Atlantic provinces, 13 were in Central Canada, 4 were
in the Prairie provinces, and 3 were on the West Coast.
Overall, 2 sites reported using diagnostic criteria for cho-
rioamnionitis from a clinical protocol, 2 reported using
preprinted orders for antibiotherapy for clinical chorioam-
nionitis, and one site reported using both.
Diagnostic Criteria
The use of different diagnostic criteria for clinical cho-
rioamnionitis was frequent or very frequent at 9 sites
(40.9%) and occasional or rare at 10 sites (45.4%). Three
sites (13.6%) were uncertain about local practices, and data
were missing for 2 sites. The most commonly used defini-
tion of fever in labour was a single oral temperature of
≥38.0°C (9 sites), which is consistent with the CPS

Table 2. Clinical criteria used for diagnosis of clinical chorioamnionitis among 23 sites of the Preterm Birth Network
No. (%) of sites
Signs or symptoms Yes, always Yes, treating physician dependant No
Uterine tenderness 3 (13.0) 17 (73.9) 3 (13.0)
Maternal tachycardia 9 (39.1) 14 (60.9) 0 (0)
Fetal tachycardia 13 (56.5) 8 (34.8) 2 (8.7)
Foul/purulent amniotic fluid 13 (56.5) 9 (39.1) 1 (4.3)
Maternal leukocytosis 3 (13.0) 13 (56.5) 7 (30.4)

30  JANUARY JOGC JANVIER 2022

 A Survey on Variation in Diagnosis and Treatment of Chorioamnionitis in Tertiary Centres in Canada
Table 3. Investigations for clinical chorioamnionitis
Investigations Always/most of the time
White blood cell count 14 (63.6)
C-reactive protein 1 (4.5)
Interleukin-6 1 (4.5)
Blood culture 12 (54.5)
Urine culture 7 (31.8)
Amniotic fluid culture 1 (4.5)
Amniotic fluid Gram staining 1 (4.5)
Amniotic fluid markers 0 (0)
Placental histology 15 (68.2)
Placental culture 6 (27.3)
guidelines. Seven sites (30.4%) reported using more than
one definition, one site reported using ACOG criteria, 4
sites (17.2 %) had no standard criteria, and the 3 sites that
used diagnostic criteria from clinical protocols had differ-
ent definitions.
At 14 sites (58.3%), isolated fever was most often an indi-
cation to initiate empiric antibiotic therapy. Maternal tachy-
cardia, foul or purulent amniotic fluid, fetal tachycardia,
and maternal leukocytosis were the other diagnostic criteria
used (Table 2). Duration of membrane rupture was a crite-
rion at 2 sites. Twelve sites did not report how many clini-
cal criteria in addition to maternal fever were used to
diagnose chorioamnionitis. Three sites (12.5 %) indicated
using one other clinical criterion, 4 (16.7 %) indicated using
2 other clinical criteria, and 5 (20.8 %) did not have stan-
dard practices. The majority (91.3%) of sites reported
using the same diagnostic criteria for preterm pregnancies
as for term pregnancies, always or most of the time. Pla-
cental histology was the most common method used to
confirm chorioamnionitis (15 of 22 sites), followed by
complete blood cell count (14 of 22 sites) and blood cul-
ture (12 of 22 sites) (Table 3).
Antibiotic Therapy
Twenty-three of 24 sites provided information regarding
choices of empirical antibiotic therapy for chorioamnioni-
tis. Only 3 sites reported using “always the same” antibiotic
therapy, 2 of which used preprinted orders. Fifteen sites
reported that antibiotic therapy differed from patient to
patient “occasionally” or “rarely” for the same diagnosis,
and 3 sites reported that antibiotic therapy differed “fre-
quently” or “very frequently,” even at one site with pre-
printed orders.
No. (%) of sites; n = 22
Sometimes/rarely Never
8 (36.4) 0 (0)
13 (59.1) 8 (36.4)
2 (9.1) 19 (86.4)
10 (45.5) 0 (0)
11 (50.0) 4 (18.2)
9 (40.9) 12 (54.5)
9 (40.9) 12 (54.5)
5 (22.7) 17 (77.3)
7 (31.8) 0 (0)
14 (63.6) 2 (9.1)
For patients not allergic to penicillin, ampicillin was by far
the most frequently prescribed treatment (15 of 23 sites;
65.2%), followed by metronidazole (10 of 23 sites; 43.5%)
and gentamicin (7 of 23; 30.4%) (Figure A;
online Appendix). Overall, 52.1% of sites indicated “always”
or “mostly” using antibiotic therapy corresponding to first-
line ACOG treatments, namely ampicillin/aminoglycoside,
with 4 sites adding either clindamycin or metronidazole to
this combination. The second most common antibiotic ther-
apy was cefazolin and metronidazole (17.4%).
Antibiotic therapies for patients who are allergic to penicillin
are shown in Figure B and the online Appendix. Clindamycin
was the most prescribed antibiotic (14 sites) always in combi-
nation with another antibiotic, preferentially an aminoglyco-
side. A combination of metronidazole and gentamicin was
also frequently used for patients with severe penicillin allergy,
and the recommended alternative, vancomycin/aminoglyco-
side, was used at one site only. The combination of cefazolin
and gentamicin was used at 4 sites as per ACOG recommen-
dations for patients with mild penicillin allergy.
The most frequently used time points of antibiotic cessa-
tion were 24 hours after return to apyrexia (12 sites),
24 hours after initiation of antibiotics (4 sites), immediately
after delivery (3 sites), and after one postpartum dose
(1 site). One site reported discontinuing antibiotics
24 hours after return to apyrexia, but only if blood cultures
were negative, and 3 sites reported no consensus on when
to terminate antibiotic treatment.
DISCUSSION
Our study shows that considerable differences exist in
practices for diagnosing and managing clinical
JANUARY JOGC JANVIER 2022  31
OBSTETRICS  OBSTÉTRIQUE
Figure. Antibiotics used for clinical chorioamnionitis in women without (A) and with (B) penicillin allergy.
chorioamnionitis in tertiary care centres in Canada. Similar
results have been reported for the United States by the
Collaborative Ambulatory Network.13 Given that effective
diagnostic and treatment measures exist, these results
underscore the difficulties associated with implementing
guidelines once they have been published.
The most common criterion for the diagnosis of cho-
rioamnionitis and initiation of empiric antibiotic therapy
during labour was a single oral temperature ≥38°C, a prac-
tice that leads to unnecessary antibiotic treatment for
patients with fever of non-infectious origin (e.g., with use
of epidural analgesia)4−6 and to overestimates of the preva-
lence of actual chorioamnionitis.
With NICHD/AGOG criteria, the sensitivity and specific-
ity of diagnosis of clinical chorioamnionitis for confirmed
chorioamnionitis has been reported to be 71.4% and
40.5%, respectively.14 This could also lead to unnecessary
antibiotic treatment in some patients and no treatment in
patients who warrant it.14 This is particularly concerning
for preterm deliveries, 40% to 70% of which may be asso-
ciated with histologically confirmed chorioamnionitis and
higher baseline rates of adverse neonatal outcomes.15,16
This suggests that less stringent criteria for the diagnosis
of chorioamnionitis should be used in preterm deliveries.
However, we found that 91.3% of sites use the same diag-
nostic criteria for term and preterm deliveries, perhaps
necessarily so given that none are specific for the latter.
ACOG recommends that confirmatory diagnoses be based
on a positive amniotic fluid test or placental pathology with
histologic evidence of infection or inflammation.10 However,
placental histologic examination is costly and not carried out
32  JANUARY JOGC JANVIER 2022
in all maternity centres in Canada, and amniotic fluid testing
is rarely performed. Regardless, findings from placental histol-
ogy are available postpartum and are of little value when time-
sensitive clinical decisions need to be made at the bedside.
We saw considerable differences across sites in the choice of
antibiotics, the duration of antibiotic treatment, and the crite-
ria determining treatment cessation. The difficulties in estab-
lishing antibiotic treatment guidelines for chorioamnionitis
from the available literature have been described elsewhere.17
Broad antimicrobial coverage has to be ensured owing to the
polymicrobial nature of this disease, and alternative recom-
mended regimens based on local antibiotic resistance patterns
are suggested in the ACOG guidelines.10 In our survey, and
consistent with ACOG guidelines, ampicillin/aminoglycoside
was the most frequently used broad-spectrum antibiotic com-
bination. This was followed by cefazolin/metronidazole,
which ensures similar coverage and may be a reasonable alter-
native.11 Some sites that participated in this survey are now
studying patterns of antimicrobial resistance in their commu-
nities to inform their choice of antibiotic combinations.
The duration of antibiotic therapy remains a subject of
debate. Based on 2 randomized controlled trials,18,19 ACOG
recommends discontinuing antibiotics immediately after
delivery for vaginal births, provided no other maternal risk
factors such as bacteremia or persistent fever are present,7
yet this was practiced at only 3 sites. Two other randomized
controlled trials showed no difference in the rate of endome-
tritis and postpartum fever between women who received a
single antibiotic dose after delivery and those who continued
antibiotics until afebrile for 24 hours.20,21 In our study most
sites reported continuing antibiotics for 24 hours after apyr-
exia. We believe that either a single-dose antibiotic or no
 A Survey on Variation in Diagnosis and Treatment of Chorioamnionitis in Tertiary Centres in Canada
antibiotics should be the standard of care for postpartum
treatment of women with clinical chorioamnionitis.
Our study should be considered in the context of certain
limitations. First, it involved only tertiary care centres, and
results cannot be generalized to all obstetric centres. Sec-
ond, we surveyed only one obstetrics/MFM specialist at
each site, and accuracy in reporting could have been
improved with more respondents. Finally, although we had
a high participation rate (82.8%), it is possible that we had
a small nonresponse bias.
CONCLUSION
This study demonstrates that there is considerable variabil-
ity in diagnostic and treatment practices for chorioamnioni-
tis in Canada and emphasizes the importance of educating
practitioners about this condition. Implementation of clini-
cal protocols and standing orders for treating chorioam-
nionitis, based on current evidence and local antimicrobial
data, should be prioritized to improve practices and health
outcomes in pregnant women and neonates.
Acknowledgements
The authors thank all MFM site investigators for their
participation and are grateful to Dr. Christian Band for
his careful review of the manuscript.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
at https://doi.org/10.1016/j.jogc.2021.06.003.
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