Funisitis is associated with adverse neonatal outcome in low-risk unselected deliveries at or near term

Association of maternal, fetal and labor variables with a low Apgar score in the fifth minute in term pregnancy: a case-control study

PURPOSE

To search for maternal, labor-related and fetal variables associated with low Apgar in the fifth minute in term pregnancy.

METHODS

A retrospective case-control study with term births was conducted in a public teaching hospital from 2013 to 2020. Cases were term births with Apgar score less than 7 in the fifth minute, and controls, the next one or two births following a case, with Apgar of 7 or more. Non-cephalic presentations, multiples and malformations were excluded. We accessed 100 cases and 190 controls. We considered significant values of p < 0.05.

RESULTS

Were accessed 27 variables which could be risk factors, from which 12 were associated with the outcome. We found a protective effect of prelabor cesarean for the outcome, odds ratio (OR) 0.38, p = 0.013. Consequently, we conducted two sets of analyses: in the whole group and in the group of laboring women. The values of OR were in general greater in the group of laboring women, compared with the whole group. We conducted multivariate analysis within the group of women in labor. The variables which fitted best in the model were nulliparity, male sex of the fetus, less than six prenatal visits and abnormal cardiotocography; all remained significant. An association of rupture of membranes more than 360 min with the outcome, even after controlling fpr duration of labor, was found; adjusted OR 2.45, p = 0.023.

CONCLUSION

Twelve variables were associated with the outcome. Prelabor cesarean had a protective effect. The time of ruptured membranes was associated with low Apgar.

Maternal and peripartum risk factors for acute funisitis among term deliveries complicated by intraamniotic infection

BACKGROUND

Acute funisitis-the histologic diagnosis of inflammation within the umbilical cord-represents a fetal inflammatory response and has been associated with adverse neonatal outcomes. Little is known regarding the maternal and intrapartum risk factors associated with the development of acute funisitis among term deliveries complicated by intraamniotic infection.

OBJECTIVE

This study aimed to identify the maternal and intrapartum risk factors associated with developing acute funisitis among term deliveries complicated by intraamniotic infection.

STUDY DESIGN

After institutional review board approval, we conducted a retrospective cohort study of term deliveries affected by clinical intraamniotic infection at a single tertiary center between 2013 and 2017, with placental pathology consistent with histologic chorioamnionitis. The exclusion criteria included intrauterine fetal demise, missing delivery information or placental pathology, and documented congenital fetal abnormalities. Maternal sociodemographic, antepartum, and intrapartum factors were compared among patients with acute funisitis on pathology to those without acute funisitis using bivariate statistics. Regression models were developed to estimate the adjusted odds ratios.

RESULTS

Of 123 patients meeting the inclusion criteria, 75 (61%) had acute funisitis on placental pathology. Compared with placental specimens without acute funisitis, acute funisitis was observed more frequently among patients with maternal BMI ≥30 kg/m2 (58.7% vs 39.6%, P=.04) and labor courses with increased rupture of membrane duration (17.3 vs 9.6 hours, P=.001). Use of fetal scalp electrode was observed less frequently in acute funisitis (5.3% vs 16.7%, P=.04) than cases without acute funisitis. In regression models, maternal BMI ≥30 kg/m2 (adjusted odds ratio, 2.67; 95% confidence interval, 1.21-5.90) and rupture of membrane >18 hours (adjusted odds ratio, 2.48; 95% confidence interval, 1.07-5.75) were significantly associated with acute funisitis. Fetal scalp electrode use (adjusted odds ratio, 0.18; 95% confidence interval, 0.04-0.71) was negatively associated with acute funisitis.

CONCLUSION

In term deliveries with intraamniotic infection and histologic chorioamnionitis, maternal BMI ≥30 kg/m2, and rupture of membrane>18 hours were associated with acute funisitis on placental pathology. As insight into the clinical impact of acute funisitis grows, the ability to predict which pregnancies are at the greatest risk for its development may allow for a tailored approach to predicting neonatal risk for sepsis and related comorbidity.

Does acute funisitis predict worse neonatal outcomes among term newborns?

BACKGROUND

Acute funisitis-the histologic diagnosis of inflammation within the umbilical cord-represents a fetal inflammatory response to infection. Although acute funisitis has been associated with an increased risk of adverse outcomes among preterm neonates, there are limited and conflicting data with term deliveries.

OBJECTIVE

This study aimed to evaluate the association between acute funisitis and neonatal morbidity in neonates born at term to pregnant patients with a clinical diagnosis of intraamniotic infection.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients who had clinically diagnosed intraamniotic infection at term, delivered vaginally at a single tertiary institution from 2013 to 2019, and had histologic chorioamnionitis on placental pathology. Patients with intrauterine fetal demise or missing neonatal/placental pathology data were excluded. The primary outcome was a neonatal sepsis composite, defined as culture-positive bacteremia, neutropenia (absolute neutrophil count<3500/μL), or immature-to-total neutrophil ratio>0.2. The secondary outcomes included composite neonatal morbidity, defined as neonatal intensive care unit admission, 5-minute Apgar score <7, bacteremia, endotracheal intubation or need for continuous positive airway pressure, intraventricular hemorrhage (grade 3 or 4), necrotizing enterocolitis (stage 3 or 4), umbilical artery pH<7.1, umbilical artery base excess>12, and neonatal mortality. The components of these composites, neonatal intensive care unit length of stay, and Kaiser early-onset sepsis score were also measured. Neonates with acute funisitis on pathology were compared with those without acute funisitis using bivariate statistics. Regression was used to estimate the relative risk of outcomes.

RESULTS

Of 184 neonates with deliveries complicated by intraamniotic infection, acute funisitis was present in 109 (59%) placental specimens. Composite neonatal sepsis was significantly higher among neonates with acute funisitis (relative risk, 1.85; 95% confidence interval, 1.13-3.03) than in those without acute funisitis. As a marker for sepsis, acute funisitis has a sensitivity of 39.4%, negative predictive value of 47.2%, specificity of 78.7%, and positive predictive value of 72.9%. An immature-to-total neutrophil ratio>0.2 (relative risk, 1.83; 95% confidence interval, 1.09-3.08) was also significantly associated with acute funisitis. Neonatal morbidity composite, intraventricular hemorrhage, necrotizing enterocolitis, neonatal intensive care unit admission, higher Kaiser early-onset sepsis scores, and other examined outcomes were not statistically associated with acute funisitis.

CONCLUSION

In term deliveries complicated by intraamniotic infection, acute funisitis was associated with increased neonatal sepsis. Current approaches for estimating neonatal sepsis risk are limited by their reliance on indirect maternal factors such as maximum maternal temperature and intrapartum antibiotic use. This study suggests that acute funisitis may serve as a marker that could be utilized to augment risk stratification at birth if a protocol for evaluating the umbilical cord in real-time were widely adopted.

Placental pathology in spontaneous and iatrogenic preterm birth: Different entities with unique pathologic features

INTRODUCTION

Placental pathology is an important contributor to the understanding of preterm birth and reveals major differences between spontaneous preterm birth (SPTB) and iatrogenic preterm birth (IPTB). The aim of this study was to investigate these relationships.

METHODS

Research midwives collected placentas from 1101 women with singleton pregnancies who were enrolled in the Safe Passage Study. Trained pathology technologists prepared and processed placenta specimens for macroscopic and microscopic examination by designated pathologists. Statistical analyses were done with STATISTICA version 13.

RESULTS

In SPTB we found more cases of accelerated villous maturation; however, the other features of maternal vascular malperfusion (MVM) were not present. The prevalence rate of funisitis was also increased. In IPTB, multiple features of MVM - accelerated villous maturation, distal villous hypoplasia, decidual arteriopathy, increased syncytial knots, increased perivillous fibrin, and prominent extravillous trophoblast were increased, as were features of fetal vascular malperfusion (FVM) - umbilical cord vessel thrombosis, avascular villi, and fetal vascular thrombosis. Increased syncytial knots were found in 26% of preterm stillbirths and in 29% of preterm infant demises as compared to 81% of IPTB infants alive at one year.

DISCUSSION

SPTB and IPTB differ. The detected "abnormal" accelerated villous maturation pattern in SPTB and preterm demises, suggests an inability of the placenta to adapt and may be a trigger for SPTB. Funisitis was the only inflammatory response significant for SPTB. MVM and FVM are implicated in IPTB, but not an inflammatory process.

Labor dystocia and risk of histological chorioamnionitis and funisitis: a study from a single tertiary referral center

Background

Intrauterine inflammation affects short- and long-term neonatal outcomes. Histological chorioamnionitis and funisitis are acute inflammatory responses in the fetal membranes and umbilical cord, respectively. Although labor dystocia includes a potential risk of intrauterine inflammation, the risk of histological chorioamnionitis and funisitis of labor dystocia has not been evaluated yet. This study aimed to examine the association between labor dystocia and risk of histological chorioamnionitis and funisitis.

Methods

In this retrospective cohort study, the cases who underwent histopathological examinations of the placenta and umbilical cord at Fukushima Medical University Hospital, Japan, between 2015 and 2020, were included. From the dataset, the pathological findings of the patients with labor dystocia and spontaneous preterm birth were reviewed. Based on the location of leukocytes, the inflammation in the placenta (histological chorioamnionitis) and umbilical cord (funisitis) was staged as 0–3. Multiple logistic regression analysis was performed to evaluate the risk of histological chorioamnionitis, histological chorioamnionitis stage ≥2, funisitis, and funisitis stage ≥2.

Result

Of 317 women who met the study criteria, 83 and 144 women had labor dystocia and spontaneous preterm birth, respectively, and 90 women were included as controls. Labor dystocia was a risk factor for histological chorioamnionitis (adjusted odds ratio, 6.3; 95% confidential interval, 1.9–20.5), histological chorioamnionitis stage ≥2 (adjusted odds ratio, 6.0; 95% confidence interval, 1.7–21.8), funisitis (adjusted odds ratio, 15.4; 95% confidence interval, 2.3–101.3), and funisitis stage ≥2 (adjusted odds ratio, 18.5; 95% confidence interval, 2.5–134.0). Spontaneous preterm birth was also a risk factor for histological chorioamnionitis (adjusted odds ratio, 3.7; 95% confidence interval, 1.7–7.8), histological chorioamnionitis stage ≥2 (adjusted odds ratio, 3.0; 95% confidence interval, 1.2–7.9), and funisitis (adjusted odds ratio, 6.6; 95% confidence interval, 1.4–30.6). However, the adjusted odds ratio was smaller in spontaneous preterm births than in labor dystocia.

Conclusion

Labor dystocia is a risk factor for severe histological chorioamnionitis and funisitis. Further studies are required to evaluate the effects of histological chorioamnionitis and funisitis on long-term neonatal outcomes.

Evaluation for the etiology of neonatal encephalopathy and the diagnosis of FIRS

A common disorder managed in the neonatal intensive care unit (NICU) is neonatal encephalopathy (NE). There are multiple causes of NE, including hypoxic-ischemic encephalopathy (HIE) and the fetal inflammatory response syndrome (FIRS). It is important to ascertain the specific cause of NE in an affected child, as it may affect the clinical management and will assist in prognostication. This paper discusses the background of inflammatory damage to the fetal brain, the history of FIRS as a clinical diagnosis, the characteristics of infants with FIRS, and methods to evaluate the etiology of NE.

The epidemiology of FIRS in term and late preterm births

The definition of FIRS requires systemic inflammation and elevated levels of IL-6 in fetal plasma. That definition does not specify how systemic inflammation is to be recognized, and perinatal measurement of IL-6 is not a standard procedure. FIRS has not been examined in a population-based study that included post-neonatal outcome so its incidence and natural history are not known. The overlap, and similarities and differences, of FIRS as compared with other causes of neonatal encephalopathy, and how these relate to findings in the placenta, have not been jointly examined in a generalizable sample. FIRS has chiefly been discussed in the obstetric literature because of the need for decisions about management of delivery and antibiotic use. If the term "FIRS" is to be employed in other contexts, consensus should be sought as to which clinical, placental, and laboratory findings are most appropriate for identification of perinatal inflammatory processes, infectious or sterile.

Acute Funisitis Correlates With the Risk of Early-Onset Sepsis in Term Newborns Assessed Using the Kaiser Sepsis Calculator

BACKGROUND

The risk of neonatal early-onset sepsis (EOS) is traditionally assessed on maternal signs of clinical chorioamnionitis. Recently, an online EOS risk calculator was developed by Kaiser Permanente using maternal and neonatal clinical parameters. We were interested in whether an increased Kaiser sepsis risk score correlates with histologic acute chorioamnionitis or acute funisitis.

DESIGN

Included in this retrospective review are 119 chorioamnionitis-exposed term neonates from January 1, 2015 and December 31, 2016. Clinical charts from mother-baby pairs were reviewed. An EOS risk score was obtained using the online Kaiser Sepsis Calculator. The presence and severity of acute chorioamnionitis and acute funisitis were recorded. A SPSS software was used for statistical analysis (IBM, New Jersey, USA).

RESULTS

The Kaiser Sepsis Calculator could identify 97 of 119 (81.5%) neonates without increased risk for sepsis. Histologic acute chorioamnionitis was present in 100 of 119 cases (84%), in which 44 cases (44%) show severe acute chorioamnionitis. Acute funisitis was recognized in 87 of 119 (73.1%) cases, all of which had concurrent acute chorioamnionitis. Severe funisitis was seen in 38 of the 87 cases (43.7%). The Kaiser Sepsis risk score correlates with the presence and severity of acute funisitis (P = .037 and P = .044, respectively) but not with the presence or the severity of acute chorioamnionitis (P = .105 and P = .672, respectively).

CONCLUSION

Our study provides histological evidence to support that the Kaiser Sepsis Calculator may help to effectively reduce unwarranted blood culture, antibiotics exposure, and neonatal intensive care unit admission in term neonates.

Association between clinical chorioamnionitis and histological funisitis at term

To predict the presence of histological funisitis at term, we examined the symptoms of clinical chorioamnionitis in 251 cases of maternal fever of 38 degrees or higher during labor at term. The examined symptoms in this study were clinical maternal findings (uterine fundal tenderness, maternal tachycardia, purulent or foul amniotic fluid or cervical discharge, and maternal white blood cell count) and fetal tachycardia. In these cases, microscopic histopathological analysis of the placenta was performed after delivery. The positive predictive value for histological funisitis in cases of maternal fever of 38 degrees or higher was only 15.5%. In cases of maternal fever with uterine fundal tenderness and purulent or foul amniotic fluid or cervical discharge at term, the positive predictive value for histological chorioamnionitis was 100%. Therefore, uterine fundal tenderness and amniotic fluid or cervical discharge with a foul odor are important symptoms to predict the presence of funisitis in cases of maternal fever of 38 degrees or higher.

Association Between Funisitis and Childhood Intellectual Development: A Prospective Cohort Study

Background: Previous studies have suggested that prenatal inflammation could damage the immature brain of preterm infants. In this study, we aimed to investigate whether funisitis could affect childhood neurodevelopment. We hypothesized that childhood neurodevelopment would vary across groups with or without funisitis.

Material sand Methods: Using data from the U.S. Collaborative Perinatal Project (1959–1976), 29,725 subjects with available intelligence quotient (IQ) were studied. Detailed placental examinations were conducted according to a standard protocol with quality control procedures. Multivariate logistic regression models were applied to evaluate the relationship between funisitis and IQ at age 4 or 7 years after adjusting for confounders.

Results: Early preterm birth children with funisitis had a 3.0-fold (95% confidence interval 1.2, 7.3) risk of low full-scale IQ (<70) at age 4 years, which disappeared until age 7 years. Term birth children with funisitis had 1.9-fold (95% confidence interval 1.2, 3.0) risk of low performance IQ at age 7 years, but they did not have increased risk of low full-scale IQ. No difference in IQ score was found in late preterm birth children.

Conclusion: Funisitis may injure the developmental brain of infants, leading to the relative low IQ in childhood at age 4, but the negative effect is only existed in performance IQ at age of 7.

Isolated acute funisitis in the absence of acute chorioamnionitis: What does it mean?

OBJECTIVE

Acute funisitis (AF) is most commonly associated with acute chorioamnionitis (AC) and ascending infection. The significance of cases of AF without associated AC or isolated funisitis (IF) is unknown. Our objective was to evaluate clinical and pathologic features of IF and to determine its significance.

STUDY DESIGN

This was a retrospective review of placentas of patients delivering at our institution from 1997 to 2017. Placentas with the diagnosis of IF comprised the study population and placentas without either AF or AC served as controls.

RESULTS

There were 156 cases and 181 controls identified. Maternal age, gestational age, birthweight and mode of delivery were similar in both groups. 132 (84.6%) of cases of IF had meconium, with 62 (47.0%) having meconium only in the membranes, 36 (27.3%) in the membranes and cord and 34 (25.6%) in the membranes and cord with associated myonecrosis. 72 (38.7%) of controls had microscopically identified meconium, with only one (1.4%) showing meconium in the cord. None had myonecrosis (p < .001). There was also a significantly higher rate of intrauterine fetal demise (IUFD) in the IF group (p = .027). but the rate of suspected Intrauterine growth restriction (IUGR) was significantly greater in the controls (p = .014).

CONCLUSION

IF is highly associated with the presence of meconium discharge and meconium-associated myonecrosis of umbilical vessels. The inflammation in IF may be the result of damage to the muscle fibers of the cord due to meconium but additional studies are necessary to understand the significance of these findings.

Defense and infection of the human placenta

The placenta functions as a shield against infection of the fetus. The innate and adaptive immune defenses of the developing fetus are poorly equipped to fight infections. Infection by bacteria, viruses, and protozoa may cause infertility, spontaneous abortion, stillbirth, growth retardation, anomalies of development, premature delivery, neonatal morbidity, and mortality. However, appreciation of the human microbiome and host cell-microbe interactions must be taken into consideration as we try to determine what interactions are pathologic. Infection is typically recognized histologically by the presence of inflammation. Yet, several factors make comparison of the placenta to other human organs difficult. The placenta comprises tissues from two persons, complicating the role of the immune system. The placenta is a temporary organ. It must be eventually expelled; the processes leading to partuition involve maternal inflammation. What is normal or pathologic may be a function of timing or extent of the process. We now must consider whether bacteria, and even some viruses, are useful commensals or pathogens. Still, recognizing infection of the placenta is one of the most important contributions placental pathologic examination can give to care of the mother and neonate. This review provides a brief overview of placental defense against infection, consideration of the placental microbiome, routes of infection, and the histopathology of amniotic fluid infection and TORCH infections.

Placental Lesions in Meconium Aspiration Syndrome

Background

Meconium aspiration syndrome (MAS) is defined by respiratory distress requiring supplemental oxygen in a meconium-stained neonate. MAS is clinically subclassified as mild, moderate, and severe according to the oxygen requirement. The aims of this study were to compare the histological findings in the placentas of MAS neonates with those of meconium-stained but non-MAS neonates and to analyze the correlation between the severity of MAS and the grade of its histological parameters.

Methods

We collected 160 singleton term placentas from neonates with meconium staining at birth from a tertiary medical center, Seoul, Republic of Korea. We reviewed hematoxylin and eosin sections of tissue samples (full-thickness placental disc, chorioamniotic membranes, and umbilical cord).

Results

Funisitis was present more frequently in MAS than in non-MAS (p < .01), of which the stage was correlated with the severity of MAS (p < .001). The histological findings consistent with maternal underperfusion and chronic deciduitis were more frequent in MAS than in non-MAS (p < .05). There was a correlation between the degree of chorionic vascular muscle necrosis and the severity of MAS (p < .05).

Conclusions

Our results suggest that fetal inflammatory response evidenced by funisitis occurs prenatally in MAS and that the stage of funisitis and of chorionic vascular muscle necrosis may be a predictive marker of the severity of MAS.