A first look at chorioamnionitis management practice variation among US obstetricians

In premature rupture of membranes, maternal serum delta neutrophil index may be a predictive factor for histological chorioamnionitis and affect fetal inflammatory markers: A retrospective cross-sectional study

PROBLEM

We aimed to investigate the predictive value of delta neutrophil index (DNI) for histological choriomanionitis (HCAM) and the effect of maternal inflammatory markers on neonatal outcomes and fetal inflammatory parameters.

METHOD OF STUDY

In this retrospective cross-sectional study, 68 pregnant women without HCAM (group 1) and 46 pregnant women diagnosed with HCAM (group 2) were divided into two groups. Demographic stories of the groups; maternal hematological parameters; maternal DNI and systemic inflammatory index (SII) values; outcomes of newborns; fetal inflammatory markers were recorded and compared between groups.

RESULTS

Maternal DNI, and SII levels were significantly higher in group 2 (p value < .05 for all). Admission to the neonatal unit (NICU) was higher in group 2 than in group 1 (p = .0001). We found that fetal inflammatory markers were significantly higher in group 2 (p values .001 for CRP, .0001 for DNI, and .002 for leukocyte). Maternal DNI was determined to be significantly diagnostic at a value of ≥1.3 in HCAM (p = .001). We observed that SII had a significant predictive value of 953036.6 (p = .019) for NICU admission. There is also a positive correlation between fetal inflammatory markers and maternal inflammatory markers.

CONCLUSIONS

We found that maternal inflammatory markers are high in HCAM, maternal DNI can predict patients who will develop HCAM, maternal SII value can predict NICU admission, fetal inflammatory markers are high in HCAM, and these markers are affected by maternal inflammatory markers.

Development and validation of a nomogram for individualized prediction of spontaneous extremely preterm birth at < 28 weeks in twin pregnancy: a retrospective cohort study

PURPOSE

To develop a nomogram to predict spontaneous preterm birth at < 28 weeks in pregnant women with twin pregnancies.

METHODS

We retrospectively studied the medical records of twin-pregnancy women with asymptomatic cervical dilation or cervical shortening between December 2015 to February 2022 in two hospitals. Data from one center was used to develop the model and data from the other was used to evaluate the model.

RESULTS

A total of 270 twin pregnancies were enrolled in the study. We incorporated 4 items (cervical length, cervical dilation, C-reactive protein and the use of cerclage) to build the 28-week nomogram with satisfactory discrimination and calibration when applied to the validation sets. The C index for the 28-week nomogram in the development and external cohort was 0.88 (95% CI, 0.84-0.93) and 0.89 (95% CI, 0.80-0.98), respectively. The nomogram reached a sensitivity of 70.70%, specificity of 97.10%, positive predicted value of 95.61% and negative predicted value of 78.77%. Moreover, the decision curve analysis indicated that the nomogram showed positive clinical benefit.

CONCLUSION

We developed and validated a nomogram with good performance in predicting individual risk of spontaneous preterm birth at < 28 in twin pregnancy.

Laboratory markers to identify acute histological chorioamnionitis in febrile parturients undergoing epidural analgesia: a retrospective study

BACKGROUND

This study aimed to investigate the effect of the pathological staging of acute histological chorioamnionitis (HCA) on laboratory indicators and to conduct further studies to reassess the threshold values used by clinicians to identify acute HCA in febrile parturients undergoing epidural analgesia.

METHODS

A retrospective study of febrile mothers receiving epidural analgesia at Nanjing Maternal and Child Health Care Hospital from January 1, 2018 to December 31, 2018. The participants were grouped by the progression of acute HCA, and the laboratory parameters were compared between groups. The ability of C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), and monocyte-leukocyte ratio (M%), alone or in combination, to identify acute HCA in febrile parturients undergoing epidural analgesia was assessed using logistic regression and ROC curves.

RESULTS

The area under the curve (AUC) of the best logistic regression model predicting HCA climbed to 0.706 (CRP + MLR). Maternal CRP, NLR, and MLR significantly and progressively increased with the progression of acute HCA (p < 0.0001). Based on the ROC curves, the following thresholds were selected to define increased laboratory indicators for identifying acute HCA: CRP ≥ 6.90 mg/L, NLR ≥ 11.93, and MLR ≥ 0.57. In addition, the AUC of the best logistic regression model predicting HCA ≥ stage 2 was 0.710, so these inflammatory markers were more precise in predicting HCA ≥ stage 2.

CONCLUSION

Increased CRP (≥ 6.90 mg/L), NLR (≥ 11.93), and MLR (≥ 0.57) may help clinicians to identify early potential acute HCA in febrile parturients receiving epidural analgesia and to monitor progression to optimize clinical treatment options.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry on November 24, 2021 ( http://www.chictr.org.cn , ChiCTR2100053554).

Evaluation of a clinical protocol for the management of fever in labor among pregnant women at term: A quality-improvement study

OBJECTIVE

To assess the impact of a quality-improvement initiative designed to increase diagnostic accuracy and adequate management of clinical chorioamnionitis (CC) at a tertiary center. Chorioamnionitis occurs in 1%-13% of term pregnancies and increases maternal and neonatal peripartum complications; often over-diagnosed, it leads to unnecessary investigations and treatments.

METHODS

This was an interrupted time-series study. In September 2017 two interventions were implemented: (1) staff training and (2) standardized clinical protocol for the management of fever in labor. All singleton term pregnancies were included. CC cases were reviewed in the pre-intervention (2015-2016, n = 179) and post-intervention (2017-2018, n = 142) groups. CC criteria based on the American College of Obstetricians and Gynecologists guidelines, antibiotics, maternal and neonatal outcomes, and pathology were compared. A cost-consequence analysis was performed.

RESULTS

Incidence of CC decreased from 8.2 to 5.6 per 10 person-year (P < 0.001). This was associated with a significant increase in diagnostic accuracy from 15.7% to 73.2% (P < 0.001). Weight-adjusted tobramycin dosage improved from 8.8% to 69.1% (P < 0.001). Maternal length of hospitalization and readmissions decreased significantly, without affecting neonatal sepsis rate. Interventions decreased yearly hospital costs associated with CC by 23.4%.

CONCLUSION

Standardizing the management of fever in labor significantly increased the diagnostic accuracy of CC and decreased the misuse of antibiotics in term pregnancies. CC costs decreased by 23.4%.

Association of clinical signs of chorioamnionitis with histological chorioamnionitis and neonatal outcomes

BACKGROUND

Chorioamnionitis is a risk factor for fetal and neonatal outcomes. Therefore, predicting histological chorioamnionitis (HCA) and neonatal outcomes using clinical parameters could be helpful in management and preventing morbidities.

OBJECTIVE

To determine if parameters of clinical chorioamnionitis (CCA) would be associated with HCA and neonatal outcomes.

STUDY DESIGN

In this cohort study using a retrospective design, we analyzed the performance of signs of CCA in predicting HCA, and neonatal outcomes. Data were extracted from the electronic health record for all neonates with documented CCA delivered at our institution from 2011 to 2016. We compared our findings based on the old ACOG definition of CCA and the new definition released in 2017 - maternal fever plus any of fetal tachycardia, maternal leukocytosis, and purulent vaginal discharge. Maternal tachycardia and uterine tenderness were removed from the new criteria. Neonatal laboratory samples on admission, 12 h and 24 h were used to define the three time points of neonatal suspected sepsis.

RESULTS

There were 530 mothers-infant dyads with chorioamnionitis. Seventy-three were preterm, and 457 were term. Eighty-eight percent of the preterm mothers had CCA, and HCA was present in 62.5% of 72 preterm placentas. Preterm infants with placental HCA significantly had lower birth weight, gestational age, placental weight, and more infants with lower 5-minute Apgar scores, compared to those with no HCA. In preterm infants, maternal urinary tract infection was significantly associated with decreased odds for HCA (OR 0.22, CI 0.10 - 0.71). More preterm babies with suspected sepsis criteria at the 3 time points had HCA (all p ≤ .01). In the term cohort, 95.4% and 65.6% had CCA and HCA, respectively. In term infants (n = 457), maternal leukocytosis (p = .002) and prolonged rupture of membranes (PROM; p = 002) were associated with HCA. Suspected sepsis was associated with PROM (p = .04), HCA (p = .0001), and maternal leukocytosis (p ≤ .05) in at least 1 of the 3 time points.

CONCLUSION

Though maternal leukocytosis was significantly associated with the presence of HCA in the term cohort, there were no CCA criteria that accurately predicted presence of HCA in either the preterm or the term infants.

The Association of Patent Ductus Arteriosus with Inflammation: A Narrative Review of the Role of Inflammatory Biomarkers and Treatment Strategy in Premature Infants

Patent ductus arteriosus (PDA) is a common cardiovascular complication that complicates clinical care in the intensive care of premature infants. Prenatal and postnatal infections and the inflammation process can contribute to PDA, and intrauterine inflammation is a known risk factor of PDA. A variety of inflammatory biomarkers have been reported to be associated with PDA. Chorioamnionitis induces the fetal inflammatory process via several cytokines that have been reported to be associated with the presence of PDA and may have a role in the vascular remodeling process or vessel dilation of the ductus. On the other hand, anti-inflammatory agents, such as antenatal steroids, decrease PDA incidence and severity in patients born to those with chorioamnionitis. Proinflammatory cytokines, which are expressed more significantly in preterm neonates and chorioamnionitis, are associated with the presence of PDA. In this review, we focus on the pathogenesis of PDA in preterm infants and the role of biomarkers associated with the perinatal inflammatory process.

Screening and diagnosis of women for chorioamnionitis: An integrative literature review

OBJECTIVE

This integrative literature review provides an overview of current best research evidence on the screening and diagnosis of women for chorioamnionitis, as no current review has been conducted. An overview of best practices on screening and diagnosis of women for chorioamnionitis can assist midwives with an accurate diagnosis, allowing for early referral and adequate management of this infection.

DESIGN

An integrative literature review was conducted using a systematic electronic literature search through EBSCOhost (CINAHL with Full Text, e-Book Collection, Health Source: Nursing/Academic Edition, MEDLINE, Open Dissertations and PsycINFO), Cochrane Online, PubMed, Scopus, followed by a manual search for grey literature using Google and a citation search. Guidelines, research studies, and reports in English related to chorioamnionitis from 2008 up until 2020 were included in the study.

FINDINGS

After critical appraisal, using the Joanna Briggs Institution's checklists, Evaluation Tool for Quantitative Research Studies' tool and the Appraisal of Guidelines for Research & Evaluation instrument, 31 articles were included. More than half (64%) of the literature included ranked on the three highest levels of evidence (Level I, II and III). Data extracted regarding screening and diagnosis of women for chorioamnionitis was synthesised into four themes, namely: screening by clinical signs and symptoms, screening by causative factors of chorioamnionitis, screening of obstetric history, and essential biomarkers to diagnose chorioamnionitis.

KEY CONCLUSIONS

Screening and recording of any risk factors will assist midwives in providing tailored health education to possibly prevent causative factors that could lead to chorioamnionitis. Although matrix-metalloproteinase-8 (MMP-8) seems the most suitable test to use for screening, an accurate diagnosis of chorioamnionitis requires a combination of screening methods and tests, such as clinical signs and symptoms, maternal biomarkers, amniotic fluid testing and histology. Screening for chorioamnionitis, particularly the parameters for maternal fever as a clinical symptom of chorioamnionitis, contributing factors and microbes responsible for chorioamnionitis, the usability of MMP-8 and the development of rapid, inexpensive, easy-to-use techniques for screening and diagnosis of chorioamnionitis, warrants further research.

IMPLICATIONS FOR PRACTICE

Findings can be used by midwives in the screening and diagnosis of women for chorioamnionitis which allows for early referral and adequate management before maternal and neonatal complications arise.

Animal Models of Chorioamnionitis: Considerations for Translational Medicine

Preterm birth is defined as any birth occurring before 37 completed weeks of gestation by the World Health Organization. Preterm birth is responsible for perinatal mortality and long-term neurological morbidity. Acute chorioamnionitis is observed in 70% of premature labor and is associated with a heavy burden of multiorgan morbidities in the offspring. Unfortunately, chorioamnionitis is still missing effective biomarkers and early placento- as well as feto-protective and curative treatments. This review summarizes recent advances in the understanding of the underlying mechanisms of chorioamnionitis and subsequent impacts on the pregnancy outcome, both during and beyond gestation. This review also describes relevant and current animal models of chorioamnionitis used to decipher associated mechanisms and develop much needed therapies. Improved knowledge of the pathophysiological mechanisms underpinning chorioamnionitis based on preclinical models is a mandatory step to identify early in utero diagnostic biomarkers and design novel anti-inflammatory interventions to improve both maternal and fetal outcomes.

Dominant bacteria and influencing factors of early intestinal colonization in very low birth weight infants: A prospective cohort study

Background

The intestine of newborns is colonized by bacteria immediately after birth. This study explored dominant bacteria and influencing factors of early intestinal colonization in the early life of very low birth weight infants (VLBWI).

Methods

We enrolled 81 VLBWI and collected anal swabs at 24 h, 7th, 14th and 21st day after birth. We conducted bacterial culture for anal swabs, then selected the colony with obvious growth advantages in the plate for further culture and identification. Afterward, we analyzed the distribution and influencing factors of intestinal dominant microbiota combined with clinical data.

Results

A total of 300 specimens were collected, of which 62.67% (188/300) had obvious dominant bacteria, including 29.26% (55/188) Gram‐positive bacteria and 70.74% (133/188) Gram‐negative bacteria. The top five bacteria with the highest detection rates were Klebsiella pneumoniae, Escherichia coli, Enterococcus faecium, Enterococcus faecalis and Serratia marcescens. Meconium‐stained amniotic fluid and chorioamnionitis were correlated with intestinal bacterial colonization within 24 h of birth. Mechanical ventilation and antibiotics were independent risk factors affecting colonization. Nosocomial infection of K. pneumoniae and S. marcescens were associated with intestinal colonization. The colonization rates of K. pneumoniae, E. coli, E. faecium, and E. faecalis increased with the birth time.

Conclusions

The colonization rate in the early life of VLBWI increased over time and the predominant bacteria were Gram‐negative bacteria. Meconium‐stained amniotic fluid and chorioamnionitis affect intestinal colonization in early life. Mechanical ventilation and antibiotics were independent risk factors for intestinal bacterial colonization. The nosocomial infection of some bacteria was significantly related to intestinal colonization.

Clinical chorioamnionitis and histologic placental inflammation: association with early-neonatal sepsis

OBJECTIVE

Chorioamnionitis and fetal inflammatory response syndrome (FIRS) are significant risk factors for early onset sepsis (EOS). Recently, the use "Intrauterine Inflammation or Infection or both" or triple I has been proposed, classifying cases into an isolated maternal fever, suspected triple I, or confirmed chorioamnionitis. Evidence suggests that the association between suspected chorioamnionitis and confirmed histological chorioamnionitis (HCA) is not consistent, as well as the impact of HCA on the development of EOS.We aimed to evaluate the association between suspected chorioamnionitis and HCA, the impact of HCA on EOS, and the effect of antepartum antibiotic prophylaxis on EOS.

METHODS

We retrospectively reviewed the medical records of all infants admitted to our institution, between 2017 and 2018, with a diagnosis of chorioamnionitis. We recorded the clinical evidence of chorioamnionitis, the histologic report of the placenta, the maternal and neonatal data, the neonatal inflammatory markers including C-reactive protein (CRP), and the incidence of EOS. The impact of antepartum antibiotic prophylaxis on the infants' CRP and EOS was calculated, and the logistic regression model was performed to estimate the association of confirmed HCA with EOS, while controlling for FIRS stage, gestation age, birth weight, maternal fever, foul-smelling amniotic fluid, and prolonged rupture of membranes.

RESULTS

During the study period, a total of 266 infants were identified; 81 (30%) infants had a confirmed HCA (HCA-present cases), and 185 (70%) infants were diagnosed with suspected triple I (HCA-absent cases). Antepartum antibiotics had been commenced in a significantly higher proportion in HCA-present cases (46%) in comparison to 14% of HCA-absent cases (p < .001). HCA-present infants were of significantly lower gestation (31.6 ± 4weeks versus 33.3 ± 4weeks, p = .004), and birth weight (1826 ± 840 g versus 2092 ± 849 g, p = .019), they had a significantly higher rate of clinical symptoms (31% versus 6%, p < .001), and a higher CRP at birth and 24 h (1.4 ± 1.5 mg/dL versus 0.3 ± 0.2 mg/dL, p < .001, and 2.1 ± 2.3 mg/dL versus 0.4 ± 0.6 mg/dL, p < .001, respectively). All HCA-present cases had evidence of FIRS; 43% were stage I, 25% stage II, and 32% were FIRS stage III. A significantly higher proportion of HCA-present infants were diagnosed with EOS (46% as compared to 6%, p < .001). The antepartum antibiotic administration was related to a significantly lower CRP at birth and 24 h only in HCA-present cases, albeit not with any reduction ιn EOS incidence. HCA was significantly associated with EOS (RR 3.18, 95% CI 2.81-5.18, p < .001). After adjusting for perinatal factors, the presence of HCA (OR 7.89, 95% CI 1.19-23.34, p = .032) and an advanced FIRS stage (OR 10.35, 95% CI 4.23-25.32, p < .001) were significantly associated with EOS.

CONCLUSIONS

Amongst infants with suspected chorioamnionitis, the diagnosis is partially supported by histological confirmation, and that is more prominent in pregnancies of a lower gestation. The presence of HCA and an advanced FIRS stage predispose to an increased risk of EOS after adjusting for other perinatal and neonatal factors. The antepartum prophylaxis against intra-amniotic infection was related to a significantly lower CRP in HCA-present cases.

Initiative to Reduce Antibiotic Exposure of Asymptomatic Infants Born to Mothers with Intraamniotic Infection

Infants born to mothers with intraamniotic infection (IAI) received antibiotic treatment per the Centers for Disease Control and Prevention and American Academy of Pediatrics guidelines in our neonatal intensive care unit (NICU) for early-onset bacterial sepsis evaluation. We conducted a quality improvement project to decrease antibiotic use and NICU admission in infants born to mothers with IAI.

Evaluating definitions for maternal fever as diagnostic criteria for intraamniotic infection in low-risk pregnancies

BACKGROUND

Conflicting statements by stakeholders in obstetric care have suggested different criteria for defining peripartum fever and suspected intraamniotic infection, which have not been evaluated.

METHODS

A case-control study of pregnancies between 35 and 41 weeks at a single tertiary care center between January 2016 and December 2017. Cases with pathology-confirmed chorioamnionitis were identified, and demographic data, risk factors, and neonatal outcomes were extracted from the medical record. The American College of Gynecology (ACOG) and National Institutes of Health (NIH) Workshop guidelines for identifying isolated maternal fever and suspected intraamniotic infection were applied, retrospectively. Odds ratios, sensitivity/specificity, and predictive value of each guideline for pathology-confirmed chorioamnionitis and for secondary outcomes of interest were determined.

RESULTS

943 mother-infant dyads were evaluated including 41 (4.3%) with pathology-confirmed chorioamnionitis. Among cases, 18 (43.9%) experienced any maternal temperature ≥38°C (100.4°F) with 12 (29.2%) and 8 (19.5%) cases meeting criteria for isolated maternal fever according to the ACOG and Workshop guidelines, respectively. Furthermore, the ACOG and Workshop guidelines correctly identified 6 (14.6%) and 3 (7.3%) of cases of pathology-confirmed chorioamnionitis with high agreement between definitions (κ = 0.63). Laboratory evaluation, antimicrobial exposure, and prolonged length of stay in offspring are substantially higher in cases as compared to controls.

CONCLUSIONS

Guidelines that rely on maternal fever definitions for the diagnosis of suspected intraamniotic infection exhibit high agreement with low sensitivity, but high specificity and negative predictive value for pathology-confirmed chorioamnionitis. Maternal temperature ≥38°C continues to drive clinical decision-making for both mother and offspring.

Is Group B Streptococcus Colonization Associated with Maternal Peripartum Infection in an Era of Routine Prophylaxis?

OBJECTIVE

This study aimed to assess whether colonization with group B streptococcus (GBS) is associated with maternal peripartum infection in an era of routine prophylaxis.

STUDY DESIGN

This study presented a secondary analysis of women delivering ≥37 weeks who underwent a trial of labor from the U.S. Consortium on Safe Labor (CSL) study. The exposure was maternal GBS colonization and the outcome was a diagnosis of chorioamnionitis, and secondarily, analyses were restricted to deliveries not admitted in labor and measures of postpartum infection (postpartum fever, endometritis, and surgical site infection). Logistic regression with generalized estimating equations was used accounting for within-woman correlations. Models adjusted for maternal age, parity, race, prepregnancy body mass index, pregestational diabetes, insurance status, study site/region, year of delivery, number of vaginal exams from admission to delivery, and time (in hours) from admission to delivery.

RESULTS

Among 170,804 assessed women, 33,877 (19.8%) were colonized with GBS and 5,172 (3.0%) were diagnosed with chorioamnionitis. While the frequency of GBS colonization did not vary by chorioamnionitis status (3.0% in both groups), in multivariable analyses, GBS colonization was associated with slightly lower odds of chorioamnionitis (adjusted odds ratio [AOR]: 0.89; 95% confidence interval [CI]: 0.83-0.96). In secondary analyses, this association held regardless of spontaneous labor on admission; and the odds of postpartum infectious outcomes were not higher with GBS colonization.

CONCLUSION

In contrast to historical data, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis.

KEY POINTS

· Data in an era prior to routine group B streptococcus (GBS) screening and prophylaxis showed that maternal GBS colonization was associated with a higher frequency of maternal peripartum infection.. · In the current study, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis.. · The results highlight potential benefits of GBS screening and intrapartum antibiotic prophylaxis beyond neonatal disease prevention, including mitigating the risk of maternal infectious morbidity..

A survey on variation in diagnosis and treatment of chorioamnionitis in tertiary centres in Canada

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. Moreover, recommended diagnostic criteria for clinical 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.

MicroRNAs miR-4535 and miR-1915-5p in amniotic fluid as predictive biomarkers for chorioamnionitis

Background:

This study was performed to investigate the clinical significance of miR-4535 and miR-1915-5p in severe chorioamnionitis.

Materials & methods:

Amniotic fluid samples from 37 patients with severe chorioamnionitis were subjected to miRNA array analysis and ddPCR™. Diagnostic values were assessed using the receiver operating characteristic curve. The patients were separated into three groups according to Blanc’s criteria.

Results:

The expression of miR-4535 and miR-1915-5p was significantly correlated with the copy number of 16S rDNA, had extremely high diagnostic accuracy for severe chorioamnionitis, and was linked to maternal and fetal inflammation.

Conclusion:

miR-4535 and miR-1915-5p serve as promising biomarkers for the diagnosis of severe chorioamnionitis.

Chorioamnionitis and fetal inflammatory response syndrome, which is linked to chorioamnionitis, are considered serious diseases in perinatal care. In this study, miR-4535 and miR-1915-5p are recognized as promising biomarkers for the diagnosis of chorioamnionitis before delivery. In particular, the increased expression of miR-4535 in amniotic fluid is expected to be regarded as a positive indicator for fetal inflammatory response syndrome, and the elevated expression of miR-4535 in serum is also considered to predictively diagnose intrauterine infection in pregnancy. Our results highlight that further studies should explore the underlying clinical significance of miR-4535 and miR-1915-5p.

Management of clinical chorioamnionitis: an evidence-based approach

This review aimed to examine the existing evidence about interventions proposed for the treatment of clinical chorioamnionitis, with the goal of developing an evidence-based contemporary approach for the management of this condition. Most trials that assessed the use of antibiotics in clinical chorioamnionitis included patients with a gestational age of ≥34 weeks and in labor. The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period. In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping. The administration of additional antibiotic therapy does not appear to be necessary after vaginal or cesarean delivery. However, if postdelivery antibiotics are prescribed, there is support for the administration of an additional dose. Patients can receive antipyretic agents, mainly acetaminophen, even though there is no clear evidence of their benefits. Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant. However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate. Once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age. Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications. The time interval between the diagnosis of clinical chorioamnionitis and delivery is not related to most adverse maternal and neonatal outcomes. Patients may require a higher dose of oxytocin to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation. The benefit of using continuous electronic fetal heart rate monitoring in these patients is unclear. We identified the following promising interventions for the management of clinical chorioamnionitis: (1) an antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole that provides coverage against the most commonly identified microorganisms in patients with clinical chorioamnionitis; (2) vaginal cleansing with antiseptic solutions before cesarean delivery with the aim of decreasing the risk of endometritis and, possibly, postoperative wound infection; and (3) antenatal administration of N-acetylcysteine, an antioxidant and antiinflammatory agent, to reduce neonatal morbidity and mortality. Well-powered randomized controlled trials are needed to assess these interventions in patients with clinical chorioamnionitis.

Maternal inflammatory markers for chorioamnionitis in preterm prelabour rupture of membranes: a systematic review and meta-analysis of diagnostic test accuracy studies

BACKGROUND

There is no consensus on the role of inflammatory markers in identifying chorioamnionitis in preterm prelabour rupture of membranes (PPROM). We set out to evaluate the accuracy of maternal blood C-reactive protein (CRP), procalcitonin and interleukin 6 (IL6) in diagnosis of histological chorioamnionitis and/or funisitis (HCA/Funisitis) in PPROM.

METHODS

We searched MEDLINE, EMBASE and The Cochrane Library from inception to January 2020 for studies where maternal blood CRP, procalcitonin or IL6 was assessed against a reference standard of HCA/Funisitis in PPROM. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess methodological quality. Hierarchical summary receiver operating characteristic (SROC) models were used to construct summary curves. Bivariate models were used to obtain summary estimates for studies with the same cut-off.

RESULTS

We included 23 studies reporting HCA/Funisitis in 902 of 1717 women, median prevalence 50% (inter-quartile range 38-57). Of these studies, 20 were prospective cohort design and 3 were retrospective cohort. Eleven studies reported the index test against a reference standard of HCA and/or funisitis, 10 reported HCA alone and 2 reported funisitis alone. Many studies had high risk of bias scores on the QUADAS-2 assessment but low concerns for applicability. Sensitivity and specificity for CRP ≥ 20 mg/L (5 studies, 252 participants) was 59% (95% CI 48-69) and 83% (95% CI 74-89) respectively. SROC curves are provided for each index test. At selected specificity of 80%, the sensitivities for CRP (all cut-offs, 17 studies, 1404 participants), PCT ( all cut-offs, 6 studies, 231 participants) and IL6 (all cut-offs, 5 studies, 299 participants) were 59%(95% CI 52-68), 56%(95% CI 50-69) and 52% (95% CI 50-86) respectively.

CONCLUSIONS

There is insufficient evidence to support use of CRP, procalcitonin or IL6 in maternal blood for diagnosis of HCA/Funisitis in PPROM. This review followed recommended methodology and data analytic methods that made the most of the data regardless of the different cut-offs used. However, the evidence is based on few studies with generally small sample sizes, poor-quality scores and substantial heterogeneity. There is a need for good-quality diagnostic accuracy studies to better assess the role of these biomarkers in PPROM.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42015023899, registered on 8 October 2015.

Risk Factors for Postpartum Maternal Infection Following Spontaneous Vaginal Delivery Complicated by Chorioamnionitis

Objective  Guidelines for the management of chorioamnionitis include intrapartum antibiotics, while postpartum antibiotics after spontaneous vaginal delivery (SVD) are reserved high-risk women. Our objective is to describe the incidence of and risk factors for postpartum infection after SVD complicated by chorioamnionitis. Study Design  This is a retrospective study of SVDs with clinically diagnosed chorioamnionitis at a single center. The primary outcome was a composite of postpartum infection. Women who developed the primary outcome were compared with those who did not using bivariate statistics. Regression models were developed to estimate adjusted odds of outcomes. Results  In this cohort, 346 women underwent SVD complicated by chorioamnionitis. Of these, 23 (6.6%) developed postpartum infections (endometritis n  = 7, urinary tract infection/pyelonephritis n  = 6, sepsis n  = 4, and perineal wound infection n  = 6). Receipt of antibiotics intra- or postpartum did not differ between groups, but women with postpartum infections were more likely to deliver prior to 32 weeks (17.4 vs. 4.9%, p  = 0.04). When controlling for antibiotic use, delivery at < 32 weeks was associated with 3.8-fold increased (95% confidence interval: 1.07-13.7) odds of postpartum infection. Conclusion  Postpartum infections occur in ∼1/15 women delivering vaginally with chorioamnionitis, with those who deliver at < 32 weeks' gestation being at increased risk.

Using the new definition of intraamniotic infection - is there morbidity among the women left out?

Background: Recently, ACOG released updated definitions for intraamniotic infection (IAI): maternal fever (≥38.0 °C) and ≥1 symptom (fetal tachycardia, maternal white blood cell count >15,000/mm³ or purulent discharge). Treatment was no longer recommended for women with fever <39.0 °C plus maternal tachycardia or fundal tenderness (previous criteria). The objective of this study was to compare postpartum infectious morbidity among women meeting previous criteria (but not the new IAI criteria) to women meeting new IAI criteria.Methods: Retrospective cohort of women delivering vaginally at a single academic center. Demographics, antepartum and intrapartum characteristics of women who met diagnostic criteria for chorioamnionitis (previous criteria) compared to those who met IAI criteria using bivariate statistics. The primary outcome was a composite of postpartum infection, including: endometritis, perineal infection, sepsis, urinary tract infection, pyelonephritis. Backward-stepwise elimination used to estimate odds of primary outcome.Results: Of 229 women who met previous IAI criteria, 51 (22.3%) did not meet new IAI criteria. Women no longer meeting IAI criteria were younger (25 versus 27 years, p = .02), more likely to have gestational hypertension (16.0 versus 3.4%, p < .01), and less likely to have third or fourth degree lacerations (2.0 versus 13.4%, p = .02). No difference in antibiotic receipt was observed. Postpartum infection occurred in 16/229 (7.0%) women overall; five (9.8%) in those not meeting new IAI criteria, and 11 (6.2%) meeting new IAI criteria. After adjusting for confounders, there was no difference in odds of postpartum infection (aOR 1.65, 95% CI 0.55-4.99).Conclusions/implications: Among women who met old ACOG criteria for IAI, but not the new criteria, postpartum infection occurred in nearly 10%. This number could be higher if these women were not treated with antibiotics.

Preoperative cefazolin rather than clindamycin or metronidazole is associated with lower postpartum infection among women with chorioamnionitis delivering by cesarean delivery

BACKGROUND

The optimal antibiotic regimen to prevent maternal postpartum infection among high-risk women treated for chorioamnionitis delivering by cesarean delivery remains to be defined. Emerging data suggest that cefazolin decreases the risk of cesarean surgical site infection.

OBJECTIVE

To investigate whether intrapartum antibiotic therapy with cefazolin versus the current standard clindamycin or metronidazole decreases the risk of postpartum infectious morbidity among women delivering by cesarean delivery who were receiving a base regimen of ampicillin or penicillin with gentamicin for chorioamnionitis.

MATERIALS AND METHODS

A secondary analysis from the Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry. We included women who delivered by cesarean delivery with presumptive chorioamnionitis (intrapartum fever >100.4°F and receipt of intrapartum antibiotics). All women received a base regimen of penicillin or ampicillin with gentamicin. We compared antibiotic therapy with cefazolin versus clindamycin or metronidazole. The primary outcome was a composite of postpartum maternal infection, including endometritis and surgical site infection. Multivariable logistic regression was used, adjusting for age, parity, race/ethnicity, insurance, body mass index at delivery, tobacco use, pregestational diabetes, American Society of Anesthesiologists classification, trial of labor prior to cesarean delivery, and postpartum antibiotics.

RESULTS

Among 1105 women with presumptive chorioamnionitis who delivered by cesarean delivery, 22.0% (n = 244) received cefazolin and 77.9% (n = 861) received clindamycin or metronidazole. Most women were in labor prior to cesarean delivery (93.8%) and received postpartum antibiotics (88.4%). Almost one-tenth (9.5%) were diagnosed with a postpartum infection, most commonly endometritis (80.9%), followed by surgical site infection (20.9%) (not mutually exclusive). Women treated with cefazolin rather than clindamycin or metronidazole had lower odds of postpartum infectious morbidity (adjusted odds ratio, 0.49; 95% confidence interval, 0.26-0.90). This association held when the outcome was restricted to surgical site infection (adjusted odds ratio, 0.11; 95% confidence interval, 0.01-0.92) but not endometritis. Similar results were observed with propensity score analysis.

CONCLUSION

Among women delivering by cesarean delivery who were treated for chorioamnionitis, additional antibiotic therapy with cefazolin decreased the risk of postpartum infection, primarily surgical site infection, compared to the current standard clindamycin or metronidazole.

Early-Onset Sepsis Risk Calculator Integration Into an Electronic Health Record in the Nursery

BACKGROUND AND OBJECTIVES

An early-onset sepsis (EOS) risk calculator tool to guide evaluation and treatment of infants at risk for sepsis has reduced antibiotic use without increased adverse outcomes. We performed an electronic health record (EHR)-driven quality improvement intervention to increase calculator use for infants admitted to a newborn nursery and reduce antibiotic treatment of infants at low risk for sepsis.

METHODS

This 2-phase intervention included programming (1) an EHR form containing calculator fields that were external to the infant's admission note, with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds and (2) discrete data entry elements into the EHR admission form with a hyperlink to the calculator Web site. We used statistical process control to assess weekly entry of risk scores and antibiotic orders and interrupted time series to assess trend of antibiotic orders.

RESULTS

During phase 1 (duration, 14 months), a mean 59% of infants had EOS calculator scores entered. There was wide variability around the mean, with frequent crossing of weekly means beyond the 3σ control lines, indicating special-cause variation. During phase 2 (duration, 2 years), mean frequency of EOS calculator use increased to 85% of infants, and variability around the mean was within the 3σ control lines. The frequency of antibiotic orders decreased from preintervention (7%) to the final 6 months of phase 2 (1%, P < .001).

CONCLUSIONS

An EHR-driven quality improvement intervention increased EOS calculator use and reduced antibiotic orders, with no increase in adverse events.

Should the diagnostic criteria for suspected clinical chorioamnionitis be changed?

Purpose of review: The criteria for the diagnosis of intra-amniotic infection (IAI) were derived from a study of women at term in labor but is currently used as the main diagnostic tool for clinical chorioamnionitis. Regarding the inconsistent usage of the term, the diagnostic utility of clinical chorioamnionitis needs to be revisited. In this review, we addressed the critical issues on why the diagnostic criteria of suspected clinical chorioamnionitis should be changed.Recent findings: Overall, the accuracy of clinical chorioamnionitis to detect intra-amniotic infection (IAI) is not high, around 50%. The accuracy of each diagnostic criteria to diagnose IAI is, for example, 51.1% with maternal tachycardia, 57.8% with fetal tachycardia, and 55.6% with maternal leukocytosis. However, it needs to be reminded that these diagnostic performances had been obtained from term pregnancies but not from preterm pregnancies. Since there is a difference between clinical chorioamnionitis and histologic chorioamnionitis or even IAI, the diagnostic criteria of clinical chorioamnionitis would be ideal if it could directly predict the development of neonatal infectious outcomes. In fact, multiple definitions of clinical chorioamnionitis either in more lenient or stringent manner are currently used, which is responsible for inconsistent association of clinical chorioamnionitis with long-term neonatal outcomes. Whereas the diagnosis of clinical chorioamnionitis in preterm is followed by expeditious delivery, the diagnosis of clinical chorioamnionitis at term pregnancy is usually conducted in laboring women and requires additional neonatal evaluation for sepsis, which suggests different implications of clinical chorioamnionitis in preterm and term pregnancy.Summary: Current diagnostic criteria of clinical chorioamnionitis should be revised, specifically in terms of sensitivity in preterm pregnancy and specificity in term pregnancy.

The cost-effectiveness of ertapenem for the treatment of chorioamnionitis after cesarean delivery

Background: Chorioamnionitis affects 1-4% of pregnancies, and patients who undergo cesarean delivery in the setting of chorioamnionitis have an increased risk of endometritis and surgical site infection (SSI). The standard treatment for chorioamnionitis after cesarean delivery is a combination regimen of intravenous ampicillin, gentamicin, and clindamycin with variable duration (single dose to 24 h). However, newer evidence suggests that ertapenem may decrease the risk of postoperative infectious morbidity with the added benefit of a single postpartum dose, compared to between 3 and 10 doses of AGC. Concerns regarding the cost of ertapenem have been cited as a deterrent for this regimen.Objective: The objective of this study was to investigate the cost-effectiveness of single-dose ertapenem compared to existing standard regimens.Methods: A decision analytic cost-effectiveness model was designed from a hospital perspective to compare four strategies for the postpartum management of chorioamnionitis after cesarean delivery: (i) no antibiotics; (ii) a one-time intravenous dose of ampicillin, gentamicin, and clindamycin (AGC-1); (iii) 24-h coverage with intravenous ampicillin, gentamicin, and clindamycin (AGC-24); and (iv) intravenous ertapenem, one dose. Medical costs, rates of SSI and endometritis following cesarean delivery, and costs of postcesarean infection (SSI or endometritis) were abstracted from the literature. Antibiotic drug costs were obtained from the pharmacy department at a private academic hospital. The cost of each regimen was calculated as costs to the hospital and included antibiotics (no antibiotics $0, AGC-1 $66, ertapenem $140, and AGC-24 $208), administration, and labor costs. Effectiveness was quantified as percentage of patients who avoided postcesarean infectious morbidity (endometritis or SSI).Results: The base case cost of each strategy was: AGC-1 $704, ertapenem $733, AGC-24 $846, and no antibiotics $971. Ertapenem had an effectiveness of 88%, AGC-1 and AGC-24 were 87% each, and no antibiotics was 81%. No antibiotics and AGC-24 were more costly and equally or less effective than comparators (dominated strategies). Ertapenem was more costly, but more effective than AGC-1, with an incremental cost-effectiveness ratio of $3738 per infection avoided. In a sensitivity analysis comparing ertapenem to the most commonly used strategy of ACG-24, the ertapenem strategy remained less costly if the rate of endometritis with ertapenem was <11% (base case estimate 8%) or the rate of SSI with ertapenem was <7% (base case estimate 4%).Conclusions: Ertapenem is a cost-saving alternative to 24-h AGC treatment for chorioamnionitis in the setting of cesarean delivery, and may be considered a cost-effective treatment when compared to a one time dose of AGC depending on infection rates.

Determinants of Initial Antibiotic Duration in Very Low Birth Weight Neonates

Introduction

Very low birth weight (VLBW) neonates (< 1500 g) are commonly exposed to prolonged antibiotic courses related to concerns for presumed early onset sepsis often with unclear indications. While antibiotics can be life-saving medications, prolonged antibiotic exposure (> 5 days) increases an infant’s risk for necrotizing enterocolitis, late onset sepsis, colonization or infection with resistant organisms, and death. The aim of this study is to describe clinical and laboratory factors that influence the length of initial antibiotic courses in VLBW neonates.

Methods

Demographics, perinatal factors, and neonatal clinical and laboratory data were compared in a single-center retrospective cohort of VLBW neonates who received ≤ 3 days versus > 5 days of initial antibiotics.

Results

A total of 121 patients were analyzed of which 117 (97%) were started on antibiotics empirically on admission, and 71 (59%) received ≤ 3 days and 50 (41%) received > 5 days of antibiotics. One (0.8%) infant had a positive blood culture (S. oralis). Demographics [gestational age (p < 0.001) and birth weight (p < 0.001)] and neonatal clinical status [Apgar score at 5 min (p = 0.001), CRIB II (p < 0.001), need for inotropes (p = 0.001), and maximum ventilator support (p < 0.001)] were significantly different between the short and prolonged course of antibiotics groups on bivariate analysis. There were no significant differences in perinatal factors or common laboratory markers of sepsis. Maximum ventilator support remained significant on multivariate analysis (p = 0.007).

Conclusion

In the VLBW population, the clinical status of the neonate, as represented by maximum ventilator support in this study, was the most important factor in determining the duration of initial antibiotic treatment. Laboratory values and perinatal risk factors did not significantly influence prescribing patterns.

Association of chorioamnionitis and its duration with adverse maternal outcomes by mode of delivery: a cohort study

OBJECTIVE

To investigate the association of chorioamnionitis and its duration with adverse maternal outcomes by mode of delivery.

DESIGN

A retrospective cohort study.

SETTING

Data from the Consortium on Safe Labor Study in the USA (2002-2008).

POPULATION

Singleton deliveries at ≥23 weeks of gestation (221 274 assessed deliveries, 62 331 by caesarean section).

METHODS

The association of chorioamnionitis, and secondarily the duration of chorioamnionitis estimated from intrapartum antibiotic use, with adverse maternal outcomes was analysed using logistic regression with generalised estimating equations, adjusting for age, parity, race, pregestational diabetes, chronic hypertension, gestational age at delivery, study site and delivery year. Analyses were stratified by vaginal versus caesarean delivery.

MAIN OUTCOME MEASURES

The composite adverse maternal outcome included: postpartum transfusion, endometritis, wound/perineal infection/separation, venous thromboembolism, hysterectomy, admission to intensive care unit and/or death.

RESULTS

Chorioamnionitis was associated with higher odds of the composite adverse maternal outcome with caesarean delivery (adjusted odds ratio 2.31; 95% CI 1.97-2.71); and the association persisted regardless of whether a woman had a trial of labour, preterm delivery or maternal group B streptococcus colonisation. The most common adverse outcomes after caesarean section were postpartum transfusion (56.0%) and wound/perineal infection or endometritis (38.6%). Chorioamnionitis was not associated with adverse maternal outcomes after vaginal delivery. The duration of chorioamnionitis as the exposure did not alter the association between chorioamnionitis and adverse maternal outcomes.

CONCLUSIONS

Chorioamnionitis, but not the estimated duration, was associated with increased odds of adverse maternal outcomes with caesarean delivery. This finding has implications for care programmes to prevent maternal morbidity after a caesarean section complicated by chorioamnionitis.

TWEETABLE ABSTRACT

Chorioamnionitis, but not its duration, increases the risk of adverse maternal outcomes with caesarean delivery.

[Diagnosis and management of intra-uterine infection: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVE

To determine the diagnosis criteria and management of intra-uterine inflammation or infection (Triple I, III).

METHODS

PubMed and Cochrane Central databases search.

RESULTS

III is defined as an infection of the fetal membranes, and/or other components like the decidua, fetus, amniotic fluid or placenta. This word should be preferred to the word chorioamnionitis that is less precise (Professional consensus). III clinical signs exhibit poor limited sensibility and specificity (EL3). The diagnosis of III is retained in case of maternal fever (defined by a body temperature≥38°C) with no alternative cause identified and at least 2 signs among the following: fetal tachycardia>160 bpm for 10min or longer, uterine pain of labor, purulent fluid from the cervical canal (Professional consensus). Maternal hyperleukocytosis>20 giga/L in the absence of corticosteroids treatment or increased plasmatic C-reactive protein also argue for III, despite their limited sensibility and specificity (EL3). III requires prompt delivery (Grade A). III is not by itself an indication for cesarean delivery (Professional consensus). Antibiotic treatment should cover Streptococcus agalactiae and Escherichia coli. Antibiotics should be started immediately and maintained all over delivery, to reduce neonatal and maternal morbidity (Grade B). Treatment should rely on a combination of betalactamin and aminoglycoside (Grade B). After vaginal delivery, one single dose of antibiotic is required. Antibiotic duration should be longer in case of bacteremia. Longer duration could be considered in case of persistent fever or of cesarean delivery (Professional consensus).

Incidence of early-onset sepsis in infants born to women with clinical chorioamnionitis

Objective To determine the frequency of sepsis and other adverse neonatal outcomes in women with a clinical diagnosis of chorioamnionitis. Methods We performed a secondary analysis of a multi-center placebo-controlled trial of vitamins C/E to prevent preeclampsia in low risk nulliparous women. Clinical chorioamnionitis was defined as either the "clinical diagnosis" of chorioamnionitis or antibiotic administration during labor because of an elevated temperature or uterine tenderness in the absence of another cause. Early-onset neonatal sepsis was categorized as "suspected" or "confirmed" based on a clinical diagnosis with negative or positive blood, urine or cerebral spinal fluid cultures, respectively, within 72 h of birth. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression. Results Data from 9391 mother-infant pairs were analyzed. The frequency of chorioamnionitis was 10.3%. Overall, 6.6% of the neonates were diagnosed with confirmed (0.2%) or suspected (6.4%) early-onset sepsis. Only 0.7% of infants born in the setting of chorioamnionitis had culture-proven early-onset sepsis versus 0.1% if chorioamnionitis was not present. Clinical chorioamnionitis was associated with both suspected [OR 4.01 (3.16-5.08)] and confirmed [OR 4.93 (1.65-14.74)] early-onset neonatal sepsis, a need for resuscitation within the first 30 min after birth [OR 2.10 (1.70-2.61)], respiratory distress [OR 3.14 (2.16-4.56)], 1 min Apgar score of ≤3 [OR 2.69 (2.01-3.60)] and 4-7 [OR 1.71 (1.43-2.04)] and 5 min Apgar score of 4-7 [OR 1.67 (1.17-2.37)] (vs. 8-10). Conclusion Clinical chorioamnionitis is common and is associated with neonatal morbidities. However, the vast majority of exposed infants (99.3%) do not have confirmed early-onset sepsis.

What's the harm? Risks and benefits of evolving rule-out sepsis practices

Asymptomatic term and late-preterm newborns with risk factors for early onset sepsis commonly undergo laboratory evaluation and receive empiric antibiotic therapy. Some have challenged the rationale for current "rule-out sepsis" practices, arguing that they lead to unnecessary overtreatment and healthcare costs. A series of recent clinical studies has explored scheduled serial observations as an alternative to laboratory testing and empiric antibiotics for asymptomatic newborns with historical risk factors for sepsis. These studies have shared the conclusion that serial observation is safe and cost-effective for well-appearing term and late-preterm babies, but they are also somewhat speculative because culture-proven early onset sepsis is an extremely low prevalence diagnosis. Here, we review the evolving consensus of optimal rule-out sepsis practices. We examine chorioamnionitis as an example of a problematic risk factor that has contributed to the controversy surrounding this topic. We also discuss how introduction of online sepsis risk calculators has allowed more precise delineation of a patient's chances of developing culture-proven infection. Finally, we analyze existing data from published studies to estimate the number needed to harm (NNH) when an observation-based strategy is used instead of a risk-based approach. We conclude that, if harm is defined as death or serious sepsis complications such as hemodynamic instability or neurologic injury, the NNH is 1610, compared to an NNH of 7 and 2.9 for IV infiltrates and delayed breastfeeding, respectively-two common and potentially consequential complications of NICU admission for a rule-out sepsis. We believe that the differential between risk of serious harm from observing a well-appearing term or late-preterm newborn with risk factors for sepsis and the risk of less significant but common NICU complications argues in favor of the ongoing trend toward less aggressive management of newborns with sepsis risks.

SOMANZ guidelines for the investigation and management sepsis in pregnancy

SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence-based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence-based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non-infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines.

Chorioamnionitis: time for a new approach

PURPOSE OF REVIEW

The association between maternal chorioamnionitis and early-onset sepsis in the newborn has long been recognized, and established guidelines recommend treating all exposed infants with broad-spectrum antibiotics until infection can be ruled out. However, recent data suggest that close observation of well appearing term and late-preterm newborns may be a preferable alternative. The present review addresses the evidence in favor of newly proposed changes to the diagnosis and management of women and newborns following a maternal diagnosis of chorioamnionitis. Potential implications of these new practice guidelines will also be discussed.

RECENT FINDINGS

A panel of experts assembled in 2015 to provide updated, evidence-based guidelines for the diagnosis and management of women and newborns following a maternal diagnosis of chorioamnionitis. Revised terminology and diagnostic criteria were proposed as well as changes in the management of newborns of mothers with suspected intrauterine infection, most notably a recommendation to observe (rather than treat) well appearing term and late-preterm newborns.

SUMMARY

A management strategy consisting of close observation of well appearing term and late-preterm infants exposed to suspected intrauterine infection is preferable to empiric antimicrobial therapy. Large prospective epidemiologic studies will be needed to ascertain the impact of these new practice guidelines on the outcomes of infants exposed to intrauterine infection and/or inflammation. Improved precision in the clinical diagnosis of intrauterine infection should improve both the quality and reproducibility of data generated from future studies.

Methods to decrease variability in histological scoring in placentas from a cohort of preterm infants

OBJECTIVE

Reliable semiquantitative assessment of histological placental acute inflammation is problematic, even among experts. Tissue samples in histology slides often show variability in the extent and location of neutrophil infiltrates. We sought to determine whether the variability in pathologists' scoring of neutrophil infiltrates in the placenta could be reduced by the use of 'regions of interest' (ROIs) that break the sample into smaller components.

DESIGN

ROIs were identified within stained H&E slides from a cohort of 56 women. ROIs were scored using a semiquantitative scale (0-4) for the average number of neutrophils by at least two independent raters.

SETTING

Preterm singleton births at Yale New Haven Hospital.

PARTICIPANTS

This study used stained H&E placental slides from a cohort of 56 women with singleton pregnancies who had a clinically indicated amniocentesis within 24 hours of delivery.

PRIMARY AND SECONDARY OUTCOME MEASURES

Interrater agreement was assessed with the intraclass correlation coefficient (ICC) and log-linear regression. Predictive validity was assessed using amniotic fluid protein profile scores (neutrophil defensin-2, neutrophil defensin-1, calgranulin C and calgranulin A).

RESULTS

Excellent agreement by the ICC was found for the average neutrophil scores within a region of interest. Log-linear analyses suggest that even where there is disagreement, responses are positively associated along the diagonal. There was also strong evidence of predictive validity comparing pathologists' scores with amniotic fluid protein profile scores.

CONCLUSIONS

Agreement among observers of semiquantitative neutrophil scoring through the use of digitised ROIs was demonstrated to be feasible with high reliability and validity.

Antibiotic Therapy for Chorioamnionitis to Reduce the Global Burden of Associated Disease

Chorioamnionitis is associated with significant maternal and neonatal morbidity and mortality throughout the world. In developed countries, great progress has been made to minimize the impact of chorioamnionitis, through timely diagnosis and appropriate treatment. In the global setting, where many women deliver outside the healthcare facilities, this diagnosis is frequently overlooked and not properly treated. In addition to its impact on maternal health, a significant proportion of neonatal morbidity and mortality can be prevented by both recognition and access to readily available treatment. With the increasing focus on saving the most vulnerable members of society, we echo the need for providing parturient women with suspected chorioamnionitis universal access to appropriate therapy. We describe known effective antibiotic therapies for chorioamnionitis and provide an overview of additional potential antimicrobial treatments that might be effectively implemented in areas with limited access to care.

Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation: retrospective cohort study

BACKGROUND

Cervical dilation in the second trimester is associated with a greater than 90% rate of spontaneous preterm birth and a poor perinatal prognosis.

OBJECTIVE

To compare the perinatal outcomes of twin pregnancies with dilated cervix in women who underwent either cerclage or expectant management.

STUDY DESIGN

Retrospective cohort study of asymptomatic twin pregnancies identified with cervical dilation of ≥1 cm at 16-24 weeks (1997-2014) at 7 institutions. Exclusion criteria were genetic or major fetal anomaly, multifetal reduction at >14 weeks, prior cerclage placement, monochorionic-monoamniotic placentation, active vaginal bleeding, labor, chorioamnionitis, elective termination of pregnancy, or medically indicated preterm birth. The primary outcome was incidence of spontaneous preterm birth at <34 weeks. Secondary outcomes were incidence of spontaneous preterm birth at <32 weeks, <28 weeks, and <24 weeks; perinatal mortality; and composite adverse neonatal outcome (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis).

RESULTS

A total of 76 women with twin pregnancy with dilated cervix of 1.0-4.5 cm were managed with either cerclage (n = 38) or expectant management (n = 38). Demographic characteristics were not significantly different. Analysis was adjusted for amniocentesis and vaginal progesterone use. In the cerclage group, 29 women (76%) received prophylactic indomethacin and 36 (94%) received prophylactic antibiotics, whereas the expectant management group did not. Interval from time at diagnosis of open cervix to delivery in the cerclage group was 10.46 ± 5.6 weeks vs 3.7 ± 3.2 weeks in the expectant management group, with a mean difference of 6.76 weeks (95% confidence interval [CI], 4.71-8.81). There were significant decreases in spontaneous preterm birth at <34 weeks (52.6% vs 94.7%; adjusted odds ratio [aOR], 0.06; 95% CI, 0.03-0.34), at <32 weeks (44.7% vs 89.4%; aOR, 0.08; 95% CI, 0.03-0.34); at <28 weeks (31.6% vs 89.4%; aOR, 0.05; 95% CI, 0.01-0.2); and at <24 weeks (13.1% vs 47.3%; aOR, 0.17; 95% CI, 0.05-0.54). There were also significant reductions in perinatal mortality (27.6% vs 59.2%; aOR, 0.24; 95% CI, 0.11-0.5), neonatal intensive care unit admission (75.9% vs 97.6%; aOR, 0.07; 95% CI, 0.01-0.66), and composite adverse neonatal outcome (33.9% vs 90.5%; aOR, 0.05; 95% CI, 0.01-0.21).

CONCLUSION

Cerclage, indomethacin, and antibiotics in twin pregnancies with dilated cervix ≥1 cm before 24 weeks were associated with significant longer latency period from diagnosis to delivery (6.7 weeks), decreased incidence of spontaneous preterm birth at any given gestational age, and improved perinatal outcome when compared with expectant management.

The placental membrane microbiome is altered among subjects with spontaneous preterm birth with and without chorioamnionitis

BACKGROUND

Preterm birth (PTB) is a leading cause of neonatal morbidity and mortality and is not uncommonly associated with chorioamnionitis. We recently have demonstrated that the placenta harbors a unique microbiome with similar flora to the oral community. We also have shown an association of these placental microbiota with PTB, history of antenatal infection, and excess maternal weight gain. On the basis of these previous observations, we hypothesized that the placental membranes would retain a microbiome community that would vary in association with preterm birth and chorioamnionitis.

OBJECTIVE

In the current study, we aimed to examine the differences in the placental membrane microbiome in association with PTB in both the presence and absence of chorioamnionitis and/or funisitis using state-of-the-science whole-genome shotgun metagenomics.

STUDY DESIGN

This was a cross-sectional analysis with 6 nested spontaneous birth cohorts (n = 9-15 subjects/cohort): Term gestations without chorioamnionitis, term with chorioamnionitis, preterm without chorioamnionitis, preterm with mild chorioamnionitis, preterm with severe chorioamnionitis, and preterm with chorioamnionitis and funisitis. Histologic analysis was performed with Redline's criteria, and inflammatory cytokines were analyzed in the cord blood. DNA from placental membranes was extracted from sterile swabs collected at delivery, and whole-genome shotgun sequencing was performed on the Illumina HiSeq platform. Filtered microbial DNA sequences were annotated and analyzed with MG-RAST (ie, Metagenomic Rapid Annotations using Subsystems Technology) and R.

RESULTS

Subjects were assigned to cohorts on the basis of gestational age at delivery and independent scoring of histologic chorioamnionitis. We found that preterm subjects with severe chorioamnionitis and funisitis had increases in cord blood inflammatory cytokines. Of interest, although the placental membrane microbiome was altered in association with severity of histologic chorioamnionitis (permutational multivariate analysis of variance P = .005), there was no observable impact with either betamethasone or antibiotic treatment. In preterm subjects with chorioamnionitis, we found a high abundance of both urogenital and oral commensal bacteria. These alterations in the microbiome were accompanied by significant variation (P < .05) in microbial metabolic pathways important in the glucose-fed pentose phosphate pathway (term subjects), or glycerophopholipid metabolism, and the biosynthesis of the siderophore group nonribosomal peptides (preterm subjects).

CONCLUSION

Consistent with ours and others previous findings, women who experienced spontaneous PTB harbor placental microbiota that further differed by severity of chorioamnionitis. Integrative metagenomic analysis revealed significant variation in distinct bacterial metabolic pathways, which we speculate may contribute to risk of preterm birth with and without severe chorioamnionitis.

Chorioamnionitis at Term: Definition, Diagnosis, and Implications for Practice

Chorioamnionitis is a serious complication during labor at term and is associated with adverse neonatal outcome affecting approximately 10% of pregnancies. It is diagnosed clinically or microbiologically or by histopathologic examination of the placenta and umbilical cord. The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. These subjective findings are neither sensitive nor specific. However, clinical chorioamnionitis requires a high index of suspicion, timely diagnosis, prompt antibiotic treatment, and delivery, which may help reduce the potentially devastating outcome of maternal and neonatal infections. This article focuses on clinical chorioamnionitis and presents the physiologic immune response during pregnancy, the definition of chorioamnionitis, clinical diagnostic criteria, and implications for practice.

Preterm cord blood CD4⁺ T cells exhibit increased IL-6 production in chorioamnionitis and decreased CD4⁺ T cells in bronchopulmonary dysplasia

BACKGROUND

Chorioamnionitis (CA) is associated with premature delivery and bronchopulmonary dysplasia (BPD). We hypothesize that preterm infants exposed to CA have reduced suppressive regulatory T cells (Treg) and increased non-regulatory T cell pro-inflammatory cytokines, increasing risk for BPD.

OBJECTIVE

To evaluate cord blood CD4(+) T cell regulatory phenotype and pro-inflammatory cytokine production in CA and BPD groups.

STUDY DESIGN

Cord blood mononuclear cells from infants (GA ⩽32 weeks), with or without placental histological evidence of CA (hChorio), were analyzed by flow cytometry. Clinical information was collected by retrospective chart review. Numbers of putative Treg (CD4(+)FoxP3(+)CD25(+)CD127Dim), CD4(+) non-Tregs, and CD4(+) T cell intracellular cytokine content following in vitro stimulation were compared with CA status and oxygen requirement at 36weeks postmenstrual age.

RESULT

Absolute Treg numbers were not different in CA and non-CA exposed samples. However, the infants who developed BPD had a significant decrease in Treg and non-regulatory T cell numbers. Greater IL-6 production was observed in hCA group.

CONCLUSION

A pro-inflammatory CD4(+) T cell status is noted in CA and BPD but the later disease is also associated with decrease in Tregs, suggesting that the development of BPD is marked by distinct inflammatory changes from those of CA exposed infants.

Chorioamnionitis: implications for the neonate

Chorioamnionitis (CA) is characterized by inflammation of the fetal membranes. The incidence increases with decreasing gestational age at birth. When suspected on clinical criteria, pathologic assessment of the placenta should be performed. Although the mechanisms are not entirely clear, CA predisposes to premature birth, neonatal sepsis, and intraventricular hemorrhage. Its role in respiratory distress syndrome, bronchopulmonary dysplasia, and neurodevelopmental impairment is mixed. Prevention and treatment are ill-defined; antibiotics for preterm premature rupture of membranes reduce the incidence and increase the length of time to delivery. Antibiotics are recommended for infants exposed to CA while laboratory studies are being performed.

Current management and long-term outcomes following chorioamnionitis

Chorioamnionitis is the process of active infection within the amniotic cavity that induces an inflammatory response. A wide variety of pathologic organisms can cause chorioamnionitis. Prompt diagnosis and timely treatment with broad-spectrum antibiotics can help avert the significant short-term and long-term consequences that may result. This review aims to summarize the up-to-date diagnosis criteria, treatment protocols, and long-term sequelae of missed diagnoses or poorly treated disease. It also calls for future studies that aim to better understand the mechanism of disease and to develop better detection and intervention methods to prevent the significant associated morbidity.

Frozen section of placental membranes and umbilical cord: an aid to early postpartum diagnosis of intra-amniotic infection

OBJECTIVES

We devised a rapid frozen section (FS) assessment technique of placental tissues and performed the first rigorous assessment of FS relative to conventional workup.

METHODS

We evaluated 49 placentas with clinical/gross suspicion of intra-amniotic infection by FS. Relative to formalin-fixed and paraffin-embedded tissues, we compared the grading, staging, and interobserver variability.

RESULTS

FS assessment demonstrated a sensitivity of 0.91 (95% CI, 0.77-0.97) and a specificity of 0.60 (95% CI, 0.36-0.80) for the presence of chorioamnionitis and a sensitivity of 0.89 (95% CI, 0.75-0.96) and a specificity of 0.69 (95% CI, 0.42-0.87) for the presence of funisitis. The χ2 goodness of fit for grade and stage in both placental membrane and umbilical cord sections was significant (P<.001). There was no significant difference in interobserver variability in comparison with permanent section results (P=0.06).

CONCLUSIONS

We conclude that FS is a reasonably sensitive screening technique, correlating well with conventional assessment, without significantly different interobserver variability.

Chorioamnionitis in the pathogenesis of brain injury in preterm infants

Chorioamnionitis (or placental infection) is suspected to be a risk factor for brain injury in premature infants. The suggested association between chorioamnionitis and cystic periventricular leukomalacia and cerebral palsy is uncertain because of the variability of study designs and definitions of chorioamnionitis. Improvements in neonatal intensive care may have attenuated the impact of chorioamnionitis on brain health outcomes. Large multicenter studies using rigorous definitions of chorioamnionitis on placental pathologies and quantitative magnetic resonance techniques may offer the optimal way to clarify the complex role of chorioamnionitis in modifying brain health and long-term outcomes.