Corioamnionitis Histológica Asociada a Muerte Fetal / Histological Chorioamnionitis Associated with Fetal Death

INTRODUCCIÓN. Anualmente ocurren más de 2 millones de muertes fetales a nivel mundial, siendo fundamental el estudio anatomopatológico placentario para disminuir el número de muertes inexplicadas. OBJETIVO. Revisar la literatura existente acerca de corioamnionitis histológica, los criterios para establecer su diagnóstico, su presencia y posible asociación en estudios de causas de muerte fetal. METODOLOGÍA. Se realizaron búsquedas en bases de datos electrónicas para recopilar estudios de causas de muerte fetal que incluyeron corioamnionitis histológica. RESULTADOS. Se encontraron 13 estudios que evaluaron mortalidad fetal y que entre sus causas incluyeron corioamnionitis histológica. DESARROLLO. El estudio microscópico placentario en muertes fetales es esencial al investigar una muerte fetal. Las anomalías placentarias son la causa más común de muerte fetal, la corioamnionitis aguda es la lesión inflamatoria más frecuente. Se detallaron los criterios más relevantes para definir corioamnionitis aguda histológica pero aún no se establece un consenso. Estudios de causas de muerte fetal en años recientes han reportado corioamnionitis histológica entre 6,3% y 41,3% de casos. Las alteraciones inflamatorias del líquido amniótico son una causa importante de muerte fetal, siendo la corioamnionitis la más frecuente en este grupo. CONCLUSIÓN. En estudios para determinar las causas de muerte fetal se evidenció corioamnionitis aguda histológica en hasta el 41,3% de casos, por lo que podría estar asociada a dicho evento. Sin embargo, es necesario establecer un sistema de estadiaje de corioamnionitis histológica mediante un panel de expertos a nivel mundial.

INTRODUCTION. Annually more than 2 million fetal deaths occur worldwide, being fundamental the placental anatomopathological study to reduce the number of unexplained deaths. OBJECTIVE. To review the existing literature on histological chorioamnionitis, the criteria to establish its diagnosis, its presence and possible association in studies of causes of fetal death. METHODOLOGY. Electronic databases were searched to collect studies of causes of fetal death that included histologic chorioamnionitis. RESULTS. Thirteen studies were found that evaluated fetal mortality and that included histologic chorioamnionitis among their causes. DEVELOPMENT: Placental microscopic study in fetal deaths is essential when investigating a fetal death. Placental abnormalities are the most common cause of fetal death, acute chorioamnionitis being the most frequent inflammatory lesion. The most relevant criteria for defining histologic acute chorioamnionitis have been detailed but consensus has not yet been established. Studies of causes of fetal death in recent years have reported histologic chorioamnionitis in between 6,3% and 41,3% of cases. Inflammatory changes in the amniotic fluid are an important cause of fetal death, with chorioamnionitis being the most frequent in this group. CONCLUSIONS. In studies to determine the causes of fetal death, histological acute chorioamnionitis was evidenced in up to 41,3% of cases, so it could be associated with this event. However, it is necessary to establish a histological chorioamnionitis staging system by means of a worldwide panel of experts.

Complicaciones neonatales asociadas al diagnóstico de corioamnionitis histológica en pacientes con parto pretérmino espontáneo en un hospital de alta complejidad en Colombia / Neonatal complications associated with the diagnosis of histological chorioamnionitis in patients with spontaneous preterm delivery in a highly complexity hospital in Colombia

INTRODUCCIÓN: La corioamnionitis histológica (CH) es causa importante de parto pretérmino y se asocia a resultados neonatales adversos, con secuelas del neurodesarrollo. Ocurre en alrededor de un 20% de embarazos a término y 60% de pretérmino. Este proceso está asociado a varias complicaciones neonatales, entre las más frecuentes: sepsis neonatal temprana, menor edad gestacional y mayor estancia hospitalaria. OBJETIVO: Establecer la asociación de complicaciones neonatales con el diagnóstico de CH en pacientes con parto pretérmino espontáneo en un hospital de alta complejidad. MÉTODOS: Estudio retrospectivo, se incluyeron 160 pacientes con parto pretérmino espontáneo con estudio histopatológico de la placenta según protocolo institucional. Se recolectan las características basales de la gestante y complicaciones neonatales. Se calcula la prevalencia de CH, y se comparan dos grupos (con y sin) la asociación de complicaciones neonatales, distribuidas por edad gestacional y peso neonatal. RESULTADOS: La prevalencia de CH es de 69% (IC95%: 61-76). Al distribuir por edad gestacional se reporta: 87% en 34 (IC 95%: 45 -67). La CH entre las 28 - 34 y > 34 semanas, se asocia a mayor sepsis neonatal temprana (p 2000 g se asocia con sepsis neonatal (p<0.05). CONCLUSIÓN: La prevalencia de CH es alta, principalmente a menor edad gestacional, se asocia a complicaciones neonatales como la sepsis neonatal temprana.

INTRODUCTION: Histological chorioamnionitis (HC) is an important cause of preterm delivery and is associated with adverse neonatal outcomes, with sequelae of neurodevelopment. It occurs in about 20% of full-term and 60% preterm pregnancies. This process is associated with several neonatal complications, among the most frequent: early neonatal sepsis, younger gestational age, and longer hospital stay. OBJECTIVE: To establish the association of neonatal complications with HC diagnosis in patients with spontaneous preterm delivery in a highly complexity hospital in Colombia. RESULTS: The prevalence of HC is 69% (95% CI: 61-76). When distributed by gestational age, it is reported: 87% in 34 (95% CI: 45-67). HC between 28 - 34 and > 34 weeks, is associated with higher early neonatal sepsis (p 2000 g is associated with early neonatal sepsis (p <0.05). CONCLUSION: The prevalence of HC is high, mainly at a lower gestational age, it is associated with neonatal complications such as early neonatal sepsis.

Cerclaje profiláctico en mujeres con nacimientos prematuros espontáneos previos, asociados con infección bacteriana ascendente / Prophylactic cerclage in women with spontaneous premature deliveries associated to ascending bacterial infection

Objetivo: Determinar la eficacia del cerclaje cervical profiláctico en pacientes con embarazos únicos, cérvix >25 mm e historia de nacimientos prematuros espontáneos, asociados con infección bacteriana ascendente (IBA). Métodos: Estudio clínico en pacientes con embarazos únicos y partos prematuros y/o abortos de 2° trimestre espontáneos previos, sin partos de término, asociados con IBA. Se incluyeron los casos con longitud cervical de >25 mm al ingreso. Se comparó el cerclaje cervical hecho en pacientes derivadas antes de las 20 semanas, con el manejo expectante en mujeres enviadas después de esta edad gestacional y que mantuvieron longitud cervical >25 mm durante los controles. Se excluyeron embarazadas con cérvix <25 mm al ingreso del estudio, con acortamiento cervical <25 mm durante el manejo con conducta expectante y mujeres con nacimientos prematuros previos sin histología placentaria. Resultados: Se incluyeron 51 pacientes, 23 con cerclaje y 28 sin cerclaje. El cerclaje cervical profiláctico, redujo significativamente la frecuencia del nacimiento prematuro <37semanas (4,3 por ciento vs 35,7 por ciento), <34 semanas (4,3 por ciento vs 28,6 por ciento) y la corioamnionitis histológica (4,3 por ciento vs 32,1 por ciento), OR (IC95 por ciento) 0,08 (0,09-0,70), 0,11(0,01-0,99) y 0,01 (0,010,83), respectivamente. Conclusiones: En pacientes con nacimientos prematuros previos asociados con IBA, embarazo único y longitud cervical >25 mm, el cerclaje profiláctico, reduce la frecuencia del nacimiento prematuro <37 y <34 semanas y de la corioamnionitis histológica.

Aims: Determine the effectiveness of prophylactic cerclage in women with singleton pregnancies, cervix >25 mm and a history of spontaneous premature deliveries associated to ascending bacterial infection (ABI). Methods: Women with singleton pregnancies and history of preterm births, with no full term deliveries, associated to ABI. Cases with >25 mm cervical length at admission were included. Cervical cerclage performed on patients derived before 20 weeks of pregnancy was compared to the expectant management of women submitted at a later gestational stage with sustained cervical length of >25 mm. Pregnant women with <25 mm cervix at referral, with cervical shortening <25 mm at expectant management, and women with previous preterm birth without placental histology were excluded. Results: 51 patients were included, 23 with cerclage and 28 without cerclage. Prophylactic cerclage significantly reduced the frequency of premature birth <37 weeks, 4.3 percent vs 35.7 percent and <34 weeks, 4.3 percent vs 28.6 percent and histologic chorioamnionitis 4.3 percent vs 32.1percent (9/28), OR (95 percent CI) 0.08 (0.09-0.70), 0.11(0.01-0.99) and 0.01 (0.01-0.83), respectively. Conclusions: In patients with preterm births associated to ABI, singleton pregnancy and cervical length >25 mm, prophylactic cerclage reduces the frequency of premature delivery <37 and <34 weeks as well as histologic chorioamnionitis.

Corioamnionitis histológica y morbimortalidad neonatal: aproximación al síndrome de respuesta inflamatoria fetal / Chorioamnionitis neonatal morbidity: approach to fetal inflammatory response syndrome

Antecedentes: El síndrome de respuesta inflamatoria fetal (SRIF) es una entidad relacionada con la presencia de inflamación intrauterina y suele asociarse a infección intraamniótica. Su consecuencia más grave es la lesión cerebral y posterior desarrollo de parálisis cerebral. Objetivo: Evaluar la relación entre el síndrome de respuesta inflamatoria fetal y el desarrollo de complicaciones neonatales. Método: Estudio descriptivo y retrospectivo, realizado en el Hospital Universitario La Paz de Madrid, buscando una aproximación al SRIF desde la corioamnionitis histológica/funiculitis. El grupo de estudio constituido por 35 gestaciones simples pretérmino recogidas durante el primer semestre de 2008 y en las que la anatomía patológica de la placenta y anexos ovulares demostró la presencia de una corioamnionitis histológica y/o funiculitis. Resultados: Siete casos (20 por ciento) presentaban clínica sospechosa de infección intraamniótica, si bien en 28 gestantes (80 por ciento) existían factores de riesgo asociados al síndrome de respuesta inflamatoria fetal. Mortalidad perinatal en el grupo estudiado fue de 11,4 por ciento (4 casos). Sólo en 2 pacientes (5,7 por ciento) se pudo relacionar la muerte con el SRIF. En 28 recién nacidos (80 por ciento) se encontró algún tipo de patología, siendo la misma inherente a dicho síndrome en 17 casos (48,6 por ciento), destacando sepsis neonatal (40 por ciento), leucomalacia periventricular (14,3 por ciento) y displasia broncopulmonar (5,7 por ciento). Conclusión: Se comprueba el alto riesgo neonatal del SRIF. El conocimiento de esta condición, abre una serie de controversias diagnósticas y terapéuticas que obliga a una reevaluación de los protocolos actuales de manejo de la amenaza de parto pretérmino y la rotura prematura de membranas de pretérmino.

Background: The fetal inflammatory response syndrome (FIRS) is an entity related to intrauterine inflammation which is commonly associated with intraamniotic infection. The most serious consequence is the neurologic damage and the subsequent development of cerebral palsy. Aims: To evaluate the relationship between the fetal inflammatory response syndrome and the development of neonatal complications. Method: Descriptive and retrospective study realized in "La Paz" University Hospital of Madrid, looking for an approximation to the FIRS from histologic chorioamnionitis/funisitis. Group of study constituted by 35 single preterm gestations collected during the first semester of 2008 and in which the pathologic anatomy study of the placenta and annexes showed the presence of histological corioamnionitis and / or funisitis. Results: Suspicious clinic was found in 7 cases (20 percent) but in 28 cases (80 percent) risk factors associated to FIRS were present. Perinatal mortality found was 11.4 percent (4 cases). Only in 2 cases (5.7 percent) the cause was relationated with FIRS. Pathology associated was found in 28 newborn (80 percent), being 17 cases (48.6 percent) pathology associated with the fetal inflammatory response syndrome, enhancing neonatal sepsis (40 percent), periventricular leukomalacia (14.3 percent), and bronchopulmonar dysplasia (5.7 percent). Conclusion: It is verified that FIRS enteals a high neonatal risk. The knowledge of this entity opens some diagnostic and therapeutic controversies. Current management protocols of preterm labor and preterm premature rupture of membranes should be revised.

Maternal and neonatal screening for Group B streptococci by SCP B gene based PCR: a preliminary study.

OBJECTIVE: To detect the magnitude of group B streptococcal (GBS) colonization and disease among a sample of pregnant women and their infants in Egypt. STUDY DESIGN: Prospective observational study. PARTICIPANTS: The study included 95 pregnant females, 35-37 weeks of gestational age, attending the antenatal outpatient clinic at AlFayom University Hospital between September 2006 and June 2007. All participants were screened with vaginorectal swabs by a conventional GBS PCR assay. Participants were grouped into group A (GBS present, 17 patients) and group B (GBS absent, 78 patients). Details with regard to labor and delivery were recorded and placental pathology was examined to detect histological chorioamnionitis. Ninety-five infant data were also recorded. All neonates of group A (17 out of 95 with known positive maternal GBS) underwent collection of simultaneous specimens from surface sites for PCR before their first bath and within four hours of birth. RESULTS: GBS carriage rate in the study sample was 17.89%. Chorioamnionitis confirmed in three patients by placental pathology (one was in group A and two in group B) was statistically not significant. Twenty-two women had rupture of membranes (< 12 hours) before delivery (four from group A and 18 from group B) that was not statistically significant. There were three infants out of 17 in group A who had GBS colonized at one or more sites by PCR which was statistically significant. However, only one infant was admitted to neonatal intensive care unit (NICU) that was not statistically significant. CONCLUSION: Maternal GBS carriage is associated with a significant increase in neonatal infection rate but is not associated with an increase in neonatal intensive care admission. An accurate evaluation of colonization rate (using a larger sample) is desired to evaluate neonatal invasive disease and determine the cost effectiveness of PCR to select an appropriate preventive strategy in Egypt.

Pathology of placenta in HIV infection.

The spectrum of HIV pathological lesions encountered in the placenta has not been well documented in the literature. To address this issue, we examined 51 placentae of HIV positive mothers, prospectively over a one year period and compared the pathology of the cases treated with zidovudine (AZT) or nevirapine (NVP) with untreated cases. We also correlated the placental pathology with the HIV status of the neonates. The maternal to child transmission rate was 4.44%. A lower fetal / placental weight ratio was seen in normal birth weight neonates compared to low birth weight neonates. No significant gross lesions were encountered and the placental disc did not show any significant decrease in dimensions. The commonest inflammatory lesion seen was chorio-amnionitis 31.37% and the commonest non-inflammatory lesion was cytotrophoblastic hyperplasia 76.47%. There was no significant decrease in the incidence of the lesions following anti-retroviral therapy in our study, and we did not find any correlation between the incidence of placental lesions and the HIV status of the newborn.

Dosis única adicional como tratamiento en el posparto para mujeres con corioamnionitis / Single additional dose postpartum therapy for women with chorioamnionitis

Objetivo: Este estudio se realizó para determinar si una sola dosis adicional de antibióticos de amplio espectro constituye un tratamiento adecuado para mujeres con corioamnionitis. Métodos: Pacientes con diagnóstico de coriamnionitis clínica recibieron tratamiento con ampicilina 2 g cada 6 horas y gentamicina 1,5 mg/kg cada 8 horas. Después del parto las pacientes fueron randomizadas para continuar con este esquema hasta que se mantuvieran afebriles y asintomáticas por 24 horas (grupo control) o recibir una sola dosis de cada fármaco en el próximo horario programado (grupo estudio). Si el parto fue por cesárea, las pacientes recibieron clindamicina 900 mg intravenoso después de cortar el cordón umbilical. El grupo control continuó recibiendo clindamicina cada 8 horas hasta que los antibióticos fueron discontinuados. El resultado primario fue la falla en el tratamiento, definida como una sola toma de temperatura de 39,0ºC o más después de la primera dosis de antibióticos en el post parto o dos cifras de 38,4ºC con al menos 4 horas de intervalo. Se estimó que 292 pacientes fueron necesarias para detectar un incremento de 150 por ciento en la tasa de falla del tratamiento, de 8 por ciento en el grupo control a 20 por ciento en el grupo estudio (alfa= 0,05; 1-beta= 0,80). Resultados: Desde el 26 de diciembre de 1999 al 18 de marzo de 2003, un total de 292 mujeres fueron enroladas en el estudio. En el análisis según intención de tratar, la falla de tratamiento no tuvo diferencia entre el grupo control (n=141) y el grupo estudio (n=151) (3,5 por ciento versus 4,6 por ciento, p=0,639). Conclusión: Si se trató precozmente en el intraparto, una sola dosis adicional de antibióticos de amplio espectro es suficiente como terapia en el post parto para mujeres inmunocompetentes con corioamnionitis.

Las lesiones placentarias en la infección humana por Trypanosoma cruzi / Placental lesions in human Trypanosoma cruzi infection

This histopathological study analyzes placentas of babies congenitally infected with T. cruzi (M+B+), or babies not infected but born from infected- (M+B-), or non infected-mothers (M-B-). Placentas M+B+ showed lesions of chorionitis, chorioamnionitis and cord edema with lymphocyte infiltration, whereas such lesions were infiltrated only with polymorphonuclear cells in M+B- and M-B- placentas. Parasites were found in M+B+ placentas, in fibroblasts and macrophages of chorion, membranes, chorionic plate, mainly in the area of membrane insertion, as well as in cells of Wharton jelly and myocytes of umbilical cord vessels. These results suggest that the materno-fetal transmission of parasites occurs mainly through the marginal sinus, spreading into the chorionic plate infecting fibroblasts and macrophages so far as to found a fetal vessel, inducing a fetal infection by hematogenous route.

Significance of maternal serum cytokines levels in preterm labor

The present study aimed to examine whether maternal serum cytokines levels are useful for the diagnosis of preterm delivery with histologic chorioamnionitis. The blood samples of 16 women who delivered preterm, between 29 and 35 weeks of gestation, were collected at delivery and the placentae were histopathologically examined for chorioamnionitis. The mean value of interleukin-6 [IL-6] was significantly higher in six women with histologic chorioamnionitis than that in ten women without histologic chorioamnionitis [mean 234.4 pg/ml, range 100-312 pg/ml, mean 62.4 pg/ml, range 5-15 pg/ml, respectively]. The IL-6 level was statistically correlated with the level of C-reactive protein [CRP] in preterm women. The levels of interleukin-8 [IL-8] did not differ between the two groups. The results suggested that the level of maternal serum interleukin-6 is more useful than other markers including CRP for the identification of women at risk of impending preterm labor with histologic chorioamnionitis

Histopatologia dos anexos ovulares na rotura prematura das membranas / Histopathology of the ovular adnexa in the premature rupture of the membranes

Estudaram-se a histopatologia de 108 anexos ovulares de pacientes com idade gestacional entre 21 e 37 semanas e cuja queixa à admissäo hospitalar preenchia os critérios de rotura prematura das membranas. Quarenta e cinco (41,7%) dos anexos estudados apresentaram sinais de infecçäo. Os diagnósticos histopatológicos mais freqüentes, quanto ao grau de infiltrado inflamatório, foram: deciduocorioamnionite (55,6%) e deciduocorionite (40%). A deciduocorioamnionite de graus leve e moderado ocorreu em 24% e 36% dos casos, respectivamente, sendo grave em 40%. A deciduocorionite apresentou-se de grau leve em 27,8%, sendo moderada e grave em 11,1% e 27,8% dos casos, respectivamente