Interaction of chorioamnionitis at term with maternal, fetal and obstetrical factors as predictors of neonatal mortality: a population-based cohort study.

BACKGROUND: Chorioamnionitis is a frequent complication of pregnancy and is known to be associated with serious adverse post-natal outcomes including death. However, the assessment of fetal well-being in labor in the context of chorioamnionitis is often challenging because of fetal tachycardia. Identifying specific risk factors for adverse neonatal outcomes in the context of chorioamnionitis could therefore be of paramount importance. This study aimed to determine if maternal and fetal risk factors for increased neonatal mortality and early neonatal mortality are modified in the context of chorioamnionitis in term pregnancies. METHODS: A retrospective population-based cohort study using the United States birth/infant death public file from 2011 to 2013 was performed, including all live births at 37 weeks gestation and beyond. Interaction between chorioamnionitis and maternal demographic variables as well as labor and delivery potential risk factors were analyzed for association with neonatal death (< 28 days) and early neonatal death (< 7 days) using multivariate logistic regressions. RESULTS: Among 9,034,428 live births, the prevalence of chorioamionitis was 1.29% (95% CI 1.28-1.30%). The incidence of neonatal death and early neonatal death were 0.09 and 0.06% in the chorioamnionitis group versus 0.06 and 0.04% in the no chorioamnionitis group (p = 0.0003 and < 0.0001), respectively. Smoking was significantly associated with neonatal death and early neonatal death in the context of chorioamnionitis (OR 2.44, CI:1.34-4.43/ 2.36 CI:1.11-5.01) but was either less strongly or not associated in the absence of chorioamnionitis (OR 1.24, CI:1.14-1.35/0.93, CI:0.82-1.05). The association between gestational age (37 weeks compared to 39 weeks) and neonatal death was more important in the context of chorioamnionitis (OR = 3.19, CI: 1.75-5.82 versus 1.63, CI: 1.49-1.79). Multivariate analysis identified the following risk factors for neonatal death and/or early neonatal death: low maternal education, extreme maternal age, obesity (BMI > 35 kg/m2), late or no prenatal care, diabetes, meconium-stained amniotic fluid, gestational ages other than 39 weeks, neonatal weight < 2500 g and delivery by vacuum or caesarian. CONCLUSIONS: Smoking as well as early term have a positive interaction with chorioamnionitis for the risk of neonatal mortality. This should be taken into account when counseling pregnant women and managing laboring pregnant women with suspected chorioamnionitis.

Factors associated with neonatal outcomes in preterm prelabor rupture of membranes after cervical cerclage.

OBJECTIVE: To evaluate risk factors associated with neonatal morbidity and mortality in pregnant women with preterm prelabor rupture of membranes (PPROM) after cervical cerclage. METHODS: A retrospective cohort study of singleton pregnancies with cervical insufficiency was conducted at a tertiary referral center in Taiwan from May 1, 2000 to July 31, 2017. Patients with PPROM after cerclage and delivered between 20 0/7 days and 36 6/7 days were recruited. Logistic and linear regression analyses were performed to evaluate various risk factors. RESULTS: Overall, 109 women were included. Mothers with a higher white blood cell count, a higher C-reactive protein (CRP) level, a lower amniotic fluid index, and chorioamnionitis were significantly associated with neonatal morbidity. Neonatal mortality was related to oligohydramnios (adjusted odds ratio [aOR] 2.98, 95% confidence interval [CI] 1.11-8.01) and chorioamnionitis (aOR 3.17, 95% CI 1.03-9.69). An elevated CRP level was associated with a shorter PPROM to delivery latency (adjusted B -16.64, 95% CI -29.88 to -3.41), but cerclage retention more than 12 hours after PPROM was associated with a prolonged latency (adjusted B 17.21, 95% CI 3.25-31.18). CONCLUSION: Oligohydramnios and chorioamnionitis are associated with neonatal mortality.

Exposure to systemic and intrauterine inflammation leads to decreased pup survival via different placental mechanisms.

PROBLEM: Exposure to systemic maternal inflammation (i.e., maternal sepsis, influenza, human immunodeficiency virus, or pyelonephritis) and intrauterine (IU) inflammation (i.e., chorioamnionitis or preterm labor) have been associated with adverse perinatal sequelae. Whether systemic and localized inflammation leading to adverse outcomes have similar placental mechanisms remain unclear. METHOD OF STUDY: We conducted a study by murine modeling systemic and localized IU inflammation with injections of either intraperitoneal (IP) or IU interleukin-1ß (IL-1ß) and compared fetoplacental hemodynamic changes, cytokine/chemokine expression, and fetal loss. RESULTS: IU IL-1ß exposure reduced offspring survival by 31.1% and IP IL-1ß exposure by 34.5% when compared with control pups. Despite this similar outcome in offspring survival, Doppler analysis revealed a stark difference: IU group displayed worsened fetoplacental hemodynamic changes while no differences were found between IP and control groups. While both IU and IP groups had increases in pro-inflammatory cytokines and chemokines, specific gene expression trends differed between the two groups, once again highlighting their mechanistic differences. CONCLUSION: While both IP and IU IL-1ß exposure similarly affected pup survival, only IU inflammation resulted in fetoplacental hemodynamic changes. We speculate that exposure to maternal systemic and IU inflammation plays a key role in fetal injury by utilizing different placental inflammatory pathways and mechanisms.

Placenta, Secret Witness of Infant Morbidities: The Relationship Between Placental Histology and Outcome of the Premature Infant.

OBJECTIVE: The microscopic and macroscopic features of the placenta can contribute to the clinical understanding of premature delivery. The aim of our study was to figure out the relationship between the histopathological findings of the placentas of premature deliveries and its effects on neonatal morbidity and mortality. MATERIAL AND METHOD: The placentas of 284 singleton preterm infants with < 35 weeks of gestation were examined. Three groups were created as the normal, chorioamnionitis and vasculopathy groups according to the histopathological findings in the placentas of the subjects. RESULTS: The mean gestational age of the infants in the study group was 30.5 ± 3.2 weeks, and the mean birth weight was 1588 ± 581 g. The pathology was normal in ninety-six (33.8%), vasculopathy in 153 (53.9%) and chorioamnionitis in 35 (12.3%). The gestation age of the infants was lower in the chorioamnionitis group. Moreover, retinopathy of prematurity, early onset neonatal sepsis, and duration of respiratory support were found to be higher in the chorioamnionitis group. In the vasculopathy group, preeclampsia and small for gestational age were found to be significantly higher. CONCLUSION: Histopathological findings of the placentas from preterm deliveries provided important data in determining the etiology of preterm delivery and outcomes of infants. Infants delivered by mothers with chorioamnionitis were particularly found to be more preterm, and these preterm infants would have a longer hospital stay, higher respiratory support requirement, and more serious morbidities.

Intrapartum fetal deaths and unexpected neonatal deaths in the Republic of Ireland: 2011 - 2014; a descriptive study.

BACKGROUND: Intrapartum fetal death, the death of a fetus during labour, is a tragic outcome of pregnancy. The intrapartum death rate of a country is reflective of the care received by mothers and babies in labour and it is through analysing these cases that good aspects of care, as well as areas for improvement can be identified. Investigating unexpected neonatal deaths that may be associated with an intrapartum event is also helpful to fully appraise intrapartum care. This is a descriptive study of intrapartum fetal deaths and unexpected neonatal deaths in Ireland from 2011 to 2014. METHODS: Anonymised data pertaining to all intrapartum fetal deaths and unexpected neonatal deaths for the study time period was obtained from the national perinatal epidemiology centre. All statistical analyses were conducted using Statistical package for the Social Sciences (SPSS). RESULTS: There were 81 intrapartum fetal deaths from 2011 to 2014, and 36 unexpected neonatal deaths from 2012 to 2014. The overall intrapartum death rate was 0.29 per 1000 births and the corrected intrapartum fetal death rate was 0.16 per 1000 births. The overall unexpected neonatal death rate was 0.17 per 1000 live births. Major Congenital Malformation accounted for 36/81 intrapartum deaths, chorioamnionitis for 18/81, and placental abruption accounted for eight babies' deaths. Intrapartum asphyxia accounted for eight of the intrapartum deaths. With respect to the neonatal deaths over half (21/36, 58.3%) of the babies died as a result of hypoxic ischaemic encephalopathy. Information is also reported on both maternal and individual baby demographics. CONCLUSIONS: This is the first detailed descriptive analysis of intrapartum deaths and unexpected intrapartum event related neonatal deaths in Ireland. The corrected intrapartum fetal death rate was 0.16 per 1000 births. Despite our results being based on the best available national data on intrapartum deaths and unexpected neonatal deaths, we were unable to identify if any of these deaths could have been prevented. A more formal confidential inquiry based system is necessary to fully appraise these cases.

Neonatal and maternal outcomes following midtrimester preterm premature rupture of the membranes: a retrospective cohort study.

BACKGROUND: Preterm premature rupture of membranes (PPROM) complicates 1% of all pregnancies and occurs in one third of all preterm deliveries. Midtrimester PPROM is often followed by spontaneous miscarriage and elective termination of ongoing pregnancies is offered in many countries. The aim of this retrospective descriptive cohort study was to investigate the natural history of midtrimester PPROM in a jurisdiction where termination of pregnancy in the absence of maternal compromise is unavailable. METHODS: Cases of midtrimester PPROM diagnosed between 14 and 23 + 6 weeks' gestation during April 2007 to June 2012 were identified following a manual search of all birth registers, pregnancy loss registers, annual reports, ultrasound reports, emergency room registers and neonatal death certificates at Cork University Maternity Hospital - a large (circa 8500 births per annum) tertiary referral maternity hospital in southwest Ireland. Cases where delivery occurred within 24 h of PPROM were excluded. RESULTS: The prevalence of midtrimester PPROM was 0.1% (42 cases/44,667 births). The mean gestation at PPROM was 18 weeks. The mean gestation at delivery was 20 + 5 weeks, with an average latency period of 13 days. Ten infants were born alive (23%; 10/42). The remainder (77%; 32/42) died in utero or intrapartum. Nine infants were resuscitated. Two infants survived to discharge. The overall mortality rate was 95% (40/42). Five women had clinical chorioamnionitis (12%; 5/42) but 69% demonstrated histological chorioamnionitis. One woman developed sepsis (2.4%; 1/42). Other maternal complications included requirement of intravenous antibiotic treatment (38%; 17/42), retained placenta (21%, 9/42) and post-partum haemorrhage (12%; 5/42). CONCLUSIONS: This study provides useful and contemporary data on midtrimester PPROM. Whilst fetal and neonatal mortality is high, long-term survival is not impossible. The increased risk of maternal morbidity necessitates close surveillance.

Effect of chorioamnionitis on mortality, early onset neonatal sepsis and bronchopulmonary dysplasia in preterm neonates with birth weight of < 1,500 grams.

The aim of the study was to investigate the effects of chorioamnionitis on mortality and early onset neonatal sepsis (EONS) and bronchopulmonary dysplasia (BPD) in preterm neonates with birth weight < or = 1,500 g. The study included 395 preterm infants born at the Zagreb Clinical Hospital Center, from January 2001 to December 2005. All the placentas from preterm deliveries were sent for pathological examination. The patients were categorized into two groups: one including patients with chorioamnionitis at placental histology (47%) and the other control group without chorioamnionitis (53%). Neonates were distributed into 3 groups according to gestational age: the first group with 132 (33%) infants born at < or = 28 weeks of gestation, the second with 202 (52%) infant born from 29 to 32 weeks of gestation and the third with 61 (15%) infants born at > or = 33 weeks gestation. Chorioamnionitis was diagnosed significantly more often in the first gestational age group (91/132-69% of infants, chi2 = 51.307, p < 0.05). The outcome was lethal in 67/395 (17%) patients; 55% of them had chorioamnionitis (chi2 = 2.421, p > 0.05). Lethal outcome ensued in 54/132 (41%) infants from the first gestational age group; 30/54 (55%) were born from pregnancies complicated by chorioamnionitis. In comparison with the control group, mortality was significantly higher in the group of premature infants with gestation < or = 28 weeks whose placentas showed chorioamnionitis (chi2 = 7.645, p < 0.01). EONS was probable or confirmed in 100/395 (25%) infants; in 66/100 (66%) infants pregnancy was complicated by chorioamnionitis (chi2 = 22.396, p < 0.01). BPD developed in 25/395 (6%) infants; in 12/25 (48%) infants placentas showed chorioamnionitis (chi2 = 0.022, p > 0.05). In conclusion, premature neonates from pregnancies complicated by chorioamnionitis are more often born at < or = 28 weeks of gestation. Chorioamnionitis in neonates whose gestation is < or = 28 weeks leads to a significantly higher rate of mortality than in neonates with a longer gestation period. A greater incidence of EONS was proven in the group of infants with chorioamnionitis. The difference between the incidence of BPD in preterm infants born from pregnancies complicated by chorioamnionitis and the control group was not significant.

Lipopolysaccharide-binding protein as marker of fetal inflammatory response syndrome after preterm premature rupture of membranes.

BACKGROUND: Intra-amniotic inflammation with preterm premature rupture of membranes (PPROM) is a risk factor for fetal inflammatory response syndrome (FIRS) and adverse neonatal outcome. OBJECTIVES: To evaluate the diagnostic accuracy of lipopolysaccharide-binding protein (LBP) for detecting FIRS in preterm neonates born after PPROM. METHODS: This was a prospective study in the level III neonatal intensive care unit (42 neonates; 23 + 6 to 31 + 6 weeks' gestation) of mothers with PPROM. Umbilical cord blood concentrations of LBP, C-reactive protein (CRP), interleukin (IL)-6 and white blood cell count with differential were measured at delivery and 24 h after birth. Neonates were classified into FIRS (n = 22) and no FIRS (n = 20) groups according to clinical criteria and IL-6 level (≥17.5 pg/ml). Histological examination of the placenta and umbilical cord was performed. Neurological examination at 12 months' corrected age was performed. RESULTS: Umbilical cord blood concentration of LBP was significantly higher in the FIRS group than in the no FIRS group at delivery (median 21.6 mg/l vs. median 2.3 mg/l; p < 0.0001) and 24 h after birth (median 17.2 mg/l vs. median 20.0 mg/l; p < 0.001). The area under the ROC curve for FIRS at delivery was 0.98 (95% CI 0.88-1.0) for LBP, 0.92 (95% CI 0.80-0.99) for CRP and 0.82 (95% CI 0.64-0.94) for immature to total neutrophil ratio. Similar results were obtained if FIRS was defined by funisitis. Umbilical cord blood concentration of LBP at delivery was significantly higher in neonates with abnormal neurological exam at 12 months than in those with normal exam (median 19.5 mg/l vs. median 3.75 mg/l; p < 0.015). CONCLUSIONS: In preterm neonates born to asymptomatic women with PPROM, LBP in cord blood at delivery is an excellent diagnostic biomarker of FIRS/funisitis with prognostic potential.

Corioamnionitis y complicaciones en el prematuro de muy bajo peso al nacer, en el Servicio de Neonatología del Hospital Nacional Arzobispo Loayza. 1ro de Agosto 2004 - 31 de Julio 2010 / Chorioamnionitis and complications in premature very low birth weight in the Neonatology Service of the National Hospital Arzobispo Loayza. August 1, 2004 - July 31, 2010

Objetivo: Determinar la asociación entre la corioamnionitis y las complicaciones en los prematuros de muy bajo peso al nacer en el servicio de neonatología del Hospital Nacional Arzobispo Loayza durante el periodo 1 de Agosto 2004 al 31 de Julio 2010. Metodología: Se realizó un estudio observacional, analítico, retrospectivo y transversal. Se revisaron 343 historias clínicas de pacientes menores de 1500 gramos, que ingresaron al servicio de neonatología en el periodo que corresponde al estudio. Resultados: El 63.6 por ciento de las madres evaluadas en el estudio tuvieron edades que fluctuaron entre los 20 a 35 años, asimismo el 60.1 por ciento de las madres no tuvieron control prenatal y el 67.1 por ciento de madres fueron cesareadas. En relación a los recién nacidos menores de 1500 gramos: El 9.3 por ciento de los neonatos tuvo el antecedente de corioamnionitis, y los pesos entre los 1000 a 1499 se identificó en el 65.6 por ciento. Las edades gestacionales entre 28-32 semanas por Capurro se observó en el 61.2 por ciento, de los cuales el 51.0 por ciento fueron de sexo masculino. Con respecto a las complicaciones en el recién nacido se observó depresión moderada (15.7 por ciento), hemorragia intraventricular (43.4 por ciento), enterocolitis necrotizante (12.5 por ciento) retinopatía de la prematuridad (19.8 por ciento), sin embargo no se observa asociación entre estas complicaciones y la corioamnionitis (p>0.05), mientras que existe relación entre corioamnionitis y sepsis neonatal (23.6 por ciento) (p<0.05). La mortalidad fue del 33.2 por ciento. Conclusiones: Existe asociación entre la corioamnionitis con sepsis neonatal y mortalidad en los prematuros de muy bajo peso al nacer. No existe relación entre la displasia broncopulmonar, enterocolitis necrotizante, hemorragia intraventricular, la retinopatía de la prematuridad y la corioamnionitis.

Objective: To determine the association between chorioamnionitis and the complications in premature, very low birth weight infants in the neonatology service of Arzobispo Loayza National Hospital during the period 1 August 2004 to 31 July 2010. Methodology: We performed an observational study, analytical, retrospective and transversal. We reviewed clinical histories of 343 patients less than 1500 grams, who were admitted to the neonatology in the period covered by the study. Results: The 63.6 per cent of mothers evaluated in the study fluctuated in age from 20 to 35 years, also the 60.1 per cent of mothers had no prenatal care and 67.1 per cent of mothers were cesarean. In relation to infants less than 1500 grams: The 9.3 per cent of infants had a history of chorioamnionitis, and weight between 1000-1499g was identified in 65.6 per cent. The gestational ages between 28-32 weeks Capurro was observed in 61.2 per cent, of which 51.0 per cent were male. With respect to complications in the newborn was observed moderate depression (15.7 per cent), intraventricular hemorrhage (43.4 per cent), necrotizing enterocolitis (12.5 per cent) retinopathy of prematurity (19.8 per cent), however there is no association between these complications and chorioamnionitis (p>0.05), while there is a relationship between chorioamnionitis and neonatal sepsis (23.6 per cent) (p<0.05). Mortality was 33.2 per cent. Conclusions: There is association between chorioamnionitis with neonatal sepsis and mortality in premature, very low birth weight. There is no relationship between bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity and chorioamnionitis.

Acute histologic chorioamnionitis is a risk factor for adverse neonatal outcome in late preterm birth after preterm premature rupture of membranes.

BACKGROUND: The objective of this study was to determine whether acute histologic chorioamnionitis is associated with adverse neonatal outcomes in late preterm infants who were born after preterm PROM. METHODOLOGY/PRINCIPAL FINDINGS: The relationship between the presence of acute histologic chorioamnionitis and adverse neonatal outcome was examined in patients with preterm PROM who delivered singleton preterm newborns between 34 weeks and 36 6/7 weeks of gestation. Nonparametric statistics were used for data analysis. The frequency of acute histologic chorioamnionitis was 24% in patients with preterm PROM who delivered preterm newborns between 34 weeks and 36 6/7 weeks of gestation. Newborns born to mothers with histologic chorioamnionitis had significantly higher rates of adverse neonatal outcome (74% vs 51%; p<0.005) than those without histologic chorioamnionitis. This relationship remained significant after adjustment for gestational age at preterm PROM, gestational age at delivery, and exposure to antenatal corticosteroids. CONCLUSIONS/SIGNIFICANCE: The presence of acute histologic chorioamnionitis is associated with adverse neonatal outcome in late preterm infants born to mothers with preterm PROM.

Histological chorioamnionitis: effects on premature delivery and neonatal prognosis.

BACKGROUND: Chorioamnionitis is closely related to premature birth and has negative effects on neonatal morbidity and mortality. METHODS: In this prospective study, 43 mothers who delivered earlier than 35 gestational weeks and their 57 infants were evaluated clinically and with laboratory findings. Placentas and umbilical cords were investigated histopathologically for chorioamnionitis and funisitis. RESULTS: The overall frequency of clinical and histological chorioamnionitis (HCA) was 8.3% and 23.2%, respectively. The frequency of HCA was 47.3% and 83.3% in mothers delivered <32 weeks and <30 weeks, respectively. Maternal demographic and clinical findings and also leukocyte and C-reactive protein values were not indicative of HCA. Infants of mothers with HCA had significantly lower Apgar scores together with higher SNAP-PE-II and CRIB scores. These infants had increased mechanical ventilator and surfactant requirements, higher incidences of patent ductus arteriosus, early sepsis, and bronchopulmonary dysplasia, and higher mortality rates. The effect of HCA on neonatal morbidity and mortality was more prominent than the effect of low birthweight and lower gestational age. CONCLUSION: Chorioamnionitis not only causes premature deliveries, but is also associated with neonatal complications and increased mortality. Clinical findings and infectious markers in mother or infant do not predict the diagnosis of histological chorioamnionitis. Therefore, placental histopathology may have a role in predicting neonatal outcome in premature deliveries, especially those below 30 weeks.

Histological characteristics of the fetal inflammatory response associated with neurodevelopmental impairment and death in extremely preterm infants.

OBJECTIVE: To test the hypothesis that increasing severity of the fetal inflammatory response (FIR) would have a dose-dependent relationship with severe neurodevelopmental impairment or death in extremely preterm infants. STUDY DESIGN: We report 347 infants of 23-28 weeks gestational age admitted to a tertiary neonatal intensive care unit between 2006 and 2008. The primary outcome was death or neurodevelopmental impairment at the 18- to 22-month follow-up. Exposure status was defined by increasing stage of funisitis (stage 1, phlebitis; stage 2, arteritis with or without phlebitis; stage 3, subacute necrotizing funisitis) and severity of chorionic plate vasculitis (inflammation with or without thrombosis). RESULTS: A FIR was detected in 110 placentas (32%). The rate of severe neurodevelopmental impairment/death was higher in infants with subacute necrotizing funisitis compared with infants without placental/umbilical cord inflammation (60% vs 35%; P < .05). Among infants with stage 1 or 2 funisitis, the presence of any chorionic vasculitis was associated with a higher rate of severe neurodevelopmental impairment/death (47% vs 23%; P < .05). After adjustment for confounding factors, only subacute necrotizing funisitis (risk ratio, 1.87; 95% CI, 1.04-3.35; P = .04) and chorionic plate vasculitis with thrombosis (risk ratio, 2.21; 95% CI, 1.10-4.46; P = .03) were associated with severe neurodevelopmental impairment/death. CONCLUSION: Severe FIR, characterized by subacute necrotizing funisitis and severe chorionic plate vasculitis with thrombosis, is associated with severe neurodevelopmental impairment/death in preterm infants.

Time-dependent effect of in utero inflammation: a longitudinal study in rats.

OBJECTIVE: To determine the impact of the duration of fetal exposure to inflammation on the neurological outcome of pups. METHOD: Time-pregnant Sprague-Dawley rats (n = 32) received intraperitoneal injection of lipopolysaccharides (LPS; 500 µg/kg), or an equivalent volume of vehicle 3, 6, 12 and 24 h before C-section. Maternal serum and amniotic fluid were tested for cytokines. Motor activity of resuscitated pups (n = 58) was analyzed using the open-field test (20 d). Brains were collected for histopathological examination. RESULTS: Perinatal mortality increased with the duration of fetal exposure to LPS. All parameters tested with the open-field test were lower in the LPS 12 h exposure group compared to the control group (p < 0.05). Tissue inhibitor of metalloproteinase 1 (TIMP-1) was statistically increased in maternal blood after 3, 6 and 12 h of LPS injection (p < 0.05 versus control). CONCLUSION: A threshold of duration of exposure to inflammation is demonstrated, before which delivery should be performed in order to prevent brain damage.

Premature rupture of membranes before 34 weeks managed expectantly: maternal and perinatal outcomes in singletons.

OBJECTIVES: To ascertain the risk factors for imminent delivery and infection in pregnant women with premature rupture of membranes (PPROM) before 34 weeks of gestation, evaluate maternal and fetal outcomes and identify obstetric factors for determining which patients meet the criteria for home follow-up. METHODS: Medical charts of all women with PPROM admitted to the Vall d'Hebron Hospital (HVH) between January 2006 and December 2010 were retrospectively reviewed. RESULTS: During the study period, 216 women were admitted with a diagnosis of PPROM <34 weeks of gestation with a singleton, live, structurally-normal fetus. Mean gestational age at delivery was 31 weeks. Sixty-two patients (28.7%) delivered before 28 weeks and 76 of the infants (35.2%) had birth weight <1,500 g. Overall, 202 infants (93.5%) survived to be discharged home. On stratifying by gestational age at PPROM diagnosis, prognosis was better when PPROM occurred near to term. Gestational age at delivery was increased in pregnant women with no oligohydramnios, no shortened cervix and with negative endocervical and vaginal cultures at PPROM diagnosis (33 weeks of gestation) vs. pregnant women with positive cultures at admission (27 weeks), oligohydramnios at admission (28 weeks) and shortened cervix (26 weeks). This difference was statistically significant (p = 0.005). CONCLUSIONS: Protective factors for PPROM could be normal AFI, cervical length >25 mm and negative cultures at PPROM diagnosis. These factors could permit home follow-up of this group of patients.

Placental pathology and long-term neurodevelopment of very preterm infants.

OBJECTIVE: The objective of the study was to compare neonatal morbidity and long-term neurodevelopmental outcome between very preterm infants with placental underperfusion and very preterm infants with histological chorioamnionitis. STUDY DESIGN: We measured the mental and motor development at age 2 and 7 years in 51 very preterm infants with placental underperfusion and 21 very preterm infants with histological chorioamnionitis. RESULTS: At 2 years, very preterm infants with placental underperfusion had poorer mental development than very preterm infants with histological chorioamnionitis (mean [SD] 90.8 [18.3] vs 104.1 [17.2], adjusted d = 1.12, P = .001). Motor development was not different between both groups (92.8 [17.2] vs 96.8 [8.7], adjusted d = 0.52, P = .12). At 7 years, large, although nonsignificant, effects were found for better mental and motor development and fewer behavioral problems in infants with histological chorioamnionitis. CONCLUSION: Placental pathology contributes to variance in mental development at 2 years and should be taken into account when evaluating neurodevelopmental outcome of very preterm infants.

Cause of death in neonates with inconclusive or abnormal T-cell receptor excision circle assays on newborn screening.

INTRODUCTION: During the first 2 years of newborn screening (NBS) for severe combined immunodeficiency (SCID), 39 infants with an abnormal or inconclusive newborn screening test for SCID died prior to assessment of immune function. We investigated if SCID or primary T-cell lymphopenia likely contributed to the death of these neonates. METHODS: This study is a detailed retrospective chart review. RESULTS: Medical records were available in all 39 infants. Three neonates were full-term infants whose deaths were due to congenital anomalies. Thirty-three infants were born <33 weeks estimated gestational age, and the majority of these infants died from complications of prematurity. Six infants died from sepsis: two due to maternal chorioamnionitis, two due to necrotizing enterocolitis, one due to early onset group B strep sepsis, and one from a likely nosocomial infection. CONCLUSIONS: There was no evidence that SCID contributed to the cause of death in neonates with an abnormal of inconclusive NBS test for SCID.

Upregulated amniotic fluid cytokines and chemokines in emergency cerclage with protruding membranes.

PROBLEM To identify the prognostic factors for pregnancy outcome in women who received emergency cerclage for dilated cervix with protruding membranes. METHOD OF STUDY A prospective cohort study was performed, and a total of 14 women who received emergency cerclage were included. Clinical features and laboratory findings including amniotic fluid cytokines and chemokines were compared between women who had successful pregnancy (survival group, n = 6) and those who had perinatal death (non-survival group, n = 8). Five healthy pregnant women served for normal controls for amniotic fluid study. RESULTS The overall neonatal survival was 42.9% in women with emergency cerclage. Serum C-reactive protein levels on postoperative day 3 and 7 were significantly higher in non-survival group when compared with those in survival group (P = 0.002, P = 0.01). Amniotic fluid levels of interleukin (IL)-1α, IL-1ß, IL-6, IL-8, IL-10, tumor necrosis factor-α, and monocyte chemoattractant protein-1 levels of the patients were significantly higher than those of normal controls. Amniotic fluid levels of IL-1α, IL-1ß, and IL-8 were significantly increased in the non-survival group when compared with those of the survival group. CONCLUSION Systemic and local inflammatory markers including proinflammatory cytokines and chemokines may predict pregnancy outcome in women with emergency cerclage for dilated cervix with protruding membranes.

Neonatal and neurodevelopmental outcomes of very low birth weight infants with histologic chorioamnionitis.

OBJECTIVE: To determine survival and neurodevelopmental outcomes at 18 months corrected age among very low birth weight infants ≤ 32 weeks gestation with histologic chorioamnionitis. STUDY DESIGN: Observational, regionalized, single-center cohort study with prospective follow-up. RESULTS: Of the 628 infants meeting the selection criteria, 303 (48%) were born to mothers with evidence of histologic chorioamnonitis. Neonates with histologic chorioamnonitis were of lower gestational age and birth weight. On univariate analysis, they were more likely to have hypotension, bronchopulmonary dysplasia, severe intraventricular hemorrhage, severe retinopathy of prematurity, early-onset sepsis, and death. Infants with histologic chorioamnonitis were more likely to have any neurodevelopmental impairment, specifically, mental delay with a lower mental developmental index. When adjusting for perinatal variables, histologic chorioamnonitis had a protective effect on mortality rates (adjusted OR = 0.44, 95% CI: 0.24-0.8; P = .01; n = 619), had a nonsignificant effect on neurodevelopmental impairment (adjusted odds ratio = 1.33, 95% CI: 0.82-2.17; P = .25; n = 496), and was associated with a 4-point lower mental developmental index at 18-months follow-up (adjusted difference -3.93, 95% CI: -7.52 to -0.33; P = .03; n = 496). CONCLUSIONS: Although infants with histologic chorioamnonitis were at an increased risk for death and neurodevelopmental impairment, after multivariate analyses, histologic chorioamnonitis was not associated with adverse long-term outcomes. Results suggest fetal protection from treatment-responsive maternal infection and inflammation.

Corioamnionitis: repercusión perinatal / Chorioamnionitis: perinatal impact

Determinar en las gestantes complicadas con corioamnionitis las características, factores maternos y las repercusiones maternas y perinatales. Estudio descriptivo, retrospectivo, epidemiológico y analítico. Departamento de Obstetricia y Ginecología, Hospital "Dr. Adolfo Prince Lara", Universidad de Carabobo, Puerto Cabello, Estado Carabobo. En las 44 pacientes las características maternas que predominaron fueron: residentes en barrios (45,45 por ciento), solteras y concubinas (77,27 por ciento), edad materna 20-24 años (40,91 por ciento) y antecedente personal hipertensión (20,45 por ciento). El diagnóstico de ingreso destacó la rotura prematura de membranas 50 por ciento e infección uro-vaginal 13,6 por ciento; eran multigestas 50,0 por ciento, y en 52,28 por ciento la edad del embarazo fue de 36 semanas y menos, en 84,08 por ciento hubo conducción-inducción del trabajo de parto, terminaron en cesárea 45,45 por ciento. Factores de riesgo: múltiples tactos (4 y más) 40,9 por ciento y tiempo entre rotura de membranas e inicio de trabajo de parto mayor de 12 horas 18,44 por ciento. El diagnóstico se hizo por la clínica y laboratorio; tratadas con antibióticos en su totalidad, acompañadas por oxitócicos 68,18 por ciento. Recién nacidos de sexo femeninos 48,84 por ciento, peso entre 3 000- 3 499 g 31,31 por ciento y tallas 45-49 cm 28,89 por ciento; índice Apgar 6 o menos 28,94 por ciento. La morbilidad perinatal neonatal fue 39,47 por ciento, especialmente por sepsis y patología respiratoria; la morbilidad materna 56,81 por ciento, por sepsis y anemia; la perinatal global 28,88 por ciento, la fetal 15,55 por ciento y la neonatal 13,13 por ciento. La corioamninitis se relacionó con múltiples tactos intraparto, el tiempo de rotura prematura de membranas al inicio del parto y las infecciones uro-vaginales; sus repercusiones revelaron elevadas cifras de morbimortalidad materna. Toda señala a implemantar programas preventivos y mejorar la atención materno-neonatal

To study the pregnant women complicated with chorioamnionitis, knowing its impact, identify characteristics and factors related maternal and establish maternal and perinatal impact. Observational, descriptive, retrospective, epidemiological and analytical study of 44 pregnant women complicated with chorioamnionitis, which occurred during the period 2005-2009. Department of Obstetrics and Gynecology, Hospital "Dr. Adolfo Prince Lara ", Universidad de Carabobo, Puerto Cabello, Estado Carabobo. Maternal characteristics were predominant in patients living in urban region (45.45 percent), single and concubines (77.27 percent), maternal age between 20-24 years (40.91 percent) and personal history hypertension (20.45 percent). In obstetrical situation, first admission diagnosis of premature rupture of membranes 50 percent and infection urology and vaginal 13.6 percent, were multiparous 50 percent, with 52.28 percent of gestational age 36 weeks and less, in 84.08 percent were induction-conduction of labor, ending 45.45 percent cesarean. Outstanding risk factors, vaginal digital exam (4 and more) 40.9 percent, exam gynecology and time between rupture of membranes at the onset of labor more than 12 hours 18.44 percent, diagnosis was mainly clinical and laboratory, were treated with antibiotics in its entirety accompanied by oxytocic 68.18 percent. The neonates were 48.84 percent female, weighing between 3 000 and 3 499 g, 31.31 percent and 28.89 percent height 45-49 cm, Apgar Index 6 or less 28.94 percent. Neonatal perinatal morbidity was 39.47 percent, represented especially by sepsis and respiratory disease, maternal morbidity 56.81 percent, given by sepsis and anemia in various forms, the overall perinatal mortality 28.88 percent, fetal mortality 15.55 percent, neonatal mortality 13.13 percent, was decisive sepsis and prematurity in all these deaths. The chorioamnionitis related to exam gynecology, premature rupture of membranes at the start time delivery..

Existing models fail to predict sepsis in an obstetric population with intrauterine infection.

OBJECTIVE: Multiple scoring systems exist to identify inpatients who are at risk for clinical deterioration. None of these systems have been evaluated in an obstetric population. We examined the Systemic Inflammatory Response syndrome (SIRS) and Modified Early Warning score (MEWS) criteria in pregnant women with chorioamnionitis. STUDY DESIGN: This was an 18-month retrospective analysis of patients with chorioamnionitis. SIRS and MEWS scores were calculated; clinical outcomes were ascertained, and test characteristics were calculated for the primary outcome of sepsis, intensive care unit transfer, or death. RESULTS: Nine hundred thirteen women with chorioamnionitis were identified. Five women experienced sepsis; there was 1 death. Five hundred seventy-five of the 913 women (63%) met SIRS criteria (95% confidence interval, 59.8-66.2%; positive predictive value, 0.9%). Ninety-two of the 913 women (10.3%) had a MEWS score of ≥ 5 (95% confidence interval, 8.3-12.2%; positive predictive value, 0.05%). CONCLUSION: SIRS and MEWS criteria do not identify accurately patients who are at risk for intensive care unit transfer, sepsis, or death among pregnant women with intrauterine infection and should not be used in an obstetric setting.