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Chorioamnionitis

Intraamniotic Infection


Presentation

Maternal fever (intrapartum temperature > 37.8°C) is the most common symptom of chorioamnionitis. Other characteristic features of the disease are fetal tachycardia, purulent amniotic fluid, uterine tenderness and maternal leukocytosis. When two or more of these symptoms are observed in the patient, the risk of neonatal sepsis increases.

Though in some cases, the pregnant women with chorioamnionitis may show no signs or symptoms, in some cases, they may appear ill, even toxic and hypotensive with cool or clammy skin. The symptoms of the suspected sepsis in the neonate and mother are often nonspecific and include findings such as behavioral abnormalities, tachypnea, cyanosis, apnea, pulmonary hemorrhage, tachycardia, vomiting and diarrhea, abnormalities in thermal regulation, pallor, overt bleeding and hypotension [7] [8].

Fishing
  • FISH and PCR were negative for all women without suspected chorioamnionitis and for the control group.[ncbi.nlm.nih.gov]
Acute Abdomen
  • A 26-year-old woman presented at 16 weeks of gestation with an acute abdomen suggestive of ruptured appendicitis. Blood cultures were positive for Bacteroides fragilis. At laparotomy, she was found to have a colouterine fistula with pelvic sepsis.[ncbi.nlm.nih.gov]
Right Flank Pain
  • Six days later, the patient presented with a temperature of 40C and right flank pain. Workup revealed an abscess in the right adrenal gland, which was diagnosed by computed tomography scan, and then drained percutaneously.[ncbi.nlm.nih.gov]

Workup

Laboratory tests

  • For asymptomatic pregnant women presenting preterm labor, the following tests must be performed namely examination of amniotic fluid, maternal blood and urine analysis, maternal blood group-B streptococcal screening. 
  • Tests for febrile pregnant women with suspected chorioamnionitis include complete blood count, C-reactive protein, Alpha1-proteinase inhibitor complex, and serum interleukin-6 levels. 
  • Evaluation of the amniotic fluid are bacterial cultures, Gram staining, pH levels, leukocyte count, levels of glucose in the blood, polymerase chain reaction, proteomic profiling, etc. 
  • Other diagnostic tests for early onset neonatal sepsis are determination of the levels of procalcitonin, serum interleukin-6 or cytokine, bacterial antigen detection in the blood, etc. [9]

Imaging

Since short cervix is a risk factor for chorioamnionitis, ultrasonography can help to detect this altered anatomy. Imaging studies helps to ascertain the health of the fetus on a regular basis [9].

Treatment

Therapy of chorioamnionitis includes early delivery and supportive care with the use of safe antibiotics. Some of the antibiotics to manage the disease are crystalline penicillin G, clindamycin, ampicillin, gentamicin, and cefotaxime.

Supportive care of the neonates are providing warmth, full resuscitation when needed, treatment of hypervolemia, respiratory acidosis, surfactant replacement therapy, glucose homeostasis and monitoring of the vital signs. Assessment of the thrombocytopenia is one of the important aspects that need to be looked into.

Some surgical options are also available for early onset bacterial infections in the neonate; however, they are rarely used. The conditions that warrant the surgical intervention are epidural and subcutaneous abscess, infections located in the pleural space, bone and joint infections, and similar conditions [10].

Prognosis

The long-term prognosis for both the mother with chorioamnionitis and the neonate is excellent. The fertility of the women is not compromised. The child born preterm may, however, suffer from the long-term complications such as neurologic impairment and chronic lung disease [11].

Complications

Some of the complications of chorioamnionitis are infection in the abdomen and pelvic regions, endometriosis, sepsis, and blood clots in the pelvis and lungs. Complications from bacterial infection in the newborn also include sepsis, meningitis and respiratory problems [12].

Etiology

When the protective mechanism of the maternal urogenital tract fails during pregnancy, there is an increase in the indigenous microbial flora or influx of highly pathogenic microorganisms in the urogenital region. In pregnant women, therefore, urogenital hygiene is important. When the microorganism reach the placenta, it leads to infection. Short cervix, bacterial virulence factors and toxin production are some of the risk factors of this disease. In healthy pregnant women, bacteria such as lactobacilli, is a natural antibiotic of the vagina and cervix, and phagocytes also help to prevent infection.

However, in women with chorioamnionitis, this host protection is compromised. Oral and rectal hygiene is therefore extremely important for normal urogenital colonization. Some of the clinical events associated with chorioamnionitis are history of preterm labor or premature birth, and premature or prolonged ruptured fetal membranes. Evidences also suggest that epidural anesthesia may be associated with maternal fever or fetal tachycardia [2] [3].

Epidemiology

In underdeveloped countries, the main reason for chorioamnionitis is the premature rupture of the membranes, which is often associated with a high mortality rate. In Africa, malnourished pregnant women are at a higher risk of having ascending urogenital infection causing chorioamnionitis.

This is believed to be due to decrease in the host defense factors. In developed countries, women receive optimum care during pregnancy with proper nutrition; hence the incidence of infection is greatly reduced [4].

Sex distribution
Age distribution

Pathophysiology

  • Abnormal bacterial colonization: Due to the abnormal colonization in the distal colon, abnormal vaginal and cervical microbial environments are created. Studies have confirmed that there are types of bacteria, which may ascend and rupture the fetal membrane and initiate the infection in amniotic fluid of the fetus causing chorioamnionitis. 
  • Urinary tract infection leads to an easy access of the bacterial pathogen to the vagina, increasing the risk of neonatal sepsis
  • Premature labor is associated with bacterial vaginosis. Early screening and treatment of vaginosis may prevent the preterm birth
  • Some other causes of the condition are related to cervical insufficiency, release of vaginal prostaglandins, etc. [5] [6]

Prevention

  • Urinary tract infections, if diagnosed, must be treated immediately. 
  • Risk of preterm labor must be determined at the earliest. 
  • Chances of development of chorioamnionitis can be reduced by regularly attending the prenatal check-up, preventing bacterial vaginosis, practicing safe sex, and getting the routine vaginal culture done, when indicated.

Summary

Chorioamnionitis is a common complication of pregnancy. It is often associated with maternal fever and other long-term adverse outcomes such as postpartum infections, sepsis, premature birth, neonatal sepsis, brain injury and stillbirthcerebral palsy and neurodevelopmental disabilities.

There exists a mechanistic relationship between the intraamniotic infection and preterm delivery. Ongoing research in the field has provided evidence for better methods of diagnosis, prevention and treatment of the condition [1].

Patient Information

Definition

Chorioamnionitis is a common complication of pregnancy which is associated with maternal fever and long-term adverse outcomes such as sepsis, brain injury, and stillbirth. Recent research provides better evidence of diagnosis, prevention and treatment of the condition. 

Cause

Abnormal bacterial colonization, urinary tract infection, premature labor associated with bacterial vaginosis, cervical insufficiency and release of vaginal prostaglandins are some of the important causes of chorioamnionitis. 

Symptoms

Some of the symptoms associated with this disease are maternal fever, illness, low blood pressure, and clammy skin.

Diagnosis

  • For pregnant women who are asymptomatic, laboratory tests such as examination of amniotic fluid, maternal blood, and Group-B streptococcal screening and urine analysis are performed. 
  • For the febrile pregnant women with suspected chorioamnionitis, complete blood count, C-reactive protein, Alpha1-proteinase inhibitor complex, serum interleukin-6 levels is done. 
  • Tests such as bacterial cultures, Gram staining, pH levels and polymerase chain reaction, ultrasonography may also be performed. 

Treatment

Women with chorioamnionitis are treated with antibiotics such as clindamycin, ampicillin, gentamicin, and cefotaxime. Supportive care of the neonates such as providing warmth, full resuscitation, glucose homeostasis and monitoring of the vital signs is important. Assessment of the thrombocytopenia is one of the important aspects that need to be looked into. Some surgical options are available for early onset bacterial infections in the neonate; though, they are rarely used.

References

Article

  1. Snyder M, Crawford P, Jamieson B, Neher JO. Clinical inquiries. What treatment approach to intrapartum maternal fever has the best fetal outcomes?. J Fam Pract. May 2007;56(5):401-2.
  2. Hassan S, Romero R, Hendler I, et al. A sonographic short cervix as the only clinical manifestation of intra-amniotic infection. J Perinat Med. 2006;34(1):13-9.
  3. Otsuki K, Yoda A, Saito H. Amniotic fluid lactoferrin in intrauterine infection. Placenta. Mar-Apr 1999;20(2-3):175-9.
  4. Katona P, Katona-Apte J. The interaction between nutrition and infection. Clin Infect Dis. May 15 2008;46(10):1582-8.
  5. Hitti J, Hillier SL, Agnew KJ, Krohn MA, Reisner DP, Eschenbach DA. Vaginal indicators of amniotic fluid infection in preterm labor. Obstet Gynecol. Feb 2001;97(2):211-9.
  6. Swadpanich U, Lumbiganon P, Prasertcharoensook W, Laopaiboon M. Antenatal lower genital tract infection screening and treatment programs for preventing preterm delivery. Cochrane Database Syst Rev. Apr 16 2008;CD006178.
  7. Apantaku O, Mulik V. Maternal intra-partum fever. J Obstet Gynaecol. Jan 2007;27(1):12-5.
  8. Gibbs RS, Duff P. Progress in pathogenesis and management of clinical intraamniotic infection. Am J Obstet Gynecol. 1991;164:1317.
  9. Greenwald J. Premature rupture of the membranes: diagnostic and management strategies. Am Fam Physician 1993.
  10. Riggs JW, Blanco JD. Pathophysiology, diagnosis, and management of intraamniotic infection. Semin Perinatol. 1998;22(4):251–9.
  11. Churgay CA, Smith MA, Blok B. Maternal fever during labor—what does it mean? J Am Board Fam Pract . 1994;7:14-24.
  12. Edwards RK. Chorioamnionitis and labor. Obstet Gynecol Clin North Am. 2005;32:287-296.

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Last updated: 2019-07-11 21:40