Clinical chorioamnionitis and histologic placental inflammation

doi:10.1016/S0029-7844(99)00416-0

Obstetrics & Gynecology

Volume 94, Issue 6, December 1999, Pages 1000-1005

https://doi.org/10.1016/S0029-7844(99)00416-0 Get rights and content

Abstract

Objective: To estimate the rate of histologic chorioamnionitis in the presence of diagnosed clinical chorioamnionitis and determine whether clinical markers of maternal and neonatal infection are associated with histologic chorioamnionitis.

Methods: We identified singleton pregnancies from 1996 in which discharge diagnoses included clinical chorioamnionitis and reviewed maternal and neonatal records for clinical evidence of chorioamnionitis and suspected or confirmed neonatal infections. Placentas were examined for acute histologic chorioamnionitis.

Results: One hundred thirty-nine pregnancies with the discharge diagnosis of maternal clinical chorioamnionitis were included. Eighty-six (61.9%) had the clinical diagnosis supported by histologic chorioamnionitis. Histologic chorioamnionitis was associated with an earlier gestational age at delivery (35.7 ± 6.5 weeks versus 38.6 ± 2.9 weeks, P = .002), lower epidural usage (72.1% versus 92.5%, P = .004), less internal monitoring (47.7% versus 75.5%, P = .001), and possible neonatal sepsis (60.5% versus 35.8%, P = .005). For 19 of 71 (26.8%) infants with possible neonatal sepsis, placentas did not show histologic chorioamnionitis.

Conclusion: Clinical chorioamnionitis and possible neonatal infection were not supported by histologic evidence for infection in 38.1% and 26.8% of cases, respectively, suggesting other noninflammatory causes of signs and symptoms.

Section snippets

Materials and methods

This was a retrospective cohort study with institutional review board approval. Study subjects were identified by review of discharge diagnoses of women who delivered at St. Peter’s University Hospital, New Brunswick, New Jersey, in 1996. All women with discharge diagnoses of chorioamnionitis were eligible for inclusion. Only singleton gestations delivered after 20 weeks’ gestation with histologic placental examinations were included. Maternal and neonatal medical records were reviewed for

Results

Among 6294 women who delivered in 1996, 189 (3%) had hospital discharge diagnoses of maternal chorioamnionitis. Of the identified pregnancies, 139 (73.5%) had maternal and infant records available and placental histologic examinations. Histologic evidence of chorioamnionitis was identified in 86 (61.9%, 95% CI 53.8%, 70%) of those pregnancies and was absent in 53 (38.1%, 95% CI 30%, 46.2%). Demographic features of cases with and without chorioamnionitis are presented in Table 1. Significant

Discussion

True clinical chorioamnionitis is a difficult diagnosis. Standardized clinical criteria have been suggested, including maternal temperature of at least 100.4F, with or without additional features such as maternal tachycardia, fetal tachycardia, uterine tenderness, foul-smelling AF, and maternal leukocytosis (more than 15,000 cells/mm³).9, 10 Unfortunately, a variety of clinical management practices can alter the reliability of some of those features, especially in preterm gestations.11, 12, 13,

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Cited by (120)

Infectious outcomes following immediate postplacental intrauterine device placement in the setting of chorioamnionitis: An exploratory, retrospective study
2023, Contraception
Citation Excerpt :
The lack of infectious outcomes in our sample may be related to overdiagnosis of chorioamnionitis. Suspicion for chorioamnionitis is common, occurring in up to 10.5% of pregnancies [7,8,9], though frequently over-diagnosed. Overdiagnosis separates mother-child dyads, prompts antibiotic overuse [2,7], and in the case of our study, deferred IUD placement in one in five individuals.
To evaluate infectious outcomes following postplacental intrauterine device (PPIUD) placement in patients with suspected chorioamnionitis.
This retrospective cohort study identified individuals desiring PPIUD who subsequently developed suspected chorioamnionitis, treated with antibiotics. We followed 12-month infectious outcomes amongst two cohorts: (1) those who received PPIUD and (2) those with placement deferred.
Of 55 followed, 18 of 22 PPIUDs were placed before chorioamnionitis was suspected; 33 placements were deferred. Neither group experienced acute infectious complications. Notably, IUDs were more often deferred when chorioamnionitis was more clearly diagnosed (20/33, 60.6% vs 4/22, 18.2% p < 0.01). Overdiagnosis of chorioamnionitis prevented IUD uptake in 10 of 55 (18.2%) individuals in this sample.
PPIUD placement in individuals with early signs of chorioamnionitis may not result in severe morbidity, in a study limited by sample size. Larger, prospective studies are needed in well-defined cohorts.
Incidental, immediate postplacental IUD placement in individuals with treated, suspected chorioamnionitis was not associated with severe morbidity within 1-year postpartum. Larger-scale, prospective studies are needed to guide the management of incidentally-placed, postplacental IUDs in the setting of mild chorioamnionitis.
Predicting chorioamnionitis in patients with preterm premature rupture of membranes using inflammatory indexes: a retrospective study
2023, Taiwanese Journal of Obstetrics and Gynecology
The prognosis of preterm premature rupture of membranes (PPROM) combined with chorioamnionitis is often unsatisfactory for both mother and newborn. Although tragic outcomes can be avoided if treated early, no effective prediction method for decision-making is available currently. This study aimed to establish an effective method with maternal inflammation indexes to predict preterm premature rupture of membranes with concomitant chorioamnionitis.
This retrospective study examined the data of 206 singleton PPROM cases and 60 normal full-term cases. The PPROM cases included 93 cases of PPROM with chorioamnionitis and 113 cases of PPROM without chorioamnionitis based on clinical manifestations, laboratory examinations, and histopathological diagnosis. Normal full-term cases were included as the control group. Peripheral blood levels of selected inflammatory indicators were observed 12 h after fetal membrane rupture. Associations between selected inflammatory indicators and chorioamnionitis diagnosis were analyzed.
Selected factors except for procalcitonin predicted chorioamnionitis in PPROM patients. Combined results of C-reactive protein and white blood cell (WBC) count showed best predictive ability with area under curve, sensitivity, and specificity of 0.702, 60.22%, and 76.11%, respectively. Furthermore including Interleukine-6 and neutrophil count provided similar predictive results.
The best predictive factor combinations for PPROM-CAM were C-reactive protein and white blood cell count. Results of this study provide a useful clinical reference for PPROM-CAM and may improve maternal and infant prognostic outcomes.
The correlation between placental histology and microbiologic infection in the diagnosis of chorioamnionitis in preterm delivery
2022, Placenta
This study sought to investigate the correlation between histologically proven chorioamnionitis and placental bacteriologic infection in preterm births.
Women who gave birth before 34 + 0 weeks’ gestation at a tertiary medical center between the years 2018–2019 were identified by a database review. Data was collected on clinical characteristics and findings on placental histology, cultures, and polymerase chain reaction. The correlation between histologically confirmed chorioamnionitis and bacteriologic infection was evaluated.
Of 183 placentas included in the study, 88 (48.1%) were histologically positive for chorioamnionitis and 95 (51.9%) were negative. Baseline characteristics were similar in the patients with and without chorioamnionitis. Concordance rates between the histology and microbiology results in the two groups were 51.1% and 64.2%, respectively. Similar types of bacterial microorganisms were isolated in both groups, though at different rates. On chi-square analysis of association, a positive microbiological study had a sensitivity of 51.1%, specificity of 64.2%, and positive predictive value of 56.9% for predicting histologically confirmed chorioamnionitis. Histologically confirmed chorioamnionitis was associated with higher antepartum white blood cell count (14.2 ± 4.6 vs 12.3 ± 3.3 K/μL; p = 0.01), higher rate of clinically suspected chorioamnionitis (10.2% vs 1.1%, p = 0.02), and higher rate of neonatal adverse composite outcome (36.4% vs. 22.1%, p = 0.009).
The correlation between histologic and bacteriologic placental findings in the setting of early premature delivery is not high, nor is the clinical yield of placental bacteriology. The discordant results might be explained by early stage of bacterial infection, hard-to-cultivate bacterial species, noninfectious conditions, or contamination of the placental surfaces during passage through the vaginal tract.
An evaluation into the use of procalcitonin levels as a biomarker of bacterial sepsis to aid the management of intrapartum pyrexia and chorioamnionitis
2022, AJOG Global Reports
Procalcitonin is an established biomarker for bacterial sepsis in the nonpregnant population with better diagnostic and prognostic value for bacterial infections.
This study aimed to evaluate whether procalcitonin levels could be used in the diagnosis and management of intrapartum sepsis in women and their neonates suspected of intrapartum bacterial sepsis.
A prospective observational cohort study was conducted at the University Hospitals of Bristol and Weston NHS Foundation Trust. Overall, 117 women and their neonates managed for suspected intrapartum sepsis from June 2020 to October 2020 were included. Procalcitonin levels were measured in addition to routine biomarkers white cell count and C-reactive protein in women and their neonates during the initial septic screen and follow-up blood samples. The placentas underwent detailed histopathology. Maternal and neonatal parameters were used to categorize cases into “high-suspicion bacterial sepsis,” “equivocal bacterial sepsis,” and “low-suspicion bacterial sepsis.” The Kruskal-Wallis test was used to compare categories with biomarker values and placental histology scores.
Procalcitonin level was increased in 6 women in the initial septic screen sample, compared with 100 women with an increased C-reactive protein level. There was a significant difference in maternal postnatal procalcitonin results between “high-suspicion bacterial sepsis” and “low-suspicion bacterial sepsis” categories (P=.004). Moreover, 71.2% of placentas showed varying degrees of chorioamnionitis.
In our cohort of women, 94.6% had normal procalcitonin levels while in labor at the time of the septic screen, consistent with the low number of confirmed bacteremia. The result provided a basis that procalcitonin may complement clinical judgment and interpretation of already used prognostic and diagnostic tests, improving patient care in the management of intrapartum sepsis.
Clinical predictive factors of histological chorioamnionitis: case-control study
2020, Heliyon
Citation Excerpt :
This inflammatory process is often clinically asymptomatic. It is described in only 0.9–10.5% of pregnancies before the presentation of the signs mentioned above [4]. Histologically, chorioamnionitis is characterized by the presence of neutrophils polynuclear cells of maternal and/or fetal origin in the amniotic membranes, the chorionic plate, and the umbilical cord [3, 5, 6].
Histological chorioamnionitis or "intrauterine inflammation or infection" (Triple I) it is an acute inflammation of amniotic membrane, chorionic plate and umbilical cord.
To assess in the event of the clinical predictive factors associated to histological chorioamnionitis.
Prospective examination of 50 placentas from aberrant pregnancies, and 50 placentas from 'normal' deliveries. The Placentas analyzed by the conventional histopathology method, and the severity of chorioamnionitis was classified histologically according to the intensity and the topography of placental inflammation.
The clinical and histopathological features of the study groups were introduced into the SPSS 13 database (License University Mohammed V-Rabat).
36/50 placentas of aberrant pregnancies showed a histological chorioamnionitis often associated to a funisitis, and 11/50 normal placentas have shown some lesions of histological chorioamnionitis mainly grade one without funisitis.
On the other hand we noted a statistically significant association between histological chorioamnionitis and premature rupture of the membranes (PROM) over than 12h (p < 0.001).
Our study confirmed the predominance of histological chorioamnionitis lesions in clinically suspected cases of chorioamnionitis with 72% versus 22% in the controls group.
Among the clinical parameters studied, only the premature rupture of the Membranes was shown a statistically significant association with the appearance of histological signs of chorioamnionitis.
In conclusion, chorioamnionitis is sometimes clinically silent. Morphological placental study could be a confirmation of this pathology, which is predominantly associated to PROM over than 12 h.
The combination of maternal blood and amniotic fluid biomarkers improves the predictive accuracy of histologic chorioamnionitis
2019, Placenta
This study was performed to determine whether the combination of maternal blood and amniotic fluid biomarkers can improve the predictive accuracy of histologic chorioamnionitis (HC).
This retrospective study included 80 singleton pregnant women who were suspected to have intrauterine infection and underwent measurement of two maternal blood biomarkers [maternal white blood cell count (mWBC) and maternal C-reactive protein level (mCRP)] and three amniotic fluid biomarkers [amniotic white blood cell count (aCell), amniotic glucose level (aGlucose), and amniotic lactate dehydrogenase level (aLDH)]. We divided the patients into two groups based on the presence or absence of HC and assessed the predictors of HC using logistic regression models: Model 1, combination of mWBC and mCRP; Model 2, combination of Model 1 and aGlucose; and Model 3, combination of Model 2, aCell, and aLDH.
The multivariable analysis showed that aCell was the only significant predictor of HC [odds ratio, 1.24; 95% confidence interval (CI), 1.06–1.68] independent of mWBC, mCRP, aGlucose, and aLDH. The c-statistics were higher in Model 3 (0.803; 95% CI, 0.701–0.905) than Model 1 (0.634; 95% CI, 0.511–0.758) and Model 2 (0.785; 95% CI, 0.684–0.887).
We found that the combination of maternal blood and amniotic fluid biomarkers can improve the predictive accuracy of HC. Therefore, our data provide relevant information to support counseling with regard to improving the predictive accuracy of HC in patients with suspected intrauterine infection.

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^☆: Dr. Ananth is supported, in part, by a grant from the Robert Wood Johnson Foundation, New Jersey, awarded to The Center for Perinatal Health Initiatives (Grant #-029553).

¹: The opinions, views, and conclusions expressed in this manuscript are those of the author(s) and not necessarily those of the Robert Wood Johnson Foundation.

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Original ArticlesClinical chorioamnionitis and histologic placental inflammation1☆,

Abstract

Section snippets

Materials and methods

Results

Discussion

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Int J Gynaecol Obstet

The changing perinatal and maternal outcome in chorioamnionitis

Obstet Gynecol

Characterization and control of intraamniotic infection in an urban teaching hospital

Am J Obstet Gynecol

Risk factors for intraamniotic infectionA prospective epidemiologic study

Am J Obstet Gynecol

Term maternal and neonatal complications of acute chorioamnionitis

Obstet Gynecol

A randomized trial of intrapartum versus immediate postpartum treatment of women with intra-amniotic infection

Obstet Gynecol

The clinical significance of placental villous edema

Pediatrics

Original Articles
Clinical chorioamnionitis and histologic placental inflammation1☆,