Chorioamnionitis Clinical Presentation

4/19/2015 ChorioamnionitisClinicalPresentation

http://emedicine.medscape.com/article/973237clinical#showall 1/13

ChorioamnionitisClinicalPresentationAuthor:MichaelPSherman,MD,FAAPChiefEditor:TedRosenkrantz,MDmore...

Updated:Apr2,2014

HistoryThetimehonoredclinicalsignsandsymptomsofchorioamnionitisincludethefollowing:

Fever(anintrapartumtemperature>100.4For>37.8C)Significantmaternaltachycardia(>120beatsperminute[bpm])Fetaltachycardia(>160180bpm)PurulentorfoulsmellingamnioticfluidorvaginaldischargeUterinetendernessMaternalleukocytosis(totalbloodleukocytecount>15,00018,000cells/L)

Ofthesecriteria,intrapartummaternalfeverappearstobethemostfrequent.[1]

Whenatleast2oftheaforementionedcriteriaarepresent,theriskofneonatalsepsisisincreased.Eachclinicalsignandsymptomofchorioamnionitis,however,isbyitselfoflowpredictivevalue.Thesignsandsymptomsofmaternalchorioamnionitisoramnioticfluidinfectionaresosubjectivethatsomeexpertshaverecommendedthefollowing:Ifaphysicianistryingtodecideaboutanevaluationandtreatmentofaninfant,asktheobstetricianifheorshebelieveschorioamnionitisispresent.Moreover,silentchorioamnionitisisprominent,[2]andthussignsandsymptomsintheinfectednewborninfanttakeonaddedsignificance.

Anincreasingordecreasingtotalleukocytecountmaybemoreimportantthanasingledetermination.Abnormalitiesineitherumbilicalveininterleukin(IL)6levelsoranincreasingneonatalimmaturetototalneutrophilratio,alongwithclinicalcriteriaassociatedwithchorioamnionitis,improvethesensitivityandpredictiveaccuracyofidentifyingthesepticneonate.

Riskofneonatalinfectionincreasesasthedurationofrupturedmembraneslengthens.[82]Chorioamnionitismayinitiateuteroplacentalbleedingoraplacentalabruption.[83]Intrauterineinfectionisincreasedinplacentapreviaandmanifestswithvaginalbleeding.[84]Laboranddeliverymayberapidinthepresenceofchorioamnionitis.Alternatively,infectionmaycauseuterineatony,requiringlabortobeaugmentedwithoxytocin.Ultimately,apoorlaborpatternmayrequireaninstrumenteddeliveryoracesareandelivery.Eachoftheseantepartumandintrapartumfactorsmustbeconsideredwhenevaluatingthenewbornforthepresenceofbacterialinfection.

Althoughmanycytokinesandinflammatorymarkershavebeenproposedasdiagnostictestsforearlyonsetsepsis(EOS),nonehasbeenofsufficientpredictivevaluetogainwideacceptance.[85,86]Somecytokinesareonlysecretedoveralimitedtimeframeduringthestartofinfection,andinflammatorymarkersmaybemoresustainedintheirpresence.Creactiveproteinsareusefultoexcludeinfectionandstopantibiotics.InvestigationssuggestthatprocalcitoninandIL6usedtogethermayenhancelaboratorydiagnosisofEOS.[85]

PhysicalThephysicalexaminationofthepregnantwomenwithchorioamnionitismayrevealnosignsorsymptomsofinfection.[2]Conversely,apregnantwomanwithchorioamnionitismayappearill,eventoxic.

Physicalsymptomsmayincludethefollowing:

FeverTachycardia(>120bpm)HypotensionDiaphoresisCoolorclammyskinUterinetendernessFoulsmellingorabnormalvaginaldischarge

Thefetusmayalsohavetachycardia(>160180bpm).AlthoughheartratecharacteristicsusedtodiagnoseEOSareunderinvestigation,[87]thistypeofanalysishasnotbeenappliedtothefetalheartratewhenchorioamnionitisisevident.Abiophysicalprofile(BPP)performedonthefetususingultrasonographymayrevealalowerthannormalscore,butultrasonicbiophysicalprofileassessmenthasnotbeenpredictiveofclinicalchorioamnionitis.[88]

Lackoffetalbreathinghasbeenassociatedwithfetalinfection.[89,90]Intrauterineultrasonographyhasidentified"sludge"attheamnioticfluidinterfacewiththecervixthatisalsoassociatedwithhyperechogenic,freefloatingmaterialintheamnioticfluid.[7]Thisfindingwasseeninasymptomaticwomenatriskforpretermdelivery.Asepticaspirationofthe"sludge"showedthematerialhadalowglucosecontent,manyneutrophils,andgrampositivecocci.Furthermore,electronicfetalmonitoringlacksprecisiontoidentifythefetalinflammatoryresponsesyndromeandsubsequentneonatalsepsis.[91]

Clinicalsignsandsymptomsofchorioamnionitisarenotalwaysassociatedwithplacentalevidenceofinflammation.[3]Thisisparticularlytrueifmaternalfeveristhesolecriterionforthediagnosis.

Epiduralanesthesiaduringtheintrapartumperiodhasbeenassociatedwithfeverinthemotherandtheneonate[92,93]however,thepathophysiologyofthefeveranditsadverseeffectsonthemother,fetus,orinfantremainscontroversial.[94,95,96,97]
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Epiduralanesthesiaandmaternaland/orneonatalfeversresultinmoreevaluationsforsepsisandantibiotictreatmentinneonates,althoughtheincidenceofsepsiscomparedwiththatinaneonatalpopulationwhosemothersdidnotreceiveepiduralanesthesiaduringlaborisunknown.Epiduralanesthesiaduringlaborisassociatedwithothertypesofneonatalmorbidity,suchasseizures,thatarealsoriskfactorsforsepsis.

Althoughtheexactmechanismsfor"epiduralfever"duringlaborremainunclear,nulliparity,dysfunctionallabor,prolongedlabor,maternalexhaustion,dehydration,and/orprolongedruptureofmembranesmaybeoperativeinpathogenesis.[98]

Inthesettingofepiduralanesthesiaduringlabor,thefollowingclinicalcoursehasbeenobserved.Thefetususuallyhastachycardiawhenthemotherisfebrileduringlabor.Atbirth,thenewbornmayalsohaveafever(temperature>37.8C).Iftheneonateisnotseptic,thetemperatureelevationdissipatesrapidlyfollowingbirth,andthenewbornsubsequentlyexhibitsnormalbehavior.Usuallyatemperatureelevationintheneonatehasreturnedtonormalwithin3060minutesafterbirth.Furthermore,thesenoninfected,febrileneonateshavenormalApgarscoresandappearremarkablywellfollowingbirth.Suchnewbornscanbeobservedforillnessratherthanundergoingasepticworkupandantibiotictherapy.However,judgmentmustbebasedonmanyfactors,includingtheintrapartumadministrationofbroadspectrumantibioticstothemother.

Maternalchorioamnionitisincreasesthepotentialthatthefollowingclinicalpresentationsmaybeevidentintheneonate.Signsandsymptomsofneonatalsepsisareoftennonspecificandsubtle.Theneonatemaydemonstratebehavioralabnormalitiessuchaslethargy,hypotonia,weakcry,andpoorsuck.

Tachypnea,respiratorydistress(eg,expiratorygrunt,retractions),cyanosis,pulmonaryhemorrhage,and/orapnea(ie,pulmonarymanifestationsofpneumonia,sepsis,orboth),mustbeimmediatelyappreciatedbycaregivers.Nurserypersonnelmustbeawarethataneonatewhoisbornwithoutrespiratorydistressbutwhodevelopssignsandsymptomsofpulmonarydiseaseinthefirst612hoursoflifehasaheightenedriskforcongenital(infectious)pneumonia.

Tachycardia,hypotension,prolongedcapillaryrefilltime,coolandclammyskin,paleormottledappearance,oliguria(ie,cardiovascularmanifestationsofsepsis),oracombinationofthesemaybeobserved.ManyofthesesignsoccurlateinthecourseofEOS.Caregiversmustalsoconsiderotherexplanationsforthesephysicalfindings,suchasdevelopmentaldefectsinthecardiovascularsystem(ie,cardiovascularmalformationswithabnormalitiesofaorticbloodflow)orinbornerrorsofmetabolism.

Abdominaldistension,vomiting,diarrhea,bloodystools,oracombinationofthesemaybeobserved.GIsymptomsmaybenonspecificinpatientswithEOS.

Thermalregulatoryabnormalities(ie,hypothermiaorhyperthermia),behavioralabnormalities,apnea,seizures(ie,CNSmanifestations),oracombinationmaybeseen.Abulgingfontanelornuchalrigidityisnotareliablesignofmeningitisinaneonate.

Pallor,petechiaeorpurpura,andovertbleeding(ie,hematopoieticinvolvement,liverinvolvement,orboth)maybeseenandrequiresimmediatediagnosticandtherapeuticattention.

Asonephysiologicsystemmayaffectanother,signsandsymptomsmayoriginatefrommorethanonedysfunctionalorgan.However,manyneonatalconditionsresembleneonatalsepsisthus,physiciancaregiversmusthaveanopenmindregardingotherclinicalconditionsthatmayinvolvesignsandsymptomsresemblingthoseofneonatalsepsis.Thoseconditionsinclude,butarenotlimitedto,thefollowing:

Cardiovascularmalformations,especiallyleftsidedobstructivelesionscausingpoorsystemiccardiacoutputEndocrinedisordersthatmayalsocauseshocklikestates,suchasdifferenttypesofcongenitaladrenalinsufficiencyorhypoglycemiaassociatedwithhyperinsulinemiaSeriousCNStraumaordysfunctionfromanycauseandsubtleseizureswithsystemicmanifestationsAnemiacausedbyunrecognizedisoimmunizationorbloodlossfromconditionssuchasfetomaternaltransfusionsyndrome

CausesMaternalchorioamnionitisoccurswhenprotectivemechanismsoftheurogenitaltractand/oruterusfailduringpregnancyorwhenincreasednumbersofmicrobialfloraorhighlypathogenicmicroorganismsareintroducedintotheurogenitalenvironment.[38,99,100,101,102,103]

Ascendinginfectionintothevagina,thenthecervix,andfinallyintotheuterinecavity,fetalmembranes,andplacentaistheconsequenceofmanyfactors(ie,innatehostdefenses,healthybacterialflora,pathologicbacterialload,bacterialvirulencefactorsandtoxinproduction).Ashortcervixhasbeenrecognizedaseitherariskfactororasurrogateformicrobialinvasionoftheamnioticfluid.[6,104]

Urogenitalhygieneisobviouslyimportantinestablishinghealthybacterialflora.Healthybacteria(ie,lactobacilli)[105]andnaturalpeptideantibioticsinthevaginaandcervixmayhavearoleinpreventinginfectionsduringpregnancy.[106]Mucus,phagocytes,andnaturalantibioticproteins(ie,lactoferrin,lysozyme,betadefensins)inthecervicovaginalsecretionsattempttomaintainanormalbacterialflora.[100]Bacterialinterference,mainlyproducedvialactobacillilivinginanacidicvaginalenvironmentandproducingbacteriocins,alsohelpstokeeppathogenicbacteriafromgainingafootholdinthecervicovaginalsecretions.[107,108]Thesemechanismsofhostprotectionmaybealteredinasignificantnumberofpregnantwomenwhodevelopchorioamnionitis.

Oralhygienemayinfluencerectalandurogenitalbacterialfloraduringpregnancy.Althoughthetheoryiscontroversial,intenseinteresthasfocusedonaconnectionamongperiodontitis,abnormalrectalcolonization,andpretermdelivery.[109,110]

Rectalbacterialfloraisbelievedtobeimportantinestablishingabnormalurogenitalcolonizationduringpregnancy.[111,112,113]Alterationsinvaginalandcervicalhostdefensemechanismsduringpregnancycausevaginitis,[114]bacterialvaginosis,urinaryinfections,andotherurogenitalinfections.Orogenitalcontactmayalsoaltereithercolonicorurogenitalmicrobialfloraandultimatelycauseascendinginfectionandchorioamnionitis.[115,116]

Similarly,coitushasbeenlinkedwithchorioamnionitis.[117,118]

Currently,researchersaretryingtounderstandhowhostdefensemechanismspreventurogenitalinfectionduringpregnancy.Theconceptofbacterialcommunitiesmaybeimportantinthepathogenesisofchorioamnionitisbecause
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certainmicrobesprovidesupporttoothers.Theprevalenceanddiversityofbacterialspeciesinfetalmembranesduringpretermlaboremphasizesfurtherresearchonthistopicisneeded.[119]Metagenomicsusesnonculture,molecularmethodstodelineateallmicrobesinhabitinganenvironment.Thus,theintestinalmicrobiomeisunderintensescrutinytounderstandnecrotizingenterocolitisorinflammatoryboweldisease.Initialreportsusingmolecularmethodstounderstandintrauterineinfection,fetalinflammation,andpretermdeliveryhavebeenpublished.[119,120]

Clinicaleventsassociatedwithchorioamnionitisincludethefollowing:

Historyofprematurebirth(withincreasingriskatearliergestationalage)PresenceofprematurelaborPrematurelyrupturedfetalmembranes(beforelaborhasitsonset)Prolongedruptureofthefetalmembranes

Inareportofpatientswithclinicalsignsandsymptomsofchorioamnionitis,38%showednohistologicevidenceofplacentalinflammation.Thus,othercausesofsignsandsymptomsthatresemblematernalchorioamnionitismustbesought.

Epiduralanesthesiaduringlabormaybeassociatedwithmaternalfeverandfetaltachycardia(seeSpecialConcerns).Otherconditions,suchasdehydrationormaternalexhaustionduringlabor,mayresultinmaternalfeverandmustbeconsideredascausesofthefebrilestate.

ContributorInformationandDisclosuresAuthorMichaelPSherman,MD,FAAPProfessor,DepartmentofChildHealth,UniversityofMissouriColumbiaSchoolofMedicineNeonatologist,Women'sandChildren'sHospitalProfessorEmeritus,DepartmentofPediatrics,UniversityofCalifornia,Davis,SchoolofMedicine

MichaelPSherman,MD,FAAPisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,AmericanAssociationfortheAdvancementofScience,AmericanAssociationofImmunologists,AmericanPediatricSociety,AmericanSocietyforMicrobiology,AmericanThoracicSociety,EuropeanSocietyforPaediatricResearch,PediatricInfectiousDiseasesSociety,PerinatalResearchSociety,SocietyforPediatricResearch,andWesternSocietyforPediatricResearch

Disclosure:Nothingtodisclose.

Coauthor(s)NaomiFLauriello,MDAssistantProfessorofNeonatology,UniversityofMissouriWomen'sandChildren'sHospital

NaomiFLauriello,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics

Disclosure:MedIQHonorariaSpeakingandteaching

KatsufumiOtsuki,MD,PhDAssociateProfessor,Chief,DepartmentofObstetricsandGynecology,ShowaUniversityKotoToyosuHospital,Japan


SpecialtyEditorBoardTedRosenkrantz,MDProfessor,DepartmentsofPediatricsandObstetrics/Gynecology,DivisionofNeonatalPerinatalMedicine,UniversityofConnecticutSchoolofMedicine

TedRosenkrantz,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,AmericanMedicalAssociation,AmericanPediatricSociety,ConnecticutStateMedicalSociety,EasternSocietyforPediatricResearch,andSocietyforPediatricResearch


MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference


ArunKPramanik,MD,MBBSProfessorofPediatrics,LouisianaStateUniversityHealthSciencesCenter

ArunKPramanik,MD,MBBSisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,AmericanThoracicSociety,NationalPerinatalAssociation,andSouthernSocietyforPediatricResearch


CarolLWagner,MDProfessorofPediatrics,MedicalUniversityofSouthCarolina

CarolLWagner,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,AmericanChemicalSociety,AmericanMedicalWomen'sAssociation,AmericanPublicHealthAssociation,AmericanSocietyforBoneandMineralResearch,AmericanSocietyforClinicalNutrition,MassachusettsMedicalSociety,NationalPerinatalAssociation,andSocietyforPediatricResearch


ChiefEditorTedRosenkrantz,MDProfessor,DepartmentsofPediatricsandObstetrics/Gynecology,DivisionofNeonatalPerinatalMedicine,UniversityofConnecticutSchoolofMedicine

TedRosenkrantz,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,AmericanMedicalAssociation,AmericanPediatricSociety,ConnecticutStateMedicalSociety,EasternSocietyforPediatricResearch,andSocietyforPediatricResearch
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AdditionalContributorsResearchbytheauthor,MichaelSherman,issupportedbyNIHgrantR44HD057744andagrantfromtheGerberFoundation.TheauthorappreciatesthereviewofthemanuscriptundertakenbyJanSherman,RN,NNP,PhD,andherhelpfulrecommendationsforimprovement.

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