Chorioamnionitis Clinical Presentation
- Author: Michael P Sherman, MD, FAAP; Chief Editor: Ted Rosenkrantz, MD more...
The time-honored clinical signs and symptoms of chorioamnionitis include the following:
Fever (an intrapartum temperature >100.4ºF or >37.8ºC)
Significant maternal tachycardia (>120 beats per minute [bpm])
Fetal tachycardia (>160-180 bpm)
Purulent or foul-smelling amniotic fluid or vaginal discharge
Maternal leukocytosis (total blood leukocyte count >15,000-18,000 cells/μL)
Of these criteria, intrapartum maternal fever appears to be the most frequent.
When at least 2 of the aforementioned criteria are present, the risk of neonatal sepsis is increased. Each clinical sign and symptom of chorioamnionitis, however, is by itself of low predictive value. The signs and symptoms of maternal chorioamnionitis or amniotic fluid infection are so subjective that some experts have recommended the following: If a physician is trying to decide about an evaluation and treatment of an infant, ask the obstetrician if he or she believes chorioamnionitis is present. Moreover, silent chorioamnionitis is prominent, and thus signs and symptoms in the infected newborn infant take on added significance.
An increasing or decreasing total leukocyte count may be more important than a single determination. Abnormalities in either umbilical vein interleukin (IL)-6 levels or an increasing neonatal immature-to-total neutrophil ratio, along with clinical criteria associated with chorioamnionitis, improve the sensitivity and predictive accuracy of identifying the septic neonate.
Risk of neonatal infection increases as the duration of ruptured membranes lengthens. Chorioamnionitis may initiate uteroplacental bleeding or a placental abruption. Intrauterine infection is increased in placenta previa and manifests with vaginal bleeding. Labor and delivery may be rapid in the presence of chorioamnionitis. Alternatively, infection may cause uterine atony, requiring labor to be augmented with oxytocin. Ultimately, a poor labor pattern may require an instrumented delivery or a cesarean delivery. Each of these antepartum and intrapartum factors must be considered when evaluating the newborn for the presence of bacterial infection.
Although many cytokines and inflammatory markers have been proposed as diagnostic tests for early onset sepsis (EOS), none has been of sufficient predictive value to gain wide acceptance.[86, 87] Some cytokines are only secreted over a limited time frame during the start of infection, and inflammatory markers may be more sustained in their presence. C-reactive proteins are useful to exclude infection and stop antibiotics. Investigations suggest that procalcitonin and IL-6 used together may enhance laboratory diagnosis of EOS.
The physical examination of the pregnant women with chorioamnionitis may reveal no signs or symptoms of infection. Conversely, a pregnant woman with chorioamnionitis may appear ill, even toxic.
Physical symptoms may include the following:
Tachycardia (>120 bpm)
Cool or clammy skin
Foul-smelling or abnormal vaginal discharge
The fetus may also have tachycardia (>160-180 bpm). Although heart rate characteristics used to diagnose EOS are under investigation, this type of analysis has not been applied to the fetal heart rate when chorioamnionitis is evident. A biophysical profile (BPP) performed on the fetus using ultrasonography may reveal a lower than normal score, but ultrasonic biophysical profile assessment has not been predictive of clinical chorioamnionitis.
Lack of fetal breathing has been associated with fetal infection.[90, 91] Intrauterine ultrasonography has identified "sludge" at the amniotic fluid interface with the cervix that is also associated with hyperechogenic, free-floating material in the amniotic fluid. This finding was seen in asymptomatic women at risk for preterm delivery. More recent studies confirm that amniotic fluid sludge is a useful marker of microbial invasion of the amniotic cavity (MIAC), histologic chorioamnionitis, and finisitis—conditions that increase the risk for preterm delivery at an extreme gestational age. Aseptic aspiration of the "sludge" showed the material had a low glucose content, many neutrophils, and gram-positive cocci. Furthermore, electronic fetal monitoring lacks precision to identify the fetal inflammatory response syndrome and subsequent neonatal sepsis.
Clinical signs and symptoms of chorioamnionitis are not always associated with placental evidence of inflammation. This is particularly true if maternal fever is the sole criterion for the diagnosis.
Epidural anesthesia during the intrapartum period has been associated with fever in the mother and the neonate[94, 95] ; however, the pathophysiology of the fever and its adverse effects on the mother, fetus, or infant remains controversial.[96, 97, 98, 99]
Epidural anesthesia and maternal and/or neonatal fevers result in more evaluations for sepsis and antibiotic treatment in neonates, although the incidence of sepsis compared with that in a neonatal population whose mothers did not receive epidural anesthesia during labor is unknown. Epidural anesthesia during labor is associated with other types of neonatal morbidity, such as seizures, that are also risk factors for sepsis.
Although the exact mechanisms for "epidural fever" during labor remain unclear, nulliparity, dysfunctional labor, prolonged labor, maternal exhaustion, dehydration, and/or prolonged rupture of membranes may be operative in pathogenesis.
In the setting of epidural anesthesia during labor, the following clinical course has been observed. The fetus usually has tachycardia when the mother is febrile during labor. At birth, the newborn may also have a fever (temperature >37.8 º C). If the neonate is not septic, the temperature elevation dissipates rapidly following birth, and the newborn subsequently exhibits normal behavior. Usually a temperature elevation in the neonate has returned to normal within 30-60 minutes after birth. Furthermore, these non-infected, febrile neonates have normal Apgar scores and appear remarkably well following birth. Such newborns can be observed for illness rather than undergoing a septic workup and antibiotic therapy. However, judgment must be based on many factors, including the intrapartum administration of broad-spectrum antibiotics to the mother.
Maternal chorioamnionitis increases the potential that the following clinical presentations may be evident in the neonate. Signs and symptoms of neonatal sepsis are often nonspecific and subtle. The neonate may demonstrate behavioral abnormalities such as lethargy, hypotonia, weak cry, and poor suck.
Tachypnea, respiratory distress (eg, expiratory grunt, retractions), cyanosis, pulmonary hemorrhage, and/or apnea (ie, pulmonary manifestations of pneumonia, sepsis, or both), must be immediately appreciated by caregivers. Nursery personnel must be aware that a neonate who is born without respiratory distress but who develops signs and symptoms of pulmonary disease in the first 6-12 hours of life has a heightened risk for congenital (infectious) pneumonia.
Tachycardia, hypotension, prolonged capillary refill time, cool and clammy skin, pale or mottled appearance, oliguria (ie, cardiovascular manifestations of sepsis), or a combination of these may be observed. Many of these signs occur late in the course of EOS. Caregivers must also consider other explanations for these physical findings, such as developmental defects in the cardiovascular system (ie, cardiovascular malformations with abnormalities of aortic blood flow) or inborn errors of metabolism.
Abdominal distension, vomiting, diarrhea, bloody stools, or a combination of these may be observed. GI symptoms may be nonspecific in patients with EOS.
Thermal regulatory abnormalities (ie, hypothermia or hyperthermia), behavioral abnormalities, apnea, seizures (ie, CNS manifestations), or a combination may be seen. A bulging fontanel or nuchal rigidity is not a reliable sign of meningitis in a neonate.
Pallor, petechiae or purpura, and overt bleeding (ie, hematopoietic involvement, liver involvement, or both) may be seen and requires immediate diagnostic and therapeutic attention.
As one physiologic system may affect another, signs and symptoms may originate from more than one dysfunctional organ. However, many neonatal conditions resemble neonatal sepsis; thus, physician caregivers must have an open mind regarding other clinical conditions that may involve signs and symptoms resembling those of neonatal sepsis. Those conditions include, but are not limited to, the following:
Cardiovascular malformations, especially left-sided obstructive lesions causing poor systemic cardiac output
Endocrine disorders that may also cause shocklike states, such as different types of congenital adrenal insufficiency or hypoglycemia associated with hyperinsulinemia
Serious CNS trauma or dysfunction from any cause and subtle seizures with systemic manifestations
Anemia caused by unrecognized isoimmunization or blood loss from conditions such as fetomaternal transfusion syndrome
Maternal chorioamnionitis occurs when protective mechanisms of the urogenital tract and/or uterus fail during pregnancy or when increased numbers of microbial flora or highly pathogenic microorganisms are introduced into the urogenital environment.[38, 101, 102, 103, 104, 105]
Ascending infection into the vagina, then the cervix, and finally into the uterine cavity, fetal membranes, and placenta is the consequence of many factors (ie, innate host defenses, healthy bacterial flora, pathologic bacterial load, bacterial virulence factors and toxin production). A short cervix has been recognized as either a risk factor or a surrogate for microbial invasion of the amniotic fluid.[6, 106]
Urogenital hygiene is obviously important in establishing healthy bacterial flora. Healthy bacteria (ie, lactobacilli) and natural peptide antibiotics in the vagina and cervix may have a role in preventing infections during pregnancy. Mucus, phagocytes, and natural antibiotic proteins (ie, lactoferrin, lysozyme, beta defensins) in the cervicovaginal secretions attempt to maintain a normal bacterial flora. Bacterial interference, mainly produced via lactobacilli living in an acidic vaginal environment and producing bacteriocins, also helps to keep pathogenic bacteria from gaining a foothold in the cervicovaginal secretions.[109, 110] These mechanisms of host protection may be altered in a significant number of pregnant women who develop chorioamnionitis.
Oral hygiene may influence rectal and urogenital bacterial flora during pregnancy. Although the theory is controversial, intense interest has focused on a connection among periodontitis, abnormal rectal colonization, and preterm delivery.[111, 112]
Rectal bacterial flora is believed to be important in establishing abnormal urogenital colonization during pregnancy.[113, 114, 115] Alterations in vaginal and cervical host defense mechanisms during pregnancy cause vaginitis, bacterial vaginosis, urinary infections, and other urogenital infections. Orogenital contact may also alter either colonic or urogenital microbial flora and ultimately cause ascending infection and chorioamnionitis.[117, 118] Similarly, coitus has been linked with chorioamnionitis.[119, 120]
Currently, researchers are trying to understand how host defense mechanisms prevent urogenital infection during pregnancy. The concept of bacterial communities may be important in the pathogenesis of chorioamnionitis because certain microbes provide support to others. The prevalence and diversity of bacterial species in fetal membranes during preterm labor emphasizes further research on this topic is needed. Metagenomics uses nonculture, molecular methods to delineate all microbes inhabiting an environment. Thus, the intestinal microbiome is under intense scrutiny to understand necrotizing enterocolitis or inflammatory bowel disease. Initial reports using molecular methods to understand intrauterine infection, fetal inflammation, and preterm delivery have been published.[121, 122]
Clinical events associated with chorioamnionitis include the following:
History of premature birth (with increasing risk at earlier gestational age)
Presence of premature labor
Prematurely ruptured fetal membranes (before labor has its onset)
Prolonged rupture of the fetal membranes
In a report of patients with clinical signs and symptoms of chorioamnionitis, 38% showed no histologic evidence of placental inflammation. Thus, other causes of signs and symptoms that resemble maternal chorioamnionitis must be sought.
Epidural anesthesia during labor may be associated with maternal fever and fetal tachycardia (see Special Concerns). Other conditions, such as dehydration or maternal exhaustion during labor, may result in maternal fever and must be considered as causes of the febrile state.
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