- Author: Michael P Sherman, MD, FAAP; Chief Editor: Ted Rosenkrantz, MD more...
During the intrapartum period, diagnosis of chorioamnionitis is usually based on clinical criteria. This is particularly true for pregnancies at term. Chorioamnionitis or intra-amniotic infection (IAI), as causes for preterm labor, should always be considered. Silent chorioamnionitis is recognized as an important cause of premature labor.
The asymptomatic pregnant mother who presents with premature labor or premature rupture of the membranes may require certain studies to exclude silent chorioamnionitis. To diagnose silent or obvious amniotic fluid infection or chorioamnionitis, the physician often uses laboratory examinations of the amniotic fluid, maternal blood, maternal urine, or a combination to make a diagnosis of infection.
Bacteriologic cultures of amniotic fluid and urogenital discharge may be diagnostic for causative pathogens. Investigators suggest that obtaining cervical cultures has an increased risk of initiating amniotic fluid infection in the presence or absence of ruptured membranes.
Examination of amniotic fluid and urogenital secretions
Amniotic fluid, obtained with amniocentesis, may be screened for leukocyte count, Gram stain, pH, glucose concentration, endotoxin, lactoferrin, cytokine levels (eg, interleukin [IL]-6, IL-8, or tumor necrosis factor [TNF]), or a combination of these measured factors.
Cytokines commonly quantified in either amniotic fluid or blood include IL-6, TNF-alpha, IL-1, and IL-8.[57, 139] No consensus has been reached regarding which cytokine offers the best sensitivity, specificity, and positive versus negative predictive accuracy, although IL-6 is most often cited in the literature. Elevated IL-6 levels in cord blood and amniotic fluid have been related to adverse long-term neurologic outcomes in the neonate.[140, 141, 142, 143] This testing has not become routine. Such diagnostic aids are certainly not used in rural communities that deliver babies.
However, Chaemsaithong et al reported the potential utility of a rapid IL-6 bedside test (20 min) (lateral flow-based immunoassay, or point of care [POC] test) for measuring IL-6 concentrations in amniotic fluid to identify women with intra-amniotic inflammation and/or infection and those who might deliver spontaneously before 34 weeks' gestation among women with preterm labor and intact membranes. Data from 136 women with singleton pregnancies who presented with symptoms of preterm labor and underwent amniocentesis showed that the POC test for amniotic fluid IL-6 concentrations had a 93% sensitivity, 91% specificity, and a positive likelihood ratio of 10 for the identification of intra-amniotic inflammation by using a threshold of 745 pg/mL. Moreover, the POC test performed similarly to enzyme-linked immunosorbent assay (ELISA) for IL-6 levels and identification of microbial invasion of the amniotic cavity (MIAC), acute inflammatory lesions of placenta, and patients at risk of impending spontaneous preterm delivery.
The same investigators found similar results in a retrospective study comprising 56 women with singleton pregnancies who presented with preterm prelabor rupture of membranes (PPROM). When they compared IL-6 concentrations in amniotic fluid measured via ELISA compared with the POC test, the POC test was 97% sensitive and 96% specific for the identification of intra-amniotic inflammation, and the POC test performance for IL-6 was not only strongly correlated to that of an ELISA test for the identification of intra-amniotic inflammation but was also equivalent for the identification of acute inflammatory placental lesions and MIAC.
Polymerase chain reaction (PCR) has been rapidly developed as a diagnostic aid. It is used to identify microbes such as human immunodeficiency virus, cytomegalovirus, herpes simplex, parvovirus, toxoplasmosis, and bacterial DNA in amniotic and other body fluids. PCR has been used for the diagnosis of amniotic fluid infection caused by bacterial pathogens, Only university or major academic centers have this relatively expensive technology available to caregivers.
Amniocentesis to obtain amniotic fluid carries the risk of rupturing the fetal membranes. For this reason, screening tests that use cervicovaginal secretions to indicate chorioamnionitis have been reported. Potential markers of cervical or chorionic inflammation include cervical or vaginal concentrations of fetal fibronectin, insulin-like growth factor binding protein-1, and sialidase. Significant association is noted among levels of cervical IL-6, fetal fibronectin, and amnionitis. Conversely, a positive mid-gestational fetal fibronectin assay was not associated with acute histologic placental inflammation at birth. Proteomic profiling of amniotic fluid detects intrauterine inflammation and/or infection and predicts subsequent neonatal sepsis. Caregivers should follow this research because in the next 5 to 10 years, proteomic profiling for inflammation or nonculture-based molecular detection of microbes may become routine in obstetrical samples.
Antenatal screening uses rectovaginal specimens to detect the presence of maternal group B streptococcal (GBS) colonization at 35-37 weeks' gestation. Using these specimens, the Centers for Disease Control and Prevention (CDC) recommends selective growth of GBS in broth followed by cultivation using the plate method. This is the criterion standard assay.
Currently, the CDC does not recommend direct PCR detection of GBS in rectovaginal samples. Rather, a rectovaginal sample should undergo enhanced growth in selective broth before performing PCR. Maternal colonization with rectovaginal GBS increases the risk of chorioamnionitis, and intrapartum prophylaxis with antibiotics reduces the incidence of neonatal infection from GBS.[146, 147]
For mothers that missed GBS screening at 35-37 weeks' gestation, intrapartum testing for GBS uses rapid detection methods on vaginal secretions.[122, 148] To date, these assays have not achieved the results of the traditional culture method. Missed screening and the failure to give intrapartum antibiotics is responsible for the persistence of neonatal GBS infection.
A rapid screening test for GBS that selects mothers who should receive intrapartum chemoprophylaxis reduces hospital costs by approximately $12,000 per prevented case. Studies from Europe have also shown effectiveness of GBS screening and intrapartum chemoprophylaxis, but the investigators comment on how PCR should be used. Other detection methods that use molecular methods and advanced bioengineering are under investigation. Clinical caregivers should keep an eye on the literature for better methods to detect GBS during labor.
Examinations of maternal blood
WBC counts or C-reactive protein (CRP) levels in maternal blood have been used to predict acute chorioamnionitis when maternal fever is present. Different studies have supported or refuted the use of CRP to diagnose chorioamnionitis.[152, 153] The CRP level may be a better predictor of the risk of chorioamnionitis than peripheral WBC counts, especially if the mother has received corticosteroids, which may falsely increase the total WBC count.
Other investigators have suggested that the alpha1-proteinase inhibitor complex in maternal blood is a better predictor of amniotic fluid infection than either CRP or WBC count. Analyzing amniotic fluid for leukocytes appears to be a better predictor of amniotic fluid infection than levels of either CRP or total WBC count in maternal blood. In fact, the combination of leukocytosis and a low glucose concentration in the amniotic fluid is highly indicative of chorioamnionitis and may be the best predictor of this condition.
Analysis of maternal serum for either IL-6 or ferritin content may also be helpful, because elevations in these mediators are associated with maternal or neonatal infection. Serum IL-6 levels may be more predictive of infection than CRP concentrations in maternal blood. Alpha1-proteinase inhibitor complex, cytokines, and ferritin in maternal blood have not gained widespread use as markers of acute chorioamnionitis.
The criterion standard for making a diagnosis of early onset bacteremia, pneumonia, or meningitis in neonates is the growth of bacteria in an appropriate specimen (ie, blood, tracheal secretions, cerebrospinal fluid [CSF]). Urinary tract infection is an infrequent cause of early-onset bacterial disease in the neonate; thus, suprapubic bladder taps are not usually required as part of an evaluation for EOS.[154, 155]
Controversy has arisen regarding the inclusion of the lumbar puncture as part of the evaluation for EOS. Some clinicians have argued that the neonate with meningitis has obvious manifestations, and the asymptomatic term neonate does not require a lumbar puncture as part of the evaluation for EOS. Other caregivers argue that a lumbar puncture can only be performed safely when life-threatening pulmonary dysfunction or hypertension resolves.
Other investigators have stressed that cases of meningitis are missed with this approach. The medical literature contains good evidence that meningitis may occur in association with sterile blood cultures. Because meningitis is a devastating neonatal infection, no lumbar puncture may result in inadequate antibiotic therapy. Thus, many believe a lumbar puncture should be performed as part of the evaluation for EOS.
Studies that are also considered specific for infection include positive findings on Gram stains of CSF or tracheal secretions.
The tracheal secretions must be obtained shortly after birth (< 4-8 h). The reason is colonization of the airways occurs from the NICU environment during this time frame. Both tracheal fluids and CSF should be sterile at birth. The presence of bacteria on microscopic analysis (ie, Gram stain) indicates that more than 10,000 colony-forming units of bacteria are present per milliliter of specimen (body fluid). However, the absence of bacteria in either CSF or tracheal secretions does not exclude infection. A final diagnosis should be based on culture results, and this testing takes hours to days.
An absence of neutrophils in CSF or tracheal secretions is expected. The presence of neutrophils in tracheal aspirates obtained after birth indicates that the fetus has mounted an inflammatory response to infection in the environment.
Studies by the primary author and separate studies by pathologists indicate that neutrophils present in tracheal secretions shortly after birth originate from the fetus or neonate and do not represent aspirated maternal neutrophils found in infected amniotic fluid. This conclusion is based on examining Y-body fluorescence in neutrophils present in the tracheal secretions of infected male neonates. In some studies, 50% of the neutrophils present in tracheal secretions of infants with suspected congenital pneumonia had Y-chromosome fluorescence, indicating a fetal origin.
Conversely, 10% of neutrophils in gastric aspirates from the same infants had Y-chromosomal fluorescence. Thus, neutrophils in gastric aspirates are primarily maternal neutrophils, and they represent WBCs present in infected amniotic fluid that is swallowed by the fetus.
Alternatively, the flux of fetal airway fluid is outward from the lung. Maternal neutrophils can gain access to the fetal lung only when gasping occurs during fetal asphyxia.
The male neutrophils observed in the gastric aspirates of these infants with congenital pneumonia indicated that neutrophils were swallowed after they left the fetal lung via the outward flux of airway fluid.
Bacterial antigen detection in CSF is also a useful test to indicate bacterial infection. Bacterial antigen detection in the urine should not be used in a neonate's evaluation for sepsis. Many factors can cause false-positive or false-negative test results during bacterial antigen detection in the urine. Surface cultures have no role in decision-making regarding the diagnosis and treatment of the neonate with early-onset bacterial infection.
All other tests used to diagnose early-onset bacterial infection in the neonate should be considered screening tests. The most common laboratory studies used to screen for neonatal sepsis are WBC profiles and CRP determinations. These tests, at best, are presumptive indicators of infection.
WBC profiles (leukopenia [< 5000/µL], leukocytosis [>30,000/µL], a markedly diminished absolute neutrophil count [< 500-1500/µL], an immature-total neutrophil ratio [>0.3-0.4]) are a commonly used screening test for the septic neonate. Note that the immature-to-total neutrophil ratio of 0.3-0.4 is higher than the previous value of 0.2 reported in the classic studies of Manroe (1977 and 1979).[158, 159] Clinical pathologists have been less accepting of the immature-to-total neutrophil ratio as a diagnostic aid in neonatal sepsis.
Studies have re-examined the WBC counts and the leukocyte profiles present in extremely preterm infants and at high altitude. Other diagnostic tests (eg, inflammatory factors, adhesion molecules, cytokines, neutrophil surface antigens, or even bacterial DNA) may be superior alternatives to this test. To date, these markers of neonatal inflammation/infection have not replaced leukocyte counts as diagnostic methods.
WBC profiles and kinetics are influenced by the genetic make-up of the patient, the gestational age, maternal noninfectious disorders such as pregnancy-induced hypertension (PIH), medications administered to the mother, fetal disease, and other factors. Reference range WBC counts in the neonate do not exclude infection, and serial studies of WBC indices at approximately 6-hour intervals may be more useful in detecting sepsis. A continued assessment of WBC kinetics offers more information regarding decision making. For example, a physician should be particularly concerned with a falling total WBC count, a declining absolute mature neutrophil count, and a rising immature-to-total neutrophil ratio. These findings, taken together, indicate depletion in the bone marrow–related storage pool of neutrophils.
Transfusion of neutrophils is no longer used because during preparation the granulocytes secrete their antimicrobial peptides, and thus these microbicides are not available for killing in phagosomes.
The predictive accuracy of WBC indices for the diagnosis of the EOS is poor. Likewise, the accuracy of CRP determinations to predict neonatal infections shortly after birth is low. However, a negative CRP is a reason to stop antibiotic therapy after 48 hours.
Akin to maternal diagnostic studies for infection, alpha1-proteinase inhibitor complex, cytokines (eg, IL-1 and IL-6 in particular, IL-1 receptor antagonist), and detection of bacterial products in neonatal blood have not gained widespread use as markers of neonatal sepsis. However, these effectors of inflammation may prove to have better predictive accuracy than WBC tests or the CRP. Procalcitonin may have better sensitivity, specificity, and positive and negative predictive value than CRP in the diagnosis of early onset neonatal sepsis. None of these tests for EOS are routinely used, especially in suburban or rural hospitals with maternity services.
The study of surface markers of inflammation on leukocytes has provided variable diagnostic use in EOS.[165, 166] More research is needed in this field.
Molecular methods to identify pathogenic bacteria in neonatal blood have engendered enormous interest because a rapid diagnosis is possible.[167, 168, 169, 170] Most hospital laboratories do not have the equipment because it is expense and the training of laboratory personal takes considerable time. A wide range of molecular probes are also required to accomplish this diagnostic task. Caregivers should pay close attention to field.
Ultrasonography may be used to ascertain fetal well-being. A biophysical profile (BPP) provides information about the status of the fetus. A low BPP score, and especially the loss of fetal breathing movements, has been associated with fetal bacterial infection after premature rupture of membranes.[90, 91] Other investigations have not confirmed the importance of a low BPP score. Specifically, the absence of fetal breathing, may not be a reliable test for amnionitis prior to 32 weeks' gestation.[171, 172]
Before the fetus is viable, vaginal ultrasonography can be used to identify women with a shortened cervical canal. A shortened cervical canal is associated with a higher risk of preterm delivery.[6, 7, 8] Researchers suggest a shortened cervical canal or cervical insufficiency are linked to ascending urogenital infection that initiates premature labor, premature rupture of the membranes, or both.
The common tests used to diagnose maternal chorioamnionitis are discussed above. Tests still in investigational stages and that have not yet come to the bedside are also discussed above.
Needle aspiration and analysis of amniotic fluid is the only invasive procedure used to confirm the diagnosis of acute chorioamnionitis. This procedure can be risky with intact fetal membranes, because the fetal membranes can rupture during or after the procedure.
Bleeding or placental abruption can also be a consequence of amniotic fluid aspiration. The procedure should be performed using ultrasonographic guidance to avoid fetal injury. For these reasons, aspiration of amniotic fluid to diagnose maternal chorioamnionitis has enjoyed limited application in obstetric practice.
Gross and microscopic examinations of the placenta, fetal membranes, and umbilical cord for evidence of inflammation and infection are crucial to make a definitive diagnosis of chorioamnionitis. Histologic chorioamnionitis is a reliable indicator of infection whether or not it is clinically apparent. Nevertheless, anatomic studies should be correlated with a culture aseptically obtained from the fetal surface of the placenta.
The microbiologic cultures should include an attempt to isolate aerobic and anaerobic bacteria. Special microbiologic techniques may be required for certain microorganisms such as Listeria monocytogenes. Only in these ways can the pathologist help the bedside clinician delineate the cause of maternal chorioamnionitis and neonatal sepsis. Clinicians are encouraged to ask pathologists for help in their search for infections causing disease in the pregnant woman, fetus, and newborn. Obstetricians must also obtain the placenta, fetal membranes, and umbilical cord samples for analytical studies when suspicious clinical circumstances are noted.
Redline and colleagues proposed a scoring system for placental examination that promotes consistency when pathologists judge the severity of chorioamnionitis.
Several physiologic scores have been proposed for neonates who have life-threatening illness, but a recent report could not conclude that these scores accurately predicted neonatal morbidity and mortality during infection.
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