Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment

Induction of epithelial cell senescence by SERPINE1 derived from fibroblasts in the amnion at parturition

Senescence of amnion epithelial cells not only disrupts the fetal membrane structure, but also becomes a source of proinflammatory signals contributing to membrane inflammation at parturition. However, the trigger initiating their senescence awaits identification. In this study, we found that SERPINE1 abundance was significantly increased in the amnion at parturition, where SERPINE1 was found predominantly expressed in amnion fibroblasts. SERPINE1 from amnion fibroblasts induced amnion epithelial cell senescence by causing vitronectin shedding from the cells thereby interrupting the association of vitronectin with integrin subunit αV, which led to the inhibition of the cell survival-associated focal adhesion pathway. In turn, proinflammatory cytokines such as interleukin-1β from senescent amnion epithelial cells enhanced SERPINE1 expression in amnion fibroblasts, thus forming a feed-forward loop between SERPINE1 production in amnion fibroblasts and epithelial cell senescence at parturition. Studies in the pregnant mice showed that intra-amniotic injection of SERPINE1 induced preterm birth with increased cellular senescence in the fetal membranes, which could be reversed by co-administration of vitronectin. Our findings indicate that SERPINE1 derived from amnion fibroblasts participates in the induction of amnion epithelial cell senescence at parturition. Intervening in the interaction of SERPINE1 with vitronectin may have therapeutic benefit in the treatment of preterm birth.

Perinatal outcomes and predictors of neonatal mortality in preterm premature rupture of membranes: a tertiary center experience

BACKGROUND

Preterm premature rupture of membranes (PPROM) is a serious obstetric condition associated with increased maternal, fetal, and neonatal morbidity and mortality. It accounts for approximately one-third of all spontaneous preterm births and is associated with complications such as respiratory distress syndrome (RDS), sepsis, pulmonary hypoplasia, and neonatal mortality. Despite significant advances in prenatal care, proper management, particularly in early gestational age, remains unclear. Identifying factors associated with neonatal mortality in PPROM is important to develop therapeutic interventions and improve perinatal outcomes.

METHODS

This retrospective study examined clinical data and neonatal outcomes in 183 pregnant women with PPROM between the gestational ages of 23 and 36 + 6 weeks who were admitted to a tertiary referral hospital. The study population was categorized into four gestational age cohorts: Group I (23-27 + 6 weeks), Group II (28-31 + 6 weeks), Group III (32-33 + 6 weeks), and Group IV (34-36 + 6 weeks). Neonatal outcomes, including admission to the neonatal intensive care unit (NICU), the incidence of respiratory distress syndrome, the requirement for oxygen and mechanical ventilation, the necessity for surfactant and inotropic support, sepsis, suspected pulmonary hypoplasia, and early and late neonatal mortality were compared between the groups.

RESULTS

Group I had the highest CRP values (18.68 ± 21.34), while Group III had the lowest (6.81 ± 5.16). Significant differences were found between the groups in terms of death at discharge, gestational age at delivery, birth weight, and presence of oligohydramnios. The intubated group had higher CRP levels and lower gestational age and birth weight. Of the 14 neonatal deaths, eight occurred in the early neonatal period, corresponding to a mortality rate of 7.6%. The neonatal mortality rate was 63.2% in Group I. No deaths were recorded in Groups II and III. In Group IV, the mortality rate was 2.2%.

CONCLUSION

Neonatal mortality was associated with low gestational age, low birth weight, and oligohydramnios. The predominant cause of early infant deaths was RDS, whereas late neonatal mortality was primarily attributed to sepsis. Specifically, active management options after 34 weeks of gestational age have demonstrated enhancements in neonatal outcomes, underscoring the significance of tailored clinical approaches in cases of PPROM.

Hypoxic-ischemic encephalopathy following intrapartum asphyxia: is it avoidable?

BACKGROUND

The proportion of term hypoxic-ischemic encephalopathy arising during intrapartum fetal surveillance remains unclear. Moreover, recent Cochrane review and other studies emphasized the need for research on the impact of admission cardiotocography and highlighted the necessity for a definition of "avoidable perinatal brain injury".

OBJECTIVE

To assess the impact of intrapartum asphyxia on neonatal hypoxic-ischemic encephalopathy occurrence and identify the proportion of cases that benefit from preventive measures.

STUDY DESIGN

This retrospective 20-year birth cohort study included admission and intrapartum cardiotocography recordings from spontaneous term (≥37 weeks of gestation) singleton deliveries at 7 maternity hospitals within the Helsinki University Hospital area, Finland, between 2005 and 2024. In newborns diagnosed with hypoxic-ischemic encephalopathy, cases following intrapartum asphyxia were identified by a normal cardiotocogram at admission, whereas antepartum exposure was indicated by an abnormal admission cardiotocogram. Cord blood gases, erythropoietin, and serum S100β concentrations were analyzed, and placentas underwent histopathological examination. Primary outcome was hypoxic-ischemic encephalopathy. Secondary outcome was fetal asphyxia, defined as the presence of severe or moderate acidemia.

RESULTS

Among 317,126 term newborns, 314 cases of hypoxic-ischemic encephalopathy were identified. Admission cardiotocogram was normal in 141 (44.9%) and abnormal in 173 (55.1%). Of those with a normal admission cardiotocogram, severe acidemia (umbilical artery pH <7.00 and/or base excess ≤-12.0 mmol/L) evolved in 127/141 (90.1%) and moderate acidemia (umbilical artery pH 7.09-7.00 and base excess -10.0 to -11.9 mmol/L) in 11/141 (7.8%). Excluding cases with a perinatal sentinel event and timely deliveries, 70 cases (49.6%) remained in which hypoxic-ischemic encephalopathy presumably developed during labor and was considered potentially avoidable. These findings suggest that in 22.3% (70/314), preventive measures should have been implemented. Newborns with abnormal cardiotocograms had higher median umbilical blood erythropoietin concentrations than those with normal admission cardiotocograms (112 U/L, interquartile range 22-1130 vs 29 U/L, interquartile range 7-680, P<.001), indicating more chronic hypoxia.

CONCLUSION

Of term newborns with hypoxic-ischemic encephalopathy and normal admission cardiotocogram, 98% were attributable to intrapartum asphyxia. Our findings indicate that half of the cases of intrapartum hypoxic-ischemic encephalopathy with a normal admission cardiotocogram were potentially avoidable, suggesting that one-fifth of all cases could have benefited from preventive measures. The findings underscore the role of optimal intrapartum care in preventing hypoxic-ischemic encephalopathy.

Obstetric Use of Prostaglandin Preparations Compared to Mechanical Methods for Cervical Ripening in Pregnancies With Premature Rupture of Membranes at Term

Background We examined the difference in obstetric outcomes between the cases using dinoprostone and those using mechanical methods in pregnant women requiring cervical ripening following premature rupture of the membranes (PROMs) at term. Methodology During the study period, dinoprostone was used in 34 nulliparous women, while mechanical methods were used in 35 nulliparous women for cervical ripening following PROM at term. We examined the differences in the delivery outcomes between the two groups. Results On the day of induction start, 2 cases (6%) in the dinoprostone group were delivered by cesarean section due to non-reassuring fetal status (NRFS), while no cases were complicated by NRFS in the mechanical methods group (P = 0.15). However, there was no significant difference in the rate of cesarean delivery between the two groups (P = 0.73). In the mechanical methods groups, 3 cases (9%) were complicated by clinical intrauterine infection, while there was no case of clinical intrauterine infection in the dinoprostone group (P = 0.08). The clinical intrauterine infection in the cases of the mechanical methods group occurred more than 2 days after the start of cervical ripening; however, there was no case of neonatal infection in the two groups. Conclusions There were differences in the characteristics of the effects between the two methods in pregnant women with PROM who have an unfavorable cervix; however, there were no differences in the final perinatal outcome.

Anesthetic management of women with primary immunodeficiencies in the obstetric setting: A French cohort study (ANEU-DIP)

Background

Primary immunodeficiencies (PIDs) encompass a large group of inherited diseases affecting the immune system. PID management is improving, enabling more patients to carry a pregnancy to term. Anesthetic care of those patients, especially obstetric neuraxial anesthesia and the associated infectious complications, has never been evaluated in this population.

Objective

This retrospective multicenter study aimed to assess the anesthetic management of women with PIDs during childbirth, focusing on potential infectious complications related to neuraxial anesthesia.

Methods

The medical records of 30 women aged 18 years or older, who are included in the French national PID registry (Reference Centre for Primary Immunodeficiencies [CEREDIH]) and who gave birth at one of the Assistance Publique-Hôpitaux de Paris maternity units between 2014 and 2024, were analyzed. Data on PID history, obstetric outcomes, and peripartum anesthesia were collected (the ANEU-DIP study, ClinicalTrials.gov identifier NCT06449066).

Results

We examined 51 deliveries (including 20 cesarean sections) among 30 women with PIDs (13 with predominantly antibody defects, 11 with T-cell immune deficiencies, and 6 with innate immune deficiencies). Of the 49 locoregional anesthesia procedures performed, 36 were epidurals, 8 were spinals, and 5 were combined spinal-epidurals. No anesthesia-related complications were reported. The distribution and severity of PIDs in the cohort were consistent with those in other French studies. Three intrauterine infections were identified, of which 2 were associated with known risk factors and subsequent favorable maternal and neonatal outcomes.

Conclusion

This study highlights the frequent use of neuraxial anesthesia in women with PIDs. No anesthesia-related complications were observed. Further research is needed to implement tailored anesthesia guidelines for this vulnerable segment of the pregnant population.

Outpatient management of prelabour rupture of membranes (PROM) at term - a re-evaluation and contribution to the current debate

OBJECTIVES

Our study aims to underpin the safety of ambulatory management for 24 h after PROM at term. Patient data from 2021 were compared with data from 2010 to 2013, when ambulatory management was first introduced at the Women's Clinic of the University Hospital of Basel.

METHODS

In this retrospective study with historical control groups, we compared a cohort of women who underwent outpatient management of PROM at term in 2021, n=78 with two previous cohorts with inpatient management in 2010-2012, n=202 and outpatient management in 2013, n=37, respectively.

RESULTS

The maternal and foetal outcomes of our cohort were comparable to those of the previous cohorts. The expected difference in shorter hospital stay was confirmed.

CONCLUSIONS

The study confirms the safety of an outpatient approach in the management of PROM at term. Further studies, especially RCTs, are needed for a definitive evaluation.

Maternal bacteremia in intrapartum fever: the role of ampicillin resistance and prolonged membrane rupture-a retrospective comparative study

OBJECTIVE

Intrapartum fever (IPF) (≥ 38.0 °C), if treated inappropriately, can lead to maternal bacteremia. In a cohort of women with IPF, we investigated perinatal, obstetrical, and microbiological outcomes, comparing those with bacteremia to those with negative blood cultures.

METHODS

A retrospective cohort study at a tertiary hospital (2010-2022) focused on women attempting vaginal delivery who were diagnosed with IPF. Outcomes were compared between those with bacteremia vs. negative blood cultures. After delivery, chorioamniotic swab cultures were obtained. Bacterial distribution and rates of ampicillin-resistant Enterobacteriaceae in blood and swab cultures were described. Women with Group B streptococcal colonization or prolonged rupture of membranes (ROM) received prophylactic ampicillin. The results were compared using univariate and multivariate analysis.

RESULTS

Overall, 78 women had bacteremia, and 341 had negative blood cultures. Women with bacteremia had higher rates of endometritis (p = 0.016), Apgar-5 < 7 (p = 0.021) and umbilical cord pH < 7.1 (p = 0.008). In multivariate analysis, prolonged ROM (p = 0.028) and prophylactic ampicillin (p = 0.036) were linked to maternal bacteremia. Maternal bacteremia (p < 0.001) was associated with higher endometritis and NICU admission rates. Blood cultures and chorioamniotic swab cultures matched in 65.9% of cases. Ampicillin-resistant Enterobacteriaceae spp. were found in 70.2% of blood cultures and 90.6% of chorioamniotic swab cultures. The rate of Enterobacteriaceae-isolated maternal bacteremia was higher among preterm than term deliveries (p = 0.034); while the rate of GBS-isolated bacteremia was lower (p < 0.001).

CONCLUSION

Ampicillin-resistant Enterobacteriaceae rates in blood and chorioamniotic swab cultures were concerning. Prolonged ROM and prophylactic ampicillin were associated with higher maternal bacteremia rates. Appropriate use of intrapartum antibiotics is essential.

Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study

AIM

To investigate the risk factors associated with postpartum urinary retention after cesarean section (CS) and to determine the associated morbidity rate.

METHODS

This study was a population-based retrospective case-control study analyzed using National Inpatient Sample (NIS) data from 2010 to 2019. The study classified women according to whether they developed postpartum urinary retention after delivery. Predictors of postpartum urinary retention occurring after CS were identified by multivariate logistic regression analysis, and the corresponding incidence rates were examined after adjusting for basic maternal demographic and clinical characteristics.

RESULTS

A total of 2,397,168 CSs were extracted from the NIS database. The overall incidence of urinary retention after CS was 0.20%. Patients who experienced urinary retention after CS demonstrated longer length of stay (LOS), higher total costs, and more postoperative complications. The following variables have been identified as potential risk factors for urinary retention: age between 25 and 34 years (OR = 1.27; 95% CI = 1.17-1.38; P < 0.001), 35 years and older (OR = 1.35; 95% CI = 1.22-1.48; P < 0.001), Asian and Pacific Islander (OR = 1.85; 95% CI = 1.68-2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28-1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09-2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06-3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07-1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79-2.07; P < 0.001), eastern hospitals (OR = 1.24; 95% CI = 1.14-1.35; P < 0.001), coagulation disorders (OR = 1.32; 95% CI = 1.08-1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94-3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20-1.89), paralysis (OR = 3.24; 95% CI = 1.95-5.38), and weight loss (OR = 2.34;95% CI = 1.26-4.35). In addition, urinary retention was associated with postoperative complications related to bladder or ureteral injury (OR = 6.12; 95% CI = 2.46-15.23), blood transfusion (OR = 1.51; 95% CI = 1.31-1.76), acute renal failure (OR = 4.74; 95% CI = 3.46-6.48), respiratory failure (OR = 2.21; 95% CI = 1.23-3.98), endometritis (OR = 1.32; 95% CI = 1.02-1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38-4.62), uterine rupture (OR = 1.75; 95% CI = 1.21-2.54), hysterectomy (OR = 2.30; 95% CI = 1.66-3.18), peritonitis (OR = 2.86; 95% CI = 1.03-7.92), severe puerperal infections (OR = 3.31; 95% CI = 2.60- 4.22), chorioamnionitis (OR = 1.78; 95% CI = 1.59-2.00). Notably, the presence of cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11-1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00-1.20), placenta previa (OR = 1.39; 95% CI = 1.06-1.84), multiple gestation (OR = 1.39; 95% CI = 1.23-1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42-10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24-25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09-1.36) was associated with a significantly increased risk of urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50-0.76), previous CS (OR = 0.87; 95% CI = 0.82-0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31-0.86) conferred some protective effect against it.

CONCLUSION

In this study, we identified an overall prevalence of 0.20% for urinary retention after CS and several risk factors, including advanced maternal age, Asian and Pacific Islander background, comorbidities, and delivery in large or teaching hospitals, particularly in the Eastern region. Protective factors included hospitals in the southern region, urban hospitals, obesity, and hypertension. Urinary retention was associated with increased postoperative complications, longer LOS, and higher healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. To mitigate these risks, healthcare professionals should prioritize antenatal screening, manage comorbidities, and closely monitor high-risk patients during the postpartum period to reduce adverse outcomes.

Maternal Immune Activation: Implications for Congenital Heart Defects

Congenital heart defects (CHD) are the most common major birth defects and one of the leading causes of death from congenital defects after birth. CHD can arise in pregnancy from the combination of genetic and non-genetic factors. The maternal immune activation (MIA) hypothesis is widely implicated in embryonic neurodevelopmental abnormalities. MIA has been found to be associated with the development of asthma, diabetes mellitus, and other diseases in the offspring. Given the important role of cardiac immune cells and cytokines in embryonic heart development, it is hypothesized that MIA may play a significant role in embryonic heart development. This review aims to stimulate further investigation into the relationship between MIA and CHD and to highlight the gaps in the knowledge. It evaluates the impact of MIA on CHD in the context of pregnancy complications, immune-related diseases, infections, and environmental and lifestyle factors. The review outlines the mechanisms by which immune cells and their secretome indirectly regulate the immuno-microenvironment of the embryonic heart by influencing placental development. Furthermore, the inflammatory cytokines cross the placenta to induce related reactions including oxidative stress in the embryonic heart directly. This review delineates the role of MIA in CHD and underscores the impact of maternal factors, especially immune factors, as well as the embryonic cardiac immuno-microenvironment, on embryonic heart development. This review extends our understanding of the importance of MIA in the pathogenesis of CHD and provides important insights into prenatal prevention and treatment strategies for this congenital condition.

Receipt of Tdap or Influenza Vaccine During Pregnancy and Odds of Clinical Chorioamnionitis: A Nested Case-Control Study

OBJECTIVE

To evaluate the odds of clinical chorioamnionitis following tetanus, diphtheria, and acellular pertussis (Tdap) or influenza vaccine receipt in pregnancy.

METHODS

In this nested case-control study, a cohort of live deliveries at two United States military hospitals, 2013-2018, was initially screened for chorioamnionitis using diagnosis codes. A sample of deliveries was selected for chart review and validation. Study cases (clinical chorioamnionitis) were defined by the presence of fever and at least one additional clinical symptom during the delivery hospitalization; controls were defined by the absence of these criteria. Descriptive statistics compared characteristics of validated cases and controls, and multivariable logistic regression models estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) with receipt of Tdap or influenza vaccine during pregnancy; observations were weighted by the inverse probability of being sampled for validation.

RESULTS

Among 6931 deliveries, 1868 were sampled for validation and 1650 (n = 305 cases, n = 1345 controls) were included for analysis. At delivery, mean age was 25.0 years for cases and 25.9 years for controls; 88.4% of cases and 63.0% of controls were primipara. Tdap vaccine was recorded in 82.8% of cases and 82.0% of controls (aOR 0.94, 95% CI 0.72, 1.23) and influenza vaccine was recorded in 61.8% of cases and 63.0% of controls (aOR 0.97, 95% CI 0.78, 1.19). Analyses that considered timing and combinations of vaccine receipt yielded similar estimates.

CONCLUSION

In this population, neither Tdap nor influenza vaccine receipt during pregnancy was associated with increased odds of clinical chorioamnionitis at delivery.

Ampicillin and gentamicin prophylaxis is superior to ampicillin alone in patients with prelabor rupture of membranes at term: the results of a randomized clinical trial

BACKGROUND

Prelabor rupture of membranes is a risk factor for maternal and neonatal infectious morbidity. Ampicillin is indicated for patients with unknown group B Streptococcus status and prelabor rupture of membranes ≥18 hours. Although ampicillin-resistant Enterobacteriaceae contribute to maternal and neonatal infectious morbidity, current guidelines on intrapartum antibiotic prophylaxis primarily target group B Streptococcus and do not adequately cover Enterobacteriaceae.

OBJECTIVE

To compare maternal and neonatal infectious morbidity between 2 antibiotic regimens: ampicillin and gentamicin vs ampicillin alone.

STUDY DESIGN

This randomized controlled trial was conducted between November 2022 and March 2024 in a tertiary university-affiliated hospital. Inclusion criteria were a term singleton pregnancy ≥37 0/7, vertex presentation, unknown group B Streptococcus status, and prelabor rupture of membranes without active labor. Exclusion criteria included penicillin/gentamicin allergy, contraindications for vaginal delivery, and current antibiotic treatment. The participants were randomized at 12 to 18 hours post prelabor rupture of membranes to receive ampicillin and gentamicin (n=102) or ampicillin alone (n=102). They were blinded from the allocation until antibiotics initiation at 18 hours post prelabor rupture of membranes. The antibiotics were administered until delivery. The primary outcome was clinical chorioamnionitis. Secondary maternal outcomes were puerperal endometritis, peripartum infections, intrapartum fever, and a composite of postpartum maternal morbidity, defined as the presence of puerperal endometritis, postpartum antibiotic treatment exceeding 24 hours, wound infection, or infection-related hospitalization >5 days. A neonatal composite adverse outcome included culture-proven neonatal sepsis, admission to the neonatal intensive care unit, empiric antibiotic treatment in the neonatal intensive care unit, performance of a sepsis workup, and infection-related hospitalization >5 days. Microbiologic findings were assessed from chorioamniotic swab cultures. An intention-to-treat analysis was performed. The number needed to treat was calculated for the primary outcome. Multivariate logistic regression was conducted to predict clinical chorioamnionitis, after controlling for antibiotic regimen, prelabor rupture of membranes duration, delivery number, body mass index, delivery week, maternal age, meconium staining, and diabetes mellitus.

RESULTS

Ampicillin and gentamicin treatment was associated with lower rates of clinical chorioamnionitis (1/102 [1.0%] vs 8/102 [7.8%], P=.035), intrapartum fever (8/102 [8.0%] vs 18/102 [18.0%], P=.036), and overall peripartum infections (1/102 [1.0%] vs 10/102 [9.8%], P=.005). The number needed to treat to prevent 1 case of clinical chorioamnionitis was 14.7 (95% confidence interval, 10.2-27.0). The rate of the composite postpartum maternal complications was also lower in the ampicillin and gentamicin group (0/102 [0%] vs 6/102 [5.9%], P=.029). Ampicillin and gentamicin treatment was associated with lower rates of the composite neonatal adverse outcome (11/102 [10.8%] vs 22/102 [21.6%], P=.036) and sepsis workups (8/102 [7.8%] vs 18/102 [17.6%], P=.036) and a shorter median neonatal intensive care unit stay (3.0 vs 3.5 days, P=.047). The frequency of positive Enterobacteriaceae cultures in chorioamniotic swab samples was lower following ampicillin and gentamicin (17/85 [20%] vs ampicillin alone 45/89 [51%], P<.001).

CONCLUSION

In term prelabor rupture of membranes, ampicillin and gentamicin prophylaxis, compared to ampicillin alone, resulted in lower rates of clinical chorioamnionitis, maternal postpartum complications, and neonatal adverse outcomes. It is time to reconsider the antimicrobial prophylactic regimen in term prelabor rupture of membranes.

IL-1β stimulates ADAMTS9 expression and contributes to preterm prelabor rupture of membranes

BACKGROUND

Preterm prelabor rupture of membranes (pPROM) is a leading cause of neonatal morbidity and mortality. While intra-amniotic infection is a well-established driver of pPROM, the role of sterile intra-amniotic inflammation remains unclear. Recent evidence suggests that interleukin-1 beta (IL-1β) promotes extracellular matrix (ECM) remodeling via downstream effectors, a disintegrin-like and metalloproteinase domain with thrombospondin type 1 motif 9 (ADAMTS9), while protein O-fucosyltransferase 2 (POFUT2) facilitates its O-fucosylation and secretion, amplifying ECM degradation. This study investigates how IL-1β-triggered nuclear factor kappa-B (NF-κB) activation promotes ADAMTS9 and POFUT2 expression, ultimately driving fetal membrane ECM remodeling and weakening in pPROM without signs of intra-amniotic infection.

METHODS

A nested case-control study included maternal serum and fetal membrane samples from 60 pregnant women (34 pPROM, 26 full-term births [FTB]). ELISA measured serum levels of IL-1β and ADAMTS9, and their correlations were analyzed. Mechanistic studies utilized primary human amniotic epithelial cells (hAECs) and fetal membrane-decidua explants with IL-1β treatment. The role of NF-κB was explored using chromatin immunoprecipitation (ChIP) and luciferase assays to assess NF-κB binding to the promoters of ADAMTS9 and POFUT2. A murine model of sterile intra-amniotic inflammation under ultrasound-guided IL-1β injection was used to validate in vitro findings and assess pregnancy outcomes.

RESULTS

Serum IL-1β and ADAMTS9 levels at 16 weeks of gestation were significantly higher in pPROM cases compared to FTB controls (P < 0.001). A combined model of these biomarkers demonstrated high predictive accuracy for pPROM (AUC = 0.83). Mechanistically, IL-1β activated NF-κB, leading to its binding to the promoters of ADAMTS9 and POFUT2. NF-κB activation promoted ADAMTS9 expression, while POFUT2 enhanced its secretion. Together, these processes drove versican degradation and ECM weakening. Intra-amniotic administration of IL-1β in mice induced fetal membrane weakening, preterm birth, and adverse neonatal outcomes, which were mitigated by the NF-κB inhibitor BAY 11-7082 treatment.

CONCLUSION

Maternal serum ADAMTS9 levels at mid-gestation are promising non-invasive biomarkers for pPROM risk stratification. Mechanistically, IL-1β-induced NF-κB activation promotes ADAMTS9 expression and POFUT2-dependent secretion, contributing to fetal membrane weakening. These findings provide new insights into the role and potential therapeutic target for sterile intra-amniotic inflammation in pPROM.

Chorioamnionitis and Two-Year Outcomes in Infants with Hypoxic-Ischemic Encephalopathy

OBJECTIVE

To determine if chorioamnionitis is associated with an increased risk of adverse 2-year outcomes among infants with hypoxic-ischemic encephalopathy (HIE).

STUDY DESIGN

This cohort study included all infants with moderate to severe HIE treated with therapeutic hypothermia and enrolled on the High-dose Erythropoietin for Asphyxia and Encephalopathy Trial. Clinical chorioamnionitis (CC) was defined as a diagnosis made by a treating obstetrician and histologic chorioamnionitis (HC) was defined as placental inflammation observed on histology. We used proportional odds regression to determine the associations between CC, HC, and an ordinal 2-year neurodevelopmental outcome measure: no neurodevelopmental impairment (NDI), mild NDI, moderate NDI, severe NDI, or death.

RESULTS

Of 500 infants, 65 (13%) were exposed to CC. Of 317 infants with placental data available, 125 (39%) were exposed to HC. Infants exposed to CC (odds ratio 0.57, 95% CI 0.34-0.95) and those exposed to HC (odds ratio 0.62, 95% CI 0.40-0.96) had a lower severity of primary outcome than unexposed infants. Infants exposed to chorioamnionitis also had lower frequencies of sentinel events (CC: P = .001; HC: P = .005), central pattern magnetic resonance imaging brain injury (CC: P = .02; HC: P = .02), and electroencephalogram background abnormalities (CC: P = .046; HC: P = .02), compared with unexposed infants.

CONCLUSIONS

Infants with HIE who were exposed to chorioamnionitis had lower severity of 2-year outcomes than unexposed infants. Our findings suggest that chorioamnionitis may lead to a lower severity of brain dysfunction than other pathophysiologic mechanisms of encephalopathy.

PPROM in the late preterm period: an argument for expectant management

Preterm prelabor rupture of membranes (PPROM) is associated with significant neonatal risks. When PPROM occurs during the late preterm period (between 34 0/7 and 36 6/7 weeks gestation), the optimal gestational age for delivery is unclear and varies by regional practice. In 2020 the American College of Obstetrician and Gynecologists (ACOG) published guidelines indicating that both expectant management and immediate delivery were considered reasonable options. Historically, studies that examined the topic of expectant management versus immediate delivery of PPROM after 34 weeks supported immediate delivery based on an observed increased risk of infectious complications without any benefit to neonatal outcome. However, these studies were small and were underpowered to detect a meaningful difference in neonatal outcomes. In this review, we examine 6 randomized controlled trials and 2 meta-analyses of randomized controlled trials that investigated neonatal and maternal outcomes of expectant management versus immediate delivery of late preterm PROM. Included in this analysis are 3 recent randomized controlled trials (PPROMEXIL, PPROMEXIL2, and PPROMT) and 2 meta-analyses that demonstrate a decreased risk of respiratory distress syndrome and NICU admission rate with expectant management. This is counterbalanced by an increased risk of chorioamnionitis with expectant management, but definitions of chorioamnionitis are variable in the trials with unclear generalizability of the outcome across the trials. Additional analysis with a childhood outcome study showed no significant difference in neurodevelopment in infants born to expectant management of late preterm PROM, and an economic analysis found that expectant management was associated with lower delivery and neonatal costs. Overall, we support expectant management of late preterm PROM if maternal and fetal status are stable and there are no contraindications to expectant management but not extending beyond 37 0/7 weeks gestation.

Neurodevelopmental Outcomes in Preterm Infants at 18 Months of Corrected Age Following Coronavirus Disease 2019 (COVID-19) Pandemic-Related Neonatal Intensive Care Unit (NICU) Care Changes

BACKGROUND

 The coronavirus disease 2019 (COVID-19) pandemic led to significant changes in neonatal intensive care unit (NICU) protocols, including restrictions on parental visitation and suspension of kangaroo mother care. These modifications likely impacted preterm infants' neurodevelopmental outcomes. While previous studies have examined the short-term developmental effects of the pandemic, the long-term neurodevelopmental consequences remain unclear. This study aimed to assess the impact of pandemic-related NICU care changes on the neurodevelopmental outcomes of preterm infants at 18 months corrected age in Japan.

METHODOLOGY

 This retrospective, single-center study was conducted at a Japanese university hospital and included preterm infants born before and during the COVID-19 pandemic. Eligible infants were those with a gestational age of less than 32 weeks or a birth weight under 1,500 g, who subsequently underwent neurodevelopmental assessment at 18 months of corrected age using the Kyoto Scale of Psychological Development 2001 (KSPD). Infants were categorized into a prepandemic group (born before March 1, 2020) and a pandemic group (born on or after March 1, 2020). To compare demographic and clinical characteristics between the groups, the Mann-Whitney U test was employed for continuous variables and the chi-square test for categorical variables. All statistical analyses were performed using a predefined significance level of p < 0.05.

RESULTS

 A total of 44 preterm infants were included (22 per group). While there were no significant differences in birth weight or neonatal morbidities between the groups, the pandemic group had a significantly older gestational age (30 vs. 28 weeks, p = 0.04). KSPD assessments revealed that the pandemic group had significantly lower cognitive-adaptive (80 vs. 92, p = 0.01) and language-social (73 vs. 89, p = 0.04) developmental quotients (DQ) compared with the prepandemic group. Postural-motor DQ was lower in the pandemic group but did not reach statistical significance (82 vs. 98, p = 0.14). To account for potential confounders, an analysis of covariance was conducted, adjusting for gestational age, birth weight, and sex. The adjusted analysis remained consistent with the unadjusted findings, confirming significantly lower cognitive-adaptive DQ (F = 4.83, p = 0.03) and language-social DQ (F = 3.94, p = 0.04) in the pandemic group. Gestational age, birth weight, and sex were not significantly associated with any DQ scores.

CONCLUSIONS

 Preterm infants born during the COVID-19 pandemic exhibited significantly lower cognitive-adaptive and language-social DQs at 18 months corrected age than prepandemic infants. These findings suggest that pandemic-related restrictions on parental involvement in the NICU may have potentially influenced neurodevelopment. Further research is needed to explore long-term developmental trajectories and interventions to support optimal outcomes in this vulnerable population.

Funisitis increases the risk of death or cerebral palsy in extremely preterm infants

BACKGROUND

The relationship between histological chorioamnionitis (inflammation of fetal membranes) and funisitis (inflammation of umbilical cord), both commonly associated with preterm birth, with subsequent development of cerebral palsy remains controversial.

OBJECTIVE

To determine if extremely preterm infants (<27 weeks) exposed to histological chorioamnionitis or funisitis are at a higher risk of death or cerebral palsy compared to those without these exposures.

STUDY DESIGN

Multicenter cohort study of prospectively collected data of preterm infants in the National Institute of Child Health and Development Neonatal Research Network. Infants born 2012 to 2019 who were 22 to 266/7 weeks of gestation, received active treatment, and had placental pathology available were included. Because preterm birth, as measured by gestational age, lies on the causal pathway for cerebral palsy, we used mediation analysis to evaluate whether the indirect mediated effect of gestational age on death or cerebral palsy contributed to the relationships of histological chorioamnionitis and funisitis with death or cerebral palsy.

MAIN OUTCOMES AND MEASURES

The primary outcome was the composite outcome of death or cerebral palsy defined by the Amiel-Tison standardized exam and Gross Motor Function Classification System ≥1 at 22 to 26 months corrected age.

RESULTS

A total of 6949 infants met the eligibility criteria. Of these, 3971 (57%) infants had histological chorioamnionitis, and 2978 (43%) did not have histological chorioamnionitis. About 90% (6248/6949) of infants had follow-up and complete cerebral palsy data. Similarly, 1057 (28%) infants had funisitis, and 2689 (72%) did not have funisitis. Of these, primary outcome data were available for 87% (3267/3746) infants. On multivariable analysis, histological chorioamnionitis was not associated with death or cerebral palsy (relative risk: 0.98 [95% confidence interval: 0.91, 1.05]). Exposure to funisitis was associated with a higher risk of death or cerebral palsy (relative risk: 1.09 [1.01, 1.21]) that was primarily mediated by preterm birth. There was a higher risk of cerebral palsy among surviving infants exposed to funisitis (relative risk: 1.23 [1.04, 1.51]) compared to those without funisitis. This association was partially (40%) mediated by preterm birth (relative risk: 1.08 [1.05, 1.12]), but the major effect (60%) appears to be a direct adverse effect of funisitis exposure on cerebral palsy development (relative risk: 1.13 [0.97, 1.40]).

CONCLUSION

Funisitis was associated with an increased risk of the combined outcome of death or cerebral palsy. In surviving infants, the direct adverse effects of funisitis appear to lead to cerebral palsy, independent of preterm birth.

The rapid diagnosis of intraamniotic infection with nanopore sequencing

BACKGROUND

Intraamniotic infection (defined as intraamniotic inflammation with microorganisms) is an important cause of the preterm labor syndrome. Methods for the detection of microorganisms in amniotic fluid are culture and/or polymerase chain reaction assay. However, both methods take time, and the results are rarely available for clinical decision-making. Nanopore sequencing technology offers real-time, long-read sequencing that can produce rapid results.

OBJECTIVE

To determine 1) the diagnostic performance of the 16S rDNA nanopore sequencing method for the identification of microorganisms in patients with intraamniotic inflammation and 2) the relationship between microbial burden and the intensity of the amniotic fluid inflammatory response.

STUDY DESIGN

We performed a prospective cohort study that included singleton pregnancies presenting with symptoms of preterm labor with intact membranes or of preterm prelabor rupture of the membranes. Amniotic fluid samples were obtained for the evaluation of bacteria in the amniotic cavity using cultivation and polymerase chain reaction-based 16S Sanger sequencing methods. Participants were classified into 4 groups according to the results of an amniotic fluid culture, 16S Sanger sequencing, and an amniotic fluid interleukin 6 concentration: 1) no intraamniotic infection and intraamniotic inflammation (interleukin 6 <2.6 ng/mL, and no microorganisms in the amniotic cavity, as determined by culture or 16S Sanger sequencing); 2) microbial invasion of the amniotic cavity without intraamniotic inflammation, defined by the presence of bacteria detected by culture or 16S Sanger sequencing; 3) sterile intraamniotic inflammation (interleukin 6 ≥2.6 ng/mL without microbial invasion of the amniotic cavity); and 4) intraamniotic infection (interkeukin 6 ≥2.6 ng/mL with microbial invasion of the amniotic cavity). Patients who underwent a mid-trimester amniocentesis, had no intraamniotic infection or intraamniotic inflammation, and delivered at term represented the control group. 16S rDNA nanopore sequencing was performed and the diagnostic indices for the identification of intraamniotic infection were determined. Bioinformatic analysis was carried out to identify microorganisms, and a read count of at least 100 or a read count exceeding that of the background species from the control group, along with a relative abundance of no less than 1%, was used.

RESULTS

1) The 16S nanopore sequencing had a sensitivity of 88.9% (8/9), specificity of 95.4% (41/43), positive predictive value of 80.0% (8/10), negative predictive value of 97.6% (41/42), positive likelihood ratio of 19.1 (95% confidence interval, 4.8-75.4), negative likelihood ratio of 0.1 (95% confidence interval, 0.02-0.7), and an accuracy of 94.2% (49/52) for the identification of intraamniotic infection (prevalence, 17% [9/52]); 2) the microbial load determined by the 16S nanopore sequencing had a strong positive correlation with the intensity of an intraamniotic inflammatory response (amniotic fluid interleukin 6 concentration; Spearman's correlation 0.9; P=.002); and 3) a subgroup of patients with intraamniotic inflammation did not have bacteria determined by culture, Sanger sequencing, or nanopore 16S, thus confirming the existence of sterile intraamniotic inflammation.

CONCLUSION

The 16S nanopore sequencing has high diagnostic indices, predictive values, likelihood ratios, and accuracy in the diagnosis of intraamniotic infection.

Comparison of balloon catheter and oral misoprostol for cervical ripening in women with pre-labor rupture of membranes: A Finnish randomized controlled trial

INTRODUCTION

Pre-labor rupture of membranes (PROM) occurs in about 8% of term pregnancies with over 70% delivering spontaneously within 24 h. However, prolonged PROM increases the risk of chorioamnionitis and neonatal sepsis. While misoprostol and oxytocin are considered safe and effective methods of labor induction, most guidelines do not encourage balloon catheter (BC) use following PROM given concerns about increased risk of chorioamnionitis. However, lack of robust evidence exists. This study aimed to compare BC and low-dose oral misoprostol (OM) regarding infectious morbidity and assess the impact of routine antibiotic prophylaxis during BC use on infection prevention.

MATERIAL AND METHODS

A randomized controlled trial comparing BC and low-dose 25 μg OM for pre-induction cervical ripening in an inpatient setting and assessing the preventive effect of prophylactic antibiotics during BC use in 175 women with PROM was carried out between 1.2.2021 and 31.12.2023 in Helsinki University Hospital. The study protocol was registered in the ISCTN registry (ISRCTN10972090). The primary outcome measures of the study were the mode of delivery, and maternal and neonatal infections.

RESULTS

Eighty-nine women (50.9%) were allocated in the BC arm and 86 women (49.1%) in the OM arm. The cesarean delivery rates were comparable (BC 19.1% [n = 17] vs. OM 11.6% [n = 10]; p = 0.17). The rate of chorioamnionitis (BC 9.1% [n = 8] vs. OM 3.5% [n = 3]; p = 0.21) or neonatal infection (BC 4.5% [n = 4] vs. OM 2.3% [n = 2]; p = 0.68) were not statistically significantly different between the groups, although there was a trend towards higher frequency of infections in the BC arm. There were no differences in the incidence of chorioamnionitis or neonatal infections when routine antibiotic prophylaxis was administered during the BC use compared to those who did not receive antibiotics (chorioamnionitis 10.9% with antibiotics vs. 8.0% without antibiotics; p = 0.68, and neonatal infection 5.3% vs. 3.9%; p = 1.00). Maternal childbirth satisfaction was similar in the BC and OM groups.

CONCLUSIONS

Our results showed almost threefold frequency of chorioamnionitis and twofold frequency of neonatal infections following the use of BC compared to OM, although the study was underpowered for reaching statistical significance. The use of prophylactic antibiotics during BC retention did not reduce the incidence of infections.

A pragmatic approach to recognize intrapartum chorioamnionitis

Chorioamnionitis is a significant contributor to non-hypoxic fetal compromise, increasing the risk of neonatal encephalopathy and cerebral palsy. This paper highlights the limitations of traditional diagnostic methods for chorioamnionitis, which rely on histopathology, microbiology, and clinical signs, and emphasizes the importance of recognizing the fetal inflammatory response using intrapartum cardiotocography (CTG). By understanding the physiological pathways of inflammation, clinicians can identify characteristic CTG patterns. This pragmatic approach allows for earlier detection and intervention, potentially improving perinatal outcomes. The paper calls for a re-evaluation of clinical management practices and advocates for a multifaceted approach that incorporates CTG findings into the diagnosis of chorioamnionitis to prevent adverse neonatal outcomes.

Molecular evidence that GBS early neonatal sepsis results from ascending infection: comparative hybrid genomics analyses show that microorganisms in the vaginal ecosystem, amniotic fluid, chorioamniotic membranes, and neonatal blood are the same

OBJECTIVES

Streptococcus agalactiae, or Group B Streptococcus (GBS), is a leading cause of neonatal sepsis. Materno-fetal transmission of the microorganisms present in the lower genital tract/perineum is considered to be the most frequent mode for acquisition of infection. It has also been proposed that, in a subset of cases, GBS causes acute chorioamnionitis, intraamniotic infection, and fetal/neonatal sepsis. However, the evidence to support this ascending pathway is derived from microbiologic studies that rely on cultivation methods, which do not have the resolution to determine if the microorganisms causing neonatal sepsis are the same as those found in the amniotic fluid and the vaginal ecosystem.

METHODS

We used whole genome sequencing of the microorganisms isolated from the vagina, amniotic fluid, chorioamniotic membranes, and neonatal blood (four isolates) in a case of early neonatal sepsis. Using hybrid genome assembly, we characterized the genomic features including virulence factors and antimicrobial resistance in four isolates from the same mother, placenta, and newborn.

RESULTS

Whole genome sequencing revealed that the microorganisms in the four clinical isolates corresponded to S. agalactiae sequence type 1, clonal complexes 1, and serotype Ib. Comparative genomic analysis illustrated similar DNA sequences of the four genomes.

CONCLUSIONS

This study presents the first evidence of the genomic similarity of microorganisms in the vaginal ecosystem, the space between the chorioamniotic membranes of the placenta, amniotic fluid, and neonatal blood.

Oxytocin with calcium vs oxytocin for induction of labor in women with term premature rupture of membranes: a randomized controlled trial

BACKGROUND

Intravenous calcium administration has shown promise in enhancing uterine contractions and reducing blood loss during cesarean delivery, but this regimen has not been compared in vaginal labor induction.

OBJECTIVE

This study aimed to determine the efficacy of oxytocin combined with calcium vs oxytocin alone for inducing labor in women with term premature rupture of membranes.

STUDY DESIGN

This single-blind, randomized controlled trial was conducted between October 2022 and May 2023 at a tertiary university hospital. Patients diagnosed with premature rupture of membranes were randomly allocated into 2 groups. The intervention group received a bolus of 10 mL of calcium gluconate followed by a continuous infusion of oxytocin via a pump (n=210), whereas the control group received only oxytocin infusion (n=218). The primary outcome was successful vaginal deliveries within 24 hours after labor induction. The secondary outcomes included the interval from labor induction to delivery, vaginal delivery blood loss, and maternal and neonatal complications.

RESULTS

Baseline characteristics, including maternal age, body mass index, and Bishop score before labor induction, were comparable between the groups. The rate of vaginal delivery within 24 hours after labor induction was statistically higher in the intervention group (79.52% vs 70.64%; P=.04). The participants in the intervention group experienced a shortened interval between labor induction and delivery (10.48 vs 11.25 hours; P=.037) and demonstrated a higher success rate in labor induction assessed by the onset of the active phase (93.80% vs 87.61%; P=.04) without increasing the cesarean delivery rate. Reduced hemorrhage was observed in the intervention group (242.5 vs 255.0 mL; P=.0015), and the maternal and neonatal outcomes were comparable between the groups.

CONCLUSION

The coadministration of calcium and oxytocin in labor induction among pregnancies with premature rupture of membranes was more efficient and safer than the administration of oxytocin alone. Our research suggests that the combination therapy of calcium and oxytocin may offer significant advantages during the process of labor induction and result in better outcomes. VIDEO ABSTRACT.

Influencing factors of intrapartum fever after epidural labor analgesia

OBJECTIVE

The objective of this study was to investigate factors influencing intrapartum fever in parturients receiving epidural labor analgesia.

METHODS

This study included 410 parturients who received epidural labor analgesia at the authors' hospital between February 2022 and February 2024. Participants were divided into a fever group (>37.5℃) and a control group (<37.5℃) based on their body temperature post-analgesia. General data, gestational comorbidities, and intrapartum-related conditions were compared. Influencing factors were analyzed using the chi-squared test and logistic regression.

RESULTS

Intrapartum fever occurred in 90 parturients (22.0%). Univariate analysis indicated that maternal age (p=0.046), parity (p=0.042), oxytocin use (p=0.041), and timing of analgesia (p<0.001) were associated with intrapartum fever. Multivariate analysis revealed that the timing of analgesia (OR 3.612, 95%CI 1.533-8.510) and amniotic fluid contamination degrees I (OR 1.072, 95%CI 1.012-3.082) and II (OR 2.874, 95%CI 1.901-9.092) were independent risk factors. No significant differences were found between the fever and control groups in body mass index, gestational age, gestational comorbidities, and artificial membrane rupture (p>0.05). Intrapartum fever increased the rate of neonatal fever within 2 h after birth (41.7 vs 18.6%, p<0.05) but did not significantly affect other neonatal health indicators.

CONCLUSION

Timing of analgesia and amniotic fluid contamination are significant factors influencing intrapartum fever in parturients receiving epidural labor analgesia.

Adverse obstetric outcomes in cases of meconium-stained amniotic fluid complicated with intrapartum fever

PURPOSE

Meconium-stained amniotic fluid (MSAF) often signifies colonization of the amniotic sac by microorganisms. This study investigated additional adverse obstetric outcomes associated with MSAF in deliveries complicated by maternal intrapartum fever (IF).

METHODS

This retrospective study included all singleton pregnancies from 2014 to 2020, with intrapartum maternal fever ≥ 38 °C during a trial of labor. In accordance with departmental protocol, all patients received intravenous antibiotic therapy consisting of ampicillin and gentamicin in the absence of allergies to these medications. Subsequent antibiotic therapy was adjusted based on the culture results. Antibiotic treatment was discontinued postpartum after 48 h without fever. Swab cultures were obtained immediately postpartum from both the maternal and fetal sides of the placenta. Maternal and fetal outcomes, along with positive placental cultures, were compared between participants with MSAF&IF and those with clear amniotic fluid &IF (control group).

RESULTS

In comparison to the control group (n = 1089), the MSAF&IF group (n = 264) exhibited significantly higher rates of cesarean delivery (CD) (p = 0.001), CD due to non-reassuring fetal heart rate (p = 0.001), and cord pH ≤ 7.1 (p = 0.004). Positive swab cultures from the placental maternal and fetal sides were more prevalent among the MSAF&IF group (23.1% vs. 17.6%, p = 0.041 and 29.2% vs. 22.9%, p = 0.032, respectively). Placental cultures yielding gastrointestinal pathogens and extended spectrum beta-lactamase were notably more common in the MSAF&IF group compared to controls (p = 0.023). However, there was no significant difference between groups regarding the rate of group B streptococcus positive placental cultures.

CONCLUSIONS

Women experiencing IF and MSAF during labor face an elevated risk of CD compared to those with IF alone. The presence of MSAF heightens the risk of positive placental cultures, particularly with gastrointestinal and extended spectrum beta-lactamase pathogens.

Quantitative Modeling to Characterize Maternal Inflammatory Response of Histologic Chorioamnionitis in Placental Membranes

PROBLEM

The placental membranes are a key barrier to fetal and uterine infection. Inflammation of the membranes, diagnosed as maternal inflammatory response (MIR) or alternatively as acute chorioamnionitis, is associated with adverse maternal-fetal outcomes. MIR is staged 1-3, with higher stages indicating more hazardous inflammation. However, the diagnosis relies upon subjective evaluation and has not been deeply characterized. The goal of this work is to develop a cell classifier for eight placental membrane cells and quantitatively characterize MIR1-2.

METHOD OF STUDY

Hematoxylin and eosin (H&E)-stained placental membrane slides were digitized. A convolutional neural network was trained on a dataset of hand-annotated and machine learning-identified cells. Overall cell class-level metrics were calculated. The model was applied to 20 control, 20 MIR1, and 23 MIR2 placental membrane cases. MIR cell composition and neutrophil distribution were assessed via density and Ripley's cross K-function. Clinical data were compared to neutrophil density and distribution.

RESULTS

The classification model achieved a test-set accuracy of 0.845, with high precision and recall for amniocytes, decidual cells, endothelial cells, and trophoblasts. Using this model to classify 53 073 cells from healthy and MIR1-2 placental membranes, we found that (1) MIR1-2 have higher neutrophil density and fewer decidual cells and trophoblasts, (2) Neutrophils colocalize heavily around decidual cells in healthy placental membranes and around trophoblasts in MIR1, (3) Neutrophil density impacts distribution in MIR, and (4) Neutrophil metrics correlate with features of clinical chorioamnionitis.

CONCLUSIONS

This paper introduces cell classification into the placental membranes and quantifies cell composition and neutrophil spatial distributions in MIR.

Fever in Pregnancy: A Rare Case of Listeria-Induced Chorioamnionitis

Listeriosis is a rare infection during pregnancy and may result in complications such as chorioamnionitis. Diagnosis is hardly made due to the nonspecific symptoms of listeriosis. A 27-year-old pregnant woman at 27 weeks and 3 days of gestation was admitted with a history of fever for 6 days and decreased fetal movement. Administration of broad-spectrum antibiotics initially did not improve her condition. Amniocentesis was suggestive of chorioamnionitis, and culture was positive for Listeria monocytogenes. In view of that, delivery was indicated for the safety of the mother and baby. Her case highlights the necessity of maintaining a high index of suspicion for listeriosis in pregnant patients with a history of exposure who present with fever without an evident underlying cause. Early diagnosis and management are very important for a better prognosis in such an illness. Educating pregnant women about dietary precautions and prompt medical care may prevent severe complications.

Vaginal microbiota of pregnant women with Ureaplasma urealyticum and Mycoplasma hominis infections

Background

The association between preterm birth and Mycoplasma species such as Mycoplasma hominis and Ureaplasma urealyticum has been extensively investigated. In a clinical setting, conventional diagnostic methods for them involve culture methods for Mycoplasma spp. and Ureaplasma spp., along with PCR tests. However, the clinical utility of these tests remains controversial, highlighting the necessity for more robust and reliable methods for identifying and understanding Mycoplasma infections.

Objective

This study aimed to assess the distribution of microbiota in pregnant women with Mycoplasma hominis and Ureaplasma urealyticum infection by the comparison of conventional diagnostic methods with vaginal microbial community analysis.

Study Design

This prospective case-control study involved 228 Korean pregnant women and utilized vaginal microbial community analysis, Ureaplasma/Mycoplasma culture, and 12-multiplex PCR for sexually transmitted diseases. Cross-correlation analysis in SPSS 27 compared the results of two conventional methods with vaginal microbial community analysis. R software generated box plots depicting the relative abundance of microorganisms. Network analysis was conducted using Cytoscape.

Results

Positive Ureaplasma urealyticum culture findings were observed in 60.2% of patients, with 76.4% positive for Ureaplasma parvum PCR and 13.2% positive for Ureaplasma urealyticum PCR. Mycoplasma hominis culture was positive only in two patients, while Mycoplasma hominis PCR was positive in eight women. Vaginal microbial community analysis identified significant differences in relative abundances of Gardnerella species type I and Fannyhessea vaginae between the Ureaplasma urealyticum PCR positive and negative groups. Mycoplasma hominis PCR positive patients exhibited significant differences in 11 bacterial species, including Gardnerella species I and Fannyhessea vaginae.

Conclusion

This study suggests that STD-PCR may be more accurate than Ureaplasma/Mycoplasma culture for the diagnosis of Mycoplasma hominis and Ureaplasma urealyticum infection. Also, the presence of Gardnerella species I and Fannyhessea vaginae implies their potential influences on Ureaplasma urealyticum and Mycoplasma hominis infections based on results of vaginal microbial community analysis. Therefore, vaginal microbial community analysis may give the more information of their pathophysiology.

The relation between low-grade fever during prolonged rupture of membranes (>12 hours) at term and infectious outcomes: a retrospective cohort study

BACKGROUND

Intrapartum fever (>38°C) is associated with adverse maternal and neonatal outcomes. However, the correlation between low-grade fever (37.5°C-37.9°C) and adverse perinatal outcomes remains controversial.

OBJECTIVE

This study aimed to compare maternal and neonatal outcomes of women with prolonged rupture of membranes (≥12 hours) at term between those with low-grade fever and those with normal body temperature.

STUDY DESIGN

This retrospective study included women hospitalized in a tertiary university-affiliated hospital between July 2021 and May 2023 with singleton term and rupture of membranes ≥12 hours. Women were classified as having intrapartum low-grade fever (37.5°C-37.9°C) or normal body temperature (<37.5°C). The co-primary outcomes, postpartum endometritis and neonatal intensive care unit admission rates, were compared between these groups. The secondary maternal outcomes were intrapartum leukocytosis (>15,000/mm2), cesarean delivery rate, postpartum hemorrhage, postpartum fever, surgical site infection, and postpartum length of stay. The secondary neonatal outcomes were early-onset sepsis, 5-minute Apgar score of <7, umbilical artery cord pH<7.2 and pH<7.05, neonatal intensive care unit admission length of stay, and respiratory distress. The data were analyzed according to rupture of membranes 12 to 18 hours and rupture of membranes ≥18 hours. In women with rupture of membranes ≥18 hours, intrapartum ampicillin was administered, and chorioamniotic membrane swabs were obtained. The likelihood ratios and 95% confidence intervals were calculated for the co-primary outcomes. A multivariate logistic regression model was used to predict puerperal endometritis controlled for rupture of membranes duration, low-grade fever (compared with normal body temperature), positive group B streptococcus status, mechanical cervical ripening, cervical ripening by prostaglandins, artificial rupture of membranes, meconium staining, epidural analgesia, and cesarean delivery. A multivariate logistic regression model was used to predict neonatal intensive care unit admission controlled for rupture of membranes duration, low-grade fever, positive group B streptococcus status, mechanical cervical ripening, artificial rupture of membranes, meconium staining, cesarean delivery, and neonatal weight of <2500 g.

RESULTS

This study included 687 women with rupture of membranes 12 to 18 hours and 1109 with rupture of membranes ≥18 hours. In both latency groups, the rates were higher for cesarean delivery, endometritis, surgical site infections, umbilical cord pH<7.2, neonatal intensive care unit admission, and sepsis workup among those with low-grade fever than among those with normal body temperature. Among women with low-grade fever, the positive likelihood ratios were 12.7 (95% confidence interval, 9.6-16.8) for puerperal endometritis and 3.2 (95% confidence interval, 2.0-5.3) for neonatal intensive care unit admission. Among women with rupture of membranes ≥18 hours, the rates were higher of Enterobacteriaceae isolates in chorioamniotic membrane cultures for those with low-grade fever than for those with normal intrapartum temperature (22.0% vs 11.0%, respectively; P=.006). Low-grade fever (odds ratio, 9.0; 95% confidence interval, 3.7-21.9; P<.001), artificial rupture of membranes (odds ratio, 4.2; 95% confidence interval, 1.5-11.7; P=.007), and cesarean delivery (odds ratio, 5.4; 95% confidence interval, 2.2-13.4; P<.001) were independently associated with puerperal endometritis. Low-grade fever (odds ratio, 3.2; 95% confidence interval, 1.7-6.0; P<.001) and cesarean delivery (odds ratio, 1.9; 95% confidence interval, 1.1-13.1; P=.023) were independently associated with neonatal intensive care unit admission.

CONCLUSION

In women with rupture of membranes ≥12 hours at term, higher maternal and neonatal morbidities were reported among those with low-grade fever than among those with normal body temperature. Low-grade fever was associated with a higher risk of Enterobacteriaceae isolates in chorioamniotic membrane cultures. Moreover, low-grade fever may be the initial presentation of peripartum infection.

A Single-Centre Retrospective Analysis of Pregnancies with Placenta Accreta Spectrum (PAS): From One-Step Surgery towards Two-Step Surgical Approach

Background: Placenta accreta spectrum (PAS) can be the cause of major morbidity and its optimal management is still controversial. The aim of this study was to compare the traditional one-step surgery with a two-step surgical approach in which the placenta is left in situ and the second final operation is delayed to minimise blood loss. Methods: We conducted a single-centre retrospective cohort study including all patients managed for PAS between 2007 and 2023. The number of units of red blood cells (RBCs) needed during surgery was the primary outcome used to compare these two approaches. Results: A total of 43 cases were included in this analysis. Twenty of these were managed with the delayed two-step surgical approach, whereas 23 received one-step surgery. The median estimated blood loss during surgery was 2000 mL and 2800 mL for two-step and one-step surgery, respectively (p = 0.095). In the two-step surgical approach, the median number of RBC units transfused during surgery was significantly lower (p = 0.049) and the odds ratio for needing more than four units of RBCs was 0.28 (95%-CI: 0.08-0.98, p = 0.043). A longer interval between the caesarean section and the second operation showed a trend toward lower blood loss (p = 0.065) and was associated with a significantly lower number of RBC units needed during surgery (p = 0.019). Conclusions: Two-step surgery for the treatment of PAS was safe in our cohort and could lead to a reduction in blood transfusion. Leaving the placenta in situ and delaying the final operation represents a possible alternative to traditional caesarean hysterectomy.

Exome sequencing reveals genetic heterogeneity and clinically actionable findings in children with cerebral palsy

Cerebral palsy (CP) is the most common motor disability in children. To ascertain the role of major genetic variants in the etiology of CP, we conducted exome sequencing on a large-scale cohort with clinical manifestations of CP. The study cohort comprised 505 girls and 1,073 boys. Utilizing the current gold standard in genetic diagnostics, 387 of these 1,578 children (24.5%) received genetic diagnoses. We identified 412 pathogenic and likely pathogenic (P/LP) variants across 219 genes associated with neurodevelopmental disorders, and 59 P/LP copy number variants. The genetic diagnostic rate of children with CP labeled at birth with perinatal asphyxia was higher than the rate in children without asphyxia (P = 0.0033). Also, 33 children with CP manifestations (8.5%, 33 of 387) had findings that were clinically actionable. These results highlight the need for early genetic testing in children with CP, especially those with risk factors like perinatal asphyxia, to enable evidence-based medical decision-making.

Effect of maternal hyperoxygenation on neonatal outcomes among women in labour with pathological cardiotocography: an open-label randomized controlled trial

BACKGROUND

Hyperoxygenation has shown promise in improving suspicious fetal heart patterns in women in labor. However, the effect of hyperoxygenation on neonatal outcomes in women in labor with pathologic fetal heart rate tracing has not been studied.

OBJECTIVE

This study aimed to evaluate the effect of fractional inspiration of oxygen of 80% compared with fractional inspiration of oxygen of 40% on neonatal outcomes in women with pathologic fetal heart rate tracing.

STUDY DESIGN

This randomized, open-label, parallel arm, outcome assessor-blinded clinical trial was conducted in a large tertiary care university hospital. Singleton parturients aged ≥18 years at term gestation in active labor (cervical dilatation of ≥6 cm) with pathologic fetal heart rate tracing were recruited in the study. Pathologic fetal heart rate tracing was defined according to the International Federation of Gynecology and Obstetrics 2015 guidelines. The International Federation of Gynecology and Obstetrics classifies fetal heart rate tracings into 3 categories (normal, suspicious, and pathologic) based on rate, variability, and deceleration. Women in the intervention arm received oxygen at 10 L/min via a nonrebreathing mask, and those in the usual care arm received oxygen at 6 L/min with a simple face mask. Oxygen supplementation was continued until cord clamping. The primary outcome measure was a 5-minute Apgar score. The secondary outcome measures were the proportion of neonatal intensive care unit admission, umbilical cord blood gas variables, level of methyl malondialdehyde in the cord blood, and mode of delivery.

RESULTS

Overall, 148 women (74 women in the high fractional inspiration of oxygen arm and 74 in the low fractional inspiration of oxygen arm) with pathologic fetal heart rate tracing were analyzed. The demographic data, obstetrical profiles, and comorbidities were comparable. The median 5-minute Apgar scores were 9 (interquartile range, 8-10) in the hyperoxygenation arm and 9 (interquartile range, 8-10) in the usual care arm (P=.12). Furthermore, the rate of neonatal intensive care unit admission (9.5% vs 12.2%; P=.6) and the requirement of positive pressure ventilation (6.8% vs 8.1%; P=.75) were comparable. Concerning cord blood gas parameters, the hyperoxygenation arm had a significantly higher base deficit in the umbilical vein and lactate level in the umbilical artery. The cesarean delivery rate was significantly lower in women who received hyperoxygenation (4.1% [3/74]) than in women who received normal oxygen supplementation (25.7% [19/74]) (P=.00). In addition, umbilical vein malondialdehyde level in the umbilical vein was lower in the hyperoxygenation group (8.28±4.65 μmol/L) than in the normal oxygen supplementation group (13.44±8.34 μmol/L) (P=.00).

CONCLUSION

Hyperoxygenation did not improve the neonatal Apgar score in women with pathologic fetal heart rate tracing. In addition, neonatal intensive care unit admission rate and blood gas parameters remained comparable. Therefore, the results of this trial suggest that a high fractional inspiration of oxygen supplementation confers no benefit on neonatal outcomes in women with pathologic fetal heart rate tracings and normal oxygen saturation.

Prenatal and Postnatal Disparities in Very-Preterm Infants in a Study of Infections between 2018-2023 in Southeastern US

BACKGROUND

The birthrate of Black preterm (BPT) infants is 65% higher than White preterm (WPT) infants with a BPT mortality that is 2.3 times higher. The incidence of culture-positive late-onset sepsis is as high as 41% in very-preterm infants. The main purpose of this study was to examine thermal gradients and the heart rate in relation to the onset of infection. This report presents disparities in very-preterm infection incidence, bacteria, and mortality data amongst BPT and WPT infants.

METHODS

367 preterms born at <32 weeks gestational age (GA) between 2019-2023 in five neonatal intensive care units (NICUs) were enrolled to study the onset of infections and dispositions; REDCap data were analyzed for descriptive statistics.

RESULTS

The 362 infants for analyses included 227 BPTs (63.7%) and 107 WPTs (29.6%), with 28 infants of other races/ethnicities (Hispanic, Asian, and other), 50.6% female, mean GA of 27.66 weeks, and 985.24 g birthweight. BPT infants averaged 968.56 g at birth (SD 257.50), and 27.68 (SD 2.07) weeks GA, compared to WPT infants with a mean birthweight of 1006.25 g (SD 257.77, p = 0.2313) and 27.67 (SD 2.00, p = 0.982) weeks GA. Of the 426 episodes of suspected infections evaluated across all the enrolled infants, the incidence of early-onset sepsis (EOS) was 1.9%, with BPT infants having 2.50 times higher odds of EOS than WPT infants (p = 0.4130, OR (odds ratio) = 2.50, p_or = 0.408). The overall incidence of late-onset sepsis (LOS) was 10.8%, with LOS in 11.9% of BPT infants versus 9.3% (p = 0.489, OR = 1.21, p_or = 0.637) of WPT infants. BPT infants made up 69.2% of the 39 infants with Gram-positive infections vs. 25.6% for WPT infants; 16 infants had Gram-negative culture-positive infections, with 81.2% being BPT infants versus 18.8% being WPT infants. Of the 27 urinary tract infections, 78% were in BPTs. The necrotizing enterocolitis incidence was 6.9%; the incidence in BPT infants was 7.5% vs. 6.5% in WPT infants. The overall mortality was 8.3%, with BPTs at 8.4% vs. WPT infants at 9.3%, (p = 0.6715).

CONCLUSIONS

BPTs had a higher rate of positive cultures, double the Gram-negative infections, a much higher rate of urinary tract infections, and a higher rate of mortality than their WPT counterparts. This study emphasizes the higher risk of morbidity and mortality for BPTs.

Correlation between intrapartum CTG findings and interleukin-6 levels in the umbilical cord arterial blood: A prospective cohort study

OBJECTIVE

to investigate the correlation between the intrapartum CardioTocoGraphic (CTG) findings "suggestive of fetal inflammation" ("SOFI") and the interleukin (IL)-6 level in the umbilical arterial blood.

STUDY DESIGN

prospective cohort study conducted at a tertiary maternity unit and including 447 neonates born at term.

METHODS

IL-6 levels were systematically measured at birth from a sample of blood taken from the umbilical artery. The intrapartum CTG traces were retrospectively reviewed by two experts who were blinded to the postnatal umbilical arterial IL-6 values as well as to the neonatal outcomes. The CTG traces were classified into "suggestive of fetal inflammation (SOFI)" and "no evidence of fetal inflammation (NEFI) according to the principles of physiologic interpretation the CTG traces. The CTG was classified as "SOFI" if there was a persistent fetal heart rate (FHR) increase > 10 % compared with the observed baseline FHR observed at the admission or at the onset of labor without any preceding repetitive decelerations. The occurrence of Composite Adverse Outcome (CAO) was defined as Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) admission due to one or more of the following: metabolic acidaemia, Apgar score at 5 min ≤ 7, need of neonatal resuscitation, respiratory distress, tachypnoea/polypnea, jaundice requiring phototherapy, hypotension, body temperature instability, poor perinatal adaptation, suspected or confirmed early neonatal sepsis.

MAIN OUTCOME MEASURES

To compare the umbilical IL-6 values between the cases with intrapartum CTG traces classified as "SOFI" and those classified as "NEFI"; to assess the correlation of umbilical IL-6 values with the neonatal outcome.

RESULTS

43 (9.6 %) CTG traces were categorized as "SOFI"; IL-6 levels were significantly higher in this group compared with the "NEFI" group (82.0[43.4-325.0] pg/ml vs. 14.5[6.8-32.6] pg/mL; p <.001). The mean FHR baseline assessed 1 h before delivery and the total labor length showed an independent and direct association with the IL-6 levels in the umbilical arterial blood (p <.001 and p = 0.005, respectively). CAO occurred in 33(7.4 %) cases; IL-6 yielded a good prediction of the occurrence of the CAO with an AUC of 0.72 (95 % CI 0.61-0.81).

CONCLUSION

Intrapartum CTG findings classified as "SOFI" are associated with higher levels of IL-6 in the umbilical arterial blood.

Antibiotic treatment of women with isolated intrapartum fever vs clinical chorioamnionitis: maternal and neonatal outcomes

BACKGROUND

Clinical chorioamnionitis refers to the presence of maternal fever (≥38°C) and at least 2 clinical signs: (1) maternal tachycardia (>100 bpm), (2) fetal tachycardia (>160 bpm), (3) maternal leukocytosis >15,000/mm2, (4) purulent vaginal discharge, and (5) uterine tenderness. Few data exist to guide the appropriate management of women with isolated intrapartum fever in the absence of other clinical signs suggesting chorioamnionitis.

OBJECTIVE

This study compared maternal and neonatal infectious outcomes and microbiological outcomes between women with isolated intrapartum fever and women with clinical chorioamnionitis.

STUDY DESIGN

This 10-year retrospective study included all the laboring women at our institution, at ≥34 weeks of gestation, with a singleton pregnancy and body temperature of ≥38.0°C, with or without other evidences of infection. According to our department protocol, women with isolated intrapartum fever received intravenous ampicillin, whereas women with clinical chorioamnionitis received intravenous ampicillin plus gentamicin. The primary outcome was puerperal endometritis, compared between women with isolated intrapartum fever (treated with ampicillin) and women with clinical chorioamnionitis (treated with ampicillin plus gentamicin). The secondary maternal outcomes consisted of (1) maternal clinical outcomes, such as cesarean delivery, surgical site infection, postpartum hemorrhage, and postpartum length of stay, and (2) microbiological studies, including positive chorioamniotic membrane swabs and blood culture. Among the secondary neonatal outcomes were early-onset sepsis, neonatal intensive care unit admission, and length of stay. Of note, 2 multivariate logistic regression models were created. A model aimed to predict puerperal endometritis controlled for gestational age of >41 weeks, diabetes mellitus, obesity, positive group B streptococcus status, rupture of membrane ≥18 hours, meconium staining, positive chorioamniotic membrane swabs, cesarean delivery, and empiric postdelivery antibiotic administration. A model aimed to predict neonatal early-onset sepsis controlled for gestational age of 34 to 37 weeks, positive group B streptococcus status, rupture of membrane ≥18 hours, and positive chorioamniotic membrane swabs.

RESULTS

Overall, 458 women met the inclusion criteria. Compared with women with clinical chorioamnionitis (n=231), women with isolated intrapartum fever (n=227) had higher rates of puerperal endometritis (3.9% vs 8.8%; P=.03), early-onset sepsis (0.4% vs 4.4%; P=.005), positive chorioamniotic membrane swabs (46.3% vs 63.9%; P<.001), and ampicillin-resistant Escherichia coli (35.5% vs 48.9%; P=.033). The rate of group B streptococcus-positive chorioamniotic membrane swabs was similar between the groups. In a subanalysis of women with negative or unknown group B streptococcus status, the puerperal endometritis and neonatal early-onset sepsis rates were higher among women with isolated intrapartum fever than women with suspected chorioamnionitis (8.7% vs 3.3% [P=.041] and 4.1% vs 0% [P<.001], respectively). In 2 multivariate analysis models, among women with isolated intrapartum fever treated with ampicillin compared with those with clinical chorioamnionitis treated with ampicillin and gentamicin, the odds ratio of antibiotic treatment of endometritis was 2.65 (95% confidence interval, 1.06-6.62; P=.036), and the odds ratio of neonatal early-onset sepsis was 8.33 (95% confidence interval, 1.04-60.60; P=.045).

CONCLUSION

Women with intrapartum fever, with or without other signs of infection, were at increased risk of maternal and neonatal complications. The use of ampicillin as a sole agent in isolated intrapartum fever might promote ampicillin-resistant E coli growth in the chorioamniotic membranes and consequently lead to puerperal endometritis and early-onset sepsis. In this context, a broad-range antibiotic should be considered.