Chorioamnionitis and Cerebral Palsy: A Meta-Analysis

Neuroimaging findings associated with the fetal inflammatory response syndrome

The fetal inflammatory response syndrome (FIRS) is a condition whereby the fetus mounts an inflammatory response to intrauterine infection/inflammation. Clinical consequences include preterm premature rupture of membranes (PPROM), spontaneous preterm delivery, neonatal sepsis, bronchopulmonary dysplasia, and brain and other organ injury. Mechanisms leading to brain injury in FIRS have been investigated in animal and human studies. We review the neuroimaging findings of brain injury in FIRS, which overlap those of hypoxic-ischemic injury, and clinical correlation is necessary for a correct diagnosis. FIRS should be considered the primary diagnosis when neuroimaging findings such as periventricular leukomalacia are identified in preterm children born as a consequence of PPROM and spontaneous preterm labor. Additionally, FIRS should be considered in term infants who do not have the most common features of HIE (e.g. a sentinel event). Systematic histopathologic examination of the placenta and umbilical cord and/or detection of characteristic inflammatory markers in such cases are needed to establish the correct diagnosis.

Utility of Doppler ultrasound in early-onset neonatal sepsis

Background:

Neonatal sepsis is an important cause of morbidity and mortality among newborns. As there is paucity of literature regarding early alteration of the cerebral blood flow (CBF) in neonatal sepsis our study aims to evaluate the changes in the CBF velocities and Doppler indices in neonates with early-onset neonatal sepsis (EONS) and to evaluate the predictive accuracy of cerebral blood flow velocities (CBFV) by using ultrasound Doppler as a diagnostic marker of EONS.

Methods:

This cross-sectional analytical study was conducted over a period of 2 years with 123 neonates enrolled in the study. The neonates were divided into two groups: Group I (with 54 neonates) - neonates with EONS and group II (with 69 neonates) - age-matched neonates without any signs of sepsis. Ultrasound Doppler examination was performed and the cerebral hemodynamics assessed in neonates during the first seventy two hours of life. Doppler indices and CBFV were measured in the internal carotid artery (ICA), middle cerebral artery (MCA), and vertebral artery (VA) of either side. Data were analyzed using the statistical program SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated at different selected cutoff values for CBFV parameters.

Results:

Lower resistance and higher peak systolic velocity and end diastolic velocity have been documented in neonates with EONS.

Conclusion:

Our study shows that the cerebral hemodynamics in neonates with EONS is altered which can be assessed bedside by noninvasive ultrasound Doppler examination.

Prenatal inflammation is associated with adverse neonatal outcomes

OBJECTIVE

The purpose of this study was to determine whether prenatal inflammation (as assessed by clinical chorioamnionitis, maternal temperature >38°C, or histologic chorioamnionitis) is associated with a composite adverse neonatal outcome.

STUDY DESIGN

We performed a prospective cohort study of women at 22 weeks to 33 weeks 6 days' gestation with symptoms of labor (April 2009 to March 2012). Relevant maternal and neonatal exposures and outcomes were recorded. Multivariable logistic regression was performed to determine the association between prenatal inflammation and neonatal outcomes that were controlled for potential confounders.

RESULTS

We analyzed 871 mother-infant pairs. The preterm birth rate was 42.0%. When we controlled for infant sex and modified the data by gestational age at delivery, prenatal inflammation remains a significant risk factor for adverse neonatal outcomes, despite advancing gestational age: clinical chorioamnionitis at 32 weeks' gestation (odds ratio [OR], 3.12; 95% confidence interval [CI], 1.02-9.52], at 36 weeks' gestation (OR, 8.88; 95% CI, 4.32-18.25), and at 40 weeks' gestation (OR, 25.30; 95% CI, 9.25-69.19); maternal temperature >38°C at 32 weeks' gestation (OR, 3.18; 95% CI, 0.66-15.42), at 36 weeks gestation (OR, 8.40; 95% CI, 3.60-19.61), and at 40 weeks gestation (OR, 22.19; 95% CI, 8.15-60.44); histologic chorioamnionitis at 32 weeks gestation (OR, 1.25; 95% CI, 0.64-2.46), at 36 weeks gestation (OR, 2.56; 95% CI, 1.54-4.23), and at 40 weeks gestation (OR, 5.23; 95% CI, 1.95-13.99).

CONCLUSION

The protective association with advancing gestational age is diminished when prenatal inflammation is present.

Risk of cerebral palsy and childhood epilepsy related to infections before or during pregnancy

BACKGROUND AND AIM

Maternal infections during pregnancy have been associated with several neurological disorders in the offspring. However, given the lack of specificity for both the exposures and the outcomes, other factors related to infection such as impaired maternal immune function may be involved in the causal pathway. If impaired maternal immune function plays a role, we would expect infection before pregnancy to be associated with these neurological outcomes.

METHODS/PRINCIPAL FINDINGS

The study population included all first-born singletons in Denmark between January 1 1982 and December 31 2004. We identified women who had hospital-recorded infections within the 5 year period before pregnancy, and women who had hospital-recorded infections during pregnancy. We grouped infections into either infections of the genitourinary system, or any other infections. Cox models were used to estimate adjusted hazard ratios (aHRs) with 95% confidence interval (CI). Maternal infection of the genitourinary system during pregnancy was associated with an increased risk of cerebral palsy (aHR = 1.63, 95% CI: 1.34-1.98) and epilepsy (aHR = 1.27, 95% CI: 1.13-1.42) in the children, compared to children of women without infections during pregnancy. Among women without hospital-recorded infections during pregnancy, maternal infection before pregnancy was associated with an increased risk of epilepsy (aHR = 1.35, 95% CI: 1.21-1.50 for infections of the genitourinary system, and HR = 1.12, 95% CI: 1.03-1.22 for any other infections) and a slightly higher risk of cerebral palsy (aHR = 1.20, 95% CI: 0.96-1.49 for infections of the genitourinary system, and HR = 1.23, 95% CI: 1.06-1.43 for any other infections) in the children, compared to children of women without infections before (and during) pregnancy.

CONCLUSIONS

These findings indicate that the maternal immune system, maternal infections, or factors related to maternal immune function play a role in the observed associations between maternal infections before pregnancy and cerebral diseases in the offspring.

Histological chorioamnionitis is associated with cerebral palsy in preterm neonates

OBJECTIVE

To determine the interaction between histological chorioamnionitis and unexplained neonatal cerebral palsy among low birth weight infants.

STUDY DESIGN

We studied 141 preterm infants below 1500 g delivered between 2000 and 2010. Clinical data, neonatal neuroimaging, laboratory results, the histopathological features of the placenta and gastric smear within the first hour of delivery, were evaluated.

RESULTS

Cerebral palsy was detected in 11 out of 141 preterm newborns (7.8%). The incidence of silent histological chorioamnionitis was 33.6% (43 of 128 cases). Chorioamniontis was significantly associated with the risk of unexplained cerebral palsy (p=0.024). There were also significant correlations between maternal genital infections and chorioamnionitis (p=0.005), and between maternal infections and a positive smear of neonatal gastric aspirates (p=0.000). The rate of cesarean section was 67.4% (95 out of 141 deliveries), and elective cesarean section was performed in 68 cases.

CONCLUSION

Intrauterine exposure to maternal infection was associated with a marked increase in the risk of cerebral palsy in preterm infants.