Candida Chorioamnionitis Leads to Preterm Birth and Adverse Fetal-Neonatal Outcome

Multimodal Management of Cervical Insufficiency Complicated by Intra-amniotic Candida albicans Infection

INTRODUCTION

Bacteria are the most common pathogens implicated in ascending infections in patients with cervical insufficiency. However, Candida albicans is a rare and serious cause of intra-amniotic infection that should be considered on the differential diagnosis. Upon diagnosis following cerclage placement, patients are generally advised to undergo immediate cerclage removal and discontinuation of the pregnancy due to the high risk of maternal and fetal morbidity. However, some patients decline and instead elect to continue the pregnancy with or without treatment. Limited data exist to guide management of these high-risk patients.

CASE PRESENTATION

 We describe a case of previable intra-amniotic C. albicans infection diagnosed following physical examination-indicated cerclage placement. The patient declined pregnancy termination and subsequently underwent systemic antifungal therapy as well as serial intra-amniotic fluconazole instillations. Fetal blood sampling confirmed transplacental transfer of maternal systemic antifungal therapy. The fetus delivered preterm and without evidence of fungemia, despite persistently positive amniotic fluid cultures.

CONCLUSION

 In a well-counseled patient with culture-proven intra-amniotic C. albicans infection declining termination of pregnancy, multimodal antifungal therapy in the form of systemic and intra-amniotic fluconazole administration may prevent subsequent fetal or neonatal fungemia and improve postnatal outcomes.

KEY POINTS

· Candida is an uncommon cause of intra-amniotic infection in the setting of cervical insufficiency.. · Multimodal antifungal therapy may prevent fetal fungemia related to intra-amniotic Candida infection.. · Fetal blood sampling confirmed transplacental passage of fluconazole after maternal administration..

Intra-amniotic Candida albicans Infection Treated With Liposomal Amphotericin B With a Successful Neonatal Outcome

Intra-amniotic infection with Candida species is an uncommon but severe condition with high fetal morbimortality and no established clinical guidelines for its management. We report a Candida albicans intra-amniotic infection diagnosed in a 25-week pregnant woman, successfully treated with high-dose liposomal amphotericin B. Pregnancy was prolonged until 30 weeks, and despite persistently positive Candida cultures in amniotic fluid, a healthy newborn was delivered without evidence of systemic infection. Amphotericin concentration was determined at birth, revealing levels over 30 times higher in mother's and cord blood than in the amniotic fluid, probably explaining the clinical protection despite failure in obtaining fungal clearance.

Composition and dynamics of intestinal fungi during the postnatal 2 months of very low birth weight infants

It has been found that intestinal fungi play a role in the composition of the intestinal microecology and in the formation and development of the immunity during childhood. We investigated the gut fungi composition of preterm infants to analysis composition and dynamics of intestinal fungi during the postnatal 2 months of very low birth weight infants. We collected feces from 34 very low birth weight infants (VLBWI) and 28 preterm infants with birth weight >1500 g. We extracted total fungal DNA from feces and analyzed the composition of gut fungus through ITS sequencing. The fungal detectable rate in the experimental group peaked on day 3 (85.19%), then gradually decreased and started to show an increasing trend again by day 28. There were significant differences in the alpha diversity of intestinal fungus between VLBWI and controls, and the VLBWI had its own characteristics at different time points in richness and diversity. A total of 10 phylums and 342 genera were identified in all VLBWI samples. The dominant fungal phylum of the VLBWI group is Ascomycota (50.3%)and Basidiomycota (48.8%). The functional metabolic activity of the experimental group was lower than that of the control group.

CONCLUSION

The composition and abundance of VLBWI intestinal fungal showed several alterations during the first 2 months of life. The prediction of gut microbiota function suggests that intestinal metabolic function may be altered in VLBWI.

WHAT IS KNOWN

• A limited number of studies has been found that symbiont fungi may be able to calibrate host immunological responses, promote development of peripheral lymphoid organs, promote T cell responses, and even may be associated with the development of certain diseases, such as inflammatory bowel disease (IBD), NEC, and allergic diseases. However, previous studies on intestinal microecology have mainly focused on adults while neglecting the role of fungi in the gut of children due to the much lower abundance of intestinal fungi than bacteria, limitations of techniques for detecting fungi, the difficulty of obtaining samples, and the absence of largescale reference databases.

WHAT IS NEW

• In recent years, the discovery and development of fungal detection technologies such as 18s rDNA sequencing technology, Internal Transcribed Spacer(ITS), and DNA fingerprinting technology have further broadened the perspective on the impact of intestinal fungal exposure in early life.

Maternal Infection and Preterm Birth: From Molecular Basis to Clinical Implications

As the leading cause of neonatal morbidity and mortality, preterm birth is recognized as a major public health concern around the world. The purpose of this review is to analyze the connection between infections and premature birth. Spontaneous preterm birth is commonly associated with intrauterine infection/inflammation. The overproduction of prostaglandins caused by the inflammation associated with an infection could lead to uterine contractions, contributing to preterm delivery. Many pathogens, particularly Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Gardnerella vaginalis, Ureaplasma urealyticum, Mycoplasma hominis, Actinomyces, Candida spp., and Streptococcus spp. have been related with premature delivery, chorioamnionitis, and sepsis of the neonate. Further research regarding the prevention of preterm delivery is required in order to develop effective preventive methods with the aim of reducing neonatal morbidity.

Vulvovaginal yeast infections, gestational diabetes and pregnancy outcome

BACKGROUND

The primary aim was to evaluate the association between gestational diabetes and blood glucose levels and vulvovaginal yeast infections in pregnancy. Secondly, we clarified the possible associations between maternal and prenatal factors, and birth outcomes and yeast infections.

METHODS

Three thousand nine hundred sixty-five pregnant women of the Kuopio Birth Cohort Study (KuBiCo) reported vulvovaginal yeast infections during pregnancy, via electronic questionnaires. Maternal and prenatal data, as well as clinical obstetric and early neonatal outcomes were registered during and after birth. The oral glucose tolerance test was performed on 3,079 women during pregnancy. Logistic regression analysis evaluated the possible multivariable associations between yeast infections, gestational diabetes and other prenatal and maternal factors.

RESULTS

No association was detected between gestational diabetes or blood glucose levels and vulvovaginal yeast infections during pregnancy. In multivariable analysis, women with yeast infections were more often multiparous, with higher education and had used more often antibiotics during pregnancy compared to others. No significant associations were detected in multivariable analysis between infections, the mode of delivery, preterm birth, birth weight or Apgar scores.

CONCLUSIONS

Women with reported vulvovaginal yeast infections managed generally well during pregnancy. They had no more gestational diabetes or higher blood glucose levels and their newborns managed equally well during early neonatal period.

Infectious and environmental placental insults: from underlying biological pathways to diagnostics and treatments

Because the placenta is bathed in maternal blood, it is exposed to infectious agents and chemicals that may be present in the mother's circulation. Such exposures, which do not necessarily equate with transmission to the fetus, may primarily cause placental injury, thereby impairing placental function. Recent research has improved our understanding of the mechanisms by which some infectious agents are transmitted to the fetus, as well as the mechanisms underlying their impact on fetal outcomes. However, less is known about the impact of placental infection on placental structure and function, or the mechanisms underlying infection-driven placental pathogenesis. Moreover, recent studies indicate that noninfectious environmental agents accumulate in the placenta, but their impacts on placental function and fetal outcomes are unknown. Critically, diagnosing placental insults during pregnancy is very difficult and currently, this is possible only through postpartum placental examination. Here, with emphasis on humans, we discuss what is known about the impact of infectious and chemical agents on placental physiology and function, particularly in the absence of maternal-fetal transmission, and highlight knowledge gaps with potential implications for diagnosis and intervention against placental pathologies.

Feto-placental Unit: From Development to Function

The placenta is an intriguing organ that allows us to survive intrauterine life. This essential organ connects both mother and fetus and plays a crucial role in maternal and fetal well-being. This chapter presents an overview of the morphological and functional aspects of human placental development. First, we describe early human placental development and the characterization of the cell types found in the human placenta. Second, the human placenta from the second trimester to the term of gestation is reviewed, focusing on the morphology and specific pathologies that affect the placenta. Finally, we focus on the placenta's primary functions, such as oxygen and nutrient transport, and their importance for placental development.

A pregnant woman with thymoma-associated pure red cell aplasia

Background

Pure red cell aplasia (PRCA) is a hematological disorder characterized by anemia with severe reticulocytopenia caused by a marked reduction in erythroid precursors in the bone marrow. PRCA is known to be associated with pregnancy, but thymoma-associated PRCA during pregnancy is very rare, and its successful management has not been reported.

Case presentation

A 37-year-old primiparous woman with severe anemia was referred to our center at 27 weeks’ gestation. She was diagnosed with PRCA based on bone aspiration findings at 33 weeks’ gestation. Magnetic resonance imaging (MRI) revealed an anterior mediastinal mass 4 cm in size suspected of being thymoma. She was therefore diagnosed with thymoma-associated PRCA during pregnancy. Surgery for thymoma was planned after delivery, since the imaging findings were suggestive of early-stage thymoma (Masaoka stage I or II). With transfusion of a total 3,360 ml of red blood cells (RBCs) during pregnancy, the patient gave birth to a baby girl weighing 2,548 g at 40 weeks’ gestation. The baby showed transient congenital cutaneous candidiasis. The placental pathology revealed subamniotic inflammation with a fungal structure. Treatment with topical anti-fungal cream immediately ameliorated the baby’s skin lesion. Maternal anemia did not improve after delivery; however, the thymoma did not increase in size. At five months after delivery, the mother underwent thymectomy with oral cyclosporine A. A pathological examination revealed Masaoka stage II-a thymoma. She completely had recovered from anemia at six months after surgery. Cyclosporine A treatment was discontinued three years after surgery. Remission has been sustained for four years since surgery.

Conclusions

A very rare case of thymoma-associated PRCA during pregnancy was diagnosed without any subjective symptoms and was expectantly managed, resulting in a good prognosis. Although bone marrow aspiration during pregnancy is an invasive test, it is important to confirm the diagnosis. Conservative management with blood transfusion was possible for early-stage thymoma-associated PRCA during pregnancy. Active surveys, including MRI, for PRCA during pregnancy led to the detection of thymoma at an early stage and the achievement of a preferable pregnancy outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05145-5.

Growing importance of urogenital candidiasis in individuals with diabetes: A narrative review

Both diabetes and fungal infections contribute significantly to the global disease burden, with increasing trends seen in most developed and developing countries during recent decades. This is reflected in urogenital infections caused by Candida species that are becoming ever more pervasive in diabetic patients, particularly those that present with unsatisfactory glycemic control. In addition, a relatively new group of anti-hyperglycemic drugs, known as sodium glucose cotransporter 2 inhibitors, has been linked with an increased risk for colonization of the urogenital region with Candida spp., which can subsequently lead to an infectious process. In this review paper, we have highlighted notable virulence factors of Candida species (with an emphasis on Candida albicans) and shown how the interplay of many pathophysiological factors can give rise to vulvovaginal candidiasis, potentially complicated with recurrences and dire pregnancy outcomes. We have also addressed an increased risk of candiduria and urinary tract infections caused by species of Candida in females and males with diabetes, further highlighting possible complications such as emphysematous cystitis as well as the risk for the development of balanitis and balanoposthitis in (primarily uncircumcised) males. With a steadily increasing global burden of diabetes, urogenital mycotic infections will undoubtedly become more prevalent in the future; hence, there is a need for an evidence-based approach from both clinical and public health perspectives.

Screening and diagnosis of women for chorioamnionitis: An integrative literature review

OBJECTIVE

This integrative literature review provides an overview of current best research evidence on the screening and diagnosis of women for chorioamnionitis, as no current review has been conducted. An overview of best practices on screening and diagnosis of women for chorioamnionitis can assist midwives with an accurate diagnosis, allowing for early referral and adequate management of this infection.

DESIGN

An integrative literature review was conducted using a systematic electronic literature search through EBSCOhost (CINAHL with Full Text, e-Book Collection, Health Source: Nursing/Academic Edition, MEDLINE, Open Dissertations and PsycINFO), Cochrane Online, PubMed, Scopus, followed by a manual search for grey literature using Google and a citation search. Guidelines, research studies, and reports in English related to chorioamnionitis from 2008 up until 2020 were included in the study.

FINDINGS

After critical appraisal, using the Joanna Briggs Institution's checklists, Evaluation Tool for Quantitative Research Studies' tool and the Appraisal of Guidelines for Research & Evaluation instrument, 31 articles were included. More than half (64%) of the literature included ranked on the three highest levels of evidence (Level I, II and III). Data extracted regarding screening and diagnosis of women for chorioamnionitis was synthesised into four themes, namely: screening by clinical signs and symptoms, screening by causative factors of chorioamnionitis, screening of obstetric history, and essential biomarkers to diagnose chorioamnionitis.

KEY CONCLUSIONS

Screening and recording of any risk factors will assist midwives in providing tailored health education to possibly prevent causative factors that could lead to chorioamnionitis. Although matrix-metalloproteinase-8 (MMP-8) seems the most suitable test to use for screening, an accurate diagnosis of chorioamnionitis requires a combination of screening methods and tests, such as clinical signs and symptoms, maternal biomarkers, amniotic fluid testing and histology. Screening for chorioamnionitis, particularly the parameters for maternal fever as a clinical symptom of chorioamnionitis, contributing factors and microbes responsible for chorioamnionitis, the usability of MMP-8 and the development of rapid, inexpensive, easy-to-use techniques for screening and diagnosis of chorioamnionitis, warrants further research.

IMPLICATIONS FOR PRACTICE

Findings can be used by midwives in the screening and diagnosis of women for chorioamnionitis which allows for early referral and adequate management before maternal and neonatal complications arise.

Infections and Pregnancy: Effects on Maternal and Child Health

Pregnancy causes physiological and immunological adaptations that allow the mother and fetus to communicate with precision in order to promote a healthy pregnancy. At the same time, these adaptations may make pregnant women more susceptible to infections, resulting in a variety of pregnancy complications; those pathogens may also be vertically transmitted to the fetus, resulting in adverse pregnancy outcomes. Even though the placenta has developed a robust microbial defense to restrict vertical microbial transmission, certain microbial pathogens have evolved mechanisms to avoid the placental barrier and cause congenital diseases. Recent mechanistic studies have begun to uncover the striking role of the maternal microbiota in pregnancy outcomes. In this review, we discuss how microbial pathogens overcome the placental barrier to cause congenital diseases. A better understanding of the placental control of fetal infection should provide new insights into future translational research.

Pattern of Antibiotic Use in the Perinatal Period in a Public University Hospital in Romania

Background and Objectives: Antibiotics are the most frequently prescribed drugs in hospitals and their prescription is increased during pregnancy and labor. There are limited data about this issue, and the safe use of antibiotics in pregnancy and antibiotic resistance remains a concern. The aim of the study is to evaluate the use of antibiotics among pregnant women attending hospital for five years. Materials and Methods: Antibiotic consumption and treatment information of patients were retrospectively collected from a hospital software program and expressed as defined daily dose (DDD) according to the World Health Organization (WHO) methodology for inpatients between 2017 and 2021. We evaluated antibiotic prescription by name, classes, and Food and Drug Administration (FDA) categories. Results: Antibiotic consumption shows a decreasing trend between 2017 and 2019, but an increasing one between 2020 and 2021. Ceftriaxone was the most prescribed antibiotic in each year, followed by cefixime, amoxicillin, metronidazole, cefuroxime, ampicillin, and ciprofloxacin. We noticed that first- and fourth-generation cephalosporins were not prescribed to these patients. A very small percentage of women in this study received antibiotics such as aminoglycosides; fluoroquinolones were generally contraindicated in the perinatal period. A large percentage of prescriptions were antibiotics classified as category B by the FDA. The most common infections that occurred in the perinatal period were those of the kidney and urinary tract in a higher number than in other studies. Conclusions: Our study shows that many classes of antibiotics used in perinatal women belong to category B antibiotics, the most prescribed being cephalosporins. Because of insufficient safety evidence and the potential for teratogenic effects on the fetus, restricted use among the category C and D antibiotic classes was seen and anticipated. Improving maternal health requires the involvement of healthcare experts in risk assessment and evaluation of existing data for appropriate antibiotic selection, dose, duration of medication, and monitoring.

Chorioamnionitis and neonatal outcomes

Chorioamnionitis or intrauterine inflammation is a frequent cause of preterm birth. Chorioamnionitis can affect almost every organ of the developing fetus. Multiple microbes have been implicated to cause chorioamnionitis, but "sterile" inflammation appears to be more common. Eradication of microorganisms has not been shown to prevent the morbidity and mortality associated with chorioamnionitis as inflammatory mediators account for continued fetal and maternal injury. Mounting evidence now supports the concept that the ensuing neonatal immune dysfunction reflects the effects of inflammation on immune programming during critical developmental windows, leading to chronic inflammatory disorders as well as vulnerability to infection after birth. A better understanding of microbiome alterations and inflammatory dysregulation may help develop better treatment strategies for infants born to mothers with chorioamnionitis.

Role of Maternal Infections and Inflammatory Responses on Craniofacial Development

Pregnancy is a tightly regulated immunological state. Mild environmental perturbations can affect the developing fetus significantly. Infections can elicit severe immunological cascades in the mother's body as well as the developing fetus. Maternal infections and resulting inflammatory responses can mediate epigenetic changes in the fetal genome, depending on the developmental stage. The craniofacial development begins at the early stages of embryogenesis. In this review, we will discuss the immunology of pregnancy and its responsive mechanisms on maternal infections. Further, we will also discuss the epigenetic effects of pathogens, their metabolites and resulting inflammatory responses on the fetus with a special focus on craniofacial development. Understanding the pathophysiological mechanisms of infections and dysregulated inflammatory responses during prenatal development could provide better insights into the origins of craniofacial birth defects.

Candida Chorioamnionitis in Mothers with Gestational Diabetes Mellitus: A Report of Two Cases

Background:Candida chorioamnionitis is rarely encountered, even though vulvovaginal candidiasis incidence is about 15%. Interestingly, it has characteristic gross and histological findings on the umbilical cord that are not to be missed. Case Report: We report two cases of Candida chorioamnionitis with presence of multiple yellowish and red spots of the surface of the umbilical cord. Microscopically, these consist of microabscesses with evidence of fungal yeasts and pseudohyphae. The yeasts and pseudohyphae were highlighted by periodic acid– Schiff and Grocott methenamine silver histochemical stains. Both cases were associated with a history of gestational diabetes mellitus. Discussion: Peripheral funisitis is a characteristic feature of Candida chorioamnionitis. It is associated with high risk of adverse perinatal and neonatal outcomes, such as preterm delivery, stillbirth and neonatal death. We recommend careful examination of the umbilical cord of mothers with gestational diabetes mellitus.

The promise of placental extracellular vesicles: models and challenges for diagnosing placental dysfunction in utero†

Monitoring the health of a pregnancy is of utmost importance to both the fetus and the mother. The diagnosis of pregnancy complications typically occurs after the manifestation of symptoms, and limited preventative measures or effective treatments are available. Traditionally, pregnancy health is evaluated by analyzing maternal serum hormone levels, genetic testing, ultrasonographic imaging, and monitoring maternal symptoms. However, researchers have reported a difference in extracellular vesicle (EV) quantity and cargo between healthy and at-risk pregnancies. Thus, placental EVs (PEVs) may help to understand normal and aberrant placental development, monitor pregnancy health in terms of developing placental pathologies, and assess the impact of environmental influences, such as infection, on pregnancy. The diagnostic potential of PEVs could allow for earlier detection of pregnancy complications via noninvasive sampling and frequent monitoring. Understanding how PEVs serve as a means of communication with maternal cells and recognizing their potential utility as a readout of placental health have sparked a growing interest in basic and translational research. However, to date, PEV research with animal models lags behind human studies. The strength of animal pregnancy models is that they can be used to assess placental pathologies in conjunction with isolation of PEVs from fluid samples at different time points throughout gestation. Assessing PEV cargo in animals within normal and complicated pregnancies will accelerate the translation of PEV analysis into the clinic for potential use in prognostics. We propose that appropriate animal models of human pregnancy complications must be established in the PEV field.

Maternal-Fetal Inflammation in the Placenta and the Developmental Origins of Health and Disease

Events in fetal life impact long-term health outcomes. The placenta is the first organ to form and is the site of juxtaposition between the maternal and fetal circulations. Most diseases of pregnancy are caused by, impact, or are reflected in the placenta. The purpose of this review is to describe the main inflammatory processes in the placenta, discuss their immunology, and relate their short- and long-term disease associations. Acute placental inflammation (API), including maternal and fetal inflammatory responses corresponds to the clinical diagnosis of chorioamnionitis and is associated with respiratory and neurodevelopmental diseases. The chronic placental inflammatory pathologies (CPI), include chronic villitis of unknown etiology, chronic deciduitis, chronic chorionitis, eosinophilic T-cell vasculitis, and chronic histiocytic intervillositis. These diseases are less-well studied, but have complex immunology and show mechanistic impacts on the fetal immune system. Overall, much work remains to be done in describing the long-term impacts of placental inflammation on offspring health.

Placental macrophages: Origin, heterogeneity, function and role in pregnancy-associated infections

Placental macrophages are a heterogenous population of immune cells present throughout pregnancy. They are essential for maintenance of the homeostatic placenta environment and host defense against infections. The characterization of placental macrophages as well as their activation have been limited for a long time by the lack of convenient tools. The emergence of unbiased methods makes it possible to reappraise the study of placental macrophages. In this review, we discuss the diversity and the functions of placental macrophages to better understand their dysfunctions during placental infections.

Early- and Late-Respiratory Outcome in Very Low Birth Weight with or without Intrauterine Inflammation

• IUI is a risk factor for spontaneous preterm birth and contributes to prematurity-associated mortality and morbidity.• HCA greatly affected Apgar's score and lung management of VLBWI at birth and later on with increased incidence of BPD.• HCA + FUN did not significantly impact on respiratory outcome.

OBJECTIVE

Intrauterine inflammation or infection (IUI) is a risk factor for spontaneous preterm birth and contributes to prematurity-associated mortality and morbidity. IUI can include inflammation, as well as infections of varying degrees of severity and duration. Histological chorioamnionitis (HCA) remains the "gold standard" for the diagnosis but clinical, microbiological, and biochemical criteria are often used to define chorioamnionitis. The impact of intrauterine inflammation on respiratory outcome, in infants with very low birth weight, is still unclear and previous data are conflicting showing increase, decrease, or no risk of respiratory complications.

STUDY DESIGN

This is a retrospective study aimed to investigate the role of IUI on neonatal respiratory outcome. Histological criteria (HCA alone and HCA + funisitis [FUN]) and "intrauterine inflammation or infection or both" "Triple I" definition were used; different management in delivery room, in the first 7 days of life (early outcome) and incidence of mild, moderate, and severe bronchopulmonary dysplasia (BPD; late outcome) were considered.

RESULTS

A total of 162 infants with very low birth weight (VLBW) with placenta histology were enrolled. Suspected TRIPLE or fever alone was present in 7.4%, and confirmed TRIPLE or HCA in 29.6% of cases (HCA alone 19.1% vs. HCA + FUN 10.5%). Preterm premature rupture of membrane (p-PROM) was strongly associated with HCA (66.6% in HCA group) and HCA was present in 80% neonates born between 22 and 24 weeks of gestational age (GA). HCA group (GA, 26 weeks; birth weight [BW], 880 g) showed lower Apgar's score, higher intubation rate, and need of ventilation in delivery room, surfactant, duration of noninvasive ventilation (NIV), severe patent ductus arteriosus (PDA), and incidence of BPD compared with no-HCA (GA, 30 weeks; BW, 1,210 g). Length of hospital stay and mortality were higher in HCA group (p = 0.01) and an increasing trend was present for HCA + FUN compared with HCA alone.

CONCLUSION

HCA greatly affected Apgar's score and lung management of VLBW infants (VLBWI) at birth and later on with increased incidence of BPD, thus impacting length of stay and quality of life, while HCA + FUN did not significantly impact on respiratory outcome. Further studies are needed to clarify the role of HCA and FUN in VLBW neonates.

Candida chorioamnionitis associated with late stillbirth: A case report

Vulvovaginal candidiasis during pregnancy is common, but serious complications, including chorioamnionitis, are infrequent. A 41-year-old woman presented at 37 weeks of gestation with reduced fetal movements, and fetal death in utero was subsequently confirmed on ultrasound. Histopathology of the cord and placenta revealed Candida infection and microabscesses on the umbilical cord. Overall, these features are suggestive of ascending infection, consistent with Candida as the causative organism. To the best of our knowledge, this is the first reported case of late stillbirth due to Candida chorioamnionitis. More research is needed to determine the mechanism whereby Candida becomes pathogenic in pregnancy. There is also no clear consensus on how to manage such patients in a subsequent pregnancy.

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Vulvovaginal candidiasis during pregnancy is common, but serious complications, including chorioamnionitis, are infrequent.

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This case describes stillbirth caused by Candida chorioamnionitis.

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Risk factors identified in this case include gestational diabetes mellitus, recent antibiotic use and vaginal douching.

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More research is needed to determine the mechanism whereby Candida becomes pathogenic in pregnancy.

Associations between the vaginal microbiome and Candida colonization in women of reproductive age

BACKGROUND

The composition of bacteria within the vaginal microbiome has garnered a lot of recent attention and has been associated with reproductive health and disease. Despite the common occurrence of yeast (primarily Candida) within the vaginal microbiome, there is still an incomplete picture of relationships between yeast and bacteria (especially lactobacilli), as well as how such associations are governed. Such relationships could be important to a more holistic understanding of the vaginal microbiome and its connection to reproductive health.

OBJECTIVE

The objective of the study was to perform molecular characterization of clinical specimens to define associations between vaginal bacteria (especially Lactobacillus species) and Candida colonization. In vitro studies were conducted to test the 2 most common dominant Lactobacillus species (Lactobacillus crispatus and Lactobacillus iners) in their ability to inhibit Candida growth and to examine the basis for such inhibition.

STUDY DESIGN

A nested cross-sectional study of reproductive-age women from the Contraceptive CHOICE Project was conducted. Vaginal swabs from 299 women were selected to balance race and bacterial vaginosis status, resulting in a similar representation of black and white women in each of the 3 Nugent score categories (normal [0-3], intermediate [4-6], and bacterial vaginosis [7-10]). Sequencing of the 16S ribosomal gene (V4 region) was used to determine the dominant Lactobacillus species present (primarily Lactobacillus iners and Lactobacillus crispatus), defined as >50% of the community. Subjects without dominance by a single Lactobacillus species were classified as Diverse. A Candida-specific quantitative polymerase chain reaction targeting the internally transcribed spacer 1 was validated using vaginal samples collected from a second cohort of women and used to assess Candida colonization. Two hundred fifty-five nonpregnant women with sufficient bacterial biomass for analysis were included in the final analysis. Generalized linear models were used to evaluate associations between Lactobacillus dominance, sociodemographic and risk characteristics, and vaginal Candida colonization. In separate in vitro studies, the potential of cell-free supernatants from Lactobacillus crispatus and Lactobacillus iners cultures to inhibit Candida growth was evaluated.

RESULTS

Forty-two women (16%) were vaginally colonized with Candida. Microbiomes characterized as Diverse (38%), Lactobacillus iners-dominant (39%), and Lactobacillus crispatus-dominant (20%) were the most common. The microbiome, race, and Candida colonization co-varied with a higher prevalence of Candida among black women and Lactobacillus iners-dominant communities compared with white women and Lactobacillus crispatus-dominant communities. Lactobacillus iners-dominant communities were more likely to harbor Candida than Lactobacillus crispatus-dominant communities (odds ratio, 2.85, 95% confidence interval, 1.03-7.21; Fisher exact test, P = .048). In vitro, Lactobacillus crispatus produced greater concentrations of lactic acid and exhibited significantly more pH-dependent growth inhibition of Candida albicans, suggesting a potential mechanism for the clinical observations.

CONCLUSION

In nonpregnant women, Lactobacillus iners-dominant communities were significantly more likely to harbor Candida than Lactobacillus crispatus-dominant communities, suggesting that Lactobacillus species have different relationships with Candida. In vitro experiments indicate that Lactobacillus crispatus may impede Candida colonization more effectively than Lactobacillus iners through a greater production of lactic acid.

Immunobiology of Acute Chorioamnionitis

Acute chorioamnionitis is characterized by neutrophilic infiltration and inflammation at the maternal fetal interface. It is a relatively common complication of pregnancy and can have devastating consequences including preterm labor, maternal infections, fetal infection/inflammation, fetal lung, brain, and gastrointestinal tract injury. In this review, we will discuss current understanding of the pathogenesis, immunobiology, and mechanisms of this condition. Most commonly, acute chorioamnionitis is a result of ascending infection with relatively low-virulence organisms such as the Ureaplasma species. Furthermore, recent vaginal microbiome studies suggest that there is a link between vaginal dysbiosis, vaginal inflammation, and ascending infection. Although less common, microorganisms invading the maternal-fetal interface via hematogenous route (e.g., Zika virus, Cytomegalovirus, and Listeria) can cause placental villitis and severe fetal inflammation and injury. We will provide an overview of the knowledge gleaned from different animal models of acute chorioamnionitis and the role of different immune cells in different maternal-fetal compartments. Lastly, we will discuss how infectious agents can break the maternal tolerance of fetal allograft during pregnancy and highlight the novel future therapeutic approaches.

Characteristics and influence of Mycoplasma/Ureaplasma cultures in amniotic fluid on perinatal outcomes

AIM

To investigate the effects of Mycoplasma/Ureaplasma cultured in amniotic fluid on perinatal characteristics in preterm delivery between 22 and 33 weeks of gestation.

METHODS

The study was conducted in a tertiary perinatal center and involved 38 pregnant women who had undergone amniocentesis to evaluate intrauterine infection due to preterm labor or premature rupture of membranes. The subjects were divided into three groups based on the culture results: negative (Negative Group, n = 24), positive for Mycoplasma/Ureaplasma (M/U Group, n = 6), and positive for other pathogens (Other Pathogens Group, n = 8). One-way analysis of variance was used to compare the three groups.

RESULTS

The incidence of histological chorioamnionitis and neonatal sepsis was significantly different among the three groups (the Negative Group and the Other Pathogens Group, P < 0.01; the M/U Group and the Other Pathogens Group, P = 0.03). In the M/U Group, no infants had sepsis, severe intraventricular hemorrhage, cystic periventricular leukomalacia, or poor neurological outcomes, but one infant developed bronchopulmonary dysplasia and needed home oxygen treatment. Although one died of gastrorrhexis, the remaining five patients had normal brain magnetic resonance imaging findings and developed normally.

CONCLUSION

The presence of Mycoplasma/Ureaplasma isolated from amniotic fluid did not cause neonatal sepsis or poor prognosis. In some infants, there was no histological chorioamnionitis in the placenta. These pathogens thus seem to be less invasive than any other microbes with respect to perinatal outcomes.

Fungi form interkingdom microbial communities in the primordial human gut that develop with gestational age

Fungal and bacterial commensal organisms play a complex role in the health of the human host. Expansion of commensal ecology after birth is a critical period in human immune development. However, the initial fungal colonization of the primordial gut remains undescribed. To investigate primordial fungal ecology, we performed amplicon sequencing and culture-based techniques of first-pass meconium, which forms in the intestine prior to birth, from a prospective observational cohort of term and preterm newborns. Here, we describe fungal ecologies in the primordial gut that develop complexity with advancing gestational age at birth. Our findings suggest homeostasis of fungal commensals may represent an important aspect of human biology present even before birth. Unlike bacterial communities that gradually develop complexity, the domination of the fungal communities of some preterm infants by Saccromycetes, specifically Candida, may suggest a pathologic association with preterm birth.-Willis, K. A., Purvis, J. H., Myers, E. D., Aziz, M. M., Karabayir, I., Gomes, C. K., Peters, B. M., Akbilgic, O., Talati, A. J., Pierre, J. F. Fungi form interkingdom microbial communities in the primordial human gut that develop with gestational age.

A routine urine test has partial predictive value in premature rupture of the membranes

OBJECTIVE

This study aimed to examine the predictive value of a routine urine test for premature rupture of the fetal membranes.

METHODS

Routine urine test data of 100 patients with preterm premature rupture of the membranes (PPROM) and 100 patients with full-term premature rupture of the membranes (PROM) were collected by the case-based method. Additionally, 100 healthy pregnant women and 100 nonpregnant adult healthy women were selected as the negative control group and blank control group, respectively. A receiver operating characteristic curve was established after identifying the different parameters.

RESULTS

We found that occult blood, glucose, ketone bodies, urine specific gravity, red blood cell count, epithelial cell count, bacteria, yeast, crystals, and electrical conductivity were significantly different between the PPROM and PROM groups. There were significant differences in occult blood, protein, glucose, ketone bodies, pH, red blood cell count, bacteria, urine specific gravity, crystals, and electrical conductivity between the PPROM and full-term groups. Receiver operating characteristic curve analysis showed that when the cut-off for bacteria was 130.15, it had the largest area under the curve value of 0.696.

CONCLUSION

A routine urine test, especially for bacterial counts, has certain predictive value for PROM.