Can the use of azithromycin during labour reduce the incidence of infection among puerperae and newborns? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns.

DATA SOURCES

We independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024.

METHODS

We included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity.

RESULTS

The pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55-0.77; I2, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52-0.74; I2, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24-0.78; P < .005); however, there was great heterogeneity among the studies (I2, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17-0.52; I2, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35-0.65; I2, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears.

CONCLUSION

In this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.

Intrapartum azithromycin to prevent maternal and neonatal sepsis and deaths: A systematic review with meta-analysis

OBJECTIVES

A systematic review with met-analysis was performed to summarise the evidence on the effect of intrapartum azithromycin on maternal and neonatal infections and deaths.

SEARCH STRATEGY

PubMed, Scopus and Web of Science databases were searched in March 2023.

SELECTION CRITERIA

Randomised controlled trials comparing intrapartum single-dose of azithromycin with placebo.

DATA COLLECTION AND ANALYSIS

Maternal infections, maternal mortality, neonatal sepsis, neonatal mortality. We used the random-effects Mantel-Haenszel method to calculate risk ratios (RR) with 95% confidence intervals (95% CI). We assessed risk of bias of the included studies and estimated the evidence certainty using the GRADE approach.

MAIN RESULTS

After screening 410 abstracts, five studies with 44 190 women and 44 565 neonates were included. The risk of bias was low in four and had some concerns in one of the studies. The risk of endometritis was 1.5% in the azithromycin group and 2.3% in the placebo group (RR 0.64, 95% CI 0.55-0.75), and the evidence certainty was high. The respective risk for chorioamnionitis was 0.05% and 0.1% (RR 0.50, 95% CI 0.22-1.18; evidence certainty moderate). The wound infection rate was lower in the azithromycin group (1.6%) than in the placebo group (2.5%), RR 0.52 (95% CI 0.30-0.89; moderate certainty evidence). The maternal sepsis rate was 1.1% in the azithromycin group and 1.7% in the placebo group (RR 0.66, 95% CI 0.56-0.77; evidence certainty high). Mortality rates did not show evidence of a difference (0.09% versus 0.08%; RR 1.26, 95% CI 0.65-2.42; moderate certainty evidence). The neonatal mortality rate was 0.7% in the azithromycin group and 0.8% in the placebo group (RR 0.94, 95% CI 0.76-1.16; moderate certainty evidence). The neonatal sepsis rate was 7.6% in the azithromycin group and 7.4% in the placebo group (RR 1.02, 95% CI 0.96-1.09; moderate certainty evidence).

CONCLUSIONS

Intrapartum administration of azithromycin to the mother reduces maternal postpartum infections, including sepsis. Impact on maternal mortality remains undecided. Azithromycin does not reduce neonatal sepsis or mortality rates.

Efficacy of prophylactic antibiotics for preterm premature rupture of membranes: a systematic review and network meta-analysis

OBJECTIVE

Various prophylactic antibiotic regimens are used in the management of preterm premature rupture of membranes. We investigated the efficacy and safety of these regimens in terms of maternal and neonatal outcomes.

DATA SOURCES

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to July 20, 2021.

STUDY ELIGIBILITY CRITERIA

We included randomized controlled trials involving pregnant women with preterm premature rupture of membranes before 37 weeks of gestation and a comparison of ≥2 of the following 10 antibiotic regimens: control/placebo, erythromycin, clindamycin, clindamycin plus gentamicin, penicillins, cephalosporins, co-amoxiclav, co-amoxiclav plus erythromycin, aminopenicillins plus macrolides, and cephalosporins plus macrolides.

METHODS

Two investigators independently extracted published data and assessed the risk of bias with a standard procedure following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Network meta-analysis was conducted using the random-effects model.

RESULTS

A total of 23 studies that recruited a total of 7671 pregnant women were included. Only penicillins (odds ratio, 0.46; 95% confidence interval, 0.27-0.77) had significantly superior effectiveness for maternal chorioamnionitis. Clindamycin plus gentamicin reduced the risk of clinical chorioamnionitis, with borderline significance (odds ratio, 0.16; 95% confidence interval, 0.03-1.00). By contrast, clindamycin alone increased the risk of maternal infection. For cesarean delivery, no significant differences were noted among these regimens.

CONCLUSION

Penicillins remain the recommended antibiotic regimen for reducing maternal clinical chorioamnionitis. The alternative regimen includes clindamycin plus gentamicin. Clindamycin should not be used alone.

Protection of the Ovine Fetal Gut against Ureaplasma-Induced Chorioamnionitis: A Potential Role for Plant Sterols

Chorioamnionitis, clinically most frequently associated with Ureaplasma, is linked to intestinal inflammation and subsequent gut injury. No treatment is available to prevent chorioamnionitis-driven adverse intestinal outcomes. Evidence is increasing that plant sterols possess immune-modulatory properties. Therefore, we investigated the potential therapeutic effects of plant sterols in lambs intra-amniotically (IA) exposed to Ureaplasma. Fetal lambs were IA exposed to Ureaplasma parvum (U. parvum, UP) for six days from 127 d-133 d of gestational age (GA). The plant sterols β-sitosterol and campesterol, dissolved with β-cyclodextrin (carrier), were given IA every two days from 122 d-131 d GA. Fetal circulatory cytokine levels, gut inflammation, intestinal injury, enterocyte maturation, and mucosal phospholipid and bile acid profiles were measured at 133 d GA (term 150 d). IA plant sterol administration blocked a fetal inflammatory response syndrome. Plant sterols reduced intestinal accumulation of proinflammatory phospholipids and tended to prevent mucosal myeloperoxidase-positive (MPO) cell influx, indicating an inhibition of gut inflammation. IA administration of plant sterols and carrier diminished intestinal mucosal damage, stimulated maturation of the immature epithelium, and partially prevented U. parvum-driven reduction of mucosal bile acids. In conclusion, we show that β-sitosterol and campesterol administration protected the fetus against adverse gut outcomes following UP-driven chorioamnionitis by preventing intestinal and systemic inflammation.

Maternal Glucose Supplementation in a Murine Model of Chorioamnionitis Alleviates Dysregulation of Autophagy in Fetal Brain

Fetal brain injury induced by intrauterine inflammation is a major risk factor for adverse neurological outcomes, including cerebral palsy, cognitive dysfunction, and behavioral disabilities. There are no adequate therapies for neuronal protection to reduce fetal brain injury, especially new strategies that may apply promptly and conveniently. In this study, we explored the effect of maternal glucose administration in a mouse model of intrauterine inflammation at term. Our results demonstrated that maternal glucose supplementation significantly increased survival birth rate and improved the neurobehavioral performance of pups exposed to intrauterine inflammation. Furthermore, we demonstrated that maternal glucose administration improved myelination and oligodendrocyte development in offspring exposed to intrauterine inflammation. Though the maternal blood glucose concentration was temporally prevented from decrease induced by intrauterine inflammation, the glucose concentration in fetal brain was not recovered by maternal glucose supplementation. The adenosine triphosphate (ATP) level and autophagy in fetal brain were regulated by maternal glucose supplementation, which may prevent dysregulation of cellular metabolism. Our study is the first to provide evidence for the role of maternal glucose supplementation in the cell survival of fetal brain during intrauterine inflammation and further support the possible medication with maternal glucose treatment.

Efficacy of a prospective community-based intervention to prevent preterm birth

OBJECTIVES

To evaluate a community-based intervention trial for the prevention of preterm birth.

METHODS

This trial was conducted on pregnant women in the Amakusa area, and in the Hitoyoshi-Kuma area, both in Japan. Prophylactic oral antibiotics were recommended for pregnant women with high-risk on preterm birth. The subjects were also encouraged to undergo a periodontal examination. An explanation of proper tooth brushing was given and full mouth scaling was allowed if deemed necessary.

RESULTS

Of 720 consented subjects in the Amakusa area and of 373 in the Hitoyoshi-Kuma area, bacterial vaginosis was found in 100 (13.9%) Amakusa residents and 71 (19.0%) Hitoyoshi-Kuma residents. Prophylactic antibiotics were prescribed for 93 Amakusa residents and 39 Hitoyoshi-Kuma residents. Among subjects who underwent a periodontal examination, periodontal disease was found in 47.7% of Amakusa residents and 59.7% of Hitoyoshi-Kuma residents. Periodontal health was improved among these women by a nonsurgical intervention during their pregnancy. Comparing the incidences of very low birth weight (VLBW) with the averages during the preceding 6 years in each area, the incidences of VLBW was 46.4% lower in Amakusa and 69.7% Hitoyoshi-Kuma during the study year.

CONCLUSIONS

A community-based multifaceted intervention might reduce the incidence of VLBW infants.

Interleukin-1 receptor antagonist protects against lipopolysaccharide induced diaphragm weakness in preterm lambs

Chorioamnionitis (inflammation of the fetal membranes) is strongly associated with preterm birth and in utero exposure to inflammation significantly impairs contractile function in the preterm lamb diaphragm. The fetal inflammatory response to intra-amniotic (IA) lipopolysaccharide (LPS) is orchestrated via interleukin 1 (IL-1). We aimed to determine if LPS induced contractile dysfunction in the preterm diaphragm is mediated via the IL-1 pathway. Pregnant ewes received IA injections of recombinant human IL-1 receptor antagonist (rhIL-1ra) (Anakinra; 100 mg) or saline (Sal) 3 h prior to second IA injections of LPS (4 mg) or Sal at 119d gestational age (GA). Preterm lambs were killed after delivery at 121d GA (term = 150 d). Muscle fibres dissected from the right hemi-diaphragm were mounted in an in vitro muscle test system for assessment of contractile function. The left hemi-diaphragm was snap frozen for molecular and biochemical analyses. Maximum specific force in lambs exposed to IA LPS (Sal/LPS group) was 25% lower than in control lambs (Sal/Sal group; p=0.025). LPS-induced diaphragm weakness was associated with higher plasma IL-6 protein, diaphragm IL-1β mRNA and oxidised glutathione levels. Pre-treatment with rhIL-1ra (rhIL-1ra/LPS) ameliorated the LPS-induced diaphragm weakness and blocked systemic and local inflammatory responses, but did not prevent the rise in oxidised glutathione. These findings indicate that LPS induced diaphragm dysfunction is mediated via IL-1 and occurs independently of oxidative stress. Therefore, the IL-1 pathway represents a potential therapeutic target in the management of impaired diaphragm function in preterm infants.

Outcomes and management strategies in pregnancies with early onset oligohydramnios

OBJECTIVE

To evaluate the outcomes and management options in pregnancies with early onset oligohydramnios.

MATERIALS AND METHODS

The file datas of all pregnancies diagnosed as oligohydramnios or anhydramnios before 27 gestational weeks between January 2006 and September 2013 were evaluated retrospectively. The underlying pathology and associated anomalies, karyotype analysis, the outcome of the pregnancy (either termination or labour), and gestational week at the time of diagnosis were analyzed.

RESULTS

A total of 54 pregnancies were evaluated; mean gestational week at the time of the diagnosis was 19.8 ± 4.6. Mean maternal age was 27.28 ± 6.03. Thirty-seven pregnancies were anhydramniotic, 13 fetuses had associated anomalies, five of them had multicyctic dysplastic kidney, five had bilateral renal agenesis, one had hypoplastic right heart syndrome, one had clubfoot, and one had ventricular septal defect and cleft palate. Karyotyping was normal regarding the fetuses with structural anomalies. Nineteen patients had premature preterm rupture of membranes and 39 patients had termination of pregnancy.

CONCLUSION

The prognosis of early onset oligohydramnios is poor. Main determinant is gestational week at the time of the diagnosis.

Antibiotics for meconium-stained amniotic fluid in labour for preventing maternal and neonatal infections

BACKGROUND

Chorioamnionitis is more likely to occur when meconium-stained amniotic fluid (MSAF) is present. Meconium may enhance the growth of bacteria in amniotic fluid by serving as a growth factor, inhibiting bacteriostatic properties of amniotic fluid. Many adverse neonatal outcomes related to MSAF result from meconium aspiration syndrome (MAS). MSAF is associated with both maternal and newborn infections. Antibiotics may be an effective option to reduce such morbidity.

OBJECTIVES

The objective of this review is to assess the efficacy and side effects of prophylactic antibiotics for MSAF during labour in preventing maternal and neonatal infections.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014). 

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing prophylactic antibiotics with placebo or no treatment during labour for women with MSAF.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included two studies with 362 pregnant women. Both studies compared ampicillin-sulbactam (N = 183) versus normal saline (N = 179) in pregnant women with MSAF. Prophylactic antibiotics appeared to have no statistically significant reduction in the incidence of neonatal sepsis (risk ratio (RR) 1.00, 95% CI 0.21 to 4.76), neonatal intensive care unit (NICU) admission (RR 0.83, 95% CI 0.39 to 1.78) and postpartum endometritis (RR 0.50, 95% CI 0.18 to 1.38). However, there was a significant decrease in the risk of chorioamnionitis (RR 0.36, 95% CI 0.21 to 0.62). No serious adverse effects were reported. Drug resistance, duration of mechanical ventilation and duration of admission to NICU/hospital were not reported. Most of the domains for risk of bias were at low risk of bias for one study and at unclear risk of bias for the other study. The quality of the evidence using GRADE was low for neonatal sepsis, postpartum endometritis, and neonatal mortality and morbidity prior to discharge (Neonatal intensive care admissions) and of moderate quality for chorioamnionitis.

AUTHORS' CONCLUSIONS

Current evidence indicates that compared to placebo, antibiotics for MSAF in labour may reduce chorioamnionitis. There was no evidence that antibiotics could reduce postpartum endometritis, neonatal sepsis and NICU admission. This systematic review identifies the need for more well-designed, adequately powered RCTs to assess the effect of prophylactic antibiotics in the incidence of maternal and neonatal complications.

Antibiotics for prelabour rupture of membranes at or near term

BACKGROUND

Prelabour rupture of the membranes (PROM) at or near term (defined in this review as 36 weeks' gestation or beyond) increases the risk of infection for the woman and her baby. The routine use of antibiotics for women at the time of term PROM may reduce this risk. However, due to increasing problems with bacterial resistance and the risk of maternal anaphylaxis with antibiotic use, it is important to assess the evidence addressing risks and benefits in order to ensure judicious use of antibiotics. This review was undertaken to assess the balance of risks and benefits to the mother and infant of antibiotic prophylaxis for PROM at or near term.

OBJECTIVES

To assess the effects of antibiotics administered prophylactically to women with PROM at 36 weeks' gestation or beyond, on maternal, fetal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014).

SELECTION CRITERIA

All randomised trials that compared outcomes for women and infants when antibiotics were administered prophylactically for prelabour rupture of the membranes at or near term, with outcomes for controls (placebo or no antibiotic).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed risk of bias in the included studies. Additional data were received from the investigators of included studies.

MAIN RESULTS

This update includes an additional two studies involving 1801 women, giving a total of four included studies of 2639 women. Whereas the previous version of this review showed a statistically significant reduction in endometritis with the use of antibiotics, no such effect was shown in this update (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.05 to 2.31). No differences were shown on the primary outcome measures of probable early-onset neonatal sepsis (average RR 0.69, 95%; CI 0.21 to 2.33); definite early-onset neonatal sepsis (average RR 0.57, 95% CI 0.08 to 4.26); maternal infectious morbidity (chorioamnionitis and/or endometritis) (average RR 0.48, 95% CI 0.20 to 1.15); stillbirth (RR 3.00, 95% CI 0.61 to 14.82); and perinatal mortality (RR 1.98, 95% CI 0.60 to 6.55), though the number of cases in the control group for these outcomes was low. There were no cases of neonatal mortality or serious maternal outcome in the studies assessed. Caesarean section was increased with the use of antibiotics (RR 1.33, 95% CI 1.09 to 1.61) as was duration of maternal stay in hospital (mean difference (MD) 0.06 days, 95% CI 0.01 to 0.11), largely owing to one study of 1640 women where repeat caesarean section, increased baseline hypertension and pre-eclampsia were evident in the antibiotic group, despite random allocation and allocation concealment.Subgroup analyses by timing of induction (early induction versus late induction) showed no difference in either probable or definite early-onset neonatal sepsis in the early induction group (RR 1.47, 95% CI 0.80 to 2.70 and RR 1.29, 95% CI 0.48 to 3.44, respectively) or the late induction group (RR 0.14, 95% CI 0.02 to 1.13 and RR 0.16, 95% CI 0.02 to 1.34, respectively), although there were trends toward reduced probable and definite early-onset neonatal sepsis in the late induction group. A test for subgroup differences confirmed a differential effect of the intervention on probable early-onset neonatal sepsis between the subgroups (Chi² = 4.50, df = 1 (P = 0.03), I² = 77.8%). No difference in maternal infectious morbidity (chorioamnionitis and/or endometritis) was found in either subgroup, though again there was a trend towards reduced maternal infectious morbidly in the late induction group (average RR 0.34, 95% CI 0.08 to 1.47). No differences were shown in stillbirth or perinatal mortality. The quality of the evidence for the primary outcomes using GRADE was judged to be low to very low.

AUTHORS' CONCLUSIONS

This updated review demonstrates no convincing evidence of benefit for mothers or neonates from the routine use of antibiotics for PROM at or near term. We are unable to adequately assess the risk of short- and long-term harms from the use of antibiotics due to the unavailability of data. Given the unmeasured potential adverse effects of antibiotic use, the potential for the development of resistant organisms, and the low risk of maternal infection in the control group, the routine use of antibiotics for PROM at or near term in the absence of confirmed maternal infection should be avoided.

Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial

OBJECTIVE

The decision of whether to retain or remove a previously placed cervical cerclage in women who subsequently rupture fetal membranes in a premature gestation is controversial and all studies to date are retrospective. We performed a multicenter randomized controlled trial of removal vs retention of cerclage in these patients to determine whether leaving the cerclage in place prolonged gestation and/or increased the risk of maternal or fetal infection.

STUDY DESIGN

A prospective randomized multicenter trial of 27 hospitals was performed. Patients included were those with cerclage placement at ≤23 weeks 6 days in singleton or twin pregnancies, with subsequent spontaneous rupture of membranes between 22 weeks 0 days and 32 weeks 6 days. Patients were randomized to retention or removal of cerclage. Patients were then expectantly managed and delivered only for evidence of labor, chorioamnionitis, fetal distress, or other medical or obstetrical indications. Management after 34 weeks was at the clinician's discretion.

RESULTS

The initial sample size calculation determined that a total of 142 patients should be included but after a second interim analysis, futility calculations determined that the conditional power for showing statistical significance after randomizing 142 patients for the primary outcome of prolonging pregnancy was 22.8%. Thus the study was terminated after a total of 56 subjects were randomized with complete data available for analysis, 32 to removal and 24 to retention of cerclage. There was no statistical significance in primary outcome of prolonging pregnancy by 1 week comparing the 2 groups (removal 18/32, 56.3%; retention 11/24, 45.8%) P = .59; or chorioamnionitis (removal 8/32, 25.0%; retention 10/24, 41.7%) P = .25, respectively. There was no statistical difference in composite neonatal outcomes (removal 16/33, 50%; retention 17/30, 56%), fetal/neonatal death (removal 4/33, 12%; retention 5/30, 16%); or gestational age at delivery (removal mean 200 days; retention mean 198 days).

CONCLUSION

Statistically significant differences were not seen in prolongation of latency, infection, or composite neonatal outcomes. However, there was a numerical trend in the direction of less infectious morbidity, with immediate removal of cerclage. These findings may not have met statistical significance if the original sample size of 142 was obtained, however they provide valuable data suggesting that there may be no advantage to retaining a cerclage after preterm premature rupture of membranes and a possibility of increased infection with cerclage retention.

Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV)

BACKGROUND

The incidence of chorioamnionitis occurs in between eight and 12 women for every 1000 live births and 96% of cases of chorioamnionitis are due to ascending infection. Following spontaneous vaginal delivery, 1% to 4% of women develop postpartum endometritis. The incidence of neonatal sepsis is 0.5% to 1% of all infants born. Maternal vaginal bacteria are the main agents for these infections. It is reasonable to speculate that prevention of maternal and neonatal infections might be possible by washing the vagina and cervix with an antibacterial agent for all women during labour. Chlorhexidine belongs to the class of compounds known as the bis-biguanides. Chlorhexidine has antibacterial action against a wide range of aerobic and anaerobic bacteria, including those implicated in peripartal infections.

OBJECTIVES

To evaluate the effectiveness and side effects of chlorhexidine vaginal douching during labour in reducing maternal and neonatal infections (excluding group B streptococcal and HIV).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2014), reference lists of retrieved reports and journal letters and editorials.

SELECTION CRITERIA

Randomized or quasi-randomized trials comparing chlorhexidine vaginal douching during labour with placebo or other vaginal disinfectant to prevent (reduce) maternal and neonatal infections (excluding group B streptococcal and HIV).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and quality, extracted and interpreted the data. A third review author analyzed and interpreted the data. The fourth author also interpreted the data.

MAIN RESULTS

We included three studies (3012 participants). There was no evidence of an effect of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. Although the data suggest a trend in reducing postpartum endometritis, the difference was not statistically significant (three trials, 3012 women, risk ratio 0.83; 95% confidence interval 0.61 to 1.13).Assessment of the quality of the evidence using GRADE indicated that the levels of evidence for all primary outcomes and one important secondary outcome were low to moderate.

AUTHORS' CONCLUSIONS

There is no evidence to support the use of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. There is a need for a well-designed randomized controlled trial using appropriate concentration and volume of vaginal chlorhexidine irrigation solution and with adequate sample size.

Orally administered misoprostol for induction of labor with prelabor rupture of membranes at term

Prelabor rupture of membranes (PROM) occurs in approximately 8% to 10% of women with term pregnancies. The management of PROM continues to be controversial. Approaches include expectant management and immediate induction of labor. The use of orally administered misoprostol for the management of women with PROM may provide significant advantages when they choose immediate induction of labor. This literature review presents current evidence that supports the use of oral misoprostol for women with PROM, including the benefits of a decreased interval time from PROM to vaginal birth, good safety profile, and reductions in the use of oxytocin augmentation and epidural anesthesia. In addition to clinically proven benefits to women of oral misoprostol for PROM, it also has the potential to reduce chorioamnionitis by reducing the number of sterile vaginal examinations performed thereby reducing the risk of ascending bacteria. Women have also reported acceptability and satisfaction when using oral misoprostol for immediate induction of labor. This review of literature discusses what is known about the use of orally administered misoprostol for the management of term PROM and makes recommendations for clinical use.

Significance of cervical ripening in pre-induction treatment for premature rupture of membranes at term

AIM

This study aimed to determine whether mechanical cervical dilatation with a laminaria tent in women with premature rupture of membranes (PROM) at term may influence the maternal/neonatal outcomes.

METHODS

We reviewed the medical records and histopathologic results of the placenta in 782 women with PROM at term. Of the 486 women seen prior to 2010 (group 1), 85 had Bishop scores of 5 or less and underwent insertion of laminaria tents (group A). In the 296 women admitted after 2010 (group 2), 27 had Bishop scores of 5 or less and underwent labor management without insertion of laminaria tents (group B). The patient characteristics, delivery course and neonatal outcomes were compared between the groups.

RESULTS

There were no significant differences in the maternal age, percentage of nulliparas, body mass index, gestational age at delivery or Bishop score between the groups. The Bishop score improved from 2.5 to 6.1 after laminaria tent insertion in group A. However, there were no significant intergroup differences in the frequency of use of labor-inducing agents or the time interval from PROM to delivery. The incidence of clinical/pathological chorioamnionitis was not higher in group A than in group B. No significant differences were found in the Apgar scores, umbilical artery pH or frequency of asphyxia neonatorum between the groups. Mechanical cervical dilatation by laminaria tent insertion neither increased the incidence of infection nor contributed to improvement of the perinatal prognosis.

CONCLUSION

Mechanical cervical dilatation does not provide any benefit for women with PROM at term.

Antibiotics for preterm rupture of membranes

BACKGROUND

Premature birth carries substantial neonatal morbidity and mortality. Subclinical infection is associated with preterm rupture of membranes (PROM). Prophylactic maternal antibiotic therapy might lessen infectious morbidity and delay labour, but could suppress labour without treating underlying infection.

OBJECTIVES

To evaluate the immediate and long-term effects of administering antibiotics to women with PROM before 37 weeks, on maternal infectious morbidity, neonatal morbidity and mortality, and longer-term childhood development.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013).

SELECTION CRITERIA

Randomised controlled trials comparing antibiotic administration with placebo that reported clinically relevant outcomes were included as were trials of different antibiotics. Trials in which no placebo was used were included for the outcome of perinatal death alone.

DATA COLLECTION AND ANALYSIS

We extracted data from each report without blinding of either the results or the treatments that women received. We sought unpublished data from a number of authors.

MAIN RESULTS

We included 22 trials, involving 6872 women and babies.The use of antibiotics following PROM is associated with statistically significant reductions in chorioamnionitis (average risk ratio (RR) 0.66, 95% confidence interval (CI) 0.46 to 0.96, and a reduction in the numbers of babies born within 48 hours (average RR 0.71, 95% CI 0.58 to 0.87) and seven days of randomisation (average RR 0.79, 95% CI 0.71 to 0.89). The following markers of neonatal morbidity were reduced: neonatal infection (RR 0.67, 95% CI 0.52 to 0.85), use of surfactant (RR 0.83, 95% CI 0.72 to 0.96), oxygen therapy (RR 0.88, 95% CI 0.81 to 0.96), and abnormal cerebral ultrasound scan prior to discharge from hospital (RR 0.81, 95% CI 0.68 to 0.98). Co-amoxiclav was associated with an increased risk of neonatal necrotising enterocolitis (RR 4.72, 95% CI 1.57 to 14.23).One study evaluated the children's health at seven years of age (ORACLE Children Study) and found antibiotics seemed to have little effect on the health of children.

AUTHORS' CONCLUSIONS

Routine prescription of antibiotics for women with preterm rupture of the membranes is associated with prolongation of pregnancy and improvements in a number of short-term neonatal morbidities, but no significant reduction in perinatal mortality. Despite lack of evidence of longer-term benefit in childhood, the advantages on short-term morbidities are such that we would recommend antibiotics are routinely prescribed. The antibiotic of choice is not clear but co-amoxiclav should be avoided in women due to increased risk of neonatal necrotising enterocolitis.

[Comparison of maternal and perinatal outcomes in the conservative treatment preterm premature membrane rupture between the use of erythromycin and clindamycin]

BACKGROUND

premature rupture of membranes occurs between 5 and 15% of pregnancies, of these, 10% occurs at term and preterm 2 to 3.5%.

OBJECTIVE

To compare maternal and perinatal outcomes from the use of erythromycin or clindamycin in women with preterm premature rupture of membranes with conservative treatment at the Regional General Hospital No. 36.

PATIENTS AND METHODS

comparative, prospective, randomized study conducted at the Regional General Hospital No. 36 of the Instituto Mexicano del Seguro Social, Puebla. The most common risk factors were cervical infections (55%) and urinary tract infection (55%). A history of premature rupture of membranes in pregnancy was reported in 12.5% of patients. Group A was prescribed erythromycin and group B, standard-dose clindamycin, these were the independent variables. Maternal outcomes (deciduoendometritis and chorioamnionitis) and perinatal (respiratory distress syndrome, necrotizing enterocolitis and sepsis) were the dependent variables. Fisher exact test was applied to the results of the study.

RESULTS

about perinatal outcome, sepsis was expressed more frequently in the clindamycin group (60%) compared with erythromycin (35%). The occurrence of respiratory distress syndrome was similar in both groups, 70 and 75% respectively. For necrotizing enterocolitis, 25 and 5%. Maternal alterations as chorioamnionitis occurred in 20% of patients in group A and 5% in group B. Endometritis results were similar in both groups.

CONCLUSIONS

comparing the maternal and perinatal outcomes with conservative management of premature rupture of membranes, results were better in the group treated with erythromycin. It is not possible to prove it statistically because of the sample size.

When the womb is no longer safe: chorioamnionitis

Intrauterine infections are a leading cause of preterm birth, cerebral palsy and neonatal sepsis. This article investigates current ideas about prevention, diagnosis and treatment from a midwifery point of view.

[Update on current care guidelines: preterm birth]

Prevention of preterm birth includes recognition of infections and other risk factors at outpatient clinics. If a woman presents with imminent preterm labour, 1. maternal corticosteroid prophylaxis should be administered if fewer than 35 gestational weeks have elapsed, 2. broad spectrum antibiotics should be administered if membranes have ruptured, 3. foetal distress and clinical chorioamnionitis should be ruled out, as they indicate immediate delivery. Deliveries less than 30 weeks of pregnancy should be centralised in tertiary units, since this improves the prognosis of newborns. Delivery can be postponed through tocolytic therapy, in order to enable corticosteroid prophylaxis and hospital referral.

Antibiotics for meconium-stained amniotic fluid in labour for preventing maternal and neonatal infections

BACKGROUND

Chorioamnionitis is more likely to occur when meconium-stained amniotic fluid (MSAF) is present. Meconium may enhance the growth of bacteria in amniotic fluid by serving as a growth factor, inhibiting bacteriostatic properties of amniotic fluid. Many adverse neonatal outcomes related to MSAF result from Meconium Aspiration Syndrome (MAS). MSAF is associated with both maternal and newborn infections. Antibiotics may be an effective option to reduce such morbidity.

OBJECTIVES

The objective of this review is to assess the efficacy and side effects of prophylactic antibiotics for MSAF during labour in preventing maternal and neonatal infections.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2010). 

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing prophylactic antibiotics with placebo or no treatment during labour for women with MSAF.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the results of the only available trial and extracted data on maternal and neonatal outcomes.

MAIN RESULTS

We included one study with 120 pregnant women. It compared ampicillin-salbactam (N = 60) versus normal saline (N = 60) in pregnant women with MSAF. Prophylactic antibiotics appeared to have no statistically significant reduction in the incidence of neonatal sepsis (risk ratio (RR) 1.00, 95% CI 0.21 to 4.76), neonatal intensive care unit (NICU) admission (RR 0.83, 95% CI 0.39 to 1.78) and postpartum endometritis (RR 0.50, 95% CI 0.18 to 1.38). However, significant decrease in the risk of chorioamnionitis (RR 0.29, 95% CI 0.10 to 0.82). No serious adverse effects were reported.

AUTHORS' CONCLUSIONS

Current evidence indicates that compared to placebo, antibiotics for MSAF in labour may reduce chorioamnionitis. There was no evidence that antibiotics could reduce postpartum endometritis, neonatal sepsis and NICU admission. This systematic review identifies the need for more well-designed, adequately powered RCTs to assess the effect of prophylactic antibiotics in the incidence of maternal and neonatal complications.

Antibiotics for preterm rupture of membranes

BACKGROUND

Premature birth carries substantial neonatal morbidity and mortality. Subclinical infection is associated with preterm rupture of membranes (PROM). Prophylactic maternal antibiotic therapy might lessen infectious morbidity and delay labour, but could suppress labour without treating underlying infection.

OBJECTIVES

To evaluate the immediate and long-term effects of administering antibiotics to women with PROM before 37 weeks, on maternal infectious morbidity, neonatal morbidity and mortality, and longer-term childhood development.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 April 2010).

SELECTION CRITERIA

Randomised controlled trials comparing antibiotic administration with placebo that reported clinically relevant outcomes were included as were trials of different antibiotics. Trials in which no placebo was used were included for the outcome of perinatal death alone.

DATA COLLECTION AND ANALYSIS

We extracted data from each report without blinding of either the results or the treatments that women received. We sought unpublished data from a number of authors.

MAIN RESULTS

We included 22 trials, involving 6800 women and babies.The use of antibiotics following PROM is associated with statistically significant reductions in chorioamnionitis (average risk ratio (RR) 0.66, 95% confidence interval (CI) 0.46 to 0.96, and a reduction in the numbers of babies born within 48 hours (average RR 0.71, 95% CI 0.58 to 0.87) and seven days of randomisation (average RR 0.79, 95% CI 0.71 to 0.89). The following markers of neonatal morbidity were reduced: neonatal infection (RR 0.67, 95% CI 0.52 to 0.85), use of surfactant (RR 0.83, 95% CI 0.72 to 0.96), oxygen therapy (RR 0.88, 95% CI 0.81 to 0.96), and abnormal cerebral ultrasound scan prior to discharge from hospital (RR 0.81, 95% CI 0.68 to 0.98). Co-amoxiclav was associated with an increased risk of neonatal necrotising enterocolitis (RR 4.72, 95% CI 1.57 to 14.23).One study evaluated the children's health at seven years of age (ORACLE Children Study) and found antibiotics seemed to have little effect on the health of children.

AUTHORS' CONCLUSIONS

The decision to prescribe antibiotics for women with PROM is not clearcut. Benefits in some short-term outcomes (prolongation of pregnancy, infection, less abnormal cerebral ultrasound before discharge from hospital) should be balanced against a lack of evidence of benefit for others, including perinatal mortality, and longer term outcomes. If antibiotics are prescribed it is unclear which would be the antibiotic of choice.Co-amoxiclav should be avoided in women at risk of preterm delivery due to increased risk of neonatal necrotising enterocolitis.

Bacterial vaginosis: a problematic infection from both a perinatal and neonatal perspective

Bacterial vaginosis (BV) infections are common in women of reproductive age and are easily diagnosed and treatable. Aside from being an annoyance when symptoms of discharge, odor, and pruritus occur in the gravid female, BV infections increase risk of late miscarriage, preterm labor, preterm premature rupture of membranes, and, consequently, preterm delivery. Antepartum and puerperal issues such as chorioamnionitis and endometritis are increased in the context of maternal BV. Moreover, the morbidities and mortality of preterm delivery are consequently increased as a result of BV during pregnancy. Although the pathology associated with BV appears to result from inflammation, more investigation is needed in terms of designing guidelines for appropriate screening and treatment for the prevention of adverse outcomes.

Antibiotic administration to patients with preterm premature rupture of membranes does not eradicate intra-amniotic infection

OBJECTIVE

Antibiotic administration has become part of the standard of care for patients with preterm premature rupture of membranes (PROM). Yet, the natural history of intrauterine infection/inflammation during antibiotic therapy remains largely unknown. This study was conducted to determine if antibiotic administration to the mother eradicates intra-amniotic infection and/or reduces the frequency of intra-amniotic inflammation, a risk factor for impending preterm labor/delivery and adverse neonatal outcome.

METHODS

A subset of patients with preterm PROM admitted to our institution underwent amniocenteses before and after antibiotic administration in order to guide clinical management. Amniotic fluid analysis consisted of a Gram stain, culture for aerobic and anaerobic bacteria as well as genital mycoplasmas, and amniotic fluid white blood cell (WBC) count. Microbial invasion of the amniotic cavity (MIAC) was defined as a positive amniotic fluid culture. Intra-amniotic inflammation was defined as an amniotic fluid WBC count >or=100/mm(3). Patients were given antibiotics and steroids after the 24(th) week of gestation. Antibiotic treatment consisted of ampicillin and erythromycin for 7 days for patients without evidence of intra-amniotic inflammation or MIAC, and ceftriaxone, clindamycin and erythromycin for 10-14 days for those with intra-amniotic inflammation or MIAC.

RESULTS

Forty-six patients with preterm PROM whose first amniocentesis was performed between 18 and 32 weeks (median 27.4 weeks) were included in the study. The overall prevalence of intra-amniotic inflammation in the first amniocentesis was 39% (18/46). Seven had a positive amniotic fluid culture for microorganisms. At the time of the second amniocentesis, six of the seven patients with a positive amniotic fluid culture had microorganisms. Of 18 patients with intra-amniotic inflammation at admission, only three showed no evidence of inflammation after antibiotic treatment. Among patients with no evidence of intra-amniotic inflammation at admission, 32% (9/28) developed inflammation despite therapy. Five of these nine patients had positive amniotic fluid cultures.

CONCLUSIONS

(1) Antibiotic administration (ceftriaxone, clindamycin, and erythromycin) rarely eradicates intra-amniotic infection in patients with preterm PROM; (2) intra-amniotic inflammation developed in one-third of patients who did not have inflammation at admission, despite antibiotic administration; (3) a sub-group of patients with documented inflammation of the amniotic cavity demonstrated a decrease in the intensity of the inflammatory process after antibiotic administration.

Placental malaria and mother-to-child transmission of human immunodeficiency virus-1

There are few studies of the association between placental malaria (PM) and mother-to-child transmission (MTCT) of human immunodeficiency virus-1 (HIV-1), and the results of published studies are inconsistent. To determine the association between PM and MTCT of HIV-1, we performed a secondary analysis of data from a clinical trial of antibiotics to reduce chorioamnionitis. Data regarding 1,662 HIV-1-infected women with live born singleton and first-born twin infants with information regarding PM and infant HIV-1 infection status at birth were analyzed. At the time of the study, women did not have access to antiretroviral drugs for treatment of acquired immunodeficiency syndrome but had received nevirapine prophylaxis to reduce the risk of MTCT of HIV-1. Placental malaria was not associated with the infant HIV-1 infection status at birth (P = 0.67). Adjustment for maternal plasma viral load and CD4+ cell count did not change these results (odds ratio = 1.06, 95% confidence interval = 0.51-2.20, P = 0.87). Placental malaria was more likely to be related to HIV-1 infection at birth among women with low viral load at baseline (P for interaction = 0.08). In conclusion, PM was not associated with infant HIV-1 infection status at birth. The interaction of maternal plasma viral load, PM, and MTCT of HIV-1 warrants further studies.

Evidence-based anesthesia: fever of unknown origin in parturients and neuraxial anesthesia

The safety of neuraxial analgesia in febrile patients is controversial. We performed an evidenced-based project in an effort to establish a guideline for our active obstetric clinical practice. Neuraxial anesthesia is generally safe for parturients, and complications are rare; however, serious adverse outcomes can result. Because of the devastating nature of the morbidity, the decision to proceed with a neuraxial anesthetic in the face of infection may be contentious. Fever and sepsis are considered relative contraindications to regional anesthesia; however, epidural anesthesia is a superior method of management of pain during labor. One must also consider that 30% to 40% of patients with chorioamnionitis require cesarean delivery. Because of the increased morbidity and mortality of general anesthesia in this population, it may be reasonable to proceed with regional anesthesia. Based on a review of the literature, it is difficult to estimate the risk of an infrequently occurring event. We recommend evaluation of each individual to determine the risks and benefits of the anesthetic. However, it is prudent to administer antibiotics before the regional anesthetic and adhere to strict aseptic technique. Postprocedure monitoring is essential for early detection and treatment of complications.

A retrospective review of ampicillin-sulbactam and amoxicillin + clavulanate vs cefazolin/cephalexin and erythromycin in the setting of preterm premature rupture of membranes: maternal and neonatal outcomes

OBJECTIVE

The purpose of this study was to compare the efficacy and outcomes of 2 different antibiotic regimens that are used to prolong latency in preterm premature rupture of membranes. The primary objective was to determine whether the use of ampicillin-sulbactam/amoxicillin + clavulanate was associated with an increased risk of necrotizing enterocolitis.

STUDY DESIGN

A retrospective review of pregnancies that were complicated by preterm premature rupture of membranes from 1999-2006 at 2 institutions was performed. Outcomes were compared between subjects who received parenteral ampicillin-sulbactam followed by oral amoxicillin + clavulanate (protocol A) and subjects who received parenteral cefazolin and erythromycin followed by oral cephalexin and erythromycin (protocol B).

RESULTS

There were 147 women who were evaluated; 88 women received protocol A, and 59 women received protocol B. There were no differences in latency period, gestational age at delivery, or route of delivery. The incidence of necrotizing enterocolitis was 8.0% and 10.2% for protocol A and protocol B, respectively (P = .64).

CONCLUSION

Ampicillin-sulbactam/amoxicillin + clavulanate was not associated with an increase in neonatal necrotizing enterocolitis. Erythromycin in combination with cefazolin and cephalexin is an effective latency antibiotic regimen.

A phase III clinical trial of antibiotics to reduce chorioamnionitis-related perinatal HIV-1 transmission

OBJECTIVE

A multisite study was conducted in Africa to assess the efficacy of antibiotics to reduce mother-to-child transmission (MTCT) of HIV-1.

DESIGN

A randomized, double-blinded, placebo-controlled, phase III clinical trial.

METHODS

HIV-1-infected women were randomly assigned at 20-24 weeks' gestation to receive either antibiotics (metronidazole plus erythromycin antenatally and metronidazole plus ampicillin intrapartum) or placebo. Maternal study procedures were performed at 20-24, 26-30, and 36 weeks antenatally, and at labor/delivery. Infants were seen at birth, 4-6 weeks, and 3, 6, 9 and 12 months. The primary efficacy endpoints were overall infant HIV-1 infection and HIV-1-free survival at 4-6 weeks. All women and infants received single-dose nevirapine prophylaxis in this study.

RESULTS

A total of 1510 live-born infants were included in the primary analysis. The proportions of HIV-1-infected infants at birth were similar (antibiotics 7.1%; placebo 8.3%; P = 0.41). Likewise, there were no statistically significant differences at 4-6 weeks in the overall risk of MTCT of HIV-1 (antibiotics 16.2%; placebo 15.8%; P = 0.89) or HIV-1-free survival (79.4% in each study arm). Post-randomization, the proportion of women with bacterial vaginosis at the second antenatal visit was significantly lower in the antibiotics arm compared with the placebo arm (23.8 versus 39.7%; P < 0.001), but the frequency of histological chorioamnionitis was not different (antibiotics 36.9%; placebo 39.7%; P = 0.30). Adverse events in mothers and their infants did not differ by randomization arm.

CONCLUSION

This simple antepartum and peripartum antibiotic regimen did not reduce the risk of MTCT of HIV-1.

The HPTN 024 Study: the efficacy of antibiotics to prevent chorioamnionitis and preterm birth

OBJECTIVE

The use of antibiotics to prevent preterm birth has achieved mixed results. Our goal in this study was to determine if antibiotics given prenatally and during labor reduce the incidence of preterm birth and histologic chorioamnionitis.

STUDY DESIGN

A double-blind randomized placebo-controlled trial of antibiotics to reduce preterm birth was conducted in 4 African sites. Both HIV-infected and uninfected pregnant women were given 2 courses of antibiotics, prenatally at 24 weeks (metronidazole 250 mg and erythromycin 250 mg tid orally for 7 days), and during labor (metronidazole 250 mg and ampicillin 500 mg q 4 hours) or identically appearing placebos. Two thousand ninety-eight HIV-infected and 335 HIV-uninfected women had evaluable end points, including gestational age determined by both obstetric and pediatric criteria and birth weight (BWT). Pre- and post-treatment rates of various sexually transmitted infections (STI) were determined and placentas were evaluated for histologic chorioamnionitis.

RESULTS

Comparing antibiotic versus placebo treated HIV-infected and uninfected women, there were few differences in mean gestational age at delivery, the percent of preterm births, the time between randomization and delivery, or BWT. Four weeks after the 24-week antibiotic/placebo course, bacterial vaginosis, and trichomoniasis were reduced by 49% to 61% in the antibiotic groups compared with the placebo groups. However, in both the HIV-infected and uninfected groups, the placentas showed no difference in the rate of histologic chorioamnionitis. There were significant differences between HIV-infected and uninfected women, with the former having less education, a history of more stillbirths, more STIs, and in this pregnancy, a lower BWT (2949 vs 3100 g, P < .0001).

CONCLUSION

Despite reducing the rate of vaginal infections, the antibiotic regimen used in this study did not reduce the rate of preterm birth, increase the time to delivery, or increase BWT. Failure of this regimen to reduce the rate of histologic chorioamnionitis may explain the reason the antibiotics failed to reduce preterm birth.

Chorioamnionitis and neonatal encephalopathy in term infants with fetal acidemia: histopathologic correlations

The aim of this study was to determine whether the presence or severity of histologic abnormalities of infection/inflammation such as chorioamnionitis, vasculitis, or funisitis confers an additional risk for neonatal encephalopathy in term infants delivered in the presence of severe fetal acidosis. The medical records as well as placental pathology of term infants (n = 51) born with a cord umbilical arterial pH <7.00 were reviewed. Abnormal outcome was predefined as Sarnat stage 2 or 3 neonatal encephalopathy in the first week of life or neonatal death as a consequence of severe brain injury. Consistent with prior data, the presence of severe fetal acidemia, a low 5-minute Apgar score, and need for cardiopulmonary resuscitation were significantly associated with neonatal encephalopathy. However, the presence of histologic chorioamnionitis had a poor predictive value and did not confer additional risk for the subsequent development of neonatal encephalopathy.

Vitamins C and E in the latency period in women with preterm premature rupture of membranes

OBJECTIVE

To determine whether supplementation with vitamins C and E after preterm premature rupture of membranes (PPROM) is associated with an increased latency period.

METHODS

In this double-blind, randomized, controlled trial, 60 women with singleton pregnancies of 26 to 34 weeks' duration and PPROM were randomly assigned to vitamin C (500 mg/day) and vitamin E (400 IU/day) or placebo until delivery. All women received 2 doses of betamethasone in the first 24 h after admission as well as broad-spectrum antibiotic prophylaxis.

RESULTS

Important demographic, as well as clinical characteristics such as number of cases of chorioamnionitis, early neonatal sepsis, and respiratory distress syndrome, were similar in the 2 groups. A statically significant difference in the mean+/-S.D. number of days of latency was found between the groups (10.5+/-5.2 days vs. 3.5+/-4.0 days (P = 0.03).

CONCLUSION

Vitamins C and E supplementation of after PPROM is associated with a longer latency before delivery.

Antenatal steroids may reduce adverse neurological outcome following chorioamnionitis: neurodevelopmental outcome and chorioamnionitis in premature infants

OBJECTIVE

To examine the effect of antenatal steroid exposure and in utero inflammation on the development of severe intraventricular haemorrhage, periventricular leukomalacia and long-term neurological outcome in infants less than 30 completed weeks gestation.

METHOD

Infants less than 30 completed weeks gestation from January 1996 to July 2001 were identified from a prospectively managed database. Placental pathology was reviewed for the presence or absence of chorioamnionitis and funisitis. Infants were divided into three groups depending on the degree of exposure to fetal inflammation (no inflammation, chorioamnionitis only and chorioamnionitis and funisitis). Data relating to gestational age, birthweight, sex, antenatal steroid exposure, surfactant treatment, days of positive pressure ventilation and days of oxygen requirement were collected. Cerebral ultrasound studies were examined for evidence of intraventricular or intraparenchymal echodensity and periventricular leukomalacia. Long-term neurological outcome was assessed by neurological examination for cerebral palsy and by Griffiths Mental Developmental Assessment for general developmental quotient.

RESULTS

Two hundred and twenty infants were identified. The mean gestational age was 27.7 weeks and the mean birthweight 1092 g. Seventy-two per cent of mothers had received a complete course of antenatal steroids. The risk of Grade III intraventricular haemorrhage or intraparenchymal echodensity was associated with exposure to in utero inflammation if a complete course of antenatal steroids had not been received (P = 0.002). This association did not exist if a complete course of antenatal steroids was given (P = 0.62). Fourteen infants had cerebral palsy (7%). The presence of cerebral palsy was also associated with in utero inflammation in the absence of complete antenatal steroid cover (P = 0.03) and not in the presence of complete cover (P = 0.59). The mean general developmental quotient on Griffiths Mental Developmental Assessment at 12 months or 3 years was not affected by exposure to in utero inflammation regardless of antenatal steroid exposure.

CONCLUSION

Risk of intraventricular haemorrhage or intraparenchymal echodensity and cerebral palsy was associated with in utero inflammation in the absence of a complete course of antenatal steroids. A complete course of antenatal steroids appeared to extinguish any association between in utero inflammation and adverse neurological outcome.

Outcome of neonates less than 30 weeks gestation with histologic chorioamnionitis

The purpose of this study was to determine the short-term outcome of newborns less than 30 weeks gestation when there is definite placental histologic chorioamnionitis. A retrospective analysis was performed of records of all neonates delivered at our institution from January 1989 through January 1999. This information was retrieved from our perinatal database and pathology database. The population was stratified according to the presence or absence of histologic chorioamnionitis. Statistical analysis was performed using student t-test and Mann-Whitney method. Logistic regression was used to control for potential confounding variables. There were 392 neonates less than 30 weeks gestation delivered during this time period. Complete placental histology was available for 342 patients (87.4%). Histologic chorioamnionitis was identified in 140 (40.9%) cases. Those with histologic chorioamnionitis delivered sooner (26.3 versus 27.5 weeks), were of lower birth weight (920.1 versus 1029.8 g), and had lower 5-minute Apgarscores. Neonatal septicaemia and pneumonia were strongly associated with underlying histologic chorioamnionitis. There was a significant reduction in the incidence of respiratory distress syndrome (RDS) when histologic chorioamnionitis was present. Severe histologic chorioamnionitis increases the risk of premature delivery and is strongly associated with neonatal sepsis. There is a significant reduction in the incidence of RDS and neonatal mortality.

Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV)

BACKGROUND

The incidence of chlorioamnionitis occurs in between 8 to 12 women for every 1000 live births and 96% of the cases of chlorioamnionitis are due to ascending infection. Following spontaneous vaginal delivery, 1% to 4% of women develop postpartum endometritis. The incidence of neonatal sepsis is 0.5% to 1% of all infants born. Maternal vaginal bacteria are the main agents for these infections. It is reasonable to speculate that prevention of maternal and neonatal infections might be possible by washing the vagina and cervix with an antibacterial agent for all women during labour. Chlorhexidine belongs to the class of compounds known as the bis-biguanides. Chlorhexidine has antibacterial action against a wide range of aerobic and anaerobic bacteria, including those implicated in peripartal infections.

OBJECTIVES

To evaluate the effectiveness and side-effects of chlorhexidine vaginal douching during labour in reducing maternal and neonatal infections (excluding Group B Streptococcal and HIV).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (July 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2002), MEDLINE (from 1966 to 2002), EMBASE (from 1980 to 2002), CINAHL (from 1982 to 2002) and LILACS (from 1982 to 2002).

SELECTION CRITERIA

Randomized or quasi-randomized trials comparing chlorhexidine vaginal douching during labour with placebo or other vaginal disinfectant to prevent (reduce) maternal and neonatal infections (excluding Group B Streptococcal and HIV).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality, extracted and entered the data into the RevMan software and interpreted the data. A third reviewer analysed and interpreted the data. The fourth reviewer also interpreted the data.

MAIN RESULTS

Three studies (3012 participants) were included. There was no evidence of an effect of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. Although the data suggest a trend in reducing postpartum endometritis, the difference was not statistically significant (relative risk 0.83; 95% confidence interval 0.61 to 1.13).

REVIEWERS' CONCLUSIONS

There is no evidence to support the use of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. There is a need for a well-designed randomized controlled trial using appropriate concentration and volume of vaginal chlorhexidine irrigation solution and with adequate sample size.

Antenatal corticosteroid therapy in premature infants

OBJECTIVE

The objective was to examine the effect of antenatal corticosteroid treatment on premature infants, with special attention to any possible adverse effects on neonatal outcome.

METHODS

A retrospective chart review of all singleton and multiple pregnancies delivered in our perinatal center between 1991 and 1999, who had a birth weight of < or =1,500 g and who were subsequently admitted to our neonatal intensive care unit. Three hundred and sixty-five infants were included in the study and divided into two groups. One group had a gestational age below 28 weeks (< or =196 days) and one group was 28 weeks (>196 days) onward.

RESULTS

Antenatal corticosteroid therapy reduced the duration of mechanical ventilation, the need for supplementary oxygen, and the need for exogenous surfactant in neonates born at >196 days's gestation (p<0.05). Corticosteroid treatment seemed to benefit the respiratory distress syndrome (RDS; p=0.051) in this group. There were less cases of necrotizing enterocolitis and neonatal death in the group with corticosteroid treatment (p<0.05). Before 28 weeks' gestation, all parameters that were examined (e.g., duration of mechanical ventilation, need for supplemental oxygen, need for exogenous surfactant, RDS) showed no significant differences between those pregnancies pre-treated with corticosteroids or those not treated with corticosteroids. There was no adverse effect of corticosteroids on chorioamnionitis and early onset sepsis in pregnancies with a premature rupture of the membranes. Repeated corticosteroid treatment had no effect on birth weight, but did not improve neonatal outcome either. The interval between last corticosteroid treatment and delivery had no influence on RDS. There was no effect of corticosteroids on periventricular leukomalacia and intraventricular hemorrhage. Regression analysis showed a higher risk of severe RDS in multiple gestations.

CONCLUSION

Antenatal betamethasone treatment reduces perinatal morbidity and mortality after 28 weeks' gestation. We found no adverse effects and also no benefit of repetitive corticosteroid treatment. The interval between last corticosteroid treatment and delivery did not influence the incidence of RDS. Dose, timing, and rate of antenatal corticosteroids should be reconsidered in multiple gestations.

Chorioamnionitis: a risk factor for fetal and neonatal morbidity

Despite widespread use of drugs to arrest preterm labor, there has been no decrease in the numbers of low-birth-weight or preterm infants in the last 20 years. Evidence from many sources links preterm birth to symptomatic and subclinical infections. Recently, an increasing body of evidence has suggested that not only is subclinical infection responsible for preterm birth but also for many serious neonatal sequelae, including periventricular leukomalacia, cerebral palsy, respiratory distress and even bronchopulmonary dysplasia and necrotizing enterocolitis. Proxies of intrauterine infection include clinical chorioamnionitis, histological chorioamnionitis and intraamniotic increase in cytokines, which have been found to be associated with acute neonatal morbidity and mortality and, at least to some degree, with neurological impairment, chronic lung disease and thymus involution in the preterm infant. The infectious/inflammatory mechanisms involved are not fully understood, and the types of microbes and genetic features of host adaptive and innate immune responses need to be better characterized.

Maternal epidural analgesia and rates of maternal antibiotic treatment in a low-risk nulliparous population

BACKGROUND

Epidural analgesia is associated with an increased rate of fever in prospective randomized trials. While the evidence suggests that epidural fever is not infectious, epidural analgesia has been associated with increased rates of antibiotic use, the indications that prompt treatment have not been examined.

METHODS

We analyzed 1235 nulliparous women with singleton term pregnancies presenting in labor with a temperature of < 99.5 degrees F. Antibiotic use during labor was categorized by indication.

RESULTS

A total of 59.6% of women received epidural analgesia. The rate of antibiotic use was significantly higher in women receiving epidural analgesia (28 vs 10.8%). After adjusting for confounders using logistic regression, epidural analgesia was associated with a relative risk of 2.6 (95% CI 2.0, 3.4) for antibiotic treatment. The majority of the increased risk was due to significantly higher rates of antibiotic treatment for presumed chorioamnionitis (9.0 vs 0.4%) in the epidural analgesia group.

CONCLUSION

Epidural-related fever results in excess maternal antibiotic treatment for presumed chorioamnionitis.

Chorioamnionitis and brain injury

The limited available evidence supports a strong association of chorioamnionitis with neonatal encephalopathy and CP in the term infant. The association of chorioamnionitis with depressed Apgar scores or neonatal seizures and with CP is equivocal in the preterm infant. Different study results may be related to differences in study populations, perhaps specifically to differences in susceptibility by stages of neurologic development as well as differences in gene frequencies associated with inflammation and thrombophilia. We require further understanding of the normal roles of cytokines in brain development, pregnancy, and inflammatory homeostasis before clinical interventions directed at cytokines, their receptors, or the inflammatory process are considered.

Antibiotic administration in patients with preterm premature rupture of membranes reduces the rate of histological chorioamnionitis: a prospective, randomized, controlled study

OBJECTIVE

To determine whether antibiotic administration in patients with preterm premature rupture of membranes is associated with a reduction in the rate of histological chorioamnionitis and funisitis.

METHODS

One hundred consecutive patients with preterm premature rupture of membranes and no labor between 24 and 34 weeks were invited to participate in this study. Eligible patients randomly received either clindamycin-gentamicin for 7 days or placebo, and were managed expectantly until 35 weeks unless fetal or maternal indications developed. Microbial invasion of the amniotic cavity was defined as the presence of a positive amniotic fluid culture obtained by transabdominal amniocentesis. Cervicovaginal infection was diagnosed when bacterial vaginosis or a positive culture for cervicovaginal pathogens or facultative bacteria associated with a significant increase in the white blood cell count were found. Histological chorioamnionitis was based on the observation of polymorphonuclear leukocyte infiltration of the chorionic plate or the extraplacental fetal membranes. Funisitis was diagnosed in the presence of polymorphonuclear leukocyte infiltration into the umbilical vessel walls or Wharton jelly. Statistics were performed using contingency tables.

RESULTS

Seventy-one patients with available histological study of the placenta were included. Thirty-five women received antibiotics and 36 were given placebo. Patients who received antibiotics had a significantly lower rate of histological chorioamnionitis than patients who received placebo (46% (16/35) vs. 69% (25/36), respectively; p < 0.05). This effect was more pronounced among women with microbial invasion of the amniotic cavity and/or cervicovaginal infection (58% vs. 89%, respectively; p < 0.01). Antibiotic therapy was associated with an increase in the frequency of placentas without histological abnormalities (29% vs. 6%; p < 0.01). The frequency of funisitis was not different between groups.

CONCLUSION

Administration of antibiotics in patients with preterm premature rupture of membranes is associated with a significant reduction in the incidence of histological chorioamnionitis but it does not modify the frequency of funisitis.

The Northwestern Twin Chorionicity Study: I. Discordant inflammatory findings that are related to chorionicity in presenting versus nonpresenting twins

OBJECTIVE

The purpose of this study was to evaluate the association between chorionicity and discordant chorioamnionitis and funisitis in twin gestations.

STUDY DESIGN

This was a retrospective analysis of 1156 twin placentas with a standardized diagnosis of chorionicity, chorioamnionitis, and funisitis for comparison between presenting and nonpresenting twins with dichorionic-separate, dichorionic-fused, and monochorionic placentas.

RESULTS

Frequencies of chorioamnionitis in the nonpresenting twin were significantly lower in dichorionic placentas (odds ratio, 0.4; 95% CI, 0.3, 0.6, in dichorionic-separate placentas; odds ratio, 0.5; 95% CI, 0.3, 0.8, in dichorionic-fused placentas) compared with monochorionic placentas. The frequency of advanced inflammation (ie, chorioamnionitis with funisitis) was significantly lower in the nonpresenting twin than in the presenting twin, but only in dichorionic-separate placentas (odds ratio, 0.2; 95% CI, 0.1, 0.4).

CONCLUSION

Dichorionic placentas confer significant protection against the spread of chorioamnionitis from the presenting to the nonpresenting gestational sac. In the more advanced process that involves the umbilical cord, only the subset of separate dichorionic placentas confers this protective effect against the spread of inflammation.

Indications for and questions about antenatal steroids

Antenatal glucocorticoid treatment of women at risk of preterm delivery between 24 and 34 weeks' gestation has been the standard of care since 1994. Recent information supports its use with preterm prolonged rupture of membranes, in very early gestations in which neonatal survival will be attempted, and in women with preeclampsia. Many women who deliver before 30 weeks' gestation have chronic silent chorioamnionitis, which does not seem to be a contraindication to antenatal glucocorticoid therapy. The preferred antenatal treatment is a short- and long-acting betamethasone combination given as 12-mg maternal injections at the identification of preterm labor and 24 hours later. Repeated courses of antenatal glucocorticoids given at 7- to 10-day intervals if preterm delivery does not occur are not indicated. Antenatal glucocorticoid therapy is very effective, and no adverse effects of a single treatment course have been identified.

[Sialic acid of glycoconjugates in amniotic fluid]

OBJECTIVES

Sialic acid is a negatively charged monosaccharide attached to non-reducing end of N- and O-linked carbohydrate chains of glycoconjugates. The claimed biological functions of sialic acid include its participation in cell to cell recognition and interaction as well as affecting the function of receptors by providing binding sites for ligand. Increased sialic acid concentration have been observed in several diseases e.g. malignancies, diabetes, inflammatory disorders, rheumatoid arthritis and alcoholism.

DESIGN

The aim of the present work was to determine if the amount of sialic acid attached to glycoconjugates of amniotic fluid changes during pregnancy.

MATERIALS AND METHODS

The sialic acid content in 47 samples of amniotic fluid derived from pregnant women with gestational age between 13 and 42 was studied by sialic acid specific lectins immunosorbent assay. The patient samples were divided into seven groups.

RESULTS

Time dependent changes in the degree of sialylation of glycoconjugates in amniotic fluid during pregnancy, particularly in advanced pregnancy were observed. Moreover, the highest sialic acid content on glycoconjugates in pregnancies complicated by premature rupture of membranes and is prolonged pregnancy were also detected.

CONCLUSIONS

Sialic acid content determination in amniotic fluid could be a potentially useful marker of inflammation process of amniochorion during pregnancy.

Preventing recurrent second trimester group B streptococcus chorioamnionitis by intermittent prophylactic ampicillin

BACKGROUND

Whereas carrying group B streptococcus during pregnancy is common, second trimester group B streptococcus chorioamnionitis with intact membranes is rare, and recurrence of the latter problem even more so.

CASE

A 38-year-old multipara with a history of recurrent second trimester group B streptococcus chorioamnionitis resulting in pregnancy loss was treated, beginning at 14 weeks' gestation, with monthly prophylactic ampicillin therapy throughout pregnancy and delivered a healthy male infant at term.

CONCLUSION

In women with recurrent pregnancy loss due to second trimester group B streptococcus chorioamnionitis, an intermittent prophylactic antibiotic regimen throughout pregnancy might increase the probability of successful pregnancy.

Premature rupture of the membranes: an evidence-based approach to clinical care

Management of the patient with premature rupture of membranes is a relatively common but often perplexing problem frequently faced by the obstetrician. Despite the recent advances in perinatal care, premature membrane rupture, especially in the preterm patient, remains a potentially serious complication with important maternal and fetal implications. This review will address the important questions concerning the management of premature rupture of membranes and will attempt to provide comprehensive answers as they appear in the medical literature.

Association between funisitis and elevated interleukin-6 in cord blood

OBJECTIVE

[corrected] To determine whether elevated plasma interleukin-6 (IL-6) in umbilical venous cord blood at delivery is associated with funisitis and whether IL-6 can be used to screen for funisitis in preterm neonates.

METHODS

At the time of delivery, umbilical venous cord blood samples were collected from 92 infants for whom placental pathology results were also available. Interleukin-6 concentrations in the umbilical venous cord blood plasma were measured by immunoassay. Histologic examinations of the placenta and umbilical cord were done to determine the presence or absence of funisitis and chorioamnionitis. For a power of 90% with an alpha of.05, 12 subjects were required in each group.

RESULTS

We found a significant association between the presence of histologic funisitis and elevated umbilical venous cord blood plasma IL-6 concentrations (defined as 10 pg/mL or greater). Of 15 infants whose umbilical cords showed funisitis, 93% (14 of 15) had elevated umbilical venous cord blood plasma IL-6 concentrations. Of 77 infants without funisitis, 32% (25 of 77) had elevated IL-6 concentrations in their cords (P <.001, two-sided Fisher exact test). The negative predictive value of IL-6 as a screening test for funisitis was 98%.

CONCLUSION

In preterm neonates, screening for funisitis by using the immunoassay for IL-6 appears to be valid. In the near future, elevated umbilical venous cord blood IL-6 concentrations at delivery could be clinically useful to identify children who might benefit from early treatment for systemic fetal inflammatory syndrome.

Antibiotics and preterm labor

In summary, a definite association has been demonstrated between preterm labor and genital tract infection. Conclusions regarding the true benefits of antibiotics as adjunctive therapy in treatment of preterm labor are inconsistent. Whereas some of the studies were able to demonstrate significant prolongation of pregnancy, no consistent reduction in either maternal or neonatal morbidity has been demonstrated. However, because the actual incidental morbidity rate is low in the populations studied, the power of this finding is also low. The potential risks for using antimicrobials has yet to be adequately addressed. It has been shown that bacterial resistance can develop when antibiotics are used without specific aim or when a specific bacteria is undertreated. It has been recently shown that prenatal and intrapartum antibiotic use is associated with an increased risk for antibiotic resistant neonatal sepsis if infection occurs. Because of these reasons, we discourage the administration of antibiotic treatment to women in preterm labor for the purpose of pregnancy prolongations. Treatment should be directed towards those with specific indications for treatment (e.g., intrapartum, group B streptococci prophylaxis, urinary tract infection, etc). The primary flaw in these many evaluations of preterm labor is the true incidence of preterm birth. The clinical diagnosis of preterm labor is a difficult one. Approximately one-half of those individuals with preterm contractions will not deliver until term. So, the use of antibiotics for all women in idiopathic preterm labor is destined to treat many women who are unlikely to benefit. If we were able to truly identify those who were in "true" labor, perhaps we could be more selective in determining who may benefit from antibiotics. Biochemical markers such as onco-fetal fibronectin could well-be a helpful marker. Goldberg et al evaluated FFN in vaginal and cervical secretions while attempting to better-predict who would have upper genital tract infection. In this large, multicenter trial, patients were tested for FFN every 2 weeks from 23 to 30 weeks gestation. In those patients who proceeded to deliver before 32 weeks gestation, increased levels of cervical FFN (> 50 ng/ml) were identified in approximately one-quarter. Fetal fibronectin was positive in 4% of their samples and was found to be twice as likely in one with bacterial vaginosis. They showed that the presence of increased FFN was associated with upper genital tract infection (clinical and histologic chorioamnionitis) as a main reason for preterm labor and delivery (increased risk 16-20-fold). Those with increased FFN levels were also shown to have an increased incidence of neonatal sepsis as well. Peaceman et al used FFN to attempt to identify those at risk for preterm delivery among women with contractions between 24 and 34 6/7 weeks gestation. Those with negative FFN were less likely to deliver within 7 days of the test. The negative predictive value was 99.7%, suggesting that this test may be helpful in identifying women who would not benefit from antibiotic treatment. However, if in the absence of prospective clinical trials demonstrating the efficacy of this approach, we discourage the use of FFN screening for this indication.