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Chorioamnionitis

Original Editor - Rana Muhammad Tahir Aslam

Top Contributors - Rana Muhammad Tahir Aslam and Narayani Nagare  

Introduction:

Chorioamnionitis as the suffix suggests is the inflammation of the fetal membranes. These fetal membranes surround the fetus and amniotic fluid. The word "Chorioamnionitis" consists of the word "chorio" and "amnion." The word "Chorio" is from the medical Latin for the "chorion" which means "outer membrane of the fetus" That is also from the Greek word "khorion" meaning "membrane encloses the fetus after birth".[1]The word "Amnion" is from modern Latin which means "innermost membrane around the embryo of higher vertebrate"The Greeks referred to amnion as "a Vase in which the blood of the sacrifice was caught"[2]Chorioamnionitis is responsible for the many long and short term neonatal complications that put the baby at the risks of many diseases such as Cerebral Palsy. This Article is grounded and covers the basic aspects of chorioamnionitis such as people who are at risk, how to avoid it how it affects the baby, why you should go for the early diagnosis and the treatment options available.

Define:

Chorioamnionitis is refers to the active infection in the amniotic sac that leads to the inflammatory changes in the Chorion and Amnion.[3] The recent studies points out that chorioamnionitis is the presence of inflammatory changes in the chorion and Amnion as well as in the fetus due to the intraamniotic infection, with the systemic signs of the infection.[4] The recent studies are more acceptable as it show us why the babies are affected by it. Chorioamnionitis is linked with a number of disabilities in the child after the birth and Cerebral Palsy tops the list, followed by epilepsy, autism and many more.[5]

Risk Factors

World wide in developed countries 1% to 4% pregnancies are affected by Chorioamnionitis. In Developing Countries there is lack of data but the likely rate is much higher than this.[6]The factors that predispose a mother to chorioamnionitis are as following

  • Ruptured Fetal Membranes [4]
  • Digital Examination before the labor and during pregnancy [4]
  • History of Previous Clinical Chorioamnionitis [4]
  • V-type Funneling[7]
  • Short Cervix[7]
  • Poor Sanitation [8]
  • Vaginal Lacerations [9]
  • Excessive vaginal examination following a vaginal tear or rupture in the membrane.[10]
  • Nulliparous Pregnancy [10]
  • Pre term Labor[10]
  • Female with known Bacterial and Viral Infection[10]

Microbiological Causes

Studies have shown that only single microorganism is not responsible for the Chorioamnionitis. In 70% of cases of intraamniotic infection and chorioamnionitis, there were the presence of polymicrobial Infectious organisms.[11] The Microorganisms that are highly responsible for causing chorioamnionitis are as follow,[4]

  • Gardnerella Vaginalis
  • Streptococcus agalactia
  • Mycoplasma hominis
  • Ureaplasma species (Ureaplasma urealyticum, Ureaplasma parvum)
  • Group B streptococcus
  • Pseudomonas aeruginosa
  • HIV/ AIDS

Signs and Symptoms

Common signs and symtoms seen in Choriamnionitis are as follows : [12]

  • Maternal Fever: A core symptom, often above 100.4°F (38°C).
  • Fetal Tachycardia & Decreased Fetal Movement: A rapid fetal heart rate, often above 160 beats per minute.
  • Maternal Leukocytosis: An elevated white blood cell count.
  • Purulent Discharge: A foul-smelling discharge from the cervix.
  • Maternal History: Age, pregnancy complications, infections, and recent illnesses.
  • Physical Exam: Vital signs, abdominal and vaginal examination, and uterine tenderness.
  • Membrane Status: Whether the membranes are ruptured or intact.
  • Meconium Presence: The presence of meconium in the amniotic fluid.

Diagnosis

Chorioamnionitis can be defined as a clinical or a histopathologic identity or from a microbiologic point of view:[12]

  • Clinical diagnosis of chorioamnionitis - Presence of clinical signs (eg, maternal fever, uterine tenderness, malodorous discharge, and maternal and fetal tachycardia) and presence of laboratory abnormalities (ie, leukocytosis).
  • Histologic chorioamnionitis - Histopathologic examination of the placenta shows diffuse infiltration of neutrophils into the chorioamniotic membranes which is the characteristic morphologic feature of acute histologic chorioamnionitis.
  • Microbiologic chorioamnionitis (intraamniotic infection) - Presence of microorganisms in the amniotic fluid, retrieved by amniocentesis.

Criteria for Diagnosis of Clinical Chorioamnionitis[12]

Clinical signs - including fever (37.8°C or 100.4°F) and 2 or more of the following: maternal tachycardia (>100 beats/min), maternal leukocytosis (white blood cell count >15,000 cells/mm3 ), uterine tenderness,fetal tachycardia (>160 beats/min), or purulent or malodorous cervical discharge.

The diagnosis of clinical chorioamnionitis is based on the presence of maternal fever and 2 signs of maternal or fetal inflammation.

Laboratory Diagnosis[12]

Amniotic fluid analysis is gold standard for the diagnosis of intraamniotic inflammation and intraamniotic infection and indicated in cases of diagnostic certainty. Diagnosis is confirmed by presence of microorganisms and inflammation. Fluid can be retrieved at the time of cesarean delivery or by transabdominal amniocentesis. Tests could include - Gram stain (not visible in normal conditions), white blood cell count (normal count < 50 cells/mm3), and glucose concentration (shows presence of intraamniotic inflammation in preterm gestation).

MMP-8 or IL-6 concentrations in amniotic fluid are good indicators of inflammation. In patients with clinical chorioamnionitis at term, a rapid assay for MMP-8 can be used at the bedside and has an 84% diagnostic accuracy in detecting intraamniotic inflammation (sensitivity: 82%; specificity: 90%; positive likelihood ratio: 8.2; negative likelihood ratio: 0.2).

In Europe, there is a commercially available quick test to measure IL-6 in amniotic fluid (Milenia QuickLine; Milenia Biotec, Bad Nauheim, Germany). A noninvasive technique for determining the inflammatory state of the amniotic cavity in patients with membrane rupture is a transcervical amniotic fluid collector. Point-of-care tests, such the IL-8 fast test, can be used to analyze amniotic fluid.

To identify intraamniotic infection, cultures are made for both aerobic and anaerobic bacteria as well as genital mycoplasmas; however, the results of these tests may not be available for days. Within a few hours, the 16S ribosomal RNA gene can be detected using molecular microbiological techniques to identify bacteria. In fact, it has recently been revealed that intraamniotic infections can be successfully diagnosed within 5 to 9 hours using nanopore sequencing, a long-read, real-time DNA sequencing technology.

Complications

The Chorioamnionitis affects the mother as well as the baby, both suffer equally. If the chorioamnionitis is not diagnosed within the time or is left un treated it can lead to many serious complications for the mother and the baby can suffer from life long disabilities.

Maternal Complications

Recent studies show that if the chorioamnionitis is not treated with in time it can cause following complications for the mother:[4]

  • Urine Atony
  • Pelvic Abscess formation
  • Septic pelvic thrombophlebitis
  • Necrotizing fasciitis
  • Hysterectomy
  • Septic Shock
  • Death

Neonatal Complications

The baby also suffer from different complications depending upon the phase of gestation the Infection reach the baby. The complications from which the baby suffer are as follows

Management

Antibiotics and augmentation of labor are the standard treatments for clinical chorioamnionitis at term.

As soon as the diagnosis is made, antimicrobial treatment begins. Treatment options for patients include ampicillin plus sulbactam 3 g IV every 6 hours, ampicillin plus gentamicin 2 g IV every 6 hours, and gentamicin 5 mg/kg every 24 or 1.5 mg/kg every 8 hours.

When the umbilical cord is clamped during a cesarean delivery, patients are given 900 mg of clindamycin intravenously. In the event of a caesarean delivery, metronidazole 500 mg IV has been suggested as a substitute for clindamycin.

For patients who are allergic to penicillins, ampicillin can be substituted with clindamycin 900 mg IV every 8 hours, vancomycin 1 g IV every 12 hours, or erythromycin 500 mg to 1 g IV every 6 hours.

Other often used antimicrobial medications include cilastatin, sulbactam, tazobactam, and clavulanic acid.A good substitute for ampicillin and gentamicin are cephalosporins.

Ertapenem, meropenem, and imipenem are examples of carbapenems, a class of antibiotics typically saved for known or suspected multidrug-resistant bacterial infections. These antibiotics are frequently used to treat multi-resistant Gram-negative bacteria, including Acinetobacter and Pseudomonas species. Because it is given intravenously every 24 hours, ertapenem is a desirable medication. Some of the antibiotics can also be administered intramuscularly; however, the intravenous route is preferable.[12]

References:

  1. ↑ Harper, Douglas. "Chorio" Online Etymology Dictionary(Accessed: 22/10/24)
  2. ↑ Harper, Douglas. "Amnion" Online Etymology Dictionary(Accessed: 22/10/24)
  3. ↑ Current Management and Long-term Outcomes Following Chorioamnionitis. Obstetrics and Gynecology Clinics of North America,Volume 41, Issue 4,2014.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment.American Journal of Obstetrics and Gynecology, Volume 230, Issue 3, Supplement,2024
  5. ↑ 5.0 5.1 5.2 Tsamantioti, E., Lisonkova, S., Muraca, G., Örtqvist, A. K., & Razaz, N. (2022).Chorioamnionitis and risk of long-term neurodevelopmental disorders in offspring: a population-based cohort study American Journal of Obstetrics and Gynecology.
  6. ↑ Johnson, C. T., Farzin, A., & Burd, I. (2014). .Current management and long-term outcomes following chorioamnionitis. Obstetrics and Gynecology Clinics
  7. ↑ 7.0 7.1 Song, W., Wang, W., Wang, F., He, X., Li, X., Feng, L., Cui, W., & Guo, Q. (2024). Risk factors for high-stage histological chorioamnionitis among pregnancies with cervical incompetence The journal of obstetrics and gynaecology research
  8. ↑ Chan, G. J., Silverman, M., Zaman, M., Murillo-Chaves, A., Mahmud, A., Baqui, A. H., & Boyd, T. K. (2016). . Prevalence and risk factors of chorioamnionitis in Dhaka, Bangladesh Journal of perinatology : official journal of the California Perinatal Association
  9. ↑ Gobioff, S., Lenchner, E., Gulersen, M., Bar-El, L., Grünebaum, A., Chervenak, F. A., & Bornstein, E. (2023). Risk factors associated with third- and fourth-degree perineal lacerations in singleton vaginal deliveries: a comprehensive United States population analysis 2016-2020. Journal of perinatal medicine.
  10. ↑ 10.0 10.1 10.2 10.3 Chorioamnionitis by Josephine R. Fowler; Leslie V. Simon. National Library of Medicine. Accessed (29/10/24)
  11. ↑ Romero, R., Miranda, J., Kusanovic, J. P., Chaiworapongsa, T. Chaemsaithong, P., Martinez, A., ... & Kim, Y. M. (2015). Clinical chorioamnionitis at term I: microbiology of the amniotic cavity using cultivation and molecular techniques . Journal of perinatal medicine.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Jung E, Romero R, Suksai M, Gotsch F, Chaemsaithong P, Erez O, Conde-Agudelo A, Gomez-Lopez N, Berry SM, Meyyazhagan A, Yoon BH. .Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment.*Am J Obstet Gynecol*. 2024
  13. ↑ 13.0 13.1 Willoughby, R. E., Jr, & Nelson, K. B. (2002).Chorioamnionitis and brain injury. Clinics in perinatology
  14. ↑ 14.0 14.1 Jain, V. G., Willis, K. A., Jobe, A., & Ambalavanan, N. (2022). Chorioamnionitis and neonatal outcomes.Pediatric research
  15. ↑ Beck, C., Gallagher, K., Taylor, L. A., Goldstein, J. A., Mithal, L. B., & Gernand, A. D. (2021). Chorioamnionitis and Risk for Maternal and Neonatal Sepsis: A Systematic Review and Meta-analysis. Obstetrics and gynecology,
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