Intraamniotic infection (IAI) or Chorioamnionitis (CA)refers to the infection of the amniotic fluid, membranes, placenta, and/or deciduas. At term, CA complicates approximately 1 to 4 percent of deliveries overall.[1,2,3]CA is a well-recognized risk factor for early-onset neonatal sepsis (EOS) [4,5]
Overall, 40 percent of cases of EOS have associated CA.. Adverse fetal/neonatal outcomes of CA include perinatal death, asphyxia, early-onset neonatal sepsis, septic shock, pneumonia, meningitis, intraventricular hemorrhage, cerebral white matter damage, and long-term disability including cerebral palsy, as well as morbidity related to preterm birth.[5,6,7,8,9]
Prolonged labor and premature rupture of membranes may be the most important risk factors for CA. Other factors include multiple digital vaginal examinations, cervical insufficiency, nulliparity, meconium-stained amniotic fluid, internal fetal or uterine contraction monitoring, and presence of genital tract pathogens.
The manifestations include fever, leukocytosis >15000 cells/mm3, feto-maternal tachycardia, uterine tenderness, foul-smelling amniotic fluid, and sometimes bacteremia.
Histopathology of affected placentae may reveal chorioamnionitis with or without funisitis. The maternal complications include dysfunctional labor, localized infections, and sepsis.
The conventional diagnostic criteria for CA clinical diagnosis included Peak Intrapartum Temperature (PIT) ≥380C PLUS at least one feature from leukocytosis>15000 cells/mm3, fetal tachycardia >160 beats per minute, Maternal tachycardia >100 beats per minute, Uterine tenderness, and foul-smelling amniotic fluid.
The recent diagnostic criteria suggested by a National Institute of Child Health and Human Development Workshop expert panel and endorsed by the American College of Obstetricians and Gynecologists (ACOG). is as follows:
A presumptive diagnosis of CA can be made in women with fever (≥39.0°C [102.2°F] or 38.0°C [100.4°F] to 38.9°C [102.02°F] on two occasions, 30 minutes apart) without another clear source PLUS one or more of the following 1. Baseline fetal heart rate >160 beats/min for ≥10 minutes, excluding accelerations, decelerations, and periods of marked variability, 2.Maternal white cell count >15,000 cells/mm3 3.Purulent-appearing fluid coming from the cervical os visualized by speculum examination. The new criteria excluded maternal tachycardia and uterine tenderness.
A Confirmed CA is based on the presence of the above criteria PLUS positive amniotic fluid test result (gram stain, glucose level, or culture results consistent with infection) or placental pathology demonstrating histologic evidence of placental infection or inflammation.
Women with CA should be given antibiotics and delivered. Broad-spectrum antibiotics should be given promptly following a diagnosis of CA to initiate treatment of both the mother and fetus. Fever should be treated by antipyretics.
Maternal intrapartum fever has been associated with a higher frequency of fetal tachycardia, intervention for non-reassuring electronic fetal monitoring, operative vaginal delivery, Cesarean delivery, neonatal depression, neonatal encephalopathy, perinatal arterial ischemic stroke, neonatal seizures, and NICU admission.[11-28]
The Committee on fetus and Neonate recommended partial sepsis workup and presumptive antibiotics to all newborn babies born with suspected maternal CA. Current, evidence-based strategies like Early-onset Sepsis risk Calculator (EOSCAL). focuses on maternal temperature and associated risk factors rather than the clinical diagnosis of chorioamnionitis.
Although fever ( ≥380C) is an essential criterion for diagnosing CA. Obstetricians frequently take the risk factors into consideration, and many mothers are treated as CA even with PIT 37.6-37.90C if they have other clinical signs or risk factors. An audit conducted in AWH (2018) showed that 50%of clinically suspected cases of CA did not satisfy the diagnostic criteria, including fever. We observed that most mothers received antipyretics at a lower temperature range ( 37.6 to 37.90C). We hypothesized that early use of antipyretics might be blunting the clinical picture of CA.
Primary Objective :
To estimate the prevalence of confirmed CA among mothers who delivered in AWH between Jan 2016 and Dec 2019 and had suspected CA with a PIT between 37.60C -37.90C.
1. To estimate the incidence and trend of CA among mothers delivering at AWH.
2. To compare the maternal risk factors, clinical features, final diagnosis, and short term neonatal outcome between those with PIT <380C ( group 1)and those with temp 380C and more(group 2)