Maternal fever (intrapartum temperature > 37.8°C) is the most common symptom of chorioamnionitis. Other characteristic features of the disease are fetal tachycardia, purulent amniotic fluid, uterine tenderness and maternal leukocytosis. When two or more of these symptoms are observed in the patient, the risk of neonatal sepsis increases.

Though in some cases, the pregnant women with chorioamnionitis may show no signs or symptoms, in some cases, they may appear ill, even toxic and hypotensive with cool or clammy skin. The symptoms of the suspected sepsis in the neonate and mother are often nonspecific and include findings such as behavioral abnormalities, tachypnea, cyanosis, apnea, pulmonary hemorrhage, tachycardia, vomiting and diarrhea, abnormalities in thermal regulation, pallor, overt bleeding and hypotension [7] [8].

• Disability

  Outcomes examined include CP, IVH, NEC, BPD, and assessments of mental and motor disability. Logistic regression was used to estimate adjusted odds ratios of each outcome. [ncbi.nlm.nih.gov]

  CP is the most common cause of severe physical disability in children in developed countries. It occurs in up to 2.4 per 1,000 live births. The condition is associated with premature babies, babies with a low birth weight, and multiple birth. [news.bbc.co.uk]

  These consequences can lead to long-term damage of the baby, including learning disabilities, delayed development, seizure disorders and cerebral palsy. Even a short deprivation of oxygen to the baby can cause severe problems. [abclawcenters.com]

  It is a common complication of pregnancy associated with potentially serious adverse maternal, fetal, and neonatal effects, as well as increased long-term risks for cerebral palsy and other neurodevelopmental disabilities. [osawodevix.ga]

• Pathologist

  At our institution, department protocol dictates that placentas of all mothers with clinical chorioamnionitis be sent for evaluation by a pathologist for histopathologic confirmation of diagnosis. [omicsonline.org]

  The Royal College of Pathologists (1993) Guidelines for postmortem reports. The Royal College of Pathologists, London 31. Vogel M (1996) Atlas der morphologischen Plazentadiagnostik, 2nd edn. Springer, Berlin Heidelberg New York, pp 40–197 32. [springermedizin.de]

  A single researcher evaluated clinical and histological information, consulting another pathologist for confirmation if needed. [ijpmonline.org]

  The pathologist was blinded to the maternal history and graded the placenta as grade 0 (control group) with no evidence of chorioamnionitis in the placenta. [jamanetwork.com]

  Examination of the placenta by a pathologist confirmed that the infection had spread to the umbilical cord, injuring the child. The standard of care was met. There was no indication that an earlier delivery was needed. [mdedge.com]

• Chronic Infection

  Impacting nearly 30% of preterm births, early subclinical chronic infection may explain the high incidence of chorioamnionitis (Goldenberg et al., 2000). Diagnosis Chorioamnionitis may be clinical or subclinical. [nursingcenter.com]

  However, chronic infection usually is subclinical and has been associated with a wide variety of neonatal organ injury, including brain, lung, eye, intestine, and thymus. 26 Lieberman E. Lang J. Richardson D.K. Frigoletto F.D. Heffner L.J. Cohen A. [pediatr-neonatol.com]

• Tachycardia

  In addition one of the following should also be documented: Maternal tachycardia (>100 bpm) Fetal tachycardia (>160 bpm) Uterine tenderness Foul smelling/ purulent discharge Maternal leukocytosis (>15,000 cell/cubic mm) Subclinical infection can be assessed [obtsguidelines.org]

  The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. [ncbi.nlm.nih.gov]

  Tachycardia: maternal and fetal tachycardia (fast heart beat) are the second most common symptom of chorioamnionitis. [birthinjuryhelpcenter.org]

  Clinical diagnosis is based on the presence of maternal fever (>38°C) and two of the following: maternal leucocytosis or leucopenia, maternal tachycardia (>100 bpm), fetal tachycardia (>160 bpm), uterine tenderness, and foul-smelling amniotic fluid 4. [oapublishinglondon.com]

• Hydrops Fetalis

  Potential complications include: intrauterine growth restriction (IUGR) premature birth hydrops fetalis (fluid build-up in the fetus) neonatal sepsis hypoxic ischemic encephalopathy (HIE) premature rupture of membranes (PROM) periventricular leukomalacia [thurswell.com]

  If chorioamnionitis and/or villitis are not properly treated, it can infrequently lead to serious outcomes in the baby, including: Hypoxic-ischemic encephalopathy (HIE) Hydrops fetalis (abnormal amounts of fluid build-up in two or more body areas of a [abclawcenters.com]

  fetalis 653.7 hypertension - see Hypertension, complicating pregnancy hypertonic uterine dysfunction 661.4 hypotonic uterine dysfunction 661.2 impacted shoulders 660.4 incarceration, uterus 654.3 incomplete dilation (cervix) 661.0 incoordinate uterus [icd9data.com]

• Spontaneous Rupture of Membranes

  She was released from the hospital and returned at 25 4/7 weeks' estimated gestational age with possible spontaneous rupture of membranes. [ncbi.nlm.nih.gov]

  • PROM is spontaneous rupture of membrane any time beyond 22nd week of pregnancy but before onset of labour. • Incidence: 10% of all pregnancies. 21. Types of PROM • 1. [slideshare.net]

• Suggestibility

  The isolation of both organisms from a clinical specimen suggests an oral source of infection. A 23-year-old black woman was admitted at 24 weeks' gestation in preterm labor. [ncbi.nlm.nih.gov]

  Increasing evidence suggests that it is low-grade chronic inflammation that leads to neurologic injury rather than acute infection.9,10 Clinicians should find this evidence reassuring because it suggests that we are doing our patients no harm when we [mdedge.com]

• Uterine Tenderness

  The mother had high fever and marked uterine tenderness, and the infant had poor Apgar scores, fever, and pulmonary infiltrates. Both recovered after receiving specific antibiotics. [ncbi.nlm.nih.gov]

• Vaginal Discharge

  Pulsed field gel electrophoresis showed that isolates from the blood, urine, and vaginal discharge were genetically identical. Intravenous pyelography revealed that she had a bilateral completed double ureter. [ncbi.nlm.nih.gov]

  Foul odor of the vaginal discharge, color change of amniotic fluid from clear to light yellow to green, and an increase in the purulence of vaginal drainage are all consistent with chorioamnionitis. [medical-dictionary.thefreedictionary.com]

  Findings of rapid heart rate (maternal tachycardia and/or fetal tachycardia), a mother’s elevated white blood cell count (leukocytosis), uterine tenderness, and/or malodorous amniotic fluid or vaginal discharge can also aid in diagnosing chorioamnionitis [yostlaw.com]

  Symptoms include maternal fever, increased maternal or fetal heart rate, tenderness in the abdomen and funky-smelling vaginal discharge. If infection is suspected, you’ll get an IV of antibiotics, and the baby will be delivered ASAP. [thebump.com]

• Foul Smelling Vaginal Discharge

  Other signs include appearing ill, sweating profusely, foul-smelling vaginal discharge, significantly rapid heart rate, or a high white blood cell count. [thurswell.com]

  Look out for these symptoms of chorioamnionitis: high temperature a foul-smelling vaginal discharge fast pulse rate pain in your abdomen. [tommys.org]

  The patient declined amniocentesis for cerclage and was treated with pelvic rest and vaginal progesterone. Five days later, she arrived at the emergency department with foul-smelling vaginal discharge. [wwwnc.cdc.gov]

  Fever [5] Maternal tachycardia (cardiac arrhythmia) Increased fetal heart rate (fetal tachycardia) [6] Sweating Uterine tenderness and pain Foul smelling vaginal discharge [5] Maternal leukocytosis (blood leukocyte count greater than 15,000-18,000 cells [pregmed.org]

Laboratory tests

• For asymptomatic pregnant women presenting preterm labor, the following tests must be performed namely examination of amniotic fluid, maternal blood and urine analysis, maternal blood group-B streptococcal screening. 
• Tests for febrile pregnant women with suspected chorioamnionitis include complete blood count, C-reactive protein, Alpha1-proteinase inhibitor complex, and serum interleukin-6 levels. 
• Evaluation of the amniotic fluid are bacterial cultures, Gram staining, pH levels, leukocyte count, levels of glucose in the blood, polymerase chain reaction, proteomic profiling, etc. 
• Other diagnostic tests for early onset neonatal sepsis are determination of the levels of procalcitonin, serum interleukin-6 or cytokine, bacterial antigen detection in the blood, etc. [9]

Imaging

Since short cervix is a risk factor for chorioamnionitis, ultrasonography can help to detect this altered anatomy. Imaging studies helps to ascertain the health of the fetus on a regular basis [9].

• Leukocytosis

  The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. [ncbi.nlm.nih.gov]

  Maternal blood draw Maternal leukocytosis (peripheral white blood cell count greater than 15,000/mm 3 ) supports the clinical diagnosis of IAI. This value exceeds the 80th percentile for normal leukocytosis in pregnancy. [clinicaladvisor.com]

  The diagnosis is based on the presence of postpartum fever, along with tachycardia, uterine tenderness, foul smelling lochia, and/or leukocytosis. [creogsovercoffee.com]

  Maternal blood draw Maternal leukocytosis (peripheral white blood cell count greater than 15,000/mm3) supports the clinical diagnosis of IAI. This value exceeds the 80th percentile for normal leukocytosis in pregnancy. [cancertherapyadvisor.com]

Therapy of chorioamnionitis includes early delivery and supportive care with the use of safe antibiotics. Some of the antibiotics to manage the disease are crystalline penicillin G, clindamycin, ampicillin, gentamicin, and cefotaxime.

Supportive care of the neonates are providing warmth, full resuscitation when needed, treatment of hypervolemia, respiratory acidosis, surfactant replacement therapy, glucose homeostasis and monitoring of the vital signs. Assessment of the thrombocytopenia is one of the important aspects that need to be looked into.

Some surgical options are also available for early onset bacterial infections in the neonate; however, they are rarely used. The conditions that warrant the surgical intervention are epidural and subcutaneous abscess, infections located in the pleural space, bone and joint infections, and similar conditions [10].

The long-term prognosis for both the mother with chorioamnionitis and the neonate is excellent. The fertility of the women is not compromised. The child born preterm may, however, suffer from the long-term complications such as neurologic impairment and chronic lung disease [11].

Complications

Some of the complications of chorioamnionitis are infection in the abdomen and pelvic regions, endometriosis, sepsis, and blood clots in the pelvis and lungs. Complications from bacterial infection in the newborn also include sepsis, meningitis and respiratory problems [12].

When the protective mechanism of the maternal urogenital tract fails during pregnancy, there is an increase in the indigenous microbial flora or influx of highly pathogenic microorganisms in the urogenital region. In pregnant women, therefore, urogenital hygiene is important. When the microorganism reach the placenta, it leads to infection. Short cervix, bacterial virulence factors and toxin production are some of the risk factors of this disease. In healthy pregnant women, bacteria such as lactobacilli, is a natural antibiotic of the vagina and cervix, and phagocytes also help to prevent infection.

However, in women with chorioamnionitis, this host protection is compromised. Oral and rectal hygiene is therefore extremely important for normal urogenital colonization. Some of the clinical events associated with chorioamnionitis are history of preterm labor or premature birth, and premature or prolonged ruptured fetal membranes. Evidences also suggest that epidural anesthesia may be associated with maternal fever or fetal tachycardia [2] [3].

In underdeveloped countries, the main reason for chorioamnionitis is the premature rupture of the membranes, which is often associated with a high mortality rate. In Africa, malnourished pregnant women are at a higher risk of having ascending urogenital infection causing chorioamnionitis.

This is believed to be due to decrease in the host defense factors. In developed countries, women receive optimum care during pregnancy with proper nutrition; hence the incidence of infection is greatly reduced [4].

• Abnormal bacterial colonization: Due to the abnormal colonization in the distal colon, abnormal vaginal and cervical microbial environments are created. Studies have confirmed that there are types of bacteria, which may ascend and rupture the fetal membrane and initiate the infection in amniotic fluid of the fetus causing chorioamnionitis. 
• Urinary tract infection leads to an easy access of the bacterial pathogen to the vagina, increasing the risk of neonatal sepsis. 
• Premature labor is associated with bacterial vaginosis. Early screening and treatment of vaginosis may prevent the preterm birth. 
• Some other causes of the condition are related to cervical insufficiency, release of vaginal prostaglandins, etc. [5] [6]

• Urinary tract infections, if diagnosed, must be treated immediately. 
• Risk of preterm labor must be determined at the earliest. 
• Chances of development of chorioamnionitis can be reduced by regularly attending the prenatal check-up, preventing bacterial vaginosis, practicing safe sex, and getting the routine vaginal culture done, when indicated.

Chorioamnionitis is a common complication of pregnancy. It is often associated with maternal fever and other long-term adverse outcomes such as postpartum infections, sepsis, premature birth, neonatal sepsis, brain injury and stillbirth, cerebral palsy and neurodevelopmental disabilities.

There exists a mechanistic relationship between the intraamniotic infection and preterm delivery. Ongoing research in the field has provided evidence for better methods of diagnosis, prevention and treatment of the condition [1].

Definition

Chorioamnionitis is a common complication of pregnancy which is associated with maternal fever and long-term adverse outcomes such as sepsis, brain injury, and stillbirth. Recent research provides better evidence of diagnosis, prevention and treatment of the condition. 

Cause

Abnormal bacterial colonization, urinary tract infection, premature labor associated with bacterial vaginosis, cervical insufficiency and release of vaginal prostaglandins are some of the important causes of chorioamnionitis. 

Symptoms

Some of the symptoms associated with this disease are maternal fever, illness, low blood pressure, and clammy skin.

Diagnosis

• For pregnant women who are asymptomatic, laboratory tests such as examination of amniotic fluid, maternal blood, and Group-B streptococcal screening and urine analysis are performed. 
• For the febrile pregnant women with suspected chorioamnionitis, complete blood count, C-reactive protein, Alpha1-proteinase inhibitor complex, serum interleukin-6 levels is done. 
• Tests such as bacterial cultures, Gram staining, pH levels and polymerase chain reaction, ultrasonography may also be performed. 

Treatment

Women with chorioamnionitis are treated with antibiotics such as clindamycin, ampicillin, gentamicin, and cefotaxime. Supportive care of the neonates such as providing warmth, full resuscitation, glucose homeostasis and monitoring of the vital signs is important. Assessment of the thrombocytopenia is one of the important aspects that need to be looked into. Some surgical options are available for early onset bacterial infections in the neonate; though, they are rarely used.

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