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PubMed2004

Diagnosis of intra-amniotic infection by proteomic profiling and identification of novel biomarkers.

CONTEXT: Intra-amniotic infection (IAI) is commonly associated with preterm birth and adverse neonatal sequelae. Early diagnosis of IAI, however, has been hindered by insensitive or nonspecific tests. OBJECTIVE: To identify unique protein signatures in rhesus monkeys with experimental IAI, a proteomics-based analysis of amniotic fluid was used to develop diagnostic biomarkers for subclinical IAI in amniotic fluid and blood of women with preterm labor. DESIGN, SETTING, AND PARTICIPANTS: Surface-enhanced laser desorption-ionization/time-of-flight mass spectrometry, gel electrophoresis, and tandem mass spectrometry were used to characterize amniotic fluid peptides in 19 chronically instrumented pregnant rhesus monkeys before and after experimental IAI. Candidate biomarkers were determined by liquid chromatography-tandem mass spectrometry. Polyclonal antibodies were generated from synthetic peptides for validation of biomarkers of IAI. Amniotic fluid peptide profiles identified in experimental IAI were subsequently tested in a cohort of 33 women admitted to Seattle, Wash, hospitals between June 25, 1991, and June 30, 1997, with preterm delivery at 35 weeks or earlier associated with subclinical IAI (n = 11), preterm delivery at 35 weeks or earlier without IAI (n = 11), and preterm contractions with subsequent term delivery at later than 35 weeks (n = 11). MAIN OUTCOME MEASURES: Identification of peptide biomarkers for occult IAI. RESULTS: Protein expression profiles in amniotic fluid showed unique signatures of overexpression of polypeptides in the 3- to 5-kDa and 10- to 12-kDa molecular weight ranges in all animals after infection and in no animal prior to infection. In women, the 10- to 12-kDa signature was identified in all 11 patients with subclinical IAI, in 2 of 11 with preterm delivery without IAI, and in 0 of 11 with preterm labor and term delivery without infection (P<.001). Peptide fragment analysis of the diagnostic peak in amniotic fluid identified calgranulin B and a unique fragment of insulinlike growth factor binding protein 1, which were also expressed in maternal serum. Mapping of other amniotic fluid proteins differentially expressed in IAI identified several immunoregulators not previously described in amniotic fluid. CONCLUSIONS: This proteomics-based characterization of the differential expression of amniotic fluid proteins in IAI identified a distinct proteomic profile in an experimental primate chorioamnionitis model that detected subclinical IAI in a human cohort with preterm labor. These diagnostic protein expression signatures, complemented by immunodetection of specific biomarkers in amniotic fluid and in maternal serum, might have application in the early detection of IAI.

Adult↗
PubMedDate not supplied

Relationship between endomyometritis and the duration of premature membrane rupture.

In this study, correlation between duration of premature rupture of the membranes (PROM) and the degree of membrane, decidua, and myometrium infections were histologically investigated. The study was carried on 61 women with term pregnancy (30 with PROM, 31 control group). During cesarean section, a full-thickness biopsy specimen of the uterine wall from serosa to decidua was obtained with scissors. Chorioamnionitis was histopathologically identified by neutrophilic leukocyte (NL) infiltration of the membranes. Endometritis or myometritis were diagnosed when the acute inflammatory process extended to the decidua or the myometrium successively. It was found that the presence and depth of NL infiltration significantly correlates with the interval between rupture of membranes and termination of pregnancy.

Biopsy↗
PubMed1992

Interleukin 6 determination in the detection of microbial invasion of the amniotic cavity.

A growing body of evidence suggests a role for cytokines in the mechanisms responsible for preterm parturition associated with intrauterine infection. Interleukin 6, a polyfunctional cytokine that is secreted by tissues in the feto-maternal interface in response to microbial products, has been implicated in the host response to intrauterine infection. The purpose of this study was to establish whether measurement of amniotic fluid concentrations of interleukin 6 could be of value in the diagnosis of microbial invasion of the amniotic cavity. Fluid was obtained by transabdominal amniocentesis from patients with preterm labour and intact chorioamniotic membranes and cultured for aerobic and anaerobic bacteria and mycoplasmas. Interleukin 6 concentrations were determined by an ELISA validated for human amniotic fluid. An interleukin 6 concentration above 11.2 ng/ml had a 93.7% sensitivity and a 92.3% specificity in the diagnosis of intra-amniotic infection. Moreover, patients with an amniotic fluid interleukin 6 level above 11.2 ng/ml and a negative amniotic fluid culture failed to respond to tocolysis, delivered a preterm infant and showed histological evidence of chorioamnionitis, and their neonates were at risk for congenital infections.

Amniotic Fluid↗
PubMed2002

Intrauterine infection and prematurity.

Intrauterine infection is a major cause of premature labor with and without intact membranes. Intrauterine infection is present in approximately 25% of all preterm births and the earlier the gestational age at delivery, the higher the frequency of intra-amniotic infection. Microorganisms may also gain access to the fetus before delivery. A fetal inflammatory response syndrome elicited in response to microbial products is associated with the impending onset of preterm labor and also with multi-systemic organ involvement in the human fetus and a higher rate of perinatal morbidity. The most common microorganisms involved in intrauterine infections are Ureaplasma urealyticum, Fusobacterium species and Mycoplasma hominis. The role of Chlamydia trachomatis and viruses in preterm labor remain to be determined. Use of molecular microbiology techniques to diagnose intrauterine infection may uncover the role of fastidious microorganisms that have not yet been discovered. Antibiotic administration to patients with asymptomatic bacteriuria is associated with a significant reduction in the rate of preterm birth. However, such benefit has not been demonstrated for patients with bacterial vaginosis, or women who carry Streptococcus agalactia, Ureaplasma urealyticum or Trichomonas vaginalis. Antibiotic administration to patients with preterm premature rupture of membranes is associated with prolongation of pregnancy and a reduction in the rate of clinical chorioamnionitis and neonatal sepsis. The benefit has not been demonstrated in patients with preterm labor and intact membranes. Major efforts are required to determine why some women develop an ascending intrauterine infection and others do not and also what interventions may reduce the deleterious effect of systemic fetal inflammation.

Amniotic Fluid↗
PubMed1992

Adverse outcome in pregnancy following amniotic fluid isolation of Ureaplasma urealyticum.

Infections in pregnancy with Ureaplasma urealyticum have been associated with a wide range of adverse outcomes, such as early abortion, stillbirth, prematurity, and neonatal morbidity and mortality. Causality has been difficult to demonstrate secondary to the high prevalence of asymptomatic lower genital tract (LGT) colonization and culture data from inaccessible or potentially contaminated sites. Between 1985 and 1989, 2461 second-trimester genetic amniocenteses were evaluated at the cytogenetics section of the Children's Hospital Medical Center of Akron. All were cultured for the genital mycoplasmas: Mycoplasma hominis and Ureaplasma urealyticum. A total of nine patients were positive, all for Ureaplasma urealyticum, with one patient excluded because of subsequent therapeutic abortion. In addition, complete follow-up data, such as indication for amniocentesis, serum alpha-fetoprotein levels, gestational age at parturition, and outcome of pregnancy, were available on 86 Ureaplasma-negative (U-) patients during an approximate 2-year span within the time-frame of the study. This was in part due to physician response to a questionnaire sent after amniocentesis. Of the eight positive cultures, 100 per cent were associated with an adverse outcome, defined as fetal loss or premature delivery. This was significant compared with the U- group (p less than 0.001) with a more than eight times greater risk of adverse outcome. Six (75 per cent) resulted in spontaneous miscarriage within 4 weeks of amniocentesis and at less than 21 weeks' gestation. Two (25 per cent) delivered prematurely, with one (12.5 per cent) neonatal death at 24+ weeks. Histological examination of all eight placentae and the seven fetuses revealed a 100 per cent incidence of chorioamnionitis and pneumonia, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Abortion, Spontaneous↗
PubMed1995

Complications of cordocentesis in high-risk pregnancies: effects on fetal loss or preterm delivery.

Between 1990 and 1993, 166 cases underwent cordocentesis and were followed for at least the following 4 weeks in the Prenatal Diagnosis and Therapy Centre of Vienna University. The indications for the procedure were structural malformations in 46.4 per cent of the cases, other high-risk diagnosis in 48.8 per cent, and maternal age over 35 years in only 4.8 per cent. We investigated retrospectively all cases of complications resulting in fetal loss or preterm labour. Abortion, intrauterine fetal death, chorioamnionitis, and preterm delivery occurred in 0.6, 5.4, 0.6 and 9.0 per cent of these cases, respectively, adding up to a total of 26 cases (15.7 per cent). Although this rate looks relatively high, 20 of the 26 cases had already displayed signs implying a complicated prognosis. Neither maternal age, gestational age, number of attempts, nor placental location correlated with fetal loss or preterm delivery. Significantly higher rates of fetal loss or preterm delivery were observed when cordocentesis was performed in cases diagnosed as duodenal/intestinal stenosis or hydrops-ascites-hydrothorax/hygroma colli (P = 0.0488 and P = 0.0005). The frequency of complications did not decrease as the experience of the operators increased.

Abortion, Spontaneous↗
PubMed2004

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.

Adrenal Cortex Hormones↗
PubMed2002

Spontaneous prolonged hypertonic uterine contractions (essential uterine hypertonus) and a possible infective etiology.

The management of a pregnant woman presenting with prolonged hypertonic uterine contractions (essential uterine hypertonus) and mildly elevated temperature at term is described. Histology of the placenta, cord and membranes, following delivery, revealed evidence of chorioamnionitis, funisitis and deciduitis. Our findings raise the possibility that essential uterine hypertonus may have an infective or inflammatory component to its etiology.

Adult↗
PubMed2001

The role of inflammation in the development of chronic lung disease in neonates.

UNLABELLED: Chronic lung disease (CLD) has been associated with chorioamnionitis and upper respiratory tract colonisation with Ureaplasma urealyticum. The aim of this review is to describe the increasing evidence that inflammation plays a critical role in the early stages of CLD of the neonate. Ongoing lung damage in the premature infant may be caused by failure to downregulate and control this inflammatory response. Tumour necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6) and IL-8 are important pro-inflammatory cytokines of which IL-8 is an important chemotactic factor in the lung. Data suggest that preterm newborns with lung inflammation may be unable to activate the anti-inflammatory cytokine IL-10. Therefore, early post-natal anti-inflammatory therapy could help in preventing development of CLD. Prophylactic dexamethasone therapy cannot yet be recommended. There are a number of potential interactions between surfactant and cytokine effects on the preterm lung which have not been evaluated. Surfactant protein A may be an important modulator of the immune response to lung injury. The role of high-frequency ventilation in the prevention of CLD still remains unclear. CONCLUSION: Many aspects of the pathogenesis of the inflammatory response in the development of chronic lung disease remain to be elucidated. Further research to identify preterm infants at highest risk for the development of this multifactorial and complex disease is needed.

Chorioamnionitis↗
PubMedDate not supplied

Amniotic infection syndrome: nosology and reproducibility of placental reaction patterns.

Clinically responsive placental examination seeks to provide useful information regarding the etiology, prognosis, and recurrence risk of pregnancy disorders. The purpose of this study was to assemble and validate a complete set of the placental reaction patterns seen with amniotic fluid infection in the hope that this might provide a standardized diagnostic framework useful for practicing pathologists. Study cases (14 with amniotic fluid infection, 6 controls) were reviewed blindly by six pathologists after agreement on a standard set of diagnostic criteria. After analysis of initial results, criteria were refined and a second, overlapping set of cases were reviewed. Majority vote served as the gold standard. Grading and staging of maternal and fetal inflammatory responses was found to be more reproducible using a two- versus three-tiered grading system than a three- versus five-tiered staging system (overall agreement 81% vs. 71%). Sensitivity, specificity, and efficiency for individual observations ranged from 67-100% (24/30 > 90%). Reproducibility was measured by unweighted kappa values and interpreted as follows: < 0.2, poor; 0.2-0.6, fair/moderate; > 0.6, substantial. Kappa values for the 12 lesions evaluated in 20 cases by the six pathologists were: acute chorioamnionitis/maternal inflammatory response (any, 0.93; severe 0.76; advanced stage, 0.49); chronic (subacute) chorioamnionitis (0.25); acute chorioamnionitis/fetal inflammatory response (any, 0.90; severe, 0.55; advanced stage, 0.52); chorionic vessel thrombi (0.37); peripheral funisitis (0.84); acute villitis (0.90); acute intervillositis/intervillous abscesses (0.65), and decidual plasma cells (0.30). Adoption of this clearly defined, clinically relevant, and pathologically reproducible terminology could enhance clinicopathologic correlation and provide a framework for future clinical research.

Adult↗
PubMedDate not supplied

Abnormal umbilical cord coiling is associated with adverse perinatal outcomes.

The normal umbilical cord coil index is one coil/5 cm, i.e., 0.2 +/- 0.1 coils completed per cm. We report the frequency and clinical correlations of abnormally coiled cords among 1329 cases referred to our placental pathology services. Twenty-one percent of cords were overcoiled and 13% were undercoiled. Abnormal cord coiling was seen at all gestational ages. Principal clinical correlations found in overcoiled cords were fetal demise (37%), fetal intolerance to labor (14%), intrauterine growth retardation (10%), and chorioamnionitis (10%). For undercoiled cords, the frequencies of these adverse outcomes were 29%, 21%, 15%, and 29%, respectively. Abnormal cord coiling was associated with thrombosis of chorionic plate vessels, umbilical venous thrombosis, and cord stenosis. Thus, abnormal cord coiling is a chronic state, established in early gestation, that may have chronic (growth retardation) and acute (fetal intolerance to labor and fetal demise) effects on fetal well-being. The cause of abnormal cord coiling is not known. Its effects on neurological status of survivors are also unknown. Antenatal detection of abnormal cord coil index by ultrasound could lead to elective delivery of fetuses at risk, thereby reducing the fetal death rate by about one-half. We recommend that the cord coil index become part of the routine placental pathology examination.

Chorioamnionitis↗
PubMed1985

The fetal biophysical profile in patients with premature rupture of the membranes--an early predictor of fetal infection.

A modified fetal biophysical profile (nonstress test, fetal movements, fetal breathing movements, fetal tone, amniotic fluid volume, and placental grading) was serially assessed in 73 patients who presented with premature rupture of the membranes and were not in labor. The last study before delivery was compared with the outcome of pregnancy. The relationships between individual variables and combinations of variables (biophysical scoring) and the outcome of pregnancy--as reflected by the development of chorioamnionitis and/or neonatal sepsis--were determined. These data suggest that the fetal biophysical profile is a useful tool for evaluating patients with rupture of the membranes. Rupture of the membranes by itself does not alter the biophysical scoring of the healthy fetus; however, a low biophysical score (less than or equal to 7) was a good predictor of impending fetal infection in patients with premature rupture of the membranes.

Apgar Score↗
PubMed1986

Premature rupture of the membranes before 28 weeks: conservative management.

The maternal and fetal outcomes of 70 consecutive singleton pregnancies with prolonged premature rupture of the membranes before 28 weeks, which were managed expectantly, were evaluated; 58.6% of the mothers developed chorioamnionitis and 13% postpartum endomyometritis. No long-term maternal sequelae were noted. None of the 22 infants born before 25 weeks survived the neonatal period. The weights of the 35 surviving infants ranged between 800 and 4100 gm. Only 29.4% of the 17 infants with long-term follow-up were both physically and developmentally normal at 6 months of age or more.

Adolescent↗
PubMed1988

The value and limitations of the Gram stain examination in the diagnosis of intraamniotic infection.

Gram stain examination of amniotic fluid is a method used for the rapid diagnosis of intraamniotic infection in patients with preterm premature rupture of membranes and preterm labor. The management of these patients relies heavily on the Gram stain results. Therefore, it is critical that the diagnostic value and limitations, optimal technique, and outcome correlates be precisely established. Most studies have focused on culture results rather than on Gram stain results to describe neonatal and maternal outcome. However, management is based on the Gram stain because culture results are not immediately available. One hundred eighty-seven amniocenteses were performed in 131 patients with preterm premature rupture of the membranes (n = 90) and preterm labor (n = 41). Spun and unspun Gram stains were performed. Centrifugation of the sample did not improve the sensitivity of the technique significantly. The agreement between the two methods was substantial (kappa index 0.89, p less than 0.001). The sensitivity of the Gram stain was 44.8% and the specificity was 97.6%. The sensitivity of the Gram stain was directly proportional to the number of bacteria present in amniotic fluid. In the presence of greater than 10(5) colony forming units per milliliter, 80% of the Gram stains were positive. The absence of both bacteria and white blood cells in a smear was associated with a negative culture of amniotic fluid in 95% of the cases. Clinical chorioamnionitis was associated with a positive Gram stain of amniotic fluid (p less than 0.001). There was a trend toward a higher incidence of endometritis in patients with a positive Gram stain compared with those with a negative Gram stain (p = 0.07). There was no neonatal infectious morbidity in patients with a true negative Gram stain. Patients with a false negative Gram stain had a 25% incidence of neonatal infectious complications (proved and suspected sepsis).

Adult↗
PubMed1990

In vitro inhibition of esterase activity in amniotic fluid: comparison with bacterial cultures.

Assessment of leukocyte esterase activity in amniotic fluid for the rapid and reliable diagnosis of chorioamnionitis has been demonstrated previously. We compared in vitro inhibition of esterase activity in amniotic fluid with bacterial cultures to identify the origins of the specific esterases released by the infecting organisms. One hundred forty-one samples were tested (90 uninfected, 51 infected). Each sample was evaluated for Gram stain, cultures, and an in vitro esterase assay followed by ebelactone inhibition. Forty-two patients had positive amniotic fluid cultures. Ebelactone produced varying degrees of inhibition of esterase activity (range, 20% to 60%) in the uninfected samples and in those infected with gram-negative organisms. There was no inhibition in the samples infected with gram-positive organisms. Thus different groups of bacteria may elicit the production of different and specific esterases in infected amniotic fluid, as shown by the differences in in vitro inhibition.

Amniotic Fluid↗
PubMed1990

Spontaneous cell death in the chorion laeve.

The granulosa cells of the dominant follicle grow, differentiate, and die in a roughly predictable amount of time. Because the simultaneous death of this population of cells results in menstruation, one may say that the life span of this population of cells "times" the menstrual cycle. Metamorphosis in amphibians and morphogenesis in several vertebrates are other examples of developmental milestones that are "timed" by the life span of specific cell populations. In all these examples, cell death is associated with a specific histology, apoptosis. Apoptosis characterizes the cell death that produces the progressive disappearance of the trophoblast in the chorion laeve as term is approached. Therefore, the histology of trophoblastic death in the near-term chorion laeve corresponds to that of populations of cells with life spans that "time" developmental events. The trophoblastic cell population of the chorion laeve is prematurely destroyed by infiltrating maternal leukocytes in cases of chorioamnionitis.

Cell Survival↗
PubMed1990

Infection and labor. VI. Prevalence, microbiology, and clinical significance of intraamniotic infection in twin gestations with preterm labor.

The purpose of this study was to establish the prevalence, microbiology, and outcome of microbial invasion of the amniotic cavity in twin gestation presenting with preterm labor and intact membranes. Amniocenteses were performed on both sacs of 46 women with twin gestations, preterm labor, and intact membranes. Indigo carmine was injected to ensure sampling of both amniotic sacs. Amniotic fluid was cultured for aerobic and anaerobic bacteria, Mycoplasma hominis, and Ureaplasma urealyticum. A positive amniotic fluid culture of at least one sac was noted in 10.8% (5/46) of patients admitted in preterm labor and in 11.9% (5/42) of women delivered of preterm neonates. Of the five patients with microbial invasion of the amniotic cavity, three had microorganisms isolated from both sacs. The presenting sac was involved in all cases, supporting an ascending route for microbial invasion of the amniotic cavity in twin gestation. Polymicrobial infection was found in three of the eight amniotic sacs with positive cultures. In two cases different organisms were isolated from each sac. All patients with positive amniotic fluid cultures were delivered of preterm infants within 48 hours of amniocentesis. Patients with positive amniotic fluid cultures presented with preterm labor at an earlier gestational age and with more advanced cervical dilatation than did women with negative amniotic fluid cultures. Clinical evidence of chorioamnionitis subsequently developed in two of five women with positive amniotic fluid cultures. The interval between amniocentesis and delivery was shorter in women with positive amniotic fluid cultures than in women with negative amniotic fluid cultures (median: 3.5 vs 168 hours, p less than 0.0001). Infants born to women with microbial invasion of the amniotic cavity had a lower median birth weight and a higher incidence of respiratory distress syndrome than those born to women with negative amniotic fluid cultures (birth weight: 1085 vs 1975 gm, p = 0.024; respiratory distress syndrome: 37.5% vs 8.3%, p = 0.04).

Amniotic Fluid↗