羊膜腔感染综合征

羊膜腔感染综合征华西医科大学附属二院妇产科（６１００４１）曾蔚越羊膜腔感染综合征（ＩＡＩＳ）是指在孕产期由于胎膜早破等原因使病原微生物进入羊膜腔引起的一类感染．包括羊水、胎膜（绒毛膜、羊膜和蜕膜）、胎盘和／或临产前、产时发生的子宫感染。羊膜腔感染（Ｉ...     

早产与羊膜腔感染

羊膜腔感染是包括羊水、胎膜(绒毛膜、羊膜)、胎盘的感染和(或)临产前、产时发生的子宫感染.约30%的早产与羊膜腔感染有关.近年研究表明,早产伴羊膜腔感染患者的胎膜、胎盘、羊水和下生殖道分泌物中前列腺素、细胞因子浓度升高,提示其可能机制为妊娠晚期微生物通过多种途径侵入羊膜腔,刺激妊娠组织产生大量细胞因子,后者又加速前列腺素的合成与释放,从而引起宫颈成熟,子宫收缩,导致早产.对确诊的羊膜腔感染或未足月胎膜早破患者给予抗生素治疗是有效的.     

细胞因子检测诊断早期羊膜腔感染

羊膜腔感染 (ｉｎｔｒａａｍｎｉｏｔｉｃｉｎｆｅｃｔｉｏｎ)对妊娠结局及围产期患病率和死亡率均有明显影响 ,一直受到产科医生的关注。传统的羊膜腔感染的诊断方法是羊水细菌培养阳性、胎盘及胎膜组织学检查发现绒毛膜、羊膜炎或绒毛膜、羊膜培养出致病菌。但胎盘及胎膜病理检查在产后才能进行 ,而羊水细菌培养也需较长时间。因此 ,人们一直在寻找能早期快速地诊断羊膜腔感染的新方法。近年来 ,应用细胞因子检测的方法 ,早期诊断羊膜腔感染取得了一定成果 ,现将此研究概况作一综述。一、细胞因子的产生及生物学效应细胞因子 (ｃｙｔｏｋ…     

羊膜腔给药进行胎儿宫内治疗

羊水对于胎儿的生长发育、宫内恒温、恒压,保护胎儿免受外界的损伤,有着极其重要的作用。一定量的羊水能使脐带在宫内自由漂浮,胎儿活动及子宫收缩时免于受压。当胎膜早破,羊水过少易导致脐带受压胎儿窘迫,以及羊水胎粪污染,以上均成为剖宫产的指征。国外１９８３年...     

基质金属蛋白酶8检测用于早期诊断羊膜腔内感染的临床价值

在自发性早产或胎膜早破的孕妇中，有10％～40％是由羊膜腔内感染引起的。目前，诊断羊膜腔内感染的“金标准”仍是在羊水中培养出病原微生物，但其耗时长，且由于不同病原微生物需要不同的方法培养，检出率低，临床实际应用价值并不高。近年来，通过测定炎症相关细胞因子和酶类来早期检测羊膜腔内感染是研究的热点。其中，中性粒细胞所生成的基质金属蛋白酶8(matrix metalloproteinase-8，MMP-8)，早期诊断羊膜腔内感染的价值尤其得到重视。本文就这一问题综述如下。     

胎儿羊膜带综合征的超声诊断和鉴别诊断

目的通过对羊膜囊中的异常带状结构的检查，提高对羊膜带综合征诊断鉴别诊断的能力。方法对伴有宫内带状回声的孕妇进行超声检查。结果60例病例中7例是羊膜带综合征，53例有羊膜腔内异常带状回声，其中羊膜外妊娠7例，羊膜片4例，子宫不全纵隔24例，胎儿颈部水囊瘤2例，胎儿全身水肿11例，未闭合的胚外体腔5例。结论羊水中的带状结构并非都是羊膜带。在检查过程中，要注意询问患者的病史，仔细分辨羊膜腔内的带状结构的特点及毗邻关系。早期在宫内观察到带状结构者，应严密随诊。     

外周血miR-200对未足月胎膜早破合并羊膜腔感染的预测价值分析CSCD

目的 探讨外周血mi R-200对未足月胎膜早破合(PPROM)并羊膜腔感染(IAC)的预测价值。方法将孕妇82例根据IAC是否发生分为IAC组(n=23)、非IAC组(n=59),选择同期健康孕妇42例为对照组。对比各组外周血mi R-200表达,以受试者工作特征曲线(ROC)分析mi R-200对PPROM孕妇IAC发生的预测。以单因素、Logistics多因素分析PPROM孕妇IAC发生的危险因素。结果 PPROM孕妇mi R-200的表达高于对照组,IAC组mi R-200的表达高于非IAC组孕妇(均P <0.05)。mi R-200预测PPROM孕妇IAC的临界值为0.645,AUC为0.812,灵敏度、特异度分别为69.49%、78.26%。期待治疗时间>168 h,阴道清洁度,白细胞(WBC)、C反应蛋白(CRP)、降钙素原(PCT)较高,mi R-200≥0.645是PPROM发生IAC的独立危险因素(均P <0.05)。结论 PPROM外周血mi R-200可用于早期预测IAC发生,高表达mi R-200是IAC的独立危险因素。     

Estimated time to emergence of secondary intra-amniotic infection or inflammation since the onset of the preterm premature rupture of membranes

ObjectivePrematurity is the most important prognostic factor for infants born following preterm premature rupture of membranes (PPROM). Therefore, when PPROM occurs between 22 and 33 weeks of gestation, prolonging pregnancy is recommended. Determination of management strategies requires screening for the presence of intra-amniotic infection or inflammation at the time of PPROM diagnosis. If intra-amniotic infection/inflammation is not detected, it is important to monitor the patient to diagnose any new infection/inflammation. We examined the period from PPROM to secondary intra-amniotic infection/inflammation and associated factors.Materials and methodsThis retrospective study was conducted at a single facility. We examined 26 patients who experienced PPROM between 26 and 33 weeks of gestation and were negative for intra-amniotic infection/inflammation at the time of diagnosis and underwent serial amniocentesis. Antibiotic therapy comprising ampicillin, amoxicillin, and clarithromycin for 7 days was started after the first amniocentesis. The period from PPROM to secondary intra-amniotic infection/inflammation was analyzed using a Kaplan–Meier survival curve. The onset of intra-amniotic infection/inflammation was considered as the time at which amniotic fluid bacterial culture results became positive, the time when amniotic fluid Interleukin (IL)-6 increased beyond 2.6 ng/mL, or the day of delivery if histological chorioamnionitis was observed in the delivered placenta. Patients were treated as censored if no intra-amniotic infection/inflammation could be confirmed in the amniotic fluid and delivered placenta.ResultsThe median time from PPROM to secondary intra-amniotic infection/inflammation was 18 days. Six patients developed intra-amniotic infection/inflammation, while 13 patients without intra-amniotic infections/inflammation delivered fewer than 7 days after PPROM. No confounding factors at the time of PPROM diagnosis were associated with the time from PPROM until secondary intra-amniotic infection/inflammation.ConclusionsThe time between PPROM and onset of secondary intra-amniotic infection/inflammation appears prolonged. Treatments other than antimicrobial agents may need to be added to prolong pregnancy.     

Amniotic fluid Interleukin-8 as a marker for intraamniotic infection

Summary We measured the amniotic fluid Interleukin-8 (AF IL-8) levels of 80 women to see whether or not AF IL-8 levels were of value in the diagnosis of intraamniotic infection. Of twelve patients developing conventional signs of infection, 9 had an AF IL-8 concentration above 10.000 pg/ml serum. In two patients, whose baby had a serious neonatal infection, AF IL-8 concentration also exceeded 10.000 pg/ml. Only one out of 66 apparently uninfected patients had an AF IL-8 level above 10.000 pg/ml. We therefore suggest that measuring the AF IL-8 levels is of value in cases of suspected intraamniotic infection.     

Matrilysin (matrix metalloproteinase 7) in parturition, premature rupture of membranes, and intrauterine infection

OBJECTIVE: Matrix metalloproteinases are enzymes capable of degrading extracellular matrix components. Matrilysin (matrix metalloproteinase 7), a novel member of this family, degrades fibronectin and proteoglycans. The objective of this study was to determine whether parturition (either term or preterm), premature rupture of the membranes, and microbial invasion of the amniotic cavity are associated with changes in the amniotic fluid concentration of matrilysin. STUDY DESIGN: A cross-sectional study was conducted with 275 women in the following categories: (1) second trimester, (2) term not in labor, (3) term in labor, (4) term with microbial invasion of the amniotic cavity, (5) preterm labor with intact membranes without microbial invasion of the amniotic cavity who delivered at term, (6) preterm labor without microbial invasion of the amniotic cavity who delivered preterm, (7) preterm labor with microbial invasion of the amniotic cavity, (8) preterm premature rupture of membranes with and without microbial invasion of the amniotic cavity, and (9) term premature rupture of membranes not in labor and without microbial invasion of the amniotic cavity. Matrilysin concentrations were measured with a sensitive specific immunoassay that was validated for amniotic fluid. RESULTS: Matrilysin was detectable in 97.4% (268/275) of the samples. The concentration of matrilysin increased with advancing gestational age (r = 0.8; P <.001). Parturition at term was not associated with a significant increase in amniotic fluid concentration of matrilysin. Preterm parturition in the absence of microbial invasion of the amniotic cavity was associated with a significant increase in amniotic fluid concentration of matrilysin (preterm labor with preterm delivery: median, 1.7 ng/mL; range, 0.45-21.6 mg/mL; vs preterm labor with term delivery: median, 1.2 ng/mL; range, 0.17-42. 1 ng/mL; P <.05). Premature rupture of membranes without microbial invasion of the amniotic cavity (either term or preterm) was not associated with a significant change in the amniotic fluid matrilysin concentration. Intra-amniotic infection was associated with a significant increase in amniotic fluid matrilysin among both patients with preterm labor and patients with preterm premature rupture of membranes (preterm labor with microbial invasion of the amniotic cavity: median, 3.2 ng/mL; range, 0.16-21.9 ng/mL; vs preterm labor and delivery without microbial invasion of the amniotic cavity: median, 1.7 ng/mL; range, 0.45-21.6 ng/mL; vs preterm labor with term delivery: median, 1.2 ng/mL; range, 0.17-42. 1 ng/mL; P <.01 for each comparison; and preterm premature rupture of membranes without microbial invasion of the amniotic cavity: median, 1.7 ng/mL; range, 0.29-13.9 ng/mL; vs preterm premature rupture of membranes with microbial invasion of the amniotic cavity: median, 3.6 ng/mL; range, 0.59-20.3 ng/mL; P <.01). CONCLUSION: Matrilysin is a physiologic constituent of amniotic fluid, and its concentration increases with advancing gestational age. Microbial invasion of the amniotic cavity in preterm gestations was associated with a significant increase in amniotic fluid concentration of matrilysin. Matrilysin therefore may play a role in the host defense mechanism.     

Amniotic fluid glucose and intraamniotic infection

Thirty-nine patients with either premature labor and/or preterm premature ruptured membranes underwent transabdominal amniocentesis to enable the following amniotic fluid analyses to be performed: culture and sensitivity, Gram's stain, and glucose determination. All nine patients with intraamniotic infection had amniotic fluid glucose values less than 10 mg/dl. Three patients with amniotic fluid glucose levels less than 10 mg/dl but without chorioamnionitis were delivered of infants within 72 hours of admission. The mean amniotic fluid glucose level of patients with intraamniotic infection (5 +/- 2.4 mg/dl) was significantly lower than in those without intraamniotic infection (39.8 +/- 18.42 mg/dl). All patients with amniotic fluid glucose values less than 10 mg/dl had either bacteria and/or white blood cells on Gram's stain. Two patients without chorioamnionitis had white cells on Gram's stain and amniotic fluid glucose values greater than 10 mg/dl. It appears that amniotic fluid glucose is more sensitive and more specific than Gram's stain in the diagnosis of intraamniotic infection. All 12 patients with low amniotic fluid glucose values were delivered of infants within 72 hours as the result of either the presence of infection or the progression of labor.     

The risk of intra-amniotic infection, inflammation and histologic chorioamnionitis in term pregnant women with intact membranes and labor

Objective

A previous study has demonstrated that term labor is associated with an increased risk of microbial invasion of the amniotic cavity, intra-amniotic inflammation and histologic chorioamnionitis. This study was performed to determine when the risk of intra-amniotic infection, inflammation and histologic chorioamnionitis begins to increase during the course of labor.

Study design

Amniotic fluid (AF) was obtained from 926 term singleton pregnant women with intact membranes during cesarean section. AF was cultured for aerobic, anaerobic bacteria and genital mycoplasmas. An AF white blood cell (WBC) count was determined. Patients were divided into five groups according to the absence or presence of regular uterine contractions and the degree of cervical dilatation. Intra-amniotic inflammation was defined as an AF WBC ≥19/mm³. Histologic chorioamnionitis was defined as the presence of acute inflammatory changes in the extra-placental membranes or the chorionic plate of the placenta, and funisitis was diagnosed in the presence of neutrophil infiltration into the umbilical vessel walls or Wharton’s jelly.

Results

(1) The more advanced the cervical dilatation, the greater the risk of intra-amniotic infection and/or inflammation and histologic chorioamnionitis; (2) The risk of intra-amniotic infection and/or inflammation increased after the cervix began to dilate (7.8% in group 1 [without regular uterine contractions] vs. 18.3% in group 2 [regular uterine contractions and cervical dilation ≤1 cm], p < 0.01); (3) however, histologic chorioamnionitis was significantly more common in women in group 3 than in group 2 (4.2% in group 2 [regular uterine contractions and cervical dilatation ≤1 cm] vs. 23.1% in group 3 [regular uterine contractions and a cervical dilatation of 2-3 cm], p < 0.05).

Conclusions

The risk of intra-amniotic infection and/or inflammation increases after the cervix begins to dilate and that of histologic chorioamnionitis increases after the cervix dilates 2 cm in term pregnant women with regular uterine contractions with intact membranes.     

The prevalence and clinical significance of intraamniotic infection with Candida species in women with preterm labor

Summary Intraamniotic infection is considered a major etiologic factor of preterm birth. Positive amniotic fluid cultures are rarely contaminated with Candida species. The presence of this microorganism is associated with a poor pregnancy outcome. Out of 773 transabdominal amniocenteses performed in women presenting with preterm labor and intact membranes, 77 patients (9.9%) had positive amniotic fluid cultures and in 5 women (6.5%) Candida species were identified. On the other hand, 625 amniocenteses were performed in women with preterm premature rupture of membranes and 178 (28%) had positive cultures. Only in 4 patients was Candida isolated (2.2%) (P=0.13 Fisher’s exact test). The importance of early and accurate diagnosis of intraamniotic infection with Candida is pointed out. A transabdominal amniocentesis for microbiological examination is suggested for every woman presenting with preterm labor or preterm premature rupture of membranes and especially for those who conceived with a retained IUD or cervical cerclage.