Bacteria and endotoxin in meconium-stained amniotic fluid at term: could intra-amniotic infection cause meconium passage?

Abstract

Background: Meconium-stained amniotic fluid (MSAF) is a common occurrence among women in spontaneous labor at term, and has been associated with adverse outcomes in both mother and neonate. MSAF is a risk factor for microbial invasion of the amniotic cavity (MIAC) and preterm birth among women with preterm labor and intact membranes. We now report the frequency of MIAC and the presence of bacterial endotoxin in the amniotic fluid of patients with MSAF at term.

Materials and methods: We conducted a cross-sectional study including women in presumed preterm labor because of uncertain dates who underwent amniocentesis, and were later determined to be at term (n?=?108). Patients were allocated into two groups: (1) MSAF (n?=?66) and (2) clear amniotic fluid (n?=?42). The presence of bacteria was determined by microbiologic techniques, and endotoxin was detected using the Limulus amebocyte lysate (LAL) gel clot assay. Statistical analyses were performed to test for normality and bivariate comparisons.

Results: Bacteria were more frequently present in patients with MSAF compared to those with clear amniotic fluid [19.6% (13/66) versus 4.7% (2/42); p?<?0.05]. The microorganisms were Gram-negative rods (n?=?7), Ureaplasma urealyticum (n?=?4), Gram-positive rods (n?=?2) and Mycoplasma hominis (n?=?1). The LAL gel clot assay was positive in 46.9% (31/66) of patients with MSAF, and in 4.7% (2/42) of those with clear amniotic fluid (p?<?0.001). After heat treatment, the frequency of a positive LAL gel clot assay remained higher in the MSAF group [18.1% (12/66) versus 2.3% (1/42), p?<?0.05]. Median amniotic fluid IL-6 concentration (ng/mL) was higher [1.3 (0.7–1.9) versus 0.6 (0.3–1.2), p?=?0.04], and median amniotic fluid glucose concentration (mg/dL) was lower [6 (0–8.9) versus 9 (7.4–12.6), p?<?0.001] in the MSAF group, than in those with clear amniotic fluid.

Conclusion: MSAF at term was associated with an increased incidence of MIAC. The index of suspicion for an infection-related process in postpartum women and their neonates should be increased in the presence of MSAF.     

Significance of assay of nucleated RBCs in umbilical cord blood in neonates with meconium-stained amniotic fluid

Background: Approximately 8–15% of all infants are born with evidence of meconium-stained amniotic fluid (MSAF). MSAF is a potentially serious sign of fetal compromise and may indicate fetal hypoxia

Objectives and aim of the work: The present study was designed to evaluate the relationship between meconium stained amniotic fluid and fetal nucleated red blood cell counts. As well, we aim to evaluate the relationship between the presence of meconium in amniotic fluid and Apgar scores in neonates.

Subjects and methods: A prospectively case-controlled study was performed on 40 women with clear amniotic fluid as control and 40 women with meconium-stained amniotic fluid as the study group. At delivery, 2?ml of umbilical cord blood was collected and analyzed for nucleated red blood cell (NRBC).

Results: The mean NRBC counts in meconium-stained amniotic fluid was significantly higher than the control group (18.35?±?7.7 and 9.6?±?4.96), respectively (p?p?Conclusion: Our results support previous studies which indicate the presence of meconium can be associated with chronic fetal hypoxia as demonstrated by elevated fetal NRBC levels.     

Amniotic fluid prostaglandin E2 in pregnancies complicated by preterm prelabor rupture of the membranes

Objective: To determine amniotic fluid prostaglandin E2 concentrations in women preterm prelabor rupture of the membranes (PPROM) with respect to microbial invasion of the amniotic cavity (MIAC), intraamniotic inflammation (IAI), microbial-associated IAI, histological chorioamnionitis, and short-term neonatal morbidity.

Methods: One hundred forty-five women with singleton pregnancies were included in this study. Amniotic fluid samples were obtained by transabdominal amniocentesis and were assayed for prostaglandin E2 concentrations by ELISA. IAI was defined as amniotic fluid interleukin-6 >745?pg/mL. Microbial-associated IAI was defined as the presence of both MIAC and IAI.

Result: No differences in prostaglandin E2 concentrations were found between women with and without MIAC (p?=?0.27). Women with IAI (p?=?0.0008) and microbial-associated IAI (p?=?0.01) had higher prostaglandin E2 concentrations than women without these complications. Women with histological chorioamnionitis had higher prostaglandin E2 concentrations only in crude analysis (p?=?0.02), but not after adjustment for gestational age at sampling (p?=?0.10). No associations between amniotic fluid prostaglandin E2 concentrations and the selected conditions of severe neonatal morbidity were found.

Conclusions: The intraamniotic inflammatory response either to infectious or to non-infectious stimulus, but not MIAC per se, seems to be a main factor associated with the elevation of the amniotic fluid PGE2 concentrations in women with PPROM.     

Cervical fluid calreticulin and cathepsin-G in pregnancies complicated by preterm prelabor rupture of membranes

Objective: The study aimed to determine the cervical calreticulin and cathepsin-G concentrations in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) with respect to the presence of microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation (IAI).

Methods: Eighty women with singleton pregnancies complicated by PPROM were included in this study. Cervical and amniotic fluids were obtained at the time of admission, and concentrations of calreticulin and cathepsin-G in cervical fluid were determined using ELISA. The MIAC was defined as a positive PCR analysis for Ureaplasma species, Mycoplasma hominis, and/or Chlamydia trachomatis and/or by positivity for the 16S rRNA gene. IAI was defined as amniotic fluid bedside IL-6 concentrations ≥745?pg/mL

Result: Neither women with MIAC nor with IAI had different cervical fluid concentrations of calreticulin (with MIAC: median 18.9?pg/mL vs. without MIAC: median 14.7?pg/mL, p?=?0.28; with IAI: median 14.3?pg/mL vs. without IAI: median 15.6?pg/mL, p?=?0.57;) or of cathepsin-G (with MIAC: median 30.7?pg/mL vs. without MIAC: median 24.7?pg/mL, p?=?0.28; with IAI: median 27.3?pg/mL vs. without IAI: median 25.1?pg/mL, p?=?0.80) than women without those complications. No associations between amniotic fluid IL-6 concentrations, gestational age at sampling, and cervical fluid calreticulin and cathepsin-G concentrations were found.

Conclusions: Cervical fluid calreticulin and cathepsin-G concentrations did not reflect the presence of MIAC or IAI in women with PPROM.     

Amniotic fluid cathepsin-G in pregnancies complicated by the preterm prelabor rupture of membranes

Objective: The aim of this study was to evaluate the amniotic fluid cathepsin-G concentrations in women with preterm prelabor rupture of membranes (PPROM) based on the presence of the microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI).

Methods: A total of 154 women with singleton pregnancies complicated by PPROM were included in this study. Amniotic fluid samples were obtained by transabdominal amniocentesis. Amniotic fluid cathepsin-G concentrations were assessed by ELISA. MIAC was determined using a non-cultivation approach. IAI was defined as an amniotic fluid bedside interleukin-6 concentration?≥?745?pg/mL.

Results: Women with MIAC had higher amniotic fluid cathepsin-G concentrations than women without MIAC (with MIAC: median 82.7?ng/mL, versus without MIAC: median 64.7?ng/mL; p?=?0.0003). Women with IAI had higher amniotic fluid cathepsin-G concentrations than women without this complication (with IAI: median 103.0?ng/mL, versus without IAI: median 66.2?ng/mL; p?p?Conclusions: The presence of either microbial-associated or sterile IAI was associated with increased amniotic fluid cathepsin-G concentrations in pregnancies complicated by PPROM. Amniotic fluid cathepsin-G appears to be a potential marker of IAI.     

Amniotic fluid clusterin in pregnancies complicated by the preterm prelabor rupture of membranes

Objective: The aim of this study was to evaluate clusterin concentrations in amniotic fluid in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) with respect to the presence of the microbial invasion of the amniotic cavity (MIAC), intra-amniotic inflammation (IAI) and microbial-associated IAI.

Methods: One hundred thirty-six women with singleton pregnancies complicated by PPROM were included in this study. Amniotic fluid samples were obtained by transabdominal amniocentesis. Amniotic fluid clusterin concentrations were assessed by enzyme-linked immunosorbent assay. MIAC was determined by a non-cultivation approach. IAI was defined as an amniotic fluid bedside interleukin-6 concentration?≥745?pg/mL. Microbial-associated IAI was characterized as the presence of both MIAC and IAI.

Result: Women with MIAC, IAI and microbial-associated IAI had lower amniotic fluid clusterin concentrations than women without these complications (with MIAC: median 1314?ng/mL versus without MIAC: median 1633?ng/mL, p?=?0.003; with IAI: median 1281?ng/mL versus without IAI: median 1575?ng/mL, p?=?0.04; with microbial associated-IAI: median 1220?ng/mL versus without microbial-associated IAI: median 1575?pg/mL; p?=?0.008). A week negative correlation between amniotic fluid clusterin concentrations and gestational age at sampling was revealed (rho=??0.30; p?=?0.0005).

Conclusions: The presence of MIAC, IAI and microbial-associated IAI was characterized by lower amniotic fluid clusterin concentrations in pregnancies complicated by PPROM.     

Cervical fluid interleukin 6 and intra-amniotic complications of preterm prelabor rupture of membranes

Objective: To determine if cervical fluid interleukin (IL)-6 concentrations in women with preterm prelabor rupture of membranes (PPROM) allows identification of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI).

Methods: One hundred forty-four women with singleton pregnancies complicated by PPROM were included in this prospective cohort study. Cervical and amniotic fluids were collected at the time of admission and concentrations of IL-6 were measured using an ELISA and point-of-care test, respectively. Cervical fluid was obtained using a Dacron polyester swab and amniotic fluid was obtained by transabdominal amniocentesis. MIAC was diagnosed based on a positive PCR result for Ureaplasma species, M. hominis, and/or C. trachomatis and/or by positivity for the 16?S rRNA gene. IAI was defined as amniotic fluid point-of-care IL-6 concentrations ≥745?pg/mL. The women were assigned to four subgroups based on the presence of MIAC and/or IAI: microbial-associated IAI (both MIAC and IAI), sterile IAI (IAI alone), MIAC alone, and without either MIAC or IAI.

Results: (1) Women with microbial-associated IAI had higher cervical fluid IL-6 concentrations (median 560?pg/mL) than did women with sterile IAI (median 303?pg/mL; p?=?.001), women with MIAC alone (median 135?pg/mL; p?=?.0004), and women without MIAC and IAI (median 180?pg/mL; p?=?.0001). (2) No differences were found in cervical fluid IL-6 concentrations among women with sterile IAI, with MIAC alone, and without MIAC and IAI. (3) A positive correlation was observed between cervical fluid IL-6 concentrations and the amount of Ureaplasma species in amniotic fluid (copies DNA/mL; rho?=?0.57, p?p?Conclusions: The presence of microbial-associated IAI is associated with the highest cervical fluid IL-6 concentrations. Cervical IL-6 can be helpful in the identification of microbial-associated IAI.     

Amniotic fluid calreticulin in pregnancies complicated by the preterm prelabor rupture of membranes

Objective: This study aimed to determine the amniotic fluid calreticulin concentrations in women with the preterm prelabor rupture of membranes (PPROM) based on the microbial invasion of the amniotic cavity (MIAC), intraamniotic inflammation (IAI) and microbial-associated IAI.

Methods: One hundred sixty-eight women with singleton pregnancies were included in this study. Amniotic fluid samples were obtained by transabdominal amniocentesis and were assayed for calreticulin concentrations by ELISA. IAI was defined as an amniotic fluid interleukin-6 concentration?>?745?pg/ml. Microbial-associated IAI was defined as the presence of both MIAC and IAI.

Result: Women with MIAC (with MIAC: median 54.4?ng/ml, versus without MIAC: median 32.6?ng/ml; p?<?0.0001), IAI (with IAI: median 66.8?ng/ml, versus without IAI: median 33.0?ng/ml; p?<?0.0001) and microbial-associated IAI (with microbial-associated IAI: median 82.5?ng/ml, versus without microbial-associated IAI: median 33.7?ng/ml; p?<?0.0001) had higher concentrations of calreticulin than women without these complications. An amniotic fluid calreticulin concentration of 81.4?ng/ml was found to be the best cutoff point for identifying women with microbial-associated IAI.

Conclusions: The presence of microbial-associated IAI is associated with increased amniotic fluid calreticulin concentrations. Calreticulin seems to be a promising marker for the early identification of PPROM complicated by microbial-associated IAI.     

Cervical and vaginal fluid soluble Toll-like receptor 2 in pregnancies complicated by preterm prelabor rupture of membranes

Objective: To determine the cervical and vaginal fluid soluble Toll-like receptor-2 (sTLR2) levels in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) and their correlation to microbial invasion of the amniotic cavity (MIAC) and/or histological chorioamnionitis (HCA).

Methods: Sixty-eight women with singleton pregnancies complicated by PPROM were included in this study. Cervical and vaginal fluid was collected at the time of admission, and levels of sTLR2 in the cervical and vaginal fluid were determined using enzyme-linked immunosorbent assay.

Result: Women with MIAC and both MIAC and HCA did not have different cervical and vaginal fluid sTLR2 levels compared to those without MIAC and without both MIAC and HCA. Women with HCA had higher cervical fluid sTLR2 levels in crude analysis (with HCA: median 11.6?pg/mL versus without HCA: median 5.5?pg/mL; p?=?0.04) but not after adjustment for gestational age at sampling (p?=?0.19). No difference in vaginal fluid sTLR2 levels between women with and without HCA was found. A positive correlation between cervical and vaginal fluid sTLR2 levels was identified (rho?=?0.54; p?Conclusions: Cervical and vaginal fluid sTLR2 levels did not reflect the presence of MIAC and/or HCA.     

Amniotic fluid markers of oxidative stress in pregnancies complicated by preterm prelabor rupture of membranes

Objective: To determine amniotic fluid total antioxidant capacity (TAC), ferric-reducing antioxidant power (FRAP) and thiobarbituric acid-reacting substances (TBARS), markers of oxidative stress, in pregnancies complicated by preterm prelabor rupture of membranes (pPROM) and their correlation to microbial invasion of the amniotic cavity (MIAC) and/or histological chorioamnionitis (HCA).

Methods: One-hundred thirty-eight women with singleton pregnancies complicated by pPROM were included in this study. Amniotic fluid was collected by transabdominal amniocentesis at the time of admission and amniotic fluid concentrations of TAC, FRAP and TBARS were measured.

Result: The presence of MIAC and/or HCA did not show any significant differences in the amniotic fluid TAC, FRAP and TBARS concentrations. Positive correlations between gestational age at sampling and amniotic fluid TAC and FRAP concentrations were found (TAC: rho?=?0.32; p?=?0.0002; FRAP: rho?=?0.36; p?<?0.0001). A negative correlation between gestation age at sampling and amniotic fluid TBARS concentrations was identified (rho?=?–0.25; p?=?0.004).

Conclusions: Oxidative stress is associated with pPROM as indicated by the presence of markers tested in the amniotic fluid; however, oxidative stress markers tested are not influenced by the presence of MIAC or HCA.     

Investigation of maternal and cord blood erythropoietin and copeptin levels in low-risk term deliveries complicated by meconium-stained amniotic fluid

Objective: To compare maternal, cord blood erythropoietin (EPO), and copeptin levels in low-risk term deliveries which are complicated by meconium-stained amniotic fluid (MSAF) to those with clear amniotic fluid. Also, to evaluate the relations between these markers and cord blood pH values.

Methods: Low-risk term pregnant women with MSAF at an active phase of labor were defined as the study group (n?=?39). Pregnant women with clear amniotic fluid were selected for the control group (n?=?41). The two groups were matched for age, body mass index and gestational age. Maternal, cord blood EPO and copeptin levels with cord blood pH values were also measured.

Results: Maternal, cord blood EPO, and copeptin levels of study and control groups were 42.6?±?9.0 versus 40.7?±?9.2, 134.2 (20.5–834.6) versus 38.4 (10.3–114.2), 4.9 (0.1–31.1) versus 4.0 (3.1–28.4), and 4.7 (2.6–25.5) versus 3.6 (2.0–23.2), respectively. The differences were statistically significant for cord blood EPO, maternal and cord blood copeptin levels (p?p?=?0.004, p?p?p?p?=?0.005, and p?=?0.009, respectively).

Conclusion: We suggest that higher cord blood EPO and maternal and cord blood copeptin levels may be an indicator of fetal acidosis in low-risk term deliveries complicated by MSAF.     

Idiopathic vaginal bleeding during pregnancy as the only clinical manifestation of intrauterine infection

Objective.?To determine the frequency and clinical significance of microbial invasion of the amniotic cavity (MIAC) in patients with vaginal bleeding in the absence of placenta previa, preterm labor or preterm premature rupture of membranes (PROM).

Study design.?This retrospective cohort study included patients who presented with vaginal bleeding between 18 and 35 weeks, and underwent an amniocentesis shortly after admission for the assessment of the microbiologic status of the amniotic cavity and/or fetal lung maturity. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as genital mycoplasmas. Patients presenting with preterm labor, preterm PROM, placenta previa, overt placental abruption, and an intrauterine device in situ were excluded, as well as those with local cervical bleeding. MIAC was defined as a positive amniotic fluid culture. Analysis was conducted with non-parametric statistics.

Results.?One hundred and fourteen patients met the entry criteria. MIAC was detected in 14% of cases (16/114). Patients with vaginal bleeding and a gestational age <?28 weeks at the time of amniocentesis had a significantly higher frequency of MIAC than those with a gestational age ??28 weeks [25% (13/52) vs. 4.8% (3/62), respectively; p?<?0.01]. Ureaplasma urealyticum was the microorganism most frequently isolated from the amniotic fluid. Except for one case admitted at 33 weeks, all patients with MIAC?had an early preterm delivery ??32 weeks. Patients with vaginal bleeding and MIAC?had a shorter procedure-to-delivery interval than those without MIAC [MIAC, median survival 19 days (95% CI 10–27 days) vs. no MIAC, median survival 50 days (95% CI 37–62 days); p?<?0.0001]. Patients with vaginal bleeding and MIAC?had a significantly lower gestational age at delivery and lower birth weight than those with vaginal bleeding and negative amniotic fluid cultures (for gestational age, median 25 weeks, range 21–33 weeks vs. median 37 weeks, range 19–42 weeks, respectively; p?<?0.01, and for birth weight, median 750?grams, range 520–1820?grams vs. 2800?grams, range 520–4880?grams, respectively; p?<?0.01), as well as a higher frequency of subsequent preterm PROM [81.3% (13/16) vs. 9.2% (9/98); p?<?0.01].

Conclusions.?MIAC was detected in 14% of patients with ‘idiopathic’ vaginal bleeding and was associated with subsequent preterm PROM and early preterm delivery. Vaginal bleeding may be the only clinical manifestation of MIAC, and it predisposes to adverse outcome.     

Unexplained fetal death is associated with increased concentrations of anti-angiogenic factors in amniotic fluid

Objective.?Angiogenesis is critical for successful pregnancy. An anti-angiogenic state has been implicated in preeclampsia, fetal growth restriction and fetal death. Increased maternal plasma concentrations of the anti-angiogenic factor, soluble vascular endothelial growth factor receptor (sVEGFR)-1, have been reported in women with preeclampsia and in those with fetal death. Recent observations indicate that an excess of sVEGFR-1 and soluble endoglin (sEng) is also present in the amniotic fluid of patients with preeclampsia. The aim of this study was to determine whether fetal death is associated with changes in amniotic fluid concentrations of sVEGFR-1 and sEng, two powerful anti-angiogenic factors.

Study design.?This cross-sectional study included patients with fetal death (n?=?35) and controls (n?=?129). Fetal death was subdivided according to clinical circumstances into: (1) unexplained (n?=?25); (2) preeclampsia and/or placental abruption (n?=?5); and (3) chromosomal/congenital anomalies (n?=?5). The control group consisted of patients with preterm labor (PTL) who delivered at term (n?=?92) and women at term not in labor (n?=?37). AF concentrations of sVEGFR-1 and sEng were determined by ELISA. Non-parametric statistics and logistic regression analysis were applied.

Results.?(1) Patients with a fetal death had higher median amniotic fluid concentrations of sVEGFR-1 and sEng than women in the control group (p?<?0.001 for each); (2) these results remained significant among different subgroups of stillbirth (p?<?0.05 for each); and (3) amniotic fluid concentrations of sVEGFR-1 and those of sEng above the third quartile were associated with a significant risk of unexplained preterm fetal death (adjusted OR?=?10.8; 95%CI 1.3–89.2 and adjusted OR 87; 95% CI 2.3–3323, respectively).

Conclusion.?Patients with an unexplained fetal death at diagnosis are characterized by an increase in the amniotic fluid concentrations of sVEGFR-1 and sEng. These observations indicate that an excess of anti-angiogenic factors in the amniotic cavity is associated with unexplained fetal death especially in preterm gestations.     

Should fetal scalp blood sampling be performed in the case of meconium-stained amniotic fluid?

Objective: To investigate the effect of using fetal scalp blood sampling on the risk of neonatal respiratory distress syndrome (NRDS) with meconium-stained amniotic fluid (MSAF).

Methods: Prospective data collection with regard to MSAF during labor for low-risk term cephalic singleton live birth from 2012 to 2014. Maternal, obstetric and neonatal data were compared according to the occurrence of respiratory distress syndrome (RDS group) or not (no RDS group).

Results: Of 515 newborns born through MSAF, 46 experienced RDS and from them 10 experienced meconium aspiration syndrome. No difference was observed according to maternal characteristic, abnormal fetal heart rate tracing pattern irrespective of its category and cesarean rate. Apgar at one?minute was lower in the group RDS (7.6 versus 8.5, p?<?0.05). The mean umbilical artery pH values did not differ between the two groups. Significant difference between newborns with and without RDS in terms of fetal scalp lactate sampling during the labor (71.1% versus 55.1%, p?<?0.05), and neonatal care unit (NCU) admissions (22.8% versus 10.8%, p?<?0.05). Secondary rather than primary meconium was associated with RDS when performing fetal scalp blood assessment (p?<?0.05). A significant correlation between RDS, fetal scalp blood assessment and MSAF diagnosed during the first stage of labor (after spontaneous rupture of membranes or at amniotomy) was found.

Conclusion: In case of MSAF, fetal scalp blood sampling did not reduce the risk of RDS.     

Ureaplasma species and Mycoplasma hominis in cervical fluid of pregnancies complicated by preterm prelabor rupture of membranes

Objective: To evaluate Ureaplasma species and Mycoplasma hominis DNA in the cervical fluid and their association with microbial invasion of the amniotic cavity (MIAC) and/or histological chorioamnionitis (HCA) in pregnancies complicated by preterm prelabor rupture of membranes (PPROM).

Study design: A prospective study of 68 women with singleton pregnancies complicated by PPROM between 24^0/7 and 36^6/7 weeks was conducted. Cervical fluid and amniotic fluid were collected from all women at the time of admission. The Ureaplasma species and Mycoplasma hominis DNA in the cervical fluid were identified using specific real-time PCR.

Results: Ureaplasma species and Mycoplasma hominis DNA were identified in 59% (40/69) of the cervical fluid samples. Women with the presence of Ureaplasma species DNA with and without Mycoplasma hominis DNA in the cervical fluid had a higher rate of MIAC alone [35% (14/40) versus 11% (3/28); p?=?0.02] and a higher rate of the presence of both MIAC and HCA [30% (12/40) versus 4% (1/28); p?=?0.01] than women without Ureaplasma species and Mycoplasma hominis DNA in the cervical fluid.

Conclusions: The presence of Ureaplasma species DNA with and without Mycoplasma hominis DNA in the cervical fluid is associated with a higher risk of MIAC or MIAC and HCA together in pregnancies complicated by PPROM.     

Cervical fluid IL-6 and IL-8 levels in pregnancies complicated by preterm prelabor rupture of membranes

Objective: To determine the cervical fluid interleukin (IL)-6 and IL-8 levels in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) and the association of these interleukins with microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis (HCA).

Methods: Sixty women with singleton pregnancies were included in this study. Cervical fluid was sampled at the time of admission using Dacron polyester swabs, which were placed into the endocervical canal for 20?s. IL-6 and IL-8 levels were determined by ELISA. The management of PPROM was active management (except for in pregnancies <28 weeks of gestation) and occurs not later than 72?h after the rupture of membranes.

Result: The women with MIAC had higher IL-6 and IL-8 levels than did the women without MIAC (IL-6: p?=?0.01; IL-8: p?=?0.003). There was no difference in IL-6 levels between women with and without HCA (p?=?0.37). The women with HCA had higher IL-8 levels only in the crude analysis (p?=?0.01) but not after adjustment for gestational age (p?=?0.06). The women with both MIAC and HCA had higher levels of IL-6 and IL-8 than did the other women (IL-6: p?=?0.003; IL-8: p?=?0.001). IL-8 level of 2653?pg/mL was found to be the best cut-off point in the identification of PPROM pregnancies complicated by both MIAC and HCA with a likelihood ratio of 24.

Conclusions: The presence of MIAC is the most important factor impacting the local cervical inflammatory response, which is determined by IL-6 and IL-8 levels in the cervical fluid. IL-8 levels seem to be a promising non-invasive marker for the prediction of pregnancies complicated by the presence of both MIAC and HCA.     

Evidence for complement activation in the amniotic fluid of women with spontaneous preterm labor and intra-amniotic infection

Objective.?The complement system plays an important role in host defense against infection. Concentrations of complement split products or anaphylatoxins (C3a, C4a, and C5a) in biological fluids are considered to reflect complement activation. The purpose of this study was to determine if term and preterm parturition are associated with evidence of complement activation in the amniotic fluid.

Study design.?Amniotic fluid (AF) samples were collected from 270 women in the following groups: (1) normal pregnant women in midtrimester (n = 70), (2) term not in labor (n = 23), (3) term in labor (n = 48), and (4) preterm labor (PTL) (n = 129). PTL was categorized into: (a) PTL without microbial invasion of the amniotic cavity (MIAC) who delivered at term (n = 42), (b) PTL who delivered preterm without MIAC (n = 57), and (c) PTL with MIAC (n = 30). C5a, C4a, and C3a concentrations in amniotic fluid were determined by ELISA. Nonparametric tests were used for statistical analysis.

Results.?(1) The median AF C5a concentration was higher in women at term than that of those in the midtrimester (p = 0.02); (2) Spontaneous labor at term was not associated with changes in AF concentrations of anaphylatoxins C3a, C4a, and C5a (all p > 0.05); (3) Among patients with PTL who delivered preterm, those with MIAC had higher AF C4a and C5a concentrations than those without infection (p < 0.01); and (4) AF C3a, C4a, and C5a concentrations were higher in patients with PTL with MIAC than in those with PTL without MIAC who delivered at term.

Conclusion.?Patients with spontaneous preterm labor and intact membranes with microbial invasion of the amniotic cavity had higher median amniotic fluid concentration of complement split products C3a, C4a, and C5a than patients without intra-amniotic infection. These findings suggest that preterm labor in the context of infection is associated with activation of the complement system.     

Vaginal fluid IL-6 and IL-8 levels in pregnancies complicated by preterm prelabor membrane ruptures

Objective: To determine the vaginal fluid interleukin (IL)-6 and IL-8 concentrations in pregnancies complicated by preterm prelabor rupture of membranes and their correlation to microbial invasion of the amniotic cavity (MIAC) as well as histological chorioamnionitis (HCA).

Methods: Sixty-eight women with singleton pregnancies were included in this study. Vaginal fluid was collected at the time of admission. IL-6 and IL-8 concentrations in the vaginal fluid were determined using ELISA.

Result: Women with MIAC had higher vaginal fluid IL-6 levels compared to those without MIAC (with MIAC: median 374?pg/mL versus without MIAC: median 174?pg/mL; p?=?0.03). IL-8 levels were higher in women with MIAC only in the crude analysis but not after adjustment for gestational age. There was no difference in the IL-6 and IL-8 concentrations between those with and without HCA. Women with both MIAC and HCA had higher IL-6 vaginal fluid levels than those without both MIAC and HCA (with MIAC and HCA: median 466?pg/mL versus without MIAC and HCA: median 178?pg/mL; p?=?0.02). IL-8 levels were higher in women with MIAC and HCA only in the crude analysis but not after adjustment for gestational age.

Conclusions: Vaginal fluid IL-6 but not IL-8 levels reflect the presence of MIAC and both MIAC and HCA.     

New onset of meconium during labor versus primary meconium-stained amniotic fluid – is there a difference in pregnancy outcome?

Abstract

Objective: To compare pregnancy outcome between deliveries complicated by new onset of meconium during labor following prior evidence of clear amniotic fluid and labors in which meconium was present to begin with.

Methods: A retrospective cohort study of all singleton term (≥37?+?0 weeks) deliveries complicated by intrapartum meconium-stained amniotic fluid in a tertiary referral medical center during the year 2012. Outcome was compared between deliveries with new onset of meconium during labor following prior evidence of clear amniotic fluid (secondary meconium group) and those in which meconium was already evident at the time of membranes rupture (primary meconium group).

Results: Of the 9167 deliveries during the study period, 694 were eligible for the study group. Of these, 537 were complicated by primary meconium and 157 by secondary meconium. Only secondary meconium, but not primary meconium, was independently associated with an increased risk of operative vaginal delivery (OVD) and adverse neonatal outcome. Pregnancies complicated by secondary meconium were independently associated with a higher rate of OVD (28.0% versus 11.4%, p?<?0.001), POP position of the fetal head (6.4% versus 2.6%, p?=?0.02), and adverse neonatal outcome (17.2% versus 8.9%, p?=?0.003).

Conclusion: Secondary meconium is associated with a higher rate of adverse obstetrical and neonatal outcome compared with primary meconium.     

Neonatal outcomes in subgroups of women with preterm prelabor rupture of membranes before 34 weeks

Objective: To evaluate the influence of microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis (HCA) on short-term neonatal outcome in women with preterm prelabor rupture of membranes before 34 weeks of gestation.

Methods: A prospective observational cohort study including 122 pregnant women with PPROM between 24+0 and 34+0. MIAC was defined as a positive PCR result for Ureaplasma species, Mycoplasma hominis and Chlamydia trachomatis and/or positive PCR result for the 16S rRNA gene in the amniotic fluid. HCA was defined according to the Salafia classification. Maternal and short-term neonatal outcomes were evaluated according to the presence or absence of MIAC and/or HCA.

Results: The presence of both MIAC and HCA was observed in 36% (45/122) of women, HCA alone in 34% (41/122) and MIAC in 5% (6/122). A significantly higher incidence of early onset sepsis was observed in newborns born from women with both MIAC and HCA [33% (15/45)] compared with women with HCA alone [12% (5/41)] or MIAC alone [0% (0/6)] or women without MIAC or HCA detected [0% (0/30); p?=?0.001].

Conclusions: The presence of both MIAC and HCA increases the risk of early onset sepsis in pregnancies complicated by preterm prelabor rupture of membranes before 34 weeks of gestation.