Antibiotic treatment reduces the intensity of intraamniotic inflammation in pregnancies with idiopathic vaginal bleeding in the second trimester of pregnancy.

BACKGROUND: Idiopathic bleeding in the second trimester of pregnancy complicates <1% of all pregnancies. This pregnancy complication can be caused by alterations in local hemostasis in the decidua due to infection/inflammation in the choriodecidual niche. This condition is associated with intraamniotic inflammatory complications. Antibiotic therapy effectively reduces the intensity of intraamniotic inflammation in certain pregnancy pathologies. However, whether antibiotic administration can reduce the intensity of the intraamniotic inflammatory response or eradicate microorganisms in patients with idiopathic bleeding during the second trimester of pregnancy remains unclear. OBJECTIVE: This study primarily aimed to determine whether antimicrobial agents can reduce the magnitude of intraamniotic inflammation in patients with idiopathic bleeding in the second trimester of pregnancy by assessing the concentration of interleukin-6 in the amniotic fluid before and after 7 days of antibiotic treatment. The secondary aim was to determine whether treatment with a combination of antibiotics altered the microbial load of Ureaplasma species DNA in amniotic fluid. STUDY DESIGN: This retrospective cohort study included singleton-gestation patients with idiopathic bleeding between 15+0 and 27+6 weeks who underwent transabdominal amniocentesis at the time of admission. Follow-up amniocentesis was performed in a subset of patients unless abortion or delivery occurred earlier. Concentrations of interleukin-6 were measured in the amniotic fluid samples, and the presence of microbial invasion of the amniotic cavity was assessed using culture and molecular microbiological methods. Intraamniotic inflammation was defined as an interleukin-6 concentration ≥3000 pg/mL in the amniotic fluid samples. RESULTS: A total of 36 patients with idiopathic bleeding in the second trimester of pregnancy were included. All the patients underwent initial amniocentesis. Patients with intraamniotic inflammation (n=25) were treated using a combination of antibiotics consisting of intravenous ceftriaxone, intravenous metronidazole, and peroral clarithromycin. The patients without intraamniotic inflammation (n=11) were treated expectantly. In total, 25 patients delivered 7 days after admission. All patients with intraamniotic inflammation at the initial amniocentesis who delivered after 7 days underwent follow-up amniocentesis. Treatment with antibiotics decreased the interleukin-6 concentration in the amniotic fluid at follow-up amniocentesis compared with that at the initial amniocentesis in patients with intraamniotic inflammation (median [interquartile range]: 3457 pg/mL [2493-13,203] vs 19,812 pg/mL [11,973-34,518]; P=.0001). Amniotic fluid samples with Ureaplasma species DNA had a lower microbial load at the time of follow-up amniocentesis compared with the initial amniocentesis (median [interquartile range]: 1.5×105 copies DNA/mL [1.3×105-1.7×105] vs 8.0×107 copies DNA/mL [6.7×106-1.6×108]; P=.02). CONCLUSION: Antibiotic therapy was associated with reduced intraamniotic inflammation in patients with idiopathic bleeding in the second trimester complicated by intraamniotic inflammation. Moreover, antibiotic treatment has been associated with a reduction in the microbial load of Ureaplasma species DNA in the amniotic fluid.

Amniotic fluid CD36 in pregnancies complicated by spontaneous preterm delivery: a retrospective cohort study.

OBJECTIVE: The aim of this study was to evaluate CD36 concentrations in amniotic fluid in pregnancies complicated by spontaneous delivery with intact fetal membranes (preterm labor, PTL) and preterm prelabor rupture of membranes (PPROM) with respect to the presence of the intra-amniotic infection. METHODS: A total of 80 women with PPROM and 71 with PTL were included in the study. Amniotic fluid samples were obtained by transabdominal amniocentesis. Amniotic fluid CD36 concentrations were assessed by enzyme-linked immunosorbent assay. Microbial colonization of the amniotic cavity (MIAC) was determined by the cultivation and non-cultivation approach. Intra-amniotic inflammation (IAI) was defined as an amniotic fluid bedside interleukin-6 concentration ≥3000 pg/mL. Intra-amniotic infection was characterized by the presence of both MIAC and IAI. RESULTS: Women with PPROM with intra-amniotic infection had higher amniotic fluid CD36 concentrations than women without infection (with infection: median 346 pg/mL, IQR 262-384 vs. without infection: median 242 pg/mL, IQR 199-304; p = .006) A positive correlation between amniotic fluid CD36 concentrations and interleukin-6 concentrations was found (rho = 0.48; p < .0001). In PTL pregnancies, no statistically significant difference was found in the amniotic fluid level of CD36 between intra-amniotic infection, sterile IAI, and negative amniotic fluid. CONCLUSIONS: The presence of intra-amniotic infection is characterized by higher amniotic fluid CD36 concentrations in pregnancies complicated by PPROM. An amniotic fluid CD36 cutoff value of 252.5 pg/mL was found to be optimal for the prediction of intra-amniotic infection. In PTL pregnancies, no statistically significant change in CD36 concentration was found with respect to the presence of intra-amniotic infection.

Cervical excisional treatment increases the risk of intraamniotic infection in subsequent pregnancy complicated by preterm prelabor rupture of membranes.

BACKGROUND: Excisional treatment of cervical intraepithelial neoplasia or very early stages of cervical cancer increases the risk of preterm prelabor rupture of membranes in subsequent pregnancies. The risk increases with the length of the excised cone. The subset of cases with preterm prelabor rupture of membranes and a history of cervical excisional treatment could also be at higher risk of intraamniotic infection/inflammation. However, there is a paucity of relevant information on this subject. OBJECTIVE: This study aimed to assess the differences in the rates of intraamniotic infection/inflammation and early-onset neonatal sepsis between singleton preterm prelabor rupture of membranes pregnancies without and with a history of cervical excisional treatment, and to investigate the association between these complications of preterm prelabor rupture of membranes and the excised cone length. STUDY DESIGN: This retrospective cohort study included 770 preterm prelabor rupture of membranes pregnancies in which transabdominal amniocentesis was performed as part of standard clinical management to assess the intraamniotic environment. The maternal and perinatal medical records of all included women were reviewed to obtain information on the absence or presence of history of cervical excisional treatment and neonatal outcomes. Women whose records contained any information on history of cervical excisional treatment were contacted by phone and in writing to inform them of the study and request permission to collect relevant information from their medical records. Women were divided into 4 subgroups according to the presence of microorganisms and/or their nucleic acids (through culturing and molecular biology methods) in amniotic fluid and/or intraamniotic inflammation (through amniotic fluid interleukin-6 concentration evaluation): intraamniotic infection (presence of both), sterile intraamniotic inflammation (intraamniotic inflammation alone), microbial invasion of the amniotic cavity without inflammation (presence of microorganisms and/or their nucleic acids in amniotic fluid alone), and negative amniotic fluid for infection/inflammation (absence of both). RESULTS: A history of cervical excisional treatment was found in 10% (76/765) of the women. Of these, 82% (62/76) had a history of only 1 treatment, and information on cone length was available for 97% (60/62) of them. Women with a history of cervical excisional treatment had higher rates of intraamniotic infection (with, 25% [19/76] vs without, 12% [85/689]; adjusted odds ratio, 2.5; adjusted P=.004), microbial invasion of the amniotic cavity without inflammation (with, 25% [19/76] vs without, 11% [74/689]; adjusted odds ratio, 3.1; adjusted P<.0001), and early-onset neonatal sepsis (with, 8% [11/76] vs without, 3% [23/689]; adjusted odds ratio, 2.9; adjusted P=.02) compared with those without such history. Quartiles of cone length (range: 3-32 mm) were used to categorize the women into 4 quartile subgroups (first: 3-8 mm; second: 9-12 mm; third: 13-17 mm; and fourth: 18-32 mm). Cone length of ≥18 mm was associated with higher rates of intraamniotic infection (with, 29% [5/15] vs without, 12% [85/689]; adjusted odds ratio, 3.0; adjusted P=.05), microbial invasion of the amniotic cavity without inflammation (with, 40% [6/15] vs without, 11% [74/689]; adjusted odds ratio, 6.1; adjusted P=.003), and early-onset neonatal sepsis (with, 20% [3/15] vs without, 3% [23/689]; adjusted odds ratio, 5.7; adjusted P=.02). CONCLUSION: History of cervical excisional treatment increases risks of intraamniotic infection, microbial invasion of the amniotic cavity without inflammation, and development of early-onset neonatal sepsis in a subsequent pregnancy complicated by preterm prelabor rupture of membranes.

Amniotic fluid soluble CD93 is elevated in the presence of intra-amniotic inflammation in preterm prelabor rupture of the fetal membranes.

OBJECTIVE: To determine the soluble form of CD93 (sCD93) concentration in amniotic fluid from pregnancies complicated by preterm prelabor rupture of membranes (PPROM) based on the presence of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation. METHODS: A total of 144 women with a singleton pregnancy complicated by PPROM were included in this study. Amniotic fluid samples were obtained by transabdominal amniocentesis. MIAC was determined by the combination of cultivation and non-cultivation techniques. Intra-amniotic inflammation was characterized as a concentration of interleukin-6 3,000 pg/mL in amniotic fluid. Women were categorized in the following groups: i) intra-amniotic infection (both MIAC and intra-amniotic inflammation), ii) sterile intra-amniotic inflammation (intra-amniotic inflammation per se), iii) colonization of the amniotic cavity (MIAC per se), and iv) negative amniotic fluid (without both MIAC and intra-amniotic inflammation). Levels of sCD93 in amniotic fluid were assessed by ELISA. RESULTS: A difference in the levels of sCD93 in amniotic fluid was found among the groups of women with intra-amniotic infection, sterile intra-amniotic inflammation, colonization of the amniotic cavity, and negative amniotic fluid (intra-amniotic infection: median 22.3 ng/mL, sterile intra-amniotic inflammation: median 21.0 ng/mL, colonization of the amniotic cavity: 8.7 ng/mL, negative: median 8.7 ng/mL; P < 0.0001). CONCLUSIONS: Intra-amniotic inflammation in PPROM, irrespectively of the presence or absence of MIAC, is associated with the elevation of the level of sCD93 in amniotic fluid.

Defining a role for Interferon Epsilon in normal and complicated pregnancies.

Interferon epsilon (IFNe) is a recently described cytokine that is constitutively expressed in the female reproductive tract. However, the role of this hormonally regulated cytokine during human pregnancy is poorly understood. Moreover, whether IFNe participates in host immune response against bacteria-driven intra-amniotic infection or cervical human papillomavirus infection during pregnancy is unknown. Herein, using a unique set of human samples derived from multiple study cohorts, we aimed to uncover the role of IFNe in normal and complicated pregnancies. We showed that IFNe is expressed in the myometrium, cervix, and chorioamniotic membranes, and may therefore represent a constitutive element of host defense mechanisms in these tissues during pregnancy. The expression of IFNe in the myometrium and cervix appeared greater in late gestation than in mid-pregnancy, but did not seem to be impacted by labor. Notably, concentrations of IFNe in amniotic fluid, but not cervical fluid, were increased in a subset of women undergoing spontaneous preterm labor with intra-amniotic infection, indicating that IFNe could participate in anti-microbial responses in the amniotic cavity. However, stimulation with Ureaplasma parvum and/or lipopolysaccharide did not enhance IFNE expression by amnion epithelial or cervical cells in vitro, implicating alternative sources of this cytokine during intra-amniotic or cervical infection, respectively. Collectively, our results represent the first characterization of IFNe expression by human reproductive and gestational tissues during normal pregnancy and suggest a role for this cytokine in intra-amniotic infection leading to preterm birth.

Clinical characteristics of colonization of the amniotic cavity in women with preterm prelabor rupture of membranes, a retrospective study.

To determine the main clinical characteristics of preterm prelabor rupture of membranes (PPROM) complicated by colonization of the amniotic cavity (microbial invasion of the amniotic cavity without intra-amniotic inflammation). A total of 302 women with PPROM were included. Transabdominal amniocentesis was performed and amniotic fluid was assessed. Based of microbial invasion of the amniotic cavity and intra-amniotic inflammation (interleukin-6 ≥ 3000 pg/mL), the women were divided into following groups: intra-amniotic infection, sterile intra-amniotic inflammation, colonization of the amniotic cavity, and negative amniotic fluid. Colonization was found in 11% (32/302) of the women. The most common bacteria identified in the amniotic fluid were Ureaplasma spp. with a lower burden than those with intra-amniotic infection (p = 0.03). The intensity of intra-amniotic inflammatory response measured by interleukin-6 was higher in women with colonization than in those with negative amniotic fluid (medians: 961 pg/mL vs. 616 pg/mL; p = 0.04). Women with colonization had higher rates of acute inflammatory placental lesions than those with negative amniotic fluid. In PPROM, colonization, caused mainly by microorganisms from the lower genital tract, might represent an early stage of microbial invasion of the amniotic cavity with a weak intra-amniotic inflammatory response.

A rodent model of intra-amniotic inflammation/infection, induced by the administration of inflammatory agent in a gestational sac, associated with preterm delivery: a systematic review.

BACKGROUND: Rodents are the most commonly used animals in the study of spontaneous preterm delivery (PTD). Intra-amniotic inflammation/infection is a frequent and important cause of PTD. Intraperitoneal and intrauterine administrations of inflammatory agents are traditional methods to establish a rodent model of PTD associated with inflammation and infection. The intra-amniotic administration of inflammatory or infectious triggering agents to rodents can be useful to study not only intra-amniotic inflammatory response but also PTD associated with intra-amniotic inflammation/infection. OBJECTIVE: This systematic review aimed mainly to assess and analyze all described methods of intra-amniotic administration of infectious and/or inflammatory agents to create a rodent model of intra-amniotic inflammation associated with PTD. METHODS: A literature search through two electronic databases from their earliest entries to February 2019 was performed. The selection criteria were as follows: (1) rodents as model animals, (2) a model of intra-amniotic inflammation/infection associated with PTD, and (3) intra-amniotic administration of triggering agents. Data extraction included specification of the study (author and year of publication), characteristics of study animals (species, strain, and number of animals), characteristics of intervention (timing and used technique), substance used for induction of intra-amniotic inflammation/infection, and outcome assessment. RESULTS: The search identified a total of 4673 articles, of which 118 were selected for full-text reading, but only 13 studies were included in the review. Intra-amniotic administration was used only in the articles that were published beyond 2004. Two different approaches were identified: (1) open surgery with direct puncture of the amniotic sacs and (2) transabdominal ultrasound-guided puncture of the gestational sacs. Live microorganisms (Ureaplasma parvum), bacterial products (extracellular membrane vesicles), and pathogen-associated (lipopolysaccharide) and damage-associated molecular patterns (high mobility group box-1, S100B, and surfactant protein A) were used to simulate intra-amniotic inflammation/infection. Differences in the effect on intra-amniotic inflammation/infection associated with PTD in the mouse model were identified among triggering agents. Intra-amniotic application of lipopolysaccharide in the rat model caused intra-amniotic inflammation, but it did not lead to PTD. CONCLUSION: The intra-amniotic administration of the triggering agents can be used to study intra-amniotic inflammatory response and intra-amniotic inflammation/infection in the rodents model.

Macrophage inflammatory protein-1α in amniotic and cervical fluids in spontaneous preterm labor with intact membranes with respect to intra-amniotic inflammation.

OBJECTIVE: Macrophage inflammatory protein 1α is a chemokine produced by various immune, epithelial, mesothelial, and fibroblast cells after exposure to bacterial lipopolysaccharide or pro-inflammatory molecules. The primary aim of this study was to determine MIP-1α concentrations in amniotic and cervical fluids from pregnancy with spontaneous preterm labor with intact membranes (PTL) with respect to the presence of intra-amniotic infection (both microbial invasion of the amniotic cavity and intra-amniotic inflammation) and sterile intra-amniotic inflammation (intra-amniotic inflammation alone). The secondary aim was to assess the diagnostic indices of MIP-1α in predicting intra-amniotic infection. MATERIALS AND METHODS: Seventy-four women with PTL were included in this study. Paired amniotic and cervical fluid samples were obtained using transabdominal amniocentesis and a Dacron polyester swab, respectively. Microbial invasion of the amniotic cavity was diagnosed based on a combination of culture and molecular biology methods. The concentration of IL-6 in the amniotic and cervical fluids was measured using an automated electrochemiluminescence immunoassay method. Intra-amniotic inflammation was defined as an amniotic fluid IL-6 concentration of ≥3000 pg/mL. The MIP-1α concentrations in the samples were assessed using an enzyme-linked immunosorbent assay. RESULTS: A difference in amniotic fluid MIP-1α was observed among women with intra-amniotic infection, sterile intra-amniotic inflammation, and negative amniotic fluid (infection: median 1779.0 pg/mL; sterile, median 102.7 pg/mL; negative, median 19.9 pg/mL; p < .0001). No difference in the concentrations of MIP-1α was identified in cervical fluid after adjustment for gestational age at sampling (infection: median 77.7 pg/mL, sterile: median 152.7 pg/mL, negative: median 18.0 pg/mL; p = .30). The presence of intra-amniotic infection was associated with elevated MIP-1α concentrations in amniotic fluid (presence: 1779.0 pg/mL vs. absence: 26.3 pg/mL, p < .0001, area under receiver operating characteristic curve = 0.87). CONCLUSIONS: In PTL pregnancies with the presence of intra-amniotic infection, the concentration of MIP-1α is elevated in amniotic fluid but not in cervical fluid. Amniotic fluid MIP-1α may provide a useful marker for intra-amniotic infection in women with PTL.

Intra-amniotic infection and sterile intra-amniotic inflammation are associated with elevated concentrations of cervical fluid interleukin-6 in women with spontaneous preterm labor with intact membranes.

OBJECTIVE: To determine the concentration of interleukin-6 (IL-6) in the cervical fluid in women with spontaneous preterm labor with intact fetal membranes (PTL) complicated by intra-amniotic infection (the presence of both microbial invasion of the amniotic cavity and intra-amniotic inflammation), or sterile intra-amniotic inflammation (the presence of intra-amniotic inflammation alone). METHODS: Eighty women with singleton pregnancies complicated by PTL between gestational ages 22 + 0 and 34 + 6 weeks were included in this retrospective cohort study. Samples of amniotic and cervical fluids were collected at the time of admission. Amniotic fluid samples were obtained via transabdominal amniocentesis, and cervical fluid was obtained using a Dacron polyester swab. Microbial invasion of the amniotic cavity was diagnosed based on the combination of culture and molecular biology methods. The concentration of IL-6 in the amniotic and cervical fluids were measured using an automated electrochemiluminescence immunoassay method. Intra-amniotic inflammation was defined as an amniotic fluid IL-6 concentration ≥3000 pg/mL. RESULTS: The presence of intra-amniotic infection and sterile inflammation was identified in 15% (12/80) and 26% (21/80) of the women, respectively. Women with intra-amniotic infection (median: 587 pg/mL; p = .01) and with sterile intra-amniotic inflammation (median: 590 pg/mL; p = .005) had higher concentrations of IL-6 in the cervical fluid than those without intra-amniotic inflammation (intra-amniotic infection: median 587 pg/mL vs. without inflammation, median: 136 pg/mL; p = .01; sterile intra-amniotic inflammation, median: 590 pg/mL vs. without inflammation, p = .005). No differences were found in the concentrations of IL-6 in the cervical fluid between women with intra-amniotic infection and sterile intra-amniotic inflammation (p = .81). CONCLUSION: In pregnancies with PTL, both forms of intra-amniotic inflammation are associated with elevated concentrations of IL-6 in the cervical fluid.

Preterm prelabor rupture of membranes without microbial invasion of the amniotic cavity and intra-amniotic inflammation: a heterogeneous group with differences in adverse outcomes.

OBJECTIVE: The absence of microbial invasion of the amniotic cavity and intra-amniotic inflammation at the time of hospital admission is the most common condition associated with preterm prelabor rupture of membranes (PPROM). Although the intensity of intra-amniotic inflammatory response does not exceed the threshold for the diagnosis of intra-amniotic inflammation in this subgroup of PPROM, whether there could be differences in outcomes concerning the intensity of intra-amniotic inflammatory response remains unclear. Therefore, the main aims of this study on PPROM without microbial invasion of the amniotic cavity and intra-amniotic inflammation were (i) to characterize the association between the intensity of intra-amniotic inflammatory response, measured according to amniotic fluid interleukin (IL)-6 concentrations, and the presence of acute histological chorioamnionitis and acute inflammation in the amnion; (ii) to characterize the association between the intensity of intra-amniotic inflammatory response and fetal inflammatory response, and (iii) to describe the short-term morbidity of infants based on the intensity of intra-amniotic inflammatory response. METHODS: This retrospective study included 131 women with singleton pregnancies with PPROM without microbial invasion of the amniotic cavity and intra-amniotic inflammation between gestational ages of 24 + 0 and 36 + 6 weeks and who had delivered within 72 h of membrane rupture. Microbial invasion of the amniotic cavity was assessed based on a combination of cultivation and non-cultivation methods. Intra-amniotic inflammation was characterized based on the amniotic fluid IL-6 concentration. In addition, a histopathological assessment of the placenta was performed. Fetal inflammatory response syndrome was characterized according to IL-6 concentration in the umbilical cord blood of >11 pg/mL. Based on the quartiles of IL-6 concentrations in the amniotic fluid, these women were divided into four subgroups (from the lowest to the highest IL-6 concentrations). RESULTS: IL-6 concentrations in amniotic fluid were higher in women with acute histological chorioamnionitis (median: 819 pg/mL vs. 520 pg/mL; p = .003) and with acute inflammation of the amnion (median: 1116 pg/mL vs. 533 pg/mL; p = .0002) than in women without these complications. The rates of acute histological chorioamnionitis and acute inflammation of the amnion were the highest in the subgroup with IL-6 concentrations above the 75th percentile in amniotic fluid (chorioamnionitis, p = .02; amnion, p = .0002). No differences in IL-6 concentrations in amniotic fluid were identified between women with and without a fetal inflammatory response syndrome (p = .40). The rate of fetal inflammatory response syndrome did not vary among the amniotic fluid IL-6 quartile subgroups of women. Moreover, no differences were noted in short-term neonatal outcomes among the amniotic fluid IL-6 quartile subgroups. CONCLUSION: A higher intensity of the intra-amniotic inflammatory response, measured by amniotic fluid IL-6 concentrations, is associated with a higher rate of acute inflammatory lesions in the placenta in the subset of PPROM pregnancies without microbial invasion of the amniotic cavity and intra-amniotic inflammation.

Cervical Gardnerella vaginalis in women with preterm prelabor rupture of membranes.

OBJECTIVE: To determine the association between microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI) and the cervical prevalence of Gardnerella vaginalis DNA in pregnancies with preterm prelabor rupture of membrane (PPROM). METHOD: In total, 405 women with singleton pregnancies complicated with PPROM were included. Cervical fluid and amniotic fluid samples were collected at the time of admission. Bacterial and G. vaginalis DNA were assessed in the cervical fluid samples using quantitative PCR technique. Concentrations of interleukin-6 and MIAC were evaluated in the amniotic fluid samples. Loads of G. vaginalis DNA ≥ 1% of the total cervical bacterial DNA were used to define the cervical prevalence of G. vaginalis as abundant. Based on the MIAC and IAI, women were categorized into four groups: with intra-amniotic infection (both MIAC and IAI), with sterile IAI (IAI without MIAC), with MIAC without IAI, and without either MIAC or IAI. RESULTS: The presence of the abundant cervical G. vaginalis was related to MIAC (with: 65% vs. without: 44%; p = 0.0004) but not IAI (with: 52% vs. without: 48%; p = 0.70). Women with MIAC without IAI had the highest load of the cervical G. vaginalis DNA (median 2.0 × 104 copies DNA/mL) and the highest presence of abundant cervical G. vaginalis (73%). CONCLUSIONS: In women with PPROM, the presence of cervical G. vaginalis was associated with MIAC, mainly without the concurrent presence of IAI.

Presence of Chlamydia trachomatis DNA in the amniotic fluid in women with preterm prelabor rupture of membranes.

OBJECTIVE: The primary aim of this study was to assess the rate and load of amniotic fluid Chlamydia trachomatis DNA and their associations with intra-amniotic infection and intra-uterine inflammatory complications in women with preterm prelabor rupture of membranes (PPROM). The secondary aim was to assess the short-term morbidity of newborns from PPROM pregnancies complicated by amniotic fluid C. trachomatis DNA. METHODS: A retrospective study of 788 women with singleton pregnancies complicated by PPROM between 24 + 0 and 36 + 6 weeks of gestation was performed. Transabdominal amniocenteses were performed at the time of admission. C. trachomatis DNA in the amniotic fluid was assessed by real-time polymerase chain reaction using a commercial AmpliSens® C. trachomatis/Ureaplasma/Mycoplasma hominis-FRT kit, and the level of Ct DNA was quantified. RESULTS: Amniotic fluid C. trachomatis DNA complicated 2% (16/788) of the PPROM pregnancies and was present in very low loads (median 57 copies DNA/mL). In addition to amniotic fluid C. trachomatis DNA, other bacteria were detected in 62% (10/16) of the C. trachomatis DNA-complicated PPROM pregnancies. Amniotic fluid C. trachomatis DNA was associated with intra-amniotic infection, histologic chorioamnionitis (HCA), and funisitis in 31%, 47%, and 33%, respectively. The presence of C. trachomatis DNA accompanied by Ureaplasma species in the amniotic fluid was associated with a higher rate of HCA than the presence of amniotic fluid C. trachomatis DNA alone. The composite neonatal morbidity in newborns from PPROM pregnancies with amniotic fluid C. trachomatis DNA was 31%. CONCLUSION: The presence of C. trachomatis DNA in the amniotic fluid is a relatively rare condition in PPROM. Amniotic fluid C. trachomatis DNA in PPROM is not related to intensive intra-amniotic and intr-auterine inflammatory responses or adverse short-term neonatal outcomes.

Antibiotic administration reduces the rate of intraamniotic inflammation in preterm prelabor rupture of the membranes.

BACKGROUND: Preterm prelabor rupture of the membranes (PPROM) is frequently complicated by intraamniotic inflammatory processes such as intraamniotic infection and sterile intraamniotic inflammation. Antibiotic therapy is recommended to patients with PPROM to prolong the interval between this complication and delivery (latency period), reduce the risk of clinical chorioamnionitis, and improve neonatal outcome. However, there is a lack of information regarding whether the administration of antibiotics can reduce the intensity of the intraamniotic inflammatory response or eradicate microorganisms in patients with PPROM. OBJECTIVE: The first aim of the study was to determine whether antimicrobial agents can reduce the magnitude of the intraamniotic inflammatory response in patients with PPROM by assessing the concentrations of interleukin-6 in amniotic fluid before and after antibiotic treatment. The second aim was to determine whether treatment with intravenous clarithromycin changes the microbial load of Ureaplasma spp DNA in amniotic fluid. STUDY DESIGN: A retrospective cohort study included patients who had (1) a singleton gestation, (2) PPROM between 24+0 and 33+6 weeks, (3) a transabdominal amniocentesis at the time of admission, and (4) intravenous antibiotic treatment (clarithromycin for patients with intraamniotic inflammation and benzylpenicillin/clindamycin in the cases of allergy in patients without intraamniotic inflammation) for 7 days. Follow-up amniocenteses (7th day after admission) were performed in the subset of patients with a latency period lasting longer than 7 days. Concentrations of interleukin-6 were measured in the samples of amniotic fluid with a bedside test, and the presence of microbial invasion of the amniotic cavity was assessed with culture and molecular microbiological methods. Intraamniotic inflammation was defined as a bedside interleukin-6 concentration ≥745 pg/mL in the samples of amniotic fluid. Intraamniotic infection was defined as the presence of both microbial invasion of the amniotic cavity and intraamniotic inflammation; sterile intraamniotic inflammation was defined as the presence of intraamniotic inflammation without microbial invasion of the amniotic cavity. RESULTS: A total of 270 patients with PPROM were included in this study: 207 patients delivered within 7 days and 63 patients delivered after 7 days of admission. Of the 63 patients who delivered after 7 days following the initial amniocentesis, 40 underwent a follow-up amniocentesis. Patients with intraamniotic infection (n = 7) and sterile intraamniotic inflammation (n = 7) were treated with intravenous clarithromycin. Patients without either microbial invasion of the amniotic cavity or intraamniotic inflammation (n = 26) were treated with benzylpenicillin or clindamycin. Treatment with clarithromycin decreased the interleukin-6 concentration in amniotic fluid at the follow-up amniocentesis compared to the initial amniocentesis in patients with intraamniotic infection (follow-up: median, 295 pg/mL, interquartile range [IQR], 72-673 vs initial: median, 2973 pg/mL, IQR, 1750-6296; P = .02) and in those with sterile intraamniotic inflammation (follow-up: median, 221 pg/mL, IQR 118-366 pg/mL vs initial: median, 1446 pg/mL, IQR, 1300-2941; P = .02). Samples of amniotic fluid with Ureaplasma spp DNA had a lower microbial load at the time of follow-up amniocentesis compared to the initial amniocentesis (follow-up: median, 1.8 × 104 copies DNA/mL, 2.9 × 104 to 6.7 × 108 vs initial: median, 4.7 × 107 copies DNA/mL, interquartile range, 2.9 × 103 to 3.6 × 107; P = .03). CONCLUSION: Intravenous therapy with clarithromycin was associated with a reduction in the intensity of the intraamniotic inflammatory response in patients with PPROM with either intraamniotic infection or sterile intraamniotic inflammation. Moreover, treatment with clarithromycin was related to a reduction in the load of Ureaplasma spp DNA in the amniotic fluid of patients with PPROM <34 weeks of gestation.

Interleukin-6 measured using the automated electrochemiluminescence immunoassay method for the identification of intra-amniotic inflammation in preterm prelabor rupture of membranes.

Introduction: We aimed to compare the amniotic fluid interleukin (IL)-6 concentrations measured using the automated electrochemiluminescence immunoassay method and ELISA, and to establish an IL-6 concentration cut-off value for intra-amniotic inflammation (IAI) in preterm prelabor rupture of membranes (PPROM), which can be used in the automated electrochemiluminescence immunoassay method.Materials and methods: A total of 120 women with PPROM were included in this study. Amniotic fluid samples were obtained through transabdominal amniocentesis. IL-6 concentrations were assessed using both the automated electrochemiluminescence immunoassay method and ELISA, the current gold standard. IAI was defined as an amniotic fluid IL-6 concentration of ≥2600 pg/mL measured using ELISA.Results: A correlation between both assays was found (Spearman's rho = 0.97; p < .0001). Based on the receiver-operating characteristic curve for the identification of IAI (area under the curve = 0.99), a cut-off value of ≥3000 pg/mL was selected for the automated electrochemiluminescence immunoassay method with a sensitivity of 88%, specificity of 99%, positive predictive value of 97%, negative predictive value of 96%, and likelihood ratio of 76.Conclusions: For amniotic fluid IL-6 concentrations assessed using the automated electrochemiluminescence immunoassay method, a cut-off value of 3000 pg/mL was indicated for diagnosing IAI in women with PPROM.

Fetal Portal System Flowmetry and Intra-Amniotic Inflammation in Preterm Prelabor Rupture of Membranes.

OBJECTIVES: To determine the pulsatility index (PI) in the fetal splenic vein, the main portal vein, the left portal vein, and the ductus venosus with respect to the presence or absence of intra-amniotic inflammation (IAI) in preterm prelabor rupture of membranes (PPROM). METHOD: Women with singleton pregnancies and PPROM, ranging in gestational age from 22+0 to 36+6 weeks, were included. Amniotic fluid samples were obtained by transabdominal amniocentesis and the amniotic fluid level of interleukin-6 (IL-6) was assessed by a point-of-care test. Doppler examination of the selected veins was performed, and the PI was assessed. IAI was defined as amniotic fluid levels of IL-6 ≥745 pg/mL. RESULTS: In total, 42 women were included. Fetuses with IAI compared with those without IAI exhibited a higher PI in the splenic vein (p = 0.005) and the main portal vein (p = 0.05). No differences were observed in the left portal vein PI (p = 0.36) and the ductus venosus PI (p = 0.98). CONCLUSION: IAI was associated with increased fetal splenic vein PI and main portal vein PI in PPROM. The absence of changes in the left portal vein PI and ductus venosus PI supports the local cause of the finding.

Association between periodontal disease and preterm prelabour rupture of membranes.

OBJECTIVE: Periodontal disease is a possible contributing factor to preterm delivery. The aim of this study was to compare the periodontal status of women with preterm prelabour rupture of membranes (PPROM) and women with uncomplicated singleton pregnancies. PATIENTS AND METHODS: Seventy-eight women with PPROM at gestational ages between 24 + 0 and 36 + 6 weeks and 77 healthy women with uncomplicated pregnancies, matched for gestational age at sampling without preterm birth, were included in this study. All women underwent evaluation of periodontal and oral hygiene status. RESULTS: Women with PPROM had higher gingival and plaque indexes in crude analysis (gingival index: median 0.80 versus 0.20; p < 0.0001; plaque index: median 0.80 versus 0.10; p < 0.0001), even after adjustment for smoking status (p < 0.0001 and p < 0.0001). Mean clinical attachment loss (CAL) and probing pocket depth (PPD) values were higher in women with PPROM in the crude analysis (CAL: median 2.3 mm versus 1.8 mm; p < 0.0001; PPD: median 2.3 mm versus 1.8; p < 0.0001), as well as after adjustment for smoking status (p < 0.0001 and p < 0.0001). CONCLUSIONS: Pregnant women with PPROM residing in central Europe had worse periodontal status than women with uncomplicated pregnancies.

Cervical human papillomavirus infection in women with preterm prelabor rupture of membranes.

OBJECTIVE: To evaluate the association between cervical human papillomavirus (HPV) infection at the time of admission and the presence of microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation (IAI) in women with preterm prelabor rupture of membranes (PPROM) and to determine the association between cervical HPV infection and short-term neonatal morbidity. METHODS: One hundred women with singleton pregnancies complicated by PPROM between the gestational ages of 24+0 and 36+6 weeks were included in the study. The presence of HPV DNA was evaluated in scraped cervical cells using polymerase chain reaction (PCR). Amniotic fluid samples were obtained by transabdominal amniocentesis. RESULTS: The rate of cervical HPV infection in women with PPROM was 24%. The rates of MIAC and IAI were not different between women with cervical HPV infection and those without cervical HPV infection [MIAC: with HPV: 21% (5/24) vs. without HPV: 22% (17/76), p = 1.00; IAI: with HPV: 21% (5/24) vs. without HPV: 18% (14/76), p = 0.77]. There were no differences in the selected aspects of short-term neonatal morbidity between women with and without cervical HPV infection. CONCLUSIONS: In women with PPROM, the presence of cervical HPV infection at the time of admission is not related to a higher risk of intra-amniotic infection-related and inflammatory complications or worse short-term neonatal outcomes.

Amniotic fluid cell-free DNA in preterm prelabor rupture of membranes.

INTRODUCTION: We evaluated the levels of cell-free nuclear DNA (nDNA) and cell-free mitochondrial DNA (mtDNA) in the amniotic fluid supernatant from pregnancies complicated by preterm prelabor rupture of membranes (PPROM) based on evidence of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI). MATERIAL AND METHODS: A total of 155 women with PPROM were included in this study. Amniotic fluid samples were obtained by transabdominal amniocentesis. The levels of cell-free nDNA and mtDNA in the amniotic fluid supernatant were assessed and quantified by real-time polymerase chain reaction. RESULTS: The levels of cell-free nDNA and mtDNA were higher in women with MIAC and IAI than in women without these conditions (nDNA: with MIAC: median 3.9 × 104 genome equivalent [GE]/mL vs without MIAC: median 1.2 × 104  GE/mL, with IAI: median: 5.3 × 104  GE/mL vs without IAI: median 1.2 × 104  GE/mL; mtDNA: with MIAC: median 9.2 × 105  GE/mL vs without MIAC: median 2.5 × 105  GE/mL, with IAI: median 1.1 × 106  GE/mL vs without IAI: median 2.5 × 105 ; all P values ≤ 0.01). Women with the microbial-associated IAI showed the highest levels of cell-free nDNA and mtDNA. CONCLUSIONS: Cell-free nDNA and mtDNA are constituents of the amniotic fluid supernatant from PPROM pregnancies. Both cell-free nDNA and mtDNA are involved in the intra-amniotic inflammatory response in women with PPROM.

Gastric fluid used to assess changes during the latency period in preterm prelabor rupture of membranes.

OBJECTIVE: To determine changes in the intraamniotic environment during the latency period using paired amniotic and gastric fluid samples in pregnancies complicated by preterm prelabor rupture of membranes (PPROM). METHODS: A total of 34 women with singleton pregnancies complicated by PPROM prior to 34 weeks were included in the study. Amniotic fluid was obtained by transabdominal amniocentesis at the time of admission. Immediately after delivery, umbilical cord blood and gastric fluid were obtained. RESULT: Microorganisms in amniotic and gastric fluid samples were found in 38% and 59% of women, respectively. Bedside IL-6 levels were higher in amniotic than in gastric fluid in pregnancies without fetal inflammatory response syndrome (FIRS) (263 pg/mL vs. 50 pg/mL; p < 0.0001), but not in pregnancies with FIRS (318 pg/mL vs. 444 pg/mL; p = 0.91). Funisitis and FIRS was associated with the highest bedside IL-6 levels in gastric fluid. A gastric fluid bedside IL-6 level of 275 pg/mL was found to be the ideal cutoff value to predict funisitis and FIRS. CONCLUSIONS: The microbial and inflammatory status of the intraamniotic compartment changes during the latency period in PPROM. Bedside IL-6 assessment of gastric fluid may be useful in the rapid diagnosis of funisitis and FIRS.