J Korean Med Sci.  2013 Aug;28(8):1226-1232. 10.3346/jkms.2013.28.8.1226.

Intra-Amniotic Infection/Inflammation as a Risk Factor for Subsequent Ruptured Membranes after Clinically Indicated Amniocentesis in Preterm Labor

• Lee SY
• Park KH
• Jeong EH
• Oh KJ
• Ryu A
• Kim A

• KMID: 1793030
• DOI: http://doi.org/10.3346/jkms.2013.28.8.1226

Abstract

The aim of this study was to determine whether intra-amniotic infection/inflammation (IAI) was associated with subsequent ruptured membranes in women with preterm labor and intact membranes who had a clinically indicated amniocentesis. This retrospective cohort study included 237 consecutive women with preterm labor (20-34.6 weeks) who underwent amniocentesis. The clinical and laboratory parameters evaluated included demographic variables, gestational age, C-reactive protein (CRP) and amniotic fluid (AF) white blood cell, interleukin-6 (IL-6) and culture results. IAI was defined as a positive AF culture and/or an elevated AF IL-6 level (>2.6 ng/mL). The primary outcome was ruptured membranes in the absence of active labor occurring within 48 hours of amniocentesis. Preterm premature rupture of membranes subsequently developed in 10 (4.2%) women within 48 hr of amniocentesis. Multivariate analysis demonstrated that only IAI was independently associated with the ruptured membranes occurring within 48 hr of amniocentesis. In the predictive model based on variables assessed before amniocentesis, only CRP level was retained. IAI is an independent risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. Prior to amniocentesis, measurement of serum CRP level can provide a risk assessment for the subsequent development of ruptured membranes after the procedure.

Keyword

Amniocentesis; C-Reactive Protein; Intra-Amniotic Infection/Inflammation; Obstetric Labor, Premature; Ruptured Membranes

MeSH Terms

Adult
Amniocentesis/*adverse effects
Amnion/physiopathology
Amniotic Fluid/cytology/metabolism/microbiology
Bacterial Infections/*etiology/microbiology
C-Reactive Protein/analysis
Cohort Studies
Demography
Female
Gestational Age
Humans
Inflammation/*etiology
Interleukin-6/metabolism
Leukocytes/cytology
Multivariate Analysis
Mycoplasma/isolation & purification
Obstetric Labor, Premature/*etiology
Pregnancy
ROC Curve
Retrospective Studies
Risk Factors
Ureaplasma urealyticum/isolation & purification
C-Reactive Protein
Interleukin-6

Figure

• 

  Fig. 1 Receiver operating characteristic curve for maternal serum C-reactive protein (CRP) in predicting ruptured membranes within 48 hr of amniocentesis. Numbers next to solid dots represent serum CRP levels (mg/L; area under the curve, 0.793; SE, 0.078; P = 0.001).

Reference

1. Romero R, Espinoza J, Gonçalves LF, Kusanovic JP, Friel L, Hassan S. The role of inflammation and infection in preterm birth. Semin Reprod Med. 2007; 25:21–39.

2. Hitti J, Hillier SL, Agnew KJ, Krohn MA, Reisner DP, Eschenbach DA. Vaginal indicators of amniotic fluid infection in preterm labor. Obstet Gynecol. 2001; 97:211–219.

3. Palacio M, Cobo T, Bosch J, Filella X, Navarro-Sastre A, Ribes A, Gratacós E. Cervical length and gestational age at admission as predictors of intra-amniotic inflammation in preterm labor with intact membranes. Ultrasound Obstet Gynecol. 2009; 34:441–447.

4. Yoon BH, Romero R, Moon JB, Shim SS, Kim M, Kim G, Jun JK. Clinical significance of intra-amniotic inflammation in patients with preterm labor and intact membranes. Am J Obstet Gynecol. 2001; 185:1130–1136.

5. Holst RM, Jacobsson B, Hagberg H, Wennerholm UB. Cervical length in women in preterm labor with intact membranes: relationship to intra-amniotic inflammation/microbial invasion, cervical inflammation and preterm delivery. Ultrasound Obstet Gynecol. 2006; 28:768–774.

6. Hassan S, Romero R, Hendler I, Gomez R, Khalek N, Espinoza J, Nien JK, Berry SM, Bujold E, Camacho N, et al. A sonographic short cervix as the only clinical manifestation of intra-amniotic infection. J Perinat Med. 2006; 34:13–19.

7. Morency AM, Rallu F, Laferrière C, Bujoldg E. Eradication of intra-amniotic Streptococcus mutans in a woman with a short cervix. J Obstet Gynaecol Can. 2006; 28:898–902.

8. Mazor M, Chaim W, Hershkowitz R, Wiznitzer A. Eradication of Viridans streptococci from the amniotic cavity with transplacental antibiotic treatment. Arch Gynecol Obstet. 1994; 255:147–151.

9. Gordon MC, Narula K, O'Shaughnessy R, Barth WH Jr. Complications of third-trimester amniocentesis using continuous ultrasound guidance. Obstet Gynecol. 2002; 99:255–259.

10. Guinn DA, Goldenberg RL, Hauth JC, Andrews WW, Thom E, Romero R. Risk factors for the development of preterm premature rupture of the membranes after arrest of preterm labor. Am J Obstet Gynecol. 1995; 173:1310–1315.

11. Biggio JR Jr, Ramsey PS, Cliver SP, Lyon MD, Goldenberg RL, Wenstrom KD. Midtrimester amniotic fluid matrix metalloproteinase-8 (MMP-8) levels above the 90th percentile are a marker for subsequent preterm premature rupture of membranes. Am J Obstet Gynecol. 2005; 192:109–113.

12. Perni SC, Vardhana S, Korneeva I, Tuttle SL, Paraskevas LR, Chasen ST, Kalish RB, Witkin SS. Mycoplasma hominis and Ureaplasma urealyticum in midtrimester amniotic fluid: association with amniotic fluid cytokine levels and pregnancy outcome. Am J Obstet Gynecol. 2004; 191:1382–1386.

13. Romero R, Yoon BH, Mazor M, Gomez R, Diamond MP, Kenney JS, Ramirez M, Fidel PL, Sorokin Y, Cotton D, et al. The diagnostic and prognostic value of amniotic fluid white blood cell count, glucose, interleukin-6, and gram stain in patients with preterm labor and intact membranes. Am J Obstet Gynecol. 1993; 169:805–816.

14. Yoon BH, Yang SH, Jun JK, Park KH, Kim CJ, Romero R. Maternal blood C-reactive protein, white blood cell count, and temperature in preterm labor: a comparison with amniotic fluid white blood cell count. Obstet Gynecol. 1996; 87:231–237.

15. ACOG Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 80: premature rupture of membranes: clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2007; 109:1007–1019.

16. Wenstrom KD, Andrews WW, Hauth JC, Goldenberg RL, DuBard MB, Cliver SP. Elevated second-trimester amniotic fluid interleukin-6 levels predict preterm delivery. Am J Obstet Gynecol. 1998; 178:546–550.

17. Ekwo EE, Gosselink CA, Woolson R, Moawad A. Risks for premature rupture of amniotic membranes. Int J Epidemiol. 1993; 22:495–503.

18. Alger LS, Lovchik JC, Hebel JR, Blackmon LR, Crenshaw MC. The association of Chlamydia trachomatis, Neisseria gonorrhoeae, and group B streptococci with preterm rupture of the membranes and pregnancy outcome. Am J Obstet Gynecol. 1988; 159:397–404.

19. Vadillo-Ortega F, Estrada-Gutiérrez G. Role of matrix metalloproteinases in preterm labour. BJOG. 2005; 112:19–22.

20. Vadillo-Ortega F, Sadowsky DW, Haluska GJ, Hernandez-Guerrero C, Guevara-Silva R, Gravett MG, Novy MJ. Identification of matrix metalloproteinase-9 in amniotic fluid and amniochorion in spontaneous labor and after experimental intrauterine infection or interleukin-1 beta infusion in pregnant rhesus monkeys. Am J Obstet Gynecol. 2002; 186:128–138.

21. Borgida AF, Mills AA, Feldman DM, Rodis JF, Egan JF. Outcome of pregnancies complicated by ruptured membranes after genetic amniocentesis. Am J Obstet Gynecol. 2000; 183:937–939.

22. Romero R, Mazor M, Munoz H, Gomez R, Galasso M, Sherer DM. The preterm labor syndrome. Ann N Y Acad Sci. 1994; 734:414–429.

23. Romero R, Yoon BH, Kenney JS, Gomez R, Allison AC, Sehgal PB. Amniotic fluid interleukin-6 determinations are of diagnostic and prognostic value in preterm labor. Am J Reprod Immunol. 1993; 30:167–183.

24. Vadillo-Ortega F, Hernandez A, Gonzalez-Avila G, Bermejo L, Iwata K, Strauss JF 3rd. Increased matrix metalloproteinase activity and reduced tissue inhibitor of metalloproteinases-1 levels in amniotic fluids from pregnancies complicated by premature rupture of membranes. Am J Obstet Gynecol. 1996; 174:1371–1376.