References: Fetal Infections; Volume 4 Issue 1

1. AUTHOR	Mercer-B-M, Lewis-R.
INSTITUTION	Department of Obstetrics and Gynecology, University of Tennessee, Memphis Health Sciences Center, USA.
TITLE	Preterm labor and preterm premature rupture of the membranes. Diagnosis and management.
SOURCE	Infect-Dis-Clin-North-Am 1997 Mar, VOL: 11 (1), P: 177-201, ISSN: 0891-5520 151 Refs.
ABSTRACT	Preterm delivery due to preterm labor and pPROM is responsible for most infant morbidity and mortality in the United States. The patient who presents with suspicious symptoms should undergo a thorough evaluation to confirm the diagnosis of either entity and identify a treatable cause. Determination of gestational age, fetal well-being, and the presence of intrauterine infection is a crucial step in subsequent management. Corticosteroid therapy has been demonstrated to be one of the most effective antenatal interventions to reduce infant morbidity and should be administered to patients with preterm labor, if feasible, when fetal pulmonary maturity is absent or undocumented. We recommend a similar protocol regarding gravidas with pPROM remote from term but recognize the need for further study in this area. Acute tocolytic therapy has been demonstrated to offer short-term benefit to enhance corticosteroid effect. However, all of the available tocolytic agents carry significant risks to the mother and fetus. As such, administration of these agents should be given only when the potential benefits outweigh the risks of administration. Evaluation for fetal pulmonary maturity and intrauterine infection, in concert with evaluation of gestational age-dependent risks of prematurity, may be helpful in determining whether tocolysis should be attempted. Adjunctive antibiotic administration has not been shown to reduce maternal or infant morbidity in the face of preterm labor. However, such treatment offers a reduction of chorioamnionitis, prolongation of latency, and a possible reduction of neonatal infectious and gestational age- dependent morbidity in the setting of pPROM remote from term. Finally, current guidelines recommend the administration of intrapartum GBS prophylaxis when preterm birth or prolonged membrane rupture is anticipated if GBS carrier status is unknown or positive. Intrapartum treatment with intravenous penicillin or ampicillin is appropriate. Author.

2. AUTHOR	Egarter-C, Leitich-H, Karas-H, Wieser-F, Husslein-P, Kaider-A, Schemper-M.
INSTITUTION	Department of Obstetrics and Gynecology, University of Vienna, Austria.
TITLE	Antibiotic treatment in preterm premature rupture of membranes and neonatal morbidity: a metaanalysis (see comments).
SOURCE	Am-J-Obstet-Gynecol 1996 Feb, VOL: 174 (2), P: 589-97, ISSN: 0002-9378.
CM	Comment in: Am-J-Obstet-Gynecol 1996 Sep; 175(3 Pt 1):755-6; Comment in: Am-J-Obstet-Gynecol 1996 Nov; 175(5):1394-5.
ABSTRACT	OBJECTIVE: We performed a metaanalysis of seven published randomized clinical trials to estimate more precisely the effect of prophylactic antibiotics on neonatal mortality, clinical sepsis of the neonate, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. STUDY DESIGN: To evaluate the effect of antibiotic treatment unaffected by other forms of treatment such as tocolytics or corticosteroids, investigations in which these additional measures were used were not included. We analyzed study patients and methods and abstracted quantitative outcome data. For each outcome both odds ratios and 95% confidence intervals were calculated. RESULTS: Among the 657 patients from seven trials published between 1989 and 1994, antibiotic therapy significantly reduced the risk of neonatal sepsis by 68% (odds ratio 0.32, 95% confidence interval 0.16 to 0.65, p=0.001) and that of intraventricular hemorrhage by 50% (odds ratio 0.50, 95% confidence interval 0.28 to 0.89, p=0.019). In contrast, no significant effect of antibiotics on overall neonatal mortality (odds ratio 0.92, 95% confidence interval 0.46 to 1.81), respiratory distress syndrome (odds ratio 0.84, 95% confidence interval 0.58 to 1.22), or necrotizing enterocolitis (odds ratio 1.27, 95% confidence interval 0.61 to 2.62) was found. CONCLUSION: This metaanalysis supports an improvement of neonatal morbidity in mothers with preterm premature rupture of membranes treated prenatally with different antibiotic regimens. Author.

3. AUTHOR	Cararach-V, Botet-F, Sentis-J, Almirall-R, Perez-Picanol-E.
INSTITUTION	Department of Obstetrics, Gynaecology and Paediatrics, Hospital Clinic, Universitat de Barcelona, Spain.
TITLE	Administration of antibiotics to patients with rupture of membranes at term: a prospective, randomized, multicentric study. Collaborative Group on PROM.
SOURCE	Acta-Obstet-Gynecol-Scand 1998 Mar, VOL: 77 (3), P: 298-302, ISSN: 0001-6349.
ABSTRACT	OBJECTIVE: To assess whether antibiotic administration changes the rate of materno-fetal infectious morbidity in premature rupture of membranes occurring later than 35 weeks of gestation. METHODS: A prospective, randomized and multicentric study in the Perinatology Units of eleven hospitals in Spain. Women were randomized to either antibiotic administration or control group. All were induced, if labor had not started spontaneously after 12 hours of ruptured membranes. Main outcome measures were maternal infection (chorioamnionitis and endometritis) and neonatal infectious morbidity (neonatal sepsis, meningitis and bronchopneumonia). RESULTS: Seven hundred and thirty-three patients were enrolled in the study, 371 in the antibiotics group and 362 in the control group. The incidence of chorioamnionitis and puerperal endometritis were reduced but the differences are statistically nonsignificant. However, the incidence of neonatal sepsis was significantly lower in newborns to mothers who had received antibiotics, 1 vs. 7 cases (Fisher's exact test, p <0.007). CONCLUSION: The study strongly suggests that prophylactic use of antibiotics in premature rupture of membranes occurring at 36 or more weeks of gestation reduces the risk of neonatal sepsis and probably maternal endometritis. Author.

4. AUTHOR	Krohn-M-A, Hitti-J.
INSTITUTION	Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, PA, USA.
TITLE	Characteristics of women with clinical intra-amniotic infection who deliver preterm compared with term.
SOURCE	Am-J-Epidemiol 1998 Jan 15, VOL: 147 (2), P: 111-6, ISSN: 0002-9262.
ABSTRACT	The authors sought to determine whether demographic factors, labor characteristics, and labor management for intra-amniotic infection (IAI) are different for IAI cases who deliver preterm compared with IAI cases who deliver at term. From 1990 through 1994, 610 women with intra-amniotic infection and 747 controls were enrolled from five hospitals in King County, Washington state. Intra-amniotic infection was diagnosed by fever 37.8 degrees C with two of the following signs: maternal or fetal tachycardia, uterine tenderness, elevated peripheral white blood cell count, and purulent amniotic fluid. Preterm IAI cases were significantly more likely than term IAI cases to have membrane rupture before contractions (odds ratio (OR) = 6.1) and prolonged membrane rupture (> 24 hours) (OR = 31.0). Term cases were more likely to experience a prolonged second stage of labor. After accounting for differences in labor characteristics, preterm IAI was less likely to be managed with a cesarean delivery, prolonged internal monitoring, or induction of labor and more likely to be managed with antimicrobials and antipyretics. When compared with preterm births without IAI, preterm IAI cases were more likely to be managed with labor augmentation. The authors believe that labor characteristics of women with preterm IAI and the risk of neonatal sepsis deserve further study. Author.

5. AUTHOR	Gugino-L.
TITLE	One warning sign enough to order test for chorioamnionitis.
SOURCE	ACOG meeting, 1998, http://www.pslgroup.com/dg/7bba2.htm.

6. AUTHOR	Teichmann-A-T, Arendt-P, Speer-C-P.
INSTITUTION	Departments of Obstetrics and Gynecology, University of Gottingen, F.R.G.
TITLE	Premature rupture of the membranes and amniotic infections--the significance of laboratory tests.
SOURCE	Eur-J-Obstet-Gynecol-Reprod-Biol 1990 Mar, VOL: 34 (3), P: 217-22, ISSN: 0301-2115.
ABSTRACT	White blood cell count (WBC), C-reactive protein (CRP) and elastase alpha 1-proteinase inhibitor complex (E alpha 1 PI) have been determined in 85 women during pregnancy and after birth to assess their diagnostic value in case of amniotic infection syndrome (AIS). In ten patients clinically diagnosed AIS could be confirmed by histopathological examination, five patients who fulfilled the clinical criteria showed no histological signs of infection. E alpha 1 PI levels were found to be elevated to above 200 micrograms/l in nine patients with clinical and histological infection and remained below this value in all but one of the cases not showing signs of AIS. On the other hand, CRP concentrations were elevated in five out of these ten women, but also showed false-positive values in patients without AIS; leucocyte counts above 15,000/mm3 have been observed in only one case before delivery. The application of betamethasone led to a marked elevation of leucocyte concentrations. CRP levels were raised substantially after birth, whereas E alpha 1 PI remained unchanged under both conditions. It is suggested that all three parameters should be taken into consideration to increase diagnostic reliability in case of suspected amniotic infections. Author.