Your Water Breaks First - A Date to PROM (Premature Rupture of Membranes) - The Chorioamnionitis Controversy

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The primary sources for this section come from the following:

Executive Summary:  Evaluation and Management of Women and Newborns With a Maternal Diagnosis of Chorioamnionitis 2016 by The American College of Obstetricians and Gynecologists; Rosemary Higgins, MD et. al., 127(3) published by Wolters Kluwer Health, Inc.

Intrauterine inflammation, infection, or both (Triple I): A new concept for chorioamnionitis Peng, Chun-Chih et al. June 2018 Pediatrics & Neonatology , Volume 59 , Issue 3 , 231 - 237

Chorioamnionitis is a bacterial infection that occurs before or during labor. The name refers to the membranes surrounding the fetus, the chorion (outer membrane) and the amnion (inner membrane), this infection is also often referred to as amnionitis or intrauterine infection. The actual condition poses the potential of significant adverse outcomes for mothers and serious adverse outcomes for babies.

Chorioamnionitis is an acute inflammation of the membranes and chorion of the placenta, and while this condition can exist even in the presence of intact membranes it is more typically seen in the setting of membrane rupture and is typically due to ascending poly microbial bacterial infectious agents. 

In other words an infectious agent introduced up and into the body by the “helping hands” of others either by the transmission of an outside infectious agent or by transmitting a preexisting infectious agent —already present in a mother’s vaginal tract— up into the uterine cavity. Preexisting extrauterine infections acquired during pregnancy rarely account for chorioamnionitis, but it is possible. My husband’s battle with “strep throat of the elbow” is a case in point, extremely rare but it does happen.

The clinical signs and laboratory data usually used to diagnose chorioamnionitis during labor have poor predictive value, may be absent or appear late, and are unreliable for identification of acute chorioamnionitis. The best means to accurately diagnose chorioamnionitis during labor are very invasive procedures.

Best diagnosis comes from either sampling the flora of a clean amniotic fluid sample through amniocentesis, however, the more definitive diagnosis comes from a sample taken from the placenta, itself.

To make matters worse, the term chorioamnionitis has been appropriated and misused, used by health care professionals as a diagnosis for a multitude of various conditions and symptoms.

The clinical use of this term is both overused and outdated and implies the presence of an infection. As you will see the clinical means of diagnosis for chorioamnionitis was used by the healthcare professionals in the Term PROM studies to determine the presence of infection.

In 2016, ACOG published an executive summary of a 2015 workshop that was convened to address the issue that there exist numerous knowledge gaps and the need for evidence-based guidelines for the diagnosis and treatment of women with what “had been commonly called” chorioamnionitis and the neonates born to these women.

As of 2018, ACOG is working towards and funding studies to re-name this clinical condition, define recommendations for assessment and management.

ACOG now recommends the use of new terminology, specifically Triple I (inflammation, infection, or both), with the term chorioamnionitis restricted to pathologic diagnosis (a diagnosis that comes from the study and testing of the placenta after birth).

The term “chorioamnionitis” has been in existence for decades. Unfortunately, this term has transitioned from its original scope—in which it was only used to express what it actually describes— an intrauterine  bacterial infection that affects the chorion and amnion membranes, and is now commonly used as term that labels a varied array of often non-related conditions characterized by infection, inflammation, or both with consequent great variations in treatment and clinical practice in both women and children.   

In the strictest sense, the term chorioamnionitis implies that a pregnant woman has an “inflammatory or an infectious” disorder of the chorion, amnion, or both.

This diagnosis often implies that the mother and her fetus may be at increased risk for developing serious infectious consequences.  Because of its connotation, the mere entry of chorioamnionitis into the patient’s record triggers a series of investigations and management decisions in the mother and the neonate, irrespective of probable cause or clinical findings.

A maternal diagnosis of chorioamnionitis has serious implications for the management of newborns. Even in well-appearing infants, this diagnosis will subject newborns to much testing, longer hospital stays, sepsis workups, NICU stays, and treatment with antibiotics.

This protocol is all used today, to prevent the rare incidence of early onset sepsis in newborns. Early onset sepsis was of genuine concern in the 1960-70’s before the routine screening and prophylactic treatment of Group B Streptococcus with antibiotics. Since routine screening and treatment for GBS is now the normal procedure, the incidence of newborn early onset sepsis has drastically reduced. 

The majority of evidence based studies regarding management of PROM today are still the studies held in the latter half of the 20th century, well before routine screening and prophylactic treatment of GBS, which is why it is essential to look at the study data from a fresh modernistic perspective.

While the majority of the information found in these sources I will hold on to for now, I need to address several infection related complications that are of great importance to accurate assessment of your choices and decisions in the presence of ruptured membranes.

If PROM presents either at term or preterm, or if your membranes have been artificially ruptured by a healthcare provider,  it is characterized as a risk factor for infection.

The spontaneous or artificial rupture of your membranes represents a “weak spot” -the potential- that in the presence of an infectious agent the potential likelihood of a neonatal or maternal infection increases.

Prolonged rupture of the membranes (more than 24 hours) increases the risk of neonatal sepsis considerably because the presence of ROM facilitates the ascension of new infectious agents to the uterine cavity and this risk becomes much higher when the rupture is accompanied by the presence of an existing subclinical intrauterine inflammation or infection or both (Triple I).

This is also true in regards to maternal infection, although you have probably gathered by now that the wellbeing of mothers is not the priority that runs the majority of obstetrical/hospital managed care.

If you genuinely have a serious infection—hooray for antibiotics, I hope you get properly diagnosed and promptly treated. Medical interventions when truly necessary are indeed life saving. However…

Often a designation of chorioamnionitis is made when any combination (or even one) of the following elements is noted: maternal fever, maternal or fetal tachycardia or both, elevated white blood cell count, uterine tenderness, and purulent fluid or purulent discharge from the cervical opening.

And here is the problem—the presence of one (or even more than one) of these signs and symptoms does not necessarily indicate intrauterine infection, or that actual chorioamnionitis is present. These finding are all subjective (not definitive, open to interpretation) and are generally neither sensitive (relating solely to this diagnosis) or specific.

The term PROM study allowed that ONE sign was enough to determine a diagnosis of clinical chorioamnionitis.

Today, the presence of a maternal fever is a commonly used justification for a diagnosis of chorioamnionitis, even if fever is the only symptom present. This diagnosis is then used as a justification to speed up delivery either by induction or by Cesarean Section.

In the presence of term PROM medical staff is already on hyper alert for the risk of infection making it even more likely that they will jump the gun at the slightest of indications and rush towards medical intervention and birth.

In reality maternal fever complicates up to one-third of labors and has many diverse causes including infection, epidural anesthesia, and inflammation.

Intrauterine infection, extrauterine infection (outside of uterus), epidural usage during labor, hyperthyroidism, dehydration, elevated ambient temperature, and the use of pyrogens such as Prostaglandin E2 for the induction of labor are all possible causes of maternal fever during labor.

These “other causes” are all confounding factors in the evidence based studies on the relation of term PROM to infection and for the most part  these “other causes” are left unaddressed by said studies.

Recently, the descriptive term “intrauterine inflammation or infection or both” (Triple I) has been proposed by a National Institute of Child Health and Human Development expert panel to replace the term chorioamnionitis and this topic is the subject matter of my sources.

They also particularly state that it is important to recognize that an isolated maternal fever does not automatically equate to infection or to chorioamnionitis. The presence of an elevated maternal temperature is not enough to make a proper diagnosis of either condition.

As I work through the evidence, the studies, the secondary analysis, and the various guidelines, I hope to put all of these risks into better perspective including the risk of infection.

But before I move on just again consider the following:

Consider that instead of intervention in the form of induction the best way to avoid ascending infection after PROM is to avoid digital vaginal exams and other invasive procedures as much as possible. This advice is entirely evidence based and has been shown to be effective repeatedly in numerous studies. The best place to pick up an infection is and always has been from someone else at the hospital.