Histologic Chorioamnionitis And Related Maternal And Neonatal Complications

ObjectiveTo investigate the correlations between histologic chorioamnionitis(HCA) and relevant maternal and neonatal complications.Methods(1) The research object and grouping:Single pregnant women and infants born at a gestational age between 28 and 33+6 weeks. Clinical data were obtained from Nanfang Hospital between June 1,2011 and June 1,2015. All the placentas were investigated histopathologically for chorioamnionitis. All the patients were categorized as HCA (+) group with histologic evidence of placental inflammationor HCA (-) without histologic evidence of placental inflammation.(2) research methods:This was a retrospective analysis, the correlations between HCA and relevant maternal and neonatal complications were analyzed.research indicators: ①The indicators of pregnant women:age, gravidity, parity, tocolysis, maternal venous antibiotics, antenatal corticosteroid, premature rupture of membranes and latency period, oligohydramnios, pregnancy complications including placenta praevia, placental abruption, diabetes mellitus, maternal hypertension, HELLP syndrome, intrahepatic cholestasis of pregnancy, and recorded materna CRP, WBC, HB level at admission and before delivery.②Neonatal indicators:gestational age(GA), birth weight, male newborn,caesarean delivery, 1-min Apgar score,5-min Apgar score, neonatal respiratory distress syndrome(NRDS), the use of pulmonary surfactant ventilator and non-invasive ventilation, bronchopulmonary dysplasia(BPD). necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), persistent pulmonary hypertension of newborn (PPHN), hypoglycemia,early onset sepsis, small for gestational age(SGA), perinatal mortality, length of stay, Cranial Ultrasound,brain MRI examination during hospitalization, and recorded neonatal CRP, WBC, procalcitonin(PCT) level at the first and the third day.(3) Statistical methods:All the data were analyzed using the SPSS 19.0 statistical software.The measurement data were tested for normality and homogeneity of variance, For the date was normal distribution and homogeneity of variance, descriptive statistical analysis with mean ± standard deviation (x±s),comparison between groups using two independent samples t-test or analysis of variance (one-way ANOVA).For the date was non normal distribution and homogeneity of variance, descriptive statistical analysis with median±quartile range(M±QR), differences between groups were tested by analysis of non-parametric test (Kruskal-Wallis).Categorical variables were showed as incidence (%),differences between groups were tested by χ2 test, When the sample number n>40and all the theoretical frequency T≥5， Pearson χ2 test was used, When the sample number n>40 and any theoretical frequency 1≤T<5, Correction χ2 test was used. Binary logistic regression was used to identify factors associated with HCA. Correlation analysis using Spearman correlation.We used Receiver Operating Characteristic (ROC) curve analysis and calculated diagnostic performance by using area under the curve (AUC),Youden index,sensitivity and specificity. A probability level of P<0.05 was considered statistically significant.Results(1) There were 1644 cases with premature delivery from June 1,2011 to June 1,2015 in our hospital obstetrics,and 1102 cases with placental pathological examination, accounting for 67%.Excluding 418 cases with multiple pregnancy,GA less than 28 weeks or more than 34 weeks and Clinical chorioamnionitis, finally 342 cases of pregnant women were included.Of 342 pregnant women,there wre 226 cases in HCA (+) group,116 cases in HCA (-) group,the incidence of HCA was 66.1% (226/342). The 342 cases of premature infants,excluding stillbirth and refuse department transference 21 cases, neonatal medical records missing 26 cases, finally 295 cases were included with Complete medical records.(2) ①The comparison of clinical indicators of pregnant women between two groups:Of the 342 pregnant women,the rate of PPROM、oligohydramnios,tocolysis and antibiotics exposure were significantly higher in the HCA (+) group compared with HCA (-) group (p< 0.05),and HCA (+) group had a prolonged PPROM compared with HCA (-) group, but there was no significant difference (P> 0.05), Maternal age, gravidity, parity, steroid exposure,placenta praevia, placental abruption, diabetes mellitus, maternal hypertension, HELLP syndrome, intrahepatic cholestasis of pregnancy were no significant differences between two groups (p>0.05).﹔isk factors analysis of HCA:When analyzed risk factors of HCA,the incidence of HCA was used as the dependent variable, the pregnancy complications and GA were used as the independent variable,pregnancy complications including PPROM, placenta praevia, placental abruption, diabetes mellitus, maternal hypertension, oligohydramnios,HELLP syndrome, intrahepatic cholestasis of pregnancy.Binary logistic regression revealed that oligohydramnios (OR=2.439) was significantly associated with HCA (P<0.05)(3) The relationship between PPROM and HCA.The incidence of PPROM was 41.2%(141/342). According to preterm premature rupture of membranes(PPROM) and latency period, all women were categorized into four groups,group A:women without premature rupture of membranes,group B:women with latency period≤48h, group C:women with latency period 49h-168h, group D:women with latency period> 168h.Maternal age,rate of gravidity, tocolysis, cesarean section, Male sex of neonate did not significantly differ among the 4 groups according to PPROM and latency period.The prevalence of HCA was significantly higher in those with PPROM than in those without PPROM(P<0.05), it was 75.2% (106/141) in patients with PPROM, and 59.7%(120/201) in patients without PPROM.There were significant differences in HCA incidence among 4 groups (P< 0.05),the incidence of HCA was higher in group B、C、D than that in the group A,and the incidence of HCA was gradually increased among group A、B、C,but it was decreased in group D than group C.When the HCA incidence of three groups was respectively compared with group A, only group C compared with group A had statistically significant (P<0.05).Spearman correlation showed that the latency period was positive correlated with the severity of HCA (P<0.01), but the relationship is not close(Spearman correlation coefficient<0.5).(2) The 342 cases of premature infants,excluding stillbirth and refuse department transference 21 cases, neonatal medical records missing 27 cases, finally 295 cases were included with Complete medical records.The neonatal birth weight of B、C、D group was no significant difference (P>0.05).Neonatal short-term Outcomes including 1-min Apgar score of≤7,SGA, NRDS, sepsis, BPD, perinatal mortality were no significant differences among group B、C、D.(4) The relationship between GA and the incidence of HCA and PPROM:The 342 pregnant women were divided into 3 parts With 30,32 as the boundary,The incidence of HCA and PPROM were analyzed.The incidence of HCA and PPROM was gradually increased with the increase of GA, but there was no significant difference (P>0.05)(5) The laboratory parameters comparison of pregnant women: ①The condition of laboratory parameters examination:Of the 226 cases of HCA (+) group,there were 212 cases examined WBC,HB level, and 172 cases examined CRP level at admission. There were 192 cases examined WBC,HB level, and 158 cases examined CRP level within 24 hours of delivery. Of the 116 cases of HCA (-) group,there were 104 cases examined WBC,HB level, and 85 cases examined CRP level at admission. There were 92 cases examined WBC,HB level, and 72 cases examined CRP level within 24 hours of delivery.(2)Statistical analysis results:The maternal WBC count of HCA(+) group was (14.0±6.7) x 109/L before delivery, and HCA(-) group was (12.2±3.8)×109/L,it was significantly higher in HCA (+) than in HCA (-) group(P<0.05).The maternal CRP、WBC level at admission and CRP level before delivery were higher in HCA (+) than in HCA (-) group,but there were no significant difference (P>0.05)(6) The comparison of clinical indicators of neonatal infants between two groups: ①The condition of Cranial Ultrasound and brain MRI examination:Of the 295 cases, there were 267 cases examined Cranial Ultrasound (90.5%), among which 182 cases were normal,38 cases with HIE,3 cases with intracranial hemorrhage(IVH),3 cases with HIE and IVH meanwhile,15 cases with cerebral ventriculomegaly,25 cases with HIE and cerebral ventriculomegaly meanwhile,1 case with Ventricle effusion.The abnormal cranial Ultrasound included HIEJVH, cerebral ventriculomegaly, Ventricle effusion.The incidence of abnormal cranial Ultrasound was 31.8%(85/267).Of the 295 cases, there were 72 cases examined brain MRI (24.4%),among which 32 cases were normal,12 cases with HIE,10 cases with IVH,5 cases with periventricular leukomalacia(PVL),11 cases with premature infant brain changes, lcase with subdural collection of fluid, lcase with hydrocephalus.The abnormal brain MRI included HIE,IVH,PVL, premature infant brain changes, subdural collection of fluid, hydrocephalus.The incidence of abnormal cranial Ultrasound was 55.6%(40/72).②Statistical analysis results:The gender and caesarean delivery of newborns were no significant difference between two groups (p>0.05).The gestational age and birth weight in HCA (+) group were (32±2.8) week and (1730.2±424) g, it were (32±2.6) week and (1630.7±416) in HCA (-) group,there were no significant difference between groups (p>0.05). Infants with HCA, compared with controls, had a significantly higher incidence of bronchopulmonary dysplasia and hypoglycemia, and lower incidence of SGA,P all <0.05.The rate of NRDS was lower,and rate of early onset sepsis was higher in HCA (+) group,but no significant difference (P>0.05).There were no significant differences of 1-min Apgar score of ≤7,5-min Apgar score of ≤7,the use of pulmonary surfactant, ventilator and non-invasive ventilation, NEC, PDA, PPHN,,perinatal mortality, length of stay, abnormal Cranial Ultrasound and brain MRI examination, HIE, IVH between two groups (P>0.05)(7) The laboratory parameters comparison of newborns:①The condition of laboratory parameters examination:Of the 195 cases of HCA (+) group,all patients examined WBC,CRP level and 121 cases examined PCT level at the first day. There were 70 cases examined WBC level,152 cases examined CRP level, and 121 cases examined PCT level the third day. Of the 100 cases of HCA (-) group, all patients examined WBC level,98 cases examined CRP level,and 79 cases examined PCT level at the first day. There were 31 cases examined WBC level,75 cases examined CRP level, and 52 cases examined PCT level the third day.Statistical analysis results: HCA(+) group newborns had a significantly higher WBC count and CRP level at the first day.and higher WBC count at the third day (P<0.05). There were no significant differences of neonatal PCT level at the first day and CRPn PCT level at the third day (P<0.05).(8) ROC curve:We used ROC curve analysis and calculated diagnostic performance.The variable included maternal WBC level before delivery,neonatal WBC、CRP level at the first day and WBC level at the third day.But the sensitivity, specificity and Youden index of the cut-offs were low, all the laboratory parameters in mother or infant do not predict the diagnosis of HCA.Conclusions(1) The incidence of HCA was 66.1% in our study.The incidence of HCA was associated with prenatal complications,single factor analysis found that,HCA was significantly associated with PPROM and oligohydramnios.Binary logistic regression revealed that oligohydramnios was a independent risk factor for HCA (OR=2.439, P<0.05)(2) The incidence of PPROM was 41.2% in this study. The prevalence of HCA was significantly higher in those with PPROM than in those without PPROM.The latency period was positive correlated with the severity of HCA,but the relationship is not close (Spearman correlation coefficient<0.5), when the duration of latency was longer than 1 week,the incidence of HCA was decreased.Neonatal short-term Outcomes were no significant differences among groups of latency period<48h,latency period 49h-168h and latency period>168h. Latency does not appear to worsen neonatal short-term outcomes in pregnancies that are complicated by PPROM.(3) There were significantly higher rate of BPD and hypoglycemia in HCA (+) group,but there were no significant difference of NRDS and early onset sepsis between groups.(4) The maternal WBC level before delivery,neonatal WBCXRP level at the first day and WBC level at the third day were significantly higher in HCA(+) group.but all the laboratory parameters in mother or infant do not predict the diagnosis of HCA.further research needed to find laboratory indicators possible early predict HCA.