Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
Am J Obstet Gynecol MFM. 2020 Aug;2(3):100176. doi: 10.1016/j.ajogmf.2020.100176. Epub 2020 Jul 6.
Chorioamnionitis can have a highly variable definition with substantial maternal and fetal morbidity, with higher frequencies in preterm births. With the recently updated intraamniotic infection diagnostic criteria by the American College of Obstetricians and Gynecologists, fewer women experiencing preterm delivery may qualify for intrapartum antibiotic treatment, potentially resulting in higher postpartum infectious morbidity.
This study aimed to estimate whether the proportion of women delivering preterm who develop postpartum endometritis differs between subjects diagnosed as having clinical chorioamnionitis and those meeting the American College of Obstetricians and Gynecologists' criteria for intraamniotic infection.
Secondary analysis was conducted using a randomized controlled trial of antenatal magnesium sulfate for the prevention of cerebral palsy. Subjects were included if they had a clinical diagnosis of chorioamnionitis and maternal temperature of ≥37.8°C and excluded if maternal temperature data were missing. The exposure group included women who met the criteria for intraamniotic infection, defined as a single maternal temperature of ≥39.0°C or maternal temperature of 38.0°C to 38.9°C plus 1 additional clinical risk factor (leukocytosis, purulent cervical drainage, or fetal tachycardia). The primary outcome was postpartum endometritis. The odds of postpartum endometritis were compared between women with intraamniotic infection and women with clinical chorioamnionitis, after adjusting for potential confounders using multivariate logistic regression.
Of the original study population, 258 of 2241 (11.8%) subjects met the criteria for chorioamnionitis. Nearly all subjects (98.5%) received antibiotic treatment between randomization and delivery. A total of 144 subjects (55.8%) met the criteria for intraamniotic infection, whereas 114 (44%) only met the criteria for clinical chorioamnionitis. A total of 40 women (15.5%) experienced postpartum endometritis. Women with intraamniotic infection had higher parity (P=.02) and higher maximum maternal temperature (P<.001) and were more likely to have received antibiotic treatment (P=.04). Postpartum endometritis rates were similar between subjects with chorioamnionitis and intraamniotic infection (12% vs 18%; P=.50). After adjustment for potential confounders, the odds of developing postpartum endometritis did not differ between subjects who met the criteria for intraamniotic infection and those who did not (adjusted odds ratio, 1.28; 95% confidence interval, 0.62-2.62).
Patients delivering preterm who receive a diagnosis of clinical chorioamnionitis in the intrapartum period seem to have similar odds of developing postpartum endometritis as those meeting the American College of Obstetricians and Gynecologists' criteria for intraamniotic infection, suggesting that this group remains at a high risk for postpartum infectious complications.
绒毛膜羊膜炎的定义差异较大，与产妇和胎儿发病率有很大关系，且早产儿发病率更高。美国妇产科医师学会最近更新了羊膜腔内感染的诊断标准，可能会导致更多经历早产分娩的女性不符合使用产时抗生素治疗的标准，从而增加产后感染性发病率。
本研究旨在评估临床绒毛膜羊膜炎和符合美国妇产科医师学会羊膜腔内感染标准的女性在分娩后发生子宫内膜炎的比例是否存在差异。
本研究为产前硫酸镁预防脑瘫的随机对照试验的二次分析。如果患者有临床绒毛膜羊膜炎诊断且体温≥37.8°C，则纳入研究；如果缺失体温数据，则排除。暴露组包括符合羊膜腔内感染标准的女性，标准为单次母体体温≥39.0°C或体温为 38.0°C 至 38.9°C 并伴有 1 个附加临床危险因素（白细胞增多、脓性宫颈分泌物或胎儿心动过速）。主要结局为产后子宫内膜炎。使用多变量逻辑回归，在调整潜在混杂因素后，比较羊膜腔内感染和临床绒毛膜羊膜炎女性的产后子宫内膜炎发生几率。
在最初的研究人群中，2241 例中有 258 例（11.8%）符合绒毛膜羊膜炎标准。几乎所有患者（98.5%）在随机分组至分娩期间都接受了抗生素治疗。144 例（55.8%）患者符合羊膜腔内感染标准，而 114 例（44%）仅符合临床绒毛膜羊膜炎标准。共有 40 例（15.5%）女性发生产后子宫内膜炎。羊膜腔内感染的女性有更高的产次（P=.02）和更高的最大母体体温（P<.001），更有可能接受抗生素治疗（P=.04）。绒毛膜羊膜炎和羊膜腔内感染的女性产后子宫内膜炎发生率相似（12% vs 18%；P=.50）。调整潜在混杂因素后，符合羊膜腔内感染标准的患者发生产后子宫内膜炎的几率与不符合标准的患者没有差异（调整后的比值比，1.28；95%置信区间，0.62-2.62）。
在产时诊断为临床绒毛膜羊膜炎的早产分娩患者发生产后子宫内膜炎的几率似乎与符合美国妇产科医师学会羊膜腔内感染标准的患者相似，这表明该组患者仍存在产后感染性并发症的高风险。
