www.AJOG.

org
Research
 Bo Jacobsson, MD, PhD

pg/mL; P < .0001) and the highest

incidence of newborns with early-
O onset sepsis (P .02).
B
CONCLUSION: Both MIAC and HCA
S affect the intensity of the intraamniotic
T inflammatory response and the
incidence of early-onset sepsis
following PPROM between 34-37
weeks. The intensity of the
intraamniotic inflammatory response
should be considered in the clinical
management of PPROM between 34-
37 weeks.
 Prelabor between 34 andinflammatory response and
R rupture of 37 weeks: the neonatal outcomes. Am J Obstet
Cite this article as: Kacerovsky M, membranes intraamniotic Gynecol 2014;210:325.e1-10.
E Musilova I, Andrys C, et al.
mature, they represent a
high-risk group with an Recent
d increased rate ofstudies
e morbidities and a higherhave

P
A rate of hospitalevaluated
readmission in the firstthe
month of life whendifferences
compared to full-termbetween
4,5
infants. expectant
and active
manageme
nt of
women
with
PPROM
between
34-37
weeks with
respect to
short-term
neonatal
morbidity,
espe-cially
for early-
onset
6,7
sepsis.
Although
these
studies
were well
designed,
they did
not shed
light on
this
problem, as
they
revealed no
difference
in the rate
of early-
onset
sepsis
between
active and
expectant
manageme
nt of
pregnancie
s
 with PPROMdilemma active <34 weeks, a con-gesta infl of of the
F between 34-37because manage dition for whichtiona am the adverse
r 6,7
weeks. Therefore,there is
6,7
ment. expectant l age mat most neonatal
outcomes
a the optimallack of This ismanagement 8,9 is(GA) ory impo asso-ciated
n management ofevidence in recommended. , the resp rtant with
R PPROM betweento justify contrast Strong evidenceintra ons deter PPROM.1,10
e 34-37 weekseither to indicates that inamni e is mina -18 Our
T
remains a clinicalexpectan PPROM addition tootic one nts group
t or
h APRIL 2014 American Journal of Obstetrics & Gynecology 325.e1
Research Obstetrics www.AJOG.org
microbiology examined in one of
weeks are actively laboratory, where our previous
recently showed that not only intra-amniotic but also fetal managed. Induction the first tube was reports on the
inflammatory responses in PPROM between 24-37 gestational of labor is initiated used for intraamniotic
weeks are highest when both microbial invasion of the amniotic or a cesarean polymerase chain inflammatory
cavity (MIAC) and acute histologic cho-rioamnionitis (HCA) are section is reaction (PCR) response in women
present.
3,19
Therefore, we hypothesize that PPROM pregnancies performed within testing for with PPROM
between 34-37 weeks com-plicated by these conditions may have 24 hours after Ureaplasma throughout the
a higher intraamniotic inflammatory response, resulting in worsemem-brane rupture species, whole range of
depending on the Mycoplasma 3
preterm delivery.
short-term neonatal morbidity when compared to PPROM
fetal status, the hominis, and
between 34-37 weeks without MIAC and HCA. Furthermore, this
maternal serum Chla-mydia
topic is of particular clinical relevance, as it may result in the
concentration of C- trachomatis, and
optimization of the clinical management of PPROM between 34-
reactive protein, the second tube
37 weeks.
and cervicovaginal was used for
Therefore, the purpose of this study was to evaluate the streptococcus beta
intensity of the intraamniotic inflammatory response, as 20
aerobic and
colonization. All anaerobic
characterized by amniotic fluid inter-leukin (IL)-6 concentrations,
these women bacterial culture.
and sub-sequent neonatal morbidity based on the presence of
receive antibiotics The third tube
MIAC and HCA in PPROM pregnancies between 34-37 weeks.
after hospital was centrifuged
admission and
MATERIALS AND METHODS amniocentesis.
for 15 minutes at
Sample collection 2000g to remove
PPROM was cells and debris,
From May 2008 through March 2013, a prospective cohort study diagnosed visually
was conducted on pregnant women at GA between 340 andusing a sterile divided into
366 weeks who were admitted to the Department of Obstet-rics speculum aliquots and
and Gynecology, University Hospital in Hradec Kralove, Czech examination stored at e70C
to until analysis.
Republic. Pregnant women with singleton preg-nancies, PPROM, confirm the
and maternal age >18 years were invited to participate in thepooling of After delivery,
study. Exclusion criteria included women with gestational amniotic fluid in the placentas
hypertension, preeclampsia, fetuses with an estimated weightthe vagina and were fixed in
<10th percentile, the presence of either congenital or confirmed by a formalin, and
chromosomal fetal abnormalities, gestational or pre-gestational positive test for tissue samples
diabetes, and signs of fetal hypoxia. The primary outcome of this the presence of from the placenta,
study was the intensity of the intra-amniotic inflammatoryinsulin-like growth umbilical cord,
response, char-acterized by IL-6 concentrations in the amniotic factorebinding and placental
fluid. The secondary outcome was neonatal morbidity. protein-1 (ACTIM membranes were
GA were established by first-trimester fetal biometry. In ourPROM test; Medix routinely
department, PPROM pregnancies between 34-37 Biochemica, Kau- processed and
niainen, Finland) embedded in
in the vaginal fluid paraffin. Tissue
when necessary.
21 sections were
stained with
Ultrasound-
hematoxylin-
guided
eosin for standard
transabdominal
histo-logic
amniocentesis was
examination.
performed upon
The study was
admission, prior to
approved by the
the administration
insti-tutional
of antibiotics. The
review board
amniotic fluid
committee (March
samples were
19, 2008; no.
immediately
200804 SO1P).
divided into 3
Written informed
poly-propylene
consent was
tubes. The first and
obtained from all
second tubes
participants. All
containing
women self-
noncentrifuged identified as
sam-ples were Caucasian. Forty-
immediately three women in the
transported to the study group were
 23 determining the intraassay
funisitis.
Diagnosis of MIAC Histopathological
IL-6 coefficients were
concentration in <10%.
MIAC was defined as a positive PCR for genital mycoplasmas examinations were the amniotic
(Ureaplasma par-vum, Ureaplasma urealyticum, and My-performed by a fluid.
18,24
IL-6
coplasma hominis) and/or Chlamydia trachomatis and/orsingle pathologist concentra- Diagno
as the growth of any bacteria in the amniotic fluid except forwho was blinded to tions were sis of
severe
coagulase-negative Staphylococcus epi-dermidis, whichthe clinical status of assessed by the
neonat
22 the patient. human IL-6
was considered a skin contaminant. al
Quantikine morbidit
Diagnosis of HCA Measure enzyme-linked y
ment of immuno-sorbent
The degree of neutrophil infiltration was evaluated separately in Maternal and
intraamnio assay (R&D
the free mem-branes (amnion and chorion-decidua), in the perinatal medical
chorionic plate, and in the umbilical cord based on the criteria tic Systems Inc, Min- records were
23 inflammat neapolis, MN). reviewed by 2
provided by Salafia et al. A diagnosis of HCA was made based
ory Amniotic fluid investigators (M.K.
on histologic grades of 3-4 for the chorion-decidua (multiple or samples were
response and I.M.). Data
confluent foci of at least 5-20 neutrophils), 3-4 for the chorionic
diluted 10-fold.
plate (at least a few neutrophils present in the connective tissue or The intensity of regarding morbidity
The sensitivity of
chorionic plate), 1-4 for the umbilical cord (any neutrophils the intraamniotic and mortality were
the test was <0.70
present in the umbilical cord), and/or 1-4 for the amnion (at least in-flammatory reviewed for all
23 response was pg/mL, and the
1 focus of at least 5 neutrophils). His-tologic grades of 1-4 for measured by interassay and
the umbilical cord were considered to indicate the presence of
325.e2 American Journal of Obstetrics & Gynecology APRIL 2014
APRIL 2014 American Journal of Obstetrics & Gynecology

T
A
B
L
E

M
a
t
e
r
n
a
325.e3

l
a
n
d
n
e
o
n
a
t
a
l
c
h
a
r
a
c
t
e
ri
s
ti
c
s
o
f nce of MIAC and/or acute HCA
Presence of MIAC and Presence of HCA Presence of MIAC
P Characteristic HCA (n [ 12) alone (n [ 37) alone (n [ 11)
P
Maternal age, y, median (range) 32 (21e40) 29(24e35) 32 (24e44)
R 2
O Prepregnancy body mass index, kg/m , 24.3 (17.6e34.4) 23.1 (18.0e36.8) 22.7 (17.9e29.7)
M median (range)
Smoking, n (%) 2 (17) 4 (11) 3 (27)
p
Gestational age at admission, wk, median (range) 35 (34e37) 36(34e37) 36 (34e37)
r
e Gestational age at delivery, wk, median (range) 35 (35e37) 36(34e37) 36 (34e37)
g Latency from PPROM to amniocentesis, h, 6.0 (3.0e20.0) 5.0 (1.0e22.0) 4.0 (2.0e23.0)
n median (range)
a
Latency from PPROM to delivery, h, median (range) 24.0 (9.0e64.0) 22.0 (6.0e94.0) 16.0 (5.0e51.0)
n
c Latency from amniocentesis to delivery, h, 14 (3e47) 11(1e92) 12 (2e28)
i median (range)
e Amniotic fluid IL-6, pg/mL, median (range) 2164.0 (226.5e6159.0) 654.8 (24.3e6072.0) 784.1 (319.4e3484.0)
s
CRP levels at admission, mg/L, median (range) 5.7 (2.2e14.1) 8.0 (1.1e82.0) 5.0 (1.0e13.0)
b 9
WBC count at admission, 10 L, median (range) 11.5 (9.0e14.0) 11.0 (6.0e17.0) 11.0 (7.0e19.0)
e Administration of antibiotics, no. (%) 12 (100) 36(97) 11 (100)
t
w Induction of labor, no. (%) 6 (50) 16(43) 5 (45)
e Spontaneous vaginal delivery, no. (%) 8 (67) 33(89) 10 (91)
e
Cesarean section, no. (%) 3 (25) 4 (11) 1 (9)
n
Forceps delivery, no. (%) 1 (8) 0 (0) 0 (0)
3 Birth weight, g, median (range) 2490 (1810e3870) 2480 (1860e2870) 2470 (1820e3310)
4
- Funisitis, no. (%) 5 (42) 7 (19) e
3 5-min Apgar score, median (range) 9 (9e10) 9 (8e10) 9 (8e10)
7
10-min Apgar score, median (range) 10 (9e10) 10(8e10) 10 (9e10)
w Continuous variables were compared using nonparametric Jonckheere-Terpstra test. Categorical variables were compared using either
Cochran-Armitage test for trend test or Fisher exact test. Presence of funisitis was considered only in groups with HCA alone and both
e MIAC and HCA. Therefore, data about funisitis are missing (-) in columns MIAC alone and without MIAC and HCA.
e CRP, C-reactive protein; HCA, histologic chorioamnionitis; IL, interleukin; MIAC, microbial invasion of amniotic cavity; PPROM, preterm
k prelabor rupture of membranes; WBC, white blood cells.
a
s Statistically significant results.
Kacerovsky. Inflammatory response in PPROM between 34-37 weeks. Am J Obstet Gynecol 2014.
a
www.AJOG.org

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c
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Obstetrics Research
Research Obstetrics www.AJOG.org
characteristics
for Mac OS X (GraphPad Software, were observed
La Jolla, CA). among these
TABLE 2 subgroups
RESULTS
Microorganisms identified in amniotic fluid A total of 118 women with PPROM
Presence of MIAC and HCA (n [ 12) Presence of MIACoccurring
alone (n [at11)
GA between 34-37 weeks
Ureaplasma species were recruited for the study. Of these
Ureaplasma species
Ureaplasma species 118 women, amniocentesis was not
Ureaplasma species
possible in 10 (8%) women, and the re-
Ureaplasma species Ureaplasma species
sults of the histopathological
Ureaplasma species Ureaplasma speciesassessment of the placenta were not
Ureaplasma species Ureaplasma speciesavailable for 9 (7%) women. The
remaining 99 women were included in
Ureaplasma species Mycoplasma hominis
the study. The overall rate of MIAC
Ureaplasma species Mycoplasma hominiswas 23% (23/99), and HCA was found
Ureaplasma species in 49% (49/99) of women. Funisitis
Chlamydia trachomatis
Haemophilus influenzae was hemolytic
Streptococcus alpha identified in 12% (12/99) of
women. Both MIAC and HCA were
Streptococcus alpha hemolyticus Streptococcus pneumoniae
present in 12% (12/99) of women.
Ureaplasma species; Mycoplasma hominis Candida albicansHCA alone and MIAC alone were
Ureaplasma species; Streptococcus present in 37% (37/99) and 11%
alpha hemolytic (11/99) of women, respectively. Almost
HCA, histologic chorioamnionitis; MIAC, microbial invasion of amniotic cavity. 40% (39/99) of women exhibited
Kacerovsky. Inflammatory response in PPROM between 34-37 weeks. Am J neither MIAC nor HCA. No
Obstet Gynecol 2014. differences in maternal and clinical

newborns. For the current study, we definedelevated C-reactive the bestcarried out ( Table 1). Ureaplasm
severe neonatal morbidity as follows: theprotein and/or af-fected cutoff valueusing SPSS No cases a species
need for tracheal intubation, respiratorywhite blood cell count] of IL-619.0 for of clinical streptococc
distress syndrome (defined by the presence between 4-120 days of concentrati Mac OS X cho- us alpha
of 2 of the following criteria: evidence oflife), on in the(IBM Corp, rioamnioni hemolytic).
respiratory compro-mise, a persistentbronchopulmonary amniotic Armonk, Table 2 lists
tis were
all mi-
oxygen requirement for >24 hours,dysplasia (defined by fluid for theNY) and present in
croorganis
administration of exogenous surfactant, andthe infants oxygen diagnosis GraphPad the study ms detected
radiographic evidence of hyaline membranerequirement at 28 days of early-Prism 5.03 population. in the
disease), transient tachypnea (any oxygen of life), pneu-monia onset sepsis The most amniotic
supplement re-quirement during the first 6
(diagnosed by in common fluid.
abnormal findings on newborns.
hours that does not increase during the bacteria
chest x-rays), and A
subsequent 18 hours as clinical conditions was Amniotic
neonatal death prior to Spearman
improve within 3-6 hours, and chest 26 Ureaplas fluid IL-6
radiographs either normal or indicatinghospital discharge. partial ma concentrat
reduced translucency, infiltrates, and correla-tion species,
Statistical analysis ions
hyperinsuf-flation of the lungs), was used to which was
We observed
intraventricular hemorrhage (diagnosed byDemographic and adjust the identified
clinical characteristics data for differences
cranial ultra-sound examinations based on in 65%
in the IL-6
the criteria defined by Papile et al ),were compared using a GA.
25
(15/23) of
concentratio
necrotizing enterocolitis (defined as thenonparametric Differences women.
ns in the
radiologic finding of either intramural gas Jonckheere-Terpstra test were Polymicro
amniotic
or free intraabdominal gas), retinopathy ofand the Mann-Whitney considered bial
fluid among
pre-maturity (identified using retinoscopy),U test for continuous statistically findings
early- and late-onset sepsis (defined as anyvariables and presented significant were found the
systemic bacterial infection docu-mentedas medians (range). Cat- at P < .05. in 9% subgroups
by a positive blood culture during the firstegorical variables were All P (2/23) of based on the
72 hours of life and the presence ofcompared using the values were women presence or
symptoms of or strong clinical suspi-cion of Cochran-Armitage test determined (Ureaplas absence of
for trends or Fisher exact from 2- ma species MIAC and
sepsis [presence of symptoms and
test and the results were sided tests, HCA (P < .
presented as numbers and all Mycoplas 0001).
(%). Receiver operating statistical ma Women with
characteristic curves analyses hominis both MIAC
were used to determine were and and HCA
exhibited the highest median concentration and differences were women women P .005; alone: P .
of IL-6 among the sub-groups (both MIAC observed in the IL-6 with both(MIAC and MIAC and 03; MIAC
and HCA: 2164.0 pg/mL; HCA alone: concentrations in the MIAC andHCA vs HCA vs and HCA vs
654.8 pg/mL; MIAC alone: 784.1 pg/mL; amniotic fluid between HCA andHCA alone: MIAC
and neither MIAC nor HCA: 383.0 pg/mL), other
325.e4 American Journal of Obstetrics & Gynecology APRIL 2014
www.AJOG.org Obstetrics Research
FIGURE 1
neither MIAC nor HCA: P < .0001) ( Figure 1). Women without
MIAC and HCA had lower amniotic fluid IL-6 concentrations than
women with HCA alone (P .03) and those with MIAC alone (P Differences
observed in
.02), as shown in Figure 2. No differences in the amniotic fluid amniotic fluid
IL-6 concentrations were observed between women with HCA IL-6
concentration
alone and those with MIAC alone (P .60) ( Figure 2). s between
Neonatal morbidity women with
both MIAC
Respiratory disorders (respiratory dis-tress syndrome or transient and HCA
tachypnea of newborns) and the need for tracheal intubation were
observed in 14% (14/99) and 3% (3/99) of newborns, respectively.
Intraventricular hemorrhages of grades I-II were found in 6%
(6/99) of new-borns. No intraventricular hemorrhages of grades III
or IV were observed. Pneumonia was diagnosed in 2% (2/99) of
newborns. Severe neonatal morbidity was observed in 25% (25/99)
of new-
 p<0.0001

p=0.03

p=0.005
7000

6000

5000

4000

3000 2164.0
2000

1000
1000
pg/mL

900
784.1
800

700 654.8

383.0
600

500
borns. This cohort of women had no
evidence of bronchopulmonary dysplasia,
retinopathy of prematurity, necrotizing400
enterocolitis, or late-onset sepsis, and no300
neonatal death.
Selected neonatal morbidities are
200
presented in Table 3 according to the
presence or absence of MIAC and/or HCA. 100
Differences were observed among 0
subgroups in early-onset sepsis
(P
.02), which was observed in 4% Interleuki
(4/99) of newborns, and severen (IL)-6
neonatal mor-bidity (P .03).concentr
Three cases of early-onset sepsis ations in
occurred in the subgroup ofamniotic
women with both MIAC andfluid with
HCA. One case (culture proven)respect
was in a woman with MIAC alone.to
Two new-borns had culture-provenpresence
early-onset sepsis (Haemophilusor
influenzae and Streptococcusabsence
pneumoniae). Differences of
microbial
invasion
of
amniotic
cavity
(MIAC)
and/or
acute
histologi
c
chorioam
nionitis
(HCA).
Pregnan
cies with
both
MIAC
and HCA
exhibited
higher
median
IL-6
value
than
those
with
HCA
alone,
MIAC
alone,
and
neither
MIAC
nor HCA.
Kacerovsk
y.
Inflammato
ry
response
in PPROM
between
34-37
weeks. Am
J Obstet
Gynecol
2014.
in severe neonatalwith a ut early-onset575 ( 49%, both MIAC and
morbidity (P .003)higher sepsis: pg/ P respect HCA. Third, no
were only observedIL-6 median mL; . ively. difference was
P
among the 3 GAconce .0
0 Second observed in the
subgroups (34-35, 35-36,ntratio 01)
, the intraamniotic
and 36-37 weeks) (n by intraa inflam-matory
Table 4). (with crud mnioti response
early- e c between groups
The IL-6
onset anal inflam with MIAC
concentrations in the
sepsis ysis matory alone and HCA
amni-otic fluid are
: and respon alone, although
shown in Table 5 basedmedia after se was these groups had
on the presence/absencen adju
highest a higher
of selected neonatal5303 stme
nt for intraamniotic
morbidities. Thepg/mL
for women
presence of early-onsetvs
GA with
sepsis was associatedwitho
Americ Journal of Gyneco 325. e5
an Obstetrics & logy
Research Obstetrics www.AJOG.org
study with that
from previously
27,28 published studies
affected by GA in PPROM.
FIGURE 2 because of the
Our finding of MIAC in PPROM
between 34-37 weeks is consistent different ways in
Amniotic fluid IL-6 concentrations according to MIAC with this, as the rate of MIAC in which PPROM is
and HCA this study did not differ managed
from previously published studies clinically and
p=0.03
eval-uating MIAC in PPROM <34
weeks.22,29
p=0.60
Nevertheless, the rate of MIAC can
vary among different populations
p=0.02
and among techniques used for
bacterial identifica-
7000

6000
tion. Two pioneering studies by
24,28
5000 Romero et al showed that the
4000
rates of MIAC
in the US population based on
3000 2164.0 cultiva-tion were 38-34% for
patients with pre-term and term
2000
rupture of membranes,
1000 respectively. Recently, DiGiulio et
1000 30
al reported the rate of MIAC as
pg/mL

900
34% by the cultivation approach,
784.1
800 45% by PCR, and 50% by
700 654.8 combining both techniques.
It is difficult to compare the data
on the incidence of HCA in this
383.0
600
because g
ther
500
of
classificat
400 ion of
300
inflam-
matory
changes
200 in the
100 placenta
and fetal
0
membran
es.
Neverthel
ess, the
rate of
HCA in
PPROM
between
34-37
weeks
seems to
be lower
than the
incidence
of HCA
in
PPROM
before
GA of 34
weeks as
found in
our
previous
3
work.
Our
 withMIAC withHCA withMIAC withoutMIAC
andHCA alone alone andHCA
(n=12) (n=37) (n=12) (n=39)
Interleukin (IL)-6 concentrations in amniotic fluid with respect to presence or absence of microbial invasion of amniotic cavity (MIAC)
and/or acute histologic chorioamnionitis (HCA). Pregnancies with MIAC alone and HCA alone exhibited higher median IL-6 values
than those with neither MIAC nor HCA. No differences in IL-6 concentrations in amniotic fluid were observed among women with
HCA alone and MIAC alone.
Kacerovsky. Inflammatory response in PPROM between 34-37 weeks. Am J Obstet Gynecol 2014.
associated with stronger intraamniotic and fetal inflammatory responses when
3,19
compared to other PPROM subgroups between GA of 24-37 weeks. Little
information is available regarding the intraamniotic inflammatory response in PPROM pregnancies between 34-37 weeks
with respect to the presence or absence of MIAC and/or HCA. In this study, we confirmed that the highest intraamniotic
inflammatory responses were observed for patients with both
inflammatory responseMeaning det M
than groups lacking bothof the ect I
MIAC and HCA. Fourth,study bac
the incidence of onlyMIAC teri
early-onset sepsis andand HCA a,
severe neonatalrepresent the
morbidity were affected the most rat
by MIAC and HCA in important e
pregnancies withconditions of
PPROM between 34-37 that MI
weeks. Fifth, the rate ofdetermine AC
severe neonatalthe is
morbidity decreasedintraamni not
with ad-vancing GAotic bel
from 34-37 weeks.inflammat iev
Finally, early-onsetory ed
sepsis was associatedresponse to
with higher IL-6and are be
concentrations, indepen-major dra
dent of GA. determina ma
nts of tic
maternal all
and y
neonatal
outcomes
in
pregnanci
es
complicat
ed by
PPROM
between
34-37
weeks.
Despite
the
difficulty
of com-
paring the
rates of
MIAC
among
studies
because
these
studies
use
different
tech-
niques to
 325.e6 Jo a APRIL
American urnl 2014

www.AJOG.org Obstetrics Research

TABLE 3
Neonatal morbidity according to MIAC and HCA
Presence of MIAC Presence of HCA Presence of MIAC Absence of MIAC P value
Characteristic, no. (%) and HCA (n [ 12) alone (n [ 37) alone (n [ 11) and HCA (n [ 39) for trend
Tracheal intubation 1 (8) 0(0) 0 (0) 2 (5) .72
Respiratory disorders 4 (33) 6(16) 2 (18) 2 (5) .02
Respiratory distress syndrome 3 (25) 3(8) 1 (9) 2 (5) .11
Transient tachypnea 1 (8) 3(8) 1 (9) 0 (0) .10
Intraventricular hemorrhage grades I-II 0 (0) 3(8) 0 (0) 3 (8) .94
Early-onset sepsis 3 (25) 0(0) 1 (9) 0 (0) .02a
Cultivation-proven early-onset sepsis 1 (8) 0(0) 1 (9) 0 (0) .31
Pneumonia 0 (0) 1(3) 1 (9) 0 (0) .72
a
Severe neonatal morbidity 6 (50) 10(27) 3 (27) 6 (15) .03

Respiratory disorders were defined as respiratory distress syndrome or transient tachypnea. Severe neonatal morbidity was defined as need for intubation, respiratory distress syndrome, pneumonia,
bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular hemorrhage, necrotizing enterocolitis, early-onset sepsis, late-onset sepsis, and/or neonatal death before hospital discharge. Intraventricular
hemorrhage grades III-IV, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, late-onset sepsis, and neonatal death before hospital discharge were not considered in analysis because of
no occurrence in cohort. Categorical variables were compared using Cochran-Armitage test for trend.

HCA, histologic chorioamnionitis; MIAC, microbial invasion of amniotic cavity.

a
Statistically significant results.
Kacerovsky. Inflammatory response in PPROM between 34-37 weeks. Am J Obstet Gynecol 2014.

demonstrated that
tissue damage by necrotic cells. 31 These endogenous molecules can almost all HCA at inflammatory
elicit re-sponses similar to those of exogenous microorganisms term are response than
through the system of pattern recognition receptors, and they have noninfectious.33 those with both
recently been identified in the am-niotic fluid.31,32 Moreover, it wasTherefore, further MIAC and HCA
recently study is needed to and a higher
clarify the role of response than
alarmins for those without both
PPROM between
34-37 weeks. MIAC and HCA.
To determine the
The next
interesting finding difference between
was that women the group with
with MIAC alone MIAC alone and
had a lower the group with
both MIAC and
HCA, we
performed a
secondary
analysis. No
 transient tachypnea. prematurity, intraventricular hemorrhage, necrotizing enterocolitis, early-
Tracheal intubation
Cultivation proven early-onset
Severe sepsis
neonatal onset sepsis, late-onset sepsis, and/or neonatal death before hospital
morbidity was discharge. Intraventricular hemorrhage grades III-IV, bronchopulmonary
Respiratory disorders
Pneumonia defined as need for dysplasia, retinopathy of prematurity, necrotizing enterocolitis, late-onset
intubation, sepsis, and neonatal death before hospital discharge were not
TABLE 4 Respiratory distress syndrome
Severe neonatal morbidity
respiratory distress considered in analysis because of no occurrence in cohort. Categorical

Neonatal morbidity according to Transient tachypnea

Respiratory
syndrome,
pneumonia,
variables were compared using Cochran-Armitage test for trend.

gestational age disorders

Intraventricular hemorrhage
defined
were
asgrades I-II
bronchopulmonary
a
Statistically significant results.
Kacerovsky. Inflammatory response in PPROM
Gestational age respiratory distress dysplasia,

Early-onset sepsis retinopathy of between 34-37 weeks. Am J Obstet Gynecol 2014.

Characteristic, no. (%) 34-35 wk (n [ 37) syndrome or
APRIL 2014 American Journal of Obstetrics & Gynecology 325.e7
Research Obstetrics www.AJOG.org
noninva-sive
a lower inflammatory response than the samples such as
group with MIAC and HCA. We can cervical and
TABLE 5 only speculate as to whether the coor- vaginal
dination of infectious and
Neonatal morbidity according to amniotic fluid IL-6 noninfectious factors (microorganisms
concentrations and alarmins together) is required for
Newborns, IL-6 pg/mL, P the group with both MIAC and HCA to
Characteristic no (%) median (range) express the strongest inflammatory
value
Tracheal intubation response. This speculation is supported
32
Yes 3 (3) 1480 (422e1502) .33by a study by Romero et al that
No 96 (97) 626 (24e6159) showed higher concentrations of
alarmin in PPROM pregnancies
Respiratory disorders complicated by either the presence of
Yes 14 (14) 458 (175e5871) .80bacteria in the amniotic fluid or high
No 85 (86) 651 (24e6159)
amniotic fluid IL-6 concentra-tions.
Nevertheless, the differences in the
Respiratory distress syndrome intraamniotic inflammatory response
Yes 9 (9) 421 (176e5871) .45between the group with MIAC alone
and the group with MIAC and HCA
No 90 (91) 653 (24e6159)
should be addressed in further
Transient tachypnea research.
Yes 5 (5) 1076 (319e1575) .56 It is unclear whether MIAC and
No 94 (95) 626 (24e6159) HCA in women with PPROM between
34-37 weeks can affect short-term
Intraventricular hemorrhage neonatal morbidity. The stratification
grades I-II into 4 subgroups based on MIAC and
Yes 6 (6) 577 (348e1273) .98HCA revealed that the presence of both
No 93 (94) 651 (24e6159) MIAC and HCA was associated with
the highest rate of early-onset sepsis
Early-onset sepsis and severe neonatal morbidity. More-
Yes 4 (4) 5303 (3484e6086) over, our results suggest that
.001
No 95 (96) 575 (24e6159) pregnancies with PPROM between 34-
37 weeks with amniotic fluid IL-6
Pneumonia concentrations <3353 pg/mL are at a
Yes 2 (2) 476 (319e632) .54low risk of early-onset sepsis. This
No 97 (98) 651 (24e6159) finding is clinically relevant, especially
in light of the fact that previous studies
Severe neonatal morbidity comparing active and expectant
Yes 25 (25) 632 (175e6086) .25management listed early-onset sepsis
6,7
No 74 (75) 613 (24e6159) as a primary outcome. We are aware
Respiratory disorders were defined as respiratory distress syndrome or transient tachypnea. Severe neonatal
that an invasive amnio-centesis must
morbidity was defined as need for intubation, respiratory distress syndrome, pneumonia, bronchopulmonary be performed to obtain amniotic fluid
dysplasia, retinopathy of pre-maturity, intraventricular hemorrhage, necrotizing enterocolitis, early-onset sepsis,
late-onset sepsis, and/or neonatal death before hospital discharge. Intraventricular hemorrhage grades III-IV,
for analysis, which is critical to
bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, late-onset sepsis, and neonatal determining the inflammatory status of
death before hospital discharge were not considered in analysis because of no occurrence in cohort. IL-6
the intraamniotic compart-ment.
concentrations between groups were compared using Mann-Whitney U test. Spearman partial correlation was
used to adjust data for gestational age at sampling. Amniocentesis is also limited by the
IL, interleukin. presence of severe oligohydramnios or
a
Adjusted for gestational age at sampling; b Statistically significant results. anhydramnios, and this seems to be a
Kacerovsky. Inflammatory response in PPROM between 34-37 weeks. Am J major clinical limitation. Therefore,
Obstet Gynecol 2014. these results should be replicated for

differences were identified with respect toperiod between PPROM HCA; P fluid. weeks neonatal
the rate of genital mycoplasmas (64% for and delivery (16 hours .51). A continuousl morbidity.
y declines The rates of
MIAC alone vs 83% for MIAC with HCA; median for MIAC alone Therefore, growing
it remainsbody of with severe
P .37, data not shown), the microbial vs 24 hours for MIAC
with HCA; P .16), or unclear evidence GA.4,34-37 neonatal
load of genital mycoplasmas (1533 Given this
latency between why theindicates morbidity
copies/mL median for MIAC alone vs 733 knowledge, decreased
amniocentesis and group withthat neonatal
copies/mL for MIAC with HCA; P .78; morbidity in we with
delivery (median 12 MIAC
data not shown), the time PPROM be- evaluated advanced
hours for MIAC alone vs alone short-term GA.
14 hours for MIAC with elicited tween 34-37
Moreover,
325.e8 American Journal of Obstetrics & Gynecology APRIL 2014
www.AJOG.org Obstetrics Research
normal and abnormal
histological cho-
preterm and term rioamnionitis, parturition: elevated
trends were observed with respect to other aspects of neonatal newborns and risk of funisitis and amniotic fluid
morbidity. However, the small sample size in the GA subgroups neonatal outcome in interleukin-6 levels in
neonatal morbidity. women with preterm women with premature
was the primary limitation that prevented us from obtaining
Semin Perinatol prelabor rupture of rupture of membranes
statis-tically significant results. 2006;30:61-8. associated with
mem- branes. J
6.
van der Ham DP, Matern Fetal intrauterine infection.
Strengths and weaknesses of the study van der Heyden JL, Neonatal Med Cytokine 1991;3:155-
The primary strength of this study is the very short interval Opmeer BC, et al. 2013;26: 1332-6. 63.
between amniocen-tesis and delivery (median 10 hours) due to Management of late- 12. Goldenber 18. Yoon BH,
the active management of PPROM. Based on this finding, we preterm premature g RL, Hauth JC, Romero R, Kim CJ,
posit that the neutrophil infiltration of the placenta and fetal rupture of Andrews WW.
et al. Amniotic fluid
membrane at the time of de-livery is very similar to the status at membranes: the
Intrauterine interleukin-6: a
PPROMEXIL-2 trial.
the time of the amniocentesis. One limita-tion of this study is Am J Obstet Gynecol infection and sensitive test for
that a noncultivation technique (specific PCR) was used for the 2012;207:276.e1-10. preterm delivery. N antenatal diagnosis
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perspective because women with low amniotic fluid IL-6 14. Kim KW,
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