To cite this article: Krunal Patel, Shauna Williams, George Guirguis, Lisa Gittens-Williams &
Joseph Apuzzio (2017): Genital tract GBS and rate of histologic chorioamnionitis in patients with
preterm premature rupture of membrane, The Journal of Maternal-Fetal & Neonatal Medicine, DOI:
10.1080/14767058.2017.1350642
Article views: 2
Download by: [University of Western Ontario] Date: 22 July 2017, At: 21:15
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE, 2017
https://doi.org/10.1080/14767058.2017.1350642
ORIGINAL ARTICLE
CONTACT Krunal Patel patelk19@njms.rutgers.edu Department of Obstetrics, Gynecology and Women’s Health, Rutgers New Jersey Medical
School, MSB E506, Newark, NJ, USA
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 K. PATEL ET AL.
with PPROM to University Hospital, Newark, NJ, United by the presence of uterine tenderness, leukocytosis
States of America, from 1 January 2003 through 31 and a maternal oral temperature greater than 100.4
December 2014. The study was approved by the IRB of degrees Fahrenheit without another source of infec-
Rutgers, New Jersey Medical School, Study ID: tion. All patients received intrapartum antimicrobials
Pro2012001205. Patients who presented with a com- as above which were discontinued in the setting of a
plaint of leakage of fluid per vagina were evaluated in patient having three consecutive negative GBS cul-
the labor and delivery unit by sterile speculum examin- tures and without a suspicion of clinical chorioamnio-
ation. Preterm PROM was confirmed with visualization nitis. Endomyometritis was defined as presence of
of fluid emanating from the cervical os, positive fern temperature greater than 100.4 F or increasing leuko-
and/or nitrazine tests. Patients with confirmed PPROM cytosis in conjunction with uterine tenderness or foul
at 34-week gestation or greater were delivered and smelling lochia and absence of another source of
were not included in the analysis. Patients with PPROM infection. HC was diagnosed by the Amsterdam pla-
confirmed at a gestational age between 23 weeks 0 cental workshop group consensus statement-sampling
days and 33 weeks 6 days and without signs of clinical and definition of placental lesion [16]. The diagnosis of
chorioamnionitis, fetal compromise or labor were admit- histologic chorioamniontis was made by review of pla-
ted to the antepartum service for expectant manage- cental pathology reports documented in the medical
ment and complete bed rest. Patients were excluded if record.
HIV infected or if GBS results or placental pathology The primary outcome of the study was HC. Patients
reports were not available. were grouped according to GBS status at the time of
Vaginal rectal swabs for GBS were obtained on admission and rates of HC were compared. Additional
admission and daily thereafter from the lower third of outcomes reviewed were the rates of clinical cho-
the vagina and rectum. The specimens were processed rioamnionitis, endomyometritis and postoperative
by the hospital laboratory as per CDC recommenda- wound infections. We also compared rates of clinical
tions. Prophylactic intravenous (IV) antibiotics were chorioamnionitis, endomyometritis, maternal sepsis,
prescribed until the results of GBS specimens were wound infection and neonatal outcomes between
available. Patients that did not meet criteria for imme- patient with and without HC. Statistical comparisons
diate delivery (gestational age less than 34 weeks, were performed using Chi-square, Fisher’s exact and
reassuring fetal heart status and no evidence of clinical Mann–Whitney tests when appropriate.
chorioamnionitis) were admitted to the antepartum
service and received betamethasone 12 mg intramus-
Results
cularly (IM) every 24 h for two doses. Aqueous penicil-
lin G was the primary antibiotic used, first a loading During the study time period, 309 patients were iden-
dose of five million units intravenously was given fol- tified as having PPROM at less than 34 weeks gesta-
lowed by 2.5 million units every 4 h until the results of tion. 128 patients were excluded, reason for exclusion
the GBS specimens were available as per departmental multifetal gestation (21), gestational age less than 23
protocol. Patients allergic to penicillin received one of weeks (20), patients were not candidate for expectant
the following regimens for GBS prophylaxis depending management (24), results of genital tract GBS coloniza-
on the risk of anaphylaxis and history of atopy: clinda- tion (13) and placental pathology (46) were not avail-
mycin 900 mg IV every 8 h, cefazolin 2-g IV loading able and HIV positive (4). Of the 181 patients who met
dose followed by 1 g IV every 12 h, or vancomycin 1 inclusion criteria, 55 (29.4%) were GBS positive and
gram IV every 12 h. Antimicrobials were stopped when 126 (69.6%) patients were GBS negative on admission.
three daily genital GBS specimens were negative or GBS positive and GBS negative groups were similar
after seven days of treatment. No other antimicrobials with respect to maternal age, gestational age, the
were prescribed. latency period of rupture of membranes, birth weight,
Patients were monitored by twice-daily nonstress rate of smoking, drug use, gonorrhea and chlamydia
tests (NST) and twice weekly biophysical profiles (BPP). (Table 1). The rate of HC was 64.2% in GBS negative
Patients were monitored for any signs of infection and group and 69% in GBS positive group (p ¼ .62).
also by a complete blood count with differential (CBC) Four patients in the cohort were diagnosed with sep-
twice a week. Patients were delivered if they went sis, 3 (3.5%) in GBS negative group and 1 (1.8%) from
into labor, there was a nonreassuring fetal heart trac- the GBS positive group (p ¼ 1). Rate of clinical cho-
ing, persistently unexplained rising leukocytosis with rioamnionitis were 19.8 and 14.5% in the GBS negative
suspected clinical chorioamnionitis or gestational age and GBS positive groups respectively (p ¼ .52). The
of 34 weeks. Clinical chorioamniontis was diagnosed rate of endomyometritis and wound infection were
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3