AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 7, NUMBER 3 July 1990
HAEMOPHILUS INFLUENZAE AMNIONITIS WITH INTACT MEMBRANES: A CASE REPORT Kaylen Silverberg, M.D., and Frank H. Boehm, M.D.
ABSTRACT
Acute chorioamnionitis is uncommon with intact membranes. Although many different organisms have been isolated from patients with amnionitis, Haemophilus has only rarely been implicated as a causative factor. Only two other cases of chorioamnionitis with intact membranes due to Haemophilus influenzae have been reported.1'2 This represents a third case of H. influenzae amnionitis, and the first case in which ascending infection is thought to be the mode of transmission. In addition, fetal breathing was absent on biophysical profile, which we have found helpful in making the diagnosis of amnionitis. CASE REPORT
A 17-year-old primigravida at 29V2 weeks gestational age presented to her local obstetrician complaining of contractions of 8 hours' duration. She also complained of chills and a heavy vaginal discharge, but denied any other complaints. On examination, she was noted to be afebrile and her cervix was 3 cm dilated. Her examination was otherwise unremarkable. She was treated with terbutaline 0.25 mg subcutaneously and dexamethasone 12 mg intramuscularly and was started on intravenous magnesium sulfate at 2 gm/hour following a 6 gm bolus. When her cervix dilated to 4 cm, she was transported to Vanderbilt University Hospital. On arrival in the early evening hours, she was noted to have a temperature of 99.6°F with a pulse of 124 and a blood pressure of 140/50 mmHg. Fetal heart tones were 150 with moderate variability on an external monitor with autocorrelation. The contractions were every 5 to 6 minutes and the abdomen was soft and nontender. Her cervix was 4 cm dilated,
100% effaced, vertex presentation, and the membranes were bulging at the minus 2 station. A spontaneous contraction stress test was negative. Sterile speculum examination was negative for ferning, nitrazine, and vaginal pool, and a wet preparation was remarkable for sheets of white cells. No trichomonads or clue cells were noted. Ultrasound revealed a 29 to 30 week single intrauterine pregnancy with normal amniotic fluid volume and an estimated fetal weight of 1470 gm. A biophysical profile score was 2/8 with only limb movement noted. No trunk movement or fetal breathing was detected. Initial laboratory evaluation was remarkable for a white blood count of 24,000. In light of the initial nonreassuring biophysical profile, a biophysical profile was repeated 3 hours later. At that time, the score was 0/8, with no fetal movement or breathing noted. The patient remained stable over the next several hours with a maximum temperature of 98.4°F. Because the possibility of intrauterine infection was strongly suspected, an amniocentesis was performed. The lecithin to sphingomyelin ratio was 1.7, phosphatidyl glycerol was absent, and the foam stability index was 0.46. A Gram's stain of the amniotic fluid revealed 1 + polymorphonuclear cells, 1+ epithelial cells, and 4+ gram-negative coccobacillary rods, suggestive of Haemophilus. Fluid was sent for aerobic and anaerobic culture and sensitivity. Shortly after the amniocentesis, the fetus began to move and developed a reactive heart tracing with a baseline rate of 130. Biophysical profile was repeated and a score of 4/8 was obtained. Trunk and limb movements were noted; however, fetal breathing was still absent. A repeat white blood count was 19,900, with a left shift. Because of these findings and the onset of mild
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Hospital, Nashville, Tennessee Reprint requests: Dr. Boehm, Division of Maternal-Fetal Medicine, C-2213 M.C.N., Vanderbilt University Medical Center, Nashville, TN 37232-2519 270
Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: NYU. Copyrighted material.
A case report of a patient with intact membranes and Haemophilus influenzae chorioamnionitis thought to be due to ascending infection is presented.
uterine tenderness, a diagnosis of chorioamnionitis was made. Blood cultures were obtained, and intravenous ampicillin, gentamicin, and clindamycin were administered. In addition, the magnesium sulfate, which was continued until a definitive diagnosis could be made, was discontinued, and oxytocin induction was begun. Two hours after starting the induction, the patient underwent a spontaneous vaginal delivery of a 1420 gm male infant with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. Umbilical artery pH was 7.35 with a base deficit of 1.5. The placenta was cultured at the time of delivery. Four hours after delivery, the patient developed a temperature of 101.6°F, and a diagnosis of endomyometritis was made. Blood, urine, and cervical cultures were obtained, but all were eventually negative. On the first postpartum day, amniotic fluid cultures returned with a heavy growth of H. influenzae, and the placenta cultures had a light growth of H. influenzae. Histopathologic evaluation of the placenta confirmed the presence of acute chorioamnionitis. The infant was treated empirically with intravenous antibiotics, but serial cultures were all negative. The patient defervesced and was discharged home on the fourth postpartum day. The infant was discharged home in good condition on the 42nd day. DISCUSSION
H. influenzae is a gram-negative coccobacillary aerobic rod that is usually associated with upper respiratory tract infections in the adult. In children, it is a common cause of otitis media and meningitis. There are several different species of Hemophilus, one of which is a relatively frequent pathogen in the female genital tract: Haemophilus vaginalis, now known as Gardnerella vaginalis, is commonly associated with bacterial vaginosis. Haemophilus ducreyi is the etiologic agent responsible for chancroid. Haemophilus parainfluenzae is a frequent inhabitant of the adult respiratory tract3 and has also been reported to be a rare cause of amnionitis.4 Haemophilus influenzae can be isolated infrequently from the female genital tract. In one study in which vaginal cultures were performed on 1083 asymptomatic pregnant women in labor, H. influenzae was only isolated twice.5 Despite its apparently rare presence in the female genital tract, it has been reported as a cause of amnionitis, almost exclusively in cases of premature rupture of membranes. There appear to be two possible mechanisms by which H. influenzae can cause amnionitis: either by hematogenous dissemination from another source or by ascending spread from the vagina.6 In the two previously reported cases of amnionitis with intact mem-
branes due to H. influenzae, both patients were infected in the second trimester, and both had evidence of distant foci of H. influenzae infection (that is, pneumonia). These patients had positive blood cultures for H. influenzae, and subsequently developed amnionitis with cultures growing H. influenzae. Both authors theorized that their patients seeded the amniotic cavity from hematogenous spread of the bacteria. Neither infant survived. It should be noted that neonatal infection with H. influenzae is frequently fulminant, with a course resembling that of group B streptococci.7 In this case, there was no clinical evidence of another focus of infection, and several sets of blood cultures were negative. The fact that cervical cultures were negative is not surprising in light of the fact that Svennson et al8 demonstrated that the same organism is cultured from the placenta and the cervical canal less than one third of the time. We therefore believe that this case resulted from ascending infection, although no source was detected. Because amniocentesis is often difficult or impossible to perform in all cases of suspected amnionitis, it would be helpful to have a noninvasive test for amnionitis when the usual triad of symptoms are lacking. Vintzileos et al9 have shown that the biophysical profile may be such a noninvasive test to screen for amnionitis. Specifically, their studies have noted a correlation between absent fetal breathing and amnionitis. Our case would give support to these findings.
REFERENCES
1. Winn HN, Egley CC: Acute Haemophilus influenzae chorioamnionitis associated with intact amniotic membranes. Am J Obstet Gynecol 156:458-459, 1987 2. Amstey MS, Ogden E: Hemophilus influenza septicemia and midtrimester abortion. J Reprod Med 1979; 22:106108, 1979 3. Jawetz E, Melinic KJ, Adelberg E: Review of Medical Microbiology. Los Altos, CA: Lange Medical Publications, 1978, p 231 4. Arias JW, Saldana LR, Conklin R: Chorioamnionitis due to Haemophilus parainfluenzae. Tex Med 77(7):47-48, 1981 5. Beargie R, Lynd P, Tucker E, et al: Perinatal infection and vaginal flora. Am J Obstet Gynecol 122:31-33, 1975 6. Plotkin SA: Routes of fetal infection and mechanisms of fetal damage. Am J Dis Child 129:444, 1975 7. Lilien LD, Yeh TF, Novak GM, et al: Early-onset Haemophilus sepsis in newborn infants: Clinical, roentgenographic, and pathologic features. Pediatrics 62:299-303, 1978 8. Svensson L, Ingemarsson I, Mardh PA: Chorioamnionitis and the isolation of microorganisms from the placenta. Obstet Gynecol 67:403-409, 1986 9. Vintzileos AM, Campbell WA, Nochimson DJ, et al: The fetal biophysical profile in patients with premature rupture of the membranes—an early predictor of fetal infection. AmJ Obstet Gynecol 152:510-516, 1985
271
Downloaded by: NYU. Copyrighted material.
HAEMOPHILUS INFLUENZAE AMNIONITIS/Silverberg, Boehm
HAEMOPHILUS INFLUENZAE AMNIONITIS WITH INTACT MEMBRANES: A CASE REPORT Kaylen Silverberg, M.D., and Frank H. Boehm, M.D.
ABSTRACT
Acute chorioamnionitis is uncommon with intact membranes. Although many different organisms have been isolated from patients with amnionitis, Haemophilus has only rarely been implicated as a causative factor. Only two other cases of chorioamnionitis with intact membranes due to Haemophilus influenzae have been reported.1'2 This represents a third case of H. influenzae amnionitis, and the first case in which ascending infection is thought to be the mode of transmission. In addition, fetal breathing was absent on biophysical profile, which we have found helpful in making the diagnosis of amnionitis. CASE REPORT
A 17-year-old primigravida at 29V2 weeks gestational age presented to her local obstetrician complaining of contractions of 8 hours' duration. She also complained of chills and a heavy vaginal discharge, but denied any other complaints. On examination, she was noted to be afebrile and her cervix was 3 cm dilated. Her examination was otherwise unremarkable. She was treated with terbutaline 0.25 mg subcutaneously and dexamethasone 12 mg intramuscularly and was started on intravenous magnesium sulfate at 2 gm/hour following a 6 gm bolus. When her cervix dilated to 4 cm, she was transported to Vanderbilt University Hospital. On arrival in the early evening hours, she was noted to have a temperature of 99.6°F with a pulse of 124 and a blood pressure of 140/50 mmHg. Fetal heart tones were 150 with moderate variability on an external monitor with autocorrelation. The contractions were every 5 to 6 minutes and the abdomen was soft and nontender. Her cervix was 4 cm dilated,
100% effaced, vertex presentation, and the membranes were bulging at the minus 2 station. A spontaneous contraction stress test was negative. Sterile speculum examination was negative for ferning, nitrazine, and vaginal pool, and a wet preparation was remarkable for sheets of white cells. No trichomonads or clue cells were noted. Ultrasound revealed a 29 to 30 week single intrauterine pregnancy with normal amniotic fluid volume and an estimated fetal weight of 1470 gm. A biophysical profile score was 2/8 with only limb movement noted. No trunk movement or fetal breathing was detected. Initial laboratory evaluation was remarkable for a white blood count of 24,000. In light of the initial nonreassuring biophysical profile, a biophysical profile was repeated 3 hours later. At that time, the score was 0/8, with no fetal movement or breathing noted. The patient remained stable over the next several hours with a maximum temperature of 98.4°F. Because the possibility of intrauterine infection was strongly suspected, an amniocentesis was performed. The lecithin to sphingomyelin ratio was 1.7, phosphatidyl glycerol was absent, and the foam stability index was 0.46. A Gram's stain of the amniotic fluid revealed 1 + polymorphonuclear cells, 1+ epithelial cells, and 4+ gram-negative coccobacillary rods, suggestive of Haemophilus. Fluid was sent for aerobic and anaerobic culture and sensitivity. Shortly after the amniocentesis, the fetus began to move and developed a reactive heart tracing with a baseline rate of 130. Biophysical profile was repeated and a score of 4/8 was obtained. Trunk and limb movements were noted; however, fetal breathing was still absent. A repeat white blood count was 19,900, with a left shift. Because of these findings and the onset of mild
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Hospital, Nashville, Tennessee Reprint requests: Dr. Boehm, Division of Maternal-Fetal Medicine, C-2213 M.C.N., Vanderbilt University Medical Center, Nashville, TN 37232-2519 270
Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: NYU. Copyrighted material.
A case report of a patient with intact membranes and Haemophilus influenzae chorioamnionitis thought to be due to ascending infection is presented.
uterine tenderness, a diagnosis of chorioamnionitis was made. Blood cultures were obtained, and intravenous ampicillin, gentamicin, and clindamycin were administered. In addition, the magnesium sulfate, which was continued until a definitive diagnosis could be made, was discontinued, and oxytocin induction was begun. Two hours after starting the induction, the patient underwent a spontaneous vaginal delivery of a 1420 gm male infant with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. Umbilical artery pH was 7.35 with a base deficit of 1.5. The placenta was cultured at the time of delivery. Four hours after delivery, the patient developed a temperature of 101.6°F, and a diagnosis of endomyometritis was made. Blood, urine, and cervical cultures were obtained, but all were eventually negative. On the first postpartum day, amniotic fluid cultures returned with a heavy growth of H. influenzae, and the placenta cultures had a light growth of H. influenzae. Histopathologic evaluation of the placenta confirmed the presence of acute chorioamnionitis. The infant was treated empirically with intravenous antibiotics, but serial cultures were all negative. The patient defervesced and was discharged home on the fourth postpartum day. The infant was discharged home in good condition on the 42nd day. DISCUSSION
H. influenzae is a gram-negative coccobacillary aerobic rod that is usually associated with upper respiratory tract infections in the adult. In children, it is a common cause of otitis media and meningitis. There are several different species of Hemophilus, one of which is a relatively frequent pathogen in the female genital tract: Haemophilus vaginalis, now known as Gardnerella vaginalis, is commonly associated with bacterial vaginosis. Haemophilus ducreyi is the etiologic agent responsible for chancroid. Haemophilus parainfluenzae is a frequent inhabitant of the adult respiratory tract3 and has also been reported to be a rare cause of amnionitis.4 Haemophilus influenzae can be isolated infrequently from the female genital tract. In one study in which vaginal cultures were performed on 1083 asymptomatic pregnant women in labor, H. influenzae was only isolated twice.5 Despite its apparently rare presence in the female genital tract, it has been reported as a cause of amnionitis, almost exclusively in cases of premature rupture of membranes. There appear to be two possible mechanisms by which H. influenzae can cause amnionitis: either by hematogenous dissemination from another source or by ascending spread from the vagina.6 In the two previously reported cases of amnionitis with intact mem-
branes due to H. influenzae, both patients were infected in the second trimester, and both had evidence of distant foci of H. influenzae infection (that is, pneumonia). These patients had positive blood cultures for H. influenzae, and subsequently developed amnionitis with cultures growing H. influenzae. Both authors theorized that their patients seeded the amniotic cavity from hematogenous spread of the bacteria. Neither infant survived. It should be noted that neonatal infection with H. influenzae is frequently fulminant, with a course resembling that of group B streptococci.7 In this case, there was no clinical evidence of another focus of infection, and several sets of blood cultures were negative. The fact that cervical cultures were negative is not surprising in light of the fact that Svennson et al8 demonstrated that the same organism is cultured from the placenta and the cervical canal less than one third of the time. We therefore believe that this case resulted from ascending infection, although no source was detected. Because amniocentesis is often difficult or impossible to perform in all cases of suspected amnionitis, it would be helpful to have a noninvasive test for amnionitis when the usual triad of symptoms are lacking. Vintzileos et al9 have shown that the biophysical profile may be such a noninvasive test to screen for amnionitis. Specifically, their studies have noted a correlation between absent fetal breathing and amnionitis. Our case would give support to these findings.
REFERENCES
1. Winn HN, Egley CC: Acute Haemophilus influenzae chorioamnionitis associated with intact amniotic membranes. Am J Obstet Gynecol 156:458-459, 1987 2. Amstey MS, Ogden E: Hemophilus influenza septicemia and midtrimester abortion. J Reprod Med 1979; 22:106108, 1979 3. Jawetz E, Melinic KJ, Adelberg E: Review of Medical Microbiology. Los Altos, CA: Lange Medical Publications, 1978, p 231 4. Arias JW, Saldana LR, Conklin R: Chorioamnionitis due to Haemophilus parainfluenzae. Tex Med 77(7):47-48, 1981 5. Beargie R, Lynd P, Tucker E, et al: Perinatal infection and vaginal flora. Am J Obstet Gynecol 122:31-33, 1975 6. Plotkin SA: Routes of fetal infection and mechanisms of fetal damage. Am J Dis Child 129:444, 1975 7. Lilien LD, Yeh TF, Novak GM, et al: Early-onset Haemophilus sepsis in newborn infants: Clinical, roentgenographic, and pathologic features. Pediatrics 62:299-303, 1978 8. Svensson L, Ingemarsson I, Mardh PA: Chorioamnionitis and the isolation of microorganisms from the placenta. Obstet Gynecol 67:403-409, 1986 9. Vintzileos AM, Campbell WA, Nochimson DJ, et al: The fetal biophysical profile in patients with premature rupture of the membranes—an early predictor of fetal infection. AmJ Obstet Gynecol 152:510-516, 1985
271
Downloaded by: NYU. Copyrighted material.
HAEMOPHILUS INFLUENZAE AMNIONITIS/Silverberg, Boehm
