AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 9, NUMBER 5/6
Sept/Nov 1992
SIGNIFICANCE OF POSITIVE CERVICAL CULTURES FOR CHLAMYDIA TRACHOMATIS IN PATIENTS WITH PRETERM PREMATURE RUPTURE OF MEMBRANES Mahmoud A. Ismail, M.D., Gabriella Pridjian, M.D., Judith U. Hibbard, M.D., Catherine Harth, M.D., and Atef A. Moawad, M.D.
We tested the hypothesis that in patients with preterm premature rupture of membranes the presence of Chlamydia trachomatis in the cervix shortens the latent period (time from rupture of membranes to delivery) and increases the incidence of chorioamnionitis and early endometritis. A total of 178 conservatively managed patients with PROM between 22 and 35 weeks' gestation had cervical cultures for chlamydia, group B Streptococcus (GBS) and Neisseria gonorrhoeae performed at the time of rupture. Patients with GBS and gonorrhea were treated at the time the culture results were available and excluded from analysis. The remaining patients were divided into group 1: 26 patients (14.6%) positive for only chlamydia (and not treated until discharge from the hospital); group 2:120 patients (67.4%) negative for all three organisms. The two groups did not differ in cesarean rate, duration of conservative management, hospital stay, or birthweight. Furthermore, the rates of chorioamnionitis (30.8% group 1; 38.3% group 2) or early endometritis (11.5% group 1; 20.8% group 2) were similar. We conclude that in patients with preterm premature rupture of membranes, the presence of chlamydia in the cervix appears to neither decrease the latent period nor increase the incidence of chorioamnionitis and early endometritis.
Preterm premature rupture of membranes (PROM) is a common perinatal complication leading to premature delivery and poor neonatal outcome.12 (For clarity, PROM will always refer to preterm premature rupture of membranes). In addition, patients with PROM are more likely to develop infectious complications, especially chorioamnionitis and endometritis.3 Etiology of PROM is generally unknown but has been associated with a variety of infectious agents in the genital tract, including Chlamydia trachomatis.4'5 The goal in management of patients with PROM is delay in delivery and prevention of infection. Whether the presence of chlamydia in the cervix of patients with PROM influences their clinical course is unclear. We have noted that the pregnant population in our clinics has a high prevalence of culture-positive cervical chlamydia, as high as 21.3% in pregnant teenagers.6 The present study was done to test the hypothesis that in patients with PROM, the presence of chlamydia in the cervix shortens the latent
period (time from rupture of membranes to delivery) and increases the incidence of peripartum infectious events.
MATERIALS AND METHODS Patients studied delivered at the Chicago Lying-in Hospital between January 1, 1983, and October 30, 1985, were between 22 and 35 weeks' gestation, and were diagnosed with PROM by both fern slide test and alkaline nitrazine test. The patient population was derived from indigent clinic patients, private patients, and perinatal network maternal transfers. Patients included in the study were those without signs of chorioamnionitis or labor at the time of presentation with ruptured membranes, as this necessitated delivery. The diagnosis of chorioamnionitis required two temperature elevations of 37.8°C or greater
Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Chicago Pritzker School of Medicine, Chicago, Illinois Reprint requests: Dr. Ismail, University of Chicago, Department of Obstetrics and Gynecology, Box 446, 5841 South Maryland Avenue, Chicago, IL 60637
368
Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: Universite Laval. Copyrighted material.
ABSTRACT
at least 4 hours apart, with at least one other sign of infection: elevated maternal white count, elevated C-reactive protein,7 uterine tenderness, maternal tachycardia, or fetal tachycardia, in the absence of other sources of infection. Labor was assessed by either subjective sensations of uterine contractions or tocodynamometry and was diagnosed when contractions were consistent and regular, 3 to 4 minutes apart. The diagnosis of chorioamnionitis and labor was left to the resident and attending physician caring for the patient. In those patients with PROM who were to be conservatively managed, the cervix was visualized with a sterile speculum, and cultures for Neisseria gonorrhoeae Group B Streptococcus (GBS), and chlamydia were obtained. No digital examinations were performed. Patients were then followed expectantly in the hospital with close monitoring for signs and symptoms of chorioamnionitis and labor. Neither corticosteroids nor tocolytic agents were used. If initial cervical cultures were positive for GBS or gonorrhea, patients received appropriate treatment promptly, often prior to delivery, and were excluded from the analysis. Development of chorioamnionitis with or without labor warranted delivery. Patients with chorioamnionitis underwent induction of labor in addition to treatment with ampicillin and gentamicin. Patients in labor without chorioamnionitis were given no antibiotics and allowed to deliver. Early postpartum endometritis was diagnosed if, within the first 48 hours after delivery, there was persistently elevated temperature, higher than 38°C on at least two separate occasions at least 4 hours apart, and uterine tenderness. Most cases were also associated with tachycardia, leukocytosis, and foul-smelling lochia. Patients previously given a diagnosis of chorioamnionitis were not given an additional diagnosis of endometritis. Treatment of endometritis consisted of a two or three drug combination of ampicillin, gentamicin, and clindamycin. Chlamydia culture results were made available at the time of discharge. Patients with positive chlamydia cultures were treated with tetracycline or erythromycin on discharge from the hospital. Pediatricians were notified of culture results. Erythromycin ophthalmic solution is the standard of care for all newborns in our institution. The medical records of all women cultured were reviewed. Statistical analysis was performed using the two-sided Student t test and the Mann-Whitney rank sum test for normally distributed and skewed interval data, respectively. Chi-square and the Fisher exact test were used for nominal data. A p value of
Sept/Nov 1992
SIGNIFICANCE OF POSITIVE CERVICAL CULTURES FOR CHLAMYDIA TRACHOMATIS IN PATIENTS WITH PRETERM PREMATURE RUPTURE OF MEMBRANES Mahmoud A. Ismail, M.D., Gabriella Pridjian, M.D., Judith U. Hibbard, M.D., Catherine Harth, M.D., and Atef A. Moawad, M.D.
We tested the hypothesis that in patients with preterm premature rupture of membranes the presence of Chlamydia trachomatis in the cervix shortens the latent period (time from rupture of membranes to delivery) and increases the incidence of chorioamnionitis and early endometritis. A total of 178 conservatively managed patients with PROM between 22 and 35 weeks' gestation had cervical cultures for chlamydia, group B Streptococcus (GBS) and Neisseria gonorrhoeae performed at the time of rupture. Patients with GBS and gonorrhea were treated at the time the culture results were available and excluded from analysis. The remaining patients were divided into group 1: 26 patients (14.6%) positive for only chlamydia (and not treated until discharge from the hospital); group 2:120 patients (67.4%) negative for all three organisms. The two groups did not differ in cesarean rate, duration of conservative management, hospital stay, or birthweight. Furthermore, the rates of chorioamnionitis (30.8% group 1; 38.3% group 2) or early endometritis (11.5% group 1; 20.8% group 2) were similar. We conclude that in patients with preterm premature rupture of membranes, the presence of chlamydia in the cervix appears to neither decrease the latent period nor increase the incidence of chorioamnionitis and early endometritis.
Preterm premature rupture of membranes (PROM) is a common perinatal complication leading to premature delivery and poor neonatal outcome.12 (For clarity, PROM will always refer to preterm premature rupture of membranes). In addition, patients with PROM are more likely to develop infectious complications, especially chorioamnionitis and endometritis.3 Etiology of PROM is generally unknown but has been associated with a variety of infectious agents in the genital tract, including Chlamydia trachomatis.4'5 The goal in management of patients with PROM is delay in delivery and prevention of infection. Whether the presence of chlamydia in the cervix of patients with PROM influences their clinical course is unclear. We have noted that the pregnant population in our clinics has a high prevalence of culture-positive cervical chlamydia, as high as 21.3% in pregnant teenagers.6 The present study was done to test the hypothesis that in patients with PROM, the presence of chlamydia in the cervix shortens the latent
period (time from rupture of membranes to delivery) and increases the incidence of peripartum infectious events.
MATERIALS AND METHODS Patients studied delivered at the Chicago Lying-in Hospital between January 1, 1983, and October 30, 1985, were between 22 and 35 weeks' gestation, and were diagnosed with PROM by both fern slide test and alkaline nitrazine test. The patient population was derived from indigent clinic patients, private patients, and perinatal network maternal transfers. Patients included in the study were those without signs of chorioamnionitis or labor at the time of presentation with ruptured membranes, as this necessitated delivery. The diagnosis of chorioamnionitis required two temperature elevations of 37.8°C or greater
Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Chicago Pritzker School of Medicine, Chicago, Illinois Reprint requests: Dr. Ismail, University of Chicago, Department of Obstetrics and Gynecology, Box 446, 5841 South Maryland Avenue, Chicago, IL 60637
368
Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: Universite Laval. Copyrighted material.
ABSTRACT
at least 4 hours apart, with at least one other sign of infection: elevated maternal white count, elevated C-reactive protein,7 uterine tenderness, maternal tachycardia, or fetal tachycardia, in the absence of other sources of infection. Labor was assessed by either subjective sensations of uterine contractions or tocodynamometry and was diagnosed when contractions were consistent and regular, 3 to 4 minutes apart. The diagnosis of chorioamnionitis and labor was left to the resident and attending physician caring for the patient. In those patients with PROM who were to be conservatively managed, the cervix was visualized with a sterile speculum, and cultures for Neisseria gonorrhoeae Group B Streptococcus (GBS), and chlamydia were obtained. No digital examinations were performed. Patients were then followed expectantly in the hospital with close monitoring for signs and symptoms of chorioamnionitis and labor. Neither corticosteroids nor tocolytic agents were used. If initial cervical cultures were positive for GBS or gonorrhea, patients received appropriate treatment promptly, often prior to delivery, and were excluded from the analysis. Development of chorioamnionitis with or without labor warranted delivery. Patients with chorioamnionitis underwent induction of labor in addition to treatment with ampicillin and gentamicin. Patients in labor without chorioamnionitis were given no antibiotics and allowed to deliver. Early postpartum endometritis was diagnosed if, within the first 48 hours after delivery, there was persistently elevated temperature, higher than 38°C on at least two separate occasions at least 4 hours apart, and uterine tenderness. Most cases were also associated with tachycardia, leukocytosis, and foul-smelling lochia. Patients previously given a diagnosis of chorioamnionitis were not given an additional diagnosis of endometritis. Treatment of endometritis consisted of a two or three drug combination of ampicillin, gentamicin, and clindamycin. Chlamydia culture results were made available at the time of discharge. Patients with positive chlamydia cultures were treated with tetracycline or erythromycin on discharge from the hospital. Pediatricians were notified of culture results. Erythromycin ophthalmic solution is the standard of care for all newborns in our institution. The medical records of all women cultured were reviewed. Statistical analysis was performed using the two-sided Student t test and the Mann-Whitney rank sum test for normally distributed and skewed interval data, respectively. Chi-square and the Fisher exact test were used for nominal data. A p value of
