AFJOG

ORIGINAL RESEARCH ABSTRACT Background: Preterm birth is a leading cause of neonatal morbidity and mortality worldwide. Approximately 60% are associated with infection. Fetal inflammatory response syndrome (FIRS) occurs in response to maternal or fetal infection and may predispose to adverse outcomes and cerebral palsy. Objectives: The aim of this study was to determine the latency period in women with PROM and determine the association with FIRS. Methods: We conducted a prospective cohort study, including women with singleton gestation with PROM between 26-38 weeks in Pretoria, South Africa. Data collection included a demographics, vaginal and urine microcopy and culture and placental histology. Results: There were 3225 patients seen between 1 August 2021 and 31 July 2022. A total of 217 patients met the criteria to be classified as critical incidents, thus giving an overall critical incidence rate of 6.7%. The median age (interquartile range [IQR]) of the patients who suffered critical incidents was 42 (34 – 54) years. The median (IQR) gravidity and parity were 2(1 – 4) and 2(1 – 3), respectively. Over a third, 37% (n = 80), of these patients were HIV positive. Of the 217 patients who met the critical incidents criteria, 78.3% (n = 170) were admitted with the intention of surgical treatment. Most, 54.4% (n = 118) of those patients were elective admissions. The three most prevalent critical incidents were omission of the procedure (46%, n = 107), followed by death (28%, n = 66) and performance of unplanned surgery (12%, n = 27). Lack of theatre time was the most common reason for procedure omission (46%, n = 49). Other reasons, namely lack of blood products (4%, n = 49), SARS-CoV-2 (Covid-19) positive results (3%, n = 7), new HIV diagnosis (2.5%, n = 6), change of management plan (2.5%, n = 6) and patient not fit for anaesthesia (2.5%, n = 6) were the following prevalent causes of omission of procedures. The most common avoidable factors were in the category of admin factors (71%, n = 75). The most common reason in this category was inadequate theatre time (46%, n = 49). Results: Seventy-two women were recruited, sixteen (22.22%) women had a deranged white cell count, 26 (37.14%) had an elevated CRP, 66 (63.77%) had a positive urine culture, and 22 women (51.16%) had a positive culture on high vaginal swab. The mean latency from rupture of membranes to delivery was 246 hours (SD 310), mean birthweight was 2003g (SD 512) and mean 5-minute Apgar score was 8.5 (SD 1.4). Twenty-five (34.7%) women had histological evidence of FIRS. Eighteen (25.35%) neonates had signs of neonatal sepsis. There were 2 (2.8%) neonatal deaths with both placentas showing signs of infection. Conclusion: Diagnosing fetal infection before birth is only easy in severe cases. Subtle or developing infection is very hard to predict. The inability of this study to correlate risk group with the presence of FIRS emphasizes the need for a high index of suspicion and consider placental examination and follow up of these neonates. Keywords: fetal inflammatory response syndrome (FIRS), preterm labour, preterm rupture of membranes (PROM), cerebral palsy (CP) INTRODUCTION Premature rupture of the membranes (PROM) occurs in 10% of pregnancies and is a risk factor for adverse pregnancy and neonatal outcomes. Preterm PROM (PPROM) is a major complication of pregnancy and accounts for 30% of spontaneous preterm births. The frequency of infection increases over time (latency period), so that when a woman with PPROM eventually goes into labor, microorganisms are detected in 75% of cases. 1-2 Intra-amniotic inflammation is frequently present in women with microorganisms in the amnioticfluideventhough, insomecases, sterile inflammation is present. The use of antibiotics in women with PPROM is grounded in the results of multiple randomized clinical trials and meta-analyses. 3 Antimicrobial agents have been shown to prolong the latency period, decrease neonatal infection, and reduce respiratory morbidity, including the need for oxygen and surfactant. Moreover, antibiotic administration also reduces the frequency of clinical chorioamnionitis. 1-3 Fetal inflammatory response syndrome (FIRS) is a complex pathophysiologic condition associated with systemic inflammation in the fetus and local inflammation in different fetal organs, which may lead to adverse outcomes. Most often, FIRS is caused by an infectious process, such as microbial invasion of the amniotic cavity or amniotic membrane or placenta (chorioamnionitis and funisitis), which can further gain access to the fetal mucosa and induce fetal inflammation. 4 Funisitis and chorionic vasculitis are considered to be the histologic manifestations of the fetal inflammatory response. When funisitis is present, there is an almost 12-fold increased risk for neonatal encephalopathy in term infants. 5 PPROM pregnancies are often complicated by the presence of hostile intra-amniotic conditions such as microbial invasion of the amniotic cavity (MIAC) and intra- amniotic inflammation (IAI). These conditions usually lead to the development of acute histological chorioamnionitis (HCA) followed by the activation of the fetal innate immune system (fetal inflammatory response), characterized by an elevation of inflammatory mediators in fetal blood. This situation results in multisystem involvement and the development of the fetal inflammatory response syndrome (FIRS), which might progress toward multiorgan dysfunction and failure. 5 FIRS results from local inflammation in different fetal organs, including the fetal brain, heart, lungs, skin, hematopoietic system, kidneys, adrenal glands, and thymus, AMini 1 , T Nkwenika 2 , G Lindeque 1 , S Adam 1 1 Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa 2 Biostatistics unit, South African Medical Research Council, Pretoria, South Africa CORRESPONDENCE: A Mini| Email: ayandaninchauke@icloud.com The prevalence and outcomes of fetal inflammatory response syndrome in women with preterm rupture of membranes African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 25