AFJOG

ORIGINAL RESEARCH and it also induces subsequent damage to these organs. FIRS is encountered in women with preterm labour with intact membranes or with PROM. 5 Antimicrobial agents are not effective in eradicating or preventing intra-amniotic inflammation/infection in PPROM. By activating the innate immune system in an effort to adjust to the inflammatory environment of the uterus, the fetus will struggle to survive. FIRS can lead to adverse neonatal outcomes, including death and multisystem organ damage. Complications of FIRS include fetal heart rate disturbances, changes in diastolic ventricular function, reduction in cardiomyocyte numbers, and patent ductus arteriosus. The most typical impairments of the respiratory system associated with FIRS in preterm infants are respiratory distress syndrome and later bronchopulmonary dysplasia. Other fetal effects include fetal dermatitis, and hepatic inflammation and disturbed lipid metabolism. 6-7 The brain has a high susceptibility to inflammation and oxidative stress. Given that the brain continues to develop and mature during the third trimester, early postnatal period, and the first few years of life, it is particularly vulnerable to injury during pregnancy and around the time of birth. Isolated deep gray matter injury, white matter injury, periventricular leukomalacia (PVL), and intraventricular hemorrhage (IVH) have been described postnatally following FIRS and appear to confer subsequent high risk for long- term cerebral palsy. Impaired learning, vision, and hearing loss also have been reported in this context. The persisting unchanged prevalence of cerebral palsy (CP) is a major cost driver in obstetric litigation, currently an international crisis in scope and volume leading to cutting of services and discontinuation of practices. CP may be due to antenatal or intrapartum events. 5, 7 However, the difficulty in diagnosing FIRS means that this potential cause may be overlooked, with increasing risk for obstetric litigation. Pathogens in the uterus related to the preterm birth are often of low virulence, such as Ureaplasma urealyticum, Chlamydia trachomatis, Mycoplasma hominis, and Trichomonas vaginalis. Unsurprisingly most cases of histological chorioamnionitis are subclinical, and merely 10% have obvious clinical manifestations of infection. 6, 8, 9 Placental pathologic examination is still the gold standard for diagnosing intrauterine inflammation, but it is posteriori and time-consuming. 10 Procedures to detect intrauterine infection at present include amniotic fluid examination via amniocentesis and fetal blood test via cordocentesis. these two methods are however invasive and too risky for general use. 8, 9 Raising maternal white blood cell count (WBC) as an independent indicator to predict intrauterine infection has been studied. It has been demonstrated that increased WBC in maternal circulation is associated with the presence of gross intrauterine infection. With regard to the role of WBC in detecting intrauterine inflammation, however, previous results were inconsistent. 11-12 C-reactive protein (CRP), an acute phase protein secreted by the liver that is part of the non-specific immune mechanisms, have very low levels in normal serum, but is rapidly synthesized in the presence of inflammation within 6-12 hours reaching a peak measurable level at 48-72 hours. If the infection and the inflammation are under control, then the CRP level may rapidly decrease into the normal range. The changes in levels are nonspecific and does not add to the solution in subtle fetal infection. 11-12 The aim of our study is to determine latency period in women with PROM, i.e. the time from rupture of membranes to delivery of the fetus, and to determine the association and prevalence of FIRS in women with PROM. Such a study has not been conducted in our setting, and may provide clues not only in pathogenic mechanisms, but also in predicting which infants may be at increased risk for developing complications from FIRS. MATERIAL AND METHODS We conducted a prospective cohort study at the Obstetric units of Steve Biko Academic Hospital and Kalafong Academic Hospital, Pretoria, South Africa, between 01 October 2018 to 31 August 2019. These are high risk obstetric units in tertiary hospitals. The sample included consecutive women who were admitted for the workup and management of PPROM, between 26 and 37 weeks 6 days gestation. PPROM was suspected on presentation with a history of drainage of liquor and confirmed on vaginal speculum examination and by findings of absent or reduced amniotic fluid on ultrasound examination. Only women with a singleton pregnancy and no known congenital abnormalities were included. Each woman completed a questionnaire on enrollment in the study to determine demographic and clinical parameters. We collected high vaginal swabs and mid-stream urine specimens for microscopy, culture and sensitivity. Blood specimens were collected on admission, to determine the WCC and CRP levels. An elevated WCC was defined as a serum count above 12.60 x 10^9/L. Elevated CRP levels were defined as serum levels at and above 10mg/L. The estimated fetal weight was determined by clinical estimation and/or ultrasound using the Hadlock formula 13 , and the latency period was calculated from time of PROM to delivery. Following delivery, the placenta was sent for histological examination by a single pathologist who reported on all the specimens. The characteristic feature of acute chorioamnionitis is diffuse infiltration of neutrophils into the chorioamniotic membranes. If the inflammatory process involves the umbilical cord (umbilical vein, umbilical artery, and the Wharton's jelly), this is referred to as funisitis. A swab was taken between the amniotic membranes and sent for microscopy, culture and sensitivity. Neonatal outcomes including Apgar score, neonatal intensive care (NICU) admission, signs of sepsis, and neonatal death were recorded. Neonatal sepsis was diagnosed in the presence of a positive culture of blood, urine, or cerebrospinal fluid. Suspected neonatal sepsis was diagnosed in the absence of a positive culture when two or more of the following criteria were present: (1) WCC of <5000 cells/mm3; (2) polymorphonuclear leukocyte count of <1800 cells/mm3; and (3) I:T ratio (ratio of bands to total neutrophils) >0.2. Statistical analysis Initial analysis including mean and the corresponding standard deviation were given for continuous variables. Frequency counts and proportions together with their associated 95% confidence intervals were given for categorical variables. Chi-square test of association of categorical data was undertaken to determine association between preterm rupture of membranes and the explanatory variables . All statistical analysis was evaluated at 5% level and using STATA 15. African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 26