AFJOG

ORIGINAL RESEARCH Table 2: Comparison of pregnancies with andwithout evidence of placental infection based on placental histology Type of critical incident Signs of placental infection (FIRS) (n=25) n (%) No signs of placental infection (n=20) n (%) p-value Gestational age 0.614 <34 weeks 18 (72) 13 (65) >34 weeks 7 (28) 7 (35) HIV 0.651 Negative 19 (76) 14 (70) Positive 6 (24) 6 (24) CRP elevated 9 (37.5) 7 (36.8) 0.965 WCC elevated 7 (28) 4 (20) 0.849 Antenatal antibiotics 25 (100) 19 (95) 0.44 Latency period 575 460 0.99 Labour 0.236 Induced 7 (28) 9 (45) Spontaneous 18 (72) 11 (55) 5 min Apgar score <7 20 (80) 18 (90) 0.43 Neonatal ICU admission 17 (68) 15 (75) 0.607 Neonatal sepsis 7 (29.1) 5 (25) 0.757 CRP= c-reactive protein; FIRS= fetal inflammatory response syndrome; HIV= human immunodeficiency virus; ICU= intensive care unit; WCC= maternal white cell count. Forty-seven neonates (65.28%) were admitted to neonatal ICU for low birth weight (n=36) and respiratory distress (n=11). Eighteen neonates had signs of neonatal sepsis (25.35%). Of these, 3 (16.7%) mothers had no evidence of infection on admission, 13 (72.2%) had urinary tract infection, 5 (27.8%) had a vaginal infection, 4 (22.2%) had both urinary tract infection and vaginal infection, 2 (11.1%) had a raised white cell count and 4 (22.2%) had a raised CRP. There were 2 (2.8%) neonatal deaths in the study population. The placenta of both fetuses showed evidence of FIRS. One neonate was born at 33 weeks with birth weight of 1673g. The 5-minute Apgar score was 2. The other neonate had a caesarean delivery for fetal distress and was born with weight of 1141g and had a 5-minute Apgar score of 7. Their neonatal period was complicated by neonatal sepsis. Table 3: Comparison of neonates born to mothers with FIRS Type of critical incident FIRS + NICU (17) FIRS + no NICU (6) p-value Antenatal Latency from PROM to delivery 239 86 0.294 Antibiotics 17 (100) 8 (100) 0.651 HIV Negative 13 (76.47) 6 (75) 0.629 Positive 4 (23.53) 2 (25) 5-minute Apgar score < 7 4 (23.53) 0 ≥ 7 13 (76.37) 8 (100) Maternal infection Positive urine culture 11 (64.71) 5 (62.50) 0.626 Positive vaginal swab 4 (36.36) 2 (50.00) 0.538 Elevated WCC 4 (23.53) 3 (37.50) 0.760 Elevated CRP 6 (37.50) 3 (37.50) 0.668 CRP= c-reactive protein; FIRS= fetal inflammatory response syndrome; HIV= human immunodeficiency virus; NICU= neonatal intensive care unit; PROM= premature rupture of membranes; WCC= white cell count. From the total of 25 confirmed neonates with FIRS, 17 were admitted to NICU. The results showed that maternal HIV infection had no influence in NICU admission (p=0.651); CRP was not predictive (p=0.668); and there was no relation between NICU admission and maternal urinary tract infection (p=0.626) and vaginal infection (p=538). DISCUSSION FIRS is a complex pathophysiologic process associated with significant fetal/neonatal mortality and morbidities. 5 Diagnosing this condition before its consequences develop remains difficult. We found that there was no correlation between the clinical picture of the woman at presentation, markers of inflammation, latency period or neonatal outcomes and the incidence of FIRS. In 25-40% the placenta in PROM shows evidence of ascending infection (amniotic fluid infection sequence) or vasculopathic problems (hemorrhage or thrombi). 14 Intraamniotic infection has clinical significance for the neonate beyond just causing preterm birth. 5, 7 The fetus may reveal an inflammatory response associated with cytokine release that can cause damage to the developing brain and lungs. 5, 7, 15 FIRS is characterized by circulating cytokines, bacterial toxins and activation of the coagulation cascade, which may predispose to cerebral palsy and other forms of adverse neurological function. The risk is evidenced for cerebral palsy and impaired neurological function when these children reach school age. 15 Cerebral palsy (CP), has seen a massive increase in litigation for alleged obstetric negligence, despite evidence that CP is largely caused by factors unrelated to obstetrical care. 16 Periventricular leukomalacia (a form of white-matter brain injury characterised by necrosis or coagulation of white matter near the lateral ventricles) and intraventricular haemorrhage, both common features in CP, are associated with prematurity and can occur before the birthing process and irrespective of the care provided by the obstetric team. Similarly, vascular infarcts are known to occur at any stage of neurological development. In many cases, there is a complex interplay of genetic, medical and environmental factors. 17 Routine pathological examination of the placenta in preterm infants could provide clues, not only regarding the cause of preterm labour or PROM, but also African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 28