The Journal of Maternal-Fetal & Neonatal Medicine

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Genital tract GBS and rate of histologic

chorioamnionitis in patients with preterm
premature rupture of membrane

Krunal Patel, Shauna Williams, George Guirguis, Lisa Gittens-Williams &

Joseph Apuzzio

To cite this article: Krunal Patel, Shauna Williams, George Guirguis, Lisa Gittens-Williams &
Joseph Apuzzio (2017): Genital tract GBS and rate of histologic chorioamnionitis in patients with
preterm premature rupture of membrane, The Journal of Maternal-Fetal & Neonatal Medicine, DOI:
10.1080/14767058.2017.1350642

To link to this article: http://dx.doi.org/10.1080/14767058.2017.1350642

Published online: 17 Jul 2017.

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE, 2017
https://doi.org/10.1080/14767058.2017.1350642

ORIGINAL ARTICLE

Genital tract GBS and rate of histologic chorioamnionitis in patients with

preterm premature rupture of membrane
Krunal Patel, Shauna Williams, George Guirguis, Lisa Gittens-Williams and Joseph Apuzzio
Department of Obstetrics, Gynecology and Women’s Health, Rutgers New Jersey Medical School, Newark, NJ, USA

ABSTRACT ARTICLE HISTORY

Introduction: Histologic chorioamnionitis (HC) is a common finding in the placenta from Received 6 April 2017
patients with preterm premature rupture of membranes (PPROM). The purpose of this study is Revised 27 June 2017
to determine if HC differs based on the Group B streptococcus (GBS) status in patients managed Accepted 30 June 2017
expectantly with PPROM <34 weeks gestation.
Methods: A retrospective study was performed of patients admitted with PPROM between 23 KEYWORDS
0/7 and 33 6/7 weeks from 2003 to 2014 at one institution. Patients were excluded if in labor, Group B streptococcus;
evidence of clinical chorioamnionitis, nonreassuring fetal status, multifetal gestation, HIV positive, histologic chorioamnionitis;
or if GBS specimens or placental histology were not available. Placental pathology results were PPROM
compared using Fisher’s exact test.
Results: One hundred eighty-one patients met inclusion criteria and 55 (30.3%) were GBS
positive. The prevalence of HC did not differ between the GBS positive and GBS negative groups
(69 versus 64.2%, respectively; p ¼ .62). Clinical chorioamnionitis, endomyometritis, wound infec-
tion, maternal and neonatal sepsis did not differ between the two groups.
Conclusions: Vaginal–rectal colonization with GBS on admission does not appear to affect the
rate of HC nor neonatal outcome in patients managed conservatively with PPROM <34 weeks
gestation.

Introduction chorionic disk, the extraplacental membranes, umbil-

Preterm premature rupture of membranes (PPROM) is
rupture of the amniotic membranes prior to the onset
of labor before 37 weeks of gestation. The relative
contribution of PPROM to preterm delivery appears to
vary greatly among different patient populations,
affecting about 10% of preterm births in national data-
bases but up to 28% in certain high-risk populations
[1,2]. Clinical chorioamnionitis have been shown to be
commonly associated with PPROM, especially at earlier
gestational ages [3]. Among women with PPROM, clin-
ical chorioamnionitis occurs in approximately 15–25%
of cases [4].
In developed countries approximately 20–30% of
pregnant women are colonized with Group B strepto-
coccus (GBS) [5,6]. If GBS colonized women do not
receive antibiotic prophylaxis during labor than about
50% of their infants are colonized at birth and about
1% of them develop invasive GBS disease [7]. Maternal
peripartum complications are higher among women
with genital tract carriage of GBS [8]. Histologic cho-
rioamnionitis (HC) is inflammation of the placental
ical cord and chorionic vessels and is associated with
preterm delivery. HC occurs in approximately 50–60%
of women with PPROM and is inversely correlated
with gestational age and birth weight [9–12].
Richardson et al. [13] reported a significant association
between placental inflammation with periventricular
leukomalacia or intraventricular hemorrhage (IVH) in
preterm infants. Musilova et al. [14] reported that GBS
was present in about 9% of vaginal fluid and 1% of
amniotic fluid in patients with PPROM. HC is associ-
ated with 50–90% positive placental culture depend-
ing of gestational age at delivery [15]. The aim of the
current study was at investigating the effect of genital
GBS colonization on the rate of HC and neonatal mor-
bidities in patients with PPROM. Our second aim was
to investigate the effect of HC on maternal and neo-
natal outcome.
Materials and methods
A retrospective cohort study was performed of all
singleton gravidas admitted for expectant management

CONTACT Krunal Patel patelk19@njms.rutgers.edu Department of Obstetrics, Gynecology and Women’s Health, Rutgers New Jersey Medical
School, MSB E506, Newark, NJ, USA
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 K. PATEL ET AL.
with PPROM to University Hospital, Newark, NJ, United
States of America, from 1 January 2003 through 31
December 2014. The study was approved by the IRB of
Rutgers, New Jersey Medical School, Study ID:
Pro2012001205. Patients who presented with a com-
plaint of leakage of fluid per vagina were evaluated in
the labor and delivery unit by sterile speculum examin-
ation. Preterm PROM was confirmed with visualization
of fluid emanating from the cervical os, positive fern
and/or nitrazine tests. Patients with confirmed PPROM
at 34-week gestation or greater were delivered and
were not included in the analysis. Patients with PPROM
confirmed at a gestational age between 23 weeks 0
days and 33 weeks 6 days and without signs of clinical
chorioamnionitis, fetal compromise or labor were admit-
ted to the antepartum service for expectant manage-
ment and complete bed rest. Patients were excluded if
HIV infected or if GBS results or placental pathology
reports were not available.
Vaginal rectal swabs for GBS were obtained on
admission and daily thereafter from the lower third of
the vagina and rectum. The specimens were processed
by the hospital laboratory as per CDC recommenda-
tions. Prophylactic intravenous (IV) antibiotics were
prescribed until the results of GBS specimens were
available. Patients that did not meet criteria for imme-
diate delivery (gestational age less than 34 weeks,
reassuring fetal heart status and no evidence of clinical
chorioamnionitis) were admitted to the antepartum
service and received betamethasone 12 mg intramus-
cularly (IM) every 24 h for two doses. Aqueous penicil-
lin G was the primary antibiotic used, first a loading
dose of five million units intravenously was given fol-
lowed by 2.5 million units every 4 h until the results of
the GBS specimens were available as per departmental
protocol. Patients allergic to penicillin received one of
the following regimens for GBS prophylaxis depending
on the risk of anaphylaxis and history of atopy: clinda-
mycin 900 mg IV every 8 h, cefazolin 2-g IV loading
dose followed by 1 g IV every 12 h, or vancomycin 1
gram IV every 12 h. Antimicrobials were stopped when
three daily genital GBS specimens were negative or
after seven days of treatment. No other antimicrobials
were prescribed.
Patients were monitored by twice-daily nonstress
tests (NST) and twice weekly biophysical profiles (BPP).
Patients were monitored for any signs of infection and
also by a complete blood count with differential (CBC)
twice a week. Patients were delivered if they went
into labor, there was a nonreassuring fetal heart trac-
ing, persistently unexplained rising leukocytosis with
suspected clinical chorioamnionitis or gestational age
of 34 weeks. Clinical chorioamniontis was diagnosed
by the presence of uterine tenderness, leukocytosis
and a maternal oral temperature greater than 100.4
degrees Fahrenheit without another source of infec-
tion. All patients received intrapartum antimicrobials
as above which were discontinued in the setting of a
patient having three consecutive negative GBS cul-
tures and without a suspicion of clinical chorioamnio-
nitis. Endomyometritis was defined as presence of
temperature greater than 100.4 F or increasing leuko-
cytosis in conjunction with uterine tenderness or foul
smelling lochia and absence of another source of
infection. HC was diagnosed by the Amsterdam pla-
cental workshop group consensus statement-sampling
and definition of placental lesion [16]. The diagnosis of
histologic chorioamniontis was made by review of pla-
cental pathology reports documented in the medical
record.
The primary outcome of the study was HC. Patients
were grouped according to GBS status at the time of
admission and rates of HC were compared. Additional
outcomes reviewed were the rates of clinical cho-
rioamnionitis, endomyometritis and postoperative
wound infections. We also compared rates of clinical
chorioamnionitis, endomyometritis, maternal sepsis,
wound infection and neonatal outcomes between
patient with and without HC. Statistical comparisons
were performed using Chi-square, Fisher’s exact and
Mann–Whitney tests when appropriate.
Results
During the study time period, 309 patients were iden-
tified as having PPROM at less than 34 weeks gesta-
tion. 128 patients were excluded, reason for exclusion
multifetal gestation (21), gestational age less than 23
weeks (20), patients were not candidate for expectant
management (24), results of genital tract GBS coloniza-
tion (13) and placental pathology (46) were not avail-
able and HIV positive (4). Of the 181 patients who met
inclusion criteria, 55 (29.4%) were GBS positive and
126 (69.6%) patients were GBS negative on admission.
GBS positive and GBS negative groups were similar
with respect to maternal age, gestational age, the
latency period of rupture of membranes, birth weight,
rate of smoking, drug use, gonorrhea and chlamydia
(Table 1). The rate of HC was 64.2% in GBS negative
group and 69% in GBS positive group (p ¼ .62).
Four patients in the cohort were diagnosed with sep-
sis, 3 (3.5%) in GBS negative group and 1 (1.8%) from
the GBS positive group (p ¼ 1). Rate of clinical cho-
rioamnionitis were 19.8 and 14.5% in the GBS negative
and GBS positive groups respectively (p ¼ .52). The
rate of endomyometritis and wound infection were
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3

Table 1. Patient characteristics. Table 3. Outcomes based on placental pathology.

GBS negative GBS positive No histologic Histologic
(N ¼ 126) (N ¼ 55) p Value chorioamnionitis chorioamnionitis
Age (years) 28 (15–42) 27 (14–43) .64 (N ¼ 62) (34.3%) (N ¼ 119) (65.7%) p Value
Estimated gestational 208 (168–238) 205 (168–236) .41 Estimated gestational 31.3 (26–34) 29.2 (24–34) <.0001
age (days) age (weeks)
Latency (days) 5 (0–53) 5 (0–55) .51 Latency (days) 10.4 (0–53) 6.5 (0–36) .23
Smoking 28 (22.2%) 17 (30%) .29 Birth weight (grams) 1802 (751–3115) 1388 (444–2780) <.0001
Drug use 21 (16.6%) 14 (25.5%) .24 Smoking 9 (14.5) 36 (30.2) .02
Gonorrhea 6 (4%) 2 (3%) 1 GBS 17 (27.4) 38 (31.9) .61
Chlamydia 12 (9.5%) 6 (10%) .79 Drug use 10 (16.1) 25 (21) .55
No prenatal care 47 (37.3%) 17 (30.9%) .51 Gonorrhea 3 (4.8) 5 (4.2) 1
Birth Weight (grams) 1572 (513–3115) 1375 (444–2725) .28 Chlamydia 7 (11.2) 11 (9.2) .79
Medians and ranges shown. Trichomoniasis 3 (4.8) 6 (5) 1
Bacterial vaginosis 2 (3.2) 3 (2.5) 1
No prenatal care 10 (16.1) 24 (20) .55
Clinical chorioamnionitis 8 (12.9) 25 (21) .22
Table 2. Maternal and neonatal outcomes. Maternal sepsis 1 (1.6) 3 (2.5) 1
Histologic chorioamnionitis 81 (64.2) 38 (69) 0.62 Wound infection 1 (1.6) 3 (2.5) 1
Endomyometritis 2 (3.2) 10 (8.4) .22
Clinical chorioamnionitis 25 (19.8) 8 (14.5) 0.52 Vaginal delivery 29 (46.7) 62 (52) .6
Endomyometritis 9 (7.1) 3 (5.4) 1
Maternal sepsis 3 (2.3) 1 (1.8) 1 Medians and ranges shown.
Wound infection 3 (2.3) 1 (1.8) 1
Cesarean delivery 61 (48.4) 29 (52.7) 0.70
Respiratory distress syndrome 47 (37.3) 25 (45.4) 0.38
Intraventricular hemorrhage 14 (11.1) 9 (16.3) 0.33 membrane sites, including the genital, rectal, and pha-
Necrotizing enterocolitis 7 (5.5) 4 (7.2) 0.73 ryngeal mucosa are colonized with GBS. In the USA,
rates of maternal colonization are estimated to be
comparable between the groups. The rate of severe about 26% [24]. In our study population, the rate of
neonatal morbidities including respiratory distress syn- GBS colonization is about 30%. In the USA, about 40%
drome, IVH and necrotizing enterocolitis were similar of all early onset bacterial sepsis were caused by GBS
between the groups (Table 2). in and estimated incidence of neonatal GBS sepsis is
When comparing outcomes based on histologic about 0.29–0.41/1000 live births [25,26]. Multiple previ-
chorioamniotis status, we found that patients with HC ous studies has shown benefit of antibiotics to
delivered at earlier gestational age (29.2 versus improve latency and neonatal outcome in patients
with PPROM, but comparison of antibiotic regimens is
31.3 weeks p < .0001) and birth weight was lower
limited. In the NICHD-MFMU trial, among GBS positive
(Table 3). Latency period was 6.5 days in HC group
patients, there was no difference in composite neo-
compare to 10.4 days in non HC group (p ¼ .23).
natal outcome when ampicillin was used compared to
ampicillin/amoxicillin and erythromycin. In our study
Discussion we used penicillin G in all patients without an allergy
and rate of neonatal complications were comparable
In this single-center retrospective study, we found that
with previous studies [27].
genital GBS colonization in patients with PPROM is not
Limitations of our study include its retrospective
associated with an increased rate of HC. The incidence
design and the small sample size of GBS positive
of HC is reported to range from 33 to 71% [17]. For
PPROM patients. The strength of the current study is
our cohort, HC was present in about 65% of this
that the study population is from one institution and
cohort and was associated with delivery at an earlier
consisted of consecutive patients with preterm PROM,
gestational age, had a lower birth weight compared to managed with a standard protocol consisting of corti-
patients without HC. Our study also shows that neo- costeroids and antibiotics.
natal morbidity such as respiratory distress syndrome, In conclusion, this single-centered, retrospective
IVH, necrotizing enterocolitis were not different cohort study demonstrates that genital GBS coloniza-
between GBS positive and GBS negative groups. tion does not appear to be associated with an
Previous studies have shown that HC was associ- increased rate of HC in patients with PPROM at less
ated with increased risk of neonatal morbidity, includ- than 34 weeks of gestation. In this era of extended
ing respiratory distress syndrome, patent ductus spectrum resistance to antimicrobials, our findings
arteriosus [18], pneumonia and neonatal sepsis [19], with use of a narrower-spectrum antibiotic suggest
IVH [20], cystic periventricular leukomalacia [21,22], that additional research is necessary for the optimal
cerebral palsy [22], bronchopulmonary dysplasia regimen in patients with PPROM prior to 34-week
[17,23] and mortality [12]. In pregnancy, mucous gestation.
4 K. PATEL ET AL.
Disclosure statement
No potential conflict of interest was reported by the authors.
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