Background

Acute funisitis—the histologic diagnosis of inflammation within the umbilical cord—represents a fetal inflammatory response to infection. Although acute funisitis has been associated with an increased risk of adverse outcomes among preterm neonates, there are limited and conflicting data with term deliveries.

Objective

This study aimed to evaluate the association between acute funisitis and neonatal morbidity in neonates born at term to pregnant patients with a clinical diagnosis of intraamniotic infection.

Study Design

This was a retrospective cohort study of pregnant patients who had clinically diagnosed intraamniotic infection at term, delivered vaginally at a single tertiary institution from 2013 to 2019, and had histologic chorioamnionitis on placental pathology. Patients with intrauterine fetal demise or missing neonatal/placental pathology data were excluded. The primary outcome was a neonatal sepsis composite, defined as culture-positive bacteremia, neutropenia (absolute neutrophil count<3500/μL), or immature-to-total neutrophil ratio>0.2. The secondary outcomes included composite neonatal morbidity, defined as neonatal intensive care unit admission, 5-minute Apgar score <7, bacteremia, endotracheal intubation or need for continuous positive airway pressure, intraventricular hemorrhage (grade 3 or 4), necrotizing enterocolitis (stage 3 or 4), umbilical artery pH<7.1, umbilical artery base excess>12, and neonatal mortality. The components of these composites, neonatal intensive care unit length of stay, and Kaiser early-onset sepsis score were also measured. Neonates with acute funisitis on pathology were compared with those without acute funisitis using bivariate statistics. Regression was used to estimate the relative risk of outcomes.

Results

Of 184 neonates with deliveries complicated by intraamniotic infection, acute funisitis was present in 109 (59%) placental specimens. Composite neonatal sepsis was significantly higher among neonates with acute funisitis (relative risk, 1.85; 95% confidence interval, 1.13–3.03) than in those without acute funisitis. As a marker for sepsis, acute funisitis has a sensitivity of 39.4%, negative predictive value of 47.2%, specificity of 78.7%, and positive predictive value of 72.9%. An immature-to-total neutrophil ratio>0.2 (relative risk, 1.83; 95% confidence interval, 1.09–3.08) was also significantly associated with acute funisitis. Neonatal morbidity composite, intraventricular hemorrhage, necrotizing enterocolitis, neonatal intensive care unit admission, higher Kaiser early-onset sepsis scores, and other examined outcomes were not statistically associated with acute funisitis.

Conclusion

In term deliveries complicated by intraamniotic infection, acute funisitis was associated with increased neonatal sepsis. Current approaches for estimating neonatal sepsis risk are limited by their reliance on indirect maternal factors such as maximum maternal temperature and intrapartum antibiotic use. This study suggests that acute funisitis may serve as a marker that could be utilized to augment risk stratification at birth if a protocol for evaluating the umbilical cord in real-time were widely adopted.

中文翻译：

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急性绳索炎是否预示着足月新生儿的新生儿结局会更差？

背景

急性绳索炎（脐带内炎症的组织学诊断）代表胎儿对感染的炎症反应。尽管急性绳索炎与早产儿不良后果风险增加有关，但足月分娩的数据有限且相互矛盾。

客观的

本研究旨在评估临床诊断为羊膜内感染的孕妇足月出生的新生儿急性绳索炎与新生儿发病率之间的关系。

学习规划

这是一项回顾性队列研究，对象为临床诊断为足月羊膜内感染、2013 年至 2019 年在同一三级机构阴道分娩、胎盘病理学患有组织学绒毛膜羊膜炎的孕妇。胎儿宫内死亡或缺失新生儿/胎盘病理数据的患者被排除在外。主要结局是新生儿败血症复合症状，定义为培养阳性菌血症、中性粒细胞减少症（绝对中性粒细胞计数<3500/μL）或未成熟中性粒细胞与总中性粒细胞的比率>0.2。次要结局包括新生儿综合发病率，定义为新生儿重症监护病房入院、5分钟阿普加评分<7、菌血症、气管插管或需要持续气道正压通气、脑室内出血（3级或4级）、坏死性小肠结肠炎（3级）或4)、脐动脉pH<7.1、脐动脉碱过剩>12和新生儿死亡率。还测量了这些复合材料的组成部分、新生儿重症监护病房的住院时间和 Kaiser 早发型败血症评分。使用双变量统计将病理学上患有急性肌腱炎的新生儿与没有急性肌腱炎的新生儿进行比较。回归用于估计结果的相对风险。

结果

在 184 名分娩并发羊膜内感染的新生儿中，109 名（59%）胎盘标本中存在急性绳索炎。患有急性肌腱炎的新生儿中，复合新生儿败血症的发生率显着高于无急性肌腱炎的新生儿（相对风险，1.85；95%置信区间，1.13-3.03）。作为脓毒症的标志物，急性绳索炎的敏感性为39.4%，阴性预测值为47.2%，特异性为78.7%，阳性预测值为72.9%。未成熟中性粒细胞与总中性粒细胞的比率>0.2（相对风险，1.83；95%置信区间，1.09-3.08）也与急性绳索炎显着相关。新生儿发病率复合、脑室内出血、坏死性小肠结肠炎、新生儿重症监护病房入住、较高的 Kaiser 早发性败血症评分以及其他检查结果与急性腱炎没有统计学相关性。

结论

在并发羊膜内感染的足月分娩中，急性绳索炎与新生儿败血症增加有关。目前估计新生儿败血症风险的方法受到对间接母体因素（例如母体最高体温和产时抗生素使用）的依赖的限制。这项研究表明，如果广泛采用实时评估脐带的方案，急性绳索炎可以作为一个标志物，用于增强出生时的风险分层。