Chorioamnionitis and Villitis
Chorioamnionitis is an infection of the placenta and fetal membranes. It occurs when bacteria move upward through the vagina and into the uterus. This bacteria can be passed to the baby during birth. These infections cause an inflammatory response, which in turn can lead to the release of prostaglandin, the ripening of the cervix, membrane injury, and early labor. Chorioamnionitis is diagnosed through non-invasive clinical means, though laboratory tests are available. Doctors can take steps to prevent chorioamnionitis and infection from being passed from mother to child by delivering the baby early, and providing the mother with prophylactic antibiotics in a timely manner in order to confer neuroprotective effects on the baby.
Villitis is inflammation of the chorionic villi (the structures covering the surface of the placenta that ensure the baby receives enough nutrients and gases from the mother). This inflammation often stems from chorioamnionitis, though it can also be due to other bacterial or viral sources such as Streptococci, herpes, rubella and syphilis. If these membranes are inflamed, the rate at which nutrients and gases can be exchanged drops significantly, increasing the risk of fetal death. Usually this inflammation is undetectable unless abscesses begin to form. Once they begin to form, they can be detected with an ultrasound test. The best way to avoid complications from villitis is to prevent inflammation in the first place by immediately diagnosing and treating any underlying infections that can trigger it.
Chorioamnionitis and Infant Injury
Chorioamnionitis, or intramniotic infection, is an inflammation of the placenta/fetal membranes (called the chorion and amnion) caused by bacteria ascending into the uterus from the vagina. The ascension of bacteria is typically associated with prolonged labor and membrane rupture (a mother’s water breaking), but choriomnionitis can also occur with intact membranes.
Chronic chorioamnionitis is commonly associated with villitis, which is inflammation of the chorionic villi on the surface of the placenta. Chorionic villi develop to maximize surface area contact with for nutrient and gas exchange between maternal and fetal blood. Villitis is very serious, and when the condition is present, the chance of fetal death is increased.
It is crucial that physicians promptly diagnose and treat chorioamnionitis and the infections that can lead to villitis. If a doctor mishandles treatment, there may be devastating consequences for the baby, including:
- Hypoxia (significantly reduced oxygen supply)
- Hydrops fetalis (abnormal amounts of fluid build-up in two or more body areas of a fetus or newborn)
- Intrauterine growth restriction (IUGR)
- Premature rupture of the membranes (PROM)
- Preterm birth
- Respiratory problems
- Encephelopathy (brain injury, such as hypoxic ischemic encephalopathy (HIE))
- Brain damage, such as cerebral palsy and periventricular leukomalacia (PVL)
- Neonatal sepsis (blood infection)
What Causes Chorioamnionitis and Villitis?
Causes of Chorioamnionitis
Chorioamnionitis (also sometimes known as intra-amniotic infection, or IAI) is an infection of the chorion and amnion, the membranes which surround the amniotic sac and the developing baby, as well as the amniotic fluid. The infection then can spread to the baby. Chorioamnionitis is caused by infectious organisms passing from the colon, cervix, or vagina to the uterus, where the baby is located. Sometimes, chorioamnionitis can occur when infectious organisms are transferred to the membranes during amniocentesis or chorionic villous sampling (CVS). Once bacteria colonize the membranes, there is a maternal and fetal inflammatory response to the infection. This response may lead to the release of prostaglandin, ripening of the cervix, membrane injury, and labor at term or prematurely. Women with premature labor or membranes that have been ruptured for a long time are at risk for chorioamnionitis, which can cause brain injury in the baby.
Causes of Villitis
Villitis is associated with placental infections. There are several conditions that can cause villitis, but in many cases the cause is unknown.
Bacterial causes of villitis include the following:
- Bacteria associated with maternal sepsis
Viral causes of villitis include:
- Cytomegalovirus (CMV)
What are the Risk Factors for Chorioamnionitis and Villitis?
Risk Factors for Chorioamnionitis
- Premature labor
- Fetal membranes that are ruptured (the water has broken) for a prolonged period
- Prolonged labor
- Nulliparity (no prior births)
- Group B streptococcus (GBS)
- Bacterial infections, such as urinary tract infection (UTI), bacterial vaginosis (BV), and ureaplasma
- Obesity during pregnancy
- Short cervix (incompetent cervix)
- Use of the hormone vaginal prostaglandin during labor
- Internal monitoring of labor
- Multiple vaginal exams
- Meconium stained amniotic fluid
- Epidural anesthesia
- Immune compromised status
- Smoking, alcohol, or drug abuse
Risk Factors for Villitis
- Viral, bacterial and protozoal infections
- Obesity during pregnancy
- Multiple pregnancy (pregnant with more than one baby)
- Urinary complications during pregnancy
What are the Signs and Symptoms of Chorioamnionitis and Villitis?
Signs and Symptoms of Chorioamnionitis
Pregnant women with chorioamnionitis may exhibit no clear signs or symptoms of infection. On the other hand, a pregnant woman with chorioamnionitis may appear ill, or have hypotension (low blood pressure), diaphoresis (excessive sweating), and/or cool, clammy skin. Maternal fever, however, is the most important clinical sign of the infection.
Signs and symptoms of chorioamnionitis include the following:
- Maternal fever
- Uterine tenderness
- Significant maternal tachycardia (heart rate > 120 beats/min.)
- Fetal tachycardia (heart rate > 160 – 180 beats/min.)
- Purulent or foul-smelling amniotic fluid or vaginal discharge
- Maternal leukocytosis (high white blood cell count)
The risk of neonatal sepsis is greatly increased when at least two of the above criteria are present.
The signs of villitis are listed below.
Signs and Symptoms of Chronic Villitis
- Elevated levels of alpha-feto-protein when IUGR is present
- Non-significant elevations of human growth hormone when testing biological screening of trisomy (abnormal number of chromosomes) in the second quarter
Signs and Symptoms of Acute Villitis
- Abscesses in the placental parenchyma (villi)
- Neutrophilic chorioamnionitis
How is Chorioamnionitis and Villitis Diagnosed?
Chorioamnionitis may be diagnosed based on signs such as maternal fever, microbiologically based on amniotic fluid culture obtained by amniocentesis, or by microscopic exam of the umbilical cord and placenta. The diagnosis typically is made based solely on clinical signs, however, since access to uncontaminated amniotic fluid or placenta for culture is invasive and usually avoided. The presence of fever (temperature > 100.4) plus two other signs (uterine tenderness, maternal or fetal tachycardia and foul/purulent amniotic fluid) is generally required for diagnosis. In addition, the presence of risk factors of chorioamnionitis, especially membrane rupture, further strengthens diagnosis.
Other diagnostic methods are listed below.
Laboratory tests for a mother with no symptoms and who is experiencing premature labor or PROM include:
- Examination of amniotic fluid
- Maternal GBS screening test
- Maternal blood studies
- Maternal urine studies
Testing of a febrile (feverish) mother with suspected chorioamnionitis includes:
- White blood cell counts
- C-reactive protein levels
- Alpha 1-proteinase inhibitor complex measurement
- Serum interleukin-6 or ferritin levels
Studies to evaluate amniotic fluid and urogenital secretions include:
- Bacterial cultures
- Leukocyte count
- Gram staining
- Glucose concentration
Ultrasonography may be used to determine the well being of the baby in the womb.
Villitis is usually not apparent (without a microscope) unless there is abscess formation. Abscesses can typically be seen with an ultrasound.
Villitis is associated with placental infections and therefore should be considered when any of the following conditions are present: CMV, chorioamnionitis, candida, HSV, GBS, group A streptococcus, syphilis, toxoplasmosis and chlamydia. It is crucial that physicians promptly diagnose and treat these infections because when villitis develops, there is an increased risk for fetal death.
How is Chorioamnionitis and Villitis Treated?
Treatment for Chorioamnionitis
Treatment for the mother and baby with chorioamnionitis includes early delivery, supportive care, and antibiotic administration.
Prompt administration of antibiotics is essential to prevent both maternal and fetal complications. Time to delivery after implementing antibiotic therapy has been shown to not affect morbidities, in certain cases. Thus C-section to expedite delivery is not indicated for chorioamnionitis unless there are other obstetric indications. Intravenous (IV) administration of ampicillin every 6 hours and gentamicin every 8-24 hours until delivery is the standard regimen. If C-section is performed, clindamycin every 8 hours (or metronidazole) usually is added for anaerobic coverage. Treatment also should include administration of a single IV additional dose of antibiotics after delivery.
Supportive measures include the use of acetaminophen (Tylenol), which is especially important during delivery to prevent neonatal encephalopathy.
Prevention of Chorioamnionitis
Prevention of chorioamnionitis is critical. PROM (or preterm PROM, PPROM) is a major cause of chorioamnionitis; up to 70% of women who develop PROM with contractions or labor have chorioamnionitis. Although PROM can cause chorioamnionitis, it must be noted that together with preterm labor, PROM frequently is caused by chorioamnionitis.
The standard for prevention of chorioamnionitis is the administration of broad spectrum antibiotics, typically involving erythromycin or azithromycin, and ampicillin for 7-10 days via IV (2 days) followed by oral routes. Labor induction and delivery is associated with reduced maternal infection and need for neonatal intensive care. When there is prolonged membrane rupture (> 18 hours) at term, prophylactic antibiotics are not indicated if the mother is not colonized with GBS. However, the Centers for Disease Control (CDC) recommends initiating GBS prophylaxis if GBS status is unknown.
Indeed, prophylactic antibiotics have been shown to be very beneficial in reducing the incidence of neonatal death, chronic lung disease, or major brain abnormalities in the baby. Antibiotics also have been shown to reduce the incidence of chorioamnionitis and neonatal sepsis, and to prolong time-to-delivery among mothers with preterm membrane rupture who are given expectant management (waiting for spontaneous labor).
Treatment and Prevention of Villitis
Research has shown that when villitis is suspected, steroids and aspirin during pregnancy are beneficial. Most of the time, the cause of villitis is unknown. However, since villitis is associated with placental infections, as discussed above, it is imperative that these infections be immediately diagnosed and treated.
What is Funisitis?
Funisitis is inflammation of the umbilical cord in response to the umbilical cord becoming infected. Funisitis often results from chorioamnionitis when infection spreads from the placental membrane to the umbilical cord, causing fetal inflammatory response syndrome (FIRS). Funisitis is very serious, as it can cause the flow of oxygen and nutrients to the baby to become compromised. Funisitis can result in stillbirth.
Medical Malpractice, Birth Injury, Chorioamnionitis and Villitis
Listed below are items that may constitute negligence:
- Failure to diagnose and properly treat chorioamnionitis
- Failure to diagnose PROM and to follow standards of care in prevention of ascending infection
- Failure to diagnose and properly treat placental infections
- Failure to closely monitor the mother and baby when risk factors for chorioamnionitis and villitis are present
- Failure to obtain adequate informed consent. This includes advising the mother of the risks and alternatives of delivery methods, such as vaginal birth versus C-section, and of the use of delivery instruments, such as forceps and vacuum extractors
- Failure to properly deliver the baby and to follow standards of care when performing a C-section or vaginal delivery, and when utilizing delivery instruments
When risk factors for chorioamnionitis and villitis are present, it is essential that the physicians monitor the mother and baby very closely and follow guidelines and medical standards of care for treatment and prevention of the infections. When a mother/baby are not properly tested for placental infections, and when standards for treating the conditions are not followed, it is negligence. If chorioamnionitis and other placental infections are not diagnosed and treated right away, very serious fetal and neonatal complications can arise. When this negligence causes injury to the mother or baby, it is medical malpractice.
Legal Help for Children with Birth Injuries from Chorioamnionitis and Villitis
At Reiter & Walsh ABC Law Centers, we are dedicated to birth injury cases. We understand the complex legal issues involved with pregnancy infection cases and will help you to obtain the compensation to which you are entitled. Our attorneys and in-house medical staff determine the causes of our clients’ injuries, the prognoses of birth injured children and areas of medical negligence. We consult closely with leading medical experts, forensic specialists and life care-planning professionals to secure our clients’ future care and their parents’ peace of mind, knowing their child will be cared for, no matter what. Our specific focus on birth injury allows our attorneys to provide unparalleled legal service to our clients.
Our attorneys handle cases all over the United States, in places including Pennsylvania, Tennessee, Mississippi, Texas, Wisconsin, Michigan, Ohio, Washington D.C., Arkansas, and more. Additionally, our team handles cases involving military hospitals and federally funded clinics. To begin your free case review, please contact Reiter & Walsh ABC Law Centers in any of the following ways:
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Video: Chorioamnionitis and Birth Injury
How Do You Pronounce Chorioamnionitis?
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