Evaluation of a Universal Real-Time Polymerase Chain Reaction for Detection of Amniotic Fluid Infection in Premature Rupture of Membranes

ABSTRACT

Managing preterm rupture of membranes (PPROM) is a balance between benefits of prolonging gestation and the risks of perinatal infection. This study evaluates a real-time polymerase chain reaction (PCR) for the detection of amniotic fluid infection and neonatal complications by amniocentesis following PPROM. A total of 61 singleton pregnancies with PPROM were analyzed retrospectively, including histopathologic examination of the placenta and neonatal complications. The real-time PCR detects a highly conserved sequence of the bacterial 16S ribosomal DNA, and its efficacy was compared with standard tests including amniotic fluid glucose concentration, lactate dehydrogenase level, and maternal white cells count and C-reactive protein levels. Sensitivity and specificity were similar for PCR (64% and 85%) and standard tests (58% and 80%). However, the PCR technique has the additional advantage of possible identification of the bacteria through sequencing and has a much better positive predictive value in the occurrence of neonatal complications (60% for PCR versus 35% for standard tests). The latency period between premature rupture of the membranes and delivery was not related to the incidence of histopathologic signs of infection in the placenta or the umbilical cord and was inversely related to the incidence of neonatal complications.

KEYWORDS

Intrauterine infection - polymerase chain reaction - premature membrane rupture - neonatal outcome

REFERENCES

• 1 Mercer B M. Preterm premature rupture of the membranes.  Obstet Gynecol. 2003;  101 178-193
• 2 Major C A, de Veciana M, Lewis D F, Morgan M A. Preterm premature rupture of membranes and abruptio placentae: is there an association between these pregnancy complications?.  Am J Obstet Gynecol. 1995;  172(2 Pt 1) 672-676
• 3 Kurkinen-Räty M, Koivisto M, Jouppila P. Perinatal and neonatal outcome and late pulmonary sequelae in infants born after preterm premature rupture of membranes.  Obstet Gynecol. 1998;  92 408-415
• 4 Williams O, Hutchings G, Debieve F, Debauche C. Contemporary neonatal outcome following rupture of membranes prior to 25 weeks with prolonged oligohydramnios.  Early Hum Dev. 2009;  85 273-277
• 5 Simhan H N, Canavan T P. Preterm premature rupture of membranes: diagnosis, evaluation and management strategies.  BJOG. 2005;  112(Suppl 1) 32-37
• 6 Caughey A B, Robinson J N, Norwitz E R. Contemporary diagnosis and management of preterm premature rupture of membranes.  Rev Obstet Gynecol. 2008;  1 11-22
• 7 Aziz N, Cheng Y W, Caughey A B. Neonatal outcomes in the setting of preterm premature rupture of membranes complicated by chorioamnionitis.  J Matern Fetal Neonatal Med. 2009;  22 780-784
• 8 Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review.  Obstet Gynecol. 2004;  104(5 Pt 1) 1051-1057
• 9 Ramsey P S, Lieman J M, Brumfield C G, Carlo W. Chorioamnionitis increases neonatal morbidity in pregnancies complicated by preterm premature rupture of membranes.  Am J Obstet Gynecol. 2005;  192 1162-1166
• 10 Porreco R P, Heyborne K D, Shapiro H. Amniocentesis in the management of preterm premature rupture of the membranes: a retrospective cohort analysis.  J Matern Fetal Neonatal Med. 2008;  21 573-579
• 11 Romero R, Yoon B H, Mazor M et al.. A comparative study of the diagnostic performance of amniotic fluid glucose, white blood cell count, interleukin-6, and gram stain in the detection of microbial invasion in patients with preterm premature rupture of membranes.  Am J Obstet Gynecol. 1993;  169 839-851
• 12 Hussey M J, Levy E S, Pombar X, Meyer P, Strassner H T. Evaluating rapid diagnostic tests of intra-amniotic infection: Gram stain, amniotic fluid glucose level, and amniotic fluid to serum glucose level ratio.  Am J Obstet Gynecol. 1998;  179(3 Pt 1) 650-656
• 13 de Lamballerie X, Zandotti C, Vignoli C, Bollet C, de Micco P. A one-step microbial DNA extraction method using “Chelex 100” suitable for gene amplification.  Res Microbiol. 1992;  143 785-790
• 14 Baker G C, Smith J J, Cowan D A. Review and re-analysis of domain-specific 16S primers.  J Microbiol Methods. 2003;  55 541-555
• 15 Chaiworapongsa T, Erez O, Kusanovic J P et al.. Amniotic fluid heat shock protein 70 concentration in histologic chorioamnionitis, term and preterm parturition.  J Matern Fetal Neonatal Med. 2008;  21 449-461
• 16 Klaschik S, Lehmann L E, Raadts A, Book M, Hoeft A, Stuber F. Real-time PCR for detection and differentiation of gram-positive and gram-negative bacteria.  J Clin Microbiol. 2002;  40 4304-4307
• 17 Klaschik S, Lehmann L E, Raadts A, Hoeft A, Stuber F. Comparison of different decontamination methods for reagents to detect low concentrations of bacterial 16S DNA by real-time-PCR.  Mol Biotechnol. 2002;  22 231-242
• 18 DiGiulio D B, Romero R, Kusanovic J P et al.. Prevalence and diversity of microbes in the amniotic fluid, the fetal inflammatory response, and pregnancy outcome in women with preterm pre-labor rupture of membranes.  Am J Reprod Immunol. 2010;  64 38-57
• 19 Kommedal O, Kvello K, Skjåstad R, Langeland N, Wiker H G. Direct 16S rRNA gene sequencing from clinical specimens, with special focus on polybacterial samples and interpretation of mixed DNA chromatograms.  J Clin Microbiol. 2009;  47 3562-3568
• 20 Perni S C, Vardhana S, Korneeva I et al.. Mycoplasma hominis and Ureaplasma urealyticum in midtrimester amniotic fluid: association with amniotic fluid cytokine levels and pregnancy outcome.  Am J Obstet Gynecol. 2004;  191 1382-1386
• 21 Witt A, Berger A, Gruber C J et al.. Increased intrauterine frequency of Ureaplasma urealyticum in women with preterm labor and preterm premature rupture of the membranes and subsequent cesarean delivery.  Am J Obstet Gynecol. 2005;  193 1663-1669
• 22 Jacobsson B, Aaltonen R, Rantakokko-Jalava K, Morken N H, Alanen A. Quantification of Ureaplasma urealyticum DNA in the amniotic fluid from patients in PTL and pPROM and its relation to inflammatory cytokine levels.  Acta Obstet Gynecol Scand. 2009;  88 63-70
• 23 Trochez-Martinez R D, Smith P, Lamont R F. Use of C-reactive protein as a predictor of chorioamnionitis in preterm prelabour rupture of membranes: a systematic review.  BJOG. 2007;  114 796-801
• 24 Han Y W, Shen T, Chung P, Buhimschi I A, Buhimschi C S. Uncultivated bacteria as etiologic agents of intra-amniotic inflammation leading to preterm birth.  J Clin Microbiol. 2009;  47 38-47
• 25 DiGiulio D B, Romero R, Amogan H P et al.. Microbial prevalence, diversity and abundance in amniotic fluid during preterm labor: a molecular and culture-based investigation.  PLoS ONE. 2008;  3 e3056