← Dr. Chapa’s OBGYN Clinical Pearls 
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Foreign. In this episode, we're going to tackle something that is not unusual in the field of obstetrics. This has to do with the clinical diagnosis of suspected intra amniotic infection, otherwise known as chorio. Now, whether that is done by isolated maternal fever or suspected affected clinical intra amniotic infection, in other words, fever and at least one other clinical factor, it's the right thing to do because we don't want to get behind maternal sepsis or a neonatal infection. Neonatal sepsis. So we got to pay attention to that. Again, whether it's isolated maternal fever or truly suspected clinical infection, which is fever plus something else like fetal tachycardia, uterine tenderness, foul smelling amniotic fluid. Okay, so you got to make the diagnosis. Here's why we're talking about this. I received a question from a podcast family member who is a senior resident in OB GYN somewhere in the country. We'll just say somewhere in the country. Now we're going to cover this very important topic. This is a good question. And more importantly, it vindicates, it validates, it supports the resident's understanding of this over the faculty. Yep. And I'm not giving any names, we don't have to say that. But here's, here's how this question went in my paraphrase. Hey, Dr. Chapa, we had a patient who clinically I diagnosed as intramniotic infection. She had a temperature of 39 degrees Celsius. She had a prolonged rupture. You know, baby was starting to get a little tachycardic. So we gave her traditional antibiotics, which was ampicillin and gentamicin, and everything was fine. Then at time of delivery, we, of course we sent the placenta, and the placenta did not confirm clinical chorioamnionitis. At morning rounds, the attending said I may have over called the diagnosis of IAI when it may have been something like, you know, epidural related fever because of the catecholamine, you know, changes that happen with the sympathetic blockade, which again, that does happen. It is correct. But because the placenta did not have clinical, I'm sorry, histological chorioamnionitis, inflammation of the chorion and the amnion. My attending told me I may have over called that, but I thought that clinical chorio sometimes is not seen as histological chorio. Am I right? So that basically is the gist as I'm looking through the question here that came in through social media. In other words, can you have historio clinical suspicion and diagnosis of intra amniotic infection, either by isolated maternal temperature elevation or as a true clinical suspicion of infection. Because of that and another clinical factor when the placenta doesn't confirm that, is that possible? So we're going to cover that in this episode. The short answer is, yes, it is absolutely possible. And we're going to explain why and how that is the case. So it's interesting, I responded back to that podcast family member, to that senior resident and said, look, good for you. You're in your Last year, your PGY4. You're about to enter your spring semester, your final semester here of residency, and look what you've learned. You are correct. Now, the trick is to tell your attending in a politically correct way that, yeah, you're actually right. And above all that, you know what? I'll do it for you because we're going to do it on this episode. No names. Again, no names. No names and no location. So it's all de identified. It's okay. It's okay. We're not gonna blow anybody's cover. But. But it does. And again, inciting with the attending, it makes sense, just, doesn't it? Right? I mean, intuitively, hey, if you are, quote, unquote, sick enough to be diagnosed with intra amniotic infection, then you would think that you would have that confirmation on placental histology. You would see inflammation in the corn and the amnion. But that's not always the case. It is not always the case. So in this specific instance, a resident is actually vindicated, validated. They're right. You don't have to see it. Although you very well could. But we're gonna explain why sometimes you don't. Thank you all for sending in your questions, your comments, just your dilemmas, because some of those are or total fuel for our podcast team as we decide what to do. I told one of our volunteers, I'm like, hey, you know, when I get a letter from this, I always feel like Casey Kasem reading, like their long distance dedication back in the day in the radio, to which the intern said, well, who's Casey Kasem? Oh, my gosh. Seriously, y', all, come on, are you with me here? Now, even though he was around way before I was, like, he started it, like in the 60s and 70s ish. But I remember him as, he was older, even in the 80s, and he had the top 40. And he would occasionally read long distance dedications from his listeners, and there were these heartfelt, very complicated issues. And then he'd tell their story with their permission, obviously nationally. And it always led back to a song. Oh yeah, just reminiscing about Casey Kasem's long distance dedications. Dear Casey, I'm a technical sergeant in the United States Air Force assigned to a remote location overseas. I've been in this country for three months and have approximately three months left to go on this tour. This is the first time in my life. I mean, his voice was just iconic. Now, Casey Kasem has nothing to do with what we're talking about, except for the fact that Casey Kasem had a wonderful podcast slash radio radio voice. Because podcast wasn't a thing back in the day. All right, I think I've set it up enough. Let's get out of Casey Kasem. Let's now get into the data on the disconnect sometimes between clinical intramniotic infection, in other words, clinical choreo and pathological or histological confirmation of the condition. We'll be right back. This is Dr. Chapa's obgyn no spin podcast.
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Good for that resident for standing his ground. Now. Never fight amongst yourselves, right? It's good to have an open discussion. Good to have good debate. That was the whole premise of the Prove me Wrong platform, right? Hey, prove me wrong. Let's talk about it. So if you disagree with something, especially when the other person is right, is correct, be open to a discussion. That's all I'm saying. Be open to a discussion. Because in this case, the resident was dead on accurate. Yes, it is possible for a patient to have clinical diagnosis of chorioamnionitis without histological evidence of inflammation of the chorion and the amnion. So this is the issue with chorioamnionitis, right? Because clinically that doesn't exist. Now let me explain. Clinically, we don't know the patient has inflammation of the chorin and the amnion because we can't see that until it's out of the patient. Right? That's why there's been these other terms like intraamniotic infection, which is what ACOG has used in its guidance, which was Committee Opinion 712, Intrapartum Management of Intra amniotic infection, recognizing that the term chorioamnionitis is a pathological histology diagnosis. All right? Inflammation of the chorin and the amnion is chorioamnionitis. And in that same ACOG committee opinion 7, 1, 2. Remember, there's three ways here to diagnose intra amniotic inflammatory condition, right? So intra amniotic infection, slash inflammation of some type. The first is isolated maternal fever. So isolated maternal fever, remember, is made when the temperature is 39 degrees Celsius or higher, which is pretty darn hot, or when there is a temperature between 38 degrees and 38.9 that remains after about 30 minutes. In other words, after you recheck it. So you don't just call it on one temperature, you do a presumptive diagnosis of isolated maternal fever. If it's one temperature of 39 degrees Celsius or an oral temperature of 38 to 38.9 that persists when it's repeated after 30 minutes, that is isolated maternal fever. The second diagnosis in this realm is suspected intra amniotic infection, which is fever, plus some other kind of clinical criteria that can include leukocytosis, even though that's hard to read, intrapartum because of demargination. So if you're going to do a white blood cell count, a cbc, you got to include the DIF to look for bendemia. Okay? Something more specific. But leukocytosis in and of itself is possible, it's just less specific. It could be purulent cervical discharge, fetal tech. Myocardia is the most sensitive or foul smelling amniotic fluid. All of these things support a clinical diagnosis of intra amniotic infection. The third way to diagnose this is after it's out of the patient and under a microscope, which is histological or confirmed intra amniotic inflammation, which is based on histology, Right? So you see inflammation of the chorion and the amnion. Now, here's the catch. And it's even in this ACOG committee opinion is that whether you diagnose it clinically or you diagnose it pathologically, it has the potential to lead to some adverse neonatal issues. Even when you send the placenta for something else and it's like, oh, by the way, that's weird. There was chorioamniotic inflammation. In other words, chorioamnionitis made cystologically, but the patient never had a temperature. Okay, so that's a disconnect where pathology says, it's there. But clinically, she was like, hey, she was afebrile. She's afebrile now. She didn't have a clinical diagnosis. So that's a discrepancy going from pathology to clinical. But our question is doing just the reverse. Is the clinical diagnosis based on either isolated maternal temperature or a clinical suspicion of infection, where that is made? And then the pathology says no. So there's discrepancies both ways. However, whether it's a clinical diagnosis or it's found on a histological diagnosis or. Both of them, okay, Both of them have an increased risk of adverse neurodevelopmental insults to the child. The good news is, is that the overall risk of things like cerebral palsy just based on these two findings still remains very low at about 2 per 1,000 live births, according to the college. Two per thousand, based on these two factors alone. Okay, so the point is, yes, histological choreo is important. It's like, whoa, that was interesting. Thank you for that input. But it doesn't necessarily imply clinical infection, nor does it imply that the child is somehow going to have some tragic hit down in neurodevelopment. As it stated in the committee opinion, a recent meta analysis of 15 studies found a significantly higher relative risk of cerebral palsy among primarily premature infants. So that's the big catch there, because prematurity is a big factor for cerebral palsy in and of itself, anyway. A relative risk of cerebral palsy among primarily premature infants exposed to either histological chorio or clinical chorio. End quote. So if you're asked, let's say, you know, you're on grand rounds or whatever, you're preparing for oral boards next year, because this one's kind of in the books now, and they ask you which kind of chorioamnionitis, clinical or pathological, is associated with an increased odds ratio of cerebral palsy? Like. Well, it's actually both. However. However, clinical chorio has a higher odds ratio. All right, so just based on histology, by Itself, the odds ratio is 1.8, and the confidence interval does cross 1. It's about 1.17 to 2.89. So it still touches 1, although it definitely favors that relationship. But the odds ratio is 1.8. So significant, but it's not at the 2 mark, which is typically considered much.
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More, it's about giving more for less. Ross, work your magic, digger of a deal. Clinical chorio, however, has an odds ratio of 2.4, although the confidence interval still does touch 1 at 1.5 to 3.8. Okay, so these confidence intervals are narrow, they are tight, but they do touch on one. So again, that's why they're not very. They are relative risks that are higher, but the absolute number is still very small. So that's the issue that we got to put into clinical context. Not everybody freak out if you find clinical. I'm sorry, pathological choriamnitis on a placenta. It's all right. It's all right. The absolute risk, just based on those two things of cerebral palsy is still very low at like two per thousand. Okay, but yes, it is important. Histological chorioamnionitis is important. Clinical chorio is a little bit more important. But both deserve just a little hat nod that. Yeah, okay. Thank you for that information. We get that, and we'll keep going. The question that our resident, that the resident sent into us from our podcast family had was, how is that possible? How can you have a clinical diagnosis but the placenta not show it when the placenta was supposed to be pretty darn sensitive and specific in a clinical situation? And the answer is, well, it's supposed to, but it's not always the case. If you take a look at the actual data where clinical chorio as a syndrome has been diagnosed, the rate of correlation to placental inflammation states that they correlate about 60 to 70% of the time. Now, that is pretty high. It's over 50%. That is the majority. So the majority of the time, you're going to be right, you're going to see it. Histologically, you're going to be correct. However, it's not over 80, it's not 90, and it surely isn't 100%. Okay, so there's discrepancies on Both ways. Clinical doesn't always match up with pathological confirmation. And pathological surely doesn't correlate that much with clinical because there's issues with both. All right. And the issue is if there's meconium but no infection, no bacterial overlay. The meconium, at least in some expert opinion reports, can cause inflammation because it's an irritant to the chorioamnion and that potentially can give some inflammatory changes that look like chorioamnionitis. Of course, in that case, the membrane should also be mextained. The idea is that not all histological chorioamnionitis is infectious. Okay. There's other issues there. But the question is, if you have a clinical diagnosis which you presume to be truly infectious, how would it be possible then that the placenta doesn't show it? So let's answer these very quickly and then we're going to be done. Just go over a couple of quick topics here of how this may be an issue. First is that it is possible to have intra amniotic inflammation that is otherwise sterile. So the labor process itself can cause some, trigger some inflammation of the chorioamnion, especially with early amniorexis, that's ruptured membranes. But the idea of sterile intraamniotic inflammation really sought to be the more minor player here, accounting for only like 5% of the cases. The other issue is that it could be a systemic response to something else happening, like an epidural. We know that there's epidural related fever for sure, but there's no way, there's no way to figure out if it's the epidural or an intra amniotic infection, short of tapping the fluid and sending that for gram stain and interleukins or culture, which nobody does, or pcr. So you have to err on the side of caution and go, look, I know it's isolated maternal temperature. I don't know if that's the epidural or not. I understand that it may be over treating this. So we're going to give antibiotics just in case. In that situation where the fever is coming from a systemic maternal inflammatory response or sympathectomy as a response to the sympathetic blockade, then you're not going to see histological chorio. Okay, so yes, you've made a clinical diagnosis because let's say there's isolated maternal temperature elevation that's actually coming from the epidural. But because we can't tease that out, the placenta may not show it. So that is the perfect example. Epidural related fever where the clinical diagnosis is made of suspected intra amniotic infection and the placenta not show is also possible that there is absolutely bacterial inflammation and infection of the choria and the amnion. But if antibiotics are started early promptly, it is possible that it becomes sterilized as the bacteria lyse and die. And antibiotics are mildly anti inflammatory as well. So early stage bacterial infection that has not yet resulted in detectable microscopic lesions or inflammation of the chorioamnion is another reason why bacterial chorio if treated early and you take away that inflammatory response, it can absolutely not show up on histology. My point I'm trying to make here guys is that the resident was correct. He or she responded back saying I thought it is possible even though I get that that most clinical cases of chorea will be confirmed by pathology isn't possible that it could be I and the pathology not show it. The answer is absolutely. The clinical accuracy of these clinical criteria for identifying intramnionic infection is just not real good. And that's the issue here. But we only have to be wrong once and miss it and not treat it. In other words, just say she just got an epidural, it's just the epidural doing it. We're not going to treat her. And that's why you do whatever you want to do do, that's okay. But the concern there is that you're getting behind the ball and iai which is localized can quickly become maternal sepsis. And that inflammatory response to the child is obviously not good for the child's neurodevelopment. So you have to see it and believe it. That is a CMQCC's issue on high blood pressure intrapartum, right? If you get a severe pressure, hey, repeat that in 15 to 20 minutes and if that thing repeats, boom, start anti potensive medications and call that severe criteria for preeclampsia. See it and believe it. Same thing here. If you have isolated maternal temperature elevation even though it may be the epidural and not be related to placentalcorioamnion inflammation. See it and believe it and treat it even though it may be overkill. This resident was correct. It is absolutely possible to have clinical diagnosis of suspected intra amniotic infection, chorio and the placenta not show it because the clinical and diagnostic accuracy of our clinical criteria is just not perfect. Now the specificity increases with things like uterine tenderness, fetal tachycardia, maternal tachycardia or bandemia, that definitely increases the accuracy to like 60, even 70%. However, nothing is perfect. There's still very poor performance of the diagnostic accuracy of clinical criteria for iai, but, but we realize that and we have to jump in anyway. And that is in ACOG's committee opinion that we stated a little while ago, which was number 71 2. So even though we may be over calling it with isolated maternal fever, which may be related to stress of labor, dehydration, maybe related to the epidural, and those things do not show up as histological chorioamnionitis, but you've got to see it and believe it and that equals antibiotics. That committee opinion was back in 2017, but it was reaffirmed this year. And as point of reference, we're coming up to the end of this year because we're doing this on 19th December 2025. So this year this was reaffirmed. So see it and believe it. The short answer is can you have clinical chorio but not have it confirmed on histology? Absolutely, you surely can. Now, again, as we stated, we're going to end this here. While 60 to 70% will have it confirmed on histology, its absence does not mean that antibiotics were not necessary. Intrapartum Podcast Family, we're so thankful for those questions. They become again the fodder, the fuel for our show. In addition, addition to things that are out in print and or in medical news, we're thankful for you. We're glad you're part of our podcast community. Thank you for all of the wonderful support. And now that we've done all that, Michael, let's wrap this up. Let's take it home. This has been Dr. Chapa Zobe Gyn, no Spin podcast Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin podcast. Sam.