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ChorioamnionitisandVillitis(Infections)

CHORIOAMNIONITIS AND VILLITIS ATTORNEYS IN MICHIGAN, OHIO,WASHINGTON DC, AND NATIONWIDE

Chorioamnionitis,orintramnioticinfection,isaninflammationoftheplacenta/fetalmembranes(calledthechorionandamnion)causedbybacteriaascendingintotheuterusfromthevagina.Theascensionofbacteriaistypicallyassociatedwithprolongedlaborandmembranerupture(amotherswaterbreaking),butchoriomnionitiscanalsooccurwithintactmembranes.

Chronicchorioamnionitisiscommonlyassociatedwithvillitis,whichisinflammationofthechorionicvillisurfaceoftheplacenta.Chorionicvillideveloptomaximizesurfaceareacontactwithmaternalbloodfornutrientandgasexchangewithfetalblood.Villitisisveryserious,andwhentheconditionispresent,thechanceoffetaldeathisincreased.

Itiscrucialthatphysicianspromptlydiagnoseandtreatchorioamnionitisandtheinfectionsthatcanleadtovillitis.Ifadoctormishandlestreatment,theremaybedevastatingconsequencesforthebabyincluding:

Hypoxia(significantlyreducedoxygensupply)Hydropsfetalis(abnormalamountsoffluidbuildupintwoormorebodyareasofafetusornewborn)Intrauterinegrowthrestriction(IUGR)Prematureruptureofthemembranes(PROM)PretermbirthRespiratoryproblemsMeningitisEncephelopathy(braininjury,suchashypoxicischemicencephalopathy)Braindamage,suchascerebralpalsyandperiventricularleukomalacia(PVL)Neonatalsepsis(bloodinfection)Fetaldeath/stillbirth

Ifyouwerediagnosedwithchorioamnionitisoraninfectionthatledtovillitisandyourchildsustainedaseriousinjuryasaresult,pleasecalloneofthebirthinjuryattorneysatReiter&WalshABCLawCenters.Wewillreviewyourmedicalrecordsanddetermineifnegligenceexists.Wellletyouknowwhatyourlegaloptionsare.Callourofficeat(888)419BABY.

CAUSES OF CHORIOAMNIONITIS AND VILLITISChorioamnionitis

Inchorioamnionitis,infectiousorganismsarepassedfromthecolon,cervixandvaginatotheuterus,wherethebabyislocated.Specifically,thechorioamnionand/orumbilicalcordoftheplacentabecomeinfectedandinflamed.Lesscommonroutesofinfectionincludepassageofinfectiousorganismsduringamniocentesisorchorionicvilloussampling.Onceinfectedwithbacteria,thereisamaternalandfetalinflammatoryresponsethatmayleadtoreleaseofthehormoneprostaglandin,ripeningofthecervix,

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membraneinjury,andlaborattermorprematurely.

Villitis

Villitisisassociatedwithplacentalinfections.Thereareseveralconditionsthatcancausevillitis,butinmanycasesthecauseisunknown.

Bacterialcausesofvillitisincludethefollowing:

ChorioamnionitisStreptococciBacteriaassociatedwithmaternalsepsis

Viralcausesofvillitisinclude:

Cytomegalovirus(CMV)ToxoplasmosisHerpesRubellaSyphilis

RISK FACTORS FOR CHORIOAMNIONITIS AND VILLITISChorioamnionitis

PrematurelaborFetalmembranesthatareruptured(thewaterhasbroken)foraprolongedperiodProlongedlaborNulliparity(nopriorbirths)GroupBstreptococcus(GBS)Bacterialinfections,suchasurinarytractinfection(UTI),bacterialvaginosis(BV)andureaplasmaObesityduringpregnancyShortcervix(incompetentcervix)UseofthehormonevaginalprostaglandinduringlaborInternalmonitoringoflaborMultiplevaginalexamsMeconiumstainedamnioticfluidEpiduralanesthesiaImmunecompromisedstatusSmoking,alcoholordrugabuse

Villitis

Viral,bacterialandprotozoalinfectionsObesityduringpregnancyMultiplepregnancy(pregnantwithmorethanonebaby)Urinarycomplicationsduringpregnancy

SIGNS AND SYMPTOMS OF CHORIOAMNIONITIS AND VILLITISChorioamnionitis

Examinationofapregnantwomanwithchorioamnionitismayrevealnosignsorsymptomsofinfection.Ontheotherhand,apregnantwomanwithchorioamnionitismayappearill,toxic,andshemayexhibithypotension(lowbloodpressure),diaphoresis(excessivesweating),and/orcool,clammyskin.Maternalfever,however,isthemostimportantclinicalsignoftheinfection.

Signsandsymptomsofchorioamnionitisincludethefollowing:

MaternalfeverDiaphoresisUterinetendernessSignificantmaternaltachycardia(heartrate>120beats/min.)Fetaltachycardia(heartrate>160180beats/min.)PurulentorfoulsmellingamnioticfluidorvaginaldischargeMaternalleukocytosis(highwhitebloodcellcount)

Theriskofneonatalsepsisisgreatlyincreasedwhenatleasttwooftheabovecriteriaarepresent.

Thesignsofvillitisarelistedbelow.

Chronicvillitis

ElevatedlevelsofalphafetoproteinwhenIUGRispresentNonsignificantelevationsofhumangrowthhormonewhentestingbiologicalscreeningof

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trisomy(abnormalnumberofchromosomes)inthesecondquarter

Acutevillitis

Abscessesintheplacentalparenchyma(villi)Neutrophilicchorioamnionitis

DIAGNOSIS OF CHORIOAMNIONITIS AND VILLITISChorioamnionitis

Chorioamnionitismaybediagnosedbasedonsignssuchasmaternalfever,microbiologicallybasedonamnioticfluidcultureobtainedbyamniocentesis,orbymicroscopicexamoftheumbilicalcordandplacenta.Thediagnosistypicallyismadebasedsolelyonclinicalsigns,however,sinceaccesstouncontaminatedamnioticfluidorplacentaforcultureisinvasiveandusuallyavoided.Thepresenceoffever(temperature>100.4)plustwoothersigns(uterinetenderness,maternalorfetaltachycardiaandfoul/purulentamnioticfluid)isgenerallyrequiredfordiagnosis.Inaddition,thepresenceofriskfactorsofchorioamnionitis,especiallymembranerupture,furtherstrengthensdiagnosis.

Otherdiagnosticmethodsarelistedbelow.

LaboratorytestsforamotherwithnosymptomsandwhoisexperiencingprematurelabororPROMinclude:

ExaminationofamnioticfluidMaternalGBSscreeningtestMaternalbloodstudiesMaternalurinestudies

Testingofafebrile(feverish)motherwithsuspectedchorioamnionitisincludes:

WhitebloodcellcountsCreactiveproteinlevelsAlpha1proteinaseinhibitorcomplexmeasurementSeruminterleukin6orferritinlevels

Studiestoevaluateamnioticfluidandurogenitalsecretionsinclude:

BacterialculturesLeukocytecountGramstainingpHGlucoseconcentration

Ultrasonographymaybeusedtodeterminethewellbeingofthebabyinthewomb.

Villitis

Villitisisusuallynotapparent(withoutamicroscope)unlessthereisabscessformation.Abscessescantypicallybeseenwithanultrasound.

Villitisisassociatedwithplacentalinfectionsandthereforeshouldbeconsideredwhenanyofthefollowingconditionsarepresent:CMV,chorioamnionitis,candida,HSV,GBS,groupAstreptococcus,syphilis,toxoplasmosisandchlamydia.Itiscrucialthatphysicianspromptlydiagnoseandtreattheseinfectionsbecausewhenvillitisdevelops,thereisanincreasedriskforfetaldeath.

TREATMENT OF CHORIOAMNIONITIS AND VILLITISChorioamnionitis

Treatmentforthemotherandbabywithchorioamnionitisincludesearlydelivery,supportivecareandantibioticadministration.

Promptadministrationofantibioticsisessentialtopreventbothmaternalandfetalcomplications.Timetodeliveryafterimplementingantibiotictherapyhasbeenshowntonotaffectmorbidities,incertaincases.ThusCsectiontoexpeditedeliveryisnotindicatedforchorioamnionitisunlessthereareotherobstetricindications.Intravenous(IV)administrationofampicillinevery6hoursandgentamicinevery824hoursuntildeliveryisthestandardregimen.IfCsectionisperformed,clindamycinevery8hours(ormetronidazole)usuallyisaddedforanaerobiccoverage.TreatmentalsoshouldincludeadministrationofasingleIVadditionaldoseofantibioticsafterdelivery.

Supportivemeasuresincludetheuseofacetaminophen(Tylenol),whichisespeciallyimportantduringdeliverytopreventneonatalencephalopathy.



Preventionofchorioamnionitis

Preventionofchorioamnionitisiscritical.PROM(orpretermPROM,PPROM)isamajorcauseofchorioamnionitisupto70%ofwomenwhodevelopPROMwithcontractionsorlaborhavechorioamnionitis.AlthoughPROMcancausechorioamnionitis,itmustbenotedthattogetherwithpretermlabor,PROMfrequentlyiscausedbychorioamnionitis.

Thestandardforpreventionofchorioamnionitisistheadministrationofbroadspectrumantibiotics,typicallyinvolvingerythromycinorazithromycin,andampicillinfor710daysviaIV(2days)followedbyoralroutes.Laborinductionanddeliveryisassociatedwithreducedmaternalinfectionandneedforneonatalintensivecare.Whenthereisprolongedmembranerupture(>18hours)atterm,prophylacticantibioticsarenotindicatedifthemotherisnotcolonizedwithGBS.However,theCentersforDiseaseControl(CDC)recommendsinitiatingGBSprophylaxisifGBSstatusisunknown.

Indeed,prophylacticantibioticshavebeenshowntobeverybeneficialinreducingtheincidenceofneonataldeath,chroniclungdiseaseormajorbrainabnormalitiesinthebaby.Antibioticsalsohavebeenshowntoreducetheincidenceofchorioamnionitisandneonatalsepsis,andtoprolongtimetodeliveryamongmotherswithpretermmembranerupturewhoaregivenexpectantmanagement(waitingforspontaneouslabor).

Villitis

Researchhasshownthatwhenvillitisissuspected,steroidsandaspirinduringpregnancyarebeneficial.Mostofthetime,thecauseofvillitisisunknown.However,sincevillitisisassociatedwithplacentalinfections,asdiscussedabove,itisimperativethattheseinfectionsbeimmediatelydiagnosedandtreated.

MEDICAL MALPRACTICE AND CHORIOAMNIONITIS / VILLITISListedbelowareitemsthatmayconstitutenegligence:

FailuretodiagnoseandproperlytreatchorioamnionitisFailuretodiagnosePROMandtofollowstandardsofcareinpreventionofascendinginfectionFailuretodiagnoseandproperlytreatplacentalinfectionsFailuretocloselymonitorthemotherandbabywhenriskfactorsforchorioamnionitisandvillitisarepresentFailuretoobtainadequateinformedconsent,whichincludesadvisingthemotheroftherisksandalternativesofdeliverymethods,suchasvaginalbirthversusCsectionandexpectantmanagementFailuretoobtainadequateinformedconsent,whichincludesadvisingthemotheroftherisksandalternativesoftheuseofdeliveryinstruments,suchasforcepsandvacuumextractorsFailuretoproperlydeliverthebabyandtofollowstandardsofcarewhenperformingaCsectionorvaginaldelivery,andwhenutilizingdeliveryinstruments

Whenriskfactorsforchorioamnionitisandvillitisarepresent,itisessentialthatthephysiciansmonitorthemotherandbabyverycloselyandfollowguidelinesandmedicalstandardsofcarefortreatmentandpreventionoftheinfections.Whenamother/babyarenotproperlytestedforplacentalinfections,andwhenstandardsfortreatingtheconditionsarenotfollowed,itisnegligence.Ifchorioamnionitisandotherplacentalinfectionsarenotdiagnosedandtreatedrightaway,veryseriousfetalandneonatalcomplicationscanarise.Whenthisnegligencecausesinjurytothemotherorbaby,itismedicalmalpractice.

DO I HAVE A CHORIOAMNIONITIS / VILLITIS CASE?Tofindoutifyouareeligibleforcompensation,contactourDetroitattorneyshandlingchorioamnionitisandvillitiscasesinMichigan,Ohio,Washington,D.C.andthroughoutthenation.AtReiter&WalshABCLawCenters,wearededicatedtobirthinjurycases.Weunderstandthecomplexlegalissuesinvolvedwithplacentalinfectioncasesandwillhelpyoutoobtainthecompensationtowhichyouareentitled.Callforafreecasereview:(888)419BABY.

Sources:

CornetteL.Fetalandneonatalinflammatoryresponseandadverseoutcome.SeminFetalNeonatalMed20049:459.LiebermanE,LangJ,RichardsonDK,etal.Intrapartummaternalfeverandneonataloutcome.Pediatrics2000105:8.SoperDE,MayhallCG,DaltonHP.Riskfactorsforintraamnioticinfection:aprospectiveepidemiologicstudy.AmJObstetGynecol1989161:562.FrigolettoFDJr,LiebermanE,LangJM,etal.Aclinicaltrialofactivemanagementoflabor.NEnglJMed1995333:745.NewtonER.Chorioamnionitisandintraamnioticinfection.ClinObstetGynecol199336:795.YoonBH,RomeroR,MoonJB,etal.Clinicalsignificanceofintraamnioticinflammationinpatientswithpretermlaborandintactmembranes.AmJObstetGynecol2001185:1130.RouseDJ,LandonM,LevenoKJ,etal.TheMaternalFetalMedicineUnitscesareanregistry:

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chorioamnionitisattermanditsdurationrelationshiptooutcomes.AmJObstetGynecol2004191:211.Kradin,RL.PerinatalInfections.In:DiagnosticPathologyofInfectiousDisease:ExpertConsult,Saunders,2010.p.465.

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