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Depression at Birth in Term Infants Exposed to Maternal Chorioamnionitis: Does Neonatal Fever Play a Role?

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Depression at Birth in Term Infants Exposed to Maternal Chorioamnionitis: Does Neonatal Fever Play a Role? Original Article Depression at Birth in Term Infants Exposed to Maternal Chorioamnionitis: Does Neonatal Fever Play a Role? Lina F. Shalak, MD have birth depression, than infants with lesser degree of temperature Jeffrey M. Perlman, MB elevation after birth. Within the NICU group, the extent of temperature Gregory L. Jackson, MD elevation was not associated with worse neurological outcomes. Abbot R. Laptook, MD Journal of Perinatology (2005) 25, 447–452. doi:10.1038/sj.jp.7211326 Published online 28 April 2005 OBJECTIVES: (1) To determine the incidence and the time course of elevated temperature following delivery in term infants with clinical chorioamnionitis (CHORIO) and (2) to determine if the extent of INTRODUCTION temperature elevation at birth is associated with increased likelihood of The presence of maternal fever has been associated with an NICU Admissions, birth depression, or with short-term neurological increased need of resuscitation at birth, lower Apgar scores, a abnormalities. higher incidence of seizures in the newborn and increased 1–3 DESIGN/METHODS: mortality. Moreover an association between clinical chorioamnionitis (CHORIO) and cerebral palsy has been described The infants were divided into two groups based on the median admission both in term and preterm infants.4–6 However, the mechanisms rectal temperature of 37.81C for the cohort. Depression at birth was that link these two conditions remain ill defined, especially for defined as either the need of positive pressure ventilation for >2 minutes, infants born at term. Since hyperthermia during and following intubation, or Apgar score <6 at 5 minutes. Neurological examination hypoxic insults in experimental animals enhances neuronal death, and assessment of encephalopathy (Sarnat staging) was performed at maternal fever associated with clinical CHORIO has been proposed birth and daily thereafter, by one investigator blinded to temperature as a potential mechanism of injury.7 However, the role of an findings. elevated temperature in the newborn, following delivery to a RESULTS: mother with CHORIO has not been systematically studied in relation to neonatal neurological outcomes. This prospective cohort Infants with higher rectal temperature at 30 minutes of life were more study of term infants delivered to mothers with CHORIO was likely to be admitted to NICU: OR (2.8, 95% confidence interval (CI) [1.8 undertaken with three objectives. First, to determine the incidence to 4.3]), and were more likely to have birth depression OR (3, 95%CI [1.4 of elevated temperatures following delivery in infants born to to 6.5]). For infants in NICU, a rectal temperature above 37.81C was mothers with clinical CHORIO admitted to the intensive care unit present in 87% in the delivery room, persisted in 47% at 30 minutes, and as compared to infants admitted to the newborn nursery, and declined to a normal temperature at 60 minutes of life in the absence of whether it is associated with depression at birth. Second, to medical interventions. There was no relationship between neurological determine the temperature decay following admission. Third, to scores and neonatal temperature. determine whether the extent of temperature elevation in infants CONCLUSIONS: born with maternal CHORIO and admitted to the intensive care Term infants exposed to CHORIO who had a higher neonatal temperature unit is associated with a greater incidence of abnormal at 30 minutes of life, were more likely to be admitted to the NICU and to neurological examination or encephalopathy. MATERIALS AND METHODS Study Population Department of Pediatrics (L.F.S., G.L.J.), University of Texas, Southwestern Medical Center, Dallas, This prospective cohort was derived from all term infants with an TX, USA; Weill Medical College of Cornell University (J.M.P.), Providence, RI, USA; and Brown Medical School (A.R.L.), Providence, RI, USA. estimated gestational age >36 weeks, born to mothers with a Address correspondence and reprint requests to Lina F. Shalak, MD, Department of Pediatrics, diagnosis of clinical CHORIO at Parkland Memorial Hospital in University of Arkansas Medical Center, 800 Marshall Street, Slot 512-5, Little Rock, USA. Dallas, Texas between July 1999 and January 2001. There were Journal of Perinatology 2005; 25:447–452 r 2005 Nature Publishing Group All rights reserved. 0743-8346/05 $30 www.nature.com/jp 447 Shalak et al. Fever in the Newborn and Birth Depression 23,231 total deliveries during the study interval, of whom 1660 Short-Term Neonatal Outcomes (7%) were born to mothers with a diagnosis of clinical CHORIO Depression at birth. Defined prior to the start of the study as: and were eligible for enrollment into this study. Clinical CHORIO An Apgar score <6 at 5 minutes, the need for bag and mask was defined according to obstetrical criteria of maternal fever ventilation >2 minutes, or requiring intubation in the delivery (axillary temperature Z381C) in the presence of fetal or maternal room for respiratory support. tachycardia, uterine tenderness or foul smelling amniotic fluid.8 The Institutional Review Board of the University of Texas Assessment of neurological abnormalities. Each infant Southwestern Medical Center approved the study. Informed consent admitted to the intensive care unit underwent serial neurological was obtained from the parents of eligible infants in the NICU prior examinations performed by one examiner (L.S.) in the first to enrollment. 12 hours after birth (mean age 6±5 hours), and a second examination at 24 hours following the initial assessment. Infants NBN Cohort with abnormalities in their neurological examinations had daily The majority of infants, that is, 1571 of 1660 (95%) infants born at examinations performed until normalization or hospital discharge term to a mother with CHORIO were admitted to a regular as previously reported.9 A Modified Dubowitz Score (MDS) was used newborn nursery (NBN). Data were systematically collected for to objectively assess for abnormalities of tone as previously 667 of these infants based on alternate month schedule over a reported.9–10 Hypotonia was defined as two SDs above the normal 12 month period during the study interval. Upon arrival to the score of 15 (MDS>19), while a score two SDs below the mean nursery, all infants had a septic work up for chorioamionitis (MDS<11) was indicative of hypertonia. The Sarnat staging was exposure that included a blood culture and complete blood cell used to characterize the degree of the encephalopathy11 as mild, count with administration of ampicillin and gentamicin for 48 moderate and severe. Infants with persistent abnormalities in their hours until confirmation of negative blood cultures. As a criterion neurological examination were further evaluated by neuroimaging for a regular nursery admission, none of the infants had required studies, as part of clinical care. respiratory support in the delivery room (i.e. no bag mask ventilation, intubations or sustained oxygen requirement). Temperature Measurements and Thermal Regulation Admission temperature was measured within 30 minutes after Temperature measurements were obtained from the rectum using birth. The medical charts were reviewed for Apgar scores, cord a digital thermometer for all infants upon admission to the blood gases, abnormal WBC counts, culture results, length of intensive or NBN at 30 minutes after birth (T 30 minutes). hospital stay, duration of antibiotics, as well as documentation of 1 Thermometers were inserted no more than 12 in rectally. pneumonia or abnormal neurological examinations as determined Subsequent temperature measurements were obtained from the by the attending physician. axilla, at 60 minutes after birth and hourly until 4 hours of age. Infants in both cohorts (Intensive Care and Newborn Nursery) were NICU Cohort admitted and placed under radiant warmers following birth and A minority of infants born to mothers with CHORIO, that is, 89 of temperature control was via servo control of the abdominal skin 1660 (5%) were admitted to the Neonatal Intensive Care unit temperature to 36.51C. (NICU Group). Infants at term were admitted to the NICU by After study initiation, an additional rectal temperature protocol if they met any of the following criteria: need for bag measurement was obtained in the delivery room, after appropriate mask ventilation, use of continuous positive airway pressure resuscitation but prior to transport to the intensive care unit (CPAP) or intubation, sustained need of oxygen, use of volume (Temperature upon delivery). Since the latter measurement expansion or any medications in the delivery room, and an Apgar included implementing a change in our nursing protocols, data score <7 at 5 minutes. The medical charts of all infants were were available for approximately two-thirds of the infants admitted reviewed for the following: maternal temperature closest to the time to the NICU. of delivery, perinatal complications such as meconium, fetal heart rate abnormalities, rectal temperature of the newborn in the Evaluation for Neonatal Sepsis delivery room, 30 and 60 minutes after birth, mode of delivery, use All infants born to mothers with CHORIO and triaged to the NICU of epidural anesthesia, need for resuscitation, Apgar scores, had two sets of blood cultures obtained at birth, and complete medications to support blood pressure, postnatal illnesses and blood counts (CBC) at 0, 12 and 24 hours. The total white cell morbidities, for example, sepsis, pneumonia, air leaks, days in count was measured with
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