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Diagnostic Validity of the Proposed Eunice Kennedy Shriver National Institute of Child Health and Human Development Criteria for Intrauterine Inflammation or Infection

Ona, Samsiya, MD; Easter, Sarah Rae, MD; Prabhu, Malavika, MD; Wilkie, Gianna, MD; Tuomala, Ruth E., MD; Riley, Laura E., MD; Diouf, Khady, MD

doi: 10.1097/AOG.0000000000003008
Obstetric Complications: Original Research: PDF Only

OBJECTIVE: To investigate the test characteristics of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) criteria for intrauterine inflammation or infection or both (triple I) and rates of adverse outcomes in a cohort of febrile intrapartum women.

METHODS: This retrospective cohort study included women at 24 weeks of gestation or greater from June 2015 to September 2017 at a single tertiary hospital with a temperature 100.4°F or greater (38.0°C) during labor or within 1 hour postpartum, all of whom had blood culture data. Women with a fetal demise, expectantly managed preterm prelabor rupture of membranes, or nonobstetric infections were excluded. Documented fever was defined as a single temperature 102.2°F or greater (39.0°C) or a temperature 100.4°F or greater (38.0°C) but less than 102.2°F (39.0°C) on two measurements 45 minutes apart. We defined two analysis groups: 1) suspected triple I, defined as women with documented fever with clinical signs of infection; and 2) isolated maternal fever, defined as women with at least one temperature 100.4°F or greater (38.0°C) who did not meet criteria for suspected triple I. We assessed test characteristics of suspected triple I to predict 1) confirmed triple I, defined as suspected triple I with placental pathology diagnostic of infection; and 2) adverse clinical infectious outcome, defined as a composite of maternal and neonatal adverse infectious outcomes. We also calculated the incidence of adverse clinical infectious outcomes for both groups.

RESULTS: Three hundred thirty-nine women were analyzed: 212 with suspected triple I and 127 with isolated maternal fever. Baseline demographic and obstetric characteristics were similar between groups. The incidence of adverse clinical infectious outcomes was 11.8% among women with suspected triple I and 9.5% among women with isolated maternal fever (P=.50). The sensitivity and specificity of suspected triple I for confirmed triple I were 71.4% (95% CI 61.4–80.1%) and 40.5% (95% CI 33.6–47.8%), respectively, and for an adverse clinical infectious outcome were 67.6% (95% CI 50.2–82.0%) and 38.1% (95% CI 32.6–43.8%), respectively.

CONCLUSION: Applying the NICHD criteria to guide clinical diagnosis and management of intrauterine infection or inflammation may overlook an important proportion of laboring febrile women at risk for adverse infectious outcomes.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria to guide clinical diagnosis and management of intrauterine infection or inflammation may overlook an important proportion of laboring febrile women at risk for adverse infectious outcomes.

Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, and the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Corresponding author: Samsiya Ona, MD, Obstetrics and Gynecology Department, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; email: sona@partners.org.

Supported by an Expanding the Boundaries Faculty Grant from the Department of Obstetrics, Gynecology and Reproductive Biology at the Brigham and Women's Hospital.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented in part at the Society for Maternal-Fetal Medicine's 38th Annual Pregnancy Meeting, January 29–February 3, 2018, Dallas, Texas.

The authors thank the pathologists who provided guidance in the interpretation of the pathology reports (Drs. Zehra Ordulu Sahin and Drucilla Jane Roberts) as well as Dr. Joe Chou, attending neonatologist, who assisted with data abstraction and transfer to REDCap from our electronic medical records.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at http://links.lww.com/AOG/B213.

Received June 29, 2018

Received in revised form September 10, 2018

Accepted September 20, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.