#Grand Rounds

‘Chorioamnionitis or Triple I’ – How Valid is the NICHD Guideline for the Diagnosis of Intrauterine Infection?

BACKGROUND AND PURPOSE:

In 2015, NICHD recommended
- Replace ‘chorioamnionitis’ with ‘Triple I’
  - Intrauterine Inflammation or Infection or both
  - Antibiotics given only for those meeting ‘Triple I’ criteria
  - Isolated fever would not necessarily be treated
- Samsiya et al. (Obstetrics & Gynecology, 2019) sought to assess the diagnostic validity of the ‘Triple I’ approach for the intrauterine infection
  - Authors additionally measured rates of adverse outcomes in a cohort of febrile intrapartum women

METHODS:

Retrospective cohort study
Women included with the following
- ≥24 weeks gestation
- Temperature ≥100.4°F (38.0°C) during labor or within 1 hour postpartum
- Available blood culture data
Fever defined as
- Single temperature ≥102.2°F (39.0°C) or
- ≥100.4°F (38.0°C) but <102.2°F (39.0°C) on two measurements 45 minutes apart
Two analysis groups were defined
- Suspected triple I
  - Documented fever with clinical signs of infection
- Isolated maternal fever
  - At least one temperature ≥100.4°F (38.0°C) in women who did not meet criteria for suspected triple I
- NICHD test characteristics ability to predict suspected triple I was assessed
  - Confirmed triple I: Suspected triple I with placental pathology confirmation
- Adverse clinical infectious outcome
  - Composite of maternal and neonatal adverse infectious outcomes

RESULTS:

339 women
- 212 with suspected triple I | 127 with isolated maternal fever
Incidence of adverse clinical infectious outcomes (P=.50)
- Women with suspected triple I: 11.8%
- Women with isolated maternal fever: 9.5%
Performance characteristics of suspected triple I for confirmed triple I
- Sensitivity: of 71.4% (95% CI 61.4–80.1%)
- Specificity: 40.5% (95% CI 33.6–47.8%)
Performance characteristics for predicting adverse clinical infectious outcomes
- Sensitivity: 67.6% (95% CI 50.2–82.0%)
- Specificity: 38.1% (95% CI 32.6–43.8%)

CONCLUSION:

NICHD criteria may miss a significant proportion of laboring febrile women at risk for adverse infectious outcomes
NICHD guideline had low sensitivity and specificity
Women with isolated fever were at risk for adverse infectious outcomes
The authors state

Following the publication of the triple I criteria, the American College of Obstetricians and Gynecologists issued a statement recommending consideration of treatment of women who fall under the umbrella of isolated maternal fever as defined by the NICHD, and our study supports this recommendation