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

Learn More – Primary Sources:

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

Related ObG Topics:

Chorioamnionitis: ACOG Committee Opinion on Diagnosis and Management

Does Intrapartum Fever Really Predict Neonatal Sepsis?

Updated Guidance on GBS Screening and Prophylaxis