Research Article: The prevalence of histologic acute chorioamnionitis among HIV infected pregnant women in Uganda and its association with adverse birth outcomes

Date Published: April 11, 2019

Publisher: Public Library of Science

Author(s): John Ategeka, Razack Wasswa, Peter Olwoch, Abel Kakuru, Paul Natureeba, Atis Muehlenbachs, Moses R. Kamya, Grant Dorsey, Gabrielle Rizzuto, Stanley J. Robboy.


Preterm birth (PTB) is a leading cause of neonatal mortality and longer-term morbidity. Acute chorioamnionitis (ACA) is a common cause of PTB, however, there are limited data on the prevalence of ACA and its association with PTB in resource limited settings.

Data and samples came from a clinical trial evaluating novel strategies for the prevention of malaria in HIV infected pregnant women in Uganda. Women were enrolled between 12–28 weeks of gestation and followed through delivery. For each placenta delivered, three placental tissue types (membrane roll, umbilical cord and chorionic plate/villous parenchyma) were collected. Slides were assessed for diagnosis of maternal and fetal ACA by microscopic evaluation of neutrophilic infiltration using a standardized grading scale. The primary outcomes were PTB (<37 weeks), low birth weight (LBW, <2500 grams), and small-for-gestational age (SGA, birth weight <10th percentile for age). Univariate and multivariate logistic regression were used to estimate associations between 1) maternal characteristics (age, education, wealth, gravidity, gestational age at enrollment, placental malaria, anti-malarial prophylaxis treatment regimen, HIV disease parameters) and ACA, and 2) associations between ACA and adverse birth outcomes. A total of 193 placentas were included in the analysis. The prevalence of maternal and fetal ACA was 44.5% and 28.0%, respectively. HIV infected women between 28–43 years of age had a higher risk of maternal ACA compared to those between 17–21 years of age (50.9% vs. 19.1%; aOR = 4.00 (1.10–14.5), p = 0.04) and the diagnosis of severe maternal ACA was associated with a significantly higher risk of PTB (28.6% vs. 6.0%; aOR = 6.04 (1.87–19.5), p = 0.003), LBW (33.3% vs. 9.4%; aOR = 4.86 (1.65–14.3); p = 0.004), and SGA (28.6% vs. 10.1%; aOR = 3.70 (1.20–11.4), p = 0.02). No maternal characteristics were significantly associated with fetal ACA and the diagnosis of fetal ACA was not associated with adverse birth outcomes. Histological evidence of severe maternal ACA was associated with an increased risk of PTB, LBW, and SGA in HIV infected, pregnant Ugandan women.

Partial Text

Preterm birth (PTB, delivery occurring prior to 37 weeks) and low birth weight (LBW, weight <2500 grams) are major determinants of infant mortality and morbidity during childhood [1, 2]. PTB is a leading cause of death among neonates [3], complications arising from PTB are the leading cause of mortality among children less than five years of age worldwide [4], and PTB can result in long term neurodevelopmental difficulties for surviving children [5]. PTB is often associated with LBW, and LBW is an important stand-alone risk factor for infant death [3]. Rates of PTB range from 5–18% of live neonates [5], with the highest incidences reported in sub-Saharan Africa and South Asia [3, 5]. The United States Agency for International Development (USAID) cooperative agreement project to combat PTB and LBW in Africa and Asia recently estimated that, in Uganda, approximately 226,000 babies are born preterm every year and 12,500 deaths occur as a direct consequence of prematurity [6].   Source:


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