The fetal inflammatory response syndrome

Ricardo Gomez, MD,b, c Roberto Romero, MD,a, b Fabio Ghezzi, MD,b Bo Hyun Yoon, MD, PhD,d
Moshe Mazor, MD,e and Stanley M. Berry, MDa
Detroit, Michigan, Bethesda, Maryland, Puente Alto, Chile, Seoul, Korea, and Beer-Sheva, Israel
OBJECTIVE: The objective of this study was to determine the frequency and clinical significance of a systemic inflammatory response as defined by an elevated plasma interleukin-6 concentration in fetuses with
preterm labor or preterm premature rupture of membranes.
STUDY DESIGN: Amniocenteses and cordocenteses were performed in 157 patients with preterm labor and
preterm premature rupture of membranes. Written informed consent and multi-institutional review board approvals were obtained. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as mycoplasmas. Amniotic fluid and fetal plasma interleukin-6 concentrations were measured with a sensitive and specific immunoassay. Statistical analyses included contingency tables, receiver operating characteristic curve
analysis, and multiple logistic regression.
RESULTS: One hundred five patients with preterm labor and 52 patients with preterm premature rupture of
membranes were included in this study. The overall prevalence of severe neonatal morbidity (defined as the
presence of respiratory distress syndrome, suspected or proved neonatal sepsis, pneumonia, bronchopulmonary dysplasia. intraventricular hemorrhage, periventricular leukomalacia, or necrotizing enterocolitis)
among survivors was 34.8% (54/155). Neonates in whom severe neonatal morbidity developed had higher
concentrations of fetal plasma interleukin-6 than fetuses without development of severe neonatal morbidity
(median 14.0 pg/mL, range 0.5 to 900 vs median 5.2 pg/mL, range 0.3 to 900, respectively; P < .005).
Multivariate analysis was performed to explore the relationship between the presence of a systemic fetal inflammatory response and subsequent neonatal outcome. To preserve a meaningful temporal relationship between the results of fetal plasma interleukin-6 concentrations and the occurrence of severe neonatal morbidity, the analysis was restricted to 73 fetuses delivered within 7 days of cordocentesis who survived. The
prevalence of severe neonatal morbidity in this subset of patients was 53.4% (39/73). A fetal plasma interleukin-6 cutoff value of 11 pg/mL was used to define the presence of a systemic inflammatory response. The
prevalence of a fetal plasma interleukin-6 level >11 pg/mL was 49.3% (36/73). Fetuses with fetal plasma interleukin-6 concentrations >11 pg/mL had a higher rate of severe neonatal morbidity than did those with fetal
plasma interleukin-6 levels 11 pg/mL (77.8% [28/36] vs 29.7% [11/37], respectively; P < .001). Stepwise logistic regression analysis demonstrated that the fetal plasma interleukin-6 concentration was an independent
predictor of the occurrence of severe neonatal morbidity (odds ratio 4.3, 95% confidence interval 1 to 18.5)
when adjusted for gestational age at delivery, the cause of preterm delivery (preterm labor or preterm premature rupture of membranes), clinical chorioamnionitis, the cordocentesis-to-delivery interval, amniotic fluid
culture, and anmiotic fluid interleukin-6 results.
CONCLUSION: A systemic fetal inflammatory response, as determined by an elevated fetal plasma interleukin-6 value, is an independent risk factor for the occurrence of severe neonatal morbidity. (Am J Obstet
Gynecol 1998;179:194-202.)

Key words: Preterm labor, intrauterine infection, fetal homeostasis, inflammatory response,
neonatal morbidity
From the Division of Maternal-Fetal Medicine, Department of Obstetrics
and Gynecology, Wayne State University/Hutzel Hospital,a the
Perinatology Research Branch, National Institute of Child Health and
Human Development,b the Department of Obstetrics and Gynecology,
Sotero del Rio Hospital,c the Department of Obstetrics and Gynecology,
Seoul National University,d and the Department of Obstetrics and
Gynecology, Ben-Gurion University.e
Presented in part at the Seventeenth Annual Meeting of the Society of
Perinatal Obstetricians, Anaheim, California, January 20-25, 1997.
Received for publication June 23, 1997; revised January 8, 1998; accepted January 15, 1998.
Reprint requests: Roberto Romero, MD, Department of Obstetrics and
Gynecology, Hutzel Hospital, Perinatology Research Branch, NICHD,
4707 St. Antoine Blvd, Detroit, MI 48201.
6/1/89113

194

Microbial invasion of the amniotic cavity is present in

10% of patients with preterm labor and intact membranes1-4 and in 30% of patients with preterm premature
rupture of membranes.5-8 Moreover, bacterial footprints
have been detected in the amniotic fluid of as many as
60% of patients with preterm labor and intact membranes.9, 10 Microorganisms in the amniotic cavity or maternal compartment may reach the human fetus and
stimulate the biosynthesis of proinflammatory
cytokines.11 Increased bioavailability of interleukin-6 (IL6) during fetal life may lead to the development of an
acute-phase response similar to that observed in adult

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patients with systemic inflammatory response syndrome,

a serious condition characterized bv multiple organ failure associated with sepsis.12 Circulating human fetal cells
are capable of transcribing messenger ribonucleic acid
for proinflammatory cytokines. We have proposed that
proinflammatory cytokines may serve as fetal signals for
the onset of preterm parturition in the context of intrauterine infection.13 The objective of this study was to
determine the frequency and clinical significance of a
systemic inflammatory response as defined by an elevated plasma IL-6 concentration in fetuses with preterm
labor or preterm premature rupture of membranes.
Patients and methods
Patients and eligibility. Women who were examined at
Hutzel Hospital with preterm labor and intact membranes or with preterm premature rupture of membranes, over a 4-year period of time, were offered amniocentesis for the diagnosis of microbial invasion of the
amniotic cavity and the assessment of fetal lung maturity.
Patients who consented to have an amniocentesis were
asked to participate in a research management protocol
that included the aspiration of additional amniotic fluid
for research purposes and cordocentesis. Criteria for eligibility into this study included (1) preterm labor with intact membranes or preterm premature rupture of membranes, (2) consent to have an amniocentesis, and (3)
availability of skilled medical staff to perform cordocentesis. Exclusion criteria were (1) clinical chorioamnionitis, (2) multiple gestation, (3) fetal distress, or (4) significant vaginal hemorrhage. Oligohydramnios was not an
exclusion criterion. The diagnosis of preterm labor was
made in the presence of regular uterine contractions (at
least 3 in 30 minutes) and documented cervical change
in patients with a gestational age of 20 to 36 weeks.
Preterm premature rupture of membranes was diagnosed by sterile speculum examination with a combination of vaginal pooling and Nitrazine and ferning tests.
Written informed consent was obtained from each patient who agreed to participate in the research protocol
before any procedures were performed. A group of fetuses (n = 29) undergoing diagnostic cordocentesis
whose perinatal outcome was normal was used to generate a reference range of fetal plasma IL-6. This control
group consisted of fetuses who underwent cordocentesis
between 19 and 42 weeks of gestation for clinical indications (eg, abnormal ultrasonographic findings, platelet
isoimmunization, and suspected fetal infection) and in
whom the clinical conditions for which they had the procedure were excluded after fetal blood and amniotic
fluid analysis. This protocol was approved by the human
investigation committees of Wayne State University and
Hutzel Hospital. Similar protocols have been approved
by the institutional review boards of the following institu-

Gomez et al 195

tions: Yale University (New Haven, Connecticut), Ben

Gurion University (Beer-Sheva, Israel), Seoul National
University (Seoul, Korea), and Sotero del Rio Hospital
(an affiliate of the Catholic University of Santiago,
Chile). Included in this manuscript are 41 patients with
preterm premature rupture of membranes who were the
subject of separate communications14, 15 about the relationship between fetal plasma IL-6 and the admission-todelivery interval.
Amniocentesis, cordocentesis, and assays for IL-6. All
patients had a detailed ultrasonographic examination before amniocentesis and cordocentesis were performed.
Electronic fetal monitoring was performed before and
after the procedure to evaluate fetal well-being.
Amniocentesis and cordocentesis procedures were performed with the freehand technique described by
Nicolaides et al.16 One percent lidocaine was given as a
local anesthetic, but no sedative drugs were administered. A 22-gauge needle was used, and a path was chosen for needle insertion that allowed the amniocentesis
and cordocentesis procedures to be carried out with a
single percutaneous needle insertion in approximately
95% of patients. Amniotic fluid studies included a Gram
stain and microbial cultures for aerobic or anaerobic bacteria and mycoplasmas, as well as the lecithin/sphyngomyelin ratio. The results of these tests were used for
subsequent clinical management decisions. Fetal blood
was collected in ethylenediaminetetra-acetic acid
(EDTA). Kleihauer-Betke stains were performed on fetal
blood, and all specimens were found to be free of maternal blood. Fetal blood was analyzed for pH and gases,
and complete white blood cell count, platelet count, and
differential cell count were performed. Results were
made available for clinical management. Amniotic fluid
and fetal plasma IL-6 concentrations were determined
with commercially available enzyme-linked immunoassays (R & D Systems, Minneapolis). Two assays were run,
one for all fetal blood samples and the other for all amniotic fluid samples. The assays were conducted by the
same person in one laboratory. For amniotic fluid samples, the sensitivity of the immunoassay was 0.5 pg/mL
(intra-assay and interassay coefficients of variation 2.7%
and 9.3%, respectively). For fetal plasma, the sensitivity
of the assay was 0.058 pg/mL (intra-assay and interassay
coefficients of variation 3.3% and 8.3%, respectively).
The results of cytokine concentrations in amniotic fluid
or fetal plasma reported herein were neither available
nor used for clinical decision-making.
Criteria for the diagnosis of chorioamnionitis and severe neonatal morbidity. Clinical chorioamnionitis was diagnosed in the presence of a temperature elevation to
37.8C or higher and two or more of the following four
criteria: uterine tenderness, malodorous vaginal discharge, fetal tachycardia >160 beats/min, and maternal

196 Gomez et al

leukocytosis >15,000 cells/mm3. The diagnosis of histologic chorioamnionitis was based on the polymorphonuclear leukocyte infiltration of the chorionic plate or of
the extraplacental fetal membranes. Severe neonatal
morbidity was defined as the presence of any of the following conditions: respiratory distress syndrome, suspected or proved neonatal sepsis, pneumonia, bronchopulmonary dysplasia, intraventricular hemorrhage,
periventricular leukomalacia, and necrotizing enterocolitis. The diagnosis of respiratory distress syndrome required the presence of respiratory grunting and retracting, increased need for oxygen, and diagnostic
radiographic and laboratory findings in the absence of
evidence for other causes of respiratory disease.
Neonatal sepsis was diagnosed in the presence of a positive culture of blood, urine, or cerebrospinal fluid.
Suspected neonatal sepsis was diagnosed in the absence
of a positive culture when two or more of the following
criteria were present: (1) white blood cell count of <5000
cells/mm3; (2) polymorphonuclear leukocyte count of
<1800 cells/mm3; and (3) I:T ratio (ratio of bands to
total neutrophils) >0.2. These criteria have been previously used in the pediatric and obstetric literature.17
Pneumonia was diagnosed in the presence of definite
clinical and radiologic findings, with or without a positive
culture from tracheal aspirate, blood, or chest tube specimen. Bronchopulmonary dysplasia was diagnosed if the
neonate required oxygen and ventilatory therapy for >28
days during the first 2 months of life, had typical radiographic changes, or had dysplasia of the bronchopulmonary tree at autopsy. Intraventricular hemorrhage was
diagnosed by ultrasonographic examination of the
neonatal head. Periventricular leukomalacia was diagnosed in the presence of cystic lesions within the periventricular white matter or persistent abnormally increased
periventricular echogenicity. Necrotizing enterocolitis
was diagnosed in the presence of abdominal distention
and feeding intolerance for at least 24 hours (vomiting
or increased gastric residual) with clear radiologic evidence of intramural air, perforation, meconium plug syndrome, or definite surgical or autopsy findings of necrotizing enterocolitis.
Statistical analysis. Two-tailed Mann-Whitney U test
was used to compare continuous nonparametric variables. Comparisons between proportions were performed with 2 or Fishers exact test. Receiver operating
characteristic curves were constructed to describe the relationship between the sensitivity (true-positive rate) and
the false-positive rate (1 Specificity) for different values
of fetal plasma IL-6 concentrations in the prediction of
severe neonatal morbidity. Logistic regression was used
to investigate the regression relationships between the
occurrence of severe neonatal morbidity and gestational
age at delivery, fetal plasma IL-6 concentrations, the

July 1998
Am J Obstet Gynecol

cause of preterm delivery (preterm labor or preterm premature rupture of membranes), amniotic fluid culture,
and amniotic fluid IL-6 results. SPSS version 7.5 (SPSS,
Inc., Chicago) and True Epistat (Epistat Services,
Richardson, Tex.) statistical packages were used for
analysis.
Results
Study population. One hundred five patients with
preterm labor and 52 patients with preterm premature
rupture of membranes were included in this study. There
were two perinatal deaths. In both cases the infants were
delivered before 24 weeks of gestation and were excluded from analysis. The overall prevalence of preterm
delivery <37 weeks was 80% (124/155). Severe neonatal
morbidity developed in 54 neonates (34.8%). Table I displays the clinical characteristics of patients according to
the presence or absence of severe neonatal morbidity.
Fetuses with subsequent development of severe neonatal
morbidity had a lower mean gestational age at admission
and at delivery, shorter procedure-to-delivery intervals,
and a higher proportion of diagnoses of preterm premature rupture of membranes, microbial invasion of the
amniotic cavity, clinical chorioamnionitis, and histologic
chorioamnionitis, as well as a significantly higher concentration of IL-6 in amniotic fluid and fetal plasma
(Table I and Fig 1, A).
Overall, microbial invasion of the amniotic cavity was
present in 26.5% (41/155) of patients. The prevalence of
microbial invasion was 10.7% (11/103) in patients with
preterm labor and intact membranes and 57.7% (30/52)
in patients with preterm premature rupture of membranes (P < .005). The most common microbial isolates
were Ureaplasma urealyticum (n = 29), Mycoplasma hominis
(n = 10), Fusobacterium species (n = 4), and Streptococcus
viridans (n = 4). Other microorganisms included
Streptococcus agalactiae, Gardnerella vaginalis, Haemophilus
influenzae, Peptostreptococcus, Prevotella, and Candida albicans. Histologic evidence of chorioamnionitis was present in 35.8% (19/53) and 65.9% (27/41) of available
placentas from patients with preterm labor and preterm
premature rupture of membranes, respectively (P < .01).
Fifteen patients had a positive amniotic fluid Gram stain,
and the infants of all of these patients were delivered
within 25 hours of amniocentesis. Nine deliveries were
spontaneous and 6 were either induced or augmented or
the patients underwent cesarean section.
Receiver operating characteristic curve analysis for the
relationship between fetal plasma IL-6 and severe neonatal morbidity. To preserve a meaningful temporal relationship between the results of fetal plasma IL-6 concentrations and the occurrence of severe neonatal
morbidity, the analysis was restricted to 73 fetuses delivered within 7 days of the cordocentesis who survived.

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Table I. Clinical characteristics of patients according to occurrence of severe neonatal morbidity*

Severe neonatal morbidity
Characteristic
Maternal age (y, mean SD)
Gestational age at admission (wk, mean SD)
Procedure-to-delivery interval (d)
Median
Range
Gestational age at delivery (wk, mean SD)
Preterm delivery (<37 wk)
Diagnosis at admission
Preterm labor
Preterm premature rupture of membranes
Positive amniotic fluid culture
Clinical chorioamnionitis
Histologic chorioamnionitis
Amniotic fluid IL-6 concentration (ng/mL)
Median
Range
Fetal plasma IL-6 concentration (pg/mL)
Median
Range

Present (n = 54)

Absent (n = 101)

Statistical significance

24.1 5.9
27.9 3.6

24.6 5.5
31.8 2.2

NS
P < .05
P < .005

1.6
0-141
29.3 3.7
53 (98.1%)

21
0-86
35.1 2.6
71 (70.3%)

P < .005
P < .05

24 (44.4%)
30 (55.6%)
29 (53.7%)
10 (18.5%)
32/45 (71%)

79 (78.2%)
22 (21.8%)
12 (11.9%)
5 (4.9%)
14/49 (28.6%)

P < .05
P < .005
P < .05
P < .005

11.9
0.005-99.5

0.9
0.06-64.3

P < .005

14.0
0.5-900

5.2
0.3-900

P < .005

*Two perinatal deaths were excluded from analysis.

Wilcoxon test for censored data.
Analysis restricted to 129 patients with fluid available.

The prevalence of severe neonatal morbid events in this

subset was 53.4% (39/73). Receiver operating characteristic curve analysis demonstrated that a value of 11
pg/mL was located close to the knee of the curve and
therefore was used to define the presence of a systemic
inflammatory response in the fetus (Fig 2). A separate
population of 29 fetuses undergoing diagnostic cordocentesis who subsequently had normal pregnancy outcomes was used to determine the reference range for
fetal plasma IL-6 throughout gestation. Fetal plasma IL-6
concentrations were mean 4.4 pg/mL, median 3.4
pg/mL, and SD 3 pg/mL. The 2 SD above the mean in
this control population coincided with the cutoff of 11
pg/mL obtained with receiver operating characteristic
curve analysis in our study population.
The prevalence of a fetal plasma IL-6 value >11 pg/mL
was 49.3% (36/73). Specifically, this condition occurred
with a frequency of 50% (21/42) in patients with
preterm premature rupture of membranes and 48.4%
(15/31) in patients with preterm labor and intact membranes. Fetuses who had subsequent development of
neonatal morbidity had higher concentrations of plasma
IL-6 than did fetuses who did not have complications
during the neonatal period (Fig 1, B). Table II shows the
incidence of severe neonatal complications according to
the presence or absence of a fetal inflammatory response. Overall, fetuses with fetal plasma IL-6 concentrations >11 pg/mL had a higher rate of severe neonatal
morbidity than did those with fetal plasma IL-6 11
pg/mL (77.8% [28/36] vs 29.7% [11/37]; P < .001).

Significant differences were found for respiratory distress

syndrome (63.9% vs 24.3%) and neonatal sepsis (33.3%
vs 8.1%; see Table II). In the 2 cases of perinatal death
that were excluded from analysis in this study, the fetal
plasma IL-6 concentrations were above 100 pg/mL.
Multivariate analysis of the relationship between fetal
plasma IL-6 concentrations and the occurrence of severe
neonatal morbidity. Stepwise logistic regression was used
to adjust for the effect of several explanatory variables on
the occurrence of adverse neonatal outcome in 59 patients with available amniotic fluid results (ie, IL-6 concentrations). Because the effect of gestational age at delivery and fetal plasma IL-6 concentrations on the odds
of development of severe neonatal morbidity was not linear but quadratic, both variables were dichotomized. For
gestational age at delivery, the mean (30.5 weeks) was
used as a cutoff value whereas a fetal plasma IL-6 concentration of 11 pg/mL was selected. The diagnosis at admission of the mother (preterm labor or preterm premature rupture of membranes), presence of clinical
chorioamnionitis, amniotic fluid culture, amniotic fluid
IL-6 results, procedure-to-delivery interval, and gestational age at delivery 30.5 or <30.5 weeks were entered
along with fetal plasma IL-6 results in a stepwise selection
procedure that was based on the maximum partial likelihood estimates (2 log likelihood). Gestational age at delivery and fetal plasma IL-6 concentrations were the only
covariates that remained significantly associated with the
subsequent development of severe neonatal morbidity
(odds ratio 32.8, 95% confidence interval 6.0 to 180.5

198 Gomez et al

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Fig 1. Fetuses with subsequent development of severe neonatal morbidity had higher plasma IL-6 concentrations than
fetuses without severe neonatal morbidity. A, Whole study population: median 14.0 pg/mL, range 0.5 to 900 vs median
5.2 pg/mL, range 0.3 to 900, respectively; P < .005; B, patients delivered within 7 days of cordocentesis: median 20.3
pg/mL [0.5 to 900] vs median 5.3 pg/mL [1.7 to 900], respectively; P < .005).

and odds ratio 4.3, 95% confidence interval 1 to 18.5, respectively). When amniotic fluid IL-6 is excluded and the
analysis is expanded to all 73 patients delivered within 7
days of cordocentesis, logistic regression analysis confirmed that only gestational age at delivery and fetal
plasma IL-6 remained significantly associated with the
subsequent development of severe neonatal morbidity
(odds ratio 21.0, 95% confidence interval 4.9 to 89.8 and
odds ratio 6.0, 95% confidence interval 1.7 to 21.7, re-

spectively). Similarly, when the analysis is restricted to the

patients delivered within 6, 5, 4, 3, 2, or 1 day of amniocentesis or cordocentesis, the contribution of fetal
plasma IL-6 to the occurrence of neonatal morbid events
remained significant. A plot of the predicted probability
that neonatal morbidity will develop according to gestational age at delivery for fetuses with and without a systemic inflammatory response is displayed in Fig 3.
Table III shows the incidence of severe neonatal com-

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Fig 2. Receiver operating characteristic curve analysis for relationship between severe neonatal morbidity and concentrations
of fetal plasma IL-6.

Fig 3. Plot of predicted probability of severe neonatal morbidity

as a function of gestational age at delivery and presence or absence of fetal plasma IL-6 >11 pg/mL.

Table II. Severe neonatal morbidity according to fetal plasma IL-6 concentrations in 73 patients delivered within 7 days
of amniocentesis or cordocentesis
Fetal plasma IL-6
Morbidity
Respiratory distress syndrome
Proved or suspected sepsis
Intraventricular hemorrhage (grades III and IV)
Periventricular leukomalacia
Necrotizing enterocolitis
Bronchopulmonary dysplasia
Overall severe neonatal morbidity

>11 pg/mL (n = 36)

11 pg/mL (n = 37)

Statistical
significance

23 (63.9%)
12 (33.3%)
1 (2.8%)
2 (5.6%)
1 (2.8%)
4 (11%)
28 (77.8%)

9 (24.3%)
3 (8.1%)
4 (10.8%)
1 (2.7%)
2 (5.4%)
2 (5.4%)
11 (29.7%)

P < .005
P < .01
NS
NS
NS
NS
P < .001

plications according to amniotic fluid culture results and

fetal plasma IL-6 concentrations in patients delivered
within 1 week of cordocentesis. The mere presence of microbial invasion of the amniotic cavity was not associated
with an increase in neonatal complications (25.9% vs
40%, groups 1 and 2, Table III). Moreover, among patients with microbial invasion of the amniotic cavity
(groups 2 and 4), the presence of a fetal inflammatory response (group 4) was associated with a significant increase in the rate of neonatal morbidity (from 40%
[4/10] to 84.6% [22/26]; P < .01). Although gestational
age at delivery in group 4 was lower than in group 2 (29.3
vs 31.9 weeks), this difference was not significant.
Table IV displays the different prenatal interventions
performed on patients delivered within 7 days of cordocentesis, according to diagnosis at admission and fetal
plasma IL-6 concentrations. No significant differences
were observed in the frequency of prenatal interventions
including tocolysis, antibiotics, corticosteroids, and indicated delivery for maternal or fetal reasons between patients with and those without fetal inflammatory re-

sponse in both subgroups, patients with preterm premature rupture of membranes and patients with preterm
labor and intact membranes (P > .05 for all comparisons
between patients with and without a fetal inflammatory
response; see Table IV).
Comment
Our results demonstrate that a fetal plasma IL-6 level
above 11 pg/mL is a major independent risk factor for
the subsequent development of severe neonatal morbidity. The prevalence of an elevated fetal plasma IL-6 value
in patients with preterm labor or premature rupture of
membranes delivered within 1 week of cordocentesis was
about 50% for either condition.
Microbial invasion of the amniotic cavity was associated wiith a fetal plasma IL-6 value >11 pg/mL (63.4%
[26/41] vs 14.9% [17/114], for fetuses with and without microbial invasion of the amniotic fluid, respectively; P < .001), suggesting that fetal exposure to microorganisms and their products may result in the
elevation of plasma IL-6 in the fetus. Although 63.4% of

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Am J Obstet Gynecol

Table III. Severe neonatal morbidity according to presence of microbial invasion of amniotic cavity and fetal plasma IL6 concentration in 73 patients delivered within 7 days of amniocentesis or cordocentesis

No.

Severe
neonatal
morbidity (%)

Gestational
age at delivery
(wk, mean SD)

Amniotic
fluid IL-6
(ng/mL, median,
range) (n = 59)

Group 1
Negative amniotic fluid culture
Fetal plasma IL-6 11 pg/mL

27

7 (25.9%)

32.1 3.1

1.2 (0.1-60.7)

Group 2
Positive amniotic fluid culture
Fetal plasma IL-6 11 pg/mL

10

4 (40%)

31.9 2.3

2.0 (0.08-19.8)

Group 3
Negative amniotic fluid culture
Fetal plasma IL-6 >11 pg/mL

10

6 (60%)

30.1 4.9

22.0 (0.5-99.5)

Group 4
Positive amniotic fluid culture
Fetal plasma IL-6 >11 pg/mL

26

22 (84.6%)

29.3 2.9

36.7 (0.5-92.8)

Depiction
of group

Group

White color in fetal or amniotic fluid compartment represents low fetal plasma IL-6 or negative amniotic fluid culture, respectively. Black
area in fetal or amniotic fluid compartment denotes elevated fetal plasma IL-6 or positive amniotic fluid culture, respectively.

Table IV. Prenatal interventions in 73 patients delivered within 7 days of amniocentesis or cordocentesis
Fetal inflammatory response
syndrome in patients
with preterm labor (n = 31)
Intervention
Tocolytics
Antibiotics
Corticosteroids
Censored observations
*Information

Fetal inflammatory response

syndrome in patients with preterm
premature rupture of membranes (n = 42)

Positive

Negative

Positive

Negative

14/15 (93%)
9/15 (60%)
10/15 (67%)
2/15 (13%)

16/16 (100%)
7/16 (44%)
11/16 (69%)
1/16 (6%)

1/21 (5%)
14/20* (70%)
7/21 (33%)
7/21 (33%)

1/21 (5%)
13/21 (62%)
9/21 (43%)
8/21 (38%)

about antibiotic administration could not be ascertained in 1 case.

fetuses with proved microbial invasion of the amniotic

cavity had an elevated fetal plasma IL-6 value, subsequent
microbial cultures obtained during the early neonatal period were positive in only one case. A potential explanation for the failure to recover microorganisms is that prenatal administration of antibiotics occurred in 59.7% of
patients delivered within 1 week of admission (43/72, see
Table IV). Another explanation is the limitation of standard microbiologic techniques in the isolation of microorganisms from neonates. Neonatal cultures for mycoplasmas were not performed in this study. The
likelihood of microbial recovery is a function of the volume and timing of collection of neonatal blood used for
culture. Inasmuch as neonatal bacteremia is unlikely to
be continuous and that chills and fever (clinical indicators of bacteremia used to time blood drawing in adults)
rarely develop in neonates, a random blood culture with
a small blood volume may not be an adequate method to
detect congenital sepsis. Finally, microbial products released after bacterial death (i.e., endotoxin) may be responsible for fetal immune activation but bacteria may

not be recoverable with standard microbiologic techniques.

The hypothesis that exposure of fetal cells to microorganisms may account for the elevated fetal plasma IL-6 in
our study is supported by the observations that cells collected from the umbilical cord blood can produce proinflammatory cytokines in vitro in response to microbial
products.
It is noteworthy that a fetal plasma IL-6 >11 pg/mL was
detected in the absence of microbial invasion of the amniotic cavity in 10 cases (see Table III, group 3). These
patients had a higher rate of neonatal morbidity (although not significantly, 60% vs 25.9%, power [1 ] =
.49) than patients with fetal plasma IL-6 <11 pg/mL
(group 1 in Table III). What is the etiology of the elevated fetal plasma IL-6 in these patients? Other than an
increase in amniotic fluid IL-6 concentrations, evidence
of infection could not be found in most cases; amniotic
fluid cultures were negative, none of the mothers had
clinical chorioamnionitis, and only 1 newborn had suspected sepsis. Of 9 placentas examined, 4 had histologic

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evidence of acute chorioamnionitis. In view of these findings, two explanations must be considered as potential
etiologies: infection that escaped detection (caused by
viruses, Chlamydia, or other fastidious microorganisms)
or a non-infection-related process. The absence of histologic chorioamnionitis in 56% of cases argues in favor of
a noninfectious process in these patients. In adults, other
causes of the systemic inflammatory response syndrome
include trauma, burns, and pancreatitis. Further studies
are required to establish the pathologic process responsible for fetal systemic inflammatory response in the absence of infection. Because fetuses affected by this condition were delivered preterm and had significant neonatal
complications, an elevated fetal plasma IL-6 cannot be
considered to be a benign state.
A major finding of our study is that an elevated fetal
plasma IL-6 was an independent predictor of neonatal
morbid events even after we corrected for gestational age
at birth and other confounders (odds ratio 4.3, 95% confidence interval 1 to 18.5). These findings suggest that
the pathophysiologic derangements responsible for
some neonatal complications traditionally attributed to
immaturity begin before birth. Such an interpretation is
consistent with several recent observations which suggest
that an inflammatory process already present at birth
may mediate short- and long-term complications of prematurity.18, 19 Indeed, neonates born with elevated umbilical cord levels of IL-6 are at risk for the development
of brain white matter lesions20 and congenital neonatal
sepsis.21 Moreover, neonates born to women with elevated amniotic fluid IL-6 and interleukin-8 and histologic
chorioamnionitis are at risk for bronchopulmonary dysplasia.22, 23 Collectively, these findings suggest that fetal
plasma IL-6 elevation is an indicator that the fetus has
been the subject of an insult severe enough to elicit a systemic inflammatory response.
We have proposed that the onset of preterm labor has
survival value and that it is initiated when the intrauterine environment is so hostile that it threatens the survival
of the maternal-fetal pair.24, 25 The evidence presented
herein supports the concept that a systemic fetal inflammatory response may be detected in a population of
women in preterm labor and preterm premature rupture
of membranes. This condition is frequently associated
with microbial invasion of the amniotic cavity, but there
are probably other pathologic conditions yet to be elucidated that are potential causes of this state. An elevated
fetal plasma IL-6, a marker of a systemic fetal inflammatory response, should probably be considered a syndrome (the fetal inflammatory response syndrome) in a
manner similar to hyperglycemia and hypercholesterolemia. Previous studies in which serial ultrasonographic examination of the fetus with preterm premature rupture of membranes was performed suggest that
decreased biophysical activities (fetal breathing move-

ments and gross body movements) were associated with

infection and the onset of spontaneous labor.17 Similarly,
a decrease in breathing movements has been reported in
fetuses during preterm labor and delivery.26
Proinflammatory cytokines such as interleukin-1 and
tumor necrosis factor have direct effects on the central
nervous system, induce somnolence, and thus may decrease gross body movements. Tumor necrosis factor and
interleukin-1induced prostaglandin E biosynthesis can
depress total breathing movements. Therefore a decrease in biophysical activity may be the fetal clinical
manifestation of the fetal inflammatory response syndrome, whereas preterm labor or preterm premature
rupture of membranes (myometrial contractions, cervical dilatation, and membrane and decidual activation
and rupture) would be the maternal counterpart.
Further study is required to determine the natural history, optimal diagnostic workup, and treatment of this
condition. The concept that the fetus of the mother with
preterm labor or preterm premature rupture of membranes may be critically ill calls for a reappraisal of the
current clinical management of these conditions. It remains to be determined whether efforts to prolong intrauterine stay with tocolysis or expectant management
in fetuses with severe subclinical disease is a wise course
of action.
We acknowledge the contribution of Dr Robert Sokol, Dr
David Cotton, Dr Ruben Quintero, Dr Mark Evans, Dr
Mitchell Dombrowski, Dr Yoram Sorokin, Dr Maurizio
Galasso, Dr Karoline Puder, Sandy Field, RN, Carolyn Sudz,
RN, Adriana Soto, RDMS, Mary King, RDMS, Tess Tagle,
RN, and Elisa Walsh, RN, of Wayne State University/the
Detroit Medical Center; Dr John C. Hobbins, Dr E. Albert
Reece, Dr Alan H. DeCherney, Dr Maurice H. Mahoney, Dr
Frederick Naftolin, and Virginia Sabo, RN, of Yale
University; Dr Ivan Rojas, Dr Ernesto Behnke, and Dr
Enrique Oyarzun of the Sotero del Rio Hospital and
Catholic University in Santiago, Chile; Dr Vaclav Insler of
the Ben Gurion University of Israel; and Dr Neil Athayde,
Dr Eli Maymon, and Dr Percy Pacora of the Perinatology
Research Branch of the National Institute of Child Health
and Human Development for their support and advice.
REFERENCES

1. Arias F, Rodriquez L, Rayne S, Kraus F. Maternal placental vasculopathy and injection: two distinct subgroups among patients
with preterm labor and preterm ruptured membranes. Am J
Obstet Gynecol 1993;168:585-91.
2. Duff P, Kopelman J. Subclinical intra-amniotic infection in
asymptomatic patients with refractory preterm labor. Obstet
Gynecol 1987;69:756-9.
3. Romero R, Sirtori M, Oyarzun E, Avila C, Mazor M, Callahan R,
et al. Infection and labor. V. Prevalence, microbiology, and clinical significance of intraamniotic infection in women with
preterm labor and intact membranes. Am J Obstet Gynecol
1989;161:817-24.
4. Romero R, Yoon BH, Mazor M, Gomez R, Diamond MP, Kenney
JS, et al. The diagnostic and prognostic value of amniotic fluid
white blood cell count, glucose, interleukin-6, and Gram stain in

202 Gomez et al

5.
6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

patients with preterm labor and intact membranes. Am J Obstet

Gynecol 1993;169:805-16.
Garite T, Freeman R. Chorioamnionitis in the preterm gestation. Obstet Gynecol 1982;59:539-45.
Romero R, Quintero R, Oyarzun E, Wu YK, Sabo V, Mazor M,
Hobbins JC. lntra-amniotic infection and the onset of labor in
preterm premature rupture of membranes. Am J Obstet
Gynecol 1988;159:661-6.
Feinstein S, Vintzileos A, Lodeiro J, Campbell W, Weinbaum P,
Nochimson DJ. Amniocentesis with premature rupture of membranes. Obstet Gynecol 1986;68:147-52.
Romero R, Yoon BH, Mazor M, Gomez R, Gonzales R, Diamond
MP, et al. A comparative study of the diagnostic performance of
amniotic fluid glucose, white blood cell count, interleukin-6,
and Gram stain in the detection of microbial invasion in patients with preterm premature rupture of membranes. Am J
Obstet Gynecol 1993;169:839-51.
Markenson G, Martin R, Foley K, Yancey M. The use of polymerase chain reaction to detect bacteria in amniotic fluid in
pregnancies complicated by preterm labor [abstract 100]. Am J
Obstet Gynecol 1997;176:S39.
Jalava J, Mantymaa ML, Ekblad U. Bacterial 165 rDNA polymerase chain reaction in the detection of intra-amniotic infection. Br J Obstet Gynaecol 1996;103:664-9.
Gomez R, Romero R, Edwin S, David C. Pathogenesis of
preterm labor and preterm premature rupture of membranes
associated with intraamniotic infection. Infect Dis Clin North
Am 1997;11:135-76.
Rangel-Frausto M, Pittet D, Costigan M, Hwang T, Davis CS,
Wenzel RP. The natural history of the systemic inflammatory response syndrome (SIRS): A prospective study. JAMA
1995;273:117-23.
Romero R, Brody DT, Oyarzun E, Mazor M, Wu YK, Hobbins JC,
et al. Infection and labor. III. Interleukin 1: a signal for the
onset of parturition. Am J Obstet Gynecol 1989;160:1117-23.
Romero R, Gomez R, Ghezzi F, Yoon BH, Mazor M, Edwin SS,
Berry SM. The onset of spontaneous preterm parturition is preceded by an intense pro-inflammatory cytokine response in
human fetus [abstract 8]. Am J Obstet Gynecol 1997;176:S3.
Romero R, Gomez R, Ghezzi F, Yoon BH, Mazor M, Edwin SS, et
al. A fetal systemic inflammatory response is followed by the

July 1998
Am J Obstet Gynecol

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.
26.

spontaneous onset of preterm parturition. Am J Obstet Gynecol

1998;179:186-93.
Nicolaides K, Soothill P, Rodeck C, Campbell S. Ultrasound
guided sampling of umbilical blood and placental blood to assess fetal well being. Lancet 1986;1:1065-7.
Vintzileos A, Campbell W, Nochimson D, Connolly ME, Fuenjer
MM, Hoehn GJ. The fetal biophysical profile in patients with
premature rupture of membranesan early predictor of fetal
infection. Am J Obstet Gynecol 1985;152:510-6.
Verma U, Tejani N, Klein S, Reale M, Beneck D, Figueroa D, et
al. Obstetric antecedents of intraventricular hemorrhage and
periventricular leukomalacia in the low-birth-weight neonate.
Am J Obstet Gynecol 1997;176:275-81.
Rojas M, Gonzalez A, Bancalari E, Claure N, Poole C, Silva-Neto
G. Changing trends in the epidemiology and pathogenesis of
neonatal chronic lung disease. J Pediatr 1995;126:605-10.
Yoon BH, Romero R, Yang SH, Jun JK, Kim IO, Choi JH, et al.
Interleukin-6 concentrations in umbilical cord plasma are elevated in neonates with white matter lesions associated with
periventricular leukomalacia. Am J Obstet Gynecol
1996;174:1433-40.
Buck C, Bundschu J, Gallati H, Bartmann P, Pohlandt F.
Interleukin-6: a sensitive parameter for the early diagnosis of
neonatal bacterial infection. Pediatrics 1994;93:54-8.
Ghezzi F, Gomez R, Romero R, David C, Field S, Edwin SS, et al.
Evidence that the injury responsible for the development of
bronchopulmonary dysplasia may begin in utero [abstract 131].
Am J Obstet Gynecol 1997;176:S47.
Yoon BH, Romero R, Kim CJ, Koo JN, Choe G, Syn HC, et al.
High expression of tumor necrosis factor- and interleukin-6 in
periventricular leukomalacia. Am J Obstet Gynecol
1997;177:406-11.
Romero R, Sepulveda W, Baumann P, Yoon BH, Brandt F,
Gomez R, et al. The preterm labor syndrome: biochemical, cytologic, immunologic, pathologic, microbiologic, and clinical
evidence that preterm labor is a heterogeneous disease [abstract
9]. Am J Obstet Gynecol 1993;168:288.
Romero R, Mazor M, Munoz H, Gomez R, Galasso M, Sherer D.
The preterm labor syndrome. Ann N Y Acad Sci 1994;734:414-29.
Vintzileos A, Campbell W, Rodis J. Fetal biophysical profile scoring: current status. Clin Perinatol 1989;16:661-89.