Amniotic Sludge and Prematurity: Systematic Review and Meta-analysis

Abstract

Objective To perform a systematic review and meta-analysis of studies on maternal, fetal, and neonatal outcomes of women with singleton pregnancies, after spontaneous conception, and with the diagnosis of amniotic sludge before 37 weeks of gestational age.

Data Sources We conducted a search on the PubMed, Cochrane, Bireme, and Theses databases until June 2022.

Selection of Studies Using the keywords intra-amniotic sludge or fluid sludge or echogenic particles, we found 263 articles, 132 of which were duplicates, and 70 were discarded because they did not meet the inclusion criteria.

Data Collection The articles retrieved were analyzed by 2 reviewers; 61 were selected for full-text analysis, 18 were included for a qualitative analysis, and 14, for a quantitative analysis.

Data Synthesis Among the maternal outcomes analyzed, there was an increased risk of preterm labor (95% confidence interval [95%CI]: 1.45–2.03), premature rupture of ovular membranes (95%CI: 1.99–3.79), and clinical (95%CI: 1.41–6.19) and histological chorioamnionitis (95%CI: 1.75–3.12). Regarding the fetal outcomes, there was a significant increase in the risk of morbidity (95%CI: 1.80–3.17), mortality (95%CI: 1.14–18.57), admission to the Neonatal Intensive Care Unit (NICU; 95%CI: 1.17–1.95), and neonatal sepsis (95%CI: 2.29–7.55).

Conclusion The results of the present study indicate that the presence of amniotic sludge is a risk marker for preterm delivery. Despite the heterogeneity of the studies analyzed, even in patients with other risk factors for prematurity, such as short cervix and previous preterm delivery, the presence of amniotic sludge increases the risk of premature labor. Moreover, antibiotic therapy seems to be a treatment for amniotic sludge, and it may prolong pregnancy.

Resumo

Objetivo Realizar revisão sistemática e metanálise de estudos que avaliaram os desfechos maternos, fetais e neonatais em gestantes de gravidez única, após concepção espontânea, e com o diagnóstico de sludge amniótico antes de 37 semanas de idade gestacional.

Fontes dos dados Realizou-se uma pesquisa nas bases de dados PubMed, Cochrane, Bireme e Teses até junho de 2022.

Seleção dos estudos Usando as palavras-chave intra-amniotic sludge ou fluid sludge ou echogenic particles, foram encontrados 263 artigos, 132 dos quais eram duplicatas, e 70 foram descartados por não corresponderem aos critérios de inclusão.

Coleta de dados Os artigos encontrados foram analisados por 2 revisores; 61 foram selecionados para análise de texto completo, 18 foram incluídos em uma análise qualitativa e 14, em uma análise quantitativa.

Síntese dos dados Entre os desfechos maternos analisados, houve aumento do risco de trabalho de parto prematuro (intervalo de confiança de 95% [IC95%]: 1.45–2.03), rotura prematura de membranas ovulares (IC95%: 1.99–3.79), e corioamnionite clínica (IC95%: 1.41–6.19) e histológica (IC95%: 1.75–3.12). Em relação aos desfechos fetais, houve aumento significativo do risco de morbidade (IC95%: 1.80–3.17), mortalidade (IC95%: 1.14–18.57), admissão em Unidade de Tratamento Intensivo (UTI) neonatal (IC95%: 1.17–1.95) e sepse neonatal (IC95%: 2.29–7.55).

Conclusão Os resultados do presente estudo indicam que a presença de sludge amniótico é um marcador de risco para parto prematuro. Apesar da heterogeneidade dos estudos analisados, até mesmo em pacientes com outros fatores de risco para prematuridade, como colo curto e trabalho de parto prematuro anterior, a presença de sludge amniótico aumenta o risco de trabalho de parto prematuro na gestação. Além do mais, a antibioticoterapia parece ser um tratamento para o sludge amniótico, e pode ser capaz de prolongar a gravidez.

Keywords

sludge - prematurity - amniotic fluid

Palavras-chave

sludge - prematuridade - líquido amniótico

Publication History

Received: 06 October 2022

Accepted: 20 January 2023

Article published online:
08 September 2023

• References

• 1 Blencowe H, Cousens S, Chou D, Oestergaard M, Say L, Moller AB. et al; Born Too Soon Preterm Birth Action Group. Born too soon: the global epidemiology of 15 million preterm births. Reprod Health 2013; 10 (Suppl 1, Suppl 1) S2
• 2 Tedesco RP, Passini Jr R, Cecatti JG, Camargo RS, Pacagnella RC, Sousa MH. Estimation of preterm birth rate, associated factors and maternal morbidity from a demographic and health survey in Brazil. Matern Child Health J 2013; 17 (09) 1638-1647
• 3 Quinn JA, Munoz FM, Gonik B, Frau L, Cutland C, Mallett-Moore T. et al; Brighton Collaboration Preterm Birth Working Group. Preterm birth: Case definition & guidelines for data collection, analysis, and presentation of immunisation safety data. Vaccine 2016; 34 (49) 6047-6056
• 4 Bazacliu C, Neu J. Necrotizing enterocolitis: long term complications. Curr Pediatr Rev 2019; 15 (02) 115-124
• 5 Niesłuchowska-Hoxha A, Cnota W, Czuba B, Ruci A, Ciaciura-Jarno M, Jagielska A. et al. A Retrospective Study on the Risk of Respiratory Distress Syndrome in Singleton Pregnancies with Preterm Premature Rupture of Membranes between 24+0 and 36+6 Weeks, Using Regression Analysis for Various Factors. BioMed Res Int 2018; 2018: 7162478-8
• 6 Silva AAM, Carvalho CA, Bettiol H, Goldani MZ, Lamy Filho F, Lamy ZC. et al. Mean birth weight among term newborns: direction, magnitude and associated factors. Cad Saude Publica. 2020; 36 (04) e00099419 . Available from: < https://doi.org/10.1590/0102-311X200099419 >. Epub 06 Apr 2020. ISSN 1678–4464. https://doi.org/10.1590/0102-311X200099419
• 7 Lamont RF. Spontaneous preterm labour that leads to preterm birth: An update and personal reflection. 2019; 79: 21-9
• 8 Brown R, Gagnon R, Delisle MF. No. 373-cervical insufficiency and cervical cerclage. J Obstet Gynaecol Can 2019; 41 (02) 233-247
• 9 Tedesco RP, Galvão RB, Guida JP, Passini-Júnior R, Lajos GJ, Nomura ML. et al; Group Brazilian Multicentre Study on Preterm Birth Study. The role of maternal infection in preterm birth: evidence from the Brazilian Multicentre Study on Preterm Birth (EMIP). Clinics (São Paulo) 2020; 75: e1508
• 10 Barinov SV, Artymuk NV, Novikova ON, Shamina IV, Tirskaya YI, Belinina AA. et al. Analysis of risk factors and predictors of pregnancy loss and strategies for the management of cervical insufficiency in pregnant women at a high risk of preterm birth. J Matern Fetal Neonatal Med 2021; 34 (13) 2071-2079
• 11 Care AG, Sharp AN, Lane S, Roberts D, Watkins L, Alfirevic Z. Predicting preterm birth in women with previous preterm birth and cervical length ≥ 25 mm. Ultrasound Obstet Gynecol 2014; 43 (06) 681-686
• 12 Mella MT, Berghella V. Prediction of preterm birth: cervical sonography. Semin Perinatol 2009; 33 (05) 317-324
• 13 Buyuk GN, Oskovi-Kaplan ZA, Kahyaoglu S, Engin-Ustun Y. Echogenic particles in the amniotic fluid of term low-risk pregnant women: does it have a clinical significance?. J Obstet Gynaecol 2021; 41 (07) 1048-1052
• 14 Ventura W, Nazario C, Ingar J, Huertas E, Limay O, Castillo W. Risk of impending preterm delivery associated with the presence of amniotic fluid sludge in women in preterm labor with intact membranes. Fetal Diagn Ther 2011; 30 (02) 116-121
• 15 Romero R, Schaudinn C, Kusanovic JP, Gorur A, Gotsch F, Webster P. et al. Detection of a microbial biofilm in intraamniotic infection. Am J Obstet Gynecol 2008; 198 (01) 135.e1-135.e5
• 16 Adanir I, Ozyuncu O, Gokmen Karasu AF, Onderoglu LS. Amniotic fluid “sludge”; prevalence and clinical significance of it in asymptomatic patients at high risk for spontaneous preterm delivery. J Matern Fetal Neonatal Med 2018; 31 (02) 135-140
• 17 Bujold E, Morency AM, Rallu F, Ferland S, Tétu A, Duperron L. et al. Bacteriology of amniotic fluid in women with suspected cervical insufficiency. J Obstet Gynaecol Can 2008; 30 (10) 882-887
• 18 Espinoza J, Gonçalves LF, Romero R, Nien JK, Stites S, Kim YM. et al. The prevalence and clinical significance of amniotic fluid ‘sludge’ in patients with preterm labor and intact membranes. Ultrasound Obstet Gynecol 2005; 25 (04) 346-352
• 19 Gorski LA, Huang WH, Iriye BK, Hancock J. Clinical implication of intra-amniotic sludge on ultrasound in patients with cervical cerclage. Ultrasound Obstet Gynecol 2010; 36 (04) 482-485
• 20 Hatanaka AR, Mattar R, Kawanami T, França MS, Rolo LC, Nomura RM. et al. Clinical significance of the presence of amniotic fluid'sludge'in asymptomatic patients at low and high risk for spontaneous preterm delivery. Ultrasound Obstet Gynecol 2014; 44 (S1): 16-6
• 21 Himaya E, Rhalmi N, Girard M, Tétu A, Desgagné J, Abdous B. et al. Midtrimester intra-amniotic sludge and the risk of spontaneous preterm birth. Am J Perinatol 2011; 28 (10) 815-820
• 22 Huang Y, Liang X, Liao J, Li Y, Chen Z. Relationship of Amniotic Fluid Sludge and Short Cervix With a High Rate of Preterm Birth in Women After Cervical Cerclage. J Ultrasound Med 2022; 41 (11) 2687-2693
• 23 Kovavisarach E, Jongfuangprinya K. Prevalence of Amniotic Fluid Sludge in Low-Risk Pregnant Women of Preterm Delivery. J Med Assoc Thai 2019; 102 (05) 4–0
• 24 Kusanovic JP, Espinoza J, Romero R, Gonçalves LF, Nien JK, Soto E. et al. Clinical significance of the presence of amniotic fluid ‘sludge’ in asymptomatic patients at high risk for spontaneous preterm delivery. Ultrasound Obstet Gynecol 2007; 30 (05) 706-714
• 25 Saade GR, Thom EA, Grobman WA, Iams JD, Mercer BM, Reddy UM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (MFMU) Network. Cervical funneling or intra-amniotic debris and preterm birth in nulliparous women with midtrimester cervical length less than 30 mm. Ultrasound Obstet Gynecol 2018; 52 (06) 757-762
• 26 Ting YH, Lao TT, Law LW, Hui SYA, Chor CM, Lau TK, Leung TY. Arabin cerclage pessary in the management of cervical insufficiency. J Matern Fetal Neonatal Med 2012; 25 (12) 2693-2695
• 27 Tsunoda Y, Fukami T, Yoneyama K, Kawabata I, Takeshita T. The presence of amniotic fluid sludge in pregnant women with a short cervix: an independent risk of preterm delivery. J Matern Fetal Neonatal Med 2020; 33 (06) 920-923
• 28 Vaisbuch E, Hassan SS, Mazaki-Tovi S, Nhan-Chang CL, Kusanovic JP, Chaiworapongsa T. et al. Patients with an asymptomatic short cervix (<or=15 mm) have a high rate of subclinical intraamniotic inflammation: implications for patient counseling. Am J Obstet Gynecol 2010; 202 (05) 433.e1-433.e8
• 29 Yasuda S, Tanaka M, Kyozuka H, Suzuki S, Yamaguchi A, Nomura Y, Fujimori K. Association of amniotic fluid sludge with preterm labor and histologic chorioamnionitis in pregnant Japanese women with intact membranes: A retrospective study. J Obstet Gynaecol Res 2020; 46 (01) 87-92
• 30 Cuff RD, Carter E, Taam R, Bruner E, Patwardhan S, Newman RB. et al. Effect of Antibiotic Treatment of Amniotic Fluid Sludge. Am J Obstet Gynecol MFM 2020; 2 (01) 100073-3
• 31 Hatanaka AR, Franca MS, Hamamoto TENK, Rolo LC, Mattar R, Moron AF. Antibiotic treatment for patients with amniotic fluid “sludge” to prevent spontaneous preterm birth: A historically controlled observational study. Acta Obstet Gynecol Scand 2019; 98 (09) 1157-1163
• 32 Jin WH, Ha Kim Y, Kim JW, Kim TY, Kim A, Yang Y. Antibiotic treatment of amniotic fluid “sludge” in patients during the second or third trimester with uterine contraction. Int J Gynaecol Obstet 2021; 153 (01) 119-124
• 33 Pustotina O. Effects of antibiotic therapy in women with the amniotic fluid “sludge” at 15-24 weeks of gestation on pregnancy outcomes. J Matern Fetal Neonatal Med 2020; 33 (17) 3016-3027
• 34 Rust O, Atlas R, Rawlinson K, Gaalen JV, Balducci J. Sonographic description of the cervix at risk for preterm birth. Am J Obstet Gynecol 2001; 184: S41
• 35 Romero R, Kusanovic JP, Espinoza J, Gotsch F, Nhan-Chang CL, Erez O. et al. What is amniotic fluid ‘sludge’?. Ultrasound Obstet Gynecol 2007; 30 (05) 793-798
• 36 Iams JD, Romero R, Culhane JF, Goldenberg RL. Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth. Lancet 2008; 371 (9607) 164-175
• 37 Kyozuka H, Murata T, Fukuda T, Suzuki E, Yazawa R, Yasuda S. et al. Labor dystocia and risk of histological chorioamnionitis and funisitis: a study from a single tertiary referral center. BMC Pregnancy Childbirth 2021; 21 (01) 263
• 38 De La Cochetière MF, Durand T, Lepage P, Bourreille A, Galmiche JP, Doré J. Resilience of the dominant human fecal microbiota upon short-course antibiotic challenge. J Clin Microbiol 2005; 43 (11) 5588-5592