A United States Army Medical Department continuing education program. The 24th Annual Armed Forces Seminar on Obstetrics and Gynecology. Does amniotic fluid analysis predict infection associated with internal fetal monitoring with Howard M list major M C. United States Army O B G Y N Department, Walter Reed, army Medical Center, Washington D C. The use of the intra uterine fetal monitor has become an accepted procedure for the evaluation of the high risk fetus and obstetrical patient. At this time, studies have produced conflicting results on the risk of infection with internal fetal monitoring. Two retrospective studies reported no increased infection but one prospective study reported that prolonged internal fetal monitoring was associated with a high rate of infection in patients with more than eight hours of ruptured membranes in labor. This study also suggested that polymorphic nuclear neutrophils in the amniotic fluid correlated to a high degree with intra uterine infection. The purpose of the present study was to evaluate the amniotic fluid obtained through an intra uterine pressure catheter in order to determine the value of polly's or bacteria in predicting clinically evident infection. 150 for specimens of amniotic fluid were collected by syringe aspiration via the internal fetal monitor, pressure catheter on 101 patients and were examined by gram stain and right stain. In addition, 53 samples from the 1st 30 patients were cultured for Aerobic and Anaerobic bacteria. three Sham cultures were done as well. Patient selection was neither random nor consecutive with respect to polly's specimens were classified as having none, less than one poly or more than one per oil immersion. Field specimens with clumps of white cells were placed in the last category. Gram stain specimens were classified as to the presence or absence of bacteria. Amniotic fluid collected during normal duty hours was immediately transported to the bacteriology lab. And semi quantitative aerobic and anaerobic cultures were immediately carried out on these specimens. Specimens collected during non duty hours were placed in a diabolical a broth and incubated on the labor floor until they were processed in the laboratory. The gas pack system was utilized for anaerobic culturing. Identification of microorganisms was carried out by standard methods And the notice was defined as a temperature of greater than or equal to 100.4°F in a patient in labor, in the presence of fetal tachycardia and or uterine tenderness with no other apparent source of infection. Endometriosis was defined as a temperature of greater than or equal to 100.4°F in a postpartum patient on any two days of hospitalization, exclusive of the 1st 24 hours in the presence of uterine tenderness and no other obvious source of fever. In addition, an elevated temperature in the presence of uterine tenderness in a patient in whom antibiotic therapy was initiated was accepted as meeting the criteria for endometriosis. If there was no other apparent source of infection, may I have the first slide please? Of 101 patients from whom amniotic fluid specimens were obtained. Seven or 6.9% met the criteria for infection Of these 74 were monitored for less than eight hours and three were monitored for greater than eight hours. The rate of infection for all patients with less than eight hours of monitoring was 5.1%. While the rate of infection for all patients monitored for more than eight hours was 13%. These groups however, were not statistically different when utilizing eight hours as the arbitrary borderline by high square analysis. One of six patients who delivered by cesarean section became infected. May I have the next slide. The average duration of fetal monitoring was 5.9 hours. The range was 0.5-29 hours. The average duration of ruptured membranes was 8.6 hours and the average duration of labor was 10.6 hours. Comparison of infected and non infected patients with respect to average length of monitoring, ruptured membranes and labor revealed that in all cases, the average number of hours for these parameters was greater in the infected patients than in the non infected patients. However, again, these groups were not statistically different, primarily due to the large range of, of the values of hours of membranes being ruptured and so on. Uh from a total of 154 specimens collected 40 or 26% were positive for polymorphic nuclear neutrophils and 71 or 46% were positive for bacteria on gram stain. May I have the next slide of the 33 patients Who had the 40 amniotic fluid specimens positive for one or more polymorphic nuclear neutrophils for oil field, only four or 12% became infected. Even of the 10 patients with one or more poly per oil field who were monitored for more than eight hours, only one or 10% became infected Of the 37 patients who had multiple amniotic fluid specimens aspirated 18 showed a progression of the number of polly's with each specimen while 10 showed no change and nine showed diminution in the number of polly's per oilfield. May I have the next slide, please? Here we see one of the oil fields on a patient that uh showed numerous clumps of polymorphic nuclear neutrophils. However, she did not meet uh clinical or federal morbidity criteria for for infection. May I see the next slide here again is another one showing a large number of clumps of polly's. May I have the next slide please? Of the 49 patients who had amniotic fluid which was positive for bacteria. On gram stain, only four or 8% showed clinical evidence of infection. One of nine patients who had positive gram stains and was monitored for more than eight hours became infected. May I have the next slide please? There were two patients who became infected who showed neither policies nor bacteria in their amniotic fluid specimens. However, in both of these cases, the only specimen collected was at the time of insertion of the fetal monitor. May I have the next slide please? Of the specimens which were cultured microorganisms were grown in 88%. The most common organisms were aerobic gram positive cox I of which staff epidermal tous viridian streptococcus, E and anaerobic oxide predominated group B streptococcus E were found in 7% of specimens. Gram negative Arabs were found in 12% with E coli being the most common. May I have the next slide please? Utilizing the gas pack system. Aerobic organisms mostly grand positive were recovered in 35% of specimens. Three sham cultures were sterile. The present study shows that in general patients with greater than one polymorphic nuclear neutrophils per oilfield were at greater risk for intra uterine infection. However, of 33 patients with greater than one poly per oilfield, only 12% developed clinical evidence of inter uterine infection even among 10 patients with greater than eight hours of internal monitoring and greater than one poly per oilfield. The infection rate was 10% in the overwhelming majority of cases with greater than one polyp for oil field and or bacterial growth in the amniotic fluid and our presence of bacteria on gram stain. The hospital course was uneventful. Thus, it appears that the analysis of amniotic fluid for the presence of white blood cells and bacteria is not valuable and prospectively determining which patients will be more likely to develop purple infection. Thank you. This program was produced through the mobile facilities of the television branch, Health Sciences, media division, Academy of Health Sciences, United States Army, Fort Sam Houston, Texas.