[Clinical study on dinoprostone suppositories 0.8 mm used in cervical ripening and labor induction of women with term pregnancy of premature rupture of the membranes: a multicenter study]

OBJECTIVE

To investigate safety and efficacy of dinoprostone suppositories (0.8 mm) used in cervical ripening and labor induction in women with term premature rupture of the membranes.

METHODS

One hundred women of term monocyesis with premature rupture of the membranes, head presentation, bishop score less than 6 (test group) and 180 women with intact fetal membranes (control group) were enrolled into this multicenter, prospective clinical study. The vaginal delivery system was inserted into the posterior fornix, and the patients were recumbent for 2 hours after insertion. The interval time from using dinoprostone suppositories to uterine contraction, to labor and delivery were recorded. The following index were also recorded and compared, including the mean inserted time of dinoprostone suppositories, fetal heart beat, meconium stained amniotic fluid, hyperstimulation of uterus and the other complications, mode of delivery, stage of labor, postpartum hemorrhage, status of neonates.

RESULTS

Three cases in test group and 23 cases in control group weren't in labor within 24 hours. The rate of labor within 24 hours in test group was significant higher than that in control group (97.0% vs. 87.2%, P < 0.01). It was observed that 73 cases undergoing vaginal deliveries (75.3%, 73/97) and 24 cases undergoing cesarean section deliveries (24.7%, 24/97)in test group and 107 cases undergoing vaginal delivery (68.2%, 107/157) and 50 cases undergoing cesarean section delivery (31.8%, 50/157) in control group, when compared the rate of vaginal or cesarean section deliveries between two group, it didn't reach statistical difference (P > 0.05). It had no significant difference in the interval time from using dinoprostone suppositories to labor starting and the mean inserted time and the total labor time between two groups (P > 0.05). The incidence of uterine tachysystole was 11.3% (11/97) in test group and 19.1% (30/157) in control group (P > 0.05), which did not reach statistical difference (P > 0.05). There wasn't neonatal asphyxia in both groups.

CONCLUSION

It was safe and efficient to use dinoprostone suppositories for cervical ripening and induction of term pregnancy with premature rupture of the membranes, however, monitoring should be intensified.

Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation

BACKGROUND

Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established.

OBJECTIVES

To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010) and the reference lists of all the identified articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction.

MAIN RESULTS

We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05). There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is a moderate heterogeneity for this outcome (I(2) = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs.

AUTHORS' CONCLUSIONS

The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.

Transabdominal amnioinfusion in preterm premature rupture of membranes

OBJECTIVE

To evaluate the effect of transabdominal amnioinfusion on prolongation of pregnancy, and maternal and neonatal outcomes in preterm premature rupture of membranes (pPROM).

METHODS

We conducted a prospective randomized controlled study of women with pPROM during singleton live pregnancy-between 26 and 33+6weeks-whose amniotic fluid index (AFI) was less than the 5th percentile. The study group underwent transabdominal amnioinfusion at admission and then weekly if their AFI fell below the 5th percentile again. The control group received expectant management.

RESULTS

The difference in the mean interval from pPROM to delivery between the groups was not statistically significant. Neonatal and maternal outcomes were significantly improved in the study group compared with the control group (fetal distress [10% vs 37%]; early neonatal sepsis [17% vs 63%]; neonatal mortality [17% vs 63%]; spontaneous delivery [83% vs 53%]; and postpartum sepsis [7% vs 33%]).

CONCLUSION

Transabdominal amnioinfusion reduced fetal distress, early neonatal sepsis, and neonatal mortality. In the study group, more participants delivered spontaneously and there were fewer cases of postpartum sepsis, although the pPROM-delivery interval was not increased.

Foetomaternal outcome in patients with or without premature rupture of membranes

BACKGROUND

Preterm premature rupture of membranes is responsible for one third of all preterm births and is associated with significant maternal, foetal and neonatal risks. The objectives were to compare the foeto-maternal outcome in patient with and without preterm premature rupture of membranes.

METHOD

This prospective comparative study was conducted in Gynae-C Unit of Ayub Teaching Hospital from Sep 2005 to Mar 2006. Total 170 cases were recruited in the study out of which 85 had Preterm Premature Rupture of Membranes (PPROM), and 85 had preterm labour without PROM. Patients' data were recorded on a performa. Maternal outcome was measured on the basis of presence of fever and mode of delivery. Foetal outcome was measured on the basis of weight of the baby, and presence of infection (fever), APGAR score and neonatal death. Analysis was performed using SPSS-10.

RESULTS

The primary data arranged in groups was divided into PPROM and no-PPROM groups. The PPROM was found to be frequent in younger age group between 15-25 years while no-PPROM was common among the age group between 26-35 years (p = 0.002). Lower socioeconomic class and history of previous one or more preterm delivery was significantly associated with PPROM (p = 0.001). Maternal fever was also significant in the PPROM group (p = 0.01). Low birth weight was statistically significant in the PPROM group. Majority of the babies born to mother were either extremely low birth weight or low birth weight, i.e., between 1-25 kg (p = 0.005). Low APGAR score at the time of delivery (p = 0.01) and foetal infection (p = 0.002) between the PROM and no-PPROM group was found to be statistically significant Neo-natal deaths was also higher in the PPROM group as compared to no PPROM group (11 verses 2) (p = 0.009).

CONCLUSION

In our study premature rupture of membrane had increased neonatal morbidity and mortality as compared to preterm birth. Strategies should be developed for its prevention.

Latency and infectious complications after preterm premature rupture of membranes: impact of body mass index

OBJECTIVE

Obesity has been associated with chronic inflammation. We hypothesized that body mass index may be inversely related to latency and directly related to infectious complications after preterm premature rupture of membranes.

STUDY DESIGN

This secondary analysis of a randomized trial of antibiotics for preterm premature rupture of membranes had information available for 562 subjects. We analyzed the association between body mass index and latency, the occurrence of chorioamnionitis, endometritis, and maternal infectious morbidity after controlling for gestational age at rupture and treatment group. Survival analysis, regression, and test of proportions were used as appropriate.

RESULTS

When evaluated as a categorical or continuous variable, body mass index did not reveal any significant associations. Latency to delivery was affected by gestational age at rupture of membrane and antibiotic therapy but not by body mass index group.

CONCLUSION

Body mass index was not associated with latency or the occurrence of maternal infectious complications during conservative management of premature rupture of membranes before 32 weeks' gestation.

Antenatal day care units versus hospital admission for women with complicated pregnancy

BACKGROUND

Antenatal day care units have been widely used as an alternative to inpatient care for women with pregnancy complications including mild and moderate hypertension, and preterm prelabour rupture of the membranes.

OBJECTIVES

The objective of this review is to compare day care units with routine care or hospital admission for women with pregnancy complications in terms of maternal and perinatal outcomes, length of hospital stay, acceptability, and costs to women and health services providers.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2009).

SELECTION CRITERIA

Randomised controlled trials comparing day care with inpatient or routine care for women with complicated pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out data extraction and assessed studies for risk of bias.

MAIN RESULTS

Three trials with a total of 504 women were included. For most outcomes it was not possible to pool results from trials in meta-analyses as outcomes were measured in different ways.Compared with women in the ward/routine care group, women attending day care units were less likely to be admitted to hospital overnight (risk ratio 0.46, 95% confidence interval 0.34 to 0.62). The average length of antenatal admission was shorter for women attending for day care, although outpatient attendances were increased for this group. There was evidence from one study that women attending for day care were significantly less likely to undergo induction of labour, but mode of birth was similar for women in both groups. For other outcomes there were no significant differences between groups.The evidence regarding the costs of different types of care was mixed; while the length of antenatal hospital stays were reduced, this did not necessarily translate into reduced health service costs.While most women tended to be satisfied with whatever care they received, women preferred day care compared with hospital admission.

AUTHORS' CONCLUSIONS

Small studies suggest that there are no major differences in clinical outcomes for mothers or babies between antenatal day units or hospital admission, but women may prefer day care.

A novel method for collecting vaginal pool for fetal lung maturity studies

OBJECTIVE

Fetal lung maturity (FLM) studies using vaginal pool can guide management in near-term gestations with rupture of membranes. Because an adequate sample may be difficult to collect using a syringe, we tested collection using a sterile sponge.

STUDY DESIGN

In this prospective study, vaginal pool was collected via both a syringe and a sponge from each gravida. Study patients experienced rupture of membranes between 34-41 weeks of gestation. Each sample was analyzed using the TDx-FLM II assay and phosphatidylglycerol (PG) testing.

RESULTS

Fifty patients were enrolled; 44 demonstrated concordant syringe/sponge results. There was 1 instance of mature TDx-FLM testing using a sponge but not a syringe; PG testing in this case was absent in both samples. Using the kappa statistic, agreement between the methods was "substantial" for TDx-FLM and "almost perfect" for PG.

CONCLUSION

Collecting vaginal pool with a sponge may provide clinically useful information, particularly when PG is present.

Prevention of PPROM: Current and future strategies

Our understanding of the pathophysiologic processes leading to preterm premature rupture of membranes (PPROM) has grown tremendously in recent years. Evidence suggests that there may be a genetic susceptibility to PPROM and that genetic and environmental elements are important cofactors in its development. A number of risk-based protocols have been proposed in an attempt to identify those women at highest risk for PPROM. While we have made advances in the area of predicting PPROM, treatments based on current risk-based systems have failed to distinguish a specific, effective preventive therapy for PPROM. The concept that genetic factors increase susceptibility or decrease resistance to disease has stimulated new work in the field of PPROM. Several maternal and fetal gene polymorphisms have been identified that are associated with an increased risk for PPROM. Patients with 'susceptible' genotypes may also have clinical risk factors for PPROM resulting in a synergistic increase in the risk for PPROM, a so-called gene-environment interaction. The concept that these gene-environment interactions represent new targets for our efforts to prevent PPROM is explored.

A prospective randomized study comparing misoprostol and oxytocin for premature rupture of membranes at term

OBJECTIVE

The aim of this randomized trial was to compare the efficacy and safety of vaginal misoprostol and oxytocin for cervical ripening and labor induction in patients with premature rupture of membrane (PROM) at term.

METHODS

Ninety-seven women with PROM at term were assigned randomly to receive intravaginal misoprostol or oxytocin. The primary outcome measure was the induction-delivery interval. Secondary outcomes included the number of women who delivered vaginally within 12 hours of the start of the induction in the two groups, the cesarean, hyperstimulation, and failed induction rates, the mode of delivery, and the neonatal outcome.

RESULTS

Forty-eight women were assigned to intravaginal misoprostol and 49 to oxytocin administration. The mean interval from induction to delivery was 10.61 +/- 2.45 hours in the misoprostol group and 11.57 +/- 1.91 hours in the oxytocin group (p = 0.063). The rates of vaginal delivery were 83.3% and 87.7% and cesarean delivery were 16.7% and 8.2% in the misoprostol and oxytocin groups, respectively. Neonatal outcomes were not significantly different. Of the cases, 8.3% in the misoprostol group and 8.2% in the oxytocin group revealed uterine contraction abnormalities.

CONCLUSION

Our study demonstrates that, intravaginally, misoprostol results in a similar interval from induction of labor to delivery when compared to oxytocin.

Prenatal and perinatal management of preterm labour

New knowledge of the pathophysiology of premature birth enables us to introduce new approaches in prenatal care as well as the management of premature delivery. These apply for the patients with subclinical risk factors, particularly with thrombophilias, chronic infections or other latent chronic infections. The peri- and pre-conceptional dispensarisation of these women might help reduce the development of premature delivery. Secondary prevention with the administration of gestagens is highly important for women with anamnestic or existing risk of premature delivery. During the underlying premature delivery, it is advisable to re-evaluate the significance of the administration of antibiotics and tocolytics as well as timing of corticoid dosage in the induction of foetal lung maturity. Using new diagnostic and therapeutic methods, the aim of present premature delivery management is to prolong the duration of pregnancy to the maximum with the lowest risk of the development of foetal inflammatory response possible and, therefore, with a low risk of long-term handicaps in children.

Clinical management of intra-amniotic infection and chorioamnionitis: a review of the literature

Intra-amniotic infection (IAI), or chorioamnionitis, complicates up to 10% of all pregnancies and up to 2% of labors at term. There is a significant risk of complications for the mother and the neonate following IAI, including sepsis and pneumonia. In addition, there is a correlation between IAI and premature rupture of membranes, preterm premature rupture of membranes, preterm labor, and preterm birth. Research in the last decade has also revealed a complex and significant association between IAI and cerebral palsy and other central nervous system damage in both the preterm and term fetus. Timely diagnosis and treatment of IAI can significantly reduce the risk of both maternal and neonatal complications.

Salvaging twin 2 after abortion of twin 1: a case report

We present intentional delayed delivery of twin 2 after a spontaneous membrane rupture and abortion oftwin1 in a dichorionic twin pregnancy at 14 weeks. As signs of infection were missing, we adopted a conservative (not expectant) management. The pregnancy was prolonged to 35 weeks' gestation. In the absence of additional risk factors, the role of conservative management of multiple pregnancies after loss of one fetus in prolonging the pregnancy to fetal viability in resource-poor setting is highlighted. The gained gestational age of 20 weeks and 4 days (144 days in all), for the remaining fetus and the healthy mother and child pair after delivery at 35 weeks are discussed. The perinatal, economic and psychological implications are highlighted. The importance of good clinical assessment in the diagnosis of cervical incompetence and using ultrasound scan as a complimentary instrument is emphasized.

Perinatal infections: the obstetrician's viewpoint

The obstetrician's role is to recognize and treat maternal systemic infections which may spread transplacentally to the fetus, and to ensure that the lower genital tract is kept free from pathogenic organisms, particularly during the last trimester of pregnancy. In some cases the obstetrician can reduce the likelihood of premature rupture of the membranes by inserting a cervical suture. Where this has not been possible conservative management should be used to keep the fetus in utero before the 34th week and more active after this time. In trapartum infections can be reduced to a minimum by keeping the membranes intact during early labour, by the aggressive use of uterine stimulants to avoid prolonged labour, by exerting extreme care to avoid sepsis during pelvic examinations and internal monitoring, and by earlier use of Caesarean section.

Prevalance of PPROM and its outcome

BACKGROUND

Prematurity is the leading cause of perinatal morbidity and mortality in developed as well as in underdeveloped countries. In one third of the patients with preterm labour there is associated premature rupture of membranes. This prospective observational study was carried out in Ayub Teaching Hospital to determine the prevalence of preterm premature rupture of membrane (PPROM) and its association with the demographic risk factors and its outcome.

METHOD

There were 889 deliveries in Gynaecology 'C' unit from September 2005 to March 2006. Out of these, 85 patients were confirmed to have PPROM. Detail history and examination along with the demographic risk factors were recorded on a performa. Every patient was followed till her delivery and the mode of delivery and maternal and foetal outcome was recorded.

RESULT

Prevalence of PPROM in this study was 16%. It was seen to be common among patients who were young (15-25 years) 58.8%, with low socioeconomic status (68.2%), and with an educational status of primary to middle (71.7%). Risk of PPROM was seen to be highest among patients giving birth to their first child (42.2%), with gestational age between 30-35 weeks (43.5% cases) and 35-37 weeks (35.2%). In 69.4% cases there was no previous history of preterm deliveries while in 30.6% cases, there were one, two, or more previous preterm deliveries. Normal vaginal delivery occurred in (65.86%), while instrumental delivery rate in PPROM was 20% and caesarean section rate was 14%. Postnatally 16.47% patients developed infection while 24 (28.2%) babies developed infection and required antibiotics. Majority of babies born to patients with PPROM were low birth weight (62.3%), and 30.5% babies required neonatal intensive care. Perinatal mortality rate was 129.9/1000 (13%) of total births.

CONCLUSION

PPROM is an important cause of preterm birth, resulting in large number of babies with low birth weight, requiring neonatal intensive care. It is associated with increased foetal morbidity and mortality. Demographic variables can be applied to develop risk scoring so as to identify high-risk cases and treating them in time to prevent ascending infection along with its complications.

Temporary Fetoscopic Tracheal Balloon Occlusion Enhanced by Hyperoncotic Lung Distension: Is There a Role in the Treatment of Fetal Pulmonary Hypoplasia from Early Preterm Premature Rupture of Membranes?

OBJECTIVES

To assess the effect of fetoscopic tracheal occlusion (FETO) enhanced by hyperoncotic distension on pulmonary hypoplasia from preterm premature rupture of membranes prior to 22 weeks of gestation (ePPROM).

METHODS AND RESULTS

In a fetus with ePPROM since 19+5 weeks of gestation, MRI at 28+2 weeks provided a lung volume of 10 ml. FETO enhanced by hyperoncotic distension was performed at 28+3 weeks. After 4-5 days, balloon dislodgement was observed. The lung volume increased to 18 ml. The baby was born at 32+4 weeks and survived to discharge.

CONCLUSIONS

FETO enhanced by hyperoncotic distension may result in impressive lung distension in fetuses with pulmonary hypoplasia from ePPROM. Further research into the life saving potential of this strategy for this common and tragic gestational event is desired.