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Wilson I, Henry A, Hinch E, Meriki N, Challis D, Smoleniec J, Welsh AW. Audit of immediate outcomes for MCDA twins following laser therapy for twin-twin transfusion syndrome at the NSW Fetal Therapy Centre. Aust N Z J Obstet Gynaecol 2016; 56:289-94. [PMID: 27029675 DOI: 10.1111/ajo.12464] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 03/03/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To audit immediate pregnancy and neonatal outcomes of selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS) at the New South Wales Fetal Therapy Centre. METHODS Retrospective cohort study of 151 TTTS cases undergoing SLPCV between July 2003 and May 2013, evaluating procedural details, delivery and perinatal outcomes. RESULTS The majority of cases were Stage III at SLPCV (56.9%), although proportion of Stage II SLPCV increased over time (P = 0.03). Survival to hospital discharge of at least one baby was 85.6% and dual survival was 52.5%. Median gestational age at delivery was 32.6 weeks (IQR 29.0-35.0 weeks) with a median of 11.4 weeks (IQR 8.3-14.7) from laser to delivery. Median birthweight was 1792 g (IQR 1288-2233 g), with 75% of babies admitted to the nursery, predominantly secondary to prematurity. Immediate SLPCV complications were in utero fetal demise <1 week postprocedure in 27 fetuses (19.6%) and/or ruptured membranes <1 week postprocedure in 9 fetuses (6.6%). CONCLUSIONS This Australian series shows that local outcomes after SLPCV for stages II-IV TTTS remain equal to the international published literature and have remained stable after an initial learning curve. Women were more likely to be Stage II rather than III in the more recent years. However, this does not appear to be attributable to altered referral patterns.
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Affiliation(s)
- Isabella Wilson
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Amanda Henry
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Maternal Fetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia.,Women's and Children's Health, St George Hospital, Sydney, New South Wales, Australia
| | - Ellen Hinch
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Neama Meriki
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Obstetrics & Gynaecology, King Saud Hospital, Riyadh, Saudi Arabia
| | - Daniel Challis
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - John Smoleniec
- Department of Maternal-Fetal Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Alec William Welsh
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Maternal Fetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
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Lucewicz A, Fisher K, Henry A, Welsh AW. Review of the correlation between blood flow velocity and polycythemia in the fetus, neonate and adult: appropriate diagnostic levels need to be determined for twin anemia-polycythemia sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:152-157. [PMID: 25580896 DOI: 10.1002/uog.14782] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/01/2014] [Accepted: 01/02/2015] [Indexed: 06/04/2023]
Abstract
Twin anemia-polycythemia sequence (TAPS) is recognized increasingly antenatally by the demonstration of an anemic twin and a polycythemic cotwin using the middle cerebral artery peak systolic velocity (MCA-PSV). While the MCA-PSV has been shown to correlate well with anemia in singleton fetuses, the evidence to support its use to diagnose fetal polycythemia appears to be less clear-cut. We aimed to evaluate fetal, neonatal and adult literature used to support the use of MCA-PSV for the diagnosis of polycythemia. Comprehensive literature searches were performed for ultrasound evidence of polycythemia in the human fetus, neonate and adult using key search terms. Only manuscripts in the English language with an abstract were considered for the review, performed in June 2014. Fifteen manuscripts were found for the human fetus, including 38 cases of TAPS. Nine of these defined fetal polycythemia as MCA-PSV < 0.8 multiples of the median (MoM), five used < 1.0 MoM and one used 0.8-1.0 MoM. Only two studies, involving a total of 15 cases, proposed a diagnostic level, acknowledging false-positive and -negative cases, though neither reported sensitivities or specificities. Six neonatal studies (96 neonates) demonstrated evidence of decreased cerebral velocities in polycythemia and a consequent increase with hemodilution. In the adult, five studies (57 polycythemic adults) demonstrated increased flow or velocity with hemodilution. Neither neonatal nor adult studies conclusively defined levels for screening for polycythemia. Despite widespread adoption of a cut-off of < 0.8 MoM in the published literature for the polycythemic fetus in TAPS, this is based upon minimal evidence, with unknown sensitivity and specificity. We recommend caution in excluding TAPS based purely upon the absence of a reduced MCA-PSV.
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Affiliation(s)
- A Lucewicz
- Department of Obstetrics & Gynaecology, Westmead Hospital, Westmead, NSW, Australia
| | - K Fisher
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - A Henry
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
- Department of Obstetrics and Gynaecology, St George Hospital, Kogarah, NSW, Australia
- Australian Centre for Perinatal Science, University of New South Wales, Randwick, NSW, Australia
- Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia
| | - A W Welsh
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
- Australian Centre for Perinatal Science, University of New South Wales, Randwick, NSW, Australia
- Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia
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Kim SH, Jung E, Lee MY, Lee BS, Won HS, Kim EAR, Kim KS. The Impact of Introduction of Fetoscopic Laser Surgery on Twin-to-Twin Transfusion Syndrome. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.4.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Soo Hyun Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euiseok Jung
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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van Klink JM, Slaghekke F, Balestriero MA, Scelsa B, Introvini P, Rustico M, Faiola S, Rijken M, Koopman HM, Middeldorp JM, Oepkes D, Lopriore E. Neurodevelopmental outcome at 2 years in twin-twin transfusion syndrome survivors randomized for the Solomon trial. Am J Obstet Gynecol 2016; 214:113.e1-7. [PMID: 26297943 DOI: 10.1016/j.ajog.2015.08.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/06/2015] [Accepted: 08/12/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The preferred treatment for twin-twin transfusion syndrome is fetoscopic laser coagulation of inter-twin vascular anastomoses on the monochorionic placenta. Severe postoperative complications can occur when inter-twin vascular anastomoses remain patent including twin-anemia polycythemia sequence or recurrent twin-twin transfusion syndrome. To minimize the occurrence of residual anastomoses, a modified laser surgery technique, the Solomon technique, was developed in which the entire vascular equator is coagulated. In the Solomon randomized controlled trial (NTR1245), the Solomon technique was associated with a significant reduction in twin-anemia polycythemia sequence and recurrence of twin-twin transfusion syndrome when compared with the standard laser surgery technique. Although a significant improvement in perinatal outcome was shown after the Solomon technique, the clinical importance should also be ascertained with long-term follow-up evaluation of the surviving children. OBJECTIVE The purpose of this study was to compare the long-term neurodevelopmental outcome in surviving children with twin-twin transfusion syndrome who were included in the Solomon randomized trial and treated with either the Solomon technique or standard laser surgery technique. STUDY DESIGN Routine standardized follow-up evaluation in survivors, at least 2 years after the estimated date of delivery, was performed at 2 of the 5 centers that participated in the Solomon trial: Buzzi Hospital Milan (Italy) and Leiden University Medical Center (The Netherlands). The primary outcome of this follow-up study was survival without long-term neurodevelopmental impairment at age 2 years. Neurodevelopmental impairment was defined as cerebral palsy, cognitive and/or motor development score of <85, bilateral blindness, or deafness. Cognitive and motor development was evaluated with the use of Bayley-III. All analyses per fetus, neonate, or child were conducted with the generalized estimated equation module to account for the effect that observations between co-twins are not independent. RESULTS The primary outcome (survival without neurodevelopmental impairment) was detected in 95 of 141 cases (67%) in the Solomon group and in 99 of 146 cases (68%) in the standard group (P = .92). Neurodevelopmental impairment in long-term survivors who were included for follow-up evaluation was detected in 12 of 107 cases (11%) in the Solomon and in 10 of 109 cases (9%) in the standard group (P = .61). Neurodevelopmental impairment was due to cerebral palsy in 1 case (1%; spastic unilateral) in the Solomon group and in 2 cases (2%; spastic unilateral and spastic bilateral) in the standard group (P = .58). Cognitive development <85 cases was detected in 2 of 105 children (2%) in the Solomon group and in 6 of 106 children (6%) in the standard group (P = .23). Motor development <85 occurred in 8 of 103 children (8%) in the Solomon group and 3 of 104 children (3%) in the standard group (P = .23). CONCLUSION We found no difference in survival without neurodevelopmental impairment between the Solomon and standard laser techniques. In view of the reduction of short-term complications and the absence of increased adverse long-term effects, these data support the use of the Solomon technique in the treatment of twin-twin transfusion syndrome.
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55
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Color-dye injection of monochorionic placentas and correlation with pregnancy complications. Placenta 2015; 36:1095-9. [DOI: 10.1016/j.placenta.2015.07.129] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/20/2015] [Accepted: 07/22/2015] [Indexed: 11/22/2022]
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56
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Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. Pediatr Res 2015; 78:247-55. [PMID: 26020146 DOI: 10.1038/pr.2015.105] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/27/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preterm premature rupture of membranes remains a major complication after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). We studied the histologic changes of fetal membranes post-FLS and investigated a possible impact of amniotic fluid (AF) dilution. METHODS Fetal membranes of 31 pregnancies that underwent FLS for TTTS were investigated histologically at delivery at different sites: trocar site of recipient sac and at distance, donor sac, and inter-twin membrane. RESULTS The trocar insertion site on the recipient sac showed no signs of histologic hallmarks of healing. Wide-spread alteration in collagen organization and higher apoptotic index in the amnion of the recipient sac which were absent in donor's and reference membranes. To explain the mechanisms, we analyzed the AF composition of recipient sacs from TTTS pregnancies vs. GA-matched healthy singleton controls and found glucose, protein and lactate dehydrogenase activity were all significantly lower in TTTS sacs consistent with over-dilution of recipient's AF (~2-fold). In-vitro exposure of healthy amniochorion to analogous dilutional stress conditions recapitulated the histologic changes and induced apoptosis and autophagy. CONCLUSION Alteration in structural integrity of the recipient's amniochorion, possibly in response to dilution stress, along with ineffective repair mechanisms may explain the increased incidence of preterm birth post-FLS.
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Müllers SM, McAuliffe FM, Kent E, Carroll S, Mone F, Breslin N, Dalrymple J, Mulcahy C, O'Donoghue K, Martin A, Malone FD. Outcome following selective fetoscopic laser ablation for twin to twin transfusion syndrome: an 8 year national collaborative experience. Eur J Obstet Gynecol Reprod Biol 2015; 191:125-9. [PMID: 26117441 DOI: 10.1016/j.ejogrb.2015.05.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/01/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE With the recognition of the role of fetoscopic laser ablation for twin to twin transfusion syndrome (TTTS), there is a requirement for auditable standards for this technically challenging and specialized treatment. The purpose of this study is to report on the perinatal and medium-term neurodevelopmental outcomes following an 8-year national single center experience in the management of TTTS using the selective fetoscopic laser ablation technique. STUDY DESIGN An audit of all cases of TTTS treated with selective laser ablation by a single national fetal medicine team was performed. Overall perinatal survival and medium-term neurodevelopmental outcomes were reported and correlated with gestational age at diagnosis, placental location, volume of amnio-reduction, Quintero staging and percentage inter-twin growth discordance. Procedure-related complications were recorded. RESULTS The overall fetal survival for the first 105 consecutive cases of TTTS was 61% (128/210 fetuses). Dual survival occurred in 47% (49/105) of cases, and with a single survival rate of 28% (30/105), perinatal survival of least one infant was achieved in 75% (79/105) of cases. No correlation was found between any clinical or sonographic marker and perinatal outcome, although dual survival was noted to be significantly decreased with increasing Quintero stage (p=0.041). Currently, 86% of survivors have been reported to have a normal medium-term neurological outcome. CONCLUSION Fetoscopic laser ablation is the established optimal treatment for severe twin to twin transfusion syndrome (TTTS). We report comparable short and medium-term outcomes following the selective fetoscopic technique comparing results from our national program with internationally published single-center outcomes, supporting the efficacy and safety of this treatment at our center.
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Affiliation(s)
- Sieglinde M Müllers
- Obstetrics & Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Fionnuala M McAuliffe
- UCD Obstetrics & Gynecology, School of Medicine and Medical Science, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Etaoin Kent
- Obstetrics & Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stephen Carroll
- Obstetrics & Gynecology, National Maternity Hospital, Dublin, Ireland
| | - Fionnuala Mone
- Obstetrics & Gynecology, National Maternity Hospital, Dublin, Ireland
| | - Noelle Breslin
- Obstetrics & Gynecology, Rotunda Hospital, Dublin, Ireland
| | - Jane Dalrymple
- Obstetrics & Gynecology, Rotunda Hospital, Dublin, Ireland
| | - Cecelia Mulcahy
- Obstetrics & Gynecology, National Maternity Hospital, Dublin, Ireland
| | - Keelin O'Donoghue
- Obstetrics & Gynecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Aisling Martin
- Obstetrics and Gynecology, The Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Fergal D Malone
- Obstetrics & Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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Long-term neurologic outcomes after common fetal interventions. Am J Obstet Gynecol 2015; 212:527.e1-9. [PMID: 25448510 DOI: 10.1016/j.ajog.2014.10.1092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/06/2014] [Accepted: 10/28/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Fetal interventions have clearly decreased mortality, but the neurological outcomes of survivors are of critical concern. Here we consolidated available data on long-term neurological outcomes after common fetal interventions to guide counseling, management, and future research. STUDY DESIGN Published studies assessing long-term neurological outcomes after common fetal interventions from 1990 through 2014 were collected. We included all studies with a cohort of more than 5 patients and with follow-up of 1 year or longer. We divided procedures into those performed for singletons and for multiples. Singleton procedures included amnioinfusion for preterm premature rupture of membranes, intrauterine transfusion for red cell alloimmunization-associated anemia, intrauterine transfusion for parvovirus-associated anemia, vesicoamniotic shunts, thoracoamniotic shunts, ventriculoamniotic shunts, fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia, and open fetal cases by myelomeningocele and others. Multiple procedures included those done for monochorionic twins including serial amnioreduction, selective fetoscopic laser photocoagulation, and selective termination. RESULTS Of 1341 studies identified, 28 met the inclusion criteria. We combined available literature for all procedures. Studies varied in their length of follow-up and method of assessing neurological status. Neurological outcome after intervention varied by procedure but was normal in 40-93%, mildly impaired in 3-33%, and severely impaired in 1-40%. Follow-up to school age was rare with the exception of procedures for monochorionic twins. CONCLUSION Fetal treatments have been successful in achieving survival in previously hopeless cases, but success should also be determined by the outcomes of survivors. Except for monochorionic twins, there is a dearth of reported long-term outcomes. Standardized reporting of long-term neurological sequelae is imperative so that meaningful analysis and study comparisons can be made.
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Van Winden KR, Quintero RA, Kontopoulos EV, Korst LM, Llanes A, Chmait RH. Pre-Operative Twin Anemia/Polycythemia in the Setting of Twin-Twin Transfusion Syndrome (TTTS). Fetal Diagn Ther 2015; 37:274-80. [DOI: 10.1159/000365919] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 07/07/2014] [Indexed: 11/19/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS) are classified as distinct clinical disorders associated with unbalanced blood flow through placental vascular communications. Typically, TAPS placentas demonstrate few <1 mm arteriovenous (AV) communications, and at fetoscopy the twins are visibly pale and plethoric. Materials and Methods: In a cohort of TTTS patients who underwent laser surgery, those with preoperative findings suggestive of anemia/polycythemia (AP) were compared to those with TTTS alone. AP was defined as middle cerebral artery peak systolic velocity in one twin >1.5 multiples of the median (MoM), and <1.0 MoM in the other. Results: Of 369 TTTS patients, 9 (2.4%) met criteria for preoperative AP. The mean number (±SD) of AV communications in the TTTS + AP group was 5.6 ± 5.7, compared with 8.8 ± 4.8 in the TTTS-alone group (p = 0.013). Five TTTS + AP patients (56%) had a few thin AV communications (mean 2.8 ± 1.6); all 5 had visibly pale and plethoric twins. The remaining 4 (44%) had large or numerous anastomoses (mean 10.5 ± 6.8); none had fetal skin color discordance. Discussion: Preoperative AP affected 2% of TTTS patients. Of these, approximately half had placental and skin color findings typically reported with isolated TAPS.
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Faas BH, Ghidini A, Van Mieghem T, Chitty LS, Deprest J, Bianchi DW. In case you missed it: thePrenatal Diagnosiseditors bring you the most significant advances of 2014. Prenat Diagn 2015; 35:29-34. [DOI: 10.1002/pd.4551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Brigitte H. Faas
- Department of Human Genetics; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Alessandro Ghidini
- Obstetrics and Gynecology; Georgetown University Hospital; Washington DC USA
| | - Tim Van Mieghem
- Obstetrics and Gynaecology; University Hospitals Leuven; Leuven Belgium
- Academic Department Development and Regeneration; Biomedical Sciences; KU Leuven Leuven Belgium
| | - Lyn S. Chitty
- UCL Institute of Child Health; Great Ormond Street Hospital for Children and UCLH NHS Foundation Trusts; London England UK
| | - Jan Deprest
- Obstetrics and Gynaecology; University Hospitals Leuven; Leuven Belgium
- Academic Department Development and Regeneration; Biomedical Sciences; KU Leuven Leuven Belgium
| | - Diana W. Bianchi
- Mother Infant Research Institute; Tufts Medical Center; Boston MA USA
- Floating Hospital for Children; Boston MA USA
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Maggio L, Carr SR, Watson-Smith D, OʼBrien BM, Lopes V, Muratore CS, Luks FI. Iatrogenic Preterm Premature Rupture of Membranes after Fetoscopic Laser Ablative Surgery. Fetal Diagn Ther 2014; 38:29-34. [DOI: 10.1159/000369250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/20/2014] [Indexed: 11/19/2022]
Abstract
Introduction: To describe the incidence and risk factors for iatrogenic premature preterm rupture of membranes (iPPROM) after fetoscopic laser surgery for the twin-to-twin-transfusion syndrome. Materials and Methods: This is a retrospective review of all patients who have undergone fetoscopic laser surgery at a single fetal treatment center since 2000. We defined iPPROM as spontaneous rupture of membranes before the onset of labor prior to 34 weeks of gestation. The iPPROM cohort was compared to the cohort without iPPROM for several preoperative, operative, and delivery characteristics. Results: Ninety-two consecutive patients were reviewed. The overall rate of iPPROM was 18.5% (n = 17). The rates of iPPROM within 1 and 4 weeks were 5.4 and 10.9%, respectively. The median interval from surgery to delivery was significantly shorter in the iPPROM group (21 vs. 62 days, p = 0.01). The mean gestational age at delivery (27.0 vs. 31.1 weeks, p = 0.02) was lower in the iPPROM group. No other characteristics studied differed significantly between the groups. Discussion: The incidence of iPPROM was substantially lower than in recent multicenter reports; however, no risk factors of iPPROM could be identified. Whether this is related to variations in surgical or anesthetic management will require further investigation.
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