Practice bulletins No. 139: premature rupture of membranes

Maternal serum advanced glycation end products level as an early marker for predicting preterm labor/PPROM: a prospective preliminary study

OBJECTIVE

To evaluate the value of maternal serum advanced glycation end products (AGEs) level at 11-13 weeks' gestation for the prediction of preterm labor and or preterm premature rupture of membranes (PPROM).

MATERIALS AND METHODS

This prospective cross-sectional study is performed in a university-affiliated hospital between February and April 2016. The participants of this study are low-risk pregnant women. Blood samples for maternal AGEs level were collected in the first trimester of pregnancy and all women completed their antenatal follow-up and delivered in our center. During the follow-up 21 women developed preterm labor/PPROM. The first trimester maternal AGEs levels of preterm labor/PPROM cases were compared with uncomplicated cases (n = 25) matched for age-parity and BMI. The predictive value of AGEs levels for preterm labor/PPROM was also assessed.

RESULTS

First-trimester AGEs levels were significantly higher in cases complicated with preterm labor/PPROM (1832 (415-6682) versus 1276 (466-6445) ng/L, p = .001 and 1722 (804-6682) versus 1343 (466-6445) ng/L, p = .025). According to receiver-operating characteristic curve analysis, the calculated cut off value of AGEs was 1538 ng/L with the sensitivity 91.7%, specificity 73.8%; and the negative and positive predictive values were 91.6% and 29.5%, respectively.

CONCLUSIONS

For the prediction of preterm labor/PPROM, the relatively high AGEs levels in the first trimester might be a useful marker.

Management of premature rupture of membranes at term: the need to correct a recurring mistake in articles, chapters, and recommendations of professional organizations

Recommendations about the management of premature rupture of membranes at term are based, in part, on a large, randomized controlled trial published in 1996: the TERMPROM trial. The original article contained an error in Table 1, in which "Interval from membrane rupture to delivery" was listed instead of "Interval from membrane rupture to study entry." While the authors and journal corrected this error, the mistake published in the original paper has made its way into subsequent publications and even in guidelines or practice bulletins issued by professional organizations, textbooks, and other publications around the world. The mistake, that half of women with premature rupture of membranes at term who were managed expectantly delivered within 5 hours and 95% delivered within 28 hours of membrane rupture, should be replaced with the actual fact that half of women with premature rupture of membranes at term who were managed expectantly delivered within 33 hours, and 95% delivered within 94-107 hours of membrane rupture. Correcting this error in contemporary health care information and publications is important to counsel patients accurately and to optimize the clinical care of women with premature rupture of membranes at term.

Childhood outcomes following preterm prelabor rupture of the membranes (PPROM): a population-based record linkage cohort study

OBJECTIVE

The objective of this study is to determine child health, development and educational outcomes for infants born following preterm prelabor rupture of the membrane (PPROM).

STUDY DESIGN

Population-based record linkage cohort study using data from NSW, Australia, 2001 to 2014.

RESULTS

Of 121 822 births at 20 to 37 weeks, 18 799 (15%) followed PPROM, 56 406 (46%) followed spontaneous labor and 46 617 (38%) were planned. Compared with infants of a similar gestational age born following spontaneous labor or planned delivery, exposure to PPROM did not increase the risk of childhood mortality, childhood hospitalization, developmentally vulnerable at school entry, low reading or numeracy scores. Median latency ranged from 12 days (interquartile range 3 to 37 days) at 25 weeks to 1 day (0 to 2 days) at 36 weeks. Longer latency and more advanced gestational age at birth were associated with better outcomes.

CONCLUSION

Infants born following PPROM are at no greater risk of adverse child health, development and education outcomes than those of similar gestational age born without PPROM.

Chorioamnionitis following preterm premature rupture of membranes and fetal heart rate variability

Introduction

The objective of this study was to identify prenatal markers of histological chorioamnionitis (HC) during pPROM using fetal computerized cardiotocography (cCTG).

Materials and methods

Retrospective review of medical records from pregnant women referred for pPROM between 26 and 34 weeks, in whom placental histology was available, in a tertiary level obstetric service over a 5-year period. Fetal heart rate variability was assessed using cCTG. Patients were included if they were monitored at least six times in the 72 hours preceding delivery. Clinical and biological cCTG parameters during the pPROM latency period were compared between cases with or without HC.

Results

In total, 222 pPROM cases were observed, but cCTG data was available in only 23 of these cases (10 with and 13 without HC) after exclusion of co-morbidities which may potentially perturb fetal heart rate variability measures. Groups were comparable for maternal age, parity, gestational age at pPROM, pPROM duration and neonatal characteristics (p>0.1). Baseline fetal heart rate was higher in the HC group [median 147.3 bpm IQR (144.2–149.2) vs. 141.3 bpm (137.1–145.4) in no HC group; p = 0.02]. The number of low variation episodes [6.4, (3.5–15.3) vs. 2.3 (1–5.2); p = 0.04] was also higher in the HC group, whereas short term variations were lower in the HC group [7.1 ms (6–7.4) vs. 8.1 ms (7.4–9); p = 0.01] within 72 hours before delivery. Differences were especially discriminant within 24 hours before delivery, with less short-term variation [5 ms (3.7–5.9) vs. 7.8 ms (5.4–8.7); p = 0.007] and high variation episodes [3.9 (4.9–3.2) vs. 0.8 (1.5–0.2); p < 0.001] in the HC group.

Conclusion

These results show differences in fetal heart rate variability, suggesting that cCTG could be used clinically to diagnoses chorioamnionitis during the pPROM latency period.

Comparison of rapid immunoassays for rupture of fetal membranes

Background

Rupture of membranes (ROM) before the onset of uterine contractions, particularly in pregnancies less than 37 weeks gestational age, is a common diagnostic problem in obstetrical practice. Timely detection of ROM is vital to support gestational age-specific interventions to optimize perinatal outcomes and minimize the risk of serious complications such as preterm delivery, fetal distress and maternal/fetal infections. Rapid bedside immunoassay tests designed to detect amniotic fluid proteins in cervicovaginal fluids have emerged as valuable clinical tools to provide timely ROM diagnosis.

Methods

In this prospective observational study, two commercially-available immunoassay tests (ROM Plus®, AmniSure®) were evaluated concurrently in 111 pregnant women who presented with the chief complaint of ROM. Immunoassay results were compared to clinical parameters for determining ROM via comprehensive, retrospective clinical chart review. Diagnostic performance characteristics were calculated including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy.

Results

Overall, diagnostic performance characteristics were robust and similar between ROM Plus® and AmniSure®, respectively: sensitivity (96.4 and 89.3%), specificity (98.8 and 100%), PPV (96.4 and 100%), NPV (98.8% and 96.5) and accuracy (98.2 and 97.3%). For term patients (≥37 weeks gestation), the sensitivities were 93.8 and 81.3% and specificities were 97.1 and 100% for ROM Plus® and AmniSure®, respectively. For preterm patients (<37 weeks gestation), both immunoassay tests provided exact concordance with clinical confirmation of ROM resulting in 100% diagnostic accuracy.

Conclusions

Both rapid immunoassay tests provided similarly excellent diagnostic accuracy for the rapid detection of ROM with only two discrepant results for ROM Plus® and three discrepant results for AmniSure® compared to clinical confirmation. The findings from this study recommend these tests for pregnant women presenting with suspected ROM to guide correct clinical management decisions to improve obstetrical and neonatal outcomes.

Trial registration

ClinicalTrials.gov, NCT02208011 (1 August 2014).

A retrospective cohort study of hospital versus home care for pregnant women with preterm prelabor rupture of membranes

OBJECTIVE

To compare maternal and neonatal outcomes between in-hospital management and prepartum care at home (PCAH) among women with preterm prelabor rupture of membranes (PPROM) before 34 weeks of pregnancy.

METHODS

In a retrospective study, data were analyzed from women who experienced PPROM between 23 and 34 weeks of pregnancy, and received care from two hospitals in British Columbia, Canada, between April 2007 and March 2012. Women were included if they had been stable in hospital for at least 72 hours and met eligibility criteria for PCAH. Management of PPROM differs at the centers: at one, women are monitored in hospital, whereas PCAH is used at the other. Outcomes were compared between management strategies. Logistic regression was used to assess severe maternal morbidity and neonatal morbidity/mortality after adjustment for pregnancy length at PPROM.

RESULTS

Among 176 included women, 87 received PCAH and 89 were managed in hospital. There was no difference in severe maternal morbidity (adjusted odds ratio [aOR] 0.64, 95% confidence interval [CI] 0.35-1.17) or neonatal morbidity/mortality (aOR 0.63, 95% CI 0.31-1.30). Latency increased and length of stay decreased with PCAH (P<0.001 for both).

CONCLUSION

Maternal and newborn outcomes were similar between women who received PCAH and those who were managed in hospital. The reduced resource use in PCAH might lead to cost savings without compromising outcomes.

Evaluation of perinatal outcomes in pregnant women with preterm premature rupture of membranes

OBJECTIVE

To determine the association between amniotic fluid index (AFI) and perinatal outcomes in preterm premature rupture of membranes (PPROM).

METHOD

A retrospective cohort study was conducted between 2008 and 2012. 86 pregnant women were included, with a diagnosis of PPROM and gestational age from 24 to 35 weeks. Women who presented hypertensive disorders, diabetes, fetuses with birth defects and infection at admission were excluded. To determine the association between AFI and perinatal outcomes, chi-square and Fisher's exact test were used if necessary, as well as risk ratio (RR) and 95% confidence intervals (95CI). Correlation between AFI and perinatal outcomes was determined by using simple linear regression, and AFI progression during pregnancy was analyzed by Z-test.

RESULTS

When comparing newborns presenting ultrasound with AFI<5cm and AFI>5cm, there was a higher frequency of perinatal mortality when the AFI was lower than 5 cm. However, when the oligohydramnios was diagnosed as severe (AFI<3cm), there was a higher frequency of Apgar scores less than seven at 1 minute, neonatal sepsis and early neonatal mortality compared to those presenting AFI>3cm. There was a positive correlation between AFI and gestational age at delivery, birth weight and Apgar scores at minutes 1 and 5. There was also a decrease in amniotic fluid volume with increased gestational age.

CONCLUSION

The presence of severe oligohydramnios after PPROM contributed to a higher frequency of perinatal complications and death.

Premature rupture of the membranes at term: time to reevaluate the management

PURPOSE

To compare maternal and neonatal outcomes in induced vs. expectant management of term PROM.

METHODS

This retrospective study included patients with term PROM. A total of 325 were enrolled: 213 managed expectantly and 112 induced at admission and matched according to gestational age. Expectant management group patients were allowed to defer labour induction up to 48 h. Primary outcome measures were maternal or foetal signs of infection (chorioamnionitis, early neonatal sepsis or postpartum endometritis) and prolonged maternal hospitalization. Secondary outcome was caesarean delivery rate.

RESULTS

All group characteristics were comparable except that expectant management included more nulliparous women. Women managed expectantly had a higher rate of prolonged hospitalization [15 (7 %) vs. 2 (1.8 %); P = 0.043] as an indication of maternal complications, compared to induction management. They also had a higher rate of caesarean delivery [34 (16.4 %) vs. 8 (7.1 %), respectively; P = 0.024]. Adjustment for parity did not change the results. Early neonatal outcomes were similar between groups.

CONCLUSIONS

Expectant management increases the likelihood of caesarean delivery and prolonged maternal hospitalization. This should be considered when advising patients with term PROM regarding labour induction.

Conservative Management and Planned Surgery for Periviable Advanced Extrauterine Abdominal Pregnancy with Favorable Outcome: Report of Two Cases

Advanced abdominal pregnancy is an extremely rare condition that poses diagnostic and management challenges. A high index of suspicion and careful assessment of the patient's symptoms, supplemented with obstetric ultrasound, and magnetic resonance imaging, are crucial for timely diagnosis and management to prevent life-threatening complications. The presence of periviable fetuses in advanced abdominal pregnancies increases the challenge to achieve a balance between maternal and fetal benefits and risks. Early diagnosis and management decisions via a multidisciplinary approach and planned delivery are of paramount importance to minimize complications and achieve favorable maternal and fetal outcomes. Even in the setting of oligohydramnios and suspected preterm premature rupture of membranes, in-patient conservative management and an individualized planned surgical approach that includes removing or leaving the placenta in place are appropriate for managing the periviable abdominal pregnancy.

Prolonged latency of preterm premature rupture of membranes and risk of neonatal sepsis

BACKGROUND

Preterm premature rupture of membranes (PPROM) is associated with inflammation and infection, and it may involve the loss of a barrier to ascending infection from the vagina, and it is possible that prolonged PPROM could be an independent risk factor for neonatal sepsis.

OBJECTIVE

The objective of the study was to determine whether prolonged latency after PPROM is associated with an increased risk of neonatal sepsis.

STUDY DESIGN

This secondary analysis of the randomized controlled trial of magnesium sulfate for the prevention of cerebral palsy evaluated whether the time interval between diagnosis of PPROM and delivery was associated with an increased risk of neonatal sepsis. Latency time was categorized by weeks of latency (0 weeks to ≥ 4 weeks). The primary outcome was confirmed neonatal sepsis. Logistic regression was used to control for confounders.

RESULTS

A total of 1596 patients with PPROM were analyzed, of whom 1390 had a < 4-week interval and 206 had an interval of ≥ 4 weeks. Confirmed neonatal sepsis occurred in 15.5% of patients in the cohort. In the univariate analysis, patients in the prolonged PPROM group were less likely to have neonatal sepsis (6.8% vs 17.2%, relative risk, 0.40 95% confidence interval, 0.24-0.66). This relationship was retained in the multivariable model; patients with prolonged PPROM ≥ 4 weeks had an adjusted odds ratio of 0.21 (95% confidence interval, 0.10-0.41) for neonatal sepsis. Neonatal sepsis was also significantly associated with earlier gestational age at rupture of membranes.

CONCLUSION

Prolonged exposure to an intrauterine environment of PPROM does not increase the risk of neonatal sepsis; prolonged PPROM ≥ 4 weeks was associated with decreased risk of neonatal sepsis.

Chorioamniotic membrane separation and preterm premature rupture of membranes complicating in utero myelomeningocele repair

BACKGROUND

Since the results of the Management of Myelomeningocele Study were published, maternal-fetal surgery for the in utero treatment of spina bifida has become accepted as a standard of care alternative. Despite promise with fetal management of myelomeningocele repair, there are significant complications to consider. Chorioamniotic membrane separation and preterm premature rupture of membranes are known complications of invasive fetal procedures. Despite their relative frequency associated with fetal procedures, few data exist regarding risk factors that may be attributed to their occurrence or the natural history of pregnancies that are affected with chorionic membrane separation or preterm premature rupture of membranes related to the procedure.

OBJECTIVE

The objective of this study was to review chorioamniotic membrane separation and preterm premature rupture of membranes in a cohort of patients undergoing fetal management of myelomeningocele repair including identification of risk factors and outcomes.

STUDY DESIGN

This was a retrospective review of patients undergoing fetal management of myelomeningocele repair and subsequent delivery from January 2011 through December 2013 at 1 institution. Patients were identified through the institutional fetal management of myelomeningocele repair database and chart review was performed. Perioperative factors and outcomes among patients with chorioamniotic membrane separation and preterm premature rupture of membranes were compared to those without. Risk factors associated with the development of chorioamniotic membrane separation and preterm premature rupture of membranes were determined.

RESULTS

A total of 88 patients underwent fetal management of myelomeningocele repair and subsequently delivered during the study period. In all, 21 patients (23.9%) were diagnosed with chorioamniotic membrane separation by ultrasound and preterm premature rupture of membranes occurred in 27 (30.7%). Among the chorioamniotic membrane separation patients, 10 (47.6%) were diagnosed with global chorioamniotic membrane separation and 11 (52.4%) with local chorioamniotic membrane separation. Earlier gestational age at the time of fetal surgery was a significant risk factor for the development of chorioamniotic membrane separation (P = .01) and preterm premature rupture of membranes (P < 0.0001). Chorioamniotic membrane separation was significantly associated with preterm premature rupture of membranes (59.1% vs 21.2%, P = .008) and earlier gestational age at delivery (32.1 ± 4.2 vs 34.4 ± 3.5 weeks, P = .01). The average number of days from chorioamniotic membrane separation to preterm premature rupture of membranes was 11.0 ± 10.1 and from chorioamniotic membrane separation to delivery was 31.0 ± 22.5. The mean time interval between fetal management of myelomeningocele repair and preterm premature rupture of membranes was 47.9 days. Mean latency period from preterm premature rupture of membranes to delivery was 25 days. Gestational age at delivery was significantly lower in patients with preterm premature rupture of membranes (31.6 ± 3.4 vs 34.9 ± 3.5 weeks, P = .0001). Using logistic regression analysis, nulliparity, gestational age at fetal management of myelomeningocele repair, and membrane separation remained significant risk factors for preterm premature rupture of membranes.

CONCLUSION

Chorioamniotic membrane separation after fetal management of myelomeningocele repair is a significant risk factor for subsequent development of preterm premature rupture of membranes and preterm delivery. Fetal management of myelomeningocele repair <23 weeks is associated with higher rates of preterm premature rupture of membranes and chorioamniotic membrane separation. Therefore fetal management of myelomeningocele repair should be deferred until ≥23 weeks to mitigate these complications. Nulliparity also appears to increase the risk for preterm premature rupture of membranes.

Biophysical and Biochemical Screening for the Risk of Preterm Labor: An Update

The heterogeneous causes of spontaneous preterm birth make prediction and prevention difficult. Recently developed biochemical and biophysical tests add significantly to clinicians' ability to evaluate and treat women at risk for spontaneous preterm birth. The primary importance of transvaginal cervical sonography and cervicovaginal fetal fibronectin lies in the high negative predictive values of the tests for preterm delivery risk. Cervical length may be useful in identifying women who are candidates for cervical cerclage or progesterone therapy for preterm birth prevention. Together, cervical length and fibronectin can be used in the triaging of women symptomatic for preterm labor.

Delivery prediction in pregnant women with spontaneous preterm birth using fetal adrenal gland biometry

OBJECTIVE

To assess the prediction of delivery within 7 days in pregnant women who showed symptoms of spontaneous preterm birth (PB) by means of fetal adrenal gland biometry and to compare these predictions with the cervical length (CL) measurement.

METHODS

We performed a prospective cross-sectional study with 53 pregnant women between 24 and 36 weeks of gestation. An ultrasound exam was performed for each participant to obtain the CL measurement (transvaginal route) and fetal adrenal gland biometry on day 1 of their hospital admission because of symptoms of spontaneous PB. The main outcome measure was the time between the ultrasound exam and delivery, which was classified into two groups: delivery  ≤7 days and delivery  >7 days. A receiver operating characteristics (ROC) curve was performed to define the cutoffs for sensitivity and specificity.

RESULTS

The prevalence of delivery within 7 days was 35.8%, which showed a statistically significant difference from the depth of the central zone of the fetal adrenal gland (p  =  0.036). The cutoff for the depth of the central zone of the fetal adrenal gland was 7.2 mm (sensitivity 66.7%, specificity 61.8% and accuracy 63.5%). These values were not significantly different than the cutoffs for cervical length measurement: 20 mm (p  =  0.267) and 9 mm (p  =  0.118).

CONCLUSION

The biometry for the central zone of the fetal adrenal gland predicted delivery within 7 days in pregnant women with spontaneous PB and had a predictive accuracy similar to that of CL measurement.

What is the optimal strategy in the management of patients with preterm premature rupture of membranes before 32 weeks of gestation?

Objective:

Our aim was to compare the outcomes of expectant management of pregnancy or immediate delivery in patients with preterm premature rupture of membranes (PPROM) between 24+⁰ and 32+⁰ weeks of pregnancy.

Materials and Methods:

This is a retrospective cohort study conducted at a tertiary medical center. Patients who were diagnosed as having PPROM between 24+⁰ and 32+⁰ weeks of gestation were selected from an electronic database. Thirty-one patients with expectant management and 22 patients with spontaneous immediate delivery were analyzed. Birth weight, Apgar score, duration of stay in the neonatal intensive care unit (NICU), composite adverse outcomes, and mortality rates of groups were compared. Binary logistic regression analysis with backward stepwise elimination was used to determine confounding factors for antenatal complications and neonatal composite adverse outcomes.

Results:

Gestational age at admission was smaller in the expectant management group. The median latency period was 6 days (range, 2-58 days). Although gestational age at delivery was similar, birth weights were smaller in expectant management group compared with the immediate delivery group (p=0.264 and p<0.05, respectively). Apgar scores, duration in the NICU, composite adverse outcomes, and neonatal mortality rates were similar in each group. Antenatal complication in the expectant management group was higher (p<0.05). Gestational age at delivery and serum C-reactive protein levels were two confounding factors for antenatal complication and gestational age at delivery was the only factor affecting composite adverse outcome.

Conclusion:

Expectant management in patients with PPROM at 24 to 32 gestational weeks might be considered as a good alternative.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial

BACKGROUND

Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity.

METHODS

The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060.

FINDINGS

Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7).

INTERPRETATION

In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term.

FUNDING

Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Direct intramuscular fetal or maternal antenatal corticosteroid therapy: short-time effects on fetal behavior and oxygenation: a comparative study

OBJECTIVE

To compare the effects of antenatal administration of corticosteroids used in two different regimens, on fetal biophysical profile (BPP), baseline fetal heart rate (BFHR), nonstress test (NST) and perinatal outcomes.

STUDY DESIGN

We evaluated the effects of single direct intramuscular (i.m.) fetal dose of dexamethasone (4 mg/kg), or four doses of 6 mg dexamethasone given to the mother 12 hours apart on the parameters of fetal BPP 0-4 hours before and after antenatal contraction stress (ACST). We evaluated two groups of 41 fetuses in the 31st gestation week at risk of fetal hypoxia at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in 2013.

RESULTS

In fetal ACST group, we found significantly different changes in fetal breathing movement before (D0-f) and after therapy (D1-f), p  =  0.019 (-11.75; -1.12), 95% confidence interval (CI), as well as in the maternal ACST group, p  =  0.001; (-11.75; -1.12), 95% CI. We found significant difference between BPP 0-m and BPP1-m in the maternal group, p =  0.000. Neonatal asphyxia occurred more often with the increased frequency of fetal breath movements after both ACST (p  =  0.04 versus p  =  0.07).

CONCLUSION

Fetal ACST results in increased fetal breathing movements. Maternal ACST can result in changes to BPP. The increase in fetal breathing movements determinates neonatal asphyxia regardless of the ACST.

A new antibiotic regimen treats and prevents intra-amniotic inflammation/infection in patients with preterm PROM

OBJECTIVES

To determine whether a new antibiotic regimen could reduce the frequency of intra-amniotic inflammation/infection in patients with preterm PROM.

STUDY DESIGN

This retrospective cohort study was conducted to evaluate the effect of antibiotics on the frequency of intra-amniotic inflammation/infection based on the results of follow-up transabdominal amniocenteses from 89 patients diagnosed with preterm PROM who underwent serial amniocenteses. From 1993-2003, ampicillin and/or cephalosporins or a combination was used ("regimen 1"). A new regimen (ceftriaxone, clarithromycin and metronidazole) was used from 2003-2012 ("regimen 2"). Amniotic fluid was cultured and matrix metalloproteinase-8 (MMP-8) concentrations were measured.

RESULTS

(1) The rates of intra-amniotic inflammation and intra-amniotic inflammation/infection in patients who received regimen 2 decreased during treatment from 68.8% to 52.1% and from 75% to 54.2%, respectively. In contrast, in patients who received regimen 1, the frequency of intra-amniotic inflammation and infection/inflammation increased during treatment (31.7% to 55% and 34.1% to 58.5%, respectively); and (2) intra-amniotic inflammation/infection was eradicated in 33.3% of patients who received regimen 2, but in none who received regimen 1.

CONCLUSION

The administration of ceftriaxone, clarithromycin and metronidazole was associated with a more successful eradication of intra-amniotic inflammation/infection and prevented secondary intra-amniotic inflammation/infection more frequently than an antibiotic regimen which included ampicillin and/or cephalosporins in patients with preterm PROM.

Labor induction in the patient with preterm premature rupture of membranes

Preterm premature rupture of membranes (PPROM) affects up to one-third of all preterm births and confers serious maternal risks, including intra-amniotic infection, and an increased risk of neonatal complications, including respiratory distress and intraventricular hemorrhage. Management of PPROM is a highly individualized process that requires an accurate determination of gestational age and causal factors, as well as the balancing of maternal and fetal risks. In this review of the existing literature on induction of labor in PPROM, we examine the differences in appropriate management of patients with early (32 weeks 0 days to 33 weeks 6 days) and near term (34 weeks 0 days to 36 weeks 6 days) PPROM, and compare the safety and efficacy of available treatment options. This review of previous research findings provides general guidelines for clinical decision making and highlights the need for future research on management of PPROM.

A new anti-microbial combination prolongs the latency period, reduces acute histologic chorioamnionitis as well as funisitis, and improves neonatal outcomes in preterm PROM

OBJECTIVE

Antibiotic administration is a standard practice in preterm premature rupture of membranes (PROM). Specific anti-microbial agents often include ampicillin and/or erythromycin. Anaerobes and genital mycoplasmas are frequently involved in preterm PROM, but are not adequately covered by antibiotics routinely used in clinical practice. Our objective was to compare outcomes of PROM treated with standard antibiotic administration versus a new combination more effective against these bacteria.

STUDY DESIGN

A retrospective study compared perinatal outcomes in 314 patients with PROM <34 weeks receiving anti-microbial regimen 1 (ampicillin and/or cephalosporins; n = 195, 1993-2003) versus regimen 2 (ceftriaxone, clarithromycin and metronidazole; n = 119, 2003-2012). Intra-amniotic infection/inflammation was assessed by positive amniotic fluid culture and/or an elevated amniotic fluid MMP-8 concentration (>23 ng/mL).

RESULTS

(1) Patients treated with regimen 2 had a longer median antibiotic-to-delivery interval than those with regimen 1 [median (interquartile range) 23 d (10-51 d) versus 12 d (5-52 d), p < 0.01]; (2) patients who received regimen 2 had lower rates of acute histologic chorioamnionitis (50.5% versus 66.7%, p < 0.05) and funisitis (13.9% versus 42.9%, p < 0.001) than those who had received regimen 1; (3) the rates of intra-ventricular hemorrhage (IVH) and cerebral palsy (CP) were significantly lower in patients allocated to regimen 2 than regimen 1 (IVH: 2.1% versus 19.0%, p < 0.001 and CP: 0% versus 5.7%, p < 0.05); and (4) subgroup analysis showed that regimen 2 improved perinatal outcomes in pregnancies with intra-amniotic infection/inflammation, but not in those without intra-amniotic infection/inflammation (after adjusting for gestational age and antenatal corticosteroid administration).

CONCLUSION

A new antibiotic combination consisting of ceftriaxone, clarithromycin, and metronidazole prolonged the latency period, reduced acute histologic chorioamnionitis/funisitis, and improved neonatal outcomes in patients with preterm PROM. These findings suggest that the combination of anti-microbial agents (ceftriaxone, clarithromycin, and metronidazole) may improve perinatal outcome in preterm PROM.

Behavioural and neurodevelopmental outcome of 2-year-old children after preterm premature rupture of membranes: follow-up of a randomised clinical trial comparing induction of labour and expectant management

OBJECTIVE

We recently reported that induction of labour does not improve short term neonatal outcome in women with late preterm premature rupture of membranes (PPROM) as compared to expectant management (PPROMEXIL trial). In this study the neurodevelopmental and behavioural outcome of the children from this trial at 2 years of age was studied.

STUDY DESIGN

We studied outcome of offspring of women randomised in the PPROMEXIL study. These women had >24h of ruptured membranes and were between 34 and 37 weeks of pregnancy when they were randomised to induction of labour (IoL) or expectant management (EM). Two years after delivery, the parents received the ages and stages questionnaire (ASQ), the child behaviour checklist (CBCL) and a general questionnaire.

RESULTS

Follow-up data were obtained from 234 children (121 after IoL, 113 after EM, response rate 59% (44% of the original 532 randomised women)). In the IoL group 16 children (14%) had an abnormal score in ≥1 domains of the ASQ, versus 27 (26%) in the EM group (difference in percentage -11.4 (95% CI -21.9 to -0.98; p=0.033)). For the CBCL, an abnormal score was found in 13% (n=15) in the IoL group and in 15% (n=16) in the EM group (difference in percentage -2.13 (95% CI -11.2 to 6.94; p=0.645)).

CONCLUSION

Although a policy of induction of labour in women with late PPROM does not improve short term neonatal outcome, it might be associated with a decrease in neurodevelopmental difficulties at the age of two years as compared to expectant management. Expectant management did not lead to a difference in behavioural problems.

Antenatal corticosteroids for preterm premature rupture of membranes: single or repeat course?

OBJECTIVE

The aim of this article is to determine the risk of maternal chorioamnionitis and neonatal morbidity in women with preterm premature rupture of membranes (PPROM) exposed to one corticosteroid course versus a single repeat corticosteroid steroid course.

STUDY DESIGN

Secondary analysis of a cohort of women with singleton pregnancies and PPROM. The primary outcome was a clinical diagnosis of maternal chorioamnionitis. Using multivariate logistic regression, we controlled for maternal age, race, body mass index, diabetes, gestational age at membrane rupture, preterm labor, and antibiotic administration. Neonatal morbidities were compared between groups controlling for gestational age at delivery.

RESULTS

Of 1,652 women with PPROM, 1,507 women received one corticosteroid course and 145 women received a repeat corticosteroid course. The incidence of chorioamnionitis was similar between groups (single course = 12.3% vs. repeat course = 11.0%; p = 0.8). Women receiving a repeat corticosteroid course were not at increased risk of chorioamnionitis (adjusted odds ratio, 1.28; 95% confidence interval, 0.69-2.14). A repeat course of steroids was not associated with an increased risk of any neonatal morbidity.

CONCLUSION

Compared with a single steroid course, our findings suggest that the risk of maternal chorioamnionitis or neonatal morbidity may not be increased for women with PPROM receiving a repeat corticosteroid course.

Antibiotic prophylaxis for term or near-term premature rupture of membranes: metaanalysis of randomized trials

OBJECTIVE

The objective of the study was to evaluate the efficacy of antibiotic prophylaxis in women with term or near-term premature rupture of membranes.

STUDY DESIGN

Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, EMBASE, ScienceDirect.com, MEDSCAPE, and the Cochrane Central Register of Controlled Trials with the use of a combination of key words and text words related to antibiotics, premature rupture of membranes, term, and trials from inception of each database to September 2014. We included all randomized trials of singleton gestations with premature rupture of membranes at 36 weeks or more, who were randomized to antibiotic prophylaxis or control (either placebo or no treatment). The primary outcomes included maternal chorioamnionitis and neonatal sepsis. A subgroup analysis on studies with latency more than 12 hours was planned. Before data extraction, the review was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42014013928). The metaanalysis was performed following the Preferred Reporting Item for Systematic Reviews and Meta-analyses statement.

RESULTS

Women who received antibiotics had the same rate of chorioamnionitis (2.7% vs 3.7%; relative risk [RR], 0.73, 95% confidence interval [CI], 0.48-1.12), endometritis (0.4% vs 0.9%; RR, 0.44, 95% CI, 0.18-1.10), maternal infection (3.1% vs 4.6%; RR, 0.48, 95% CI, 0.19-1.21), and neonatal sepsis (1.0% vs 1.4%; RR, 0.69, 95% CI, 0.34-1.39). In the planned subgroup analysis, women with latency longer than 12 hours, who received antibiotics, had a lower rate of chorioamnionitis (2.9% vs 6.1%; RR, 0.49, 95% CI, 0.27-0.91) and endometritis (0% vs 2.2%; RR, 0.12, 95% CI, 0.02-0.62) compared with the control group.

CONCLUSION

Antibiotic prophylaxis for term or near-term premature rupture of membranes is not associated with any benefits in either maternal or neonatal outcomes. In women with latency longer than 12 hours, prophylactic antibiotics are associated with significantly lower rates of chorioamnionitis by 51% and endometritis by 88%.

Streptococcus agalactiae in pregnancies complicated by preterm prelabor rupture of membranes

OBJECTIVE

The main aim of this study was to evaluate the presence of Streptococcus agalactiae (S. agalactiae) in the vagina and the amniotic fluid in pregnancies complicated by preterm prelabor rupture of membranes (PPROM). The next aim was to evaluate the incidence of S. agalactiae early onset sepsis in newborns from PPROM pregnancies, with respect to the presence of S. agalactiae in the vagina and the amniotic fluid.

METHODS

Singleton gestations with PPROM between 24 + 0 and 36 + 6 were included. A vaginal swab was obtained, and amniocentesis was performed at admission. The presence of S. agalactiae in the vagina and in the amniotic fluid was assessed by culture and by real-time polymerase chain reaction, respectively.

RESULTS

In total, 336 women were included. The presence of S. agalactiae in the vaginal and amniotic fluid was found in 9% (31/336) and 1% (3/336) of women. One woman had S. agalactiae in the amniotic fluid but was negative for the presence of S. agalactiae in the vaginal fluid. Early onset neonatal sepsis developed in one newborn from pregnancies complicated by the presence of S. agalactiae in the amniotic fluid.

CONCLUSION

The presence of S. agalactiae in the vagina and amniotic fluid complicated approximately each 10th and each 100th PPROM pregnancy. Cultivation-negative findings of S. agalactiae in the vagina did not exclude the positivity of the amniotic fluid for S. agalactiae and the development of early onset sepsis in newborns.

Preterm labor: role of the nurse practitioner

The nurse practitioner may play a pivotal role in diagnosing preterm labor through risk assessment and physical exam. While treatment and management of preterm labor are usually beyond the nurse practitioner's scope of practice, they can play an important role in preventing preterm birth through assessment, action, or advocacy.

Transvaginal cervical length and amniotic fluid index: can it predict delivery latency following preterm premature rupture of membranes?

OBJECTIVE

We sought to determine whether transvaginal cervical length (TVCL), amniotic fluid index (AFI), or a combination of both can predict delivery latency within 7 days in women presenting with preterm premature rupture of membranes (PPROM).

STUDY DESIGN

This was a prospective observational study of TVCL measurements in 106 singleton pregnancies with PPROM between 23-33 weeks. Delivery latency was defined as the period (in days) from the initial TVCL after PPROM to delivery of the infant, with our primary outcome being delivery within 7 days of TVCL. The independent predictability of significant characteristics for delivery within 7 days was determined using multiple logistic regression. Sensitivity, specificity, and predictive values were used to examine whether the presence of a short TVCL, AFI, or a combination of both affected the risk of delivery within 7 days.

RESULTS

Delivery within 7 days occurred in 51/106 (48%) of pregnancies. Median duration (interquartile range) from PPROM to delivery and TVCL to delivery was 8 days (4.0-16.0) and 8 days (3.0-15.0), respectively. Using multiple regression TVCL as a continuous variable (odds ratio, 0.65; 95% confidence interval, 0.44-0.97; P < .05), AFI ≤5 cm (odds ratio, 4.69; 95% confidence interval, 1.58-13.93; P < .01) were determined to be independent predictors of delivery within 7 days. In all, 42 women (40%) had a TVCL ≤2 cm, while 62 (59%) had AFI ≤5 cm. A total of 26 women (25%) had a combination of both TVCL ≤2 cm and AFI ≤5 cm, while 28 women (27%) had neither characteristic. The predictive value of delivery within 7 days for a TVCL ≤2 cm was 62%, and for an AFI ≤5 cm was 58%. Having a combination of low TVCL and low AFI did not increase the predictive value of delivery within 7 days (58%). In contrast, only 3 of 27 women (11%) with neither characteristic delivered within 7 days. The predictive value of delivery >7 days for TVCL >2 cm alone was 61%. This predictive value changed when analyzed in conjunction with an AFI ≤5 cm and >5 cm at 42% and 89%, respectively.

CONCLUSION

A shorter TVCL and an AFI ≤5 cm independently predict delivery within 7 days in women presenting with PPROM. The combination of an AFI >5 cm and TVCL >2 cm greatly improved the potential to remain undelivered at 7 days following cervical length assessment. These findings may be helpful for counseling and optimizing maternal and neonatal care in women with PPROM.

A retrospective comparison of antibiotic regimens for preterm premature rupture of membranes

OBJECTIVE

To evaluate whether the use of ampicillin and azithromycin leads to a similar latency period in preterm premature rupture of membranes as ampicillin and erythromycin and whether the substitution of azithromycin for erythromycin effects rates of other outcomes.

METHODS

We performed a retrospective cohort study of women with preterm premature rupture of membranes between 24 and 34 completed weeks of gestation and compared two groups: those who received ampicillin and erythromycin and those who received ampicillin and azithromycin. Primary outcome was length of latency (defined as time from first antibiotic dose to delivery) and secondary outcomes were rates of chorioamnionitis, cesarean delivery, Apgar scores, birth weight, neonatal death, neonatal sepsis, and neonatal respiratory distress syndrome.

RESULTS

Of 168 women who met inclusion criteria, 75 received ampicillin and erythromycin and 93 received ampicillin and azithromycin. There was no difference in latency between groups: 9.6±13.2 days (erythromycin) compared with 9.4±10.0 (azithromycin) days (P=.40). Secondary outcomes did not differ between groups. We had 80% power to detect a difference of 5 days.

CONCLUSION

Among women with preterm premature rupture of membranes between 24 and 34 completed weeks of gestation, substitution of azithromycin for erythromycin in the recommended antibiotic regimen did not affect latency or any other measured maternal or fetal outcomes.

LEVEL OF EVIDENCE

III.

Placental alpha-microglobulin-1 and combined traditional diagnostic test: a cost-benefit analysis

OBJECTIVE

We sought to evaluate if the placental alpha-microglobulin (PAMG)-1 test vs the combined traditional diagnostic test (CTDT) of pooling, nitrazine, and ferning would be a cost-beneficial screening strategy in the setting of potential preterm premature rupture of membranes.

STUDY DESIGN

A decision analysis model was used to estimate the economic impact of PAMG-1 test vs the CTDT on preterm delivery costs from a societal perspective. Our primary outcome was the annual net cost-benefit per person tested. Baseline probabilities and costs assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2013 US dollars.

RESULTS

Annual net benefit from PAMG-1 was $20,014 per person tested, while CTDT had a net benefit of $15,757 per person tested. If the probability of rupture is <38%, PAMG-1 will be cost-beneficial with an annual net benefit of $16,000-37,000 per person tested, while CTDT will have an annual net benefit of $16,000-19,500 per person tested. If the probability of rupture is >38%, CTDT is more cost-beneficial. Monte Carlo simulations of 1 million trials selected PAMG-1 as the optimal strategy with a frequency of 89%, while CTDT was only selected as the optimal strategy with a frequency of 11%. Sensitivity analyses were robust.

CONCLUSION

Our cost-benefit analysis provides the economic evidence for the adoption of PAMG-1 in diagnosing preterm premature rupture of membranes in uncertain presentations and when CTDT is equivocal at 34 to <37 weeks' gestation.