Treatment with amniopatch of premature rupture of membranes after first-trimester chorionic villus sampling

Preterm prelabor rupture of membranes after first-trimester chorionic villus sampling: A case report and review of the literature

Rupture of membranes in the first trimester is extremely rare. Generally at this gestational age, rupture is a complication of invasive genetic testing. Little is known about the complications or sequelae of such an occurrence and therefore the management options are limited. This article reports the case of a 35-year-old woman who had rupture of membranes after chorionic villus sampling in the first trimester; it describes her pregnancy course and eventual positive outcome. Regardless of gestational age at time of fluid loss, treatment options are limited. This article reviews the evidence regarding first-trimester rupture and the outcomes of expectant management.

Residual amniotic fluid volume predicts the sealing of preterm prelabor rupture of fetal membranes in the pre- and periviable period

OBJECTIVE

Preterm prelabor rupture of fetal membranes (pPROM) is a leading cause of preterm birth. When pPROM occurs around the pre- and periviable period, the perinatal outcome is unfavorable. However, there have been a few cases in which the leakage of amniotic fluid ceases and the ruptured fetal membranes are spontaneously sealed.

MATERIALS AND METHODS

The prognosis of 38 cases of pPROM at less than 27 weeks of gestation in Kyoto University Hospital were studied. The clinical factors related to the sealing of fetal membranes were investigated.

RESULTS

Spontaneous sealing was confirmed in five patients (13%), and sealing occurred within 14 days of pPROM. Women in the no sealing group delivered at 26.3 ± 0.5 weeks of gestation, whereas women in the sealing group delivered at term at 38.8 ± 0.4 weeks (p < 0.0001). The maximum vertical pocket (MVP) of amniotic fluid at the time of pPROM diagnosis was 2.2 ± 0.3 cm in the no sealing group and 3.8 ± 0.5 cm in the sealing group (p = 0.043). All cases of sealing occurred when the MVP at diagnosis was more than 2 cm, and there were no cases of sealing if the MVP at diagnosis was less than 2 cm. In addition, the value of C-reactive protein at ROM was less than 0.4 mg/dL in all cases in the sealing group.

CONCLUSION

The residual volume of sterile amniotic fluid at the onset of pPROM may predict the possibility of fetal membrane sealing.

Interventional resealing of preterm premature rupture of the membranes: a systematic review and meta-analysis

OBJECTIVE

To compare the effectiveness and outcomes of interventional resealing of membranes, "amniopatch" for spontaneous vs. iatrogenic preterm premature rupture of the membranes (sPPROM and iPPROM).

METHODS

We performed a systematic review of literature involving an electronic search of the following databases: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Scopus. An indirect meta-analysis was then performed to compare the obstetric, maternal, fetal, and neonatal outcomes of amniopatch between the sPPROM and iPPROM groups.

RESULTS

The mean gestational age (GA) at the time rupture was 17.8 ± 1.8 and 25.2 ± 3.8 weeks for iPPROM and sPPROM, respectively, p = .005. Mean GA at the time of amniopatch procedure was 19.2 ± 2.07 weeks for iPPROM and 23 ± 3.1 weeks of gestation for sPPROM, p = .023. The rates of fluid re-accumulation (sPPROM 26% and iPPROM 53%, p = .09) were comparable between the sPPROM and iPPROM groups. Neonatal outcomes except for the rate of IUFD were also comparable between the groups. The incidence of IUFD was significantly higher in the iPPROM group (ES: 24%; 95% CI: 8.00-44.0%; p < .001), compared to sPPROM (ES: 0%; 95% CI: 0.00-4.00%). Obstetric and maternal outcomes were comparable between the two groups.

CONCLUSIONS

Amniopatch appears to be a feasible and safe procedure for PPROM treatment. Further research is warranted to investigate the effectiveness of this procedure and establish a standardized criterion for the appropriate selection of patients that could benefit from this intervention.

Application of Tissue Engineering and Regenerative Medicine in Prelabor Rupture of Membranes: a Review of the Current Evidence

Preterm prelabor rupture of membranes (PPROM) is the main cause of preterm delivery, resulting in increased perinatal morbidity and mortality. Several techniques have been studied for the healing of ruptured membranes, with some success. Before new techniques using tissue/organ engineering are applied in clinical practice, these techniques must be validated in clinical trials. To address this issue, the objective of this study was to summarize the current literature on interventions to seal or heal the amniotic membranes after PPROM. An electronic search was conducted using the keywords "fetal membranes," "premature rupture," "amnion," "tissue engineering," "fibrin tissue adhesive," "regenerative medicine," "tissue adhesive," "wound healing," and "fetoscopy" through the MEDLINE, Embase, and Cochrane CENTRAL databases, with the limitation of English-language studies. Through a review of the identified studies, it was found that spontaneous healing of the fetal membrane has not been successful. Several efforts have been made to seal membranes before or after rupture using different methods, including amniopatches, collagen, tissue patches, fibrin sealant, mussel-mimetic sealant, engineered cell matrix, and immunological supplements. However, most studies have been conducted in ex vivo or in vivo settings, so the safety and applicability of these techniques to spontaneous rupture of membranes in clinical settings have not been sufficiently tested. Overall, the current evidence is limited regarding the safety and effectiveness of interventions against PPROM.

Sealing procedures for preterm prelabour rupture of membranes

BACKGROUND

Preterm prelabour rupture of the membranes (PPROM) complicates approximately 2% of pregnancies and can be either spontaneous or iatrogenic in nature. Complications of PPROM include prematurity, chorioamnionitis, neonatal sepsis, limb position defects, respiratory distress syndrome, pulmonary hypoplasia chronic lung disease, periventricular leukomalacia and intraventricular haemorrhage.A number of different sealing techniques have been employed which aim to restore a physical barrier against infection and encourage the re-accumulation of amniotic fluid. Routine use of sealants is currently not recommended due to a lack of sufficient evidence to support the safety and effectiveness of such interventions.

OBJECTIVES

To assess the effects of sealing techniques following PPROM against each other, or versus standard care (including no sealant), on maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different techniques for sealing preterm prelabour ruptured membranes. Cluster-randomised trials and trials using a cross-over design were not eligible for inclusion in this review. We planned to include abstracts when sufficient information was provided.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy.

MAIN RESULTS

We included two studies (involving 141 women - with data from 124 women). We considered both studies as being at high risk of bias. Meta-analysis was not possible because the included studies examined different interventions (both in comparison with standard care) and reported on few, but different, outcomes. One study compared cervical adapter (mechanical sealing), and the other study examined an immunological membrane sealant. Neither of the included studies reported on this review's primary outcome of interest - perinatal mortality. Similarly, data were not reported for the majority of this review's secondary infant and maternal outcomes. Cervical adapter (mechanical sealing) versus standard care (one study, data from 35 participants)No data were reported for this review's primary outcome - perinatal mortality. Data were reported for few of this review's infant or maternal secondary outcomes.There was no clear difference between the mechanical sealing group and the standard care control in relation to the incidence of neonatal sepsis (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.28 to 5.09 (very low-quality evidence)) or chorioamnionitis (RR 1.19, 95% CI 0.28 to 5.09 (very low-quality evidence)). Oral immunological membrane sealant versus standard care (one study, data from 94 participants)No data were available for perinatal mortality (this review's primary outcome) or for the majority of this review's infant and maternal secondary outcomes. Compared to standard care, the immunological membrane sealant was associated with a reduction in preterm birth less than 37 weeks (RR 0.48, 95% CI 0.34 to 0.68 (very low-quality evidence)) and a reduction in neonatal death (RR 0.38, 95% CI 0.19 to 0.75 (very low-quality evidence)). However, there was no clear difference between groups in terms of neonatal sepsis (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)) or respiratory distress syndrome (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)).

AUTHORS' CONCLUSIONS

There is insufficient evidence to evaluate sealing procedures for PPROM. There were no data relating to this review's primary outcome (perinatal mortality) and the majority of our infant and maternal secondary outcomes were not reported in the two included studies.There was limited evidence to suggest that an immunological membrane sealant was associated with a reduction in preterm birth at less than 37 weeks and neonatal death, but these results should be interpreted with caution as this is based on one small study, with a high risk of bias, and the intervention has not been tested in other studies.Although midtrimester PPROM is not a rare occurrence, there are only a small amount of published data addressing the benefits and risks of sealing procedures. Most of these studies are retrospective and cohort based and could therefore not be included in our data-analysis.This review highlights the paucity of prospective randomised trials in this area. Current evidence provides limited information both on effectiveness and safety for the interventions described. Given the paucity of high-quality data, we recommend that future research efforts focus on the conduct of randomised trials assessing the effect of promising interventions that have been only evaluated to date in cohort studies (e.g. amniopatch). Future trials should address outcomes including perinatal mortality, preterm birth, neonatal death, respiratory distress syndrome, neonatal sepsis and developmental delay. They should also evaluate maternal outcomes including sepsis, mode of delivery, length of hospital stay and emotional well-being.

Severe midtrimester oligohydramnios: treatment strategies

PURPOSE OF REVIEW

Nearly 1% of pregnancies are affected by some type of midtrimester oligohydramnios. Evidence is currently accumulating that suggests the better efficacy of the new therapeutic procedures relative to conventional management. This review summarizes the available evidence.

RECENT FINDINGS

The prolongation of the period between the diagnosis of oligohydramnios and delivery following amnioinfusion and amniopatch techniques appears to be strongly associated with the gestational age and whether the situation was based on rupture of the membranes or not. Case series reveal that amnioinfusion significantly improves the perinatal outcome and prolongs the pregnancy in severe second-trimester oligohydramnios in both idiopathic cases and those involving rupture of the amniotic membranes [preterm prelabor rupture of the membranes (PPROM)]. There is clear evidence of a lower frequency of perinatal complications and successfully prolonged gestation in iatrogenic PPROM after the amniopatch technique relative to population controls.

SUMMARY

Identification of potentially modifiable risk factors for the successful prolongation of pregnancy complicated with midtrimester oligohydramnios, and previable PPROM is needed for the improvement of treatment strategies and prognosis. Randomized trials are needed to determine whether amniotic fluid-replenishing strategies can improve pregnancy outcomes.

Amniopatch for iatrogenic rupture of the fetal membranes

With the increased use of invasive fetal procedures, the number of women facing post-procedure membrane rupture is increasing. Here we review the use of platelets and fresh frozen plasma for sealing iatrogenic fetal membrane defects by describing the mechanisms of action of the amniopatch procedure as well as published experience. In cases of iatrogenic preterm pre-labour rupture of the membranes, amniopatch effectively seals the fetal membranes in over two-thirds of cases. There is a risk of 16% of in utero fetal death, which may occur at varying intervals from the procedure and often for unknown reasons. Amniopatch has also been used as a treatment of chorionic membrane separation. In summary, current experience suggests that in cases of early onset but persistent amniotic fluid leakage following an invasive fetal procedure, amniopatch is an option.

[Amniopatch to treat iatrogenic rupture of the fetal membranes]

OBJECTIVE

With the increased use of invasive fetal procedures, the number of patients facing postprocedure membrane rupture is increasing. We aimed to describe the use of platelets and fresh frozen plasma for sealing iatrogenic fetal membrane defects.

PATIENTS AND METHODS

We describe the mechanisms of action of the amniopatch procedure as well as published experience.

RESULTS

Amniopatch effectively sealed the fetal membranes in over two thirds of published cases (n=44). There is a risk of 17% of in utero fetal death, which may occur remotely from the procedure and is often unexplained.

DISCUSSION AND CONCLUSION

In case of early onset but persistent amniotic fluid leakage following an invasive fetal procedure, amniopatch may be offered.

In vitro evaluation of the ability of platelet-rich plasma to seal an iatrogenic fetal membrane defect

OBJECTIVES

The purpose of the study is to evaluate the ability of platelet-rich plasma (PRP) to seal an iatrogenic fetal membrane defect.

METHODS

First, we evaluated the stability of a PRP plug in an amniotic fluid environment. Further, we evaluated the sealing capability of PRP plugs in an in vitro model that mimics a fetoscopic membrane defect. Finally, we examined its influence on membrane repair and cell proliferation in monolayer cell cultures and amnion-chorion tissue explants.

RESULTS

PRP plugs persisted in an amniotic fluid for a median time of 7 weeks. PRP plugs also provided waterproof sealing of a fetoscopic membrane defect. Finally, PRP stimulated cell proliferation in a monolayer cell culture and provided a good matrix for cell proliferation and migration in amnion-chorion tissue explants.

CONCLUSION

Our in vitro experiments suggest that PRP plugs may provide a long-lasting, waterproof sealing of fetal membrane defects and stimulate fetal membrane repair.

Enrichment of collagen plugs with platelets and amniotic fluid cells increases cell proliferation in sealed iatrogenic membrane defects in the foetal rabbit model

OBJECTIVES

The purpose of this study was to evaluate cell proliferation in platelet-enriched collagen plugs with and without addition of amniotic fluid-derived heterologous foetal cells to seal an iatrogenic membrane defect in the foetal rabbit model.

METHODS

Amniotic fluid cells were harvested from three donor does at 23 days of gestation (term = 32 days) and labelled with carboxyfluorescein diacetate succinimidyl ester (CFDA-SE). In 42 other does, foetal membrane defects were induced by foetoscopic needle puncture at 23 days of gestation, and closed with either a platelet-enriched collagen plug with (n = 44) or without (n = 32) amniotic fluid cells. At 30 days of gestation, the defects were harvested and assessed microscopically.

RESULTS

The plugs enriched with heterologous amniotic fluid cells more commonly had proliferating cells in the centre of the plug than those without cell addition. CFDA-SE labelling confirmed the presence of heterologous amniotic fluid cells over the entire membrane plug. Cell typing showed a mixture of fibroblasts and epithelial cells at the wound edges, whereas in the centre, there was an abundance of fibroblasts.

CONCLUSION

When sealing iatrogenic membrane defects in the foetal rabbit model, enrichment of collagen plugs with platelets and amniotic fluid-derived heterologous foetal cells increases local cell proliferation.