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Kim MS, Kim S, Seo Y, Oh MY, Yum SK. Impact of preterm premature rupture of membranes and oligohydramnios on in-hospital outcomes of very-low-birthweight infants. J Matern Fetal Neonatal Med 2023; 36:2195523. [PMID: 36997167 DOI: 10.1080/14767058.2023.2195523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
OBJECTIVE To analyze neonatal outcomes in very-low-birthweight (VLBW) infants depending on the presence of preterm premature rupture of membranes (PPROM), oligohydramnios, or both. METHODS The electronic medical records of VLBW infants admitted during the study period, January 2013 to September 2018, were reviewed. Neonatal outcomes (primary outcome: neonatal death; secondary outcome: neonatal morbidity) were compared depending on whether the infant was affected by PPROM or oligohydramnios. Logistic regression analysis was performed to assess the association of PPROM and oligohydramnios with neonatal outcomes. RESULTS Three hundred and nineteen VLBW infants were included: (1) 141 infants in the PPROM group vs. 178 infants in the non-PPROM group, and (2) 54 infants in the oligohydramnios group vs. 265 infants in the non-oligohydramnios group. The infants affected by PPROM were at significantly younger gestational ages at birth with lower 5-min Apgar scores than those not affected by PPROM. Histologic chorioamnionitis was significantly more frequent in the PPROM group than in the non-PPROM group. The proportions of small-for-gestational-age infants and infants affected by multiple births were significantly higher in the non-PPROM group. The median (interquartile range) PPROM latency and onset were 50.5 (9.0 - 103.0) h and 26.6 (24.1 - 28.5) weeks, respectively. Based on the logistic regression analysis assessing the association of PPROM and oligohydramnios with the significant neonatal outcome, oligohydramnios was significantly associated with neonatal death (odds ratio [OR] = 2.831, 95% confidence interval [CI] 1.447 - 5.539), air leak syndrome (OR = 2.692, 95% CI 1.224 - 5.921), and persistent pulmonary hypertension (PPH) (OR = 2.380, 95% CI 1.244 - 4.555). PPROM per se was not associated with any neonatal outcome. However, early onset PPROM and prolonged PPROM latency were associated with neonatal morbidity and mortality. When PPROM was accompanied by oligohydramnios, it was associated with increased odds for PPH (OR = 2.840, 95% CI 1.335 - 6.044), retinopathy of prematurity (OR = 3.308, 95% CI 1.325 - 8.259), and neonatal death (OR = 2.282, 95% CI 1.021 - 5.103). CONCLUSION PPROM and oligohydramnios affect neonatal outcomes differently. Oligohydramnios, but not PPROM, is a significant risk factor for adverse neonatal outcomes, which is presumably related to pulmonary hypoplasia. Prenatal inflammation appears to complicate neonatal outcomes in infants affected by early PPROM and prolonged PPROM latency.
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Affiliation(s)
- Min Soo Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sol Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yumi Seo
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Moon-Yeon Oh
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sook Kyung Yum
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Galletta MAK, Schultz R, Sartorelli MFGDOP, Guerra ECL, Agra IKR, Peres SV, Francisco RPV. Clinical characteristics, complications, and predictive model of histological chorioamnionitis in women with preterm premature rupture of membranes. PLoS One 2023; 18:e0283974. [PMID: 37023210 PMCID: PMC10079121 DOI: 10.1371/journal.pone.0283974] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
We aimed to analyze the impact of histological chorioamnionitis (HCA) in the presence of preterm premature rupture of the membranes (PPROM) on obstetric and neonatal outcomes, and its possible predictability. A retrospective cohort analysis of PPROM cases (20-37 weeks) was conducted comparing the patients with and without HCA, seeking a predictive model of HCA using logistic regression. A total of 295 cases of PPROM were selected, of which 72 (24.4%) had HCA. The group with HCA had a shorter latency period and a greater number of clinical and laboratory criteria in the evolution. The group with HCA had a worse comparative result and presented: lower gestational age at delivery, lower average birth weight, lower Apgar scores, longer neonatal hospitalization, worse maternal clinical conditions and, higher rates of stillbirth, low birth weight (LBW), very low birth weight (VLBW), complications in pregnancy and childbirth, and cesarean delivery due to fetal distress or chorioamnionitis. A predictive model for HCA was developed, with the following independent variables: abdominal pain (odds ratio [OR] = 11.61), uterine activity (noticeable contractions on physical exam) (OR = 5.97), fever (OR = 5.77), latency > 3 days (OR = 2.13), and C-reactive protein (OR = 1.01). With this model, an adequate receiver operating characteristic curve was found, with an area under the curve of 0.726, and some HCA probability curves were constructed for different clinical situations. In this novel study, we present a non-invasive predictive model, with clinical and laboratory variables, which may help in decision-making in a patient with PPROM.
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Affiliation(s)
- Marco Aurélio Knippel Galletta
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Regina Schultz
- Division of Pathological Anatomy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | | | - Eliane Cerqueira Leite Guerra
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Isabela Karine Rodrigues Agra
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Stela Verzinhasse Peres
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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Paulsen V, Jakob M, Gembruch U, Heep A, Bartmann P. Previable preterm premature rupture of membranes: 117 cases with neonatal outcomes in light of current research. J Neonatal Perinatal Med 2023; 16:21-31. [PMID: 36872792 DOI: 10.3233/npm-221054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
BACKGROUND ppPROM < 24 + 0 weeks of gestation complicates < 1 % of all pregnancies but is responsible for significant maternal and neonatal morbidity. It is associated with 18-20% of perinatal deaths. OBJECTIVE To evaluate neonatal outcome after expectant management in ppPROM in order to obtain evidence-based information for purposes of future counselling. METHODS A single-centre, retrospective cohort study of 117 neonates born 1994 to 2012 after ppPROM < 24 weeks of gestation with a latency period > 24 hours and admission to the NICU of the Department of Neonatology, University of Bonn. Data of pregnancy characteristics and neonatal outcome were collected. The results were compared to those found in the literature. RESULTS The mean gestational age at ppPROM was 20.45±2,9 weeks (range 11 + 2 -22 + 6) with a mean latency period of 44.7±34.8 days (range 1-135). Mean gestational age at birth was 26.77±3.22 weeks (range 22 + 2-35 + 3). 117 newborns were admitted to the NICU, the overall survival rate at discharge was 72.6% (85/117). Non-survivors had a significantly lower gestational age and higher rates of intra-amniotic infections. The most common neonatal morbidities were RDS (76.1%), BPD (22.2%), pulmonary hypoplasia (PH) (14.5%), neonatal sepsis (37.6%), IVH (34.1% all grades, 17.9% grades III/IV), NEC (8.5%) and musculoskeletal deformities (13.7%). Mild growth restriction as a new complication of ppPROM was observed. CONCLUSIONS Neonatal morbidity after expectant management is similar to that described for infants without ppPROM, but carries a higher risk of pulmonary hypoplasia and mild growth restriction.
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Affiliation(s)
- V Paulsen
- Department of Neonatology and Paediatric Intensive Care, University of Bonn, Bonn, Germany.,University Children's Hospital of Cologne, Medical Faculty, University of Cologne, Cologne, Germany
| | - M Jakob
- Department of Otorhinolaryngology, Head and Neck Surgery, Pan Clinic Neumarkt, Cologne, Germany
| | - U Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - A Heep
- Medical Centre Oldenburg University, Children's Hospital Oldenburg, Oldenburg, Germany
| | - P Bartmann
- Department of Neonatology and Paediatric Intensive Care, University of Bonn, Bonn, Germany
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Gauthier-Moulinier H, Ndour D, Rabilloud M, Nguyen KA. Outcomes of pregnancies with preterm premature rupture of membranes occurring before 24 weeks of gestation: An 11-year observational study. Int J Gynaecol Obstet 2023. [PMID: 36707064 DOI: 10.1002/ijgo.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 01/06/2023] [Accepted: 01/26/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE This study describes the fetal and neonatal outcomes and their predictive factors in pregnancies with preterm premature rupture of membranes (PPROM) before 24 weeks of gestation. METHODS A retrospective study was conducted using the patient database of a tertiary university hospital in Lyon, France. All of the medical data of women diagnosed with PPROM before 24 weeks of gestation from 2008 to 2018 were extracted. R software was used for descriptive and analytical statistics. RESULTS The study included 78 women. Mean gestational age (GA) at PPROM was 19.6 weeks (13.1 to 23.9 weeks). Fifteen (19.2%) pregnancies were terminated, 37 (47.4%) resulted in intrauterine fetal death (IUFD), and 26 (33.3%) children were born alive at an average of 26.9 weeks of gestation. Fourteen children survived and 12 died after birth; 50% of survivors had pulmonary hypoplasia. Within 7 days after PPROM, 46% of IUFD occurred and 36% of pregnancies ended. PPROM before 20 weeks of gestation and chorioamnionitis are statistically associated with IUFD, whereas a latency period of more than 2 weeks is statistically related to live birth. CONCLUSION PPROM before 24 weeks of gestation is associated with a high rate of IUFD, preterm birth, and postpartum mortality.
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Affiliation(s)
| | - Daouda Ndour
- Department of Neonatalogy, National Hospital Center Dalal Jamm, Dakar, Senegal
| | - Muriel Rabilloud
- Université Lyon 1, Villeurbanne, France.,Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Kim-An Nguyen
- Hospices Civils de Lyon, NICU, Femme Mère Enfant Hospital, Lyon, France.,University of Lyon 1, EMET, LBBE, UMR CNRS 5558, Villeurbanne, France
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Abrahami Y, Saucedo M, Rigouzzo A, Deneux‐Tharaux C, Azria E. Maternal mortality in women with pre-viable premature rupture of membranes: An analysis from the French confidential enquiry into maternal deaths. Acta Obstet Gynecol Scand 2022; 101:1395-1402. [PMID: 36207816 PMCID: PMC9812097 DOI: 10.1111/aogs.14452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/21/2022] [Accepted: 08/25/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Pre-viable premature rupture of membranes (pre-viable PROM) is a rare event occurring in less than 1% of pregnancies. Nevertheless, it can be responsible for severe maternal complications, the risk of which needs to be balanced with the possibility to prolong the pregnancy up to viable gestational age. Maternal sepsis was reported in 1%-5% of women who received conservative management and prophylactic antibiotics, but information on maternal mortality is lacking. Our objective was to identify maternal deaths in women who had pre-viable PROM, describe the characteristics of the women, explore preventability factors within the care they received, and estimate the lethality of pre-viable PROM. MATERIAL AND METHODS We identified all maternal deaths associated with pre-viable PROM from the 2001-2015 French National Confidential Enquiry into Maternal Deaths (NCMM). Data on women's characteristics and the care they received were extracted from the ENCMM database. The lethality was determined after estimating the total number of pregnant women with pre-viable PROM from the national hospital discharge database. RESULTS Between 2001 and 2015, we identified seven maternal deaths associated with pre-viable PROM, representing 0.6% of all maternal deaths over this period (ie, maternal mortality ratio 0.06/100 000 live births). Six maternal deaths were attributed to sepsis after genital infection by Gram-negative bacilli and one to postpartum hemorrhage due to placenta accreta. Four of these seven cases were considered preventable. The main preventability factors were delayed diagnosis, delayed fetal extraction, and inappropriate antibiotic treatment. The estimated lethality was 4.5/10 000 women with pre-viable PROM. CONCLUSIONS Maternal death associated with pre-viable PROM is rare but possible. Most of these deaths seem preventable, with areas for improvement related to earlier diagnosis and better treatment of uterine infections, which can evolve rapidly.
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Affiliation(s)
- Ylann Abrahami
- Department of Obstetrics and GynecologyGroupe Hospitalier Saint‐JosephParisFrance
| | - Monica Saucedo
- Université Paris Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAParisFrance
| | - Agnès Rigouzzo
- DREAM, Department of Anesthesiology and Intensive CareArmand Trousseau University Hospital, Assistance Publique‐Hôpitaux de ParisParisFrance
| | - Catherine Deneux‐Tharaux
- Université Paris Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAParisFrance
| | - Elie Azria
- Department of Obstetrics and GynecologyGroupe Hospitalier Saint‐JosephParisFrance
- Université Paris Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAParisFrance
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Early Neurodevelopmental Outcomes after Previable Preterm Prelabour Rupture of Membranes (pPPROM). Case Rep Pediatr 2022; 2022:3428841. [PMID: 36193210 PMCID: PMC9526558 DOI: 10.1155/2022/3428841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/23/2022] [Indexed: 11/22/2022] Open
Abstract
Objective To describe the early neurodevelopmental outcomes following fetal exposure to previable preterm prelabour rupture of membranes (pPPROM). Methods This was a secondary analysis of a subgroup of neonates born following pPPROM from a retrospective cohort study (2009–2015). Surviving infants who underwent standardized neurodevelopmental evaluation at 18–24 months corrected age (CA) between 2017 and 2019 were eligible for inclusion. Data abstracted from hospital charts were linked to prospectively collected developmental outcomes stored in an electronic database from a regional neonatal follow-up clinic. The primary outcome was Bayley-III composite scores (compared to the population mean 100, standard deviation (SD) 15). Secondary outcomes included presence of cerebral palsy, vision loss, hearing impairment, and requirement of rehabilitation therapy. Descriptive statistics were used to present results. Results 25.7% (19/74) of neonates born after pPPROM survived to hospital discharge, but only 21.6% (16/74) survived to 18–24 months CA. Of these, 9 infants were eligible for follow-up at the regional clinic and 7 had developmental outcomes stored in the electronic database. Infants exposed to pPPROM exhibited Bayley-III scores more than 1 SD below the population mean across all three domains: cognitive 84.9 (SD 12.2); motor 82.3 (SD 11.5); and language 66.4 (SD 18.9). There were particular deficiencies in language development with 71% (5/7) scoring more than 2 SDs below the population mean. There were no cases of cerebral palsy. Conclusions Only 1 in 5 infants born following expectantly managed pPPROM survived to 18–24 months CA. These infants born after pPPROM had significantly lower Bayley-III scores and particular deficiencies in language development. Better understanding of early neurodevelopmental challenges following pPPROM will help refine counselling of families contemplating expectant management and provide insights into the postnatal educational resources required to improve long-term developmental outcomes for these children.
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Can E, Oğlak SC, Ölmez F. Maternal and neonatal outcomes of expectantly managed pregnancies with previable preterm premature rupture of membranes. J Obstet Gynaecol Res 2022; 48:1740-1749. [PMID: 35411577 DOI: 10.1111/jog.15239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/06/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to describe the maternal and fetal outcomes associated with expectant management following previable preterm premature rupture of membranes (PPROM) before 24 weeks of gestation. We also analyzed the risk estimates of potential confounders to clarify whether these variables are contributed to the risk of postnatal mortality among these neonates. METHODS This retrospective cohort study included all pregnant patients who experienced previable PPROM before 24 weeks of gestation at a tertiary maternal-fetal medicine center. We used the neonatal data from birth until discharge. RESULTS A total of 128 women were enrolled. The survival to discharge rate was 60.9%. The median latency period (80 vs. 20 days, respectively, p < 0.001) was significantly longer, the median gestational week at delivery (34 vs. 25 weeks, respectively, p < 0.001) and median birth weight (2100 vs. 710 g, p < 0.001) was significantly higher in the survivor group than the non-survivor group. Surviving neonates had significantly lower frequencies of anhydramnios at any time during the latency period than the non-survivor neonates (38.4% vs. 86.0%, respectively, p < 0.001). CONCLUSION This study demonstrated an opposite correlation between the duration of latency period and gestational age at PPROM with earlier membrane rupture in pregnancies having a longer latency period, which additionally clarifies the higher gestational age at delivery. The antepartum factors that increased the possibility of postnatal mortality within our study included the gestational week at delivery, duration of the latency period, anhydramnios at any time during the latency period, and birth weight.
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Affiliation(s)
- Esra Can
- Department of Obstetrics and Gynecology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Süleyman Cemil Oğlak
- Department of Obstetrics and Gynecology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Fatma Ölmez
- Department of Obstetrics and Gynecology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
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Abstract
OBJECTIVE This study aimed to compare neonatal and maternal outcomes between immediate and delayed prophylactic antibiotic administration after previable prelabor premature rupture of membranes (PROM) less than 24 weeks of gestation. STUDY DESIGN Retrospective cohort study of singleton pregnancies with PROM between 160/7 and 236/7 weeks of gestational age conducted at a single tertiary care referral center between June 2011 and December 2015. Patients with multiple gestations, fetal anomalies, those who elected augmentation, or with a contradiction to expectant management, such as suspected intra-amniotic infection or stillbirth, were excluded from the study. We compared pregnancy characteristics, maternal complications, and neonatal outcomes between women who received a course of antibiotics within 24 hours of PROM and women who received antibiotics after 24 hours of PROM. The primary outcome was neonatal survival to hospital discharge. Secondary outcomes included gestational age at delivery, time from PROM to delivery, neonatal birth weight, days in the neonatal intensive care unit (NICU), composite adverse neonatal outcomes, and maternal morbidity. RESULTS Ninety-four women met inclusion criteria, 57 (61%) received antibiotics within 24 hours of PROM and 37 (39%) received antibiotics 24 hours after PROM. Baseline maternal characteristics were similar in both groups. The mean gestational age at PROM was similar between groups at 20.8 ± 2.3 weeks in the immediate antibiotics group and 20.6 ± 2.1 weeks in the delayed antibiotics group (p = 0.48). Compared with delayed antibiotic administration, immediate antibiotic administration was not associated with a significant difference in latency time from PROM to delivery, rate of stillbirth, days in an ICU, or adverse neonatal outcomes. Maternal outcomes also did not differ significantly between groups. Neonatal birth weight was lower in the immediate antibiotics group (p = 0.012). CONCLUSION Our data suggest that there is no maternal or neonatal benefit to immediate administration of latency antibiotics compared with delayed administration. KEY POINTS · Adverse neonatal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Maternal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Neonatal birth weight was lower in infants that received immediate antibiotics after previable PROM..
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Günes A, Kiyak H, Yüksel S, Bolluk G, Erbiyik RM, Gedikbasi A. Predicting previable preterm premature rupture of membranes (pPPROM) before 24 weeks: maternal and fetal/neonatal risk factors for survival. J OBSTET GYNAECOL 2021; 42:597-606. [PMID: 34382497 DOI: 10.1080/01443615.2021.1935818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We sought to compare maternal and neonatal risk factors in cases with previable premature rupture of membranes (pPPROM, between 14-24 weeks) for optimal counselling. Therefore, 192 pregnancies of 485 cases which met selection criteria and agreed to follow-up were retrospectively analysed. Mean gestational age at pPPROM was 20.45 weeks. Live births occurred in 171 cases, but 67 (39.2%) of them died in the neonatal period (neonatal death group) and 104 cases (60.8%) constituted surviving neonate group. Of the surviving neonates, 37 (33.7%) experienced at least one complication. Most seen maternal complications were chorioamnionitis (24.48%) and placental abruption (8.33%). Although amniotic fluid volume, length of pPPROM period, completing antibiotherapy and CRP values were significant, amniotic fluid volume and length of pPPROM showed also significance for multivariate regression analysis for maternal risk factors. Risk factors for birth were gestational age at pPPROM, gestational age at birth, new-born weight at birth, 1st and 5th minute Apgar scores, umbilical cord pH value and need for neonatal resuscitation. Furthermore, development of respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage and retinopathy of premature were additional risk factors for neonate. Of them, gestational age at birth, new-born weight at birth, respiratory distress syndrome and retinopathy of prematurity were also significant in multivariate regression analysis.Impact StatementWhat is already known on this subject? Management of previable premature rupture of membranes is controversial and there is no definite consensus on the approach. The factor that best predicts neonatal survival is the gestational age at birth (Deutsch et al. 2010).What do the results of this study add? Appropriate counselling for pPPROM cases is important especially during antenatal period (maternal factors) and postpartum period (neonatal factors). Maternal infection risk is increased with an increased latency period of PPROM. As the gestational age at birth increases, the survival rate increases and neonatal complication rates decrease. Other important determinants of neonatal survival and well-being are the presence of oligo-anhydramnios and latency period of previable PPROM to delivery.What are the implications of these findings for clinical practice and/or further research? Counselling the patient with previable PPROM about pregnancy complications and paediatric outcome is challenging because of the small size, different gestational age ranges, and retrospective nature of the multiple studies on this subject. The most important feature of our study was the relatively high number of patients compared to other series. Thus, we can counsel pregnant women with PPROM prior to 24 weeks of gestation about the maternal antenatal factors and neonatal postnatal factors with related outcomes and help make an informed decision regarding termination or conservative follow-up. Nevertheless, there is a need for larger multicentric prospective studies to validate our data and to establish the prognosis of previable PPROM for both mother and foetus.
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Affiliation(s)
- Aylin Günes
- Department of Obstetrics and Gynecology, Istanbul Şişli Etfal Training and Research Hospital, Istanbul, Turkey
| | - Hüseyin Kiyak
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Semra Yüksel
- Department of Obstetrics and Gynecology, Istanbul Taksim GOP Training and Research Hospital, Istanbul, Turkey
| | - Gökhan Bolluk
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Rabia Merve Erbiyik
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Ali Gedikbasi
- Department of Maternal Fetal Medicine, İstanbul Aydin University Medical School, Istanbul, Turkey
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Pylypjuk C, Majeau L. Perinatal Outcomes and Influence of Amniotic Fluid Volume Following Previable, Preterm Prelabor Rupture of Membranes (pPPROM): A Historical Cohort Study. Int J Womens Health 2021; 13:627-637. [PMID: 34234574 PMCID: PMC8254139 DOI: 10.2147/ijwh.s303120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/02/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine perinatal outcomes and influence of amniotic fluid volume in pregnancies complicated by previable, preterm prelabor rupture of membranes (pPPROM). Patients and methods This was a historical cohort study from two tertiary-level maternity hospitals (January 1, 2009 to December 31, 2015). All pregnancies complicated by pPPROM were identified using ICD coding of discharge abstracts. Hospital charts were reviewed to collect maternal demographics, pregnancy and delivery events, and immediate postnatal outcomes (including survival). Post-processing review of stored ultrasound images was performed to evaluate the relationship between amniotic fluid volume and outcomes. Results A total of 113 pregnancies were eligible and 99 were included in the final analysis (74 with “expectant management” and 25 opting for elective termination). The median gestational age at pPPROM was 20+6 weeks [IQR 19+4 to 21+5]. For those choosing expectant management, the median latency between pPPROM and delivery was 7 days, median gestational at delivery was 23+1 weeks, and neonatal survival to discharge was 27.5% overall. There was a trend towards higher rates of pregnancy termination at one hospital (31.7%) compared to the other (15.4%), but no difference between sites with respect to latency, mode of delivery, or survival amongst those managed expectantly. There was a relationship between survival and gestational age at pPPROM (p<0.04), as well as initial amniotic fluid volume category: 52.6% of survivors had normal initial amniotic fluid volumes whereas the majority of previable losses had oligohydramnios and the majority of stillbirths had anhydramnios. Conclusion After expectant management, more than one in four newborns following pPPROM survived to hospital discharge. While gestational age at rupture was most strongly correlated with survival, normal initial amniotic fluid volumes were mostly seen in survivors whereas stillbirths more frequently had anhydramnios. These findings will help to improve counseling and care of patients with pPPROM and in guiding long-term follow-up studies.
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Affiliation(s)
- Christy Pylypjuk
- Department of Obstetrics, Gynecology & Reproductive Sciences and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ladonna Majeau
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Esteves JS, Nassar de Carvalho PR, Sa R, Gomes Junior SC. Maternal and perinatal outcomes in midtrimester rupture of membranes. J Matern Fetal Neonatal Med 2020; 35:3460-3466. [PMID: 33032477 DOI: 10.1080/14767058.2020.1821641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to assess neonatal and maternal adverse outcomes following expectant management of preterm prelabor rupture of membranes (PPROM) between 18 and 26 weeks and to identify maternal morbidity and prognostic factors for neonatal outcomes. METHODS Data were collected from all pregnant women who presented PPROM between 18+0 and 26+0 weeks admitted into two tertiary centers in Brazil from 2005 to 2016. The neonatal adverse outcomes (mortality or the development of a severe morbidity) and maternal adverse outcomes were analyzed and compared among four groups (180/7 to 200/7 weeks, 20+1 to 220/7 weeks, 22+1 to 240/7 weeks and 24+1 to 260/7 weeks). A multiple logistic regression was performed for each predictor of neonatal adverse outcomes, and the area under the receiver operating characteristics curves for birth weight and gestational age at birth were calculated. RESULTS Of the 101 women with PPROM during the study period, 97 fulfilled the eligible criteria. Among these patients, 30 (30.9%) had a miscarriage or stillbirth. Overall there were 67/97 (69.1%) livebirths, 45/97 newborns survived to discharge (46.3%), and 53/97 (54.6%) experienced severe neonatal adverse outcome. The median latency period was seven days, with 36 (37.1%) patients ending the pregnancy in 2-14 days. Among 29 patients with PPROM at 24+1 to 260/7 weeks, only 13 (44.8%) delivered between 2 and 14 days. Multivariate analysis has demonstrated that the independent predictor for adverse neonatal outcome was birthweight. The maternal morbidity was high; however, the expectant management did not increase the rate of severe maternal morbidity. CONCLUSIONS PPROM between 18+0 and 26+0 weeks has high morbidity and mortality, and the only significant independent predictor of severe adverse neonatal outcomes is birthweight. Maternal morbidity is high, however, the expectant management is not increased by expectant management.
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Affiliation(s)
- Juliana Silva Esteves
- Department of Obstetrics, Rua Sacadura Cabral, Hospital Federal Servidores do Estado, Rio de Janeiro, Brazil
| | - Paulo Roberto Nassar de Carvalho
- Clínica Perinatal Barra, Diagnostic Center, Rio de Janeiro, Brazil.,Department of Obstetrics, Instituto Fernandes Figueira/Fiocruz, Rio de Janeiro, Brazil
| | - Renato Sa
- Materno Infantil Department, Universidade Federal Fuminense, Niteroi, Brazil
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Masereka EM, Naturinda A, Tumusiime A, Munguiko C. Implementation of the Perinatal Death Surveillance and Response guidelines: Lessons from annual health system strengthening interventions in the Rwenzori Sub-Region, Western Uganda. Nurs Open 2020; 7:1497-1505. [PMID: 32802370 PMCID: PMC7424478 DOI: 10.1002/nop2.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/01/2020] [Indexed: 11/21/2022] Open
Abstract
Aim To determine the health facility-based perinatal mortality rate, its causes and avoidable factors using the perinatal mortality surveillance and response guidelines. Design This was an action study conducted in one of the districts in Western Uganda from 1 January-31 December 2019. Methods A total of 20 perinatal death cases were recruited consecutively. Data were collected using a Ministry of Health Perinatal Death Surveillance and Response (PDSR) questionnaire containing questions on pregnancy, delivery and immediate postnatal care. We used descriptive statistics to describe key data elements. Results We found a health facility-based perinatal mortality rate of 17.3 deaths per 1,000 live births. Birth asphyxia was the most common cause of perinatal deaths. Seven, three and ten mothers delayed seeking, reaching and receiving appropriate health care, respectively.
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Affiliation(s)
- Enos Mirembe Masereka
- Department of Nursing and MidwiferySchool of MedicineKabale UniversityKabaleUganda
- Department of Nursing and MidwiferySchool of Health SciencesMountains of the Moon UniversityFort PortalUganda
| | - Amelia Naturinda
- Infectious Diseases InstituteSchool of MedicineCollege of Health SciencesMakerere UniversityKampalaUganda
| | - Alex Tumusiime
- Department of Nursing and MidwiferySchool of MedicineKabale UniversityKabaleUganda
| | - Clement Munguiko
- Department of Nursing and MidwiferySchool of Health SciencesMountains of the Moon UniversityFort PortalUganda
- Department of NursingSchool of Health SciencesSoroti UniversitySorotiUganda
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13
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Alla S, Ramseyer A, Whittington JR, Peeples S, Ounpraseuth ST, Magann EF. Maternal features at time of preterm prelabor rupture of membranes and short-term neonatal outcomes. J Matern Fetal Neonatal Med 2020; 35:2128-2134. [PMID: 32602391 DOI: 10.1080/14767058.2020.1782376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: The objective of this study was to assess if maternal and obstetric characteristics other than gestational age at the time of rupture impact short-term neonatal outcomes.Methods: This is a retrospective observational study from a single tertiary care referral center. This study reviewed women with a singleton pregnancy complicated by preterm prelabor rupture of membranes over a 3-year period from May of 2014 through May of 2017. Maternal characteristics and short term neonatal outcomes were collected.Results: We identified 210 pregnancies complicated by preterm prelabor rupture of membranes. Eighteen of these patients had rupture of membranes prior to viability. Of the maternal characteristics at time of admission studied, gestational age at rupture and race influenced short term neonatal outcomes. Women who identified as race other than white had neonates with lower rates of intubation than neonates born to white patients. Gestational age at rupture significantly influenced the neonatal intensive care unit length of stay. Each additional week gained before rupture occurred was associated with a 17.1% decrease in length of stay. Maternal age, gravidity, parity, body mass index, single deepest pocket, and amniotic fluid index did not influence short term neonatal outcomes.Conclusions: Gestational age at rupture of membranes is the most predictive factor associated with short term neonatal outcomes. Race may also influence short term neonatal outcomes. Other maternal characteristics do not seem to influence short term neonatal outcomes. This information can assist with patient counseling on admission for preterm prelabor rupture of membranes and expected neonatal course.
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Affiliation(s)
- Sarada Alla
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Abigail Ramseyer
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie R Whittington
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sara Peeples
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Park GY, Park WS, Sung SI, Kim MS, Lee MH, Jeon GW, Kim SS, Chang YS. Neonatal outcome comparisons between preterm infants with or without early pulmonary hypertension following prolonged preterm premature rupture of membranes before 25 gestational weeks in Korean Neonatal Network. J Matern Fetal Neonatal Med 2020; 35:1286-1294. [PMID: 32228112 DOI: 10.1080/14767058.2020.1749590] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective: To determine the outcomes of very low birth weight infants (VLBWIs) following maternal mid-trimester prolonged preterm premature rupture of membranes (PPROM) and subsequent early pulmonary hypertension (PH).Design: Prospective cohort study.Setting: A nationwide web-based registry of VLBWIs from 67 neonatal intensive care units.Patients: VLBWIs registered on the Korean Neonatal Network and born between 23 and 34 gestational weeks.Methods: VLBWIs exposed to maternal PPROM prior to 25 gestational weeks and lasting ≥7 days (PPROM25, n = 402) were matched 1:1 with infants not exposed or exposed within 24 h to PPROM (CON, n = 402), using propensity score matching. The PPROM25 group was subdivided into PPROM25 groups with or without early PH, defined as exposure to inhaled nitric oxide or other pulmonary vasodilators to treat PH within 3 days of life. Clinical variables and major outcomes were compared, and risk factors for mortality and morbidities were analyzed.Results: Of 1790 infants with maternal PPROM, the PPROM25 group comprised 402 (22.5%) infants. Survival rates were similar between the CON and PPROM25 groups (71.6% vs 74.4%); however, the incidence of bronchopulmonary dysplasia (BPD) differed (47.8% and 60.2%, p < .05). Infants in the PPROM25 group with early PH had higher mortality (55.6%) and more severe intraventricular hemorrhage (IVH) (31.7%) than infants in the PPROM25 group without early PH (21.9% and 14.3%, respectively; p < .05). In multivariate analysis, lower 5 min Apgar score and the presence of oligohydramnios increased the risk of development of early PH. The presence of PPROM25 was founded to be a significant risk factor for BPD and early PH in relation to mortality and severe IVH, respectively.Conclusions: In VLBWIs, prolonged exposure to maternal mid-trimester PPROM increased the risk of BPD. Subsequent early PH immediately after birth increased mortality and severe IVH, thus, requires special attention.
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Affiliation(s)
- Ga Young Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Min Sun Kim
- Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Myung Hee Lee
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Ga Won Jeon
- Department of Pediatrics, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Sung Shin Kim
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Maternal morbidity after early preterm delivery (23-28 weeks). Am J Obstet Gynecol MFM 2020; 2:100125. [PMID: 33345871 DOI: 10.1016/j.ajogmf.2020.100125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/03/2020] [Accepted: 04/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Previous research has focused mainly on neonatal outcomes associated with preterm and periviable delivery, but maternal outcomes with preterm delivery are less well described. OBJECTIVE This study aimed to determine if early preterm delivery results in an increase in maternal morbidity. STUDY DESIGN This is a retrospective cohort study conducted at a tertiary care center over a 5-year time period. Subjects were women identified by review of neonatal intensive care unit admission logs. Women were included if they delivered between 23 0/7 and 28 6/7 weeks' gestation and their neonate was admitted to the neonatal intensive care unit. The prevalence of maternal morbidities was assessed, including blood transfusion, maternal infection, placental abruption, postpartum depression or positive depression screen, hemorrhage, and prolonged maternal postpartum hospitalization. A composite outcome comprising blood transfusion, maternal infectious morbidity, placental abruption, and postpartum depression was developed. Outcomes for women who delivered between 23 0/7 and 25 6/7 weeks' gestation (early group) and 26 0/7 and 28 6/7 weeks' gestation (late group) were compared. Multivariate logistic regression analysis was performed to evaluate contributors to the composite morbidity, controlling for confounding. RESULTS A total of 82 women met the inclusion criteria: 38 in the early group and 44 in the late group. Maternal demographics were similar between the groups. The early group was significantly more likely to experience composite maternal morbidity (60.5% vs 27.3%; P=.004) and infection (42.1% vs 13.6%; P=.006). Regression analysis determined that delivery at a later gestational age was associated with lower rates of composite morbidity (odds ratio, 0.6; 95% confidence interval, 0.41-0.83). CONCLUSION In this study, data suggest that maternal morbidity is higher with delivery at periviable gestational ages. Composite morbidity and maternal infection were more frequent in women who delivered at less than 26 weeks' gestation. The management of women at risk for delivery at early gestational ages should include a discussion of increased maternal complications.
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Sorano S, Fukuoka M, Kawakami K, Momohara Y. Prognosis of preterm premature rupture of membranes between 20 and 24 weeks of gestation: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol X 2019; 5:100102. [PMID: 32021974 PMCID: PMC6994403 DOI: 10.1016/j.eurox.2019.100102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/02/2019] [Accepted: 11/12/2019] [Indexed: 11/22/2022] Open
Abstract
Background The previous study on prognosis of preterm premature rupture of fetal membranes (pPROM) near the limit of viability showed various survival rate raging from 26 to 57 %%. This may be partly due to the fact that treatment of prematurely born babies vary from one country to another, or sometimes within a single country. In Japan, resuscitation efforts are made to newborns of early gestational age, normally from 22 weeks of gestation. Objective To assess the natural history and short- and long-term prognosis in pregnancies complicated by preterm premature rupture of membranes (pPROM) near the limit of viability in a hospital in Japan. Method We conducted a single-center retrospective cohort study. Cases with diagnosis of pPROM at a gestational age of 20–23 6/7 weeks and delivered in our hospital between April 2007 and December 2017 were examined. Result 66 cases were included and of those, 54 (81.1 %) newborns survived to discharge. Of the neonates who survived to discharge, 42 (77.8 % of survivors) experienced severe morbidity at the time of discharge. Multivariate logistic regression analysis showed that later gestational age at pPROM and longer latency period were significantly associated with survival with no severe morbidities (per one day increase, adjusted odds ratio (OR) 1.37, 95 % CI 1.03–1.83, p = 0.033 and per one day increase, adjusted OR 1.11, 95 % CI 1.02–1.21, p = 0.015). Of 23 cases followed at 36 months, 8 (34.8 %) showed developmental delay. Conclusion The survival rate was significantly higher than the previous studies, yet many of the survivors experienced short-term severe morbidity. Of those who experienced short-term severe morbidity, however, more than half showed normal range development at 36 months.
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Affiliation(s)
- Sumire Sorano
- Corresponding author at: Department of Obstetrics and Gynecology, Tokyo Metropolitan Ohtsuka Hospital, 2-8-1 Minamiotsuka, Toshima, Tokyo 170-0005, Japan.
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[Antenatal management in case of preterm premature rupture of membranes before fetal viability: CNGOF Preterm Premature Rupture of Membranes Guidelines]. ACTA ACUST UNITED AC 2018; 46:1076-1088. [PMID: 30409732 DOI: 10.1016/j.gofs.2018.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the maternal, perinatal and long-term prognosis in the event of previable premature rupture of the membranes (PROM) and to specify the interventions likely to reduce the risks and improve the prognosis. METHODS The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS Previable PROM is a rare event whose frequency varies from 0.3 to 1% according to estimates (NP4). When occurring as a complication of amniocentesis, the prognosis is generally better than when spontaneous (NP3). Between 23 and 39% of women will deliver in the week following PROM and nearly 40% of women will not have given birth 2 weeks after (NP3). The frequency of medical termination of pregnancy varies greatly according to the studies (NP4), as does that of fetal death (NP4). Hospital survival and survival rates without major morbidity as a proportion of conservatively treated patients range from 17-55% and 26-63%, respectively (NP4). Neonatal prognosis is largely dominated by prematurity and its complications (NP3). The frequency of maternal sepsis varies from 0.8 to 4.8% in the most recent studies (NP4). Only one case of maternal death is reported, although 3 cases were identified in France between 2007 and 2012 (NP3). Information is a major component of the care to be provided to women and their partners (Professional consensus). An initial period of hospitalization may be proposed after previable PROM (Professional consensus). Thereafter, there is no argument to recommend hospital management rather than extra-hospital management when there is no argument in favour of intrauterine infection (Professional consensus). An evaluation of the amount of amniotic fluid by ultrasound may be proposed at the initial consultation and after a period of 7 to 14 days if pregnancy continues (Professional consensus). Prophylactic antibiotic treatment is recommended as soon as PROM is diagnosed (Professional consensus). The gestational age at which corticosteroid therapy may be proposed will depend on the thresholds selected for neonatal resuscitation care. In particular, it will take into account parental positioning (Professional consensus). From the time of the decision to perform neonatal resuscitation until the gestational age of 32 weeks, it is recommended to administer MgSO4 to the woman whose delivery is imminent (Grade A). Tocolysis is not recommended in this context (Professional consensus). In certain situations, meeting strictly the conditions mentioned by the CSP article L. 2213-1, a maternal request for medical interruption of pregnancy may be discussed. CONCLUSION The levels of evidence of scientific work on the management of previable PROM are low, therefore, most of the recommendations proposed here are based on professional agreement by "reasonable" extension of recommendations valid for later gestational ages.
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Sim WH, Ng H, Sheehan P. Maternal and neonatal outcomes following expectant management of preterm prelabor rupture of membranes before viability. J Matern Fetal Neonatal Med 2018; 33:533-541. [PMID: 29961407 DOI: 10.1080/14767058.2018.1495706] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: To provide center-based outcome data on obstetric and neonatal complications arising from expectantly managed pregnancies affected by preterm prelabor rupture of membranes (PPROM) before viability.Materials and methods: We collected data on 130 consecutive pregnancies complicated by spontaneous rupture of membranes before 24 week's gestation, occurring over a 7-year period. These were women who delivered >24 h after membrane rupture, and had no signs of chorioamnionitis or advanced labor at admission. Women with amniocentesis-induced PPROM (n = 7) were analyzed separately. The descriptive statistics of obstetrics and neonatal outcomes were reported.Results: The overall neonatal survival to discharge rate was 33.8%. Stratification of patients into early (12 to 19+6 weeks' gestation) and late pre-viable PPROM (20 to 23+6 weeks' gestation) revealed a 3.6-fold increase in survival rate in the latter group (12.2% versus 43.8%, p < .001). Pre-viable PPROM following amniocentesis predicted a 100% survival outcome, however anhydramnios impacted negatively. The most common neonatal morbidities of those admitted to intensive care unit were respiratory distress syndrome (78.7%) and bronchopulmonary dysplasia (84.4%). The most common maternal morbidities affecting pre-viable PPROM were clinical chorioamnionitis (47.7%), histological chorioamnionitis (81.8%), retained products of conception (39.3%) and preterm labor (45.4%).Conclusions: Later gestational ages at PPROM were associated with better survival rates, however neonatal morbidity remained high. Women experiencing pre-viable PPROM following amniocentesis can be reassured, while those with anhydramnios at any time during the latency period should be adequately counseled regarding poorer outcomes.
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Affiliation(s)
- Winnie Huiyan Sim
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Pregnancy Research Centre, Royal Women's Hospital, Melbourne, VIC, Australia
| | - Hamon Ng
- Pregnancy Research Centre, Royal Women's Hospital, Melbourne, VIC, Australia
| | - Penelope Sheehan
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Pregnancy Research Centre, Royal Women's Hospital, Melbourne, VIC, Australia
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Kiver V, Boos V, Thomas A, Henrich W, Weichert A. Perinatal outcomes after previable preterm premature rupture of membranes before 24 weeks of gestation. J Perinat Med 2018; 46:555-565. [PMID: 28822226 DOI: 10.1515/jpm-2016-0341] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 07/11/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A current descriptive assessment of perinatal outcomes in pregnancies complicated by previable preterm premature rupture of membranes (pPPROM) at <24 weeks of gestation, after expectant treatment. STUDY DESIGN Maternal and short-term neonatal data were collected for patients with pPPROM. RESULTS Seventy-three patients with 93 fetuses were hospitalized with pPPROM at 15-24 weeks' gestation. Among these patients, 27.4% (n=20) chose pregnancy termination, 27.4% (n=20) miscarried and 45.2% (n=33) proceeded to live births. After a median latency period of 38 days, ranging from 1 to 126 days, 24 singletons and 20 multiples were live-born, of whom 79.5% (n=35) survived the perinatal period. The main neonatal sequelae were pulmonary hypoplasia (29.5%; n=13), connatal infection (56.8%; n=25), intraventricular hemorrhage (25%; n=11; resulting in five neonatal deaths) and Potter's syndrome (15.9%; n=7). Nine newborns died, within an average of 2.8 days (range, 1-10 days). The overall neonatal survival rate was 51.5% - including miscarriages but not elective terminations. The intact survival rate was 45.5% of all live-born neonates. CONCLUSIONS Even with limited treatment options, overall neonatal survival is increasing. However, neonatal mortality and morbidity rates remain high. The gestational age at membrane rupture does not predict neonatal outcome.
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Affiliation(s)
- Verena Kiver
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany, Tel.: +49 (030) 450 664487
| | - Vinzenz Boos
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anke Thomas
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Weichert
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
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20
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Park GY, Park WS, Yoo HS, Ahn SY, Sung SI, Kim SS, Chang YS. Short-term outcomes comparison between preterm infants with and without acute hypoxic respiratory failure attributable to presumed pulmonary hypoplasia after prolonged preterm premature rupture of membranes before 25 gestational weeks. J Matern Fetal Neonatal Med 2018; 32:1938-1945. [DOI: 10.1080/14767058.2017.1421934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ga Young Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Soo Yoo
- Department of Pediatrics, Seoul Metropolitan Children Hospital, Seoul, South Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Shin Kim
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Sung JH, Kuk JY, Cha HH, Choi SJ, Oh SY, Roh CR, Kim JH. Amniopatch treatment for preterm premature rupture of membranes before 23 weeks' gestation and factors associated with its success. Taiwan J Obstet Gynecol 2017; 56:599-605. [DOI: 10.1016/j.tjog.2017.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/26/2022] Open
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23
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Bentsen MH, Satrell E, Reigstad H, Johnsen SL, Vollsæter M, Røksund OD, Greve G, Berg A, Markestad T, Halvorsen T. Mid-childhood outcomes after pre-viable preterm premature rupture of membranes. J Perinatol 2017; 37:1053-1059. [PMID: 28661513 DOI: 10.1038/jp.2017.97] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 04/20/2017] [Accepted: 04/27/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Investigate cardiorespiratory outcomes in children surviving previable preterm premature rupture of membranes (PV-PPROM) before 22 weeks' gestational age (GA) with minimum 2 weeks latency. STUDY DESIGN Single institution, follow-up of retrospectively identified children who were born after PV-PPROM during 2000-2004, and individually matched preterm-born controls. RESULTS Eleven PV-PPROM and matched control children were included at mean age of 10.5 and 10.7 years. Rupture of membranes occurred at mean GA 182 and 276 weeks and birth at 283 and 286 weeks, respectively. Compared to controls, the PV-PPROM group had significantly poorer lung function, findings on echocardiography indicating mild pulmonary hypertension, and lower peak oxygen consumption. Chart reviews suggested more motor difficulties and a tendency towards more problems with learning and attention. CONCLUSION The findings highlight a preterm-born sub-group in need of targeted long-term monitoring and possibly interventions regarding future cardiorespiratory and neurodevelopmental function.
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Affiliation(s)
- M H Bentsen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Odontology, University of Bergen, Norway
| | - E Satrell
- Department of Clinical Science, Faculty of Medicine and Odontology, University of Bergen, Norway
| | - H Reigstad
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - S L Johnsen
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - M Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Odontology, University of Bergen, Norway
| | - O D Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Occupational Therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway
| | - G Greve
- Department of Clinical Science, Faculty of Medicine and Odontology, University of Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - A Berg
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Odontology, University of Bergen, Norway
| | - T Markestad
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Odontology, University of Bergen, Norway
| | - T Halvorsen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Odontology, University of Bergen, Norway
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25
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Sim WH, Araujo Júnior E, Da Silva Costa F, Sheehan PM. Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability. J Perinat Med 2017; 45:29-44. [PMID: 27780154 DOI: 10.1515/jpm-2016-0183] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/29/2016] [Indexed: 11/15/2022]
Abstract
AIM To assess the contemporary maternal and neonatal outcomes following expectant management of preterm premature rupture of membranes (PPROM) prior to 24 weeks' gestation and to identify prognostic indicators of this morbid presentation. METHODS We performed a systematic review in the Pubmed and EMBASE databases to identify the primary (perinatal mortality, severe neonatal morbidity and serious maternal morbidity) and secondary (neonatal survival and morbidity) outcomes following expectant management of previable PPROM. RESULTS Mean latency between PPROM and delivery ranged between 20 and 43 days. Women with PPROM <24 weeks had an overall live birth rate of 63.6% and a survival-to-discharge rate of 44.9%. The common neonatal morbidities were respiratory distress syndrome, bronchopulmonary dysplasia and sepsis. The majority of neonatal deaths within 24 h post birth were associated with pulmonary hypoplasia, severe intraventricular haemorrhage and neonatal sepsis. The common maternal outcomes were chorioamnionitis and caesarean sections. The major predictors of neonatal survival were later gestational age at PPROM, adequate residual amniotic fluid levels, C-reactive protein <1 mg/dL within 24 h of admission and PPROM after invasive procedures. CONCLUSION Pregnancy latency and neonatal survival following previable PPROM has improved in recent years, although neonatal morbidity remains unchanged despite recent advances in obstetric and neonatal care. There is heterogeneity in management practices across centres worldwide.
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Ecker JL, Kaimal A, Mercer BM, Blackwell SC, deRegnier RAO, Farrell RM, Grobman WA, Resnik JL, Sciscione AC, Sciscione AC. Periviable birth: Interim update. Am J Obstet Gynecol 2016; 215:B2-B12.e1. [PMID: 27103153 DOI: 10.1016/j.ajog.2016.04.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.
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Outcomes of Pregnancies Complicated by Preterm Premature Rupture of Membranes Between 20 and 24 Weeks of Gestation. Obstet Gynecol 2016; 128:313-320. [DOI: 10.1097/aog.0000000000001530] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McLaughlin LM, Gardener GJ. Neonatal outcomes after prelabour rupture of membranes before 24 weeks' gestation. J Paediatr Child Health 2016; 52:722-7. [PMID: 27439632 DOI: 10.1111/jpc.13210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to determine neonatal outcomes in pregnancies complicated by prelabour rupture of membranes (PROM) before 24 weeks' gestation. METHODS We performed a retrospective review of medical records over a 5-year period (2007-2011) at Mater Health Services, South Brisbane, Australia. Data relating to the antenatal and perinatal course of pregnancies complicated by PROM before 24 weeks' gestation were collected. Data were also collected on neonatal diagnoses, management and outcomes for all liveborn infants resulting from these pregnancies. RESULTS One hundred and six pregnancies were complicated by PROM before 24 weeks' gestation. Thirty-three (31%) of these pregnancies resulted in delivery at pre-viable gestations (<23 weeks). There were 36 (37%) infants who survived to hospital discharge. At discharge, 47% of infants had chronic lung disease, with 81% of this group requiring supplemental oxygen at home. CONCLUSIONS Almost one-third of pregnancies complicated by PROM before 24 weeks resulted in pre-viable preterm delivery. In pregnancies continuing to a viable gestation, there remained a significant risk of neonatal mortality and morbidity, primarily due to respiratory disease.
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Affiliation(s)
- Linda M McLaughlin
- Department of Neonatology, Mater Mothers' Hospital, South Brisbane, Queensland, Australia.,Department of Paediatrics and Child Health, The University of Queensland, Mater Health Services, South Brisbane, Queensland, Australia
| | - Glenn J Gardener
- Mater Centre for Maternal Fetal Medicine, Mater Mothers' Hospital, South Brisbane, Queensland, Australia
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Linehan LA, Walsh J, Morris A, Kenny L, O'Donoghue K, Dempsey E, Russell N. Neonatal and maternal outcomes following midtrimester preterm premature rupture of the membranes: a retrospective cohort study. BMC Pregnancy Childbirth 2016; 16:25. [PMID: 26831896 PMCID: PMC4734873 DOI: 10.1186/s12884-016-0813-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 01/22/2016] [Indexed: 11/18/2022] Open
Abstract
Background Preterm premature rupture of membranes (PPROM) complicates 1 % of all pregnancies and occurs in one third of all preterm deliveries. Midtrimester PPROM is often followed by spontaneous miscarriage and elective termination of ongoing pregnancies is offered in many countries. The aim of this retrospective descriptive cohort study was to investigate the natural history of midtrimester PPROM in a jurisdiction where termination of pregnancy in the absence of maternal compromise is unavailable. Methods Cases of midtrimester PPROM diagnosed between 14 and 23 + 6 weeks’ gestation during April 2007 to June 2012 were identified following a manual search of all birth registers, pregnancy loss registers, annual reports, ultrasound reports, emergency room registers and neonatal death certificates at Cork University Maternity Hospital - a large (circa 8500 births per annum) tertiary referral maternity hospital in southwest Ireland. Cases where delivery occurred within 24 h of PPROM were excluded. Results The prevalence of midtrimester PPROM was 0.1 % (42 cases/44,667 births). The mean gestation at PPROM was 18 weeks. The mean gestation at delivery was 20 + 5 weeks, with an average latency period of 13 days. Ten infants were born alive (23 %; 10/42). The remainder (77 %; 32/42) died in utero or intrapartum. Nine infants were resuscitated. Two infants survived to discharge. The overall mortality rate was 95 % (40/42). Five women had clinical chorioamnionitis (12 %; 5/42) but 69 % demonstrated histological chorioamnionitis. One woman developed sepsis (2.4 %; 1/42). Other maternal complications included requirement of intravenous antibiotic treatment (38 %; 17/42), retained placenta (21 %, 9/42) and post-partum haemorrhage (12 %; 5/42). Conclusions This study provides useful and contemporary data on midtrimester PPROM. Whilst fetal and neonatal mortality is high, long-term survival is not impossible. The increased risk of maternal morbidity necessitates close surveillance. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-0813-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Aoife Linehan
- The Department of Obstetrics and Gynaecology, University College Cork and Cork University Hospital, Cork, Ireland.
| | - Jennifer Walsh
- The Department of Obstetrics and Gynaecology, University College Cork and Cork University Hospital, Cork, Ireland
| | - Aoife Morris
- The Department of Obstetrics and Gynaecology, University College Cork and Cork University Hospital, Cork, Ireland
| | - Louise Kenny
- The Department of Obstetrics and Gynaecology, University College Cork and Cork University Hospital, Cork, Ireland.,The Irish Centre for Fetal and Neonatal Translational Research, Cork, Ireland
| | - Keelin O'Donoghue
- The Department of Obstetrics and Gynaecology, University College Cork and Cork University Hospital, Cork, Ireland
| | - Eugene Dempsey
- The Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Noirin Russell
- The Department of Obstetrics and Gynaecology, University College Cork and Cork University Hospital, Cork, Ireland
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Ecker JL, Kaimal A, Mercer BM, Blackwell SC, deRegnier RAO, Farrell RM, Grobman WA, Resnik JL, Sciscione AC, Sciscione AC. #3: Periviable birth. Am J Obstet Gynecol 2015; 213:604-14. [PMID: 26506448 DOI: 10.1016/j.ajog.2015.08.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.
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Short-Term and Long-Term Postnatal Outcomes of Expectant Management After Previable Preterm Premature Rupture of Membranes With and Without Persistent Oligohydramnios. Obstet Gynecol 2015; 126:947-953. [DOI: 10.1097/aog.0000000000001099] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Acaia B, Crovetto F, Ossola MW, Nozza S, Baffero GM, Somigliana E, Pietrasanta C, Pugni L, Mosca F, Fedele L. Predictive factors for neonatal survival in women with periviable preterm rupture of the membranes. J Matern Fetal Neonatal Med 2013; 26:1628-34. [PMID: 23570530 DOI: 10.3109/14767058.2013.794206] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify clinical, hematological or instrumental factors available at the time of the diagnosis that may predict neonatal survival in periviable preterm premature rupture of the membranes (PROM). METHODS We report on a cohort (n = 85) of women with periviable PROM (14-23.6 weeks' gestation) occurring over a 10-year period in a single institution. The main outcome chosen was the survival rate beyond the neonatal period. Variables considered were those available at 24 h after admission. RESULTS The overall survival rate was 49%. In the multivariate analysis, significant contributions for the prediction of neonatal survival were provided by four variables: genetic amniocentesis-related cause of PROM (p < 0.001), gestational age at PROM (p = 0.019), CRP > 1 mg/dl within 24 h after admission (p = 0.042) and oligohydramnios (largest vertical pocket ≤2 cm) (p = 0.041). The corresponding adjusted odds ratio (OR)s were 73.9 (95% CI: 7.9-694.7), 1.5 (95% CI: 1.1-2.0) per week, 0.26 (95% CI: 0.07-0.95) and 0.20 (95% CI: 0.04-0.93), respectively. CONCLUSIONS Genetic amniocentesis-related cause of PROM, gestational age at PROM, C-reactive protein >1 mg/dl and oligohydramnios are significantly associated with survival in women with periviable PROM. The evaluation of these few and easily available variables may help physicians and patients in the decision-making process of this demanding condition.
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Affiliation(s)
- Barbara Acaia
- Department of Obstetrics and Gynecology , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico
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Current world literature. Curr Opin Obstet Gynecol 2012; 24:470-8. [PMID: 23154665 DOI: 10.1097/gco.0b013e32835ae910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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