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Williamson M, Dong S, D'Souza R, Brignardello-Petersen R, Ronzoni S. Outpatient versus inpatient management of preterm prelabor rupture of membranes: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024. [PMID: 38946314 DOI: 10.1111/aogs.14903] [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: 01/17/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION To compare neonatal, obstetrical, and maternal outcomes associated with outpatient versus inpatient management of pregnancies with preterm prelabor rupture of membranes (PPROM). MATERIAL AND METHODS A search of MEDLINE, EMBASE, the Cochrane Database and Central Register from January 1, 1990 to July 31, 2023 identified randomized controlled trials (RCTs) and cohort studies comparing outpatient with inpatient management for pregnant persons diagnosed with PPROM before 37 weeks' gestation. No language restriction was applied. We applied a random effects model for meta-analysis. Trustworthiness was assessed using recently published guidance and Risk of bias using the RoB 2.0 tool for RCTs and ROBINS-I tool for cohort studies. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the certainty of evidence (COE). Outcomes of interest included perinatal mortality, neonatal morbidities, latency and gestational age at delivery, and maternal morbidities. RCTs and cohort studies were analyzed separately. This study was registered in the International Prospective Register of Systematic Reviewsr: CRD42022295275. RESULTS From 2825 records, two RCTs and 10 cohort studies involving 1876 patients were included in the review and meta-analysis. Outpatient management protocols varied but generally included brief initial hospitalization, strict eligibility criteria, and surveillance with laboratory and ultrasound investigations. Outpatient management showed lower rates of neonatal respiratory distress syndrome (cohort: RR 0.63 [0.52-0.77, very low COE]), longer latency to delivery (RCT: MD 7.43 days [1.14-13.72 days, moderate COE], cohort: MD 8.78 days [2.29-15.26 days, low COE]), higher gestational age at birth (cohort: MD 7.70 days [2.02-13.38 days, low COE]), lower rates of Apgar scores <7 at 5 min of life (cohort: RR 0.66 [0.50-0.89, very low COE]), and lower rates of histological chorioamnionitis (cohort: RR 0.74 [0.62-0.89, low COE]) without increased risks of adverse neonatal, obstetrical, or maternal outcomes. CONCLUSIONS Meta-analysis of data from RCTs and cohort studies with very low-to-moderate certainty of evidence indicates that further high-quality research is needed to evaluate the safety and potential benefits of outpatient management for selected PPROM cases, given the moderate-to-high risk of bias in the included studies.
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Affiliation(s)
- Monica Williamson
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan Dong
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Stefania Ronzoni
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Fetal Medicine Unit, Ontario Fetal Center, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Powell JM, Frank ZC, Clark GV, Lo JO, Caughey AB. Expectant management of preterm premature rupture of membranes at 34 weeks: a cost effectiveness analysis. J Matern Fetal Neonatal Med 2022; 35:9136-9144. [PMID: 34915811 PMCID: PMC10148142 DOI: 10.1080/14767058.2021.2017874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine the outcomes and cost effectiveness of expectant management versus immediate delivery of women who experience preterm premature rupture of membranes (PPROM) at 34 weeks. METHODS A cost-effectiveness model was built using TreeAge software to compare outcomes in a theoretical cohort of 37,455 women with PPROM at 34 weeks undergoing expectant management until 37 weeks versus immediate delivery. Outcomes included fetal death, neonatal sepsis, neonatal death, neonatal neurodevelopmental delay, healthy neonate, maternal sepsis, maternal death, cost, and quality-adjusted life years. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000 per quality-adjusted life year. RESULTS In our theoretical cohort of 37,455 women, expectant management yielded 58 fewer neonatal deaths and 164 fewer cases of neonatal neurodevelopmental delay. However, it resulted in 407 more cases of neonatal sepsis and 2.7 more cases of maternal sepsis. Expectant management resulted in 3,531 more quality-adjusted life years and a cost savings of $71.9 million per year, making it a dominant strategy. Univariate sensitivity analysis demonstrated expectant management was cost effective until the weekly cost of antepartum admission exceeded $17,536 (baseline estimate: $12,520) or the risk of maternal sepsis following intraamniotic infection exceeded 20%. CONCLUSION Our model demonstrated that expectant management of PPROM at 34 weeks yielded better outcomes on balance at a lower cost than immediate delivery. This analysis is important and timely in light of recent studies suggesting improved neonatal outcomes with expectant management. However, individual risks and preferences must be considered in making this clinical decision as expectant management may increase the risk of adverse perinatal outcomes when the risk of puerperal infection increases.
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Affiliation(s)
- Jacqueline M Powell
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Zoë C Frank
- Department of Obstetrics & Gynecology, Creighton University Arizona Health Education Alliance, Phoenix, AZ, USA
| | - Grace V Clark
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Jamie O Lo
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
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Rath W, Maul H, Kyvernitakis I, Stelzl P. Preterm Premature Rupture of Membranes – Inpatient Versus Outpatient Management: an Evidence-Based Review. Geburtshilfe Frauenheilkd 2022; 82:410-419. [PMID: 35392068 PMCID: PMC8983112 DOI: 10.1055/a-1515-2801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the increasing burden on
obstetric departments and the growing importance of satisfaction and right to self-determination in pregnant women, outpatient management in PPROM is a possible alternative to inpatient
monitoring. The most important criterion for this approach is to ensure the safety of both the mother and the child. Due to the small number of cases (n = 116), two randomised controlled
trials (RCTs) comparing inpatient and outpatient management were unable to draw any conclusions. By 2020, eight retrospective comparative studies (cohort/observational studies) yielded the
following outcomes: no significant differences in the rate of maternal complications (e.g., chorioamnionitis, premature placental abruption, umbilical cord prolapse) and in neonatal
morbidity, significantly prolonged latency period with higher gestational age at birth, higher birth weight of neonates, and significantly shorter length of stay of preterm infants in
neonatal intensive care, shorter hospital stay of pregnant women, and lower treatment costs with outpatient management. Concerns regarding this approach are mainly related to unpredictable
complications with the need for rapid obstetric interventions, which cannot be performed in time in an outpatient setting. Prerequisites for outpatient management are the compliance of the
expectant mother, the adherence to strict selection criteria and the assurance of adequate monitoring at home. Future research should aim at more accurate risk assessment of obstetric
complications through studies with higher case numbers and standardisation of outpatient management under evidence-based criteria.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät, Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Holger Maul
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, c/o. Asklepios Klinik Barmbek, Hamburg, Germany
| | - Ioannis Kyvernitakis
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, c/o. Asklepios Klinik Barmbek, Hamburg, Germany
| | - Patrick Stelzl
- Universitätsklinik für Gynäkologie, Geburtshilfe und Gynäkologische Endokrinologie, Kepler Universitätsklinikum, Johannes Kepler Universität Linz, Linz, Austria
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Ronzoni S, Cobo T, D’Souza R, Asztalos E, O’Rinn SE, Cao X, Herranz A, Melamed N, Ferrero S, Barrett J, Aldecoa V, Palacio M. Individualized treatment of preterm premature rupture of membranes to prolong the latency period, reduce the rate of preterm birth, and improve neonatal outcomes. Am J Obstet Gynecol 2022; 227:296.e1-296.e18. [PMID: 35257664 DOI: 10.1016/j.ajog.2022.02.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/05/2022] [Accepted: 02/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Preterm premature rupture of membranes complicates approximately 3% of pregnancies. Currently, in the absence of chorioamnionitis or placental abruption, expectant management, including antenatal steroids for lung maturation and prophylactic antibiotic treatment, is recommended. The benefits of individualized management have not been adequately explored. OBJECTIVE This study aimed to compare the impact of 2 different management strategies of preterm premature rupture of membranes in 2 tertiary obstetrical centers on latency of >7 days, latency to birth, chorioamnionitis, funisitis, and short-term adverse maternal and neonatal outcomes. STUDY DESIGN This was a multicenter retrospective study of women with singleton pregnancies with preterm premature rupture of membranes from 23 0/7 to 33 6/7 weeks of gestation between 2014 and 2018 and undelivered within 24 hours after hospital admission managed at Sunnybrook Health Sciences Center, Toronto, Canada (standard management group), and BCNatal (Hospital Clínic of Barcelona and Hospital Sant Joan de Déu Barcelona), Barcelona, Spain (individualized management group), following local protocols. The standard management group received similar management for all patients, which included a standard antibiotic regimen and routine maternal and fetal surveillance, whereas the individualized management group received personalized management on the basis of amniocentesis at hospital admission (if possible), to rule out microbial invasion of the amniotic cavity and targeted treatment. The exclusion criteria were cervical dilatation >2 cm, active labor, contraindications to expectant management (acute chorioamnionitis, placental abruption, or abnormal fetal tracing), and major fetal anomalies. The primary outcome was latency of >7 days, and the secondary outcomes included latency to birth, chorioamnionitis, and short-term adverse maternal and neonatal outcomes. Statistical comparisons between groups were conducted with propensity score weighting. RESULTS A total of 513 pregnancies with preterm premature rupture of membranes were included in this study: 324 patients received standard management, and 189 patients received individualized management, wherein amniocentesis was performed in 112 cases (59.3%). After propensity score weighting, patients receiving individualized management had a higher latency of >7 days (76.0% vs 41.6%; P<.001) and latency to birth (18.1±14.7 vs 9.7±9.7 days; P<.001). Although a higher rate of clinical chorioamnionitis was suspected in the individualized management group than the standard group (34.5% vs 22.0%; P<.01), there was no difference between the groups in terms of histologic chorioamnionitis (67.2% vs 73.4%; P=.16), funisitis (57.6% vs 58.1%; P=.92), or composite infectious maternal outcomes (9.1% vs 7.9%; P=.64). Prolonged latency in the individualized management group was associated with a significant reduction of preterm birth at <32 weeks of gestation (72.1% vs 90.5%; P<.001), neonatal intensive care unit admission (75.6% vs 83.0%; P=.046), and neonatal respiratory support at 28 days of life (16.1% vs 26.1%; P<.01) compared with that in the standard management group. Moreover, prolonged latency was not associated with neonatal severe morbidity at discharge (survival without severe morbidity, 80.4% vs 73.5%; P=.09). CONCLUSION Individualized management of preterm premature rupture of membranes may prolong pregnancy and reduce preterm birth at <32 weeks of gestation, the need for neonatal support, and neonatal intensive care unit admissions, without an increase in histologic chorioamnionitis, funisitis, neonatal infection-related morbidity, and short-term adverse maternal and neonatal outcomes.
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Lorthe E, Letouzey M, Torchin H, Foix L'helias L, Gras-Le Guen C, Benhammou V, Boileau P, Charlier C, Kayem G. Antibiotic prophylaxis in preterm premature rupture of membranes at 24-31 weeks' gestation: perinatal and 2-year outcomes in the EPIPAGE-2 cohort. BJOG 2021; 129:1560-1573. [PMID: 34954867 PMCID: PMC9546066 DOI: 10.1111/1471-0528.17081] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/05/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022]
Abstract
Objective To compare different antibiotic prophylaxis administered after preterm premature rupture of membranes to determine whether any were associated with differences in obstetric and/or neonatal outcomes and/or neurodevelopmental outcomes at 2 years of corrected age. Design Prospective, nationwide, population‐based EPIPAGE‐2 cohort study of preterm infants. Setting France, 2011. Sample We included 492 women with a singleton pregnancy and a diagnosis of preterm premature rupture of membranes at 24–31 weeks. Exclusion criteria were contraindication to expectant management or indication for antibiotic therapy other than preterm premature rupture of membranes. Antibiotic prophylaxis was categorised as amoxicillin (n = 345), macrolide (n = 30), third‐generation cephalosporin (n = 45) or any combinations covering Streptococcus agalactiae and >90% of Escherichia coli (n = 72), initiated within 24 hours after preterm premature rupture of membranes. Methods Population‐averaged robust Poisson models. Main Outcome Measures Survival at discharge without severe neonatal morbidity, 2‐year neurodevelopment. Results With amoxicillin, macrolide, third‐generation cephalosporin and combinations, 78.5%, 83.9%, 93.6% and 86.0% of neonates were discharged alive without severe morbidity. The administration of third‐generation cephalosporin or any E. coli‐targeting combinations was associated with improved survival without severe morbidity (adjusted risk ratio 1.25 [95% confidence interval 1.08–1.45] and 1.10 [95 % confidence interval 1.01–1.20], respectively) compared with amoxicillin. We evidenced no increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen. Conclusion In preterm premature rupture of membranes at 24–31 weeks, antibiotic prophylaxis based on third‐generation cephalosporin may be associated with improved survival without severe neonatal morbidity when compared with amoxicillin, with no evidence of increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen. Tweetable Abstract Antibiotic prophylaxis after PPROM at 24–31 weeks: 3rd‐generation cephalosporins associated with improved neonatal outcomes. Antibiotic prophylaxis after PPROM at 24–31 weeks: 3rd‐generation cephalosporins associated with improved neonatal outcomes.
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Affiliation(s)
- Elsa Lorthe
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathilde Letouzey
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Neonatal Pediatrics, Poissy Saint Germain Hospital, Versailles Saint Quentin en Yvelines University, France
| | - Héloïse Torchin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Neonatal Pediatrics, Cochin Port Royal Hospital, APHP, Paris, France
| | - Laurence Foix L'helias
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Neonatal Pediatrics, Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Christèle Gras-Le Guen
- Department of pediatrics, pediatrics emergency unit and general pediatrics, Nantes University Hospital, hôpital Mère-Enfant, CHU de Nantes, 7, quai Moncousu, 44000, Nantes, France
| | - Valérie Benhammou
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France
| | - Pascal Boileau
- Department of Neonatal Pediatrics, Poissy Saint Germain Hospital, Versailles Saint Quentin en Yvelines University, France.,UFR des sciences de la Santé Simone Veil, Versailles St Quentin en Yvelines University, Montigny le Bretonneux, France
| | - Caroline Charlier
- Université de Paris, Hôpital Universitaire Necker-Enfants Malades, Division of Infectious Diseases and Tropical Medicine, Assistance Publique-Hôpitaux de Paris, Institut Pasteur, Biology of Infection Unit, French National Reference Center and WHO Collaborating Center for Listeria, Inserm U1117, Paris, France
| | - Gilles Kayem
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Gynecology and Obstetrics, Trousseau Hospital, APHP, Sorbonne University, Paris, France
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Lorthe E, Kayem G. Tocolysis in the management of preterm prelabor rupture of membranes at 22-33 weeks of gestation: study protocol for a multicenter, double-blind, randomized controlled trial comparing nifedipine with placebo (TOCOPROM). BMC Pregnancy Childbirth 2021; 21:614. [PMID: 34496799 PMCID: PMC8425321 DOI: 10.1186/s12884-021-04047-2] [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: 07/30/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022] Open
Abstract
Background Preterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation complicates 1% of pregnancies and accounts for one-third of preterm births. International guidelines recommend expectant management, along with antenatal steroids before 34 weeks and antibiotics. Up-to-date evidence about the risks and benefits of administering tocolysis after PPROM, however, is lacking. In theory, reducing uterine contractility could delay delivery and reduce the risks of prematurity and its adverse short- and long-term consequences, but it might also prolong fetal exposure to inflammation, infection, and acute obstetric complications, potentially associated with neonatal death or long-term sequelae. The primary objective of this study is to assess whether short-term (48 h) tocolysis reduces perinatal mortality/morbidity in PPROM at 22 to 33 completed weeks of gestation. Methods A randomized, double-blind, placebo-controlled, superiority trial will be performed in 29 French maternity units. Women with PPROM between 220/7 and 336/7 weeks of gestation, a singleton pregnancy, and no condition contraindicating expectant management will be randomized to receive a 48-hour oral treatment by either nifedipine or placebo (1:1 ratio). The primary outcome will be the occurrence of perinatal mortality/morbidity, a composite outcome including fetal death, neonatal death, or severe neonatal morbidity before discharge. If we assume an alpha-risk of 0.05 and beta-risk of 0.20 (i.e., a statistical power of 80%), 702 women (351 per arm) are required to show a reduction of the primary endpoint from 35% (placebo group) to 25% (nifedipine group). We plan to increase the required number of subjects by 20%, to replace any patients who leave the study early. The total number of subjects required is thus 850. Data will be analyzed by the intention-to-treat principle. Discussion This trial will inform practices and policies worldwide. Optimized prenatal management to improve the prognosis of infants born preterm could benefit about 50,000 women in the European Union and 40,000 in the United States each year. Trial registration ClinicalTrials.gov identifier: NCT03976063 (registration date June 5, 2019). Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04047-2.
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Affiliation(s)
- Elsa Lorthe
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Gilles Kayem
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France. .,Department of Gynecology and Obstetrics, Trousseau Hospital, APHP, FHU Prema, Sorbonne University, Paris, France.
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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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Abstract
There is an association between vaginal microbiota dysbiosis and preterm premature rupture of membranes (PPROM). In PPROM, reduced Lactobacillus spp abundance is linked to the emergence of high-risk vaginal microbiota, close to the time of membrane rupture. Although PPROM itself can change vaginal microbial composition, antibiotic therapy profoundly effects community structure. Erythromycin may have a beneficial effect in women deplete in Lactobacillus spp but damages a healthy microbiome by targeting Lactobacillus spp. Increased rates of chorioamnionitis and early-onset neonatal sepsis are associated with vaginal microbiota dysbiosis close to the time of delivery.
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Mendez-Figueroa H, Chauhan SP. Tocolytic Therapy in Preterm Premature Rupture of Membranes. Obstet Gynecol Clin North Am 2020; 47:569-586. [PMID: 33121645 DOI: 10.1016/j.ogc.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
"Trials evaluating tocolytic use in preterm premature rupture of membranes (PPROM) have been small and lacked adequate power to evaluate uncommon outcomes. There still is much controversy on the benefit, length of use, route, and drug of choice among clinicians treating patients with PPROM. Most professional medical societies would propose to consider the use of tocolytics for 48 hours to allow for corticosteroid administration or to allow for maternal transfer to a higher level of care. Longer treatment regimens may lead to adverse maternal and perinatal outcomes. Insufficient data are available to make stronger and more definitive recommendations."
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Affiliation(s)
- Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), 6431 Fannin Street, MSB 3.264, Houston, TX 77030, USA.
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), 6431 Fannin Street, MSB 3.264, Houston, TX 77030, USA
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Unit policies regarding tocolysis after preterm premature rupture of membranes: association with latency, neonatal and 2-year outcomes (EPICE cohort). Sci Rep 2020; 10:9535. [PMID: 32533019 PMCID: PMC7293322 DOI: 10.1038/s41598-020-65201-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 04/29/2020] [Indexed: 11/09/2022] Open
Abstract
After preterm premature rupture of membranes (PPROM), antibiotics and antenatal steroids are effective evidence-based interventions, but the use of tocolysis is controversial. We investigated whether a unit policy of tocolysis use after PPROM is associated with prolonged gestation and improved outcomes for very preterm infants in units that systematically use these other evidence-based treatments. From the prospective, observational, population-based EPICE cohort study (all very preterm births in 19 regions from 11 European countries, 2011-2012), we included 607 women with a singleton pregnancy and PPROM at 24-29 weeks' gestation, of whom 101, 195 and 311 were respectively managed in 17, 32 and 45 units with no-use, restricted and liberal tocolysis policies for PPROM. The association between unit policies and outcomes (early-onset sepsis, survival at discharge, survival at discharge without severe morbidity and survival at two years without gross motor impairment) was investigated using three-level random-intercept logistic regression models, showing no differences in neonatal or two-year outcomes by unit policy. Moreover, there was no association between unit policies and prolongation of gestation in a multilevel survival analysis. Compared to a unit policy of no-use of tocolysis after PPROM, a liberal or restricted policy is not associated with improved obstetric, neonatal or two-year outcomes.
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Questionnaire survey on the management of pregnant women with preterm premature rupture of membranes. Obstet Gynecol Sci 2020; 63:286-292. [PMID: 32489973 PMCID: PMC7231944 DOI: 10.5468/ogs.2020.63.3.286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/22/2019] [Accepted: 11/13/2019] [Indexed: 11/08/2022] Open
Abstract
Objective The aim of this survey was to study the status of the actual practice in the management of preterm premature rupture of membranes (PPROM) between 34.0 and 36.6 weeks of gestation. Methods This survey was designed for obstetricians who work in secondary or tertiary medical institutions and attended the Korean Society of Maternal Fetal Medicine conference held on July 1, 2017, in Korea, using a structured questionnaire consisting of 5 questions. Results The most commonly used antibiotic was cephalosporin monotherapy (34.5%). Antenatal corticosteroids were applied up to 34.0 weeks of gestation in half of the respondents. The frequency of expectant management was higher than that of immediate delivery in women with PPROM between 34.0 and 36.6 weeks of gestation (57.4%). The most important factor in determining immediate delivery was the symptoms of chorioamnionitis. Conclusion The present survey showed a considerable variation in the actual management of PPROM in women, especially the optimal timing of delivery. More evidenced-based studies with statistical power are required to decrease the heterogeneity of clinical practice.
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Thomson AJ. Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24 +0 Weeks of Gestation: Green-top Guideline No. 73. BJOG 2019; 126:e152-e166. [PMID: 31207667 DOI: 10.1111/1471-0528.15803] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chackowicz A, Czuzoj-Shulman N, Abenhaim HA. The effects of tocolysis on neonatal septic death in women with PPROM: a retrospective cohort study. Arch Gynecol Obstet 2018; 298:897-902. [PMID: 30206736 DOI: 10.1007/s00404-018-4871-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 08/14/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE In women with preterm premature rupture of membranes (PPROM), particularly those with suspected chorioamnionitis, the benefit of tocolysis on neonatal outcome remains unclear. Our purpose was to evaluate the effect of tocolysis on neonatal septic death in women with PPROM with and without chorioamnionitis. METHODS A retrospective cohort study was used to address our study objective. We created a cohort consisting of all live births between 24 and 32 weeks' gestation that were registered in the Linked Birth and Infant Death data files (2009-2013) from the United States. Multivariate logistic regression was used to evaluate the effect of tocolysis on neonatal septic death at 7 and 28 days in births with and without chorioamnionitis. RESULTS Of the 46,968 births that met our inclusion criteria, tocolysis was administered to 6264 (13.3%). Tocolysis was more commonly prescribed to Caucasians, smokers, in multiple birth pregnancies, and to women with a history of preterm births. Tocolysis was not significantly associated with neonatal septic death at 7 days (OR 0.66, 95% CI 0.39-1.13) or at 28 days (OR 0.85, 95% CI 0.60-1.19). This was consistent in pregnancies with and without chorioamnionitis. Furthermore, tocolysis was associated with a reduced risk of neonatal septic death at 7 days when administered between 24 and 27 weeks' gestation (OR 0.44, 95% CI 0.22-0.88). CONCLUSIONS In the setting of PPROM, tocolysis does not appear to increase the risk of neonatal septic death at 7 and 28 days. Therefore, consideration should be given to its administration if clinically indicated.
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Affiliation(s)
- Ariel Chackowicz
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
| | - Nicholas Czuzoj-Shulman
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
| | - Haim Arie Abenhaim
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada. .,Department of Obstetrics and Gynecology and Epidemiology, Jewish General Hospital, McGill University, 5790 Cote-des-Neiges, H412, Montreal, QC, H3T 1E2, Canada.
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14
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Pettit KE, Caballero A, Wakefield BW, Dudley DJ, Ferguson JE, Boyle A, Chisholm CA. Targeted delivery at 34 versus 35 weeks in women with preterm prelabor rupture of membranes. J Matern Fetal Neonatal Med 2018; 32:3331-3335. [DOI: 10.1080/14767058.2018.1463365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Kate E. Pettit
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Amaya Caballero
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Brian W. Wakefield
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Donald J. Dudley
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Virginia, Charlottesville, VA, USA
| | - James E. Ferguson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Annelee Boyle
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Christian A. Chisholm
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Virginia, Charlottesville, VA, USA
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15
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Rewatkar M, Jain S, Jain M, Mohod K. C-reactive protein and white blood cell count as predictors of maternal and neonatal infections in prelabour rupture of membranes between 34 and 41 weeks of gestation. J OBSTET GYNAECOL 2018; 38:622-628. [PMID: 29430983 DOI: 10.1080/01443615.2017.1398221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Prelabour rupture of the membranes (PLROM) is defined as rupture of membranes before the onset of labour. It is one of the most common clinical events, where pregnancy can turn into a high-risk situation for mother and foetus. As prevention of PLROM is difficult, one has to concentrate on management to reduce its complications. Accurate prediction of infection remains a main challenge in cases of PLROM. We conducted a prospective study of all women admitted for PLROM at or after 34-41 weeks of gestation to investigate the predictive value of C-reactive protein (CRP) and white blood cell (WBC) count for early-onset neonatal infection (EONI) and maternal chorioamnionitis. The analysis was done by comparing areas under ROC curves and sensitivity. Lowest best cut off of maternal serum CRP level >4.9 mg/l and lowest cut off of WBC count 12,450/cumm have good predictive values for maternal chorioamnionitis and EONI. Impact statement What is already known on this subject? The ability to detect chorioamnionitis and predict neonatal infection at an early stage would be helpful in its treatment and would make it possible to prolong the pregnancy. What do the results of this study add? Maternal serum CRP level and WBC count obtained at admission are predictors of chorioamnionitis and EONI although WBC count alone is not a good indicator of them. A lowest best cut off of serum CRP level >4.9 mg/l and lowest cut off of WBC count 12,450/cumm have good predictive values for maternal chorioamnionitis and EON. What are the implications of these findings for clinical practice and/or further research? We propose that maternal serum CRP level and WBC count should be used as screening test for EONI and chorioamnionitis rather than a diagnostic test.
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Affiliation(s)
- Manisha Rewatkar
- a Department of Obstetrics & Gynaecology , MGIMS , Sevagram , India
| | - Shuchi Jain
- a Department of Obstetrics & Gynaecology , MGIMS , Sevagram , India
| | - Manish Jain
- b Department of Paediatrics , MGIMS , Sevagram , India
| | - Kanchan Mohod
- c Department of Biochemistry , MGIMS , Sevagram , India
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16
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Brown RG, Marchesi JR, Lee YS, Smith A, Lehne B, Kindinger LM, Terzidou V, Holmes E, Nicholson JK, Bennett PR, MacIntyre DA. Vaginal dysbiosis increases risk of preterm fetal membrane rupture, neonatal sepsis and is exacerbated by erythromycin. BMC Med 2018; 16:9. [PMID: 29361936 PMCID: PMC5782380 DOI: 10.1186/s12916-017-0999-x] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/20/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Preterm prelabour rupture of the fetal membranes (PPROM) precedes 30% of preterm births and is a risk factor for early onset neonatal sepsis. As PPROM is strongly associated with ascending vaginal infection, prophylactic antibiotics are widely used. The evolution of vaginal microbiota compositions associated with PPROM and the impact of antibiotics on bacterial compositions are unknown. METHODS We prospectively assessed vaginal microbiota prior to and following PPROM using MiSeq-based sequencing of 16S rRNA gene amplicons and examined the impact of erythromycin prophylaxis on bacterial load and community structures. RESULTS In contrast to pregnancies delivering at term, vaginal dysbiosis characterised by Lactobacillus spp. depletion was present prior to the rupture of fetal membranes in approximately a third of cases (0% vs. 27%, P = 0.026) and persisted following membrane rupture (31%, P = 0.005). Vaginal dysbiosis was exacerbated by erythromycin treatment (47%, P = 0.00009) particularly in women initially colonised by Lactobacillus spp. Lactobacillus depletion and increased relative abundance of Sneathia spp. were associated with subsequent funisitis and early onset neonatal sepsis. CONCLUSIONS Our data show that vaginal microbiota composition is a risk factor for subsequent PPROM and is associated with adverse short-term maternal and neonatal outcomes. This highlights vaginal microbiota as a potentially modifiable antenatal risk factor for PPROM and suggests that routine use of erythromycin for PPROM be re-examined.
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Affiliation(s)
- Richard G Brown
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, W12 0NN, UK
| | - Julian R Marchesi
- Centre for Digestive and Gut Health, Imperial College London, London, W2 1NY, UK.,School of Biosciences, Cardiff University, Cardiff, CF103AX, UK
| | - Yun S Lee
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, W12 0NN, UK
| | - Ann Smith
- School of Biosciences, Cardiff University, Cardiff, CF103AX, UK
| | - Benjamin Lehne
- Department of Epidemiology & Biostatistics, Medicine, Imperial College London, London, W2 1PG, UK
| | - Lindsay M Kindinger
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, W12 0NN, UK
| | - Vasso Terzidou
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, W12 0NN, UK.,Chelsea & Westminster Hospital, Imperial College Healthcare NHS Trust, London, SW10 9NH, UK
| | - Elaine Holmes
- Centre for Digestive and Gut Health, Imperial College London, London, W2 1NY, UK.,Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, UK
| | - Jeremy K Nicholson
- Centre for Digestive and Gut Health, Imperial College London, London, W2 1NY, UK.,Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, UK
| | - Phillip R Bennett
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, W12 0NN, UK.,Queen Charlotte's Hospital, Imperial College Healthcare NHS Trust, London, W12 0HS, UK
| | - David A MacIntyre
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, W12 0NN, UK.
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17
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Dundar B, Dincgez Cakmak B, Ozgen G, Tasgoz FN, Guclu T, Ocakoglu G. Platelet indices in preterm premature rupture of membranes and their relation with adverse neonatal outcomes. J Obstet Gynaecol Res 2017; 44:67-73. [DOI: 10.1111/jog.13484] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 07/23/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Betul Dundar
- Department of Obstetrics and Gynecology; Bursa Yuksek Ihtisas Research and Training Hospital; Bursa Turkey
| | - Burcu Dincgez Cakmak
- Department of Obstetrics and Gynecology; Bursa Yuksek Ihtisas Research and Training Hospital; Bursa Turkey
| | - Gulten Ozgen
- Department of Obstetrics and Gynecology; Bursa Yuksek Ihtisas Research and Training Hospital; Bursa Turkey
| | - Fatma Nurgul Tasgoz
- Department of Obstetrics and Gynecology; Bursa Yuksek Ihtisas Research and Training Hospital; Bursa Turkey
| | - Tugberk Guclu
- Department of Obstetrics and Gynecology; Bursa Yuksek Ihtisas Research and Training Hospital; Bursa Turkey
| | - Gokhan Ocakoglu
- Department of Biostatistics; Uludag University Medical Faculty; Bursa Turkey
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18
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Dussaux C, Senat MV, Bouchghoul H, Benachi A, Mandelbrot L, Kayem G. Preterm premature rupture of membranes: is home care acceptable? J Matern Fetal Neonatal Med 2017; 31:2284-2292. [DOI: 10.1080/14767058.2017.1341482] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Chloé Dussaux
- Department of Obstetrics and Gynecology, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris, University Denis Diderot, Colombes, France
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, Assistance Publique des Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, Assistance Publique des Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris, Hôpital Antoine Béclère, University Paris-Sud, Clamart, France
| | - Laurent Mandelbrot
- Department of Obstetrics and Gynecology, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris, University Denis Diderot, Colombes, France
| | - Gilles Kayem
- Department of Obstetrics and Gynecology, Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, University Pierre and Marie Curie, Paris, France
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19
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Palmer L, Grabowska K, Burrows J, Rowe H, Billing E, Metcalfe A. A retrospective cohort study of hospital versus home care for pregnant women with preterm prelabor rupture of membranes. Int J Gynaecol Obstet 2017; 137:180-184. [PMID: 28186639 DOI: 10.1002/ijgo.12122] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/06/2017] [Accepted: 02/07/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare maternal and neonatal outcomes between in-hospital management and prepartum care at home (PCAH) among women with preterm prelabor rupture of membranes (PPROM) before 34 weeks of pregnancy. METHODS In a retrospective study, data were analyzed from women who experienced PPROM between 23 and 34 weeks of pregnancy, and received care from two hospitals in British Columbia, Canada, between April 2007 and March 2012. Women were included if they had been stable in hospital for at least 72 hours and met eligibility criteria for PCAH. Management of PPROM differs at the centers: at one, women are monitored in hospital, whereas PCAH is used at the other. Outcomes were compared between management strategies. Logistic regression was used to assess severe maternal morbidity and neonatal morbidity/mortality after adjustment for pregnancy length at PPROM. RESULTS Among 176 included women, 87 received PCAH and 89 were managed in hospital. There was no difference in severe maternal morbidity (adjusted odds ratio [aOR] 0.64, 95% confidence interval [CI] 0.35-1.17) or neonatal morbidity/mortality (aOR 0.63, 95% CI 0.31-1.30). Latency increased and length of stay decreased with PCAH (P<0.001 for both). CONCLUSION Maternal and newborn outcomes were similar between women who received PCAH and those who were managed in hospital. The reduced resource use in PCAH might lead to cost savings without compromising outcomes.
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Affiliation(s)
- Lynne Palmer
- Maternal Infant Child Youth Program, Fraser Health Authority, Surrey, BC, Canada
| | - Kirsten Grabowska
- Department of Obstetrics and Gynecology, Fraser Health Authority, Surrey, BC, Canada.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Jason Burrows
- Department of Obstetrics and Gynecology, Fraser Health Authority, Surrey, BC, Canada.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Hilary Rowe
- Neonatal and Pediatric Pharmacy, Fraser Health Authority, Lower Mainland Pharmacy Services, Surrey, BC, Canada
| | - Erin Billing
- Maternal Infant Child Youth Program, Fraser Health Authority, Surrey, BC, Canada
| | - Amy Metcalfe
- Departments of Obstetrics and Gynecology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
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20
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Bimson BE, Rosenn BM, Morris SA, Sasso EB, Schwartz RA, Brustman LE. Current trends in the diagnosis and management of gestational diabetes mellitus in the United States*. J Matern Fetal Neonatal Med 2016; 30:2607-2612. [PMID: 27819164 DOI: 10.1080/14767058.2016.1257603] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Brianne E. Bimson
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Barak M. Rosenn
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Sara A. Morris
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Elizabeth B. Sasso
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Rachelle A. Schwartz
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Lois E. Brustman
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
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21
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Sheibani L, Fong A, Henry DE, Norton ME, Truong YN, Anyikam A, Laurent LC, Rao R, Wing DA. Maternal and neonatal outcomes after antenatal corticosteroid administration for PPROM at 32 to 33 6/7 weeks gestational age. J Matern Fetal Neonatal Med 2016; 30:1676-1680. [DOI: 10.1080/14767058.2016.1222366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Lili Sheibani
- University of California, Irvine Health, Orange, CA, USA,
| | - Alex Fong
- University of California, Irvine Health, Orange, CA, USA,
| | - Dana E. Henry
- University of California, San Francisco, Medical Center, San Francisco, CA, USA,
| | - Mary E. Norton
- University of California, San Francisco, Medical Center, San Francisco, CA, USA,
| | - Yen N. Truong
- University of California, Davis, Medical Center, Sacramento, CA, USA,
| | - Adanna Anyikam
- University of California, San Diego Medical Center, San Diego, CA, USA, and
| | - Louise C. Laurent
- University of California, San Diego Medical Center, San Diego, CA, USA, and
| | - Rashmi Rao
- University of California, Los Angeles, Medical Center, Los Angeles, CA, USA
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22
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Catt E, Chadha R, Tang S, Palmquist E, Lange I. Management of Preterm Premature Rupture of Membranes: A Comparison of Inpatient and Outpatient Care. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:433-40. [DOI: 10.1016/j.jogc.2016.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/18/2015] [Indexed: 10/21/2022]
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23
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Morris JM, Roberts CL, Bowen JR, Patterson JA, Bond DM, Algert CS, Thornton JG, Crowther CA. Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial. Lancet 2016; 387:444-52. [PMID: 26564381 DOI: 10.1016/s0140-6736(15)00724-2] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. METHODS The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. FINDINGS Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). INTERPRETATION In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. FUNDING Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.
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Affiliation(s)
- Jonathan M Morris
- Perinatal Research, Kolling Institute, Northern Sydney Local Health District, and Sydney Medical School Northern, University of Sydney, St Leonards, NSW, Australia.
| | - Christine L Roberts
- Perinatal Research, Kolling Institute, Northern Sydney Local Health District, and Sydney Medical School Northern, University of Sydney, St Leonards, NSW, Australia
| | - Jennifer R Bowen
- Perinatal Research, Kolling Institute, Northern Sydney Local Health District, and Sydney Medical School Northern, University of Sydney, St Leonards, NSW, Australia; Department of Neonatology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jillian A Patterson
- Perinatal Research, Kolling Institute, Northern Sydney Local Health District, and Sydney Medical School Northern, University of Sydney, St Leonards, NSW, Australia
| | - Diana M Bond
- Perinatal Research, Kolling Institute, Northern Sydney Local Health District, and Sydney Medical School Northern, University of Sydney, St Leonards, NSW, Australia
| | - Charles S Algert
- Perinatal Research, Kolling Institute, Northern Sydney Local Health District, and Sydney Medical School Northern, University of Sydney, St Leonards, NSW, Australia
| | - Jim G Thornton
- School of Clinical Sciences, Division of Obstetrics and Gynaecology, City Hospital, University of Nottingham, Nottingham, UK
| | - Caroline A Crowther
- The Robinson Institute, Women's and Children's Hospital, Adelaide, SA, Australia; Liggins Institute, The University of Auckland, Grafton, Auckland, New Zealand
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24
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Tsafrir Z, Margolis G, Cohen Y, Cohen A, Laskov I, Levin I, Mandel D, Many A. Conservative management of preterm premature rupture of membranes beyond 32 weeks' gestation: is it worthwhile? J OBSTET GYNAECOL 2015; 35:585-90. [PMID: 25774537 DOI: 10.3109/01443615.2014.990432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We aimed to investigate whether conservative management of preterm premature rupture of membranes (PPROM) at 32-34 weeks' gestation improves outcome. In this retrospective analysis of singleton pregnancies, the study group included patients with PPROM at 28-34 weeks' gestation and the control group included patients presented with spontaneous preterm delivery at 28-34 weeks' gestation. Both groups were subdivided according to gestational age - early (28-31 weeks' gestation) versus late (32-34 weeks' gestation). Adverse neonatal outcome included neonatal death, intraventricular haemorrhage grade 3/4, respiratory distress syndrome, periventricular leucomalacia and neonatal sepsis. The study and control groups included 94 and 86 women, respectively. The study group had a lower incidence of adverse neonatal outcome at the earlier weeks (28-31), compared with the control group at the same gestational age. In contrast, at 32-34 weeks' gestation no difference in the risk for adverse neonatal outcome was noticed. Additionally, within the study group, chorioamnionitis rate was significantly higher among those who delivered at 32-34 weeks' gestation (p < 0.01). No advantage for conservative management of PPROM was demonstrated beyond 31 weeks' gestation. Moreover, conservative management of PPROM at 32-34 weeks' gestation may expose both mother and neonate to infectious morbidity.
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Affiliation(s)
| | | | - Y Cohen
- a The Department of Gynecology
| | - A Cohen
- a The Department of Gynecology
| | | | - I Levin
- a The Department of Gynecology
| | - D Mandel
- b Neonatal Intensive Care Unit, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University , Tel Aviv , Israel
| | - A Many
- a The Department of Gynecology
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25
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Horton AL, Lai Y, Rouse DJ, Spong CY, Leveno KJ, Varner MW, Mercer BM, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, O'Sullivan MJ, Hankins GDV, Caritis SN. Effect of magnesium sulfate administration for neuroprotection on latency in women with preterm premature rupture of membranes. Am J Perinatol 2015; 32:387-92. [PMID: 25241107 PMCID: PMC4369158 DOI: 10.1055/s-0034-1387930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aims to evaluate whether magnesium sulfate administration for neuroprotection prolongs latency in women with preterm premature rupture of membranes (PPROM) between 24 and 31(6/7) weeks' gestation. STUDY DESIGN This is a secondary analysis of a randomized controlled trial of magnesium sulfate for prevention of cerebral palsy. Gravid women with a singleton pregnancy between 24 and 31(6/7) weeks' gestation with PPROM without evidence of labor were randomized to receive magnesium sulfate, administered intravenously as a 6-g bolus followed by a constant infusion of 2 g per hour up to 12 hours, or placebo. Maternal outcomes for this analysis were delivery in less than 48 hours and in less than 7 days from randomization. Neonatal outcomes included a composite of respiratory distress syndrome, interventricular hemorrhage grades 3 or 4, periventricular leukomalacia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, or death. RESULTS A total of 1,259 women were included. The rate of delivery < 48 hours was not different in the magnesium sulfate and the placebo groups (22.2 and 20.7%, p = 0.51). Delivery < 7 days was similar between groups (55.4 and 51.4%, p = 0.16). Median latency was also similar between groups (median [interquartile range], 6.0 days [range, 2.4-13.8 days] and 6.6 days [range, 2.4-15.1 days], p = 0.29). Composite neonatal outcomes did not differ between groups. CONCLUSION Magnesium sulfate administration given for neuroprotection in women with a singleton gestation with PPROM and without labor before 32 weeks does not impact latency.
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Affiliation(s)
- Amanda L Horton
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois
| | - Yinglei Lai
- Department of Obstetrics and Gynecology, George Washington University Biostatistics Center, Washington, District of Columbia
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Catherine Y Spong
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio
| | - Jay D Iams
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Thomas Jefferson University and Drexel University, Philadelphia, Pennsylvania
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas
| | - Fergal D Malone
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Mary J O'Sullivan
- Department of Obstetrics and Gynecology, University of Miami, Miami, Florida
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abou El Senoun G, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation. Cochrane Database Syst Rev 2014; 2014:CD008053. [PMID: 24729384 PMCID: PMC11008104 DOI: 10.1002/14651858.cd008053.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established. OBJECTIVES To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and the reference lists of all the identified articles. SELECTION CRITERIA Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction. MAIN RESULTS We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05). There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is moderate heterogeneity for this outcome (I² = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs. AUTHORS' CONCLUSIONS The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.
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Affiliation(s)
- Ghada Abou El Senoun
- Queen's Medical Centre, Nottingham University HospitalDepartment of Obstetrics and GynaecologyDerby RoadNottinghamNottinghamshireUKNG7 2UH
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Hatem A Mousa
- Leicester Royal InfirmaryUniversity Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine UnitInfirmary SquareLeicesterUKLE1 5WW
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Frenette P, Dodds L, Armson BA, Jangaard K. Preterm prelabour rupture of membranes: effect of latency on neonatal and maternal outcomes. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:710-717. [PMID: 24007706 DOI: 10.1016/s1701-2163(15)30861-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare risks of infection and prematurity-related outcomes according to latency periods among women with preterm prelabour rupture of membranes (PPROM). METHODS Women with PPROM occurring between 24+0 and 36+6 weeks of gestation were identified from a provincial population-based perinatal database in Nova Scotia. The primary outcomes included composite variables for serious maternal and neonatal infectious morbidity and neonatal prematurity-related morbidity. Logistic regression was used to quantify the relationship between latency period (< 24 hours, 24 hours to < 48 hours, 48 hours to < 7 days, and ≥ 7 days) and maternal and neonatal outcomes. Separate analyses were conducted for gestational age groups 24+0 to 33+6 weeks and 34+0 to 36+6 weeks. RESULTS There were 4329 women included in the cohort. The composite variables representing serious maternal or neonatal infectious morbidity were not significantly associated with latency for either gestational age group. For PPROM occurring at gestational ages of 24+0 to 33+6 weeks, the odds of neonatal prematurity-related morbidity were significantly decreased at the latency periods of 48 hours or more compared with < 24 hours latency. For PPROM at 34+0 to 36+6 weeks of gestation, the odds of prematurity-related morbidity at 48 hours to < 7 days latency was decreased compared with latencies < 24 hours (OR 0.4; 95% CI 0.2 to 0.8). CONCLUSION Postponing delivery following PPROM may contribute to less prematurity-related morbidity, even close to term, without putting mother or neonate at substantial risk for serious infectious morbidity. Generalization of these findings to other obstetric populations should be informed by the underlying risk of infection.
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Affiliation(s)
| | - Linda Dodds
- Perinatal Epidemiology Research Unit, Dalhousie University, Halifax NS; Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS; Department of Pediatrics, Dalhousie University, Halifax NS
| | - B Anthony Armson
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS
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Beckmann M, Gardener G. Hospital versus outpatient care for preterm pre-labour rupture of membranes. Aust N Z J Obstet Gynaecol 2012; 53:119-24. [DOI: 10.1111/ajo.12021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 10/17/2012] [Indexed: 11/28/2022]
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Nayot D, Penava D, Da Silva O, Richardson BS, de Vrijer B. Neonatal outcomes are associated with latency after preterm premature rupture of membranes. J Perinatol 2012; 32:970-7. [PMID: 22422118 DOI: 10.1038/jp.2012.15] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine factors associated with latency time to birth after preterm premature rupture of membranes (PPROM) and the impact on neonatal outcomes. STUDY DESIGN Data on singleton pregnancies with PPROM (n=1535 infants) were prospectively collected in a computerized perinatal/neonatal database at a tertiary care perinatal center. Latency was characterized as ≤72h versus >72 h after PPROM. RESULT The percentage of women with latency to birth >72 h decreased from 67% in very preterm (gestational age (GA) 25 to 28 weeks) to 10% in late preterm women (GA 33 to 36 weeks). PPROM women with latency ≤72 h were more likely to have pregnancy-induced hypertension and birth weight <3%; PPROM women with latency >72 h were more likely to have received steroids and develop clinical chorioamnionitis. PPROM <32 weeks GA with latency ≤72 h was associated with a two-fold higher incidence of severe neonatal morbidity, while PPROM between 29 to 34 weeks GA and latency ≤72 h was associated with a higher incidence of moderate neonatal morbidity. CONCLUSION A latency period >72 h was associated with a decreased incidence of adverse neonatal outcomes up to 32 weeks GA for severe and 34 weeks GA for moderate morbidity indices.
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Affiliation(s)
- D Nayot
- Department of Obstetrics and Gynaecology, Children Health Research Institute, University of Western Ontario, London, ON, Canada
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Al-Mandeel H, Alhindi MY, Sauve R. Effects of intentional delivery on maternal and neonatal outcomes in pregnancies with preterm prelabour rupture of membranes between 28 and 34 weeks of gestation: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2012; 26:83-9. [PMID: 22882130 DOI: 10.3109/14767058.2012.718388] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the effects of intentional delivery (ID) over expectant management (EM) in pregnancies complicated by preterm prelabour rupture of membranes (PPROM) between 28 and 34 weeks of gestation on maternal and neonatal outcomes. METHODS We searched Ovid MEDLINE, EMBASE, CINAHL, CENTRAL and Science Citation Index; contacted experts and checked reference lists of relevant studies. Studies were included if they were randomized controlled trials in all languages. RESULTS Five randomized trials were included and 488 subjects were analyzed. Overall, the results showed significant heterogeneity. Maternal infection as well as respiratory distress syndrome (RDS) & neonatal sepsis (NS) were not different between the two groups. Neonatal death, however, was significantly higher (risk ratio: 5.81; 95% CI: 1.35-25.08; p = 0.03) in the ID group after excluding studies that gave antenatal steroids. Incidence of cesarean section was significantly higher in the intentional delivery group, as well (risk ratio: 1.35; 95% CI: 1.02-1.80; p = 0.03). CONCLUSION Based on the available evidence, ID in pregnancies complicated with PPROM between 28 and 34 weeks carries some maternal and neonatal risks with no added benefits. Thus, this treatment should not be considered as an option for women with PPROM before 34 weeks of gestation in the absence of other indications for early delivery.
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Affiliation(s)
- Hazem Al-Mandeel
- Department of Obstetrics & Gynecology, King Saud University, Riyadh, Saudi Arabia.
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Abstract
It is well recognised that birth before 32 weeks of gestation is associated with substantial neonatal morbidity and mortality and these risks have been extensively reported. The focus of perinatal research for many years has therefore been very preterm and extremely preterm delivery, since the likelihood and severity of adverse neonatal outcomes are highest within this group. In contrast, until recently, more mature preterm infants have been understudied and indeed, almost ignored by researchers.
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Abstract
The decision of when to deliver a patient for medical or obstetric complication directly affects the neonatal outcome. When the fetus is in danger due to suspected utero-placental insufficiency, the decision to deliver is thought to benefit the neonate. However, the opposite may be true when a normally developing fetus needs to be delivered for a maternal indication such as a persistently bleeding placenta praevia. These decisions are made daily by obstetric providers. The following is a review of obstetric decision-making for moderate and late preterm pregnancies.
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Abstract
Despite the increase in indicated late preterm births, spontaneous preterm labor and preterm premature rupture of the fetal membranes are the most common antecedent diagnoses leading to births between 34-0/7 and 36-6/7 weeks of gestation. Regional and institutional variation in the rates of late spontaneous preterm birth suggests that there may be opportunities to reduce the number of these births. This article summarizes the factors contributing to late spontaneous preterm birth and offers suggestions to improve care for these mothers and infants.
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Affiliation(s)
- Jay D Iams
- Ohio Perinatal Quality Collaborative, The Ohio State University Medical Center, Columbus, OH, USA.
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Maloni JA. Lack of evidence for prescription of antepartum bed rest. EXPERT REVIEW OF OBSTETRICS & GYNECOLOGY 2011; 6:385-393. [PMID: 22140399 PMCID: PMC3226811 DOI: 10.1586/eog.11.28] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antepartum bed-rest treatment is based on assumptions that it is both effective and safe for mother and fetus. However, research indicates, that bed-rest treatment is ineffective for preventing preterm birth and fetal growth restriction, and for increasing gestational age at birth and infant birthweight. Studies of women treated with pregnancy bed-rest identify numerous side effects, including muscle atrophy, bone loss, weight loss, decreased infant birthweight in singleton gestations and gestational age at birth, and psychosocial problems. Studies conducted by aerospace scientists who have used bed rest as a model for the study of weightlessness in space using nonpregnant individuals report similar results. Antepartum bed-rest treatment should be discontinued until evidence of effectiveness is found.
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Affiliation(s)
- Judith A Maloni
- Case Western Reserve University, Frances Payne Bolton School of Nursing, 10900 Euclid Avenue, Cleveland, OH 44106-4904, USA, Tel.: +1 216 368 2912, ,
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Mariona FG, Cabero L. Are we ready for a new look at the diagnosis of premature rupture of membranes? J Matern Fetal Neonatal Med 2011; 25:403-7. [DOI: 10.3109/14767058.2011.581715] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Popowski T, Goffinet F, Maillard F, Schmitz T, Leroy S, Kayem G. Maternal markers for detecting early-onset neonatal infection and chorioamnionitis in cases of premature rupture of membranes at or after 34 weeks of gestation: a two-center prospective study. BMC Pregnancy Childbirth 2011; 11:26. [PMID: 21470433 PMCID: PMC3088535 DOI: 10.1186/1471-2393-11-26] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Accepted: 04/07/2011] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Accurate prediction of infection, including maternal chorioamnionitis and early-onset neonatal infection, remains a critical challenge in cases of preterm rupture of membranes and may influence obstetrical management. The aim of our study was to investigate the predictive value for early-onset neonatal infection and maternal histological and clinical chorioamnionitis of maternal biological markers in routine use at or after 34 weeks of gestation in women with premature rupture of membranes. METHODS We conducted a two-center prospective study of all women admitted for premature rupture of membranes at or after 34 weeks of gestation. The association of C-reactive protein, white blood cell count, vaginal sample bacteriological results, and a prediction model at admission, for early-onset neonatal infection and maternal chorioamnionitis were analyzed by comparing areas under the receiver operating characteristic curves and specificity. RESULTS The study included 399 women. In all, 4.3% of the newborns had an early-onset neonatal infection and 5.3% of the women had clinical chorioamnionitis. Histological chorioamnionitis was detected on 10.8% of 297 placentas tested. White blood cell counts and C-reactive protein concentrations were significantly associated with early-onset neonatal infection and included in a prediction model. The area under the receiver operating characteristic curve of this model was 0.82 (95% CI [0.72, 0.92]) and of C-reactive protein, 0.80 (95% CI [0.68, 0.92]) (p = 1.0). Specificity was significantly higher for C-reactive protein than for the prediction model (48% and 43% respectively, p < 0.05). C-reactive protein was associated with clinical and histological chorioamnionitis, with areas under the receiver operating characteristic curve of 0.61 (95% CI [0.48, 0.74]) and 0.62 (95% CI [0.47, 0.74]), respectively. CONCLUSIONS The concentration of C-reactive protein at admission for premature rupture of membranes is the most accurate infectious marker for prediction of early-onset neonatal infection in routine use with a sensitivity > 90%. A useful next step would be a randomized prospective study of management strategy comparing CRP at admission with active management to assess whether this more individualized care is a safe alternative strategy in women with premature rupture of membranes at or after 34 weeks.
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Affiliation(s)
- Thomas Popowski
- Epidemiological Research Unit on Perinatal and Women's Health, INSERM U953, Paris, France
| | - François Goffinet
- Epidemiological Research Unit on Perinatal and Women's Health, INSERM U953, Paris, France
- Department of Obstetrics and Gynecology, Maternity Port-Royal, Cochin-Saint Vincent-de-Paul Hospital, Paris, France and University Paris V, Paris, France
| | - Françoise Maillard
- Epidemiological Research Unit on Perinatal and Women's Health, INSERM U953, Paris, France
| | - Thomas Schmitz
- Department of Obstetrics and Gynecology, Hôpital Robert Debré, Paris, France and University Paris VII, Paris, France
| | - Sandrine Leroy
- Epidemiological Research Unit on Perinatal and Women's Health, INSERM U953, Paris, France
- Centre for Statistics in Medicine University of Oxford, Oxford, UK
| | - Gilles Kayem
- Epidemiological Research Unit on Perinatal and Women's Health, INSERM U953, Paris, France
- Department of Obstetrics and Gynecology, CHI Creteil, Creteil, France
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Maloni JA. Antepartum bed rest for pregnancy complications: efficacy and safety for preventing preterm birth. Biol Res Nurs 2010; 12:106-24. [PMID: 20798159 DOI: 10.1177/1099800410375978] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Preterm birth is the major maternal-child health issue across developed nations and the leading cause of perinatal mortality and morbidity. Of all deaths of infants <1 year of age in the United States in 2005, 68.6% occurred in infants born prior to term. Although the preterm birth rate in European countries is 5-7%, the U.S. preterm birth rate is 12.7%, representing an increase of 9% since 2000. Antepartum bed rest/activity restriction (ABR/AR) has been a mainstay of treatment to prevent preterm birth for the past 30 years prescribed for nearly 1 million women in the United States annually, despite a lack of evidence for its effectiveness. In fact, there is increasing evidence that ABR causes several adverse physiologic and psychological side effects among women and their infants. Unfortunately, these findings have had little impact on clinical practice. This integrative review of literature provides a comprehensive analysis of the evidence for the practice of prescribing ABR and its physiologic, behavioral, and experiential side effects. It also presents a model to guide continuing research about the effects of maternal bed rest as well as evidence supporting the use of home care with bed rest, a different, safe, and feasible model of prenatal care for treating women with pregnancy complications used particularly in other countries. Finally, suggestions to improve the health of high-risk pregnant and postpartum women and their infants are provided.
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Affiliation(s)
- Judith A Maloni
- Case Western Reserve University, Frances Payne BoltonSchool of Nursing, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
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The Effect of Preterm Premature Rupture of Membranes on Neonatal Mortality Rates. Obstet Gynecol 2010; 116:1381-1386. [DOI: 10.1097/aog.0b013e3181fe3d28] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smith V, Devane D, Higgins S. Practices for predicting and preventing preterm birth in Ireland: a national survey. Ir J Med Sci 2010; 180:63-7. [PMID: 20953982 DOI: 10.1007/s11845-010-0604-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 09/28/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Preterm birth can result in adverse outcomes for the neonate and/or his/her family. The accurate prediction and prevention of preterm birth is paramount. This study describes and critically analyses practices for predicting and preventing preterm birth in Ireland. METHODS A questionnaire seeking information on practices for predicting and preventing preterm birth was mailed to all consultant obstetricians practising in Ireland in February 2006. RESULTS For predicting preterm birth, 97% of respondents did not use foetal fibronectin testing, 71% carried out routine second and third trimester cervical assessments and 75% routinely screened for genital tract infection. For preventing preterm birth, 62% prescribed bed rest, 24% prescribed antibiotics, 14% routinely inserted a cervical cerclage in women with a history of mid-trimester miscarriage and 61% routinely used tocolytics. CONCLUSION The findings of this survey, for the most part, reflect the empirical evidence base, international practices and best practice recommendations.
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Affiliation(s)
- V Smith
- School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, 24 D'Olier Street, Dublin 2, Ireland.
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Stuebe A, Ecker J, Bates DW, Zera C, Bentley-Lewis R, Seely E. Barriers to follow-up for women with a history of gestational diabetes. Am J Perinatol 2010; 27:705-10. [PMID: 20387186 PMCID: PMC3811130 DOI: 10.1055/s-0030-1253102] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Women with gestational diabetes (GDM) are at increased risk for type 2 diabetes (T2DM), but many do not receive recommended follow-up. We sought to identify barriers to follow-up screening. We surveyed primary care providers (PCPs) and obstetric and gynecology care providers (OBCPs) in a large health system. We also assessed documentation of GDM history in the health care system's electronic medical record. Four hundred seventy-eight clinicians were surveyed, among whom 207 responded. Most participants (81.1%) gave an accurate estimate of risk of progression to T2DM. PCPs were less likely than OBCPs to ask patients about history of GDM (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20 to 0.90), but they were far more likely to indicate that they order glucose screening for women with a known history (OR 4.31, 95% CI 2.01 to 9.26). Providers identified poor communication between OBCPs and PCPs as a major barrier to screening. Fewer than half (45.8%) of 450 women with GDM by glucose tolerance test criteria had that history documented on their electronic problem list. Clinicians are aware that women with GDM are at high risk of developing type 2 diabetes, but they do not routinely assess and screen patients, and communication between OBCPs and PCPs can be improved.
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Affiliation(s)
- Alison Stuebe
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599, USA.
| | - Jeffrey Ecker
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - David W. Bates
- Division of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health, 75 Francis Street, Boston, MA 02115
| | - Chloe Zera
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
| | - Rhonda Bentley-Lewis
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115
| | - Ellen Seely
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115
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Abstract
Chorioamnionitis is a common complication of pregnancy associated with significant maternal, perinatal, and long-term adverse outcomes. Adverse maternal outcomes include postpartum infections and sepsis whereas adverse infant outcomes include stillbirth, premature birth, neonatal sepsis, chronic lung disease, and brain injury leading to cerebral palsy and other neurodevelopmental disabilities. Research in the past 2 decades has expanded understanding of the mechanistic links between intra-amniotic infection and preterm delivery as well as morbidities of preterm and term infants. Recent and ongoing clinical research into better methods for diagnosing, treating, and preventing chorioamnionitis is likely to have a substantial impact on short and long-term outcomes in the neonate.
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Affiliation(s)
- Alan T. N. Tita
- Assistant Professor of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, School of Medicine, University of Alabama at Birmingham
| | - William W. Andrews
- Charles E. Flowers Professor and Chairman, Department of Obstetrics and Gynecology, School of Medicine, University of Alabama at Birmingham
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El Senoun GA, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation. Cochrane Database Syst Rev 2010:CD008053. [PMID: 20393965 PMCID: PMC4170988 DOI: 10.1002/14651858.cd008053.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established. OBJECTIVES To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010) and the reference lists of all the identified articles. SELECTION CRITERIA Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction. MAIN RESULTS We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05). There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is a moderate heterogeneity for this outcome (I(2) = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs. AUTHORS' CONCLUSIONS The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.
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Affiliation(s)
- Ghada Abou El Senoun
- Department of Obstetrics and Gynaecology, Queen’s Medical Centre, Nottingham University Hospital, Nottingham, UK
| | - Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool, Liverpool, UK
| | - Hatem A Mousa
- University Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine Unit, Leicester Royal Infirmary, Leicester, UK
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Nuthalapaty F, Lu G, Ramin S, Nuthalapaty E, Ramin KD, Ramsey PS. Is there a preferred gestational age threshold of viability?: A survey of maternal-fetal medicine providers. J Matern Fetal Neonatal Med 2009; 20:293-7. [PMID: 17437236 DOI: 10.1080/14767050701198821] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To characterize variation and factors associated with the perceived gestational age for the threshold of viability among maternal-fetal medicine (MFM) providers. METHODS We performed a web-based online survey of 1375 MFM providers. For this secondary analysis, a subset of survey questions targeted toward perceptions of the limit of viability was analyzed to identify how the respondents viewed the optimal threshold of viability gestational age. Comparative statistics were performed to assess various characteristics that influence the perceived threshold of viability. RESULTS Five hundred and eight providers (37%), representing all 50 states and 13 countries, responded to the survey. The reported threshold of viability varied among survey respondents: 22 weeks, 2.0%; 23 weeks, 37.2%; 24 weeks, 55.3%; 25 weeks, 3.4%; and 26 weeks, 2.2%. No significant differences were noted in the reported threshold of viability with respect to practitioner age (<50 years old vs. > or =50 years old, p = 0.42), nursery availability (level III vs. other, p = 0.46), and years in practice (<10 years vs. > or =10 years, p = 0.86). Significant differences in the reported threshold of viability were noted with respect to practitioner gender with males tending to have a lower gestational age threshold than females (p = 0.005). Significant differences were also noted among practitioners from academic vs. community/private practice settings (p = 0.008). A logisitic regression model, adusting for both gender and practice setting, revealed that male gender was independently associated with selection of a threshold of viability less than 24 weeks of gestation: male gender OR 1.8 (95% CI 1.3-2.7, p = 0.002); academic practice setting OR 1.1 (95% CI 0.8-1.6, p = 0.50). CONCLUSIONS Perceived threshold of viability among MFM providers varies with the majority of practitioners identifying 23-24 weeks of gestation. Significant difference, however, exists between practitioner genders.
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Affiliation(s)
- Francis Nuthalapaty
- Center for Research in Women's Health, Division of Maternal-Fetal Medicine, University of Alabama at Birmingham, Birmingham, AL 35249-7333, USA
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Hartling L, Chari R, Friesen C, Vandermeer B, Lacaze-Masmonteil T. A systematic review of intentional delivery in women with preterm prelabor rupture of membranes. J Matern Fetal Neonatal Med 2009; 19:177-87. [PMID: 16690512 DOI: 10.1080/14767050500451470] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the effect of intentional delivery versus expectant management in women with preterm prelabor rupture of membranes (PPROM). METHODS We searched electronic databases and trials registries, contacted experts, and checked reference lists of relevant studies. Studies were included if they were randomized controlled trials comparing intentional delivery versus expectant management after PPROM, the gestational age of participants was between 30 and 36 weeks, and the study reported one of several pre-determined outcomes. RESULTS Four studies were included in the meta-analysis. No difference was found between intentional delivery and expectant management in neonatal intensive care unit (NICU) length of stay (LOS) (weighted mean difference (WMD) -0.81 day, 95% confidence interval (CI) -1.66, 0.04), respiratory distress syndrome (risk difference (RD) -0.01, 95% CI -0.07, 0.06), and confirmed neonatal sepsis (RD -0.01, 95% CI -0.05, 0.04). One study found a significantly lower incidence of suspected neonatal sepsis among the intentional delivery group (RD -0.31, 95% CI -0.50, -0.12; number needed to treat (NNT) 3, 95% CI 2, 8). Maternal LOS was significantly shorter for the intentional delivery group (WMD -1.39 day, 95% CI -2.03, -0.75). There was a significant difference in the incidence of clinical chorioamnionitis favoring intentional delivery (RD -0.16, 95% CI -0.23, -0.10; NNT 6, 95% CI 5, 11). There was no significant difference in the incidence of other maternal outcomes, including cesarean section (RD 0.05, 95% CI -0.01, 0.11). CONCLUSIONS Intentional delivery may be favorable to expectant management for some maternal outcomes (chorioamnionitis and LOS). There is insufficient evidence to suggest that either strategy is beneficial or harmful for the baby. Large multicenter trials with primary neonatal outcomes are required to assess whether intentional delivery is associated with less neonatal morbidity.
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Affiliation(s)
- Lisa Hartling
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
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Oboro VO, Adekanle BA, Apantaku BD, Onadipe OA. Pre-term pre-labour rupture of membranes: Effect of chorioamnionitis on overall neonatal outcome. J OBSTET GYNAECOL 2009; 26:740-3. [PMID: 17130019 DOI: 10.1080/01443610600955776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Our objective was to evaluate the association between clinical chorioamnionitis following preterm pre-labour rupture of membranes (PPROM) and adverse neonatal outcome. We compared retrospectively, adverse neonatal outcome of singleton pregnancies with documented PPROM who developed chorioamnionitis (cases) with those who did not (controls). Our result showed that poor neonatal outcome was significantly associated with chorioamnionitis (34% vs 13%; p = 0.008). This association was found on multiple logistic regression analysis to be independent (p < 0.05) of other risk factors for poor neonatal outcome, viz: latency period (p = 0.002) and gestational age at delivery (p < 0.001). We conclude that chorioamnionitis complicating PPROM worsen neonatal outcome. The implication of this on expectant management of PPROM is discussed.
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Affiliation(s)
- V O Oboro
- Department of Obstetrics and Gynaecology, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria.
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Kayem G, Maillard F. Rupture prématurée des membranes avant terme : attitude interventionniste ou expectative ? ACTA ACUST UNITED AC 2009; 37:334-41. [DOI: 10.1016/j.gyobfe.2009.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 03/04/2009] [Indexed: 01/20/2023]
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Pasquier JC, Picaud JC, Rabilloud M, Claris O, Ecochard R, Moret S, Mellier G. Neonatal outcomes after elective delivery management of preterm premature rupture of the membranes before 34 weeks’ gestation (DOMINOS study). Eur J Obstet Gynecol Reprod Biol 2009; 143:18-23. [DOI: 10.1016/j.ejogrb.2008.10.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 07/10/2008] [Accepted: 10/05/2008] [Indexed: 10/21/2022]
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Fox NS, Gelber SE, Kalish RB, Chasen ST. History-indicated cerclage: practice patterns of maternal-fetal medicine specialists in the USA. J Perinat Med 2009; 36:513-7. [PMID: 18651834 DOI: 10.1515/jpm.2008.083] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE There is limited evidence supporting the effectiveness of history-indicated cerclage in preventing spontaneous pregnancy loss or preterm birth. This study was undertaken to estimate the practice patterns of maternal-fetal medicine specialists in regards to history-indicated cerclage. METHODS We performed a mail-based survey of all SMFM specialists in the US. Subjects were asked whether they would recommend a history-indicated cerclage at 12-14 weeks in a patient whose prior pregnancy was her first pregnancy and ended in a spontaneous, painless loss at 19 weeks with no identifiable cause. RESULTS A total of 827 (46%) of SMFM members responded of which 75% would recommend a history-indicated cerclage for this patient. Twenty-one percent would not recommend one, but would place one if desired by the patient. Only 4% would not place a history-indicated cerclage in this scenario. A total of 71% believed a history-indicated cerclage was associated with moderate or significant benefit, and 89% believed it involved minimal or no risk. Female gender, non-academic practice, practicing in the southern region and greater interval since residency training were all independently associated with the recommendation for a history-indicated cerclage. CONCLUSIONS Despite limited level-I evidence supporting its use, a history-indicated cerclage is recommended by most maternal-fetal medicine specialists.
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Affiliation(s)
- Nathan S Fox
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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Fox NS, Gelber SE, Kalish RB, Chasen ST. The recommendation for bed rest in the setting of arrested preterm labor and premature rupture of membranes. Am J Obstet Gynecol 2009; 200:165.e1-6. [PMID: 19019329 DOI: 10.1016/j.ajog.2008.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 06/02/2008] [Accepted: 08/01/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objective of the study was to estimate practice patterns regarding bed rest in women with preterm premature rupture of membranes (PPROM) and arrested preterm labor. STUDY DESIGN This was a mail-based survey of all Society for Maternal-Fetal Medicine members in the United States asking whether they would recommend bed rest in the setting of arrested preterm labor or PPROM at 26 weeks. Bed rest was defined as no more than 1-2 hours per day out of bed, with permitted activities including bathroom use, bathing, and brief ambulation inside the home/hospital. RESULTS Seventy-one percent and 87% would recommend bed rest for women with cervical dilation and arrested preterm labor and women with PPROM, respectively, even though the majority believed bed rest was associated with minimal or no benefit. Female sex, nonacademic practice, and practice location in the South or West were independently associated with the recommendation for bed rest. CONCLUSION Despite the belief that bed rest is associated with minimal or no benefit, most maternal-fetal medicine specialists recommend bed rest for arrested preterm labor and PPROM. Randomized, prospective trials are needed to evaluate the efficacy of bed rest in these settings.
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