Contemporary management of preterm premature rupture of membranes (PPROM): a survey of maternal-fetal medicine providers

Outpatient versus inpatient management of preterm prelabor rupture of membranes: A systematic review and meta-analysis

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.

Expectant management of preterm premature rupture of membranes at 34 weeks: a cost effectiveness analysis

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.

Preterm Premature Rupture of Membranes – Inpatient Versus Outpatient Management: an Evidence-Based Review

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.

Individualized treatment of preterm premature rupture of membranes to prolong the latency period, reduce the rate of preterm birth, and improve neonatal outcomes

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.

Antibiotic prophylaxis in preterm premature rupture of membranes at 24-31 weeks' gestation: perinatal and 2-year outcomes in the EPIPAGE-2 cohort

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.

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)

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 22^0/7 and 33^6/7 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.

Perinatal Outcomes and Influence of Amniotic Fluid Volume Following Previable, Preterm Prelabor Rupture of Membranes (pPPROM): A Historical Cohort Study

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.

Vaginal Microbiome in Preterm Rupture of Membranes

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.

Tocolytic Therapy in Preterm Premature Rupture of Membranes

"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."

Unit policies regarding tocolysis after preterm premature rupture of membranes: association with latency, neonatal and 2-year outcomes (EPICE cohort)

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.

Questionnaire survey on the management of pregnant women with preterm premature rupture of membranes

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.

The effects of tocolysis on neonatal septic death in women with PPROM: a retrospective cohort study

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.

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

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.

Vaginal dysbiosis increases risk of preterm fetal membrane rupture, neonatal sepsis and is exacerbated by erythromycin

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Conservative management of preterm premature rupture of membranes beyond 32 weeks' gestation: is it worthwhile?

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.

Effect of magnesium sulfate administration for neuroprotection on latency in women with preterm premature rupture of membranes

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.

Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation

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.

Preterm prelabour rupture of membranes: effect of latency on neonatal and maternal outcomes

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.

Neonatal outcomes are associated with latency after preterm premature rupture of membranes

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.

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

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.

NEONATAL OUTCOMES FOLLOWING LATE PRETERM BIRTH

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.

Obstetric decision-making and the late and moderately preterm infant

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.

Spontaneous late preterm births: what can be done to improve outcomes?

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.

Lack of evidence for prescription of antepartum bed rest

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.

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

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.

Antepartum bed rest for pregnancy complications: efficacy and safety for preventing preterm birth

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.

Practices for predicting and preventing preterm birth in Ireland: a national survey

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.

Barriers to follow-up for women with a history of gestational diabetes

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.

Diagnosis and management of clinical chorioamnionitis

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.

Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation

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.

Is there a preferred gestational age threshold of viability?: A survey of maternal-fetal medicine providers

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.

A systematic review of intentional delivery in women with preterm prelabor rupture of membranes

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.

Pre-term pre-labour rupture of membranes: Effect of chorioamnionitis on overall neonatal outcome

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.

History-indicated cerclage: practice patterns of maternal-fetal medicine specialists in the USA

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.

The recommendation for bed rest in the setting of arrested preterm labor and premature rupture of membranes

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.