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Birgisdottir BT, Hulthén Varli I, Saltvedt S, Lu K, Abtahi F, Åden U, Holzmann M. Short-term variation of the fetal heart rate as a marker of intraamniotic infection in pregnancies with preterm prelabor rupture of membranes: a historical cohort study. J Matern Fetal Neonatal Med 2024; 37:2345855. [PMID: 38679588 DOI: 10.1080/14767058.2024.2345855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/16/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Intraamniotic infection (IAI) and subsequent early-onset neonatal sepsis (EONS) are among the main complications associated with preterm prelabor rupture of membranes (PPROM). Currently used diagnostic tools have been shown to have poor diagnostic performance for IAI. This study aimed to investigate whether the exposure to IAI before delivery is associated with short-term variation of the fetal heart rate in pregnancies with PPROM. METHODS Observational cohort study of 678 pregnancies with PPROM, delivering between 24 + 0 and 33 + 6 gestational weeks from 2012 to 2019 in five labor units in Stockholm County, Sweden. Electronic medical records were examined to obtain background and exposure data. For the exposure IAI, we used the later diagnosis of EONS in the offspring as a proxy. EONS is strongly associated to IAI and was considered a better proxy for IAI than the histological diagnosis of acute chorioamnionitis, since acute chorioamnionitis can be observed in the absence of both positive microbiology and biochemical markers for inflammation. Cardiotocography traces were analyzed by a computerized algorithm for short-term variation of the fetal heart rate, which was the main outcome measure. RESULTS Twenty-seven pregnancies were categorized as having an IAI, based on the proxy diagnosis of EONS after birth. Fetuses exposed to IAI had significantly lower short-term variation values in the last cardiotocography trace before birth than fetuses who were not exposed (5.25 vs 6.62 ms; unadjusted difference: -1.37, p = 0.009). After adjustment for smoking and diabetes, this difference remained significant. IAI with a later positive blood culture in the neonate (n = 12) showed an even larger absolute difference in STV (-1.65; p = 0.034), with a relative decrease of 23.5%. CONCLUSION In pregnancies with PPROM, fetuses exposed to IAI with EONS as a proxy have lower short-term variation of the fetal heart rate than fetuses who are not exposed. Short-term variation might be useful as adjunct surveillance in pregnancies with PPROM.
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Affiliation(s)
- Brynhildur Tinna Birgisdottir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Pregnancy and Childbirth, Karolinska University Hospital, Stockholm, Sweden
| | - Ingela Hulthén Varli
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Pregnancy and Childbirth, Karolinska University Hospital, Stockholm, Sweden
| | - Sissel Saltvedt
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Pregnancy and Childbirth, Karolinska University Hospital, Stockholm, Sweden
| | - Ke Lu
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Farhad Abtahi
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
- Division of Ergonomics, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Ulrika Åden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Division of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Holzmann
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Pregnancy and Childbirth, Karolinska University Hospital, Stockholm, Sweden
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El Adam S, Johnston K, Venkataraman M, Patel VP. Surrogate endpoints for neonatal outcome: A rapid review. Health Sci Rep 2024; 7:e2279. [PMID: 39100713 PMCID: PMC11295175 DOI: 10.1002/hsr2.2279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/09/2024] [Accepted: 07/12/2024] [Indexed: 08/06/2024] Open
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Ohkuchi A, Okazaki K, Iwamoto S, Sako M, Kobayashi T, Yanagihara I, Nomiyama M. A phase II, multicenter, nonblinded, randomized controlled trial for evaluating protective effects of ABPC/SBT plus, azithromycin versus erythromycin, in pregnant women with pPROM occurring at <28 weeks of gestation on the development of BPD in neonates: Study protocol. PLoS One 2024; 19:e0304705. [PMID: 38980858 PMCID: PMC11232965 DOI: 10.1371/journal.pone.0304705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/13/2024] [Indexed: 07/11/2024] Open
Abstract
This is a protocol for PPROM-AZM Study, phase II, nonblinded, randomized controlled trial. Bronchopulmonary dysplasia (BPD) at a postmenstrual age of 36 weeks (BPD36) is often observed in infants with preterm premature rupture of the membranes (pPROM). A regimen of ampicillin (ABPC) intravenous infusion for 2 days and subsequent amoxicillin (AMPC) oral administration for 5 days plus erythromycin (EM) intravenous infusion for 2 days followed by EM oral administration for 5 days is standard treatment for pPROM. However, the effect on the prevention of moderate/severe BPD36 using the standard treatment has not been confirmed. Recently, it is reported that ampicillin/sulbactam (ABPC/SBT) plus azithromycin (AZM) was effective for the prevention of moderate/severe BPD36 in pPROM patients with amniotic infection of Ureaplasma species. Therefore, our aim is to evaluate the occurrence rate of the composite outcome of "incidence rate of either moderate/severe BPD36 or intrauterine fetal death, and infantile death at or less than 36 weeks 0 days" comparing subjects to receive ABPC/SBT for 14 days plus AZM for 14 days (intervention group) and those to receive ABPC/SBT for 14 days plus EM for 14 days (control group), in a total of 100 subjects (women with pPROM occurring at 22-27 weeks of gestation) in Japan. The recruit of subjects was started on April 2022, and collection in on-going. We also investigate the association between the detection of Ureaplasma species and occurrence of BPD36. In addition, information on any adverse events for the mother and fetus and serious adverse events for infants are collected during the observation period. We allocate patients at a rate of 1:1 considering two stratification factors: onset of pPROM (22-23 or 24-27 weeks) and presence/absence of a hospital policy for early neonatal administration of caffeine. Trial registration: The trial number in the Japan Registry of Clinical Trials is jRCTs031210631.
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Affiliation(s)
- Akihide Ohkuchi
- Maternal and Fetal Neonatal Intensive Care Unit, Jichi Medical University Hospital, Tochigi, Japan
| | - Kaoru Okazaki
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Fuchu-shi, Tokyo, Japan
| | - Shintaro Iwamoto
- Division of Biostatistics, Department of Data Science, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Mayumi Sako
- Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Tohru Kobayashi
- Department of Data Science, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Itaru Yanagihara
- Department of Developmental Medicine, Research Institute, Osaka Women's and Children's Hospital, Izumi-shi, Osaka, Japan
| | - Makoto Nomiyama
- Department of Obstetrics and Gynecology, National Hospital Organization Saga Hospital, Saga-shi, Saga, Japan
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Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
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Xu L, Yang T, Wen M, Wen D, Jin C, An M, Wang L, Liu Y, Fan J. Frontiers in the Etiology and Treatment of Preterm Premature Rupture of Membrane: From Molecular Mechanisms to Innovative Therapeutic Strategies. Reprod Sci 2024; 31:917-931. [PMID: 37989803 DOI: 10.1007/s43032-023-01411-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023]
Abstract
Preterm premature rupture of membranes (pPROM) poses a significant threat to fetal viability and increases the risk for newborn morbidities. The perinatal period of preterm infants affected by pPROM is often characterized by higher rates of mortality and morbidity, with associated risks of cerebral palsy, developmental delays, compromised immune function, respiratory diseases, and sensory impairments. pPROM is believed to result from a variety of causes, including but not limited to microbially induced infections, stretching of fetal membranes, oxidative stress, inflammatory responses, and age-related changes in the fetal-placental interface. Maternal stress, nutritional deficiencies, and medically induced procedures such as fetoscopy are also considered potential contributing factors to pPROM. This comprehensive review explores the potential etiologies leading to pPROM, delves into the intricate molecular mechanisms through which these etiologies cause membrane ruptures, and provides a concise overview of diagnostic and treatment approaches for pPROM. Based on available therapeutic options, this review proposes and explores the possibilities of utilizing a novel composite hydrogel composed of amniotic membrane particles for repairing ruptured fetal membranes, thereby holding promise for its clinical application.
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Affiliation(s)
- Ludan Xu
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Tiantian Yang
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Meiling Wen
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China
- Research Center for Nanobiomaterials & Regenerative Medicine, College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Dawei Wen
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Chaoyang Jin
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Meiwen An
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Li Wang
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Yang Liu
- Institute of Biomedical Engineering, College of Biomedical Engineering, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan University of Technology, Taiyuan, Shanxi, China.
- Research Center for Nanobiomaterials & Regenerative Medicine, College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan, Shanxi, China.
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China.
| | - Junmei Fan
- Department of Reproductive Medicine Center, Children's Hospital of Shanxi and Women Health Center of Shanxi, Affiliated of Shanxi Medical University, Taiyuan, Shanxi, China.
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Van Mechelen K, Hundscheid TM, van Westering-Kroon E, Bartoš F, Villamor E. Association between Antenatal Antibiotic Exposure and Bronchopulmonary Dysplasia: A Systematic Review and Bayesian Model-Averaged Meta-Analysis. Neonatology 2024; 121:378-387. [PMID: 38310865 DOI: 10.1159/000536220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Antenatal antibiotic exposure has been suggested as a risk factor for bronchopulmonary dysplasia (BPD). We aimed to summarize the evidence from randomized controlled trials (RCTs) and observational studies on this potential association. METHODS PubMed/Medline and Embase databases were searched. BPD was classified as BPD28 (supplemental oxygen during 28 days or at postnatal day 28), BPD36 (supplemental oxygen at 36 weeks postmenstrual age), BPD36 or death, and BPD-associated pulmonary hypertension (BPD-PH). Bayesian model-averaged (BMA) meta-analysis was used to calculate Bayes factors (BFs). The BF10 is the ratio of the probability of the data under the alternative hypothesis (H1) over the probability of the data under the null hypothesis (H0). RESULTS We included 6 RCTs and 27 observational studies (126,614 infants). Regarding BPD28, BMA showed that the evidence in favor of H0 (lack of association with antenatal antibiotics) was weak for the RCTS (BF10 = 0.506, 6 studies) and moderate for the observational studies (BF10 = 0.286, 10 studies). Regarding BPD36, the evidence in favor of H0 was moderate for the RCTs (BF10 = 0.127, 2 studies) and weak for the observational studies (BF10 = 0.895, 14 studies). Evidence in favor of H0 was also weak for the associations with BPD36 or death (BF10 = 0.429, 2 studies) and BPD-PH (BF10 = 0.384, 2 studies). None of the meta-analyses showed evidence in favor of H1. CONCLUSIONS The currently available evidence suggests a lack of association between antenatal antibiotics and BPD. However, our results should not be interpreted as an argument for widespread use of antibiotics in the setting of preterm delivery.
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Affiliation(s)
- Karen Van Mechelen
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands,
| | - Tamara M Hundscheid
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Elke van Westering-Kroon
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - František Bartoš
- Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Eduardo Villamor
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Hong S, Lee SJ, Kim YM, Lee YE, Park Y, Kim HJ, Park KH. Complement Activation Fragments in Cervicovaginal Fluid Are Associated with Intra-Amniotic Infection/Inflammation and Spontaneous Preterm Birth in Women with Preterm Premature Rupture of Membranes. Am J Perinatol 2024; 41:290-299. [PMID: 34666383 DOI: 10.1055/a-1673-0280] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We sought to determine whether the levels of complement and other inflammatory and angiogenic mediators in cervicovaginal fluid (CVF) are independently associated with intra-amniotic infection and/or inflammation (IAI) and imminent spontaneous preterm birth (SPTB, £48 hours of sampling) in women with preterm premature rupture of membranes (PPROM). STUDY DESIGN This was a retrospective study consisting of 85 singleton pregnant women with PPROM at 200/7 to 336/7 weeks. Amniotic fluid (AF) obtained via amniocentesis was cultured and assayed for interleukin-6. CVF samples collected at the time of amniocentesis were assayed for complement C3a, C4a, and C5a, HSP70 (heat shock protein 70), M-CSF (macrophage colony-stimulating factor), M-CSF-R (macrophage colony-stimulating factor-receptor), S100 A8, S100 A9, thrombospondin-2, VEGF (vascular endothelial growth factor-receptor), and VEGFR-1 (vascular endothelial growth factor-receptor 1) by enzyme-linked immunosorbent assay. RESULTS Multivariate logistic regression analyses revealed that elevated CVF concentrations of complement C3a, 4a, and 5a were significantly associated with an increased risk of IAI and imminent SPTB, whereas those of M-CSF were associated with IAI, but not imminent SPTB (p = 0.063), after adjustment for baseline covariates (e.g., gestational age at sampling). However, univariate, and multivariate analyses showed that the CVF concentrations of angiogenic (thrombospondin-2, VEGF, and VEGFR-1) and inflammatory (HSP70, M-CSF-R, S100 A8, and S100 A9) proteins were not associated with either IAI or imminent SPTB. CONCLUSION In women with PPROM, elevated CVF concentrations of complement C3a, C4a, and C5a are independently related to an increased risk of IAI and imminent SPTB. These findings suggest that complement activation in CVF is significantly involved in mechanisms underlying preterm birth and in the host response to IAI in the context of PPROM. KEY POINTS · Elevated CVF levels of C3a, 4a and 5a are associated with IAI and SPTB.. · CVF C3a, 4a and 5a have better predictability for SPTB, compared to AF WBC.. · Elevated CVF levels of M-CSF were associated with IAI, but not SPTB..
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Affiliation(s)
- Subeen Hong
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se Jin Lee
- Department of Obstetrics and Gynecology, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Yu Mi Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Eun Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yehyon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyeon Ji Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyo Hoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Zhang L, Fang X, Li Z, Han X, Du H, Qu P, Xu F, Wu L, Li Y. Establishment of a prediction model for histological chorioamnionitis and its association with outcomes of premature infants. Front Pediatr 2023; 11:1194563. [PMID: 37654686 PMCID: PMC10466889 DOI: 10.3389/fped.2023.1194563] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/27/2023] [Indexed: 09/02/2023] Open
Abstract
Aim This study aims to construct a prediction model for histological chorioamnionitis (HCA) and analyze the associations between the predicted risk of HCA and adverse outcomes in preterm infants. Methods In total, 673 subjects were included in this cohort study and divided into HCA group (n = 195) and non-HCA group (n = 478). A stepwise method was used to screen the predictors for HCA, binary logistic regression was used to construct the prediction model, and the associations between the predicted risk of HCA and adverse outcomes were analyzed. Results HCA occurred in 195 patients, accounting for 29.0%. The sensitivity of the prediction model was 0.821 [95% confidence interval (CI): 0.767-0.874)], the specificity was 0.684 (95% CI: 0.642-0.726), the positive predictive value was 0.514 (0.459-0.570), the negative predictive value was 0.903 (95% CI: 0.873-0.934), the area under the curve was 0.821 (95% CI: 0.786-0.855), and the accuracy was 0.724 (95% CI: 0.690-0.757). The predicted risk of HCA was associated with a higher risk of bronchopulmonary dysplasia (BPD) [odds ratio (OR) = 3.48, 95% CI: 1.10-10.95)], sepsis (OR = 6.66, 95% CI: 2.17-20.43), and neonatal infections (OR = 9.85, 95% CI: 3.59-26.98), but not necrotizing enterocolitis (OR = 0.67, 95% CI: 0.24-1.88), retinopathy of prematurity (OR = 1.59, 95% CI: 0.37-6.85), and brain damage (OR = 1.77, 95% CI: 0.82-3.83). After adjusting for confounders including gestational week at birth and birth weight, the risk of neonatal infections (OR = 5.03, 95% CI: 2.69-9.41) was increased in preterm infants' exposure to HCA. Conclusion The model showed good predictive performance for identifying pregnant women with a higher risk of HCA. In addition, HCA was associated with the risk of BPD, sepsis, and infections in neonates.
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Affiliation(s)
- Li Zhang
- Department of Neonatology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Xin Fang
- Graduate School of Xi’an Medical University, Xi’an, China
| | - Zhankui Li
- Department of Neonatology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Xiang Han
- Department of Obstetric, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Hongyan Du
- Department of Pathology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Pengfei Qu
- Translational Medicine Center, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Feifei Xu
- Graduate School of Xi’an Medical University, Xi’an, China
| | - Lizhi Wu
- Department of Neonatology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Yajun Li
- Department of Neonatology, Northwest Women’s and Children’s Hospital, Xi’an, China
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Li Y, Zhang C, Huang X, Tang J. Effect of Antimicrobial Exposure in Pregnancy on Adverse Pregnancy Outcomes and Admission Rate to the Neonatal Intensive Care Unit: A Multi-Center Cohort Study. Infect Drug Resist 2023; 16:2441-2451. [PMID: 37128496 PMCID: PMC10148650 DOI: 10.2147/idr.s392504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/27/2023] [Indexed: 05/03/2023] Open
Abstract
Purpose Antimicrobial agents are frequently prescribed during pregnancy. This study aims to explore the association between antimicrobial exposure and pregnancy outcomes. Patients and Methods A multi-center retrospective cohort study of pregnant patients (n=370) was conducted in 22 tertiary hospitals in China. Adverse pregnancy outcomes and admission of neonate to neonatal intensive care unit (NICU) were considered as outcomes. The effect of antimicrobial exposure on pregnancy outcomes was assessed using a multivariate logistic regression model. Results Use of first-generation cephalosporins during pregnancy was associated with a significantly higher risk of adverse pregnancy outcomes (odds ratio [OR]: 3.64 [95% confidence interval, CI: 1.43-9.24], P = 0.007) and admission of neonate to the NICU (OR: 3.41, 95% CI: 1.37-8.53, P=0.009) compared with use of third-generation cephalosporins, after adjusting for gestational age of exposure to antimicrobial agents, cesarean section, and antimicrobial dose. Similarly, a higher risk of adverse pregnancy outcomes (OR: 14.76, 95% CI: 4.43-49.11) and neonatal NICU admission (OR: 11.74, 95% CI: 3.59-38.35) were observed among women with first-generation cephalosporins use compared with mothers with no antimicrobial use. Conclusion Both first- and third-generation cephalosporins use was associated with an increased risk of adverse pregnancy and neonatal outcomes. In addition, first-generation cephalosporins were associated with an increased risk of those pregnant and neonatal outcomes, when compared with third-generation cephalosporins. We should require to determine the indications and contraindications for use of cephalosporins during pregnancy.
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Affiliation(s)
- Yueyan Li
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China
| | - Chen Zhang
- Institute of Reproduction and Development, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China
| | - Xuan Huang
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China
| | - Jing Tang
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China
- Correspondence: Jing Tang, Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China, Tel +86 21 33180593, Fax +86 21 33180593, Email
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10
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Pullattayil AK, Weiner GM. Interventions to Prevent Bronchopulmonary Dysplasia in Preterm Neonates: An Umbrella Review of Systematic Reviews and Meta-analyses. JAMA Pediatr 2022; 176:502-516. [PMID: 35226067 DOI: 10.1001/jamapediatrics.2021.6619] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) has multifactorial etiology and long-term adverse consequences. An umbrella review enables the evaluation of multiple proposed interventions for the prevention of BPD. OBJECTIVE To summarize and assess the certainty of evidence of interventions proposed to decrease the risk of BPD from published systematic reviews. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science were searched from inception until November 9, 2020. STUDY SELECTION Meta-analyses of randomized clinical trials comparing interventions in preterm neonates that included BPD as an outcome. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in duplicate. Quality of systematic reviews was evaluated using Assessment of Multiple Systematic Reviews version 2, and certainty of evidence was assessed using Grading of Recommendation, Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES (1) BPD or mortality at 36 weeks' postmenstrual age (PMA) and (2) BPD at 36 weeks' PMA. RESULTS A total of 154 systematic reviews evaluating 251 comparisons were included, of which 110 (71.4%) were high-quality systematic reviews. High certainty of evidence from high-quality systematic reviews indicated that delivery room continuous positive airway pressure compared with intubation with or without routine surfactant (relative risk [RR], 0.80 [95% CI, 0.68-0.94]), early selective surfactant compared with delayed selective surfactant (RR, 0.83 [95% CI, 0.75-0.91]), early inhaled corticosteroids (RR, 0.86 [95% CI, 0.75-0.99]), early systemic hydrocortisone (RR, 0.90 [95% CI, 0.82-0.99]), avoiding endotracheal tube placement with delivery room continuous positive airway pressure and use of less invasive surfactant administration (RR, 0.90 [95% CI, 0.82-0.99]), and volume-targeted compared with pressure-limited ventilation (RR, 0.73 [95% CI, 0.59-0.89]) were associated with decreased risk of BPD or mortality at 36 weeks' PMA. Moderate to high certainty of evidence showed that inhaled nitric oxide, lower saturation targets (85%-89%), and vitamin A supplementation are associated with decreased risk of BPD at 36 weeks' PMA but not the competing outcome of BPD or mortality, indicating they may be associated with increased mortality. CONCLUSIONS AND RELEVANCE A multipronged approach of delivery room continuous positive airway pressure, early selective surfactant administration with less invasive surfactant administration, early hydrocortisone prophylaxis in high-risk neonates, inhaled corticosteroids, and volume-targeted ventilation for preterm neonates requiring invasive ventilation may decrease the combined risk of BPD or mortality at 36 weeks' PMA.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH) & KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | | | | | - Gary M Weiner
- Department of Pediatrics-Neonatology, University of Michigan, Ann Arbor
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11
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Abstract
OBJECTIVE This study aimed to compare neonatal and maternal outcomes between immediate and delayed prophylactic antibiotic administration after previable prelabor premature rupture of membranes (PROM) less than 24 weeks of gestation. STUDY DESIGN Retrospective cohort study of singleton pregnancies with PROM between 160/7 and 236/7 weeks of gestational age conducted at a single tertiary care referral center between June 2011 and December 2015. Patients with multiple gestations, fetal anomalies, those who elected augmentation, or with a contradiction to expectant management, such as suspected intra-amniotic infection or stillbirth, were excluded from the study. We compared pregnancy characteristics, maternal complications, and neonatal outcomes between women who received a course of antibiotics within 24 hours of PROM and women who received antibiotics after 24 hours of PROM. The primary outcome was neonatal survival to hospital discharge. Secondary outcomes included gestational age at delivery, time from PROM to delivery, neonatal birth weight, days in the neonatal intensive care unit (NICU), composite adverse neonatal outcomes, and maternal morbidity. RESULTS Ninety-four women met inclusion criteria, 57 (61%) received antibiotics within 24 hours of PROM and 37 (39%) received antibiotics 24 hours after PROM. Baseline maternal characteristics were similar in both groups. The mean gestational age at PROM was similar between groups at 20.8 ± 2.3 weeks in the immediate antibiotics group and 20.6 ± 2.1 weeks in the delayed antibiotics group (p = 0.48). Compared with delayed antibiotic administration, immediate antibiotic administration was not associated with a significant difference in latency time from PROM to delivery, rate of stillbirth, days in an ICU, or adverse neonatal outcomes. Maternal outcomes also did not differ significantly between groups. Neonatal birth weight was lower in the immediate antibiotics group (p = 0.012). CONCLUSION Our data suggest that there is no maternal or neonatal benefit to immediate administration of latency antibiotics compared with delayed administration. KEY POINTS · Adverse neonatal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Maternal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Neonatal birth weight was lower in infants that received immediate antibiotics after previable PROM..
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12
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Ishiguro A, Sasaki A, Motojima Y, Oka S, Nishiguchi R, Nakagawa R, Nishimura E, Iwatani A, Iwasaki Y, Miyahara N, Saito K, Haga M, Ito K, Kanai M, Hussein MH, Kabe K. Randomized Trial of Perfusion-Based Circulatory Management in Infants of Very Low Birth Weight. J Pediatr 2022; 243:27-32.e2. [PMID: 34942176 DOI: 10.1016/j.jpeds.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/15/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To establish the superiority of blood flow (BF)-based circulatory management over conventional blood pressure (BP)-based management strategies used for preventing intraventricular hemorrhage (IVH) in infants of very low birth weight (VLBW). STUDY DESIGN We conducted a nonblinded, single-centered randomized trial with the aim to prevent IVH by managing BF. Infants with VLBW were assigned randomly to a BF-based group or BP-based (BP group) circulatory management group. The incidence of IVH was the outcome of interest. The IVH also data were compared among healthy patients and patients responsive and unresponsive to the intervention. RESULTS A total of 219 and 220 infants with VLBW were assigned to the BF and BP groups, respectively. The IVH incidence rate was lower in the BF group, but the difference was not statistically significant (BF group, 6.8% vs BP group, 10.9%; P = .14). In 21% of patients of the BP group and 20% of the BF group, the intervention failed. In BF group, the IVH incidence rate was significantly greater in infants with unsuccessful intervention when compared with healthy individuals (6% vs 23%, P = .001). Multivariate logistic regression analysis revealed a correlation between low blood flow and IVH (aOR 3.24; 95% CI 1.49-7.08, P = .003) but not between low BP and IVH (P = .73). CONCLUSIONS The BF management protocol did not significantly decrease the incidence of IVH. However, after further optimization, we speculate the treatment strategy holds promise in decreasing the incidence of IVH. Trial registration UMIN-CTR: UMIN000013296.
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Affiliation(s)
- Akio Ishiguro
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.
| | - Ayumi Sasaki
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Yukiko Motojima
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Shuntaro Oka
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Ryo Nishiguchi
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Ryouta Nakagawa
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Eri Nishimura
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Ayaka Iwatani
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Yuka Iwasaki
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Naoyuki Miyahara
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Kana Saito
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Mitsuhiro Haga
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Kanako Ito
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Masayo Kanai
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Mohamed Hamed Hussein
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Kazuhiko Kabe
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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13
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Dibo M, Ventimiglia MS, Valeff N, Serradell MDLÁ, Jensen F. An overview of the role of probiotics in pregnancy-associated pathologies with a special focus on preterm birth. J Reprod Immunol 2022; 150:103493. [DOI: 10.1016/j.jri.2022.103493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 01/20/2022] [Accepted: 02/08/2022] [Indexed: 10/19/2022]
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Müller H, Stähling AC, Bruns N, Weiss C, Ai M, Köninger A, Felderhoff-Müser U. Latency duration of preterm premature rupture of membranes and neonatal outcome: a retrospective single-center experience. Eur J Pediatr 2022; 181:801-811. [PMID: 34605998 PMCID: PMC8821059 DOI: 10.1007/s00431-021-04245-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/01/2021] [Accepted: 08/27/2021] [Indexed: 11/27/2022]
Abstract
In preterm premature rupture of membranes (PPROM), a decision between early delivery with prematurity complications and pregnancy prolongation bearing the risk of chorioamnionitis has to be made. To define disadvantages of delayed prolongation, latency duration of PPROM in expectantly managed pregnancies was investigated. We included those PPROMs > 48 h leading to preterm birth prior 37 weeks' gestation and retrospectively analyzed 84 preterm infants fulfilling these criteria. The association between latency duration/appearance of PPROM and respiratory outcome (primary outcomes) and neurological outcome (secondary outcomes) was investigated. The study showed that latency duration of PPROM is not associated with clinical or histological chorioamnionitis (p = 0.275; p = 0.332). As the numerous clinical parameters show multicollinearity between each other, we performed a multiple regression analysis to consider this fact. Respiratory distress syndrome is significantly associated with gestational age at PPROM (p < 0.001), and surfactant application is significantly associated with PPROM duration (p = 0.014). The other respiratory parameters including steroids and diuretics therapy, bronchopulmonary dysplasia, and the neurological parameters (intraventricular hemorrhage, Bayley II testing at a corrected age of 24 months) were not significantly associated with PPROM duration or gestational age at PPROM diagnosis.Conclusion: Latency duration of PPROM was not associated with adverse neonatal outcome in expectantly and carefully managed pregnancies, but respiratory distress syndrome was pronounced. The observed effect of pronounced respiratory distress syndrome can be treated with surfactant preparations and was not followed by increased rate of bronchopulmonary dysplasia. What is Known: • In case of preterm premature rupture of membranes, a decision between pregnancy prolongation with the risk of chorioamnionitis and early delivery with prematurity complications has to be made. • Chorioamnionitis is a dangerous situation for the pregnant woman and the fetus. • Impaired neurodevelopmental outcome is strongly correlated with pronounced prematurity due to the increased rate of serious complications. What is New: • Respiratory distress syndrome is significantly associated with gestational age at PPROM, and surfactant application is significantly associated with PPROM duration. • Latency duration of PPROM is not associated with adverse respiratory neonatal outcome (therapy with continuous positive airway pressure, therapy with diuretics and/or steroids, bronchopulmonary dysplasia) in expectantly and carefully managed pregnancies. • Intraventricular hemorrhage and Bayley II testing at a corrected age of 24 months are not associated with latency duration of PPROM when pregnancies are carefully observed.
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Affiliation(s)
- Hanna Müller
- Neonatology and Pediatric Intensive Care, Department of Pediatrics, University of Marburg, Baldingerstraße, 35043, Marburg, Germany. .,Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Ann-Christin Stähling
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany ,Clinic for Urology and Pediatric Urology, Marien-Hospital Marl, KKRN GmbH, Hervester Str.57, 45768 Marl, Germany
| | - Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Maria Ai
- Department of Pediatrics, University Hospital of Erlangen, University of Erlangen-Nürnberg, Loschgestr. 15, 91054 Erlangen, Germany
| | - Angela Köninger
- Department of Gynecology and Obstetrics, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
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15
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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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16
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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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17
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Kole-White MB, Nelson LA, Lord M, Has P, Werner EF, Rouse DJ, Hardy EJ. Pregnancy latency after preterm premature rupture of membranes: oral versus intravenous antibiotics. Am J Obstet Gynecol MFM 2021; 3:100333. [PMID: 33607320 DOI: 10.1016/j.ajogmf.2021.100333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/27/2021] [Accepted: 02/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Following the destruction of pharmaceutical production facilities in Puerto Rico by Hurricane Maria in September 2017, a shortage of small-volume bags of sterile intravenous fluid for infusion led to a decreased ability to administer intravenous azithromycin and ampicillin efficiently for use in the treatment of patients with preterm premature rupture of membranes. OBJECTIVE This study aimed to assess pregnancy latency after preterm premature rupture of membranes following treatment with oral-only antibiotics compared with treatment with intravenous antibiotics followed by oral antibiotics. STUDY DESIGN This is a retrospective historic control study comparing women with preterm premature rupture of membranes who were initiated on a 7-day oral-only regimen of azithromycin and amoxicillin (modified regimen) during a 12-month period beginning December 2017 (during which time there was a shortage of small-volume bags of intravenous fluid) to women with preterm premature rupture of membranes who were initiated on a 2-day regimen of intravenous ampicillin and azithromycin followed by 5 days of oral amoxicillin and azithromycin (standard regimen) from December 2016 to December 2018. Women were included in the study if they were diagnosed with preterm premature rupture of membranes at <34 weeks' gestation and were started on latency antibiotics, and women were excluded from the study if they had a contraindication to expectant management, a cerclage, or suspected fetal anomalies. The primary outcome was pregnancy latency, defined as time from the first dose of antibiotics to delivery. RESULTS The 37 women who received the modified regimen and the 79 women who received the standard regimen had similar baseline characteristics. Mean (standard deviation) gestational age at time of preterm premature rupture of membranes was similar between the modified (30.5 weeks' gestation [±3.1]) and standard regimen groups (30.2 weeks' gestation [±3.2]), and the rate of group B streptococcus rectovaginal colonization was similar for both groups (27% vs 24%; P=.95). Pregnancy latency did not differ in the modified vs standard regimen (mean difference, -0.15 days; 95% confidence interval, -4.87 to 4.58) There was no statistically significant difference in the relative risk of composite maternal infection (relative risk, 0.43; 95% confidence interval, 0.05-3.53) or composite neonatal infection (relative risk, 0.43; 95% confidence interval, 0.05-3.52). CONCLUSION Although limited by small sample size, our study suggested that adoption of an oral-only antibiotic regimen for pregnancy latency following preterm premature rupture of membranes is worthy of further study.
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Affiliation(s)
- Martha B Kole-White
- Division of Maternal-Fetal Medicine, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI (Drs Kole-White and Lord, Mr Has, and Drs Werner and Rouse).
| | - Linda A Nelson
- Department of Pharmacy, Women and Infants Hospital, Providence, RI (Dr Nelson)
| | - Megan Lord
- Division of Maternal-Fetal Medicine, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI (Drs Kole-White and Lord, Mr Has, and Drs Werner and Rouse)
| | - Phinnara Has
- Division of Maternal-Fetal Medicine, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI (Drs Kole-White and Lord, Mr Has, and Drs Werner and Rouse)
| | - Erika F Werner
- Division of Maternal-Fetal Medicine, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI (Drs Kole-White and Lord, Mr Has, and Drs Werner and Rouse)
| | - Dwight J Rouse
- Division of Maternal-Fetal Medicine, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI (Drs Kole-White and Lord, Mr Has, and Drs Werner and Rouse)
| | - Erica J Hardy
- Divisions of Infectious Disease and Obstetric Medicine, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI (Dr Hardy)
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Luo P, Zhang K, Chen Y, Geng X, Wu T, Li L, Zhou P, Jiang PP, Ma L. Antenatal Antibiotic Exposure Affects Enteral Feeding, Body Growth, and Neonatal Infection in Preterm Infants: A Retrospective Study. Front Pediatr 2021; 9:750058. [PMID: 35004538 PMCID: PMC8727690 DOI: 10.3389/fped.2021.750058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Antibiotics are widely prescribed by obstetricians, which exposes a large number of infants to antenatal antibiotics (AAB). The effect of AAB on various aspects of neonatal development of preterm infants remains unclear. Methods: In this retrospective study, infants born with gestational age (GA) between 22 +0 and 36 +6 weeks at our unit from 2017 to 2019 were included. Multivariable analysis was adopted to examine the associations between AAB exposure and various outcomes related to enteral feeding process, body growth, and neonatal infection after adjusting for potential confounders. Further subanalysis on the exposure level of AAB and stratified analysis by GA (<34 vs. ≥34 weeks) were also conducted. Results: In this cohort comprising 2,543 preterm infants, AAB was associated with decreased risks of feeding intolerance (odds ratio [OR]: 0.63, 95% confidence interval [CI]: 0.48-0.82) and neonatal infection (OR: 0.63, 95% CI: 0.41-0.94). Higher AAB exposure level was associated with higher Z scores of birth weight (β = 0.37, 95% CI: 0.27-0.47), but lower Δbodyweight Z-scores (β = -0.20, 95% CI: -0.27 to -0.13). AAB was positively associated with the parameters related to body growth in infants with GA <34 weeks but negatively associated in those with GA ≥34 weeks. Conclusions: AAB exposure affects the enteral feeding process and neonatal infection. The effects on body growth vary by the exposure level of AAB and GA of infants. A well-designed prospective and preferably multi-centre study with predefined parameters is required to confirm our findings.
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Affiliation(s)
- Ping Luo
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Kun Zhang
- Department of Obstetrics, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
| | - You Chen
- Department of Neonatology, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
| | - Xiuwen Geng
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Tong Wu
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Li Li
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Ping Zhou
- Department of Neonatology, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
| | - Ping-Ping Jiang
- School of Public Health, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
| | - Liya Ma
- Department of Children Healthcare, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
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19
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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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20
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Baser E, Aydogan Kirmizi D, Ulubas Isik D, Ozdemirci S, Onat T, Serdar Yalvac E, Demirel N, Moraloglu Tekin O. The effects of latency period in PPROM cases managed expectantly. J Matern Fetal Neonatal Med 2020; 33:2274-2283. [PMID: 32089027 DOI: 10.1080/14767058.2020.1731465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Preterm premature rupture of membranes (PPROM), associated with prematurity, is an important obstetric complication that may cause neonatal mortality and morbidity. The optimal delivery time is controversial in cases with the expectant approach. The fetal effects of long-term exposure to PPROM are unknown. This study aimed to evaluate the maternal and fetal outcomes of expectantly-managed PPROM cases with different latency periods at 240/7-346/7 weeks of gestation.Material and method: The study group consisted of 206 patients at 240/7-346/7 weeks of gestation who met the inclusion criteria. Patients were divided into three groups according to their weeks of PPROM diagnosis as 240/7-286/7, 290/7-316/7, and 320/7-346/7. The period from membrane rupture to delivery was defined as the latency period and divided into three subgroups as 3-7 days, 8-13 days and ≥14 days. In addition to the demographic characteristics of the patients, maternal and obstetric complications, primary and secondary neonatal outcomes were compared between the groups. Primary neonatal outcomes were determined in terms of pathological Apgar scores (<5 at minute 1, <7 at minute 5), requiring resuscitation, admission to Neonatal Intensive Care Unit (NICU) and NICU length of stay. Secondary neonatal outcomes were determined in terms of respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, patent ductus arteriosus, periventricular leukomalacia, and neonatal sepsis. In addition, for the prediction of morbidity and mortality, newborns were evaluated by SNAPPE II (Score for Neonatal Acute Physiology with Perinatal extension-II) consisting of the combination of biochemical and physiological parameters, using the parameters including mean blood pressure (mm/Hg), corporal temperature (°C), PO2/FiO2 ratio, lowest serum pH, multiple seizures, urine output (ml/kg/hr), Apgar score, birth weight, and small for gestational age. The higher the score of SNAPPE II, the higher the morbidity and mortality risk of neonates. For the statistical analysis, the Kruskal Wallis and one-way ANOVA tests were utilized for the numerical data. Categorical data were compared using the chi-square test. The receiver operating characteristic (ROC) test was used to determine the threshold value of the data affecting neonatal morbidity.Results: The mean PPROM week was found to be 29.7 ± 3.0 weeks and the mean delivery week was 31.8 ± 2.5 weeks. The mean latency period for all the patients was 15.1 ± 13.8 days. Clinic chorioamnionitis was observed in 17% of the cases. The lowest chorioamnionitis rate (8.6%) was in the 3-7-day latency period group. Total complications were significantly lower in the 290/7-316/7 week PPROM group in which the latency period was ≥14 days, compared to those in 3-7 days and 8-13 days (p = .001). Total complications were lower in the < 32 weeks PPROM groups in which the latency period was ≥14 days compared to those obtained in 3-7 days and 8-13 days. There was no significant difference between the latency period and total complications after 32 weeks (p = .422). The best discriminative cutoff value of SNAPPE-II for neonatal morbidity was 11.0 (sensitivity 82%, specificity 80%). In the present study, the optimal latency period for the best neonatal outcomes was found to be 34.5 days (sensitivity 70% and specificity 84%) between weeks 240/7-286/7, and 11.0 days between weeks 290/7-316/7 (sensitivity 68% and specificity 85%).Conclusions: Our findings indicated that a long latency period did not increase neonatal morbidity and there was no increase in neonatal complications after 32 weeks of the gestational period compared to those obtained before 32 weeks.
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Affiliation(s)
- Emre Baser
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Demet Aydogan Kirmizi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Dilek Ulubas Isik
- Department of Neonatology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Health Science University, Ankara, Turkey
| | - Safak Ozdemirci
- Department of Obstetrics and Gynecology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Health Science University, Ankara, Turkey
| | - Taylan Onat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Ethem Serdar Yalvac
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Nihal Demirel
- Department of Neonatology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Health Science University, Ankara, Turkey
| | - Ozlem Moraloglu Tekin
- Department of Obstetrics and Gynecology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Health Science University, Ankara, Turkey
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21
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Antibiotic administration can eradicate intra-amniotic infection or intra-amniotic inflammation in a subset of patients with preterm labor and intact membranes. Am J Obstet Gynecol 2019; 221:142.e1-142.e22. [PMID: 30928566 DOI: 10.1016/j.ajog.2019.03.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/13/2019] [Accepted: 03/21/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Intra-amniotic infection is present in 10% of patients with an episode of preterm labor, and is a risk factor for impending preterm delivery and neonatal morbidity/mortality. Intra-amniotic inflammation is often associated with intra-amniotic infection, but is sometimes present in the absence of detectable microorganisms. Antibiotic treatment of intra-amniotic infection has traditionally been considered to be ineffective. Intra-amniotic inflammation without microorganisms has a prognosis similar to that of intra-amniotic infection. OBJECTIVE To determine whether antibiotics can eradicate intra-amniotic infection or intra-amniotic inflammation in a subset of patients with preterm labor and intact membranes. MATERIALS AND METHODS The study population consisted of women who met the following criteria: 1) singleton gestation between 20 and 34 weeks; 2) preterm labor and intact membranes; 3) transabdominal amniocentesis performed for the evaluation of the microbiologic/inflammatory status of the amniotic cavity; 4) intra-amniotic infection and/or intra-amniotic inflammation; and 5) received antibiotic treatment that consisted of ceftriaxone, clarithromycin, and metronidazole. Follow-up amniocentesis was performed in a subset of patients. Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas, and polymerase chain reaction was performed for Ureaplasma spp. Intra-amniotic infection was defined as a positive amniotic fluid culture or positive polymerase chain reaction, and intra-amniotic inflammation was suspected when there was an elevated amniotic fluid white blood cell count or a positive result of a rapid test for matrix metalloproteinase-8. For this study, the final diagnosis of intra-amniotic inflammation was made by measuring the interleukin-6 concentration in stored amniotic fluid (>2.6 ng/mL). These results were not available to managing clinicians. Treatment success was defined as eradication of intra-amniotic infection and/or intra-amniotic inflammation or delivery ≥37 weeks. RESULTS Of 62 patients with intra-amniotic infection and/or intra-amniotic inflammation, 50 received the antibiotic regimen. Of those patients, 29 were undelivered for ≥7 days and 19 underwent a follow-up amniocentesis. Microorganisms were identified by culture or polymerase chain reaction of amniotic fluid obtained at admission in 21% of patients (4/19) who had a follow-up amniocentesis, and were eradicated in 3 of the 4 patients. Resolution of intra-amniotic infection/inflammation was confirmed in 79% of patients (15/19), and 1 other patient delivered at term, although resolution of intra-amniotic inflammation could not be confirmed after a follow-up amniocentesis. Thus, resolution of intra-amniotic inflammation/infection or term delivery (treatment success) occurred in 84% of patients (16/19) who had a follow-up amniocentesis. Treatment success occurred in 32% of patients (16/50) with intra-amniotic infection/inflammation who received antibiotics. The median amniocentesis-to-delivery interval was significantly longer among women who received the combination of antibiotics than among those who did not (11.4 days vs 3.1 days: P = .04). CONCLUSION Eradication of intra-amniotic infection/inflammation after treatment with antibiotics was confirmed in 79% of patients with preterm labor, intact membranes, and intra-amniotic infection/inflammation who had a follow-up amniocentesis. Treatment success occurred in 84% of patients who underwent a follow-up amniocentesis and in 32% of women who received the antibiotic regimen.
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22
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[Antibiotic prophylaxis in preterm premature rupture of membranes: CNGOF preterm premature rupture of membranes guidelines]. ACTA ACUST UNITED AC 2018; 46:1043-1053. [PMID: 30392988 DOI: 10.1016/j.gofs.2018.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To analyse benefits and risks of antibiotic prophylaxis in the management of preterm premature rupture of membranes. METHODS PubMed and Cochrane Central databases search. RESULTS Streptoccoccus agalactiae (group B streptococcus) and Escherichia coli are the two main bacteria identified in early neonatal sepsis (EL3). Antibiotic prophylaxis at admission is associated with significant prolongation of pregnancy (EL2), reduction in neonatal morbidity (EL1) without impact on neonatal mortality (EL2). Co-amoxiclav could be associated with an increased risk for neonatal necrotising enterocolitis (EL2). Antibiotic prophylaxis at admission in women with preterm premature rupture of the membranes is recommended (Grade A). Monotherapy with amoxicillin, third generation cephalosporin and erythromycin can be used as well as combination of erythromycin and amoxicillin (Professional consensus) for 7 days (GradeC). Shorter treatment is possible when initial vaginal culture is negative (Professional consensus). Co-amxiclav, aminoglycosides, glycopeptides, first and second generation cephalosporin, clindamycin and metronidazole are not recommended (Professional consensus). CONCLUSIONS Antibiotic prophylaxis against Streptoccoccus agalactiae (group B streptococcus) and E. coli is recommended in women with preterm premature of the membranes (Grade A). Monotherapy with amoxicillin, third generation cephalosporin or erythromycin, as well as combination of erythromycin and amoxicillin are recommended (Professional consensus).
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Quist-Nelson J, Parker P, Mokhtari N, Di Sarno R, Saccone G, Berghella V. Progestogens in singleton gestations with preterm prelabor rupture of membranes: a systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2018; 219:346-355.e2. [PMID: 29614278 DOI: 10.1016/j.ajog.2018.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/20/2018] [Accepted: 03/24/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE DATA Preterm prelabor rupture of membranes occurs in 3% of all pregnancies. Neonatal benefit is seen in uninfected women who do not deliver immediately after preterm prelabor rupture of membranes. The purpose of this study was to evaluate whether the administration of progestogens in singleton pregnancies prolongs pregnancy after preterm prelabor rupture of membranes. STUDY Searches were performed in MEDLINE, OVID, Scopus, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to "progesterone," "progestogen," "prematurity," and "preterm premature rupture of membranes" from the inception of the databases until January 2018. We included all randomized controlled trials of singleton gestations after preterm prelabor rupture of membranes that were randomized to either progestogens or control (either placebo or no treatment). Exclusion criteria were trials that included women who had contraindications to expectant management after preterm prelabor rupture of membranes (ie, chorioamnionitis, severe preeclampsia, and nonreassuring fetal status) and trials on multiple gestations. We planned to include all progestogens, including but not limited to 17-α hydroxyprogesterone caproate, and natural progesterone. STUDY APPRAISAL AND SYNTHESIS METHODS The primary outcome was latency from randomization to delivery. Metaanalysis was performed with the use of the random effects model of DerSimonian and Laird to produce relative risk with 95% confidence interval. Analysis was performed for each mode of progestogen administration separately. RESULTS Six randomized controlled trials (n=545 participants) were included. Four of the included trials assessed the efficacy of 17-α hydroxyprogesterone caproate; 1 trial assessed rectal progestogen, and 1 trial had 3 arms that compared 17-α hydroxyprogesterone caproate, rectal progestogen, and placebo. The mean gestational age at time randomization was 26.9 weeks in the 17-α hydroxyprogesterone caproate group and 27.3 weeks in the control group. 17-α Hydroxyprogesterone caproate administration was not found to prolong the latency period between randomization and delivery (mean difference, 0.11 days; 95% confidence interval, -3.30 to 3.53). There were no differences in mean gestational age at delivery, mode of delivery, or maternal or neonatal outcomes between the 2 groups. Similarly, there was no difference in latency for those women who received rectal progesterone (mean difference, 4.00 days; 95% confidence interval, -0.72 to 8.72). CONCLUSION Progestogen administration does not prolong pregnancy in singleton gestations with preterm prelabor rupture of membranes.
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Müller H, Storbeck T, Katzer D, Bruns N, Wössner-Stegmann G, Ai M, Köninger A, Müller A, Felderhoff-Müser U, Bagci S. Neurological outcome at 24 months corrected age of prematurely born infants after preterm premature rupture of membranes (PPROM) of at least 7 days: a two-center experience in Germany. J Matern Fetal Neonatal Med 2018; 33:1315-1320. [PMID: 30153748 DOI: 10.1080/14767058.2018.1517327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Preterm premature rupture of membranes (PPROM) is a risk factor for chorioamnionitis (CA) and injury to the fetal brain. However, prolongation of gestation prevents morbidity and decreases complications of prematurity. The current investigation is to define risk factors for the adverse neurological outcome from the influence of PPROM of at least 7 days.Methods: A case-control study included three groups of preterm infants born at the University Hospitals Bonn and Essen, Germany. The first group consisted of infants with PPROM of at least 7 days and no chorioamnionitis (CA) (PPROM group), the second included preterm infants with CA (CA group), and the third group consisted of infants without PPROM and CA (control group). The outcome was assessed using Bayley Scales of Infant Development at a corrected age of 24 months. Each group consisted of 20 corresponding infants with an identical birth weight and gestational age at birth.Results: There was no significant difference between the mental development index (MDI) and psychomotor development index (PDI) scores (mean ± SD): the MDI score was 101 ± 14 in the PPROM group, 98 ± 12 in the CA group and 96 ± 17 in the control group; the PDI score 96 ± 10, 89 ± 16, and 90 ± 17, respectively. Multiple regression analysis revealed no significant influence of PPROM and CA on neurological outcome.Conclusions: PPROM of at least 7 days has no influence on neurodevelopmental outcome at a corrected age of 24 months when birth is initiated in the case of beginning CA.
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Affiliation(s)
- Hanna Müller
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Tobias Storbeck
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - David Katzer
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Gaby Wössner-Stegmann
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Maria Ai
- Department of Pediatric Surgery, University Hospital of Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Angela Köninger
- Department of Gynecology and Obstetrics, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Soyhan Bagci
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
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Govindaswami B, Jegatheesan P, Nudelman M, Narasimhan SR. Prevention of Prematurity: Advances and Opportunities. Clin Perinatol 2018; 45:579-595. [PMID: 30144857 DOI: 10.1016/j.clp.2018.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Preterm birth (PTB) rate varies widely and has significant racial and ethnic disparities. Although causal mechanisms are ill understood, socioenvironment, phenotype, and genotype provide insight into pathways for preventing PTB. Data suggest varied response to current medical interventions is explicable Approved by underlying pharmacogenomics. Currently, prevention focuses on minimizing iatrogenic PTB and risk reduction especially in those with prior PTB using proven medical and public health strategies. In the future, preventive approaches will be based on better understanding of sociodemography, nutrition, lifestyles, and underlying individual genetic and epigenetic variation. Statistical approaches and "big-data" models are critical in future study.
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Affiliation(s)
- Balaji Govindaswami
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA.
| | - Priya Jegatheesan
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
| | - Matthew Nudelman
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
| | - Sudha Rani Narasimhan
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
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26
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Kiver V, Boos V, Thomas A, Henrich W, Weichert A. Perinatal outcomes after previable preterm premature rupture of membranes before 24 weeks of gestation. J Perinat Med 2018; 46:555-565. [PMID: 28822226 DOI: 10.1515/jpm-2016-0341] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 07/11/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A current descriptive assessment of perinatal outcomes in pregnancies complicated by previable preterm premature rupture of membranes (pPPROM) at <24 weeks of gestation, after expectant treatment. STUDY DESIGN Maternal and short-term neonatal data were collected for patients with pPPROM. RESULTS Seventy-three patients with 93 fetuses were hospitalized with pPPROM at 15-24 weeks' gestation. Among these patients, 27.4% (n=20) chose pregnancy termination, 27.4% (n=20) miscarried and 45.2% (n=33) proceeded to live births. After a median latency period of 38 days, ranging from 1 to 126 days, 24 singletons and 20 multiples were live-born, of whom 79.5% (n=35) survived the perinatal period. The main neonatal sequelae were pulmonary hypoplasia (29.5%; n=13), connatal infection (56.8%; n=25), intraventricular hemorrhage (25%; n=11; resulting in five neonatal deaths) and Potter's syndrome (15.9%; n=7). Nine newborns died, within an average of 2.8 days (range, 1-10 days). The overall neonatal survival rate was 51.5% - including miscarriages but not elective terminations. The intact survival rate was 45.5% of all live-born neonates. CONCLUSIONS Even with limited treatment options, overall neonatal survival is increasing. However, neonatal mortality and morbidity rates remain high. The gestational age at membrane rupture does not predict neonatal outcome.
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Affiliation(s)
- Verena Kiver
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany, Tel.: +49 (030) 450 664487
| | - Vinzenz Boos
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anke Thomas
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Weichert
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
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27
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Tchirikov M, Schlabritz-Loutsevitch N, Maher J, Buchmann J, Naberezhnev Y, Winarno AS, Seliger G. Mid-trimester preterm premature rupture of membranes (PPROM): etiology, diagnosis, classification, international recommendations of treatment options and outcome. J Perinat Med 2018; 46:465-488. [PMID: 28710882 DOI: 10.1515/jpm-2017-0027] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/19/2017] [Indexed: 12/12/2022]
Abstract
Mid-trimester preterm premature rupture of membranes (PPROM), defined as rupture of fetal membranes prior to 28 weeks of gestation, complicates approximately 0.4%-0.7% of all pregnancies. This condition is associated with a very high neonatal mortality rate as well as an increased risk of long- and short-term severe neonatal morbidity. The causes of the mid-trimester PPROM are multifactorial. Altered membrane morphology including marked swelling and disruption of the collagen network which is seen with PPROM can be triggered by bacterial products or/and pro-inflammatory cytokines. Activation of matrix metalloproteinases (MMP) have been implicated in the mechanism of PPROM. The propagation of bacteria is an important contributing factor not only in PPROM, but also in adverse neonatal and maternal outcomes after PPROM. Inflammatory mediators likely play a causative role in both disruption of fetal membrane integrity and activation of uterine contraction. The "classic PPROM" with oligo/an-hydramnion is associated with a short latency period and worse neonatal outcome compared to similar gestational aged neonates delivered without antecedent PPROM. The "high PPROM" syndrome is defined as a defect of the chorio-amniotic membranes, which is not located over the internal cervical os. It may be associated with either a normal or reduced amount of amniotic fluid. It may explain why sensitive biochemical tests such as the Amniosure (PAMG-1) or IGFBP-1/alpha fetoprotein test can have a positive result without other signs of overt ROM such as fluid leakage with Valsalva. The membrane defect following fetoscopy also fulfils the criteria for "high PPROM" syndrome. In some cases, the rupture of only one membrane - either the chorionic or amniotic membrane, resulting in "pre-PPROM" could precede "classic PPROM" or "high PPROM". The diagnosis of PPROM is classically established by identification of nitrazine positive, fern positive watery leakage from the cervical canal observed during in specula investigation. Other more recent diagnostic tests include the vaginal swab assay for placental alpha macroglobulin-1 test or AFP and IGFBP1. In some rare cases amniocentesis and infusion of indigo carmine has been used to confirm the diagnosis of PPROM. The management of the PPROM requires balancing the potential neonatal benefits from prolongation of the pregnancy with the risk of intra-amniotic infection and its consequences for the mother and infant. Close monitoring for signs of chorioamnionitis (e.g. body temperature, CTG, CRP, leucocytes, IL-6, procalcitonine, amniotic fluid examinations) is necessary to minimize the risk of neonatal and maternal complications. In addition to delayed delivery, broad spectrum antibiotics of penicillin or cephalosporin group and/or macrolide and corticosteroids have been show to improve neonatal outcome [reducing risk of chorioamnionitis (average risk ratio (RR)=0.66), neonatal infections (RR=0.67) and abnormal ultrasound scan of neonatal brain (RR=0.67)]. The positive effect of continuous amnioinfusion through the subcutaneously implanted perinatal port system with amniotic fluid like hypo-osmotic solution in "classic PPROM" less than 28/0 weeks' gestation shows promise but must be proved in future prospective randomized studies. Systemic antibiotics administration in "pre-PPROM" without infection and hospitalization are also of questionable benefit and needs to be further evaluated in well-designed randomized prospective studies to evaluate if it is associated with any neonatal benefit as well as the relationship to possible adverse effect of antibiotics on to fetal development and neurological outcome.
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Affiliation(s)
- Michael Tchirikov
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Natalia Schlabritz-Loutsevitch
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center (TTUHSC), School of Medicine at the Permian Basin, Odessa, TX, USA
| | - James Maher
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center (TTUHSC), School of Medicine at the Permian Basin, Odessa, TX, USA
| | - Jörg Buchmann
- Department of Pathology, Martha-Maria Hospital, Halle-Dölau, Halle, Germany
| | - Yuri Naberezhnev
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Andreas S Winarno
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Gregor Seliger
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
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Saghafi N, Pourali L, Ghazvini K, Maleki A, Ghavidel M, Karbalaeizadeh Babaki M. Cervical bacterial colonization in women with preterm premature rupture of membrane and pregnancy outcomes: A cohort study. Int J Reprod Biomed 2018. [DOI: 10.29252/ijrm.16.5.341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Sim WH, Araujo Júnior E, Da Silva Costa F, Sheehan PM. Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability. J Perinat Med 2017; 45:29-44. [PMID: 27780154 DOI: 10.1515/jpm-2016-0183] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/29/2016] [Indexed: 11/15/2022]
Abstract
AIM To assess the contemporary maternal and neonatal outcomes following expectant management of preterm premature rupture of membranes (PPROM) prior to 24 weeks' gestation and to identify prognostic indicators of this morbid presentation. METHODS We performed a systematic review in the Pubmed and EMBASE databases to identify the primary (perinatal mortality, severe neonatal morbidity and serious maternal morbidity) and secondary (neonatal survival and morbidity) outcomes following expectant management of previable PPROM. RESULTS Mean latency between PPROM and delivery ranged between 20 and 43 days. Women with PPROM <24 weeks had an overall live birth rate of 63.6% and a survival-to-discharge rate of 44.9%. The common neonatal morbidities were respiratory distress syndrome, bronchopulmonary dysplasia and sepsis. The majority of neonatal deaths within 24 h post birth were associated with pulmonary hypoplasia, severe intraventricular haemorrhage and neonatal sepsis. The common maternal outcomes were chorioamnionitis and caesarean sections. The major predictors of neonatal survival were later gestational age at PPROM, adequate residual amniotic fluid levels, C-reactive protein <1 mg/dL within 24 h of admission and PPROM after invasive procedures. CONCLUSION Pregnancy latency and neonatal survival following previable PPROM has improved in recent years, although neonatal morbidity remains unchanged despite recent advances in obstetric and neonatal care. There is heterogeneity in management practices across centres worldwide.
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von Linsingen R, Bicalho MDG, de Carvalho NS. Baby born too soon: an overview and the impact beyond the infection. J Matern Fetal Neonatal Med 2016; 30:1238-1242. [PMID: 27380453 DOI: 10.1080/14767058.2016.1209653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Spontaneous preterm delivery, prematurity, and low birth weight due to prematurity account for a great part of neonatal morbidity and mortality. Inflammation may cause preterm labor, with the involvement of different mediators that produce diverse aspects of the inflammatory response. Although bacteria are considered to be the main trigger for intrauterine infection/inflammation, immunological factors also appear to be involved. Recently, molecular genetic studies have helped us better understand the underlying pathophysiologic processes. During mammalian pregnancy, maternal-fetal tolerance involves a number of immunosuppressive factors produced by placenta. Recently, placenta-derived exosomes have emerged as new immune regulators in the maternal immune tolerance. This review focuses on the specific immune parameters that become altered during human pregnancy, the identity and function of some immune modulators that have been best characterized to date, as well as a comprehensive evaluation of the pregnancy-associated mechanisms that downregulate proinflammatory immunity to a level sufficient to prevent the triggering of premature common pathway of labor and damage to developing organs.
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Affiliation(s)
- Renate von Linsingen
- a Department of Gynecology and Obstetrics - Infectious Diseases in Gynecology and Obstetrics Sector , Federal University of Paraná , Curitiba , Brazil
| | - Maria da Graça Bicalho
- b Department of Genetics , Federal University of Paraná , Curitiba , Brazil , and.,c Departamento de Genética , Laboratory de Immunogenetics and Histocompatibility (LIGH), Centro Politécnico, Setor de Ciências Biológicas , Curitiba , Brazil
| | - Newton Sérgio de Carvalho
- a Department of Gynecology and Obstetrics - Infectious Diseases in Gynecology and Obstetrics Sector , Federal University of Paraná , Curitiba , Brazil
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Heng YJ, Pennell CE, McDonald SW, Vinturache AE, Xu J, Lee MWF, Briollais L, Lyon AW, Slater DM, Bocking AD, de Koning L, Olson DM, Dolan SM, Tough SC, Lye SJ. Maternal Whole Blood Gene Expression at 18 and 28 Weeks of Gestation Associated with Spontaneous Preterm Birth in Asymptomatic Women. PLoS One 2016; 11:e0155191. [PMID: 27333071 PMCID: PMC4917227 DOI: 10.1371/journal.pone.0155191] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/25/2016] [Indexed: 01/08/2023] Open
Abstract
The heterogeneity of spontaneous preterm birth (SPTB) requires an interdisciplinary approach to determine potential predictive risk factors of early delivery. The aim of this study was to investigate maternal whole blood gene expression profiles associated with spontaneous preterm birth (SPTB, <37 weeks) in asymptomatic pregnant women. The study population was a matched subgroup of women (51 SPTBs, 114 term delivery controls) who participated in the All Our Babies community based cohort in Calgary (n = 1878). Maternal blood at 17–23 (sampling time point 1, T1) and 27–33 weeks of gestation (T2) were collected. Total RNA was extracted and microarray was performed on 326 samples (165 women). Univariate analyses determined significant clinical factors and differential gene expression associated with SPTB. Thirteen genes were validated using qRT-PCR. Three multivariate logistic models were constructed to identify gene expression at T1 (Model A), T2 (Model B), and gene expression fold change from T1 to T2 (Model C) associated with SPTB. All models were adjusted for clinical factors. Model C can predict SPTB with 65% sensitivity and 88% specificity in asymptomatic women after adjusting for history of abortion and anaemia (occurring before T2). Clinical data enhanced the sensitivity of the Models to predict SPTB. In conclusion, clinical factors and whole blood gene expression are associated with SPTB in asymptomatic women. An effective screening tool for SPTB during pregnancy would enable targeted preventive approaches and personalised antenatal care.
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Affiliation(s)
- Yujing J. Heng
- Departments of Obstetrics & Gynaecology and Physiology, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- * E-mail:
| | - Craig E. Pennell
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia
| | - Sheila W. McDonald
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Angela E. Vinturache
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Departments of Obstetrics & Gynaecology and Physiology & Pharmacology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Jingxiong Xu
- Departments of Obstetrics & Gynaecology and Physiology, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Mary W. F. Lee
- Departments of Obstetrics & Gynaecology and Physiology, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Laurent Briollais
- Departments of Obstetrics & Gynaecology and Physiology, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Andrew W. Lyon
- Department of Pathology and Lab Medicine, University of Saskatchewan, St Paul’s Hospital, Saskatoon Health Region, Saskatoon, SK, Canada
| | - Donna M. Slater
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Departments of Obstetrics & Gynaecology and Physiology & Pharmacology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Alan D. Bocking
- Departments of Obstetrics & Gynaecology and Physiology, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Lawrence de Koning
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Calgary Laboratory Services, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David M. Olson
- Departments of Obstetrics & Gynecology, Physiology and Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Siobhan M. Dolan
- Department of Obstetrics & Gynecology and Women's Health (Reproductive Genetics), Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Suzanne C. Tough
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen J. Lye
- Departments of Obstetrics & Gynaecology and Physiology, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
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Lee Y, Chen C, Chu D, Ko M. Factors associated with potentially harmful antibiotic prescription during pregnancy: a population-based study. J Eval Clin Pract 2016; 22:200-6. [PMID: 26446517 DOI: 10.1111/jep.12454] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 12/18/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Inappropriate antibiotic prescriptions during pregnancy may adversely affect the fetus. There were few studies on factors associated with antibiotic prescriptions potentially harmful to the fetus. METHODS This was a population-based cross-sectional study using data from National Health Insurance Research Database. We calculated the frequency of antibiotic prescription according to the status of pregnancy, type of infections, characteristics of patients, doctors and medical institutions. According to the British National Formulary, sulfonamides, trimethoprim, tetracycline and quinolones were classified as antibiotics potentially harmful to the fetus. A multivariate logistic regression analysis was performed to evaluate the independent effect of various characteristic on antibiotic prescriptions, during pregnancy, potentially harmful to the fetus. RESULTS Among the 19 464 pregnant subjects, 6554 (33.67%) received antibiotic prescriptions during pregnancy. Antibiotic prescriptions potentially harmful to the fetus accounted for 6.31% of all antibiotic prescriptions during pregnancy. Pregnant women aged <20 years, in their first trimester, and who were presenting with urogenital infections had the highest risks of receiving antibiotic prescriptions potentially harmful to the fetus. Non-gynaecologists, doctors aged 39-49 or ≥50 years, and doctors at clinics had higher risks of prescribing antibiotics potentially harmful to the fetus. CONCLUSIONS Measures to improve the quality of practices should include efforts to increase awareness of antibiotic prescription guidelines for the treatment of infections in the pregnant population.
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Affiliation(s)
- Yichen Lee
- Department of Health Administration, Tzu-Chi University of Science and Technology, Hualien, Taiwan
| | - Chuchieh Chen
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Dachen Chu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.,Department of Emergency Medicine and Surgery, Taipei City Hospital, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Mingchung Ko
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.,Department of Emergency Medicine and Surgery, Taipei City Hospital, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
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Kim SA, Park KH, Lee SM. Non-Invasive Prediction of Histologic Chorioamnionitis in Women with Preterm Premature Rupture of Membranes. Yonsei Med J 2016; 57:461-8. [PMID: 26847301 PMCID: PMC4740541 DOI: 10.3349/ymj.2016.57.2.461] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/27/2015] [Accepted: 06/11/2015] [Indexed: 01/14/2023] Open
Abstract
PURPOSE To develop a model based on non-invasive clinical and ultrasonographic parameters for predicting the likelihood of subsequent histologic chorioamnionitis in women with preterm premature rupture of membranes (PPROM) and to determine whether the inclusion of invasive test results improves the predictive value of the model. MATERIALS AND METHODS This retrospective cohort study included 146 consecutive women presenting with PPROM (20-33 weeks). Transvaginal ultrasonographic assessment of cervical length was performed. Maternal serum C-reactive protein (CRP) levels and white blood cell (WBC) counts were measured after amniocentesis. Amniotic fluid (AF) obtained by amniocentesis was cultured, and interleukin-6 (IL-6) levels and WBC counts were determined. The primary outcome measure was histologic chorioamnionitis. RESULTS Risk scores based on serum CRP concentrations and gestational age (model 1) were calculated for each patient. The model was shown to have adequate goodness of fit and an area under the receiver operating characteristic curve (AUC) of 0.742. When including AF test results (e.g., AF IL-6 levels) in model 1, serum CRP concentrations were found to be insignificant, and thus, were excluded from model 2, comprising AF IL-6 levels and gestational age. No significant difference in AUC was found between models 1 and 2. CONCLUSION For women with PPROM, the newly developed model incorporating non-invasive parameters (serum CRP and gestational age) was moderately predictive of histologic chorioamnionitis. The inclusion of invasive test results added no predictive information to the model in this setting.
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Affiliation(s)
- Su Ah Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyo Hoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
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Toda N, Hoshina T, Koga Y, Ochiai M, Kaku N, Yamamura K, Torisu H, Ihara K, Takada H, Maehara Y, Hara T. Analysis of Death Due to Infectious Diseases in Patients Hospitalized in the Pediatric Ward of a Single Japanese Tertiary Medical Facility. Jpn J Infect Dis 2016; 69:464-470. [PMID: 26902210 DOI: 10.7883/yoken.jjid.2015.591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In developed countries, the infection related-mortality rates in children hospitalized in tertiary medical facilities, where many patients with underlying disease are also hospitalized, are uncertain. We investigated the characteristics of infectious diseases-related fatal cases in the pediatric ward of a Japanese tertiary medical facility. A total of 188 patients who died in the pediatric ward or intensive care unit at Kyushu University Hospital from 2002 to 2011 were enrolled. The patient characteristics were investigated based on their medical records. A total of 35 patients died of infections, 31 of whom had underlying diseases. Most patients died of sepsis or pneumonia (n = 27). All 9 patients who died within 7 days of birth were premature. Nine of the 13 patients with malignancy or hematological disorders died of hematopoietic stem cell transplantation (HSCT)-associated infections. The ratio of infectious disease-related fatal cases to the total cases decreased in the latter half of the study period. In particular, the proportion of preterm infants who died of infections was significantly lower in the latter 5 years (p = 0.02). Many of the infectious disease-related fatal cases were in premature infants and HSCT or post-HSCT patients. However, the mortality due to infectious diseases decreased in these patient groups.
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Affiliation(s)
- Naoko Toda
- Departments of Pediatrics, Graduate School of Medical Sciences, Kyushu University
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Lee J, Romero R, Kim SM, Chaemsaithong P, Yoon BH. A new antibiotic regimen treats and prevents intra-amniotic inflammation/infection in patients with preterm PROM. J Matern Fetal Neonatal Med 2015; 29:2727-37. [PMID: 26441216 DOI: 10.3109/14767058.2015.1103729] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To determine whether a new antibiotic regimen could reduce the frequency of intra-amniotic inflammation/infection in patients with preterm PROM. STUDY DESIGN This retrospective cohort study was conducted to evaluate the effect of antibiotics on the frequency of intra-amniotic inflammation/infection based on the results of follow-up transabdominal amniocenteses from 89 patients diagnosed with preterm PROM who underwent serial amniocenteses. From 1993-2003, ampicillin and/or cephalosporins or a combination was used ("regimen 1"). A new regimen (ceftriaxone, clarithromycin and metronidazole) was used from 2003-2012 ("regimen 2"). Amniotic fluid was cultured and matrix metalloproteinase-8 (MMP-8) concentrations were measured. RESULTS (1) The rates of intra-amniotic inflammation and intra-amniotic inflammation/infection in patients who received regimen 2 decreased during treatment from 68.8% to 52.1% and from 75% to 54.2%, respectively. In contrast, in patients who received regimen 1, the frequency of intra-amniotic inflammation and infection/inflammation increased during treatment (31.7% to 55% and 34.1% to 58.5%, respectively); and (2) intra-amniotic inflammation/infection was eradicated in 33.3% of patients who received regimen 2, but in none who received regimen 1. CONCLUSION The administration of ceftriaxone, clarithromycin and metronidazole was associated with a more successful eradication of intra-amniotic inflammation/infection and prevented secondary intra-amniotic inflammation/infection more frequently than an antibiotic regimen which included ampicillin and/or cephalosporins in patients with preterm PROM.
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Affiliation(s)
- JoonHo Lee
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Roberto Romero
- b Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NICHD/NIH/DHHS , Bethesda, MD, and Detroit, MI , USA .,c Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA .,d Department of Epidemiology and Biostatistics , Michigan State University , East Lansing , MI , USA .,e Center for Molecular Medicine and Genetics, Wayne State University , Detroit , MI , USA
| | - Sun Min Kim
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Republic of Korea .,f Department of Obstetrics and Gynecology , Seoul Metropolitan Government --Seoul National University Boramae Medical Center , Seoul , Republic of Korea , and
| | - Piya Chaemsaithong
- b Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NICHD/NIH/DHHS , Bethesda, MD, and Detroit, MI , USA .,g Department of Obstetrics and Gynecology , Wayne State University School of Medicine , Detroit , MI , USA
| | - Bo Hyun Yoon
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Republic of Korea
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Baldwin EA, Walther-Antonio M, MacLean AM, Gohl DM, Beckman KB, Chen J, White B, Creedon DJ, Chia N. Persistent microbial dysbiosis in preterm premature rupture of membranes from onset until delivery. PeerJ 2015; 3:e1398. [PMID: 26644969 PMCID: PMC4671185 DOI: 10.7717/peerj.1398] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/20/2015] [Indexed: 01/28/2023] Open
Abstract
Background. Preterm Premature Rupture of Membranes (PPROM) is a major leading cause of preterm births. While the cause for PPROM remains unidentified, it is anticipated to be due to subclinical infection, since a large proportion of PPROM patients display signs of chorioamnionitis. Since subclinical infections can be facilitated by dysbiosis, our goal was to characterize the vaginal microbiome and amniotic fluid discharge upon PPROM, through latency antibiotic treatment, and until delivery, to detect the presence of pathogens, microbiota alteration, and microbial response to treatment. Methods. Enrolled subjects (15) underwent routine institutional antenatal care for PPROM, including the administration of latency antibiotics. Serial vaginal swabs were obtained from diagnosis of PPROM through delivery and the sequencing of the V3-V5 region of the 16S rRNA gene was performed for all collected samples. Results. The results show that Lactobacilli species were markedly decreased when compared to vaginal swabs collected from uncomplicated pregnancy subjects with a matched gestational time. Prevotella and Peptoniphilus were the most prevalent taxa in PPROM subjects at presentation. The vaginal microbiome of the PPROM subjects varied substantially intra- and inter-subjects. Several taxa were found to be significantly reduced during and after the antibiotic treatment: Weeksella, Lachnospira, Achromobacter, and Pediococcus. In contrast, Peptostreptococcus and Tissierellaceae ph2 displayed a significant increase after the antibiotic treatment. However, the relative abundance of Lactobacillus, Prevotella, and Peptoniphilus was not substantially impacted during the hospitalization of the PPROM subjects. The deficiency of Lactobacillus, and constancy of known pathogenic species, such as Prevotella and Peptoniphilus during and after antibiotics, highlights the persistent dysbiosis and warrants further investigation into mitigating approaches. Discussion. PPROM is responsible for one third of all preterm births. It is thought that subclinical infection is a crucial factor in the pathophysiology of PPROM because 25-40% of patients present signs of chorioamnionitis on amniocentesis. Here we sought to directly assess the bacterial content of the vagina and leaking amniotic fluid of subjects at presentation, throughout treatment and up until delivery, in order to search for common pathogens, microbiota changes, and microbial response to latency antibiotic treatment. We have found that the vaginal microbiome of PPROM subjects is highly variable and displays significant changes to treatment. However, the unchanging deficiency of Lactobacillus, and persistence of known pathogenic species, such as Prevotella and Peptoniphilus from presentation, through antibiotic treatment and up until delivery, highlights the persistent dysbiosis and warrants further investigation into mitigating approaches.
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Affiliation(s)
| | | | | | - Daryl M. Gohl
- Genomics Center, University of Minnesota, Minneapolis, MN, USA
| | | | - Jun Chen
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Bryan White
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, United States
- Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | | | - Nicholas Chia
- Department of Surgical Research, Mayo Clinic, Rochester, MN, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
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Lamont RF. Advances in the Prevention of Infection-Related Preterm Birth. Front Immunol 2015; 6:566. [PMID: 26635788 PMCID: PMC4644786 DOI: 10.3389/fimmu.2015.00566] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 10/23/2015] [Indexed: 11/17/2022] Open
Abstract
Infection-related preterm birth (PTB) is more common at early gestational ages and is associated with major neonatal mortality and morbidity. Abnormal genital tract microflora in early pregnancy predicts late miscarriage and early PTB. Accordingly, it is logical to consider antibiotics as an intervention. Unfortunately, the conclusions of systematic reviews and meta-analyses (SR&MAs) carried out in an attempt to explain the confusion over the heterogeneity of individual studies are flawed by the fact that undue reliance was placed on studies which: (a) had a suboptimal choice of antibiotic (mainly metronidazole) or used antibiotics not recommended for the treatment of bacterial vaginosis (BV) or BV-related organisms; (b) used antibiotics too late in pregnancy to influence outcome (23–27 weeks); and (c) included women whose risk of PTB was not due to abnormal genital tract colonization and hence unlikely to respond to antibiotics. These risks included: (a) previous PTB of indeterminate etiology; (b) low weight/body mass index; or (c) detection of fetal fibronectin, ureaplasmas, Group B streptococcus or Trichomonas vaginalis). While individual studies have found benefit of antibiotic intervention for the prevention of PTB, in meta-analyses these effects have been negated by large methodologically flawed studies with negative results. As a result, many clinicians think that any antibiotic given at any time in pregnancy to any woman at risk of PTB will cause more harm than good. Recently, a more focused SR&MA has demonstrated that antibiotics active against BV-related organisms, used in women whose risk of PTB is due to abnormal microflora, and used early in pregnancy before irreversible inflammatory damage has occurred, can reduce the rate of PTB. This review presents those data, the background and attempts to explain the confusion using new information from culture-independent molecular-based techniques. It also gives guidance on the structure of putative future antibiotic intervention studies.
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Affiliation(s)
- Ronald F Lamont
- Research Unit of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Institute of Clinical Research, Odense University Hospital, University of Southern Denmark , Odense , Denmark ; Division of Surgery, University College London , London , UK
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Kayem G, Girard G. Gestion anténatale du risque d’infection amnio-choriale en cas de rupture prématurée des membranes avant 37 semaines d’aménorrhée. Arch Pediatr 2015; 22:1056-63. [DOI: 10.1016/j.arcped.2015.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 11/25/2014] [Accepted: 03/26/2015] [Indexed: 11/29/2022]
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Lee J, Romero R, Kim SM, Chaemsaithong P, Park CW, Park JS, Jun JK, Yoon BH. A new anti-microbial combination prolongs the latency period, reduces acute histologic chorioamnionitis as well as funisitis, and improves neonatal outcomes in preterm PROM. J Matern Fetal Neonatal Med 2015; 29:707-20. [PMID: 26373262 DOI: 10.3109/14767058.2015.1020293] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Antibiotic administration is a standard practice in preterm premature rupture of membranes (PROM). Specific anti-microbial agents often include ampicillin and/or erythromycin. Anaerobes and genital mycoplasmas are frequently involved in preterm PROM, but are not adequately covered by antibiotics routinely used in clinical practice. Our objective was to compare outcomes of PROM treated with standard antibiotic administration versus a new combination more effective against these bacteria. STUDY DESIGN A retrospective study compared perinatal outcomes in 314 patients with PROM <34 weeks receiving anti-microbial regimen 1 (ampicillin and/or cephalosporins; n = 195, 1993-2003) versus regimen 2 (ceftriaxone, clarithromycin and metronidazole; n = 119, 2003-2012). Intra-amniotic infection/inflammation was assessed by positive amniotic fluid culture and/or an elevated amniotic fluid MMP-8 concentration (>23 ng/mL). RESULTS (1) Patients treated with regimen 2 had a longer median antibiotic-to-delivery interval than those with regimen 1 [median (interquartile range) 23 d (10-51 d) versus 12 d (5-52 d), p < 0.01]; (2) patients who received regimen 2 had lower rates of acute histologic chorioamnionitis (50.5% versus 66.7%, p < 0.05) and funisitis (13.9% versus 42.9%, p < 0.001) than those who had received regimen 1; (3) the rates of intra-ventricular hemorrhage (IVH) and cerebral palsy (CP) were significantly lower in patients allocated to regimen 2 than regimen 1 (IVH: 2.1% versus 19.0%, p < 0.001 and CP: 0% versus 5.7%, p < 0.05); and (4) subgroup analysis showed that regimen 2 improved perinatal outcomes in pregnancies with intra-amniotic infection/inflammation, but not in those without intra-amniotic infection/inflammation (after adjusting for gestational age and antenatal corticosteroid administration). CONCLUSION A new antibiotic combination consisting of ceftriaxone, clarithromycin, and metronidazole prolonged the latency period, reduced acute histologic chorioamnionitis/funisitis, and improved neonatal outcomes in patients with preterm PROM. These findings suggest that the combination of anti-microbial agents (ceftriaxone, clarithromycin, and metronidazole) may improve perinatal outcome in preterm PROM.
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Affiliation(s)
- JoonHo Lee
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Korea
| | - Roberto Romero
- b Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development , NIH, Bethesda, MD and Detroit, MI , USA .,c Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA .,d Department of Epidemiology and Biostatistics , Michigan State University , East Lansing , MI , USA .,e Center for Molecular Medicine and Genetics, Wayne State University , Detroit , MI , USA , and
| | - Sun Min Kim
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Korea
| | - Piya Chaemsaithong
- b Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development , NIH, Bethesda, MD and Detroit, MI , USA .,f Department of Obstetrics and Gynecology , Wayne State University School of Medicine , Detroit , MI , USA
| | - Chan-Wook Park
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Korea
| | - Joong Shin Park
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Korea
| | - Jong Kwan Jun
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Korea
| | - Bo Hyun Yoon
- a Department of Obstetrics and Gynecology , Seoul National University College of Medicine , Seoul , Korea
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Garabedian C, Bocquet C, Duhamel A, Rousselle B, Balagny S, Clouqueur E, Tillouche N, Deruelle P. [Preterm rupture of membranes: Is home care a safe management?]. ACTA ACUST UNITED AC 2015; 45:278-84. [PMID: 25847826 DOI: 10.1016/j.jgyn.2015.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/20/2015] [Accepted: 02/27/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Compare the maternal and neonatal outcomes in pregnancies complicated by preterm prelabour rupture of membranes (PPROM), which were managed either at home (HAD) or hospital (HC). MATERIALS AND METHODS Retrospective study in two level III maternities during 2 years. Inclusion criteria in HAD were: singleton pregnancy, PPROM between 24 and 35 weeks of gestation, absence of chorioamnionitis, clinical stability at D7 of the rupture, cervical dilatation <3 cm, patient residing in the geographic area. RESULTS Thirty-two patients were included in the HAD group and 24 in the HC group. Our populations were similar in the 2 groups. The duration of latency was longer in the HAD group than in the HC group (27.5 d [20-37] versus 16.5 d [12.5 to 29.5]; P=0.026). Patients in the HAD group received fewer antibiotics with a similar rate of chorioamnionitis. No difference in terms of obstetrical and neonatal outcomes was observed. Number of days in neonatal resuscitation was lower in the HAD group than in the HC group (12.5 d [10-22] versus 43 d [20-52]; P=0.003). CONCLUSION HAD seems to be an alternative to continuous hospitalization for patients followed for PPROM between 24 and 35 weeks. A randomized study with a larger number of patients, including other data such as maternal satisfaction and cost analysis, would be interesting to confirm those preliminary results.
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Affiliation(s)
- C Garabedian
- Pôle d'obstétrique, pôle Femme-Mère-Nouveau-né, maternité Jeanne-de-Flandre, clinique d'obstétrique, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France.
| | - C Bocquet
- Pôle d'obstétrique, pôle Femme-Mère-Nouveau-né, maternité Jeanne-de-Flandre, clinique d'obstétrique, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - A Duhamel
- EA2694, département de biostatistiques, UDSL, université de Lille, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - B Rousselle
- Hospitalisation à domicile, CHRU de Lille, 59037 Lille, France
| | - S Balagny
- Hospitalisation à domicile, CHRU de Lille, 59037 Lille, France
| | - E Clouqueur
- Pôle d'obstétrique, pôle Femme-Mère-Nouveau-né, maternité Jeanne-de-Flandre, clinique d'obstétrique, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - N Tillouche
- Pôle Femme-Mère-Nouveau-né, centre hospitalier de Valenciennes, 59322 Valenciennes, France
| | - P Deruelle
- Pôle d'obstétrique, pôle Femme-Mère-Nouveau-né, maternité Jeanne-de-Flandre, clinique d'obstétrique, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France; Faculté de médecine Henri-Warembourg, université de Lille, 59045 Lille cedex, France
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Armstrong-Wells J, Donnelly M, Post MD, Manco-Johnson MJ, Winn VD, Sébire G. Inflammatory predictors of neurologic disability after preterm premature rupture of membranes. Am J Obstet Gynecol 2015; 212:212.e1-9. [PMID: 25223243 DOI: 10.1016/j.ajog.2014.09.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/27/2014] [Accepted: 09/10/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The maternal-fetal inflammatory response contributes to both preterm premature rupture of membranes (PPROM) and adverse neurological outcomes. Additionally, cytokines associated with fetal placental inflammation can be detrimental to brain development regardless of inciting infection. We investigated whether differential patterns of cytokine markers in maternal and fetal plasma samples reflect subtypes of placental inflammation and neurological outcomes at 6 months in infants born to mothers with PPROM. STUDY DESIGN Within a prospective cohort study of 25 women with PPROM, plasma cytokines (interleukin [IL]-1β, IL-6, IL-8, and tumor necrosis factor-α) were measured by enzyme-linked immunosorbent assay from maternal blood samples at rupture and delivery, and from fetal umbilical cord blood samples. Patterns of cytokine expression were correlated with specific placenta pathologies. Infants underwent cranial ultrasound after birth and standardized neurological examinations at 6 months' corrected gestational age. Predictors of inflammation and adverse neurological outcome were assessed by logistic regression, adjusting for gestational age at birth. RESULTS Inflammation of the fetal side of the placenta was associated with elevated maternal IL-6 and IL-8 at delivery and fetal IL-1β, IL-6, IL-8, and tumor necrosis factor-α. Worse neurological outcome at 6 months was associated with inflammation of the fetal side of the placenta and shorter duration from rupture of membrane to delivery, independent of gestational age at birth or cranial ultrasound results. CONCLUSION Our findings support the connection between fetal inflammation with adverse neurological outcome with PPROM, regardless of cranial ultrasound results. Further longitudinal studies are needed to adequately examine these patterns, and will aid in risk assessment and intervention strategies.
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Affiliation(s)
- Jennifer Armstrong-Wells
- Department of Pediatrics (Neurology), University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO; Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO.
| | - Meghan Donnelly
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Miriam D Post
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO
| | - Marilyn J Manco-Johnson
- Department of Pediatrics (Hematology/Oncology/BMT), University of Colorado School of Medicine, Aurora, CO
| | - Virginia D Winn
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Guillaume Sébire
- Department of Pediatrics and Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
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Abstract
Chorioamnionitis is the process of active infection within the amniotic cavity that induces an inflammatory response. A wide variety of pathologic organisms can cause chorioamnionitis. Prompt diagnosis and timely treatment with broad-spectrum antibiotics can help avert the significant short-term and long-term consequences that may result. This review aims to summarize the up-to-date diagnosis criteria, treatment protocols, and long-term sequelae of missed diagnoses or poorly treated disease. It also calls for future studies that aim to better understand the mechanism of disease and to develop better detection and intervention methods to prevent the significant associated morbidity.
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Joergensen JS, Kjær Weile LK, Lamont RF. The early use of appropriate prophylactic antibiotics in susceptible women for the prevention of preterm birth of infectious etiology. Expert Opin Pharmacother 2014; 15:2173-91. [DOI: 10.1517/14656566.2014.950225] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Manuck TA, Varner MW. Neonatal and early childhood outcomes following early vs later preterm premature rupture of membranes. Am J Obstet Gynecol 2014; 211:308.e1-6. [PMID: 24858202 DOI: 10.1016/j.ajog.2014.05.030] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 04/14/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Data regarding long-term outcomes of neonates reaching viability following early preterm premature rupture of membranes (PPROM; <25.0 weeks at rupture) are limited. We hypothesized that babies delivered after early PPROM would have increased rates of major childhood morbidity compared with those with later PPROM (≥25.0 weeks at rupture). STUDY DESIGN This was a secondary analysis of a multicenter randomized controlled trial of magnesium sulfate vs placebo for cerebral palsy prevention. Women with singletons and PPROM of 15-32 weeks were included. All women delivered at 24.0 weeks or longer. Those with PPROM less than 25.0 weeks (cases) were compared with women with PPROM at 25.0-31.9 weeks (controls). Composite severe neonatal morbidity (sepsis, severe intraventricular hemorrhage, periventricular leukomalacia, severe necrotizing enterocolitis, bronchopulmonary dysplasia, and/or death) and composite severe childhood morbidity at age 2 years (moderate or severe cerebral palsy and/or Bayley II Infant and Toddler Development scores greater than 2 SD below the mean) were compared. RESULTS A total of 1531 women (275 early PPROM cases) were included. Demographics were similar between the groups. Cases delivered earlier (26.6 vs 30.1 weeks, P < .001) and had a longer rupture-to-delivery interval (20.0 vs 10.4 days, P < .001). Case neonates had high rates of severe composite neonatal morbidity (75.6% vs 21.8%, P < .001). Children with early PPROM had higher composite severe childhood morbidity (51.6% vs 22.5%, P < .001). Early PPROM remained associated with composite severe childhood morbidity in multivariable models, even when controlling for delivery gestational age and other confounders. CONCLUSION Early PPROM is associated with high rates of neonatal morbidity. Early childhood outcomes at age 2 years remain poor compared with those delivered after later PPROM.
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[A case study regarding the use of antibiotic therapies for the treatment of preterm premature rupture of fetal membranes, and emergence of antibiotic resistant bacteria]. ACTA ACUST UNITED AC 2014; 44:164-70. [PMID: 24842643 DOI: 10.1016/j.jgyn.2013.12.005] [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: 07/13/2013] [Revised: 12/01/2013] [Accepted: 12/04/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of this retrospective study is to compare two types of antimicrobial management used to treat premature rupture of membranes in pregnancy. This study evaluates both duration and the type of antibiotic therapy used for treatment. PATIENTS AND METHODS The antimicrobials used to treat premature rupture of membranes include a first generation cephalosporin in one group and amoxicillin in the other group. Cephalosporin was used over a 7-day period to treat 38 cases, whereas amoxicillin was used through delivery in 52 cases. Emergence of multidrug-resistant Gram negative bacteria (GNB) on maternal of neonatal sampling was the primary outcome. RESULTS Emergence of antibiotic resistant GNB can be seen under both antibiotic regimens and appears to be linked to the duration of latency, and to duration of antibiotic treatment. Other outcomes (duration of latency period, gestational age at delivery, maternal and neonatal complications) were similar in both groups. CONCLUSION Antibiotic treatment in PPROM favors a selection of GNB. This emergence is positively linked with the duration of latency between rupture of membranes and delivery and with the length of antibiotic administration. The extension of antibiotherapy does not alter other maternal or neonatal parameters.
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Ekin A, Gezer C, Taner CE, Ozeren M, Uyar I, Gulhan I. Risk factors and perinatal outcomes associated with latency in preterm premature rupture of membranes between 24 and 34 weeks of gestation. Arch Gynecol Obstet 2014; 290:449-55. [DOI: 10.1007/s00404-014-3227-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/17/2014] [Indexed: 11/25/2022]
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Amniotic fluid infection, inflammation, and colonization in preterm labor with intact membranes. Am J Obstet Gynecol 2014; 210:125.e1-125.e15. [PMID: 24274987 DOI: 10.1016/j.ajog.2013.11.032] [Citation(s) in RCA: 262] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/20/2013] [Accepted: 11/20/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to compare intraamniotic inflammation vs microbial invasion of the amniotic cavity (MIAC) as predictors of adverse outcome in preterm labor with intact membranes. STUDY DESIGN Interleukin-6 (IL-6) was measured in prospectively collected amniotic fluid from 305 women with preterm labor. MIAC was defined by amniotic fluid culture and/or detection of microbial 16S ribosomal DNA. Cases were categorized into 5 groups: infection (MIAC; IL-6, ≥11.3 ng/mL); severe inflammation (no MIAC; IL-6, ≥11.3 ng/mL); mild inflammation (no MIAC; IL-6, 2.6-11.2 ng/mL); colonization (MIAC; IL-6, <2.6 ng/mL); negative (no MIAC; IL-6, <2.6 ng/mL). RESULTS The infection (n = 27) and severe inflammation (n = 36) groups had similar latency (median, <1 day and 2 days, respectively) and similar rates of composite perinatal morbidity and mortality (81% and 72%, respectively). The colonization (n = 4) and negative (n = 195) groups had similar outcomes (median latency, 23.5 and 25 days; composite morbidity and mortality rates, 21% and 25%, respectively). The mild inflammation (n = 47) groups had outcomes that were intermediate to the severe inflammation and negative groups (median latency, 7 days; composite morbidity and mortality rates, 53%). In logistic regression adjusting for gestational age at enrollment, IL-6 ≥11.3 and 2.6-11.2 ng/mL, but not MIAC, were associated significantly with composite morbidity and mortality rates (odds ratio [OR], 4.9; 95% confidence interval [CI], 2.2-11.2, OR, 3.1; 95% CI, 1.5-6.4, and OR, 1.8; 95% CI, 0.6-5.5, respectively). CONCLUSION We confirmed previous reports that intraamniotic inflammation is associated with adverse perinatal outcomes whether or not intraamniotic microbes are detected. Colonization without inflammation appears relatively benign. Intraamniotic inflammation is not simply present or absent but also has degrees of severity that correlate with adverse outcomes. We propose the designation amniotic inflammatory response syndrome to denote the adverse outcomes that are associated with intraamniotic inflammation.
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Favrais G, Tourneux P, Lopez E, Durrmeyer X, Gascoin G, Ramful D, Zana-Taieb E, Baud O. Impact of common treatments given in the perinatal period on the developing brain. Neonatology 2014; 106:163-72. [PMID: 25012048 DOI: 10.1159/000363492] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 05/07/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Over the last decades, considerable progress has been made in the perinatal management of high-risk preterm neonates, changing the landscape of pathological conditions associated with neurological impairments. Major focal destructive lesions are now less common, and the predominant neuropathological lesion is diffuse white-matter damage in the most immature infants. Similarly, over the last few years, we have observed a trend towards a decrease in neurological impairment in the absence of treatments specifically aimed at neuroprotection. OBJECTIVES We examined whether recent changes in treatment strategies in perinatal care during the perinatal period could have had an indirect beneficial impact on the occurrence of brain lesions and their consequences. METHODS Thus, we reviewed the effects of the most common treatments administered during the perinatal period to the mother or to very preterm infants on brain damage and neurocognitive follow-up. RESULTS Antenatal steroids and exogenous surfactant are the two main treatments capable of leading to neuroprotection in very preterm infants. Randomized controlled trials are currently investigating the effects of inhaled nitric oxide and erythropoietin, while antenatal magnesium sulphate and caffeine are also likely to provide some neuroprotection, but this needs to be further investigated. Finally, other common treatments against pain, haemodynamic failure and patent ductus arteriosus have conflicting or no effects on the developing brain. CONCLUSION While specific neuroprotective drugs are still awaited, recent advances in perinatal care have been associated with an unexpected but significant decrease in the incidence of both severe brain lesions and neurological impairment.
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Zilberman D, Williams SF, Kurian R, Apuzzio JJ. Does genital tract GBS colonization affect the latency period in patients with preterm premature rupture of membranes not in labor prior to 34 weeks? J Matern Fetal Neonatal Med 2013; 27:338-41. [DOI: 10.3109/14767058.2013.816279] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ferrazzi E, Muggiasca ML, Fabbri E, Fontana P, Castoldi F, Lista G, Primerano L, Livio S, Di Francesco S. Assessment of fetal inflammatory syndrome by "classical" markers in the management of preterm labor: a possible lesson from metabolomics and system biology. J Matern Fetal Neonatal Med 2013; 25:54-61. [PMID: 23025770 DOI: 10.3109/14767058.2012.716984] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
There exists a huge gap between protocols issued by scientific bodies and evidence derived by system biology studies on the multifactorial origin of threatened preterm delivery and their different associations with neonatal outcome. The objective of this prospective study was the analysis obstetrical and neonatal outcome in a cohort of pregnant patients treated for the risk of preterm delivery according to maternal and fetal assessment determined by amniotic fluid samples. Methods. Threatened preterm delivery and premature rupture of membranes between 24 + 1 and 32 + 6 weeks of gestation were treated by prolonged tocolytic regimens and if necessary by antibiotics for maternal infections when intra-amniotic inflammation (IAI) was excluded on the basis of negative white blood cell count in the amniotic fluid, or opposite, by delivery after a course of betamethasone and 48 hours maintenance tocolysis. Twenty-three cases were compared with 22 historical controls treated by the same teams according to the 48 hours treat and wait criteria. In addition to this, cases with normal and abnormal amniotic fluid white blood cell were compared. Results. Maternal and fetal conditions at admission were not significantly different between the study and control cohort for all maternal and fetal variables. Clinical indices were significantly improved as regard to latency from admission to delivery, number of newborns admitted to neonatal intensive care unit and length of stay in neonatal intensive care unit. Not any perinatal death or sepsis occurred in the study cohort. Overall, improved neonatal outcomes were observed in the study cohort. Composite major neonatal eventful outcomes occurred in 26% of cases vs. 50% in controls. The limited number of cases was not powered enough to reach a statistical significance for these variables. Continued tocolysis on demand and full regimen of mono or combined antibiotic regimen for maternal infection achieved significantly longer delay between admission to delivery with improved in neonatal outcome in cases negative for IAI: only 2 of 14 newborns suffered of major neonatal complications vs. 4 of 9 newborns delivered for IAI. Conclusions. Fetuses without IAI can be treated conservatively and their stay in utero prolonged without harm. However, we confirmed that when IAI is already active in utero a worse neonatal outcome is already partly predetermined. These positive findings must be interpreted with cautions given the limited number of cases considered by this study.
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Affiliation(s)
- Enrico Ferrazzi
- Department of Obstetrics, Neonatology and Gynecology, Unit of Obstetrics and Gynecology, Buzzi Children’s Hospital, I.C.P., Clinical and Biological Sciences University Department, University of Milan, Italy.
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