Preterm premature rupture of the membranes: current approaches to evaluation and management

Angiogenic imbalance in pregnancies with preterm prelabor rupture of membranes between 34 and 37 weeks of gestation

INTRODUCTION

This study aimed to identify whether microbial invasion of the amniotic cavity and/or intra-amniotic inflammation in women with late preterm prelabor rupture of membranes (PPROM) was associated with changes in concentrations of soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF) and its ratio in maternal serum, and whether placental features consistent with maternal vascular malperfusion further affect their concentrations.

MATERIAL AND METHODS

This historical study included 154 women with singleton pregnancies complicated by PPROM between gestational ages 34+0 and 36+6 weeks. Transabdominal amniocentesis was performed as part of standard clinical management to evaluate the intra-amniotic environment. Women were categorized into two subgroups based on the presence of microorganisms and/or their nucleic acids in amniotic fluid (determined by culturing and molecular biology method) and intra-amniotic inflammation (by amniotic fluid interleukin-6 concentration evaluation): (1) those with the presence of microorganisms and/or inflammation (at least one present) and (2) those with negative amniotic fluid for infection/inflammation (absence of both). Concentrations of sFlt-1 and PlGF were assessed using the Elecsys® sFlt-1 and Elecsys® PlGF immunoassays and converted into multiples of medians.

RESULTS

Women with the presence of microorganisms and/or inflammation in amniotic fluid had lower serum concentrations of sFlt-1 and sFlt-1/PlGF ratios and higher concentrations of PlGF compared with those with negative amniotic fluid. (sFlt-1: presence: median 1.0 multiples of the median (MoM), vs negative: median: 1.5 MoM, P = 0.003; PlGF: presence: median 0.7 MoM, vs negative: median 0.4 MoM, P = 0.02; sFlt-1/PlGF: presence: median 8.9 vs negative 25.0, P = 0.001). Higher serum concentrations of sFlt-1 and sFlt-1/PlGF ratios as well as lower concentrations of PlGF were found in the subsets of women with maternal vascular malperfusion than in those without maternal vascular malperfusion.

CONCLUSIONS

Among women experiencing late PPROM, angiogenic imbalance in maternal serum is primarily observed in those without both microbial invasion of the amniotic cavity and intra-amniotic inflammation. Additionally, there is an association between angiogenic imbalance and the presence of maternal vascular malperfusion.

[Impact of the mode of follow-up of preterm premature rupture of membranes before 36 weeks of gestation on the latency period]

INTRODUCTION

Preterm premature rupture of membranes (PPROM) is the main cause of premature delivery, complicating 1-3% of all pregnancies. Conventional hospitalization (CH) is the most frequent mode of follow-up, but homecare (HC) seems to be an alternative.

OBJECTIVES

Study of the impact of the monitoring mode on the duration of the latency period and on the latency ratio after PPROM, and analysis of the risk factors modifying this ratio.

METHODS

This was a bicentric retrospective cohort study here-abouts including patients who presented a PPROM between 24 and 36weeks of gestation from 2016 to 2018. Patients had a follow-up in HC at Lille University Hospital center (UHC) and in CH at Nantes UHC according to two different follow-up protocols. The latency ratio corresponded to the real latency period divided by the latency period to theoretical term.

RESULTS

We included 154 patients: 102 in HC and 52 in CH. The mean latency period was significantly higher in HC: 36.9±21.8 days, corresponding to an 85.5±23.7% latency ratio versus 20.2±12 days, corresponding to an 66.9±29.8% latency ratio in CH (P<0.001). The latency ratio in CH was correlated with term at PPROM (P=0.001).

CONCLUSIONS

The duration of the latency period seems prolonged for PPROM followed by HC management versus CH in selected populations. This study suggests a benefit to HC in stable patients.

The Role of Cerclage in Subsequent Pregnancy following Previable Prelabor Rupture of Membranes

OBJECTIVE

 This study aimed to ascertain the outcomes associated with a cervical cerclage among individuals with a history of previable prelabor rupture of membranes (PROM).

STUDY DESIGN

 This study was a retrospective cohort study conducted at a single tertiary center between 2011 and 2021. We included individuals with a history of previable (before 24 weeks) PROM and the subsequent viable pregnancy. Women with multifetal gestation, preterm birth (PTB) or cerclage in previous gestation, or abdominal cerclage after trachelectomy were excluded. Primary outcome was PTB rate (delivery <37 weeks). Recurrence of preterm PROM and adverse composite maternal and neonatal outcomes (CMO and CNO) were evaluated as secondary outcomes. CMO included any of the following: suspected chorioamnionitis, endometritis, red blood cell transfusion, uterine rupture, unplanned hysterectomy, or death. CNO included any of the following: previable PTB (<24 weeks of gestation), bronchopulmonary dysplasia, grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, mechanical ventilation, seizures, hypoxic ischemic encephalopathy, or death.

RESULTS

 During the study period, 118 individuals had a history of previable PROM and a documented subsequent pregnancy, out of which 74 (62.7%) met inclusion criteria. Nineteen (25.7%) of eligible individuals underwent a cerclage for prior previable PROM and were compared with controls (n = 55, 74.3%). Women who underwent a cerclage had higher rates of PTB < 37 weeks (63.2 vs. 10.9%, p < 0.001; odds ratio [OR]: 14.00, 95% confidence interval [CI]: 3.97-49.35) and < 34 weeks (21.1 vs. 3.6%, p = 0.03; OR: 7.07, 95% CI: 1.18-42.39) compared with those without cerclage. Furthermore, recurrent preterm PROM and previable PTB rates were higher among patients who underwent cerclage. The survival curve further indicated that individuals with cerclage delivered earlier. CMO and CNO rates were similar in those with and without cerclage.

CONCLUSION

 Cerclage placement in individuals with prior previable PROM was associated with higher rates of recurrent preterm PROM and PTB.

KEY POINTS

· The management of individuals in a subsequent pregnancy following previable PROM is a conundrum.. · Cerclage following previable PROM is associated with higher rates of recurrent preterm PROM and PTB.. · Composite maternal and neonatal outcome rates were similar in those with and without cerclage..

Vaginal probiotics as an adjunct to antibiotic prophylaxis in the management of preterm premature rupture of membranes: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the efficacy of vaginal probiotics administration in combination with prophylactic antibiotics versus antibiotic prophylaxis only on perinatal outcomes in women with preterm premature rupture of membrane (PPROM).

METHODS

Four different databases were searched from inception till March 2023. We selected randomized controlled trials (RCTs) that compared vaginal probiotics along with antibiotics versus antibiotics only among pregnant women who were presented with PPROM between 24 and 34 weeks of gestation. We performed the meta-analysis using Revman software. Our primary outcomes were gestational age at birth and latency period duration. Our secondary outcomes were the rate of admission in the neonatal intensive care unit (NICU), infant birth weight, length of stay in the NICU, and neonatal complications.

RESULTS

Four RCTs, involving a total of 339 patients, were included in the meta-analysis. The gestational age at the time of delivery and latency period duration were significantly higher among probiotics + antibiotics group (p = 0.01 & p < 0.001). There was a significant reduction in the rate of NICU admission and length of NICU stay among the probiotics + antibiotics group compared to the antibiotics only group. A significant improvement in the infant birth weight after delivery was demonstrated among the probiotics + antibiotics group (p = 0.002). Although there was a decrease in the incidence of neonatal sepsis and respiratory distress syndrome within probiotics + antibiotics group versus antibiotics only group, these differences were not statistically significant (p > 0.05).

CONCLUSIONS

The combination of vaginal probiotics and antibiotic prophylaxis has been shown to effectively improve perinatal outcomes in women with PPROM. Further trials are needed to validate our findings.

Disseminated primary herpes simplex infection imitating preterm prelabor rupture of membranes - a case report

Background

We describe a case of primary herpes simplex virus (HSV) infection imitating preterm prelabor rupture of membranes (PPROM) and review the intricacies of establishing the diagnosis.

Case presentation

At 18 weeks of gestation, a patient was referred for suspected PPROM following leakage of fluid and a positive nitrazine test. The patient had a swollen inguinal lymph node, intermittent fevers, transaminitis, labial lesions, and cervical ulceration with vaginal discharge. Amniotic fluid volume was normal. An HSV PCR test was positive. Intravenous acyclovir followed by oral valacyclovir resulted in resolution of symptoms.

Conclusion

Discharge from HSV cervicitis can present as nitrazine-positive pooling, imitating PPROM. A high index of suspicion is warranted, especially when the amniotic fluid volume is normal and arborization is not seen on microscopic exam.

Trajectories of maternal D-dimer are associated with the risk of developing adverse maternal and perinatal outcomes: a prospective birth cohort study

OBJECTIVE

To assess the relationships of maternal D-dimer trajectories with the risk of developing adverse maternal and perinatal outcomes (AMPOs).

METHODS

A prospective birth cohort study was conducted in China, and 7,095 women who had singleton birth were included. The latent class growth model was used to determine the maternal D-dimer trajectory.

RESULTS

Three maternal D-dimer trajectories were identified: (1) slight increase (43.6%), (2) rapid rise (51.3%), (3) sustained high (5.1%). Compared to pregnant women with a slight increase in D-dimer trajectory, the risk of gestational diabetes mellitus, placenta previa, macrosomia, large for gestational age (LGA), and increased postpartum bleeding was significantly increased in those with a rapid rise trajectory (adjusted OR=1.22, 2.00, 1.80, and 1.56, adjusted β=15.92∼25.1ml, respectively, P<0.05), and women with a sustained high trajectory also demonstrated a relatively elevated risk of macrosomia and LGA (adjusted OR=2.11 and 1.82, respectively, P<0.05). While the odds of pregnancy-induced hypertension, low birth weight, and small for gestational age in pregnant women with the rapid rise D-dimer trajectory and fetal distress in those with sustained high trajectory exhibited a reduction (adjusted OR=0.62, 0.38, 0.54, and 0.64, respectively, P<0.05).

CONCLUSION

This study highlights the influence of inappropriate maternal D-dimer trajectories on the risk of AMPOs.

Evaluation and Management of Premature Rupture of Membranes: A Review Article

Premature rupture of membranes (PROM), now also referred to as "pre-labour rupture of membranes," is the rupture of gestational membranes after 37 weeks but before the process of labour begins. When membrane rupture occurs before 37 weeks of gestation, it is referred to as preterm PROM (PPROM). Prematurity is held accountable for the majority of newborn morbidity and mortality. PROM causes around one-third of all preterm deliveries and complicates 3% of pregnancies. Significant morbidity and mortality rates have been associated with PROM. Preterm (PROM) pregnancies are more difficult to manage. Pre-labour rupture of membranes is characterised by its short latency, higher intrauterine infection risk, and greater umbilical cord compression probability. Women with preterm PROM are more likely to develop chorioamnionitis and placental abruption. Various diagnostic modalities include sterile speculum examination, the nitrazine test, the ferning test, and the latest advances, which are the Amnisure test and the Actim test. Despite all these tests, there is still a need for newer, non-invasive, rapid, and accurate tests. Admission to a hospital, amniocentesis to rule out infection, and, if necessary, prenatal corticosteroids and broad-spectrum antibiotics are all alternatives for treatment. As a result, the clinician managing a pregnant woman whose pregnancy has been affected by PROM plays a crucial role in the management and must be well aware of probable complications and control measures to reduce risks and increase the likelihood of the required outcome. PROM's proclivity for recurrence in later pregnancies provides a chance for prevention. Furthermore, prenatal and neonatal care developments will continue to enhance the outcomes of women and their children. The purpose of this article is to summarise the concepts related to the evaluation and management of PROM.

Compared perinatal outcomes of two prophylactic antibiotic regimens for preterm premature rupture of membranes: a randomized controlled trial

BACKGROUND

Prophylactic antibiotic use in preterm premature rupture of membranes is associated with significantly reduced intra-amniotic infection and improved neonatal outcome, although data are insufficient to determine the optimal antibiotic regimen. Ampicillin resistance has changed the epidemiology of neonatal sepsis.

OBJECTIVE

This study aimed to determine the efficacy of two antibiotic regimens in prolonging the latency period in women with preterm premature rupture of membranes.

STUDY DESIGN

This randomized-controlled trial was conducted in 3 tertiary university-affiliated hospitals. A total of 124 women with preterm premature rupture of membranes at <37 weeks of gestation were randomized into two antibiotic prophylactic protocols: ampicillin + roxithromycin and cefuroxime + roxithromycin. The latency period length, neonatal adverse outcomes, and maternal infectious morbidity, including intrauterine infection, intrapartum fever, postpartum antibiotic treatment, endometritis, and wound infection, were measured and compared.

RESULTS

Maternal infectious morbidity was higher in the ampicillin group than in the cefuroxime group (17.7% vs 6.5%; 1-sided P value =.048). The pathogen distribution among placenta, membrane, cord, and uterine cultures differed between the groups (P=.017). Enterobacteriaceae spp. cultures were identified in 68.6% of the cultures in the ampicillin group and 43.2% in the cefuroxime group (P=.036). The composite neonatal adverse outcome was higher in the ampicillin group than in the cefuroxime group (55 [88.7%] vs 46 [74.2%]; 1-sided P value =.03). The proportion of primiparas with a latency period >4 days was significantly higher in the cefuroxime group than in the ampicillin group (odds ratio, 3.69; 95% confidence interval, 1.175-11.607; P=.025).

CONCLUSION

In combination with roxithromycin, the use of cefuroxime, as a prophylactic in women with premature rupture of membranes at <37 weeks of gestation, showed longer pregnancy in primiparas and less maternal and neonatal morbidity than the use of ampicillin. Further larger studies are needed to support our results.

Preterm prelabor rupture of membranes in singletons: maternal and neonatal outcomes

OBJECTIVES

To determine the effect of gestational age at delivery on maternal and neonatal outcomes in preterm prelabor rupture of membranes (PPROM) and assess various predictors of neonatal and infant mortality in these pregnancies.

METHODS

United States birth data from CDC-National Center for Health Statistics natality database for years 2004-2008 was used to identify singleton pregnancies with PPROM and delivery from 32 0/7 to 36 6/7 weeks. Controls were singletons at 37-40 weeks, without PPROM. Maternal and neonatal complications reported by all states were analyzed along with neonatal outcomes such as chorioamnionitis and hyaline membrane disease, reported by a subgroup of states. OR (95% CI) were calculated after adjusting for preeclampsia, diabetes, chronic hypertension, maternal race, and infant sex.

RESULTS

There were 134,502 PPROM cases and similar number of controls. There was a significant decrease in need for prolonged ventilation, hyaline membrane disease, 5 min Apgar score <7, and NICU admission with advancing gestational age. Placental abruption decreased and chorioamnionitis and cord prolapse were not different between 34 and 37 weeks. We found reductions in early death, neonatal death, and infant mortality with advancing gestational age (p<0.001 for each). Gestational age at delivery was the strongest predictor for early death, neonatal death, and infant mortality in PPROM. These differences persisted after adjusting for antenatal steroid use.

CONCLUSIONS

We provide population-based evidence showing a decrease in neonatal complications and death with advancing gestational age in PPROM. Gestational age at delivery in pregnancies with PPROM is the strongest predictor of mortality risk.

Different azithromycin protocols for management of preterm prelabour rupture of membranes: a randomized clinical trial

BACKGROUND

Preterm prelabor rupture of membranes is associated with polymicrobial infection; hence broad-spectrum antibiotics are recommended. Nowadays, Azithromycin is used instead of Erythromycin due to erythromycin shortages, its ease of administration, decreased cost, and better side effect profile. This study aimed to evaluate the efficacy of different azithromycin protocols for the conservative management of preterm prelabor rupture of membranes.

METHODS

It was a single-blinded randomized clinical trial including pregnant women at 24-36⁺⁶ weeks with viable singleton pregnancies and confirmed preterm prelabor rupture of membranes from January 01, 2020, to June 01, 2021. The participants were randomized into two groups: Group I was made of women who received Azithromycin 1000 mg PO once, and Group II of women who received Azithromycin 500 mg PO once, followed by Azithromycin 250 mg PO daily for four days. The primary study outcome was the length of the latency period from the diagnosis of preterm prelabor rupture of membranes to delivery (days).

RESULTS

The latency period in group I was significantly higher than that in Group II (5.80 ± 5.44 days vs. 2.88 ± 2.37; respectively, p = 0.0001). The mean gestational age at the time of delivery was significantly higher in Group I (p = 0.0001). However, postpartum endometritis and respiratory distress syndrome (RDS) rates were significantly higher in Group II (p = 0.003 and p = 0.0001, respectively).

CONCLUSION

The higher dose of Azithromycin was associated with better maternal and neonatal outcomes.

TRIAL REGISTRATION

Clinical trial identification number: Clinical trial.gov: NCT04202380 (17/ 12/ 2019). Date of registration: 1/1 /2020. Date of initial participant enrollment30 /1/2020. URL of the registration site: https://www.

CLINICALTRIALS

gov/ct2/show/NCT04202380.

Association of subclinical markers of inflammation with preterm premature rupture of membranes and adverse neonatal results: a case control study

AIM

The study aims to investigate the relationship between subclinical inflammatory factors, which are known to be closely related to inflammation, with preterm premature rupture of membranes (PPROM) and adverse postpartum outcomes.

MATERIALS AND METHODS

The case control type study was conducted between January 1, 2021, and January 2022. 525 pregnant women, including 272 PPROM and 253 normal patients, were added to the study.

RESULTS

There was a positive relationship between PPROM and PCT (platelet crit), MPV (mean platelet volume), NLR (neutrophil-to-lymphocyte ratio), and MLR (monocytes to lymphocyte ratio) values. ROC analysis, PCT > 0.19, MPV > 8.78, NLR > 2.82, and MLR > 0.24 were significantly related to improved risk of PPROM (P < 0.05). In logistic regression analysis, a one-unit rise in PCT resulted in a 3.9-fold rise in RDS risk and a one-unit increase in NLR resulted in a 1.6-fold significant rise in sepsis risk (p < 0.05).

CONCLUSION

NLR and PCT parameters were found to be related to adverse neonatal outcomes.

Developing a Core Outcome Set for the Evaluation of Antibiotic Use in Prelabor Rupture of Membranes: A Systematic Review and Semi-Structured Interview

Background: Prelabor rupture of membranes (PROM) is associated with maternal and neonatal infections. Although guidelines suggest prophylactic antibiotics for pregnant women with PROM, the optimal antibiotic regimen remains controversial. Synthesizing the data from different studies is challenging due to variations in reported outcomes.

Objective: This study aimed to form the initial list of outcomes for the core outcome set (COS) that evaluates antibiotic use in PROM by identifying all existing outcomes and patients’ views.

Methods: Relevant studies were identified by searching PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang, and VIP databases. We also screened the references of the included studies as a supplementary search. We extracted basic information from the articles and the outcomes. Two reviewers independently selected the studies, extracted the data, extracted the outcomes, and grouped them into domains. Then, semi-structured interviews based on the potential factors collected by the systematic review were conducted at West China Second Hospital of Sichuan University. Pregnant women who met the diagnostic criteria for PROM were enrolled. Participants reported their concerns about the outcomes. Two researchers identified the pregnant women’s concerns.

Results: A total of 90 studies were enrolled in this systematic review. The median outcomes in the included studies was 7 (1–31), and 109 different unique outcomes were identified. Pre-term PROM (PPROM) had 97 outcomes, and term PROM (TPROM) had 70 outcomes. The classification and order of the core outcome domains of PPROM and TPROM were consistent. The physiological domain was the most common for PPROM and TPROM outcomes. Furthermore, 35.1 and 57.1% outcomes were only reported once in PPROM and TPROM studies, respectively. Thirty pregnant women participated in the semi-structured interviews; 10 outcomes were extracted after normalized, and the outcomes were reported in the systematic review. However, studies rarely reported pregnant women’s concerns.

Conclusion: There was considerable inconsistency in outcomes selection and reporting in studies about antibiotics in PROM. An initial core outcomes set for antibiotics in PROM was formed.

Early-onset neonatal sepsis and antibiotic use in Indonesia: a descriptive, cross-sectional study

BACKGROUND

Early diagnosis and prompt antibiotic treatment are crucial to reducing morbidity and mortality of early-onset sepsis (EOS) in neonates. However, this strategy remains challenging due to non-specific clinical findings and limited facilities. Inappropriate antibiotics use is associated with ineffective therapy and adverse outcomes. This study aims to determine the characteristics of EOS and use of antibiotics in the neonatal-intensive care units (NICUs) in Indonesia, informing efforts to drive improvements in the prevention, diagnosis, and treatment of EOS.

METHODS

A descriptive study was conducted based on pre-intervention data of the South East Asia-Using Research for Change in Hospital-acquired Infection in Neonates project. Our study population consisted of neonates admitted within 72 h of life to the three participating NICUs. Neonates who presented with three or more clinical signs or laboratory results consistent with sepsis and who received antibiotics for 5 consecutive days were considered to have EOS. Culture-proven EOS was defined as positive blood or cerebrospinal fluid culture. Type and duration of antibiotics used were also documented.

RESULTS

Of 2,509 neonates, 242 cases were suspected of having EOS (9.6%) with culture-proven sepsis in 83 cases (5.0% of neonatal admissions in hospitals with culture facilities). The causative organisms were mostly gram-negative bacteria (85/94; 90.4%). Ampicillin / amoxicillin and amikacin were the most frequently prescribed antibiotics in hospitals with culture facilities, while a third-generation cephalosporin was mostly administered in hospital without culture facilities. The median durations of antibiotic therapy were 19 and 9 days in culture-proven and culture-negative EOS groups, respectively.

CONCLUSIONS

The overall incidence of EOS and culture-proven EOS was high in Indonesia, with diverse and prolonged use of antibiotics. Prospective antibiotic surveillance and stewardship interventions are required.

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

According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the increasing burden on obstetric departments and the growing importance of satisfaction and right to self-determination in pregnant women, outpatient management in PPROM is a possible alternative to inpatient monitoring. The most important criterion for this approach is to ensure the safety of both the mother and the child. Due to the small number of cases (n = 116), two randomised controlled trials (RCTs) comparing inpatient and outpatient management were unable to draw any conclusions. By 2020, eight retrospective comparative studies (cohort/observational studies) yielded the following outcomes: no significant differences in the rate of maternal complications (e.g., chorioamnionitis, premature placental abruption, umbilical cord prolapse) and in neonatal morbidity, significantly prolonged latency period with higher gestational age at birth, higher birth weight of neonates, and significantly shorter length of stay of preterm infants in neonatal intensive care, shorter hospital stay of pregnant women, and lower treatment costs with outpatient management. Concerns regarding this approach are mainly related to unpredictable complications with the need for rapid obstetric interventions, which cannot be performed in time in an outpatient setting. Prerequisites for outpatient management are the compliance of the expectant mother, the adherence to strict selection criteria and the assurance of adequate monitoring at home. Future research should aim at more accurate risk assessment of obstetric complications through studies with higher case numbers and standardisation of outpatient management under evidence-based criteria.

Prevalence and Load of Cervical Ureaplasma Species With Respect to Intra-amniotic Complications in Women With Preterm Prelabor Rupture of Membranes Before 34 weeks

Objectives: To determine the prevalence and load of Ureaplasma spp. DNA in the cervical fluid of women with singleton pregnancies complicated by preterm prelabor rupture of membranes (PPROM) with respect to intra-amniotic infection, sterile intra-amniotic inflammation, and colonization of the amniotic fluid.

Methods: A total of 217 women with PPROM between gestational ages 24 + 0 and 33 + 6 weeks were included in this study. Paired amniotic and cervical fluid samples were collected at the time of admission via transabdominal amniocentesis and using a Dacron polyester swab, respectively. Microbial invasion of the amniotic cavity was diagnosed using a combination of culture and molecular biology methods. Intra-amniotic inflammation was determined based on the concentration of interleukin-6 in the amniotic fluid. Based on the presence or absence of these conditions, the women were stratified into the following subgroups: intra-amniotic infection (with both), sterile intra-amniotic inflammation (with inflammation only), colonization (with microorganisms only), and negative amniotic fluid (without either). The Ureaplasma spp. DNA load in the cervical fluid was assessed using PCR.

Results:Ureaplasma spp. DNA in the cervical fluid was found in 61% (133/217) of the women. Women with negative amniotic had similar prevalence of Ureaplasma spp. DNA in cervical fluid (55%) to those with sterile intra-amniotic inflammation (54%) but lower than those with intra-amniotic infection (73%) and colonization (86%; p < 0.0001). Women with negative amniotic fluid had a lower load of Ureaplasma spp. DNA in their cervical fluid (median: 4.7 × 10³ copies of DNA/ml) than those with intra-amniotic infection (median: 2.8 × 10⁵ copies DNA/ml), sterile intra-amniotic inflammation (median: 5.3 × 10⁴ copies DNA/ml), and colonization (median: 1.2 × 10⁵ copies DNA/mL; p < 0.0001).

Conclusion: In conclusion, in PPROM at <34 weeks, the presence of intra-amniotic infection, sterile intra-amniotic inflammation, or colonization of the amniotic fluid was associated with a higher prevalence and/or load of Ureaplasma spp. DNA in the cervical fluid than the absence of intra-amniotic complications.

Clinical characteristics of colonization of the amniotic cavity in women with preterm prelabor rupture of membranes, a retrospective study

To determine the main clinical characteristics of preterm prelabor rupture of membranes (PPROM) complicated by colonization of the amniotic cavity (microbial invasion of the amniotic cavity without intra-amniotic inflammation). A total of 302 women with PPROM were included. Transabdominal amniocentesis was performed and amniotic fluid was assessed. Based of microbial invasion of the amniotic cavity and intra-amniotic inflammation (interleukin-6 ≥ 3000 pg/mL), the women were divided into following groups: intra-amniotic infection, sterile intra-amniotic inflammation, colonization of the amniotic cavity, and negative amniotic fluid. Colonization was found in 11% (32/302) of the women. The most common bacteria identified in the amniotic fluid were Ureaplasma spp. with a lower burden than those with intra-amniotic infection (p = 0.03). The intensity of intra-amniotic inflammatory response measured by interleukin-6 was higher in women with colonization than in those with negative amniotic fluid (medians: 961 pg/mL vs. 616 pg/mL; p = 0.04). Women with colonization had higher rates of acute inflammatory placental lesions than those with negative amniotic fluid. In PPROM, colonization, caused mainly by microorganisms from the lower genital tract, might represent an early stage of microbial invasion of the amniotic cavity with a weak intra-amniotic inflammatory response.

Acute Histological Chorioamnionitis and Birth Weight in Pregnancies With Preterm Prelabor Rupture of Membranes: A Retrospective Cohort Study

Aim: To assess the association between the birth weight of newborns from pregnancies with preterm prelabor rupture of membranes (PPROM) and the presence of acute histological chorioamnionitis (HCA) with respect to the: i) fetal and maternal inflammatory responses and ii) acute inflammation of the amnion.

Material and Methods: This retrospective cohort study included 818 women with PPROM. A histopathological examination of the placenta was performed. Fetal inflammatory response was defined as the presence of any neutrophils in umbilical cord (histological grades 1–4) and/or chorionic vasculitis (histological grade 4 for the chorionic plate). Maternal inflammatory response was defined as the presence of histological grade 3–4 for the chorion-decidua and/or grade 3 for the chorionic plate and/or grade 1–4 for the amnion. Acute inflammation of the amnion was defined as the presence of any neutrophils in the amnion (histological grade 1–4 for the amnion). Birth weights of newborns were expressed as percentiles derived from INTERGROWTH-21st standards for the i) estimated fetal weight and ii) newborn birth weight.

Results: No difference in percentiles of birth weights of newborns was found among the women with the women with HCA with fetal inflammatory response, with HCA with maternal inflammatory response and those without HCA. Women with HCA with acute inflammation of the amnion had lower percentiles of birth weights of newborns, derived from the estimated fetal weight standards, than women with HCA without acute inflammation of the amnion and those with the absence of HCA in the crude (with acute inflammation: median 46, without acute inflammation: median 52, the absence of HCA: median 55; p = 0.004) and adjusted (p = 0.02) analyses. The same subset of pregnancies exhibited the highest rate of newborns with a birth weight of ≤25 percentile. When percentiles were derived from the newborn weight standards, no differences in birth weights were observed among the subgroups.

Conclusion: Acute inflammation of the amnion was associated with a lower birth weight in PPROM pregnancies, expressed as percentiles derived from the estimated fetal weight standards.

Risk factors associated with shortened latency before delivery in outpatients managed for preterm prelabor rupture of membranes

INTRODUCTION

Preterm prelabor rupture of membranes (PPROM) occurs in 3% of pregnancies and is the main cause (~30%) of premature delivery. Home care seems to be a safe alternative for the management of patients with PPROM, who have a longer latency than those with PPROM managed with conventional hospitalization. We aimed to identify the risk factors associated with a shortened latency before delivery in women with PPROM managed as outpatients.

MATERIAL AND METHODS

The design was a retrospective cohort study and the setting was a Monocentric Tertiary centre (Lille University Hospital, France) from 2009 to 2018. All consecutive patients in home care after PPROM at 24-36 weeks were included. For the main outcome measure we calculated the latency ratio for each patient as the ratio of the real latency period to the expected latency period, expressed as a percentage. The risk factors influencing this latency ratio were evaluated.

RESULTS

A total of 234 patients were managed at home after PPROM. Mean latency was 35.5 ± 20.7 days, corresponding to an 80% latency ratio. In 196 (83.8%) patients the length of home care was more than 7 days. A lower latency ratio was significantly associated with oligohydramnios (p < 0.001), gestational age at PPROM (p = 0.006), leukocyte count at PPROM more than 12 × 10⁹ /L (p = 0.025), and C-reactive protein concentration more than 5 mg/L at 7 days after PPROM (p = 0.046). Cervical length was not associated with a lower latency ratio.

CONCLUSIONS

Women with PPROM managed with home care are stable. The main risk factor associated with a reduced latency is oligohydramnios. Outpatients with oligohydramnios should be informed of the probability of a shortened latency period.

Clinical Early-Onset Sepsis Is Equally Valid to Culture-Proven Sepsis in Predicting Outcome in Infants after Preterm Rupture of Membranes

BACKGROUND

Culture-proven sepsis is the gold standard in early-onset neonatal sepsis diagnosis. Infants born ≤29 weeks gestation after preterm rupture of membranes in the years 2009-2015 were included in a retrospective cohort study performed at a level III fetal-maternal unit. The study aimed to compare culture-proven sepsis, clinical sepsis and positive laboratory biomarkers ≤72 h as predictors of mortality before discharge and the combined outcome of mortality or severe short-term morbidity (severe cerebral morbidity, bronchopulmonary dysplasia and retinopathy).

RESULTS

Of the 354 patients included, culture-proven sepsis, clinical sepsis and laboratory biomarkers were positive in 2.3%, 8.5% and 9.6%, respectively. The mortality rate was 37.5% for patients with culture-proven sepsis (3/8), 33.3% for patients with clinical sepsis (10/30) and 8.8% for patients with positive laboratory biomarkers (3/34), respectively. Mortality or severe morbidity occurred in 75.0% of patients with culture-proven sepsis (6/8), 80.0% of patients with clinical sepsis (24/30) and 44.1% of patients with positive laboratory biomarkers (15/34), respectively.

CONCLUSION

In preterm infants after preterm rupture of membranes, clinical sepsis was almost four times more common and at least equally valuable in predicting mortality and mortality or severe morbidity compared to culture-proven sepsis.

Birth weight and intra-amniotic inflammatory and infection-related complications in pregnancies with preterm prelabor rupture of membranes: a retrospective cohort study

OBJECTIVE

To assess the association between the birth weight of newborns and microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation in pregnancies with preterm prelabor rupture of membranes.

METHODS

A total of 528 pregnancies with preterm prelabor rupture of membranes were included in this retrospective cohort study. Transabdominal amniocentesis to determine the presence of MIAC (through culturing and molecular biology methods) and intra-amniotic inflammation (according to amniotic fluid interleukin-6 level) was performed as part of standard clinical management. Based on the presence of MIAC and/or intra-amniotic inflammation, the participants were divided into four subgroups: with intra-amniotic infection (presence of both), with sterile IAI (intra-amniotic inflammation alone), with colonization (MIAC alone), and with negative amniotic fluid (absence of both). Birth weights of newborns are expressed as percentiles derived from INTERGROWTH-21st standards for (i) newborn birth weight and (ii) estimated fetal weight.

RESULTS

No differences in birth weights, expressed as percentiles derived from newborn weight standards (infection: median 52; sterile: median 54; colonization: median 50; negative amniotic fluid: median 51; p = .93) and estimated fetal weight standards (infection: median 47; sterile: median 51; colonization: median 47; negative amniotic fluid: median 53; p = .48) were found among the four subgroups. No differences in percentiles (derived from both standards) were found in the subset of participants who delivered within 72 h after rupture of membranes (newborn weight standard, p = .99; estimated fetal weight standard, p = .81).

CONCLUSIONS

No association was identified between the birth weight of newborns and the presence of intra-amniotic inflammatory and infection-related complications in pregnancies with preterm prelabor rupture of membranes.

Neonatal lymphocyte subpopulations analysis and maternal preterm premature rupture of membranes: a pilot study

OBJECTIVES

Preterm premature rupture of membranes (pPROM) causes preterm delivery, and increases maternal T-cell response against the fetus. Fetal inflammatory response prompts maturation of the newborn's immunocompetent cells, and could be associated with unfavorable neonatal outcome. The aims were (1) to examine the effects of pPROM on the newborn's and mother's immune system and (2) to assess the predictive value of immune system changes in neonatal morbidity.

METHODS

Mother-newborn pairs (18 mothers and 23 newborns) who experienced pPROM and controls (11 mothers and 14 newborns), were enrolled. Maternal and neonatal whole blood samples underwent flow cytometry to measure lymphocyte subpopulations.

RESULTS

pPROM-newborns had fewer naïve CD4 T-cells, and more memory CD4 T-cells than control newborns. The effect was the same for increasing pPROM latency times before delivery. Gestational age and birth weight influenced maturation of the newborns' lymphocyte subpopulations and white blood cells, notably cytotoxic T-cells, regulatory T-cells, T-helper cells (absolute count), and CD4/CD8 ratio. Among morbidities, fewer naïve CD8 T-cells were found in bronchopulmonary dysplasia (BPD) (p=0.0009), and more T-helper cells in early onset sepsis (p=0.04).

CONCLUSIONS

pPROM prompts maturation of the newborn's T-cell immune system secondary to antigenic stimulation, which correlates with pPROM latency. Maternal immunity to inflammatory conditions is associated with a decrease in non-major histocompatibility complex (MHC)-restricted cytotoxic cells.

Utility of Routine Testing for Chlamydia and Gonorrhea in the Setting of Preterm Delivery or Premature Preterm Rupture of Membranes

This study aimed to explore the rates of positive and negative Chlamydia trachomatis and Neisseria gonorrhoeae test results in patients screened for these infections and later experienced preterm delivery or preterm premature rupture of membranes. The team conducted a retrospective chart review of patients admitted for preterm premature rupture of membranes or who experienced preterm delivery between April 1, 2009, and April 30, 2015. Patients lacking chlamydia and gonorrhea screening before admission were excluded from the study. Four hundred and six patients met the inclusion criteria. The prevalence of chlamydia infection at initial prenatal screening before admission was 13.3%. Among those for whom the prenatal chlamydia test was negative, 1.7% of patients had a positive subsequent chlamydia test on admission screening. Among those for whom the prenatal chlamydia test was positive, 18.5% had a positive subsequent chlamydia test on admission screening. Positive prenatal test (P=.002) and age 25 years or less (P<.001) were associated with positive admission screening for chlamydia, though only a positive prenatal test remained significant in a logistic regression model (odds ratio, 8.56; 95% CI, 2.67-27.49; P=.003). The prevalence of gonorrhea was low at 0.2% of patients positive for gonorrhea at prenatal testing and 0.5% of patients positive for gonorrhea at admission testing. Our results suggest that individualization based on patient characteristics may be utilized to decrease re-testing. More research is needed to identify possible additional risk factors for new infection or re-infection and the most optimal timing for re-screening during the prenatal period.

Intra-amniotic inflammatory complications in preterm prelabor rupture of membranes and long-term neurodevelopmental outcomes of infants: a systematic review

OBJECTIVE

To perform a systematic review of the literature available on the association between the presence of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation and long-term neurodevelopmental outcomes of infants from pregnancies complicated by preterm prelabor rupture of membranes (PPROM).

METHODS

A literature search, from their earliest entries to May 2020, was performed by employing three electronic databases (Web of Science, PubMed, and Scopus). The selection criteria were as follows: (1) singleton pregnancies with PPROM; (2) available information regarding MIAC and/or intra-amniotic inflammation; (3) long-term (at least one year of the corrected age) neurodevelopmental outcomes of respective infants.

RESULTS

The initial search identified 10,953 articles, of which 8 were selected for full-text reading; however, none were included in the review owing to the following reasons: (i) spontaneous preterm labor with intact membranes and/or indicated (iatrogenic) preterm delivery were included in the studies without providing separate data for PPROM (n = 5); (ii) long-term, at least one year of the corrected age, neurodevelopmental outcomes of infants were not assessed (n = 1); (iii) the presence of both the abovementioned reasons (n = 1); (iv) amniotic fluid was not assessed, and a long-term neurodevelopmental outcome was not evaluated (n = 1).

CONCLUSION

The literature search provides evidence of a knowledge gap in the association between the presence of MIAC and/or intra-amniotic inflammation and long-term neurodevelopmental outcomes in infants with PPROM.

Mechanism of Human Fetal Membrane Biomechanical Weakening, Rupture and Potential Targets for Therapeutic Intervention

Using a novel in vitro model system combining biochemical/histologic with bioengineering approaches has provided significant insights into the physiology of fetal membrane weakening and rupture along with potential mechanistic reasons for lack of efficacy of currently clinically used agents to prevent preterm premature rupture of the membranes (pPROM) and preterm births. Likewise, the model has also facilitated screening of agents with potential for preventing pPROM and preterm birth.

Prophylactic anticoagulation for preterm premature rupture of membranes: a decision analysis

BACKGROUND

The current standard of care in the setting of preterm premature rupture of membranes involves antenatal hospitalization until delivery. The reduced physical activity during this time compounds the heightened risk for venous thromboembolism in pregnancy. Prophylactic anticoagulation can decrease this risk of venous thromboembolism; however, this benefit must be balanced against the risks of precluding neuraxial analgesia or increasing the risk of postpartum hemorrhage.

OBJECTIVE

The objective of this study was to determine the optimal modality for venous thromboembolism prophylaxis during hospitalization for preterm premature rupture of membranes using a decision analysis model.

STUDY DESIGN

A decision-analytical Markov model was constructed using the TreeAge software comparing the use of unfractionated heparin, low-molecular-weight heparin or no anticoagulation in women with a singleton pregnancy who were hospitalized for preterm premature rupture of membranes after 24 weeks and remained hospitalized until delivery. Maternal outcomes examined included attainment of neuraxial analgesia (vs no analgesia for vaginal delivery or general anesthesia for cesarean delivery), venous thromboembolism, postpartum hemorrhage, and maternal death. Probabilities and utilities were derived from existing literature. Sensitivity analyses were performed to interrogate model assumptions, and a Monte Carlo probabilistic sensitivity analysis was performed to examine the robustness of the model.

RESULTS

In this decision-analytical model, no prophylactic anticoagulation maximized maternal utilities. Clinical outcomes among a theoretical cohort of 100,000 women are shown in the Table. The 1- and 2-way sensitivity analyses supported this conclusion. Monte Carlo probabilistic sensitivity analysis indicated that no prophylaxis was the preferred choice in 56% of simulations, unfractionated heparin in 34% of simulations, and low-molecular-weight heparin in 10% of simulations.

CONCLUSION

Our results do not support the routine use of prophylactic anticoagulation in women admitted to the hospital for preterm premature rupture of membranes. These findings can be used to inform clinical decisions when admitting low-risk singleton pregnancies to the hospital in the setting of preterm premature rupture of membranes.

Cervical Gardnerella vaginalis in women with preterm prelabor rupture of membranes

Objective

To determine the association between microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI) and the cervical prevalence of Gardnerella vaginalis DNA in pregnancies with preterm prelabor rupture of membrane (PPROM).

Method

In total, 405 women with singleton pregnancies complicated with PPROM were included. Cervical fluid and amniotic fluid samples were collected at the time of admission. Bacterial and G. vaginalis DNA were assessed in the cervical fluid samples using quantitative PCR technique. Concentrations of interleukin-6 and MIAC were evaluated in the amniotic fluid samples. Loads of G. vaginalis DNA ≥ 1% of the total cervical bacterial DNA were used to define the cervical prevalence of G. vaginalis as abundant. Based on the MIAC and IAI, women were categorized into four groups: with intra-amniotic infection (both MIAC and IAI), with sterile IAI (IAI without MIAC), with MIAC without IAI, and without either MIAC or IAI.

Results

The presence of the abundant cervical G. vaginalis was related to MIAC (with: 65% vs. without: 44%; p = 0.0004) but not IAI (with: 52% vs. without: 48%; p = 0.70). Women with MIAC without IAI had the highest load of the cervical G. vaginalis DNA (median 2.0 × 10⁴ copies DNA/mL) and the highest presence of abundant cervical G. vaginalis (73%).

Conclusions

In women with PPROM, the presence of cervical G. vaginalis was associated with MIAC, mainly without the concurrent presence of IAI.

Active Versus Expectant Management for Preterm Premature Rupture of Membranes at 34-36 Weeks of Gestation and the Associated Adverse Perinatal Outcomes

OBJECTIVE

 To compare the type of management (active versus expectant) for preterm premature rupture of membranes (PPROM) between 34 and 36 + 6 weeks of gestation and the associated adverse perinatal outcomes in 2 tertiary hospitals in the southeast of Brazil.

METHODS

 In the present retrospective cohort study, data were obtained by reviewing the medical records of patients admitted to two tertiary centers with different protocols for PPROM management. The participants were divided into two groups based on PPROM management: group I (active) and group II (expectant). For statistical analysis, the Student t-test, the chi-squared test, and binary logistic regression were used.

RESULTS

 Of the 118 participants included, 78 underwent active (group I) and 40 expectant management (group II). Compared with group II, group I had significantly lower mean amniotic fluid index (5.5 versus 11.3 cm, p = 0.002), polymerase chain reaction at admission (1.5 versus 5.2 mg/dl, p = 0.002), time of prophylactic antibiotics (5.4 versus 18.4 hours, p < 0.001), latency time (20.9 versus 33.6 hours, p = 0.001), and gestational age at delivery (36.5 versus 37.2 weeks, p = 0.025). There were no significant associations between the groups and the presence of adverse perinatal outcomes. Gestational age at diagnosis was the only significant predictor of adverse composite outcome (x² [1] = 3.1, p = 0.0001, R² Nagelkerke = 0.138).

CONCLUSION

 There was no association between active versus expectant management in pregnant women with PPROM between 34 and 36 + 6 weeks of gestation and adverse perinatal outcomes.

Comprehensive proteomic investigation of infectious and inflammatory changes in late preterm prelabour rupture of membranes

Preterm prelabour rupture of membranes beyond the 34th week of gestation (late PPROM) is frequently associated with the risk of the microbial invasion of the amniotic fluid (MIAC) and histological chorioamnionitis (HCA). Hence, we employed a Tandem Mass Tag-based approach to uncover amniotic fluid proteome response to the presence of MIAC and HCA in late PPROM. Protein dysregulation was associated with only five cases in the group of 15 women with confirmed MIAC and HCA. Altogether, 138 amniotic fluid proteins were changed in these five cases exclusively. These proteins were particularly associated with excessive neutrophil responses to infection, such as neutrophil degranulation and extracellular trap formation. We believe that the quantification of these proteins in amniotic fluid may assist in revealing women with the highest risk of excessive inflammatory response in late PPROM.

Tocolysis compared with no tocolysis in women with threatened preterm birth and ruptured membranes: A propensity score analysis

INTRODUCTION

In women with preterm ruptured membranes and contractions, the administration of tocolysis is controversial. This study compares tocolysis with no tocolysis in women with threatened preterm birth and ruptured membranes.

OBJECTIVE

To compare tocolysis with no tocolysis in women with threatened preterm birth and ruptured membranes.

STUDY DESIGN

Data from the APOSTEL III RCT was combined with data from the National Maternity Hospital, Dublin. In the APOSTEL III trial, women with threatened preterm birth were randomized to atosiban or nifedipine. Patient data from Ireland were obtained from a cohort of women with threatened preterm birth with ruptured membranes. The Irish women received no tocolytic treatment. Only women with ruptured membranes and contractions were selected. We studied women with singleton or twin pregnancies and a gestational age between 25⁺⁰ and 33⁺⁶ weeks. Propensity score matching was performed to create comparable groups. Primary outcome was a composite adverse neonatal outcome. Secondary outcomes were individual components of the primary outcome, as well as neonatal intensive care unit (NICU) admission, gestational age at delivery, prolongation of pregnancy and mode of delivery.

RESULTS

153 women from the Apostel III trial were compared with 51 eligible women of the Irish cohort. We could match 46 women who received tocolysis and 46 women who received no tocolysis. All women had ruptured membranes. Maternal age, BMI, parity and gestational age at study entry were comparable between the groups after matching. There were no statistically significant differences in neonatal composite outcome (9.6 % in the tocolysis group versus 18 % in the control group, OR 0.46, 95 % CI 0.13-1.63). We found a lower incidence of NICU admission in the tocolysis group (63 %) than in the control group (94 %; OR 0.11, 95 % CI 0.03-0.41), which could be explained by differences in national admission policies. There were no statistically significant differences between tocolysis and no tocolysis in any of the other outcomes including sepsis, gestational age at delivery and time to delivery.

CONCLUSION

In this propensity score analysis of women with threatened preterm birth and ruptured membranes, tocolytic therapy did not alter composite adverse neonatal outcome or time to delivery.

Antibiotics for Prophylaxis in the Setting of Preterm Prelabor Rupture of Membranes

"For many years, providers have been using antibiotics to prevent infection in women who present with preterm prelabor rupture of membranes (PPROM). Given the polymicrobial nature of intra-amniotic infection, the recommended regimen includes a 7-day course of ampicillin and erythromycin, although many substitute of azithromycin. This regimen is used from viability to 34 weeks, independent of the number of fetuses present. Meta-analyses have shown that antibiotics for this indication are associated with lower rates of maternal and fetal infection, as well as longer pregnancy latency. Thus, latency antibiotics are recommended for all women with PPROM through 34 weeks of gestation."

Extracellular granzyme A in amniotic fluid is elevated in the presence of sterile intra-amniotic inflammation in preterm prelabor rupture of membranes

INTRODUCTION

To determine the levels of granzyme A in amniotic fluid in pregnancies complicated by preterm prelabor rupture of membranes (PPROM), based on the presence of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI).

METHODS OF STUDY

A total of 166 women with singleton pregnancies complicated by PPROM were included. Amniocentesis was performed at the time of admission and assessments of MIAC (using both cultivation and non-cultivation techniques) and IAI (interleukin-6 in amniotic fluid) were performed on all subjects. Based on the presence/absence of MIAC and IAI, the women were further divided into the following subgroups: intra-amniotic infection, sterile IAI, colonization, and absence of both MIAC and IAI. Amniotic fluid granzyme A levels were assessed using ELISA.

RESULTS

Women with MIAC had lower levels of granzyme A in the amniotic fluid than women without this condition (with MIAC: median 15.9 pg/mL vs. without MIAC: median 19.9 pg/mL, p = .03). Women with sterile IAI had higher amniotic fluid granzyme A levels than women with intra-amniotic infection, colonization and women with the absence of either MIAC or IAI (intra-amniotic infection: median 15.6 pg/mL; sterile IAI: median 31.8 pg/mL; colonization: median 16.9 pg/mL; absence of both MIAC and IAI: median 18.8 pg/mL; p = .02).

CONCLUSIONS

The presence of sterile IAI was associated with elevated levels of granzyme A in amniotic fluid.

Prelabor Rupture of Membranes: ACOG Practice Bulletin Summary, Number 217

Preterm birth occurs in approximately 10% of all births in the United States and is a major contributor to perinatal morbidity and mortality (). Prelabor rupture of membranes (PROM) that occurs preterm complicates approximately 2-3% of all pregnancies in the United States, representing a significant proportion of preterm births, whereas term PROM occurs in approximately 8% of pregnancies (). The optimal approach to assessment and treatment of women with term and preterm PROM remains challenging. Management decisions depend on gestational age and evaluation of the relative risks of delivery versus the risks (eg, infection, abruptio placentae, and umbilical cord accident) of expectant management when pregnancy is allowed to progress to a later gestational age. The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented. This Practice Bulletin is updated to include information about diagnosis of PROM, expectant management of PROM at term, and timing of delivery for patients with preterm PROM between 34 0/7 weeks of gestation and 36 6/7 weeks of gestation.

Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217

Preterm birth occurs in approximately 10% of all births in the United States and is a major contributor to perinatal morbidity and mortality (). Prelabor rupture of membranes (PROM) that occurs preterm complicates approximately 2-3% of all pregnancies in the United States, representing a significant proportion of preterm births, whereas term PROM occurs in approximately 8% of pregnancies (). The optimal approach to assessment and treatment of women with term and preterm PROM remains challenging. Management decisions depend on gestational age and evaluation of the relative risks of delivery versus the risks (eg, infection, abruptio placentae, and umbilical cord accident) of expectant management when pregnancy is allowed to progress to a later gestational age. The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented. This Practice Bulletin is updated to include information about diagnosis of PROM, expectant management of PROM at term, and timing of delivery for patients with preterm PROM between 34 0/7 weeks of gestation and 36 6/7 weeks of gestation.

Comparison of placental α microglobulin-1 protein assay (Amnisure) with speculum examination for the diagnosis of premature preterm rupture of membranes (PPROM): a clinical evaluation

In this study, we aimed to compare the clinical outcomes of Premature Preterm Rupture of Membranes (PPROM) cases diagnosed by classical speculum examination and by placental alpha microglobulin-1 protein (PAMG-1) assay. The medical records of all patients with singleton pregnancies that were diagnosed with PPROM were retrospectively reviewed. Singleton pregnancies with PPROM diagnosis that was confirmed either by direct visualisation of amniotic fluid leaking through the cervix or by placental alpha microglobulin-1 protein (PAMG-1) assay if no amniotic fluid leakage was documented were included in the study. Demographics, prenatal and postnatal characteristics were reviewed from the medical charts and were recorded. The study included 138 pregnancies with PPROM; 111 patients in clinical speculum examination group and 27 in PAMG-1 assay group. There were no significant differences in maternal and pregnancy characteristics between the clinical speculum examination and PAMG-1 assay groups. Foetal outcomes were comparable between clinical speculum examination and PAMG-1 assay groups. In the clinical speculum examination group, there were nine (8.1%) chorioamnionitis cases, however, there were no chorioamnionitis cases in the PAMG-1 assay group during the latency period (p = .21).Impact statementWhat is already known on this subject? Placental alpha microglobulin-1 protein assay uses immunochromatography method to detect trace amount of placental alpha microglobulin-1 protein in vaginal fluids and has high sensitivity and specificity for ROM diagnosis. However, to the best of our knowledge, the clinical outcome of ROM cases detected by classical speculum examination and by placental alpha microglobulin-1 protein assay has not been compared in the literature previously.What do the results of this study add? Although statistically insignificant, cases diagnosed by PAMG-1 assay had lower risk of chorioamnionitis during latency period.What are the implications of these findings for clinical practice and/or further research? Whether cases diagnosed by PAMG-1 assay represent a milder form of rupture of membranes than cases diagnosed by classical speculum examination group warrants further research.

Can maternal characteristics on admission for preterm prelabor rupture of membranes predict pregnancy latency?

BACKGROUND

Latency duration after preterm prelabor rupture of membranes has been an area of investigation for many years. Previously described factors associated with latency include gestational age at the time of rupture, cervical dilation of >1 cm, vaginal bleeding at the time of presentation, and oligohydramnios. However, little is known about the impact of composite maternal factors and presenting symptoms on the duration or prediction of the latency period.

OBJECTIVE

This study aimed to determine whether maternal factors and subjective presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes.

STUDY DESIGN

This is a retrospective observational study of singleton pregnancies complicated by preterm prelabor rupture of membranes for over 3 years at a single institution utilizing a uniform management protocol. Maternal demographics, obstetrical data, maternal subjective symptoms and physical examination findings on admission, amniotic fluid volume assessment, presence of contractions, and maternal perception of feeling unwell were collected and analyzed. Clinical characteristics were summarized with mean and standard deviation for continuous measures and frequency and percentages for categorical variables. For skewed variables, medians with 25th and 75th percentiles were reported. Cumulative latency duration (ie, survival time) was estimated with a Kaplan-Meier model. Multivariable Cox proportional hazards regression model with backward variable selection was used to determine the effects of maternal factors on latency duration.

RESULTS

Of the 212 patients available for analysis, there was a considerable variability in the latency duration with values ranging between 0 and 119 days. Factors related to latency duration included maternal age, parity, gestational age at rupture, cervical dilation, amniotic fluid volume, and contractions. Advancing maternal age (P=.012), increased gestational age at rupture (P<.0001), cervical dilation of ≥3 (vs 0; P<.0001), anhydramnios or oligohydramnios (vs normal amniotic fluid; P<.0001), cramping (P=.012), and painful contractions (P=.015) were associated with a shorter latency duration. Utilizing these statistically significant factors, we constructed a nomogram to predict latency for 1-day, 1-week, and overall median latency duration.

CONCLUSION

Maternal factors and presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes. We created a nomogram for clinical use that provides a visual display of the probability of pregnancy latency. This tool may be useful for counseling and providing additional information on expectations for providers and patients with pregnancies complicated by preterm prelabor rupture of membranes.

Antibiotic administration reduces the rate of intraamniotic inflammation in preterm prelabor rupture of the membranes

BACKGROUND

Preterm prelabor rupture of the membranes (PPROM) is frequently complicated by intraamniotic inflammatory processes such as intraamniotic infection and sterile intraamniotic inflammation. Antibiotic therapy is recommended to patients with PPROM to prolong the interval between this complication and delivery (latency period), reduce the risk of clinical chorioamnionitis, and improve neonatal outcome. However, there is a lack of information regarding whether the administration of antibiotics can reduce the intensity of the intraamniotic inflammatory response or eradicate microorganisms in patients with PPROM.

OBJECTIVE

The first aim of the study was to determine whether antimicrobial agents can reduce the magnitude of the intraamniotic inflammatory response in patients with PPROM by assessing the concentrations of interleukin-6 in amniotic fluid before and after antibiotic treatment. The second aim was to determine whether treatment with intravenous clarithromycin changes the microbial load of Ureaplasma spp DNA in amniotic fluid.

STUDY DESIGN

A retrospective cohort study included patients who had (1) a singleton gestation, (2) PPROM between 24+0 and 33+6 weeks, (3) a transabdominal amniocentesis at the time of admission, and (4) intravenous antibiotic treatment (clarithromycin for patients with intraamniotic inflammation and benzylpenicillin/clindamycin in the cases of allergy in patients without intraamniotic inflammation) for 7 days. Follow-up amniocenteses (7^th day after admission) were performed in the subset of patients with a latency period lasting longer than 7 days. Concentrations of interleukin-6 were measured in the samples of amniotic fluid with a bedside test, and the presence of microbial invasion of the amniotic cavity was assessed with culture and molecular microbiological methods. Intraamniotic inflammation was defined as a bedside interleukin-6 concentration ≥745 pg/mL in the samples of amniotic fluid. Intraamniotic infection was defined as the presence of both microbial invasion of the amniotic cavity and intraamniotic inflammation; sterile intraamniotic inflammation was defined as the presence of intraamniotic inflammation without microbial invasion of the amniotic cavity.

RESULTS

A total of 270 patients with PPROM were included in this study: 207 patients delivered within 7 days and 63 patients delivered after 7 days of admission. Of the 63 patients who delivered after 7 days following the initial amniocentesis, 40 underwent a follow-up amniocentesis. Patients with intraamniotic infection (n = 7) and sterile intraamniotic inflammation (n = 7) were treated with intravenous clarithromycin. Patients without either microbial invasion of the amniotic cavity or intraamniotic inflammation (n = 26) were treated with benzylpenicillin or clindamycin. Treatment with clarithromycin decreased the interleukin-6 concentration in amniotic fluid at the follow-up amniocentesis compared to the initial amniocentesis in patients with intraamniotic infection (follow-up: median, 295 pg/mL, interquartile range [IQR], 72-673 vs initial: median, 2973 pg/mL, IQR, 1750-6296; P = .02) and in those with sterile intraamniotic inflammation (follow-up: median, 221 pg/mL, IQR 118-366 pg/mL vs initial: median, 1446 pg/mL, IQR, 1300-2941; P = .02). Samples of amniotic fluid with Ureaplasma spp DNA had a lower microbial load at the time of follow-up amniocentesis compared to the initial amniocentesis (follow-up: median, 1.8 × 10⁴ copies DNA/mL, 2.9 × 10⁴ to 6.7 × 10⁸ vs initial: median, 4.7 × 10⁷ copies DNA/mL, interquartile range, 2.9 × 10³ to 3.6 × 10⁷; P = .03).

CONCLUSION

Intravenous therapy with clarithromycin was associated with a reduction in the intensity of the intraamniotic inflammatory response in patients with PPROM with either intraamniotic infection or sterile intraamniotic inflammation. Moreover, treatment with clarithromycin was related to a reduction in the load of Ureaplasma spp DNA in the amniotic fluid of patients with PPROM <34 weeks of gestation.

Maternal features at time of preterm prelabor rupture of membranes and short-term neonatal outcomes

Objective: The objective of this study was to assess if maternal and obstetric characteristics other than gestational age at the time of rupture impact short-term neonatal outcomes.Methods: This is a retrospective observational study from a single tertiary care referral center. This study reviewed women with a singleton pregnancy complicated by preterm prelabor rupture of membranes over a 3-year period from May of 2014 through May of 2017. Maternal characteristics and short term neonatal outcomes were collected.Results: We identified 210 pregnancies complicated by preterm prelabor rupture of membranes. Eighteen of these patients had rupture of membranes prior to viability. Of the maternal characteristics at time of admission studied, gestational age at rupture and race influenced short term neonatal outcomes. Women who identified as race other than white had neonates with lower rates of intubation than neonates born to white patients. Gestational age at rupture significantly influenced the neonatal intensive care unit length of stay. Each additional week gained before rupture occurred was associated with a 17.1% decrease in length of stay. Maternal age, gravidity, parity, body mass index, single deepest pocket, and amniotic fluid index did not influence short term neonatal outcomes.Conclusions: Gestational age at rupture of membranes is the most predictive factor associated with short term neonatal outcomes. Race may also influence short term neonatal outcomes. Other maternal characteristics do not seem to influence short term neonatal outcomes. This information can assist with patient counseling on admission for preterm prelabor rupture of membranes and expected neonatal course.

Amniotic fluid glucose level in PPROM pregnancies: a glance at the old friend

Introduction: To determine the amniotic fluid glucose levels in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) based on the presence of microbial invasion of the amniotic cavity and/or intra-amniotic inflammation.Methods of Study: A total of 142 women with singleton pregnancies complicated by PPROM between gestational ages 24 + 0 and 36 + 6 weeks were included. Amniocentesis was performed at the time of admission. The assessments of microbial invasion of the amniotic cavity (using both cultivation and non-cultivation techniques) and intra-amniotic inflammation (amniotic fluid interleukin-6 levels ≥ 3000 pg/mL) were performed on all the women. Based on the presence of microbial invasion of the amniotic cavity and/or intra-amniotic inflammation, the women were further categorized into the subgroups: (i) intra-amniotic infection (the presence of both microbial invasion of the amniotic cavity and intra-amniotic inflammation); (ii) sterile intra-amniotic inflammation (the presence of intra-amniotic inflammation without microbial invasion of the amniotic cavity); (iii) colonization (the presence of microbial invasion of the amniotic cavity without intra-amniotic inflammation); and (iv) negative amniotic fluid (the absence of either microbial invasion of the amniotic cavity or intra-amniotic inflammation). Amniotic fluid glucose levels were assessed using enzymatic reference method with hexokinase.Results: There was a difference in the amniotic fluid glucose levels among the women with intra-amniotic infection, sterile intra-amniotic inflammation, colonization, and those with negative amniotic fluid (p < .0001). No difference was found in the amniotic fluid glucose levels between women with intra-amniotic infection and those with sterile intra-amniotic inflammation [infection: median 11.6 mg/dL (0.7 mmol/L) vs. sterile: median 6.3 mg/dL (0.4 mmol/L); p = .41] and between women with colonization and negative amniotic fluid [colonization: median 21.6 mg/dL (1.2 mmol/L) vs. negative: median 23.4 mg/dL (1.3 mmol/L; p = .67]. Women with intra-amniotic infection and sterile intra-amniotic inflammation had lower amniotic fluid glucose levels than women with colonization and with negative amniotic fluid in crude analysis as well as after adjustment for gestational age at sampling. Amniotic fluid glucose level of 10 mg/dL (0.56 mmol/L) was the optimal concentration for the identification of intra-amniotic inflammation in women with PPROM.Conclusions: The presence of intra-amniotic inflammation was associated with lower amniotic fluid glucose levels in singleton pregnancies complicated with PPROM. An amniotic fluid glucose level of 10 mg/dL (0.56 mmol/L) was the optimal concentration for the identification of intra-amniotic inflammation in PPROM pregnancies. In the absence of better amniotic fluid markers, amniotic glucose could be used as a marker of intra-amniotic inflammation, with very good specificity in PPROM pregnancies.

A cut-off value for systemic immune-inflammation index in the prediction of adverse neonatal outcomes in preterm premature rupture of the membranes

AIM

To determine a cut-off value for systemic immune-inflammation index (SII)(neutrophil × platelet /lymphocyte) in the prediction of adverse neonatal outcomes in preterm premature rupture of the membranes (PPROM).

METHODS

This retrospective cohort study was conducted among singleton pregnancies with PPROM. Cases were divided into two main groups: Group 1) PPROM diagnosed at 24th-28th weeks of gestation and Group 2) PPROM diagnosed at >28th-34th weeks of gestation. Thereafter, main study groups were divided into two subgroups: Subgroup A: pregnancies with favorable neonatal outcomes and Subgroup B: pregnancies with composite adverse neonatal outcomes. Subgroups were compared in terms of demographic features, clinical characteristics, laboratory test results and SII values. Furthermore, cut-off values of SII for the prediction of composite adverse neonatal outcomes were determined for two main groups. A Mann-Whitney U test was conducted to compare the median values and the chi-square test was used to compare categorical variables among the groups. Receiver operating characteristic (ROC) curves were used to assess the performance of SII value in predicting composite adverse neonatal outcomes.

RESULTS

Significant differences were observed for median platelet and SII values between the subgroups (P < 0.001 for both in group 1 and P = 0.002 and P = 0.005, respectively, in group 2). Cut-off values of 1695.14 10⁹ /L (83.3% sensitivity, 85.7% specificity) and 1430.90 × 10⁹ /L (71.4% sensitivity, 75.7% specificity) for composite adverse neonatal outcomes were determined, respectively in group 1 and 2 according to the ROC curve analysis.

CONCLUSION

SII may be used as an additional indicator for the prediction of adverse neonatal outcomes in PPROM.

Targeting bromodomain-containing proteins to prevent spontaneous preterm birth

Preterm birth is a global healthcare challenge. Spontaneous preterm birth (sPTB) is commonly caused by inflammation, yet there are currently no effective therapies available. The Bromodomain and Extra-Terminal motif (BET) proteins, Bromodomain-containing protein (Brd) 2 (Brd2), Brd3 and Brd4 regulate inflammation in non-gestational tissues. The roles of Brd2-4 in human pregnancy are unknown. Using human and mouse models, the present study has identified the Brd proteins part of the process by which inflammation induces parturition. Using human clinical samples, we demonstrate that labor and infection increase the expression of Brds in the uterus and fetal membranes. In primary human myometrial, amnion and decidual cells, we found that global Brd protein inhibition, as well as selective inhibition of Brds, suppressed inflammation-induced expression of mediators involved in myometrial contractions and rupture of fetal membranes. Importantly, studies in the mouse model demonstrate that the pan-Brd inhibitor JQ1 reduced intrauterine inflammation induced by bacterial endotoxin LPS as well as decreasing the effectiveness of LPS to induce parturition. These results implicate BET proteins as novel therapeutic targets for reducing inflammation associated with spontaneous preterm labor.

Antenatal corticosteroids for pregnant women with COVID-19 infection and preterm prelabor rupture of membranes: a decision analysis

Background: While antenatal corticosteroids are routinely used to decrease adverse neonatal outcomes following preterm delivery, corticosteroids are also associated with worse outcomes in patients with viral respiratory infections. Currently in the setting of the COVID-19 pandemic, it is unclear whether antenatal corticosteroids for infant benefit outweigh the potential harm to a pregnant woman with a COVID-19 infection.Objective: To determine at which gestational ages administering antenatal corticosteroids is the optimal management strategy for hospitalized women with preterm prelabor rupture of membranes (PPROM) who have a COVID-19 infection.Methods: We designed a decision-analytic model to assess the maternal and infant outcomes associated with antenatal corticosteroid administration for risk of preterm delivery following rupture of membranes in the setting of a COVID-19 infection. We used a theoretical cohort of 10,000 women at each gestational age between 24 and 32 weeks who were hospitalized with PPROM and found to be COVID-19 positive. Maternal outcomes included intensive care unit admission and death related to COVID-19 infection. The infant outcomes of interest included respiratory distress syndrome, intraventricular hemorrhage, neurodevelopmental delay, and death, and were assessed along with maternal and infant quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were used to evaluate model assumptions.Results: In our theoretical cohort of 10,000 women with COVID-19 infection and preterm prelabor rupture of membrane between 24 and 32 weeks, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths at each gestational age. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths at each gestational age. Antenatal corticosteroid administration also resulted in fewer cases of respiratory distress syndrome, intraventricular hemorrhage, and infant death. Overall, we found that between 24 and 30 weeks of gestation, administering antenatal corticosteroids was the optimal management strategy as it resulted in higher combined QALYs than no corticosteroid use. For 31 and 32 weeks of gestation, antenatal corticosteroid administration resulted in lower combined QALYs. On sensitivity analyses, we found that with increasing gestational age, the probability which antenatal corticosteroids was the optimal management strategy decreased.Conclusion: Administration of antenatal corticosteroids was an effective management strategy compared to no corticosteroid administration at gestational ages less than 31 weeks. These results provide data for clinicians to utilize when counseling pregnant patients hospitalized with PPROM and have a COVID-19 infection.

A novel extended prophylactic antibiotic regimen in preterm pre-labor rupture of membranes: A randomized trial

OBJECTIVES

Prophylactic antibiotic use in preterm pre-labor rupture of membranes (PPROM) is associated with a significant reduction in intra-amniotic infection and improved neonatal outcome. However, data is insufficient to determine the optimal antibiotic regimen. Considering the rise in Escherichia coli and Klebsiella pneumonia early-onset sepsis rate and the emergence of ampicillin resistance, our aim is to compare the efficiency of two antibiotic regimens in prolonging pregnancy and reducing infectious morbidity.

DESIGN

This multicenter randomized unblinded controlled prospective trial compared two antibiotic prophylactic protocols in PPROM: ampicillin + roxithromycin vs. cefuroxime + roxithromycin in 84 women with PPROM, from 12/2015-12/2019.

RESULTS

The median latency period was significantly longer (p = 0.039) in the cefuroxime + roxithromycin group (4.63 [0.59-50.18] days) than in the ampicillin + roxithromycin group (2.3 [0.15-58.3] days). Neonatal admission to neonatal intensive care unit rate, hospitalization length, neonatal respiratory distress syndrome, neonatal fever, and need for respiratory support or mechanical ventilation, were similar between the groups. K. pneumonia cultures were significantly more frequent in the ampicillin + roxithromycin group. None of the cultures were group B Streptococcus positive.

CONCLUSIONS

To prolong latency period and reduce gram-negative early-onset sepsis, cefuroxime + roxithromycin is recommended as the first-line protocol in PPROM.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02819570.

Lactobacilli-dominated cervical microbiota in women with preterm prelabor rupture of membranes

BACKGROUND

To determine the association between microbial invasion of the amniotic cavity (MIAC) and the presence of Lactobacillus crispatus- or Lactobacillus iners-dominated cervical microbiota in pregnancies with preterm prelabor rupture of membrane. Next, to assess the relationship between the presence of L. crispatus- or L. iners-dominated cervical microbiota and short-term neonatal morbidity.

METHOD

A total of 311 women were included. Cervical samples were obtained using a Dacron polyester swab and amniotic fluid samples were obtained by transabdominal amniocentesis. Bacterial DNA, L. crispatus, and L. iners in the cervical samples were assessed by PCR. Cervical microbiota was assigned as L. crispatus- or L. iners-dominated when the relative abundance of L. crispatus or L. iners was ≥50% of the whole cervical microbiota, respectively.

RESULTS

Women with MIAC showed a lower rate of L. crispatus-dominated cervical microbiota (21% vs. 39%; p = 0.003) than those without MIAC. Lactobacillus crispatus-dominated cervical microbiota was associated with a lower rate of early-onset sepsis (0% vs. 5%; p = 0.02).

CONCLUSIONS

The presence of L. crispatus-dominated cervical microbiota in women with preterm prelabor rupture of membrane was associated with a lower risk of intra-amniotic complications and subsequent development of early-onset sepsis of newborns.

Cellular immune responses in amniotic fluid of women with preterm prelabor rupture of membranes

Background Preterm birth is the leading cause of perinatal morbidity and mortality. Preterm prelabor rupture of membranes (pPROM) occurs in 30% of preterm births; thus, this complication is a major contributor to maternal and neonatal morbidity. However, the cellular immune responses in amniotic fluid of women with pPROM have not been investigated. Methods Amniotic fluid samples were obtained from women with pPROM and a positive (n = 7) or negative (n = 10) microbiological culture. Flow cytometry was performed to evaluate the phenotype and number of amniotic fluid leukocytes. The correlation between amniotic fluid immune cells and an interleukin-6 (IL-6) concentration or a white blood cell (WBC) count in amniotic fluid was calculated. Results Women with pPROM and a positive amniotic fluid culture had (1) a greater number of total leukocytes in amniotic fluid, including neutrophils and monocytes/macrophages and (2) an increased number of total T cells in amniotic fluid, namely CD4+ T cells and CD8+ T cells, but not B cells. The numbers of neutrophils and monocytes/macrophages were positively correlated with IL-6 concentrations and WBC counts in amniotic fluid of women with pPROM. Conclusion Women with pPROM and a positive amniotic fluid culture exhibit a more severe cellular immune response than those with a negative culture, which is associated with well-known markers of intra-amniotic inflammation.

Child outcomes after amnioinfusion compared with no intervention in women with second-trimester rupture of membranes: a long-term follow-up study of the PROMEXIL-III trial

OBJECTIVE

To assess the effect of transabdominal amnioinfusion or no intervention on long-term outcomes in children born after second-trimester prelabour rupture of the membranes (PROM between 16^+0/7 -24^+0/7  weeks) and oligohydramnios.

POPULATION

Follow up of infants of women who participated in the randomised controlled trial: PPROMEXIL-III (NTR3492).

METHODS

Surviving infants were invited for neurodevelopmental assessment up to 5 years of corrected age using a Bayley Scales of Infant and Toddler Development or a Wechsler Preschool and Primary Scale of Intelligence. Parents were asked to complete several questionnaires.

MAIN OUTCOME MEASURES

Neurodevelopmental outcomes were measured. Mild delay was defined as -1 standard deviation (SD), severe delay as -2 SD. Healthy long-term survival was defined as survival without neurodevelopmental delay or respiratory problems.

RESULTS

In the amnioinfusion group, 18/28 children (64%) died versus 21/28 (75%) in the no intervention group (relative risk 0.86; 95% confidence interval [CI] 0.60-1.22). Follow-up data were obtained from 14/17 (82%) children (10 amnioinfusion, 4 no intervention). In both groups, 2/28 (7.1%) had a mild neurodevelopmental delay. No severe delay was seen. Healthy long-term survival occurred in 5/28 children (17.9%) after amnioinfusion versus 2/28 (7.1%) after no intervention (odds ratio 2.50; 95% CI 0.53-11.83). When analysing data for all assessed survivors, 10/14 (71.4%) survived without mild neurodevelopmental delay and 7/14 (50%) were classified healthy long-term survivor.

CONCLUSIONS

In this small sample of women suffering second-trimester PROM and oligohydramnios, amnioinfusion did not improve long-term outcomes. Overall, 71% of survivors had no neurodevelopmental delay.

TWEETABLE ABSTRACT

Healthy long-term survival was comparable for children born after second-trimester PROM and treatment with amnioinfusion or no intervention.

Preterm prelabor rupture of membranes prior to early preterm delivery elevates the risk of later respiratory-related hospitalizations in the offspring

OBJECTIVE

Preterm prelabor rupture of membranes (PPROM) precedes 30%-40% of all preterm births. Early preterm delivery (<34 gestation weeks) is a well-established risk factor for short- and long-term respiratory morbidity in the offspring. We aimed to ascertain whether the presence of PPROM, before early preterm delivery, independently impacts long-term respiratory hospitalizations in the offspring.

STUDY DESIGN

A population-based retrospective cohort analysis was performed including all singleton early preterm deliveries. Exposure was defined as the presence of PPROM. Hospitalizations of the offspring up to the age of 18 years involving respiratory-related morbidity were evaluated. A Kaplan-Meier survival curve and multivariable Cox regression model were used to assess the association.

RESULTS

During the study period, 3309 early preterm deliveries met the inclusion criteria. In 22.4% of cases (n = 742), PPROM was documented. Rates of respiratory-related hospitalizations of the offspring up to the age of 18 years were significantly higher in the exposed group (12.5% vs 9.4% in the unexposed group, P = .023). The survival curve demonstrated significantly higher cumulative incidence of respiratory hospitalizations in the exposed group (logrank P = .018). In the Cox regression model controlled for gestational age, and other clinically relevant confounders - PPROM before early preterm deliveries was independently associated with an increased risk for long-term childhood respiratory-related hospitalizations in the offspring (adjusted hazard ratio 1.40, 95% confidence interval, 1.05-1.87, P = .021).

CONCLUSION

Fetal exposure to PPROM before early preterm delivery was associated with an increased risk for long-term respiratory hospitalizations in the offspring.

Microbial burden and inflammasome activation in amniotic fluid of patients with preterm prelabor rupture of membranes

Background Intra-amniotic inflammation, which is associated with adverse pregnancy outcomes, can occur in the presence or absence of detectable microorganisms, and involves activation of the inflammasome. Intra-amniotic inflammasome activation has been reported in clinical chorioamnionitis at term and preterm labor with intact membranes, but it has not yet been investigated in women with preterm prelabor rupture of membranes (preterm PROM) in the presence/absence of detectable microorganisms. The aim of this study was to determine whether, among women with preterm PROM, there is an association between detectable microorganisms in amniotic fluid and intra-amniotic inflammation, and whether intra-amniotic inflammasome activation correlates with microbial burden. Methods Amniotic fluids from 59 cases of preterm PROM were examined for the presence/absence of microorganisms through culture and 16S ribosomal RNA (rRNA) gene quantitative real-time polymerase chain reaction (qPCR), and concentrations of interleukin-6 (IL-6) and ASC [apoptosis-associated spec-like protein containing a caspase recruitment domain (CARD)], an indicator of inflammasome activation, were determined. Results qPCR identified more microbe-positive amniotic fluids than culture. Greater than 50% of patients with a negative culture and high IL-6 concentration in amniotic fluid yielded a positive qPCR signal. ASC concentrations were greatest in patients with high qPCR signals and elevated IL-6 concentrations in amniotic fluid (i.e. intra-amniotic infection). ASC concentrations tended to increase in patients without detectable microorganisms but yet with elevated IL-6 concentrations (i.e. sterile intra-amniotic inflammation) compared to those without intra-amniotic inflammation. Conclusion qPCR is a valuable complement to microbiological culture for the detection of microorganisms in the amniotic cavity in women with preterm PROM, and microbial burden is associated with the severity of intra-amniotic inflammatory response, including inflammasome activation.