What we have learned regarding antibiotic therapy for the reduction of infant morbidity after preterm premature rupture of the membranes

Neonatal complications of premature rupture of membranes in mothers receiving cefotaxime and ampicillin: A randomized clinical trial

Introduction

Premature rupture of membranes (PROM) is one of the most common and important causes of premature births and peripartum mortality. Maternal antibiotic treatment affects the infantile prognosis. This study was conducted to compare the efficacy of Ampicillin and Cefotaxime administered for the parturients on neonatal outcomes.

Material and Methods

A comparison between the effects of Cefotaxime and Ampicillin on infantile complications of PROM was done in this clinical trial. Two hundred and twenty parturients with PROM who needed antibiotic therapy were randomized in two groups of control (Ampicillin) and intervention (Cefotaxime) treatments. The maternal/fetal statuses up to accouchement and the infants' status up to transfer to neonatal intensive care unit, death, or discharge from hospital were followed. The Apgar score, cardiac, respiratory and nervous systems, infection, immaturity, asphyxia, and mortality rates were compared in both groups.

Results

The differences between the two groups were significant in: Apgar score min1 and min5, need for resuscitation, asphyxia, need for hospitalization, infection, and mortality rate.

Conclusion

Administration of Cefotaxime in parturients with PROM improved the Apgar scores and decreased respiratory complications, infection, asphyxia, mortality rate, and need for ICU hospitalization in infants.

Antibiotic use in endodontic treatment during pregnancy: A narrative review

More than half of pregnant women are usually affected by odontogenic pain affects. Pain often accompanies periapical or pulp infections and increases the risks to pregnant patients and their fetuses. The American Dental Association, in partnership with the American College of Obstetricians and Gynecologists, has offered a strong declaration reaffirming the significance of suitable and timely oral health care as an indispensable constituent of a healthy pregnancy. However, there is lack of knowledge about the use of antibiotics in endodontic treatment. Therefore, the present study would review the researches done in this area and tries to provide comprehensive and complete information about the use of antibiotics in endodontic treatment during pregnancy. Based on the results, it can be said that using antibiotics during pregnancy are allowed, and they can be used normally and safely by pregnant women.

Early Neurodevelopmental Outcomes after Previable Preterm Prelabour Rupture of Membranes (pPPROM)

Objective

To describe the early neurodevelopmental outcomes following fetal exposure to previable preterm prelabour rupture of membranes (pPPROM).

Methods

This was a secondary analysis of a subgroup of neonates born following pPPROM from a retrospective cohort study (2009–2015). Surviving infants who underwent standardized neurodevelopmental evaluation at 18–24 months corrected age (CA) between 2017 and 2019 were eligible for inclusion. Data abstracted from hospital charts were linked to prospectively collected developmental outcomes stored in an electronic database from a regional neonatal follow-up clinic. The primary outcome was Bayley-III composite scores (compared to the population mean 100, standard deviation (SD) 15). Secondary outcomes included presence of cerebral palsy, vision loss, hearing impairment, and requirement of rehabilitation therapy. Descriptive statistics were used to present results.

Results

25.7% (19/74) of neonates born after pPPROM survived to hospital discharge, but only 21.6% (16/74) survived to 18–24 months CA. Of these, 9 infants were eligible for follow-up at the regional clinic and 7 had developmental outcomes stored in the electronic database. Infants exposed to pPPROM exhibited Bayley-III scores more than 1 SD below the population mean across all three domains: cognitive 84.9 (SD 12.2); motor 82.3 (SD 11.5); and language 66.4 (SD 18.9). There were particular deficiencies in language development with 71% (5/7) scoring more than 2 SDs below the population mean. There were no cases of cerebral palsy.

Conclusions

Only 1 in 5 infants born following expectantly managed pPPROM survived to 18–24 months CA. These infants born after pPPROM had significantly lower Bayley-III scores and particular deficiencies in language development. Better understanding of early neurodevelopmental challenges following pPPROM will help refine counselling of families contemplating expectant management and provide insights into the postnatal educational resources required to improve long-term developmental outcomes for these children.

Premature rupture of membranes - A cause of foetal complications among lupus: A cohort study, systematic review and meta-analysis

OBJECTIVE

The present study aimed to analyse the frequency of premature rupture of membranes (PROMs) among 190 women with systemic lupus erythematosus (SLE) followed up at the Hospital Universitário Pedro Ernesto from 2011 to 2018 and to review the literature on PROM in patients with SLE.

METHODS

A cohort study of SLE patients was conducted by analysing the following variables: sociodemographic characteristics, clinical manifestations of lupus, modified disease activity index for pregnancy, drugs used during pregnancy, intercurrent maternal infections and obstetric outcomes. Additionally, seven electronic databases (PubMed, Embase, Cochrane, Scielo, Scielo Brazil, Virtual Health Library Regional Portal and Google Scholar) were systematically searched. The search was updated on 3 February 2020.

RESULTS

Infections (relative risk (RR): 3.26, 95% confidence interval (CI): 1.5-6.7, p = .001), history of serositis (RR: 2.59, 95% CI: 1.31-5.11, p = .006) and anti-RNP positivity (RR: 3.08, 95% CI: 1.39-6.78, p = .005) were associated risk factors for PROM, while anti-RNP positivity (RR: 3.37, 95% CI: 1.35-8.40; p = .009) were associated with premature PROM (PPROM). The prevalence of PROM and PPROM was 28.7% and 12.9%, respectively. In the systematic review, the prevalence of PROM and PPROM was 2.7%-35% (I² = 87.62%) and 2.8%-20% (I² = 79.56%), respectively.

CONCLUSIONS

PROM, both at term and preterm, occurs more frequently in women with lupus than in the general population. A history of serositis, anti-RN, infections and immunosuppression during pregnancy may increase the susceptibility to PROM. The systematic review did not find any study with the main objective of evaluating PROM/PPROM in women with lupus.

Abuse of Antibiotics in Perinatology: Negative Impact for Health and the Economy

To use medications appropriately, patients need to be treated based on their clinical conditions, in doses that are based on their individual requirements, for an adequate amount of time, and at the lowest expense. The perinatal period is characterized by an excessive use of antibiotics. This antibiotic abuse can lead to antibiotic resistance, microbiome alterations, and dysbiosis, which have been associated with serious complications such as infections, abnormal brain development, allergies, autoimmune disorders, obesity, and an increase in mortality as well as an increase in health care expenditures. The need to optimize antibiotic utilization in perinatal medicine has never been more urgent; there is not much more time to wait.

Abnormal cervical cytology is associated with preterm delivery: A population based study

INTRODUCTION

Increasing evidence suggests that cervical intraepithelial neoplasia, with or without subsequent treatment, is associated with preterm delivery. We aimed to explore the association between abnormal cervical cytology of different severity and the subsequent obstetric outcomes such as preterm delivery.

MATERIAL AND METHODS

The historical register-based cohort study comprised 19 822 women in the Western Region of Sweden who had at least one abnormal cervical cytology from 1978 to 2012 before the age of 45 and a subsequent singleton delivery. The reference group comprised 39 644 women with normal cervical cytology and a subsequent singleton delivery, matched by age and parity. Data were retrieved from the Swedish National Cervical Screening Registry, linked to the Swedish Medical Birth Register and Statistic Sweden. The study outcomes were spontaneous preterm delivery before 37 and 34 weeks, low birthweight (≤2500 g), small-for-gestational-age, preterm premature rupture of membranes and neonatal mortality. Multivariable log binominal regression analyses were applied.

RESULTS

Preterm delivery before 37 weeks was more common among women with abnormal cervical cytology compared with reference group: 6% vs 4.5%; adjusted relative risk 1.30 (95% confidence interval 1.21-1.39). High vs low-grade abnormal cervical cytology implied a higher risk: 7% vs 5.8% (P < 0.001). Early preterm delivery before 34 weeks, preterm premature rupture of membranes and low birthweight, but not small-for-gestational-age and neonatal mortality, were significantly more common in women with abnormal cervical cytology compared with the reference group.

CONCLUSIONS

Abnormal cervical cytology may imply an increased risk of preterm delivery. Further studies are needed to investigate whether that risk is related to treatment.

Simplified management protocol for term neonates after prolonged rupture of membranes in a setting with high rates of neonatal sepsis and mortality: a quality improvement study

In low-income and middle-income countries, courses of antibiotics are routinely given to term newborns whose mothers had prolonged rupture of membranes (PROM). Rational antibiotic use is vital given rising rates of antimicrobial resistance and potential adverse effects of antibiotic exposure in newborns. However missing cases of sepsis can be life-threatening.This is a quality improvement evaluation of a protocol for minimal or no antibiotics in term babies born after PROM in Papua New Guinea. Asymptomatic, term babies born to women with PROM >12 hours prior to birth were given a stat dose of antibiotics, or no antibiotics if the mother had received intrapartum antibiotics, reviewed and discharged at 48-72 hours with follow-up. Clinical signs of sepsis within the first week and the neonatal period were assessed. Of 170 newborns whose mothers had PROM, 133 were assessed at 7 days: signs of sepsis occurred in 10 babies (7.5%; 95% CI 4.4% to 13.2%) in the first week. Five had isolated fever, four had skin pustules and one had fever with periumbilical erythema. An additional four (3%) had any sign of sepsis between 8 and 28 days. There was one case of bacteraemia and no deaths. 37 were lost to follow-up, but hospital records did not identify any subsequent admissions for infection. A rate of sepsis was documented that was comparable with other studies in low-income countries. This protocol may reduce antimicrobial resistance and consequences of antibiotic exposure in newborns, provided safeguards are in place to monitor for signs of sepsis.

Genital tract GBS and rate of histologic chorioamnionitis in patients with preterm premature rupture of membrane

INTRODUCTION

Histologic chorioamnionitis (HC) is a common finding in the placenta from patients with preterm premature rupture of membranes (PPROM). The purpose of this study is to determine if HC differs based on the Group B streptococcus (GBS) status in patients managed expectantly with PPROM <34 weeks gestation.

METHODS

A retrospective study was performed of patients admitted with PPROM between 23 0/7 and 33 6/7 weeks from 2003 to 2014 at one institution. Patients were excluded if in labor, evidence of clinical chorioamnionitis, nonreassuring fetal status, multifetal gestation, HIV positive, or if GBS specimens or placental histology were not available. Placental pathology results were compared using Fisher's exact test.

RESULTS

One hundred eighty-one patients met inclusion criteria and 55 (30.3%) were GBS positive. The prevalence of HC did not differ between the GBS positive and GBS negative groups (69 versus 64.2%, respectively; p = .62). Clinical chorioamnionitis, endomyometritis, wound infection, maternal and neonatal sepsis did not differ between the two groups.

CONCLUSIONS

Vaginal-rectal colonization with GBS on admission does not appear to affect the rate of HC nor neonatal outcome in patients managed conservatively with PPROM <34 weeks gestation.

A new antibiotic regimen treats and prevents intra-amniotic inflammation/infection in patients with preterm PROM

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.

A new anti-microbial combination prolongs the latency period, reduces acute histologic chorioamnionitis as well as funisitis, and improves neonatal outcomes in preterm PROM

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.

Changes in maternal blood inflammatory markers as a predictor of chorioamnionitis: a prospective multicenter study

PROBLEM

To evaluate the inflammatory pattern in maternal circulation from women with preterm premature rupture of membranes (PPROM) considering the occurrence of histologically confirmed chorioamnionitis (HCA).

METHOD OF STUDY

A prospective study was conducted in 121 women with PPROM between 24 and 34 + 0 weeks of gestation. Association between white blood cells (WBC) count, plasma CRP, IL-6, MCP-1 and IP-10 levels, and HCA was assessed.

RESULTS

The rate of HCA was 44.7% (54/121). During the 5 days preceding delivery, median CRP, WBC, and IL-6 levels were significantly higher in the HCA than in no-HCA group (P < 0.001). Variations in IL-6, IP-10 levels, during the 24-72 hr before delivery, were predictors of the occurrence of HCA, but the diagnostic accuracy was low [Receiver Operating Characterictic (ROC) curve, area under the curve (AUC) = 0.56].

CONCLUSION

An increase in IL-6, CRP, IP-10 maternal plasma levels was confirmed in PPROM women with HCA. Longitudinal follow-up of these markers did not add valuable information regarding HCA.

Antibiotic use and misuse during pregnancy and delivery: benefits and risks

Although pregnancy is considered as a physiological state, most pregnant women in developed countries receive multiple medications to prevent maternal or neonatal complications, with antibiotics among the most frequently prescribed. During pregnancy, antibiotics are often prescribed in the context of preterm labor, intrapartum fever, prevention of neonatal Group B Streptococcus fever, and cesarean section. Outside this period, they are commonly prescribed in the community setting for respiratory, urinary, and ear, nose and throat infection symptoms. Whereas some of the current indications have insightful reasons to justify their use, potential risks related to overuse and misuse may surpass the benefits. Of note, the recent 2014 World Health Assembly expressed serious concern regarding antibiotic resistance due to antibiotic overuse and misuse and urged immediate action to combat antibiotic resistance on a global scale. Most studies in the obstetrics field have focused on the benefits of antibiotics for short-term maternal and neonatal complications, but with very little (if any) interest in long-term consequences.

Repeated maternal intramuscular or intraamniotic erythromycin incompletely resolves intrauterine Ureaplasma parvum infection in a sheep model of pregnancy

OBJECTIVE

Ureaplasma spp are the most commonly isolated microorganisms in association with preterm birth. Maternal erythromycin administration is a standard treatment for preterm prelabor rupture of membranes. There is little evidence of its effectiveness in eradicating Ureaplasma spp from the intrauterine cavity and fetus. We used a sheep model of intrauterine Ureaplasma spp infection to investigate the efficacy of repeated maternal intramuscular and intraamniotic erythromycin treatment to eradicate such an infection.

STUDY DESIGN

Thirty ewes with singleton pregnancies received an intraamniotic injection of 10(7) color change units of erythromycin-sensitive Ureaplasma parvum serovar 3 at 55 days' gestation. At 116 days' gestation, 28 ewes with viable fetuses were randomized to receive (1) intraamniotic and maternal intramuscular saline solution treatment (n = 8), (2) single intraamniotic and repeated maternal intramuscular erythromycin treatment (n = 10), or (3) single maternal intramuscular and repeated intraamniotic erythromycin treatment (n = 10). Fetuses were surgically delivered at 125 days' gestation. Treatment efficacy was assessed by culture, quantitative polymerase chain reaction, and histopathologic evaluation.

RESULTS

Animals treated with intraamniotic erythromycin had significantly less viable U parvum serovar 3 in the amniotic fluid at delivery. However, neither combination of maternal intramuscular and intraamniotic erythromycin treatment successfully cleared U parvum serovar 3 from the amniotic fluid or fetal tissues. Three de novo erythromycin-resistant U parvum isolates were identified in erythromycin-treated animals.

CONCLUSION

Erythromycin treatment, given both to the ewe and into the amniotic cavity, fails to eradicate intrauterine and fetal U parvum serovar 3 infection and may lead to development of erythromycin resistant U parvum.

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

Preterm premature rupture of the membranes (PROM) complicates 3% of pregnancies and is responsible for approximately one third of all preterm births. Because preterm PROM presents a clinical situation where early delivery is to be anticipated and prenatal and neonatal complications are common, the physician caring for women with this common obstetric complication has an opportunity to intervene in a manner that can improve perinatal outcome. This article addresses clinically relevant questions regarding the evaluation and management of preterm PROM.

Prevention of neonatal sepsis

Neonatal sepsis is a leading infectious cause of infant mortality. While use of intrapartum antibiotic prophylaxis in the United States has led to dramatic declines in perinatal sepsis caused by the bacteria group B streptococcus, interventions to prevent perinatal sepsis due to other causes have not yet been clearly defined. This article synthesizes information on neonatal sepsis disease burden, trends, and risk factors and reviews current and potential approaches to neonatal sepsis prevention.

Research agenda for preterm birth: recommendations from the March of Dimes

Preterm birth (PTB) is a common, serious, and costly health problem affecting nearly 1 in 8 births in the United States. Burdens from PTB are especially severe for the very preterm infant (<32 weeks' gestation), comprising 2% of all US births. Successful prevention needs to include newly focused and adequately funded research, incorporating new technologies and recognition that genetic, environmental, social, and behavioral factors interact in complex pathogeneses and multiple pathways leading to PTB. The March of Dimes Scientific Advisory Committee created this prioritized research agenda, which is aimed at garnering serious attention and expanding resources to make major inroads into the prevention of PTB, targeting six major, overlapping categories: epidemiology, genetics, disparities, inflammation, biologic stress, and clinical trials. Analogous to other common, complex disorders, progress in prevention will require incorporating multipronged risk reduction strategies that are based on sound scientific discovery, as well as on effective translation into clinical care.

Prevalence, Management, and Outcomes of Preterm Prelabour Rupture of the Membranes of Women in Canada

OBJECTIVES

To determine the prevalence of preterm prelabour rupture of the membranes (PPROM) at Canadian university-affiliated perinatal referral centres, to assess the different management strategies, and to review neonatal outcomes.

METHODS

Twelve Canadian university-affiliated perinatal referral centres provided information on their management of PPROM, and 9 participated in data collection to determine prevalence. All women presenting with PPROM during a 2-week period were observed until delivery, and obstetric and neonatal outcome data were subsequently obtained. The total number of deliveries in each centre was recorded for the same time period. We also determined the incidence of PPROM and the neonatal outcome for all women presenting with PPROM at the Kingston General Hospital from January 1999 to December 2001 by retrospective chart review.

RESULTS

In the 9 academic centres, 27 women (1 with a twin pregnancy) presented with PPROM during the 2-week period. There were 1168 deliveries during the same time period, giving a prevalence of PPROM of 2.3%. Overall, 53% of placentas submitted for histopathology after PPROM demonstrated evidence of chorioamnionitis. In the retrospective chart review, we found 153 cases of confirmed PPROM from January 1999 to December 2001,an incidence of 2.8%. Clinical management in all centres was similar for most women who presented with PPROM prior to 34 weeks' gestation. Management after 34 weeks' gestation varied among the 12 centres, ranging from immediate induction of labour to expectant management and induction at a greater gestational age (GA).

CONCLUSIONS

The increased neonatal morbidity associated with PPROM appears to be inversely related to GA. Increased risk of chorioamnionitis is related to increased time from PPROM to delivery.