Rupture of the membranes and postpartum infection

Maternal morbidity and perinatal outcome in preterm premature rupture of membranes before 37 weeks gestation

OBJECTIVE: To assess the maternal morbidity and perinatal outcome in pre-term pre mature rupture of membranes between 24 to 37 weeks gestation.

METHODS: This observational study was carried out in Gynaecology & Obstetrics Unit – I, at University Hospital Hyderabad, from October 2010 to October 2011. It included one hundred patients admitted through the outpatient department, as well as from casualty department of University Hospital Hyderabad. Detailed Clinical examination of the patient was done. Systemic review was also done to see any co-morbidity. All patients had laboratory investigations. Inclusion criteria were all patients gestational age between 24 to 37 weeks with preterm premature rupture of membrane (PPROM) confirmed by ultrasound and clinical examination regardless of their age. Exclusion criteria were patients with congenital anomalies, multiple pregnancy, pre-eclampsia & eclampsia, diabetes mellitus, polyhydramnios1 intrauterine growth restriction and placenta abruption. Data was collected using a proforma. Detailed workup including history, general physical examination, abdomen and pelvic examination and relevant specific investigations were noted.

RESULTS: Out of 100 patients included in this study Primigravida were 17% and multigravida 83%. There was wide variation of age ranging from a minimum of 20to >40 years. The mean age was 30+ 3.1 years. Mostly patients belonged to the poor class in 72% cases followed by middle class in 21% and upper class 7%. Analysis shows that out of 100 mothers 26% had PROM of <24 hrs duration and 74% had >24 hrs of duration. Maternal outcome in 16 cases of Preterm Premature Rupture of Membrane findings revealed septicemia in 12% cases and Chorioamnionitis in 12% cases. Fetal outcome in 27 cases of preterm premature rupture of membrane revealed prematurity in 5% cases, fetal distress in 4% cases, cord compression in 5% cases, necrotizing enterocolitis in 2% cases, hypoxia in 9% cases and pulmonary hypoplasia in 2% cases.

CONCLUSION: Low socioeconomic status is associated with increased neonatal morbidity due to fetal distress, cord compression, necrotizing enterocolitis, hypoxia and pulmonary hypoplasia at the time of delivery. An appropriate and accurate diagnosis of PROM is critical to optimize pregnancy outcome. It is suggested that the timely diagnosis and management of preterm PROM will allow obstetric care providers to optimize perinatal outcome and minimize neonatal morbidity.

Risk factors for hospital admission related to excessive and/or prolonged postpartum vaginal blood loss after the first 24 h following childbirth

A population case-control study was used to determine risk factors for excessive and/or prolonged vaginal bleeding (described collectively as vaginal loss problems) and uterine infection from 24 h to 3 months postpartum. Data were obtained from women whose maternity care took place in one of two health districts in the south of England. The cases were women remaining in or admitted to hospital with excessive or prolonged vaginal blood loss from 24 h to 3 months postpartum. Two controls for each case were identified; these were women whose delivery was the nearest in time and in the same location as the case delivery. Medical and midwifery records were searched retrospectively to cover hospital admissions for vaginal blood loss problems or uterine infection in postpartum women from 1 January 1994 to 31 December 1995. Data were analysed for 243 cases and 486 controls. Univariable analysis identified 28 variables associated with being a case. Using multivariable analysis, nine factors remained in the final model, with a history of secondary postpartum haemorrhage (PPH) being the most strongly predictive (OR [95% confidence interval] 6.0 [2.1, 16.8]). Vaginal bleeding prior to 24 weeks' gestation (OR 3.0 [1.6, 5.9]), third trimester hospital admission (OR 2.0 [1.4, 2.8]), maternal smoking (OR 2.7 [1.8, 3.9]), a prolonged (OR 3.1 [1.2, 7.5]) or incomplete third stage (OR 2.1 [1.0, 4.4]), and primary PPH (OR 4.7 [1.9, 11.6]) for blood loss >500 mL, were predictive of becoming a case. No significant association was identified for parity (OR 1.1 [0.8, 1.5]) or method of delivery, spontaneous (OR 1.0 [0.7, 1.3]), instrumental (OR 1.4 [0.9, 2.2]) or operative (OR 1.2 [0.8, 1.9]). This is a neglected area of women's health after childbirth, and the value of this study is in the identification of potential risk factors for postpartum morbidity related to vaginal blood loss. Where morbidity occurs, early diagnosis, management and treatment are likely to reduce its extent or duration. It is considered that raising awareness about these factors, both among healthcare professionals and women themselves, may play an important part in the recognition and treatment of postpartum morbidity.

Treatments for secondary postpartum haemorrhage

BACKGROUND

Secondary postpartum haemorrhage is any abnormal or excessive bleeding from the birth canal occurring between 24 hours and 12 weeks postnatally. In developed countries, two per cent of postnatal women are admitted to hospital with this condition, half of them undergoing uterine surgical evacuation; in developing countries it is a major contributor to maternal death.

OBJECTIVES

To evaluate the relative effectiveness and safety of the treatments used for secondary postpartum haemorrhage.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (May 2001), the Cochrane Controlled Trials Register (The Cochrane Library, issue 2, 2001), MEDLINE (back to 1966) and EMBASE (back to 1988). The National Research Register was also searched. The reference lists of trial reports and reviews were searched by hand. Where possible, further sources were sought from the first named authors of the papers identified.

SELECTION CRITERIA

All randomised or quasi randomised comparisons between drug therapies, surgical therapies and placebo or no treatment for the management of secondary postpartum haemorrhage occurring between 24 hours and three months following a pregnancy of at least 24 weeks gestation.

DATA COLLECTION AND ANALYSIS

Reports of possibly eligible studies were scrutinised by two investigators. The third investigator acted as an advisor/arbitrator.

MAIN RESULTS

Of the 45 papers identified, none met the inclusion criteria.

REVIEWER'S CONCLUSIONS

No information is available from randomised controlled trials to inform the management of women with secondary postpartum haemorrhage. This topic may have received little attention because it is perceived as being associated with maternal morbidity rather than mortality in developed countries; it is only recently that the extent and importance of postnatal maternal morbidity has been recognised. A well designed randomised controlled trial comparing the various drug therapies for women with secondary postpartum haemorrhage against each other and against placebo or no treatment groups is needed.

Medication use during the perinatal period

OBJECTIVE

To briefly describe the drug therapy administered during the perinatal period of pregnancy for common maternal and fetal complications, and to identify those agents that should not be used for these conditions.

DATA SOURCES

References were obtained from an ongoing literature search of peer-reviewed obstetric and gynecologic journals and other selected medical and pharmacy journals available in the English language. Primary search vehicle was a weekly review of the tables of contents of nearly 1,300 medical journals provided by Reference Update (Institute of Scientific Information, Philadelphia). MEDLINE searches were also conducted using key terms for each subtopic.

STUDY SELECTION

Specific references were selected for each topic based on the adequacy of their study design, patient population, and a recent publication date. Reviews were used if a large number of primary references would have been required to adequately describe the topic.

DATA EXTRACTION

Most references reflected the current opinions expressed in the Educational (Technical) Bulletin and Committee Opinion series published by the American College of Obstetricians and Gynecologists. Recent, well-conducted studies that arrived at different conclusions were also included.

DATA SYNTHESIS

Data obtained from each reference reflected the conclusions of the authors based on their research or an analysis of the research on others on the appropriate use of the drug(s) for the specific condition being treated.

CONCLUSION

Drug therapy during the perinatal period is frequently required and can be beneficial for the mother, fetus, and newborn. Many complications previously associated with severe morbidity and mortality, such as infections, premature rupture of membranes, preterm labor, hypertension, maternal pain during labor, and postpartum hemorrhage, are now controlled with appropriate pharmacologic therapy. All health professionals who provide services to pregnant women should be knowledgeable in this drug therapy.