Impact of duration of rupture of membranes on outcomes of premature infants

Impact of Extended Membrane Rupture on Neonatal Inflammatory Responses and Composite Neonatal Outcomes in Early-Preterm Neonates-A Prospective Study

Background/Objectives: Prolonged prelabour rupture of membranes (PROMs), and the resulting inflammatory response, can contribute to the occurrence of adverse neonatal outcomes, especially for early-preterm neonates. This prospective study aimed to measure neonates' inflammatory markers in the first 72 h of life based on ROM duration. The second aim was to examine the relationship between PROMs, serum inflammatory markers, and composite adverse neonatal outcomes after controlling for gestational age (GA). Methods: Data from 1026 patients were analyzed considering the following groups: group 1 (ROM < 18 h, n = 447 patients) and group 2 (ROM > 18 h, n = 579 patients). These groups were further segregated depending on the GA at the moment of membranes' rupture into subgroup 1 (<33 weeks of gestation and 6 days, n = 168 patients) and subgroup 2 (at least 34 completed weeks of gestation, n = 858 patients). Multiple logistic regressions and interaction analyses adjusted for GA considering five composite adverse neonatal outcomes and predictors were employed. Results: PROMs and high c-reactive protein (CRP) values significantly increased the risk of composite outcome 1 occurrence by 14% (95%CI: 1.03-1.57, p < 0.001). PROMs and high CRP values increased the risk of composite outcome 5 by 14% (95%CI: 1.07-1.78, p < 0.001), PROM and leukocytosis by 11% (95%CI: 1.02-1.59, p = 0.001), and PROMs and high PCT values by 21% (95%CI: 1.04-2.10, p < 0.001). Conclusions: The combination of PROMs and high CRP values significantly increased the risk of all evaluated adverse composite outcomes in early-preterm neonates and should point to careful monitoring of these patients.

Sex-based differences in placental DNA methylation profiles related to gestational age: an NIH ECHO meta-analysis

The placenta undergoes many changes throughout gestation to support the evolving needs of the foetus. There is also a growing appreciation that male and female foetuses develop differently in utero, with unique epigenetic changes in placental tissue. Here, we report meta-analysed sex-specific associations between gestational age and placental DNA methylation from four cohorts in the National Institutes of Health (NIH) Environmental influences on Child Health Outcomes (ECHO) Programme (355 females/419 males, gestational ages 23-42 weeks). We identified 407 cytosine-guanine dinucleotides (CpGs) in females and 794 in males where placental methylation levels were associated with gestational age. After cell-type adjustment, 55 CpGs in females and 826 in males were significant. These were enriched for biological processes critical to the immune system in females and transmembrane transport in males. Our findings are distinct between the sexes: in females, associations with gestational age are largely explained by differences in placental cellular composition, whereas in males, gestational age is directly associated with numerous alterations in methylation levels.

Neonatal outcomes in women with preterm premature rupture of membranes at periviable gestational age

To examine the outcomes of preterm infants born to women with preterm premature rupture of membranes (PPROM) at periviable gestational age. This is an observational retrospective cohort study analyzing data collected on singleton deliveries complicated by prolonged premature rupture of membranes occurring between 17 and 33 weeks of gestation. Neonatal outcomes including birth weight, Apgar score, retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, hearing impairment and mortality were evaluated. Ninety-four preterm infants who were born after a prolonged premature rupture of membranes of at least 7 days were included in the study. Median gestational week at onset of membrane rupture was 27.1 ± 4.2 weeks (range 17–33) and median latency period in days was 16 ± 21.8 (range 7–105). The cohort was stratified by gestational week (GW) at onset of PPROM (group 1: 17–23, group 2: 24–27, and group 3: 28–33). We found that the survival rate to discharge within neonates born after prolonged rupture of membrane at gestational week less than 24 weeks is 79.2% and 88.9% in group 2. These neonates did not show an increased rate of major morbidities compared to neonates born following membrane rupture at gestational week 24 to 27. We described a high survival rate to discharge without major morbidities following prolonged preterm membrane rupture of at least 7 days of latency before viability.

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

BACKGROUND

Preterm premature rupture of membranes complicates approximately 3% of pregnancies. Currently, in the absence of chorioamnionitis or placental abruption, expectant management, including antenatal steroids for lung maturation and prophylactic antibiotic treatment, is recommended. The benefits of individualized management have not been adequately explored.

OBJECTIVE

This study aimed to compare the impact of 2 different management strategies of preterm premature rupture of membranes in 2 tertiary obstetrical centers on latency of >7 days, latency to birth, chorioamnionitis, funisitis, and short-term adverse maternal and neonatal outcomes.

STUDY DESIGN

This was a multicenter retrospective study of women with singleton pregnancies with preterm premature rupture of membranes from 23 0/7 to 33 6/7 weeks of gestation between 2014 and 2018 and undelivered within 24 hours after hospital admission managed at Sunnybrook Health Sciences Center, Toronto, Canada (standard management group), and BCNatal (Hospital Clínic of Barcelona and Hospital Sant Joan de Déu Barcelona), Barcelona, Spain (individualized management group), following local protocols. The standard management group received similar management for all patients, which included a standard antibiotic regimen and routine maternal and fetal surveillance, whereas the individualized management group received personalized management on the basis of amniocentesis at hospital admission (if possible), to rule out microbial invasion of the amniotic cavity and targeted treatment. The exclusion criteria were cervical dilatation >2 cm, active labor, contraindications to expectant management (acute chorioamnionitis, placental abruption, or abnormal fetal tracing), and major fetal anomalies. The primary outcome was latency of >7 days, and the secondary outcomes included latency to birth, chorioamnionitis, and short-term adverse maternal and neonatal outcomes. Statistical comparisons between groups were conducted with propensity score weighting.

RESULTS

A total of 513 pregnancies with preterm premature rupture of membranes were included in this study: 324 patients received standard management, and 189 patients received individualized management, wherein amniocentesis was performed in 112 cases (59.3%). After propensity score weighting, patients receiving individualized management had a higher latency of >7 days (76.0% vs 41.6%; P<.001) and latency to birth (18.1±14.7 vs 9.7±9.7 days; P<.001). Although a higher rate of clinical chorioamnionitis was suspected in the individualized management group than the standard group (34.5% vs 22.0%; P<.01), there was no difference between the groups in terms of histologic chorioamnionitis (67.2% vs 73.4%; P=.16), funisitis (57.6% vs 58.1%; P=.92), or composite infectious maternal outcomes (9.1% vs 7.9%; P=.64). Prolonged latency in the individualized management group was associated with a significant reduction of preterm birth at <32 weeks of gestation (72.1% vs 90.5%; P<.001), neonatal intensive care unit admission (75.6% vs 83.0%; P=.046), and neonatal respiratory support at 28 days of life (16.1% vs 26.1%; P<.01) compared with that in the standard management group. Moreover, prolonged latency was not associated with neonatal severe morbidity at discharge (survival without severe morbidity, 80.4% vs 73.5%; P=.09).

CONCLUSION

Individualized management of preterm premature rupture of membranes may prolong pregnancy and reduce preterm birth at <32 weeks of gestation, the need for neonatal support, and neonatal intensive care unit admissions, without an increase in histologic chorioamnionitis, funisitis, neonatal infection-related morbidity, and short-term adverse maternal and neonatal outcomes.

Perinatal Outcomes Associated with Latency in Late Preterm Premature Rupture of Membranes

This study aims to evaluate the perinatal outcomes of preterm premature rupture of membrane (PPROM) with latency periods at 33 + 0-36 + 6 weeks of gestation. This retrospective case-control study included women with singleton pregnancies who delivered at 33 + 0-36 + 6 weeks at Korea University Ansan Hospital in South Korea between 2006-2019. The maternal and neonatal characteristics were compared between different latency periods (expectant delivery ≥72 h vs. immediate delivery <72 h). Data were compared among 345 women (expectant, n = 39; immediate delivery, n = 306). There was no significant difference in maternal and neonatal morbidities between the groups, despite the younger gestational age in the expectant delivery group. Stratified by gestational weeks, the 34-week infants showed a statistically significant lower exposure to antenatal steroids (73.4% vs. 20.0%, p < 0.001), while the incidence of respiratory distress syndrome (12.8%) and the use of any respiratory support (36.8%) was higher than those in the 33-week infants, without significance. Our study shows that a prolonged latency period (≥72 h) did not increase maternal and neonatal morbidities, and a considerable number of preterm infants immediately delivered at 34 weeks experienced respiratory complications. Expectant management and antenatal corticosteroids should be considered in late preterm infants with PPROM.

Transabdominal amniocentesis in expectant management of preterm premature rupture of membranes: A single center prospective study

AIMS

The aim of this study was to evaluate the role of IL-6 point-of-care test in amniotic fluid obtained from serial amniocentesis in expectantly managed women with PPROM between 24 and 34 weeks of gestation.

METHODS

We conducted a prospective observational cohort study which included 62 pregnant women with PPROM in gestational weeks between 22+0 and 34+0. Women aged >18 years were eligible if they presented with PPROM and a singleton pregnancy. Only women who delivered at >24.0 weeks were included in the study. In all women, the maternal blood sampling and a transabdominal amniocentesis were performed at the time of admission prior to the administration of corticosteroids, antibiotics, or tocolytics, to rule out signs of chorioamnionitis. Maternal temperature, maternal serum C-reactive protein (CRP) and white blood cell (WBC) counts were assayed every subsequent day until delivery. Amniotic fluid was used for the clinical assessment (IL-6 point-of-care test, identification of microorganisms in the amniotic fluid. After one week of expectant management of PPROM, second amniocentesis with amniotic fluid sampling was performed in patients who did not deliver. For all newborns, medical records regarding neonatal morbidity and mortality were reviewed.

RESULTS

In total, 62 women aged 19 to 41 years were recruited in the study. The mean gestational age at the time of PPROM was 31+0, the mean gestational age at labor was 32+1, and the median time from PPROM to childbirth was 112 h. IL-6 point-of-care test values above 1,000 pg/mL (positive Il-6 AMC) were found in 12 women (19.4%) with median interval from PPROM to childbirth 56 h (min-max: 6.4-288). IL-6 point-of-care test values below 1,000 pg/mL (negative Il-6 AMC) were found in 51 women (81.0%). The neonatal mortality rate was 1.9% and was associated with prematurity.

CONCLUSION

The major clinical finding of our study is that serial transabdominal amniocentesis with Il-6 point-of-care test helps to identify a high inflammatory status in amniotic fluid in women with PPROM. Subsequent expectant management of women with PPROM does not lead to worsening of short-term neonatal outcomes.

Maternal and perinatal outcomes in midtrimester rupture of membranes

OBJECTIVE

The aim of this study was to assess neonatal and maternal adverse outcomes following expectant management of preterm prelabor rupture of membranes (PPROM) between 18 and 26 weeks and to identify maternal morbidity and prognostic factors for neonatal outcomes.

METHODS

Data were collected from all pregnant women who presented PPROM between 18⁺⁰ and 26⁺⁰ weeks admitted into two tertiary centers in Brazil from 2005 to 2016. The neonatal adverse outcomes (mortality or the development of a severe morbidity) and maternal adverse outcomes were analyzed and compared among four groups (18^0/7 to 20^0/7 weeks, 20⁺¹ to 22^0/7 weeks, 22⁺¹ to 24^0/7 weeks and 24⁺¹ to 26^0/7 weeks). A multiple logistic regression was performed for each predictor of neonatal adverse outcomes, and the area under the receiver operating characteristics curves for birth weight and gestational age at birth were calculated.

RESULTS

Of the 101 women with PPROM during the study period, 97 fulfilled the eligible criteria. Among these patients, 30 (30.9%) had a miscarriage or stillbirth. Overall there were 67/97 (69.1%) livebirths, 45/97 newborns survived to discharge (46.3%), and 53/97 (54.6%) experienced severe neonatal adverse outcome. The median latency period was seven days, with 36 (37.1%) patients ending the pregnancy in 2-14 days. Among 29 patients with PPROM at 24⁺¹ to 26^0/7 weeks, only 13 (44.8%) delivered between 2 and 14 days. Multivariate analysis has demonstrated that the independent predictor for adverse neonatal outcome was birthweight. The maternal morbidity was high; however, the expectant management did not increase the rate of severe maternal morbidity.

CONCLUSIONS

PPROM between 18⁺⁰ and 26⁺⁰ weeks has high morbidity and mortality, and the only significant independent predictor of severe adverse neonatal outcomes is birthweight. Maternal morbidity is high, however, the expectant management is not increased by expectant management.

Neonatal and Childhood Outcomes Following Preterm Premature Rupture of Membranes

Preterm premature rupture of membranes (PPROM) is almost uniformly associated with preterm birth and thus sequelae of prematurity explain many of the complications associated with this condition. However, the unique inflammatory environment and oligohydramnios associated with PPROM may impart unique neonatal and childhood morbidity compared with other preterm birth pathways.

Periviable Premature Rupture of Membranes

Periviable deliveries (less than 26 weeks) are a small percentage of deliveries but account for a disproportionately high number of long-term morbidities. Few studies describe interventions and outcomes for periviable preterm premature rupture of membranes (PPROM). The available reports may include only those neonates who received resuscitation, making interpretation and application difficult. Counseling should consider the impact of oligohydramnios on fetal lung development. This article discusses standard and experimental interventions that may offer neonatal benefit. Antenatal corticosteroids, antibiotics, and magnesium sulfate may improve outcomes but data to support an improvement in outcome are limited. Studies specifically evaluating these interventions are needed.

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.

Preterm prelabor rupture of membranes: evaluating latency and neonatal morbidity for pregnancies with expectant management ≥34 weeks

Objective: To evaluate the association between latency and neonatal morbidity for pregnancies with expectant management of PPROM ≥34 w.Materials and Methods: A retrospective cohort of singletons with PPROM from 2011 to 2016. Exposure was defined as latency (period from diagnosis of PPROM to delivery) and was analyzed as a count variable (i.e. number of days) and binary variable (≥7 days and <7 days; ≥21 days and <21 days). Primary outcome was composite neonatal morbidity defined as need for respiratory support, culture positive neonatal sepsis, and/or neonatal antibiotics >72 h. Fisher's exact test, chi-square test, Mann-Whitney U and binary logistic regression tests were performed with p<.05 considered significant.Results: Of 813 pregnancies, 104 met inclusion criteria: 73 (70.2%) pregnancies with PPROM diagnosed at <34 weeks and 31 (29.8%) pregnancies with PPROM diagnosed ≥34 weeks. A total of 58 (55.8%) pregnancies had a latency of ≥7 days and 46 (44.2%) had a latency <7 days. There was no difference in composite neonatal morbidity for latency ≥7 d versus <7 d (aOR 0.92; 95% CI 0.30-2.82) or latency as a count variable (aOR 0.70; 95% CI 0.23-2.13). However, a latency ≥21 d was associated with increased composite neonatal morbidity (aOR 10.24, 95% CI 1.42-73.99).Conclusion: In pregnancies with PPROM expectantly managed ≥34 w, a latency of ≥7 d is not associated with significant differences in neonatal morbidity. However, different latency thresholds may be more clinically relevant for late preterm pregnancies. The increase in composite neonatal morbidity associated with a latency >21 days should be an area of future investigation and may suggest there is a population of pregnancies with PPROM which may not benefit from expectant management past 34 weeks.

The effects of latency period in PPROM cases managed expectantly

Objective: Preterm premature rupture of membranes (PPROM), associated with prematurity, is an important obstetric complication that may cause neonatal mortality and morbidity. The optimal delivery time is controversial in cases with the expectant approach. The fetal effects of long-term exposure to PPROM are unknown. This study aimed to evaluate the maternal and fetal outcomes of expectantly-managed PPROM cases with different latency periods at 24^0/7-34^6/7weeks of gestation.Material and method: The study group consisted of 206 patients at 24^0/7-34^6/7weeks of gestation who met the inclusion criteria. Patients were divided into three groups according to their weeks of PPROM diagnosis as 24^0/7-28^6/7, 29^0/7-31^6/7, and 32^0/7-34^6/7. The period from membrane rupture to delivery was defined as the latency period and divided into three subgroups as 3-7 days, 8-13 days and ≥14 days. In addition to the demographic characteristics of the patients, maternal and obstetric complications, primary and secondary neonatal outcomes were compared between the groups. Primary neonatal outcomes were determined in terms of pathological Apgar scores (<5 at minute 1, <7 at minute 5), requiring resuscitation, admission to Neonatal Intensive Care Unit (NICU) and NICU length of stay. Secondary neonatal outcomes were determined in terms of respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, patent ductus arteriosus, periventricular leukomalacia, and neonatal sepsis. In addition, for the prediction of morbidity and mortality, newborns were evaluated by SNAPPE II (Score for Neonatal Acute Physiology with Perinatal extension-II) consisting of the combination of biochemical and physiological parameters, using the parameters including mean blood pressure (mm/Hg), corporal temperature (°C), PO₂/FiO₂ ratio, lowest serum pH, multiple seizures, urine output (ml/kg/hr), Apgar score, birth weight, and small for gestational age. The higher the score of SNAPPE II, the higher the morbidity and mortality risk of neonates. For the statistical analysis, the Kruskal Wallis and one-way ANOVA tests were utilized for the numerical data. Categorical data were compared using the chi-square test. The receiver operating characteristic (ROC) test was used to determine the threshold value of the data affecting neonatal morbidity.Results: The mean PPROM week was found to be 29.7 ± 3.0 weeks and the mean delivery week was 31.8 ± 2.5 weeks. The mean latency period for all the patients was 15.1 ± 13.8 days. Clinic chorioamnionitis was observed in 17% of the cases. The lowest chorioamnionitis rate (8.6%) was in the 3-7-day latency period group. Total complications were significantly lower in the 29^0/7-31^6/7week PPROM group in which the latency period was ≥14 days, compared to those in 3-7 days and 8-13 days (p = .001). Total complications were lower in the < 32 weeks PPROM groups in which the latency period was ≥14 days compared to those obtained in 3-7 days and 8-13 days. There was no significant difference between the latency period and total complications after 32 weeks (p = .422). The best discriminative cutoff value of SNAPPE-II for neonatal morbidity was 11.0 (sensitivity 82%, specificity 80%). In the present study, the optimal latency period for the best neonatal outcomes was found to be 34.5 days (sensitivity 70% and specificity 84%) between weeks 24^0/7-28^6/7, and 11.0 days between weeks 29^0/7-31^6/7 (sensitivity 68% and specificity 85%).Conclusions: Our findings indicated that a long latency period did not increase neonatal morbidity and there was no increase in neonatal complications after 32 weeks of the gestational period compared to those obtained before 32 weeks.

Refining evidence-based retinopathy of prematurity screening guidelines: The SCREENROP study

Purpose

Retinopathy of prematurity (ROP) is a potentially blinding condition affecting premature infants for which less than 10% of babies undergoing screening require treatment. This study assessed and validated predictors of developing clinically significant ROP (type 2 or worse) and ROP requiring treatment.

Design

Nationwide retrospective cohort study.

Methods

This study included infants born between January 2014 and June 2016, admitted to level 3 neonatal intensive care units across Canada who underwent ROP screening. Data were derived from the Canadian Neonatal Network database. Predefined ≥ 1% risk for clinically significant retinopathy or prematurity and ROP requiring treatment was set as threshold for screening. Thirty-two potential predictors were analyzed, to identify and validate the most important ones for predicting clinically significant ROP. The predictors were determined on a derivation cohort and tested on a validation cohort. Multivariable logistic regression modeling was used for analysis.

Results

Using a sample of 4,888 babies and analyzing 32 potential predictors, capturing babies with ≥1% risk of developing clinically significant ROP equated to screening babies with birth weight (BW) <1,300 g or gestational age (GA) <30 weeks while capturing babies with ≥1% risk of requiring ROP treatment equated to screening babies with BW <1,200 g or GA <29 weeks.

Conclusions

The Canadian ROP screening criteria can be modified to screen babies with BW <1,200 g or GA <30 weeks. Using these criteria, babies requiring treatment would be identified while reducing the number of babies screened unnecessarily.

[Epidemiology, risk factors and child prognosis: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVES

To synthetize the available evidence regarding the incidence and risk factors of preterm premature rupture of membranes (PPROM). To describe the evolution of pregnancy, neonatal outcomes and the prognosis of infants born in a context of PPROM, according to the existence of an associated intrauterine infection and to the latency duration.

METHOD

Consultation of the Medline database, from 1980 to February 2018.

RESULTS

PPROM before 37 and before 34 weeks' gestation occur in 2-3% and <1% of pregnancies, respectively (LE2). Although many risk factors are identified, few are modifiable, and the vast majority of patients have no risk factors (LE2). Consequently, individual prediction of the risk of PPROM and primary prevention measures have not been shown to be effective and are not recommended in clinical practice (Grade B). Most women give birth within the week following PPROM (LE2). The main complications of PPROM are prematurity, intrauterine infection and obstetric and maternal complications (LE2). Latency duration and the frequency of complications decrease with increasing gestational age at PPROM (LE2). Neonatal prognosis is largely conditioned by gestational age at birth, with no apparent over-risk of poor outcomes linked to PPROM compared to other causes of preterm birth (LE2). In contrast, intrauterine infection is associated with an increased risk of in utero fetal death (LE3), necrotizing enterocolitis (LE1) and early-onset sepsis (LE2). The association of intrauterine infection with neurological morbidity remains controversial. Prolongation of latency, from gestational age at PPROM, is beneficial for the child (LE2).

CONCLUSION

PPROM is a major cause of prematurity and short- and long-term mortality and morbidity. Antenatal care is an important issue for obstetric and pediatric teams, aiming to reduce complications and adverse consequences for both mother and child.

Outcomes of hypoxic respiratory failure at birth associated with previable rupture of membranes

OBJECTIVE

To characterize clinical outcomes of infants born after previable rupture of membranes (pROM, < 23 weeks gestation and latency period ≥ 2 weeks) in relation to refractory hypoxic respiratory failure (rHRF).

STUDY DESIGN

pROM neonates categorized as rHRF (FiO₂ > 0.6 for ≥ 2 h) and treated (high frequency ventilation + inhaled nitric oxide) were compared with no rHRF group. Primary outcome was survival until discharge. Factors associated with rHRF and mortality were identified.

RESULT

Overall, mortality and disability rates were 28% and 22%, respectively. Treated rHRF group (n = 32) had longer period of ROM, mortality was (31% vs. 14%; p = 0.20), with similar survival-without-disability (54% vs. 47%; p = 0.67). Higher gestational age at birth [1.57 (1.03,2.39)] and cesarean delivery [12.6 (1.22,125)] were associated with increased survival.

CONCLUSION

Birth after pROM is associated with high rates of adverse outcomes, independent of latency period. Following treatment, rHRF infants may have similar long-term outcomes as those without rHRF.

Mid-trimester preterm premature rupture of membranes (PPROM): etiology, diagnosis, classification, international recommendations of treatment options and outcome

Mid-trimester preterm premature rupture of membranes (PPROM), defined as rupture of fetal membranes prior to 28 weeks of gestation, complicates approximately 0.4%-0.7% of all pregnancies. This condition is associated with a very high neonatal mortality rate as well as an increased risk of long- and short-term severe neonatal morbidity. The causes of the mid-trimester PPROM are multifactorial. Altered membrane morphology including marked swelling and disruption of the collagen network which is seen with PPROM can be triggered by bacterial products or/and pro-inflammatory cytokines. Activation of matrix metalloproteinases (MMP) have been implicated in the mechanism of PPROM. The propagation of bacteria is an important contributing factor not only in PPROM, but also in adverse neonatal and maternal outcomes after PPROM. Inflammatory mediators likely play a causative role in both disruption of fetal membrane integrity and activation of uterine contraction. The "classic PPROM" with oligo/an-hydramnion is associated with a short latency period and worse neonatal outcome compared to similar gestational aged neonates delivered without antecedent PPROM. The "high PPROM" syndrome is defined as a defect of the chorio-amniotic membranes, which is not located over the internal cervical os. It may be associated with either a normal or reduced amount of amniotic fluid. It may explain why sensitive biochemical tests such as the Amniosure (PAMG-1) or IGFBP-1/alpha fetoprotein test can have a positive result without other signs of overt ROM such as fluid leakage with Valsalva. The membrane defect following fetoscopy also fulfils the criteria for "high PPROM" syndrome. In some cases, the rupture of only one membrane - either the chorionic or amniotic membrane, resulting in "pre-PPROM" could precede "classic PPROM" or "high PPROM". The diagnosis of PPROM is classically established by identification of nitrazine positive, fern positive watery leakage from the cervical canal observed during in specula investigation. Other more recent diagnostic tests include the vaginal swab assay for placental alpha macroglobulin-1 test or AFP and IGFBP1. In some rare cases amniocentesis and infusion of indigo carmine has been used to confirm the diagnosis of PPROM. The management of the PPROM requires balancing the potential neonatal benefits from prolongation of the pregnancy with the risk of intra-amniotic infection and its consequences for the mother and infant. Close monitoring for signs of chorioamnionitis (e.g. body temperature, CTG, CRP, leucocytes, IL-6, procalcitonine, amniotic fluid examinations) is necessary to minimize the risk of neonatal and maternal complications. In addition to delayed delivery, broad spectrum antibiotics of penicillin or cephalosporin group and/or macrolide and corticosteroids have been show to improve neonatal outcome [reducing risk of chorioamnionitis (average risk ratio (RR)=0.66), neonatal infections (RR=0.67) and abnormal ultrasound scan of neonatal brain (RR=0.67)]. The positive effect of continuous amnioinfusion through the subcutaneously implanted perinatal port system with amniotic fluid like hypo-osmotic solution in "classic PPROM" less than 28/0 weeks' gestation shows promise but must be proved in future prospective randomized studies. Systemic antibiotics administration in "pre-PPROM" without infection and hospitalization are also of questionable benefit and needs to be further evaluated in well-designed randomized prospective studies to evaluate if it is associated with any neonatal benefit as well as the relationship to possible adverse effect of antibiotics on to fetal development and neurological outcome.

Childhood outcomes following preterm prelabor rupture of the membranes (PPROM): a population-based record linkage cohort study

OBJECTIVE

The objective of this study is to determine child health, development and educational outcomes for infants born following preterm prelabor rupture of the membrane (PPROM).

STUDY DESIGN

Population-based record linkage cohort study using data from NSW, Australia, 2001 to 2014.

RESULTS

Of 121 822 births at 20 to 37 weeks, 18 799 (15%) followed PPROM, 56 406 (46%) followed spontaneous labor and 46 617 (38%) were planned. Compared with infants of a similar gestational age born following spontaneous labor or planned delivery, exposure to PPROM did not increase the risk of childhood mortality, childhood hospitalization, developmentally vulnerable at school entry, low reading or numeracy scores. Median latency ranged from 12 days (interquartile range 3 to 37 days) at 25 weeks to 1 day (0 to 2 days) at 36 weeks. Longer latency and more advanced gestational age at birth were associated with better outcomes.

CONCLUSION

Infants born following PPROM are at no greater risk of adverse child health, development and education outcomes than those of similar gestational age born without PPROM.

A predictive neonatal mortality score for women with premature rupture of membranes after 22-27 weeks of gestation

OBJECTIVE

Premature rupture of the membranes (PROM) remains a leading cause of neonatal morbidity. The objectives of the present study were to analyze the outcomes of pregnancies complicated by PROM between 22 and 27⁺⁶ weeks of gestation (WG) and to study antepartum risk factors that might predict neonatal death.

PATIENTS AND METHODS

One hundred and seven pregnancies were analyzed over a 3-year period in a tertiary maternity hospital. The collected maternal and neonatal data were used to model and predict the outcome of PROM.

RESULTS

Prevalence of PROM (for live births) was 1.08%, and the overall survival rate was 59.8%. From preselected candidate variables, gestational age (GA) at PROM (p = .0002), a positive vaginal culture for pathogenic bacteria (p = .01), primiparity (p = .02), and the quantity of amniotic fluid (p = .03) were included in a multivariable logistic regression analysis. The corresponding adjusted odds ratios [95% confidence interval] were, respectively, 0.91 [0.87-0.96], 11.08 [1.65-74.42], 0.55 [0.33-0.91], and 0.97 [0.95-0.99]. These parameters were used to build a predictive score for neonatal death.

CONCLUSIONS

The survival rate after PROM at 22-27⁺⁶ weeks of gestation was 59.8%. Our predictive model (built using multivariable logistic regression) may be of value for obstetricians and neonatologists counseling couples after PROM.

Impact of Latency Duration on the Prognosis of Preterm Infants after Preterm Premature Rupture of Membranes at 24 to 32 Weeks' Gestation: A National Population-Based Cohort Study

OBJECTIVE

To assess the impact of latency duration on survival, survival without severe morbidity, and early-onset sepsis in infants born after preterm premature rupture of membranes (PPROM) at 24-32 weeks' gestation.

STUDY DESIGN

This study was based on the prospective national population-based Etude Épidémiologique sur les Petits Ȃges Gestationnels 2 cohort of preterm births and included 702 singletons delivered in France after PPROM at 24-32 weeks' gestation. Latency duration was defined as the time from spontaneous rupture of membranes to delivery, divided into 4 periods (12 hours to 2 days [reference], 3-7 days, 8-14 days, and >14 days). Multivariable logistic regression was used to assess the relationship between latency duration and survival, survival without severe morbidity at discharge, or early-onset sepsis.

RESULTS

Latency duration ranged from 12 hours to 2 days (18%), 3-7 days (38%), 8-14 days (24%), and >14 days (20%). Rates of survival, survival without severe morbidity, and early-onset sepsis were 93.5% (95% CI 91.8-94.8), 85.4% (82.4-87.9), and 3.4% (2.0-5.7), respectively. A crude association found between prolonged latency duration and improved survival disappeared on adjusting for gestational age at birth (aOR 1.0 [reference], 1.6 [95% CI 0.8-3.2], 1.2 [0.5-2.9], and 1.0 [0.3-3.2] for latency durations from 12 hours to 2 days, 3-7 days, 8-14 days, and >14 days, respectively). Prolonged latency duration was not associated with survival without severe morbidity or early-onset sepsis.

CONCLUSION

For a given gestational age at birth, prolonged latency duration after PPROM does not worsen neonatal prognosis.

Prolonged latency of preterm premature rupture of membranes and risk of neonatal sepsis

BACKGROUND

Preterm premature rupture of membranes (PPROM) is associated with inflammation and infection, and it may involve the loss of a barrier to ascending infection from the vagina, and it is possible that prolonged PPROM could be an independent risk factor for neonatal sepsis.

OBJECTIVE

The objective of the study was to determine whether prolonged latency after PPROM is associated with an increased risk of neonatal sepsis.

STUDY DESIGN

This secondary analysis of the randomized controlled trial of magnesium sulfate for the prevention of cerebral palsy evaluated whether the time interval between diagnosis of PPROM and delivery was associated with an increased risk of neonatal sepsis. Latency time was categorized by weeks of latency (0 weeks to ≥ 4 weeks). The primary outcome was confirmed neonatal sepsis. Logistic regression was used to control for confounders.

RESULTS

A total of 1596 patients with PPROM were analyzed, of whom 1390 had a < 4-week interval and 206 had an interval of ≥ 4 weeks. Confirmed neonatal sepsis occurred in 15.5% of patients in the cohort. In the univariate analysis, patients in the prolonged PPROM group were less likely to have neonatal sepsis (6.8% vs 17.2%, relative risk, 0.40 95% confidence interval, 0.24-0.66). This relationship was retained in the multivariable model; patients with prolonged PPROM ≥ 4 weeks had an adjusted odds ratio of 0.21 (95% confidence interval, 0.10-0.41) for neonatal sepsis. Neonatal sepsis was also significantly associated with earlier gestational age at rupture of membranes.

CONCLUSION

Prolonged exposure to an intrauterine environment of PPROM does not increase the risk of neonatal sepsis; prolonged PPROM ≥ 4 weeks was associated with decreased risk of neonatal sepsis.

What is the optimal strategy in the management of patients with preterm premature rupture of membranes before 32 weeks of gestation?

Objective:

Our aim was to compare the outcomes of expectant management of pregnancy or immediate delivery in patients with preterm premature rupture of membranes (PPROM) between 24+⁰ and 32+⁰ weeks of pregnancy.

Materials and Methods:

This is a retrospective cohort study conducted at a tertiary medical center. Patients who were diagnosed as having PPROM between 24+⁰ and 32+⁰ weeks of gestation were selected from an electronic database. Thirty-one patients with expectant management and 22 patients with spontaneous immediate delivery were analyzed. Birth weight, Apgar score, duration of stay in the neonatal intensive care unit (NICU), composite adverse outcomes, and mortality rates of groups were compared. Binary logistic regression analysis with backward stepwise elimination was used to determine confounding factors for antenatal complications and neonatal composite adverse outcomes.

Results:

Gestational age at admission was smaller in the expectant management group. The median latency period was 6 days (range, 2-58 days). Although gestational age at delivery was similar, birth weights were smaller in expectant management group compared with the immediate delivery group (p=0.264 and p<0.05, respectively). Apgar scores, duration in the NICU, composite adverse outcomes, and neonatal mortality rates were similar in each group. Antenatal complication in the expectant management group was higher (p<0.05). Gestational age at delivery and serum C-reactive protein levels were two confounding factors for antenatal complication and gestational age at delivery was the only factor affecting composite adverse outcome.

Conclusion:

Expectant management in patients with PPROM at 24 to 32 gestational weeks might be considered as a good alternative.

The Pediatrix BabySteps® Data Warehouse--a unique national resource for improving outcomes for neonates

The Pediatrix Medical Group Clinical Data Warehouse represents a unique electronic data capture system for the assessment of outcomes, the management of quality improvement (CQI) initiatives, and the resolution of important research questions in the neonatal intensive care unit (NICU). This system is described in detail and the manner in which the Data Warehouse has been used to measure and improve patient outcomes through CQI projects and research is outlined. The Pediatrix Data Warehouse now contains more than 1 million patients, serving as an exceptional tool for evaluating NICU care. Examples are provided of how significant outcome improvement has been achieved and several papers are cited that have used the "Big Data" contained in the Data Warehouse for novel observations that could not be made otherwise.