Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group

Maternal and perinatal infectious morbidity in term prelabor rupture of membrane according to two induction of labor protocols

PURPOSE

The optimal labor-induction protocol in women with prelabor rupture of membranes (PROM) is unknown. Whether the management of women with a previous cesarean delivery (CD) with PROM is different remains controversial. We investigated maternal and perinatal outcomes according to two induction protocols of 24 h vs. 12 h.

METHODS

In July 2021, our protocol of induction of labor in term-PROM was extended from 12 h to 24 h post-PROM. We compared obstetrical and neonatal outcomes before and after the change. A subgroup analysis of women with previous CD was performed. Results were compared using a univariate analysis. A multivariable model was described to predict neonatal intensive care unit admission (NICU) and clinical chorioamnionitis.

RESULTS

The 24 h and 12 h ROM-to-induction protocol groups included 962 and 802 women, respectively. In the 24 h group, a higher proportion of women labored spontaneously (p < 0.001), the rate of chorioamnionitis was higher (p = 0.017), and the CD rate was similar. Admission to the NICU (p = 0.012), antibiotic administration (p = 0.003), and respiratory distress (p = 0.002) were also greater in the 24 h induction group. Among women with a history of CD (n = 143), the need for oxytocin (p = 0.003) and delivery by CD (p = 0.016) were lower in the 24 vs. 12 h group.

CONCLUSION

Our results advocate shared decision-making in the expectant management of term-PROM. Women should be informed of the lower chance for induction and the higher risk of infections and neonatal complications with a 24-h induction approach. Longer expectant management in women with a previous CD resulted in significantly lower induction and CD rates.

Nulliparas at Term with Premature Rupture of Membranes and an Unfavorable Cervix: Labor Induction with Prostaglandin or Oxytocin? A Retrospective Matched Case Study

Background: Induction of labor (IOL) in nulliparas with premature rupture of membranes (PROM) and an unfavorable cervix at term poses challenges. Our study sought to investigate the impact of prostaglandin E2 (PGE2) compared to oxytocin on the duration of IOL in this specific group of parturients. Methods: This was retrospective matched-case study. All nulliparas with term PROM who underwent induction between January 2006 to April 2023 at Shaare Zedek Medical Center were identified. Cases induced by either PGE2 or oxytocin were matched by the following criteria: (1) time from PROM to IOL; (2) modified Bishop score prior to IOL ≤ 5; (3) newborn birthweight; and (4) vertex position. The primary outcome was time from IOL to delivery. Results: Ninety-five matched cases were identified. All had a modified Bishop score ≤ 5. Maternal age (26 ± 4.7 years old, p = 0.203) and gestational age at delivery (38.6 ± 0.6, p = 0.701) were similar between the groups. Matched factors including time from PROM to IOL (23.5 ± 19.2 versus 24.3 ± 21.4 p = 0.780), birth weight of the newborn (3111 g versus 3101 g, p = 0.842), and occiput anterior position (present on 98% in both groups p = 0.687) were similar. Time from IOL to delivery was significantly shorter by 3 h and 36 min in the group induced with oxytocin than in the group induced with PGE2 (p = 0.025). Within 24 h, 55 (58%) of those induced with PGE2 delivered, compared to 72 (76%) of those induced with oxytocin, (p = 0.033). The cesarean delivery rates [18 (19%) versus 17 (18%)], blood transfusion rates [2 (2%) versus 3 (3%)], and Apgar scores (8.8 versus 8.9) were similar between the groups (PGE2 versus oxytocin, respectively), p ≥ 0.387. Conclusions: Induction with oxytocin, among nulliparas with term PROM and an unfavorable cervix, was associated with a shorter time from IOL to delivery and a higher rate of vaginal delivery within 24 h, with no difference in short-term maternal or neonatal adverse outcomes.

Exposure to Prolonged Rupture of Membranes at Term Increases the Risk for Ventilatory Support in Uninfected Neonates

OBJECTIVE

 The effects of prolonged rupture of membranes (ROMs) on perinatal outcomes are still unclear, and it remains controversial for the management of those labors. This study aims to evaluate how the exposure of pregnant women to a prolonged ROM (≥ 24 hours) affects maternal and neonatal outcomes.

STUDY DESIGN

 This retrospective cohort study included singleton pregnant women at term delivering between January 2019 and March 2020 in a tertiary hospital. All relevant sociodemographic, pregnancy, and perinatal variables (maternal age, prepregnancy body mass index, labor, and delivery outcomes) were collected anonymously. Data were compared between the "ROM < 24 hours" and "ROM ≥ 24 hours" study groups.

RESULTS

 A total of 2,689 dyads were included in the study and divided according to their ROM-delivery time: ROM <24 hours (2,369 women, 88.1%), and ROM ≥ 24 hours (320 women, 11.9%). Maternal baseline characteristics were comparable except for the rate of nulliparous women, which was significantly higher among patients with ROM ≥ 24 hours. No significant differences were found regarding infectious neonatal outcomes. However, mechanical ventilation and continuous positive airway pressure were more common among neonates born after ROM ≥ 24 hours. The greater likelihood of neonatal respiratory distress was also confirmed among infants born to Group-B Streptococcus-negative women with ROM ≥ 24 hours (15 out of 267 neonates, 5.6% vs. 52 out of 1,529 with ROM < 24 hours, 3.4%, p = 0.04).

CONCLUSION

 According to the actual expectant policy, prolonged ROM is associated with an increased risk of respiratory support in noninfected neonates. Further investigations are required to explain such an association.

KEY POINTS

· The management of women with prolonged rupture of membranes is controversial.. · The exposure of pregnant women to a prolonged rupture of membranes affects neonatal outcomes.. · Prolonged rupture of membranes is associated with an increased risk of respiratory support, in group-B Streptococcus-negative neonates..

Prelabour rupture of the membranes at term: antibiotic overuse in Italy

BACKGROUND

The proper management of women with premature rupture of membrane (PROM) and not spontaneously entering in labour remains controversial. The aim of this study was to identify the current management for women with PROM at term according to the Group B Streptococcus (GBS) status across different Italian hospitals.

METHODS

Anonymous online survey evaluating: the current practice of women with PROM in terms of management (expectant management vs. induction of labour) and antibiotic prophylaxis according to GBS status.

RESULTS

In case of negative GBS status, the 82.4% of respondents wait until 24 hours before labour induction. Antibiotics are administered for prophylaxis in 35.3%, 27.5% and 2% at 18, 12 and 24 hours respectively. The remaining 35.3% of respondents are divided between those using antibiotics only with signs of infections or according to different risk factors (i.e. meconium-stained amniotic fluid or suspected infection). Neonates born from a mother with negative GBS status almost never (90.2%) receive prophylactic antibiotics. In case of positive GBS status, induction is started as soon as possible by 49.1% of respondents; the remnants choose to wait 6 (15.7%), 12 (17.6%), 18 (3.9%) and 24 (13.7%) hours. Antibiotics are administered as soon as possible by 78.4% of clinicians. In the neonates, 51% of neonatologist administer antibiotics upon clinical indications (suspected sepsis); 15.7% use antibiotics routinely or with a short interval between maternal antibiotics and delivery (17.6%).

CONCLUSIONS

The management after PROM is highly heterogeneous with an inappropriate extension of antibiotic prophylaxis in cases with negative GBS status.

Peripartum Pharmacotherapy: A Pharmacist's Guide

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

Perinatal Outcomes of Late Preterm Rupture of Membranes with or without Latency Antibiotics

OBJECTIVE

 This study aimed to examine whether the addition of latency antibiotics in late preterm rupture of membranes (ROM) decreases neonatal infection and increases latency.

STUDY DESIGN

 This retrospective two-center study was conducted at Holy Family Hospital (HFH) in Nazareth and Emek Medical Center (EMC) in Afula, on data collected between January 2017 and April 2023. HFH is the smaller institution. EMC and HFH implement similar policies regarding ROM at 340/7 to 366/7 weeks' gestation; the only difference is that a 10-day course of latency antibiotics is implemented at EMC. All women with ROM between 340/7 and 366/7 weeks' gestation who were admitted to one of the centers during the study period, and had a live fetus without major malformations, were included. The primary outcome was neonatal sepsis rate. Secondary outcomes included a composite of neonatal sepsis, mechanical ventilation ≥24 hours, and perinatal death. Additionally, gestational age at delivery and delivery mode were examined.

RESULTS

 Overall, 721 neonates were delivered during the study period: 534 at EMC (where latency antibiotics were administered) and 187 at HFH. The gestational age at ROM was similar (35.8 and 35.9 weeks, respectively, p = 0.14). Neonatal sepsis occurred in six (1.1%) neonates at EMC and one (0.5%) neonate at HFH (adjusted p = 0.71; OR: 1.69; 95% Confidence Interval [CI]: 0.11-27.14). The composite secondary outcome occurred in nine (1.7%) and three (1.6%) neonates at EMC and HFH, respectively (adjusted p = 0.71; OR: 0.73; 95% CI: 0.14-3.83). The gestational age at delivery was 36.1 and 36.2 weeks at EMC and HFH, respectively (mean difference: 5 h; adjusted p = 0.02). The cesarean delivery rate was 24.7% and 19.3% at EMC and HFH, respectively (adjusted p = 0.96).

CONCLUSION

 Latency antibiotics administered to women admitted with ROM between 340/7 and 366/7 weeks' gestation did not decrease the rate of neonatal sepsis.

KEY POINTS

· Latency antibiotics in late preterm ROM does not decrease neonatal sepsis.. · Latency antibiotics in late preterm ROM does not prolong gestational age at delivery.. · Latency antibiotics in late preterm ROM does not affect the mode of delivery..

The ethics of induction of labor at 39 weeks in low-risk nulliparas in research and clinical practice

The "A Randomized Trial of Induction Versus Expectant Management" trial (ARRIVE trial) published in 2018 suggested that induction of labor can be considered a "reasonable option" for low-risk nulliparous women at ≥39 weeks of gestation. The study results led some professional societies to endorse the option for elective induction of labor at 39 weeks of gestation in low-risk nulliparas, and this has begun to change obstetrical practice. The ARRIVE trial provided valuable information supporting the benefits of induction of labor; however, the trial is insufficient to serve as the primary justification for widespread elective induction of labor at 39 weeks of gestation in low-risk nulliparas because of concerns about external validity. Thus, the French ARRIVE trial was designed to test the hypothesis in a different setting that elective induction of labor at 39 weeks of gestation in low-risk nulliparas leads to a lower cesarean delivery rate than expectant management. This ongoing trial has been criticized as "pseudoscientific" and telling "women where, when, and how to give birth." We reject these allegations and extensively examine the ethical framework that should govern clinical and research interventions, including elective induction of labor at 39 weeks of gestation in low-risk nulliparas. This study aimed to discuss the ethical issues that emerge from randomized trials of elective induction of labor at 39 weeks of gestation in low-risk nulliparas and the ethics of the clinical practice itself. The analysis of existing evidence shows the importance of further research on induction of labor at 39 weeks of gestation in low-risk women. Certain aspects of research ethics in this area, particularly the consent of pregnant women in a context where autonomy remains fragile, call for vigilance. In addition, we emphasize that childbirth is not only a medical object but also a social phenomenon that cannot be regarded only from the perspective of a health risk to be managed by clinical research. Further research on this issue is needed to allow pregnant women to make informed decisions, and the results should be integrated with social issues. The perspective of women is required in constructing, evaluating, and implementing medical interventions in childbirth, such as induction of labor at 39 weeks of gestation.

Comparison of Misoprostol with Foley Catheter vs Misoprostol alone for Cervical Ripening and Induction of Labor in Patients with Premature Rupture of Membrane: A Randomized Clinical Trial Study

Background

This study evaluates the effect of misoprostol alone in comparison with misoprostol with Foley catheter in preparing the cervix for induction of labor in women with premature rupture of the amniotic sac.

Materials and Methods

This randomized clinical trial study was performed from 2017 to 2019 on 206 pregnant women with singleton pregnancy and gestational age more than 36 weeks, whose rupture of the amniotic sac had occurred less than 12 hours and had a Bishop score less than 4. These women were randomly assigned to two groups of Foley catheters with misoprostol (intervention group, P = 103) or misoprostol alone (control group, P = 103) to induce labor. In both groups, sublingual misoprostol (25 micrograms) was administered at intervals of 4-6 hours. The collected data were analyzed by SPSS.21 software.

Results

There is no significant difference between age and Bishop score in the two groups (P = 0.19, P = 0.31, respectively). Lower doses (0 to 3) of misoprostol were used in the intervention group versus 0 to 5 doses in the control group (P = 0.001). Delivery time was shorter in the intervention group (10.83 hours vs. 13.10 hours in the control group, P = 0.001). Also, the probability of complications such as fever, tachysystole, and hospitalization of an infant in the neonatal intensive care unit (NICU) did not increase.

Conclusion

An intracervical Foley catheter with misoprostol is more effective in inducing labor in pregnancies with premature rupture of the membranes than using misoprostol alone and can be a safe and effective option.

Timing of antibiotic prophylaxis in term prelabor rupture of membranes: A retrospective cohort study using propensity-score matching

OBJECTIVE

To assess whether earlier administration of antibiotic prophylaxis after prelabor rupture of membranes (PROM) at term would decrease the incidence of maternal and neonatal infections.

METHODS

This is a retrospective cohort study comparing women with term PROM who were initiated antibiotic prophylaxis within or after 6 h, and within or after 12 h from PROM to delivery during January 2019 to December 2021. Women with term PROM receiving cephalosporin and without contraindications to vaginal delivery or confirmed or suspected infection were included in the study. The primary outcome was puerperal infection, which refers to the reproductive tract infection occurring within 42 days of delivery. The type of pharmacoeconomic evaluation was selected based on the results of compared effectiveness between the early group and the late group. Propensity-score matching (PSM) was used to adjust confounding. Subgroup and sensitivity analyses were used to verify the robustness of results.

RESULTS

We enrolled 5353 women with term PROM, including 4331 initiated with antibiotic within 6 h, 1022 after 6 h, 5077 within 12 h, and 276 after 12 h. After PSM, no significant difference was observed in the baseline characteristics of the groups. There was no statistical difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in puerperal infection (4.6% vs. 4.3%, P = 0.826; 2.9% vs. 4.6%, P = 0.471, respectively), total maternal infection, neonatal sepsis, and total neonatal infection. Cost-minimization analysis showed there was no significant difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in direct medical costs.

CONCLUSION

This study showed that there was no statistical difference in the efficacy and economy of antibiotic prophylaxis used within 6-12 h after rupture of membranes versus after 6-12 h in women with term PROM.

Pre-labour Rupture of Membranes at Term in Women With Gestational Diabetes and the Risk of Neonatal Hypoglycemia

OBJECTIVES

The management for improving maternal and neonatal outcomes of women with gestational diabetes mellitus (GDM) arriving at the delivery ward with pre-labour rupture of membranes (PROM) has not been elucidated. We tested the hypothesis that prolonged PROM in women with GDM would result in higher rates of neonatal hypoglycemia.

METHODS

We retrospectively enrolled women with diet or insulin-controlled GDM who presented with spontaneous clear PROM. Each woman was allocated into one of two groups based on the PROM-delivery time: <18 hours (group 1) and ≥18 hours (group 2). The primary outcome was the incidence of neonatal hypoglycemia, defined as glucose <40 mg/dL (2.2 mmol/L) within 24 hours of birth.

RESULTS

We ultimately analyzed 631 cases of GDM (6.7%), 371 with PROM-delivery <18 hours, and 260 with PROM-delivery ≥18 hours. The incidence of neonatal hypoglycemia did not differ between the two groups, reaching 7.3%. Women in group 2 were at increased risk of both cesarean delivery (20% vs. 12.4%, P < 0.01) and maternal chorioamnionitis morbidity (6.5% vs. 1.3%, P < 0.001).

CONCLUSIONS

In a sub-group of women with GDM, a PROM-delivery time ≥18 hours is not associated with higher rates of neonatal hypoglycemia, but higher rates of chorioamnionitis and cesarean delivery were noted. Therefore, we suggest consideration for early delivery when managing women with GDM and PROM.

Frequency of Maternal Anemia in Patients Presenting With Preterm Premature Rupture of Membranes

BACKGROUND

Preterm premature rupture of membranes (PPROM) is the rupture of fetal membranes before 38 weeks of gestation. The etiology is multifactorial. Maternal anemia is one of the factors leading to PPROM. This study aims to determine the frequency of maternal anemia in patients presenting with PPROM.

MATERIALS AND METHODS

This cross-sectional study was carried out at the Department of Obstetrics and Gynecology, Lady Reading Hospital, Peshawar. This study was conducted from July 1 to December 31, 2021. One hundred and twenty two patients with PPROM presenting to the Department of Obstetrics and Gynecology were included. The diagnosis of PPROM was made based on the history of the PV leak, followed by confirmation with the nitrazine litmus test, microscopic fern test, and ultrasonographic amniotic fluid index measurement. Anemia was determined by examination of hemoglobin levels in the maternal blood samples. Hb <11gm/dl was labeled as anemia. IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. was used for statistical analysis.

RESULTS

 The age of the patients ranged from 20 to 40 years. The mean age was 29.14 ± 6.194 years. 63 patients (51.6%) were multiparous (parity 2 to 4). Maternal anemia was observed in 39 patients (32.0%). A significant association (p = 0.005) was observed between maternal anemia and grand multiparity (parity 2 to 4).

CONCLUSION

 Maternal anemia significantly contributes to PPROM, especially in multiple pregnancies. Meticulous family planning and consistent obstetrical monitoring throughout pregnancy are key to addressing this, potentially reducing both maternal anemia risk and PPROM complications.

The optimal induction timing in prelabor rupture of membranes: a retrospective study

OBJECTIVE

Term prelabour rupture of membrane (PROM) occurs in 8% of term deliveries, but it is unclear when to initiate induction. Our objective was to assess the optimal timing of oxytocin induction in the management of term PROM in terms of maternal and neonatal outcomes.

METHODS

A retrospective cohort study was performed at a single tertiary care center from 2010 to 2020. All singleton pregnancies with PROM beyond 37 weeks gestation, without regular uterine contractions, were included. Eligible women were divided into three groups according to the timing of oxytocin induction (≤12; 12-24; ≥24 h) following PROM.

RESULTS

Of 9,443 women presented with the term PROM, 1676 were included. They were classified according to the timing of oxytocin induction initiation following PROM: 1,127 within 12 h; 285 within 12-24 h; 264 after 24 h. There were no significant differences in baseline demographic characteristics between groups. Women who presented at our emergency department were induced earlier delivered significantly sooner than those who received oxytocin later (45 vs. 28.2 vs. 23.2 h, respectively, p < .001. Maternal infection rate was similar and unrelated to oxytocin starting time. Induction at <12 h from PROM was associated with reduced rate of antibiotic administration compared with other timings (26.8% vs. 38.6% vs. 33.33%, respectively; p < .001), and the same was found for neonatal composite adverse outcomes (RR = 1.27, p = .0307).

CONCLUSION

In term PROM, early induction (within 12 h of PROM) may be recommended to reduce the time-do-delivery interval and increase the delivery rate within 24 h. It may be of economic significance and improve women satisfaction. Furthermore, early induction may also improve neonatal outcomes, without worsening maternal outcomes.

Term prelabor rupture of membranes: immediate induction is the optimal management

Term prelabor rupture of membranes, defined as rupture of membranes before the onset of labor at ≥37 weeks of gestation, is a common obstetrical event occurring in 8% of pregnancies. However, most relevant guidelines are inconclusive regarding the management of this condition and the optimal timing of induction of labor. Here, we present evidence from randomized controlled trials and a recent meta-analysis indicating that an immediate induction of labor in term premature rupture of membranes is associated with several maternal and neonatal benefits compared with expectant management, without increasing the risk of cesarean delivery. Given these findings, we strongly believe that immediate induction of labor is the optimal management strategy in case of term prelabor rupture of membranes.

Systematic review on the management of term prelabour rupture of membranes

INTRODUCTION

Prelabour rupture of membranes at term affects approximately 10% of women during pregnancy, and it is often associated with a higher risk of infection than when the membranes are intact. In an attempt to control the risk of infection, two main approaches have been used most widely in clinical practice: induction of labour (IOL) soon after the rupture of membranes, also called active management (AM), and watchful waiting for the spontaneous onset of labour, also called expectant management (EM). In addition, previous studies have demonstrated that vaginal examinations increase the risk of chorioamnionitis. However, the effect of vaginal examinations in the context of prelabour rupture of membranes have not been researched to the same extent.

METHODS

This systematic review analyses and critiques the latest research on the management of term prelabour rupture of membranes, including the effect of vaginal examinations during labour, with a focus on the outcomes of both normal birth, and chorioamnionitis. Due to its complexity, three research questions were identified using the PICO diagram, and subsequently, the results from these searches were combined. The systematic review aimed to identify randomised controlled trials (RCTs) and observational studies that compared active vs expectant management, included number of vaginal examinations and had chorioamnionitis and/or normal birth as outcomes. The following databases were used: MEDLINE, EMBASE, Maternity and Infant care, LILACS, CINAHL and the Cochrane Central Register of Controlled trials. Quality was assessed using a tool developed especifically for this study that included questions from CASP and the Cochrane risk of bias tool. Due to the high degree of heterogeneity meta-analysis was not deemed appropriate. Therefore, simple narrative analysis was carried out.

RESULTS

Thirty-two studies met the inclusion criteria, of which 27 were RCTs and 5 observational studies. The overall quality of the studies wasn't high, 15 out of the 32 studies were deemed to be low quality and only 17 out of 32 studies were deemed to be of intermediate quality. The systematic review revealed that the management of term prelabour rupture of membranes continues to be controversial. Previous research has compared active management (Induction of labour shortly after the rupture of membrane) against expectant management (watchful waiting for the spontaneous onset of labour). Although previous studies have demonstrated that vaginal examinations increase the risk of chorioamnionitis, no prospective studies have included an intervention to reduce the number of vaginal examinations.

CONCLUSION

A RCT assessing the consequences of active management and expectant management as well as the effect of vaginal examinations during labour for term prelabour rupture of membranes is necessary.

Effect of maternal age and body mass index on induction of labor with oral misoprostol for premature rupture of membrane at term: A retrospective cross-sectional study

The aim of this study was to evaluate the effect of maternal age and body mass index (BMI) on induction of labor with oral misoprostol for premature rupture of membrane (PROM) at term. We have conducted retrospective cross-sectional study, including only term (37 weeks or more of gestation) PROM in healthy nulliparous women with a negative vaginal-rectal swab for group B streptococcus, a single cephalic fetus with normal birthweight, and uneventful pregnancy that were induced after 24 h from PROM. Ninety-one patients were included. According to the multivariate logistic regression, age and BMI odds ratio (OR) for induction success were 0.795 and 0.857, respectively. The study population was divided into two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). Older women reported a higher induction failure rate (p < 0.001); longer time to cervical dilation of 6 cm (p = 0.03) and delivery (p < 0.001). Obese women reported a higher induction failure rate (p = 0.01); number of misoprostol doses (p = 0.03), longer time of induction (p = 0.03) to cervical dilatation of 6 cm (p < 0.001), and delivery (p < 0.001); and higher cesarean section (p = 0.012) and episiotomy rate (p = 0.007). In conclusion, maternal age and BMI are two of the main factors that influence oral misoprostol efficacy and affect the failure of induction rate in term PROM.

Twenty-four versus 48 hours of expectant management in the setting of premature rupture of membranes at term among women with a prior cesarean delivery

OBJECTIVES

Compare two approaches of expectant management in the setting of term premature rupture of membranes (PROM) among women with prior cesarean delivery.

METHODS

A retrospective study conducted in a tertiary care center during 2006 to 2017, including primiparous women with singleton pregnancy and a prior low-transverse cesarean delivery who presented with term PROM and requested trial of labor after cesarean (TOLAC). Outcomes were compared between the two campuses at our center: campus A enabled expectant management up to 48 hours following PROM and campus B enabled up to 24 hours after PROM.

RESULTS

A total of 158 women met the inclusion criteria and were divided into two groups. Maternal characteristics of the two groups were similar. In campus B, the rate of oxytocin administration was significantly higher as compared with campus A (46.6% versus 26.0%, P = 0.01). The rate of successful TOLAC was similar between the groups (84.0% versus 84.5%, P = 0.96). Rates of chorioamnionitis, uterine rupture, postpartum hemorrhage, recurrent hospitalization, and Apg scores did not differ between the groups.

CONCLUSION

Expectant management up to 48 hours in women with TOLAC presenting with term PROM was associated with a lower rate of induction of labor and similar maternal and neonatal outcomes.

Optimal timing of labor induction after prelabor rupture of membranes at term: a secondary analysis of the TERMPROM study

BACKGROUND

In the case of prelabor rupture of membranes at term, the risk for neonatal and maternal infectious morbidity increases progressively with time from prelabor rupture of membranes. Although most studies identified a benefit associated with early induction within the first 24 hours following term prelabor rupture of membranes, there is currently no precise data regarding how early should induction be scheduled.

OBJECTIVE

This study aimed to identify the optimal timing of labor induction among women with term prelabor rupture of membranes by comparing the maternal and neonatal outcomes associated with labor induction with those of expectant management at any given 1-hour interval following prelabor rupture of membranes.

STUDY DESIGN

This was a secondary analysis of data from the TERMPROM trial, an international, multicenter, randomized clinical trial on immediate delivery vs expectant management of women with prelaor rupture of membranes at term (≥37+0/7 weeks' gestation). We considered all participants as a single cohort of women with term prelabor rupture of membranes, irrespective of the original randomized study group allocation. For each given 1-hour time interval within the first 36 hours following prelabor rupture of membranes, we compared the outcomes of subjects for whom labor induction was initiated during this interval with those of subjects managed expectantly at the same time interval. The primary neonatal outcome was a composite of neonatal infection and admission to the neonatal intensive care unit. The primary maternal outcomes included maternal infection (clinical chorioamnionitis or postpartum fever) and cesarean delivery.

RESULTS

Of the 4742 subjects who met the study criteria, 2622 underwent labor induction, and 2120 experienced a spontaneous onset of labor. The rates of the neonatal composite outcome, neonatal admission to intensive care unit, and maternal infection increased progressively with time after prelabor rupture of membranes. The risk for these outcomes was lower among women who underwent induction when compared with those managed expectantly within the first 15 to 20 hours after prelabor rupture of membranes without affecting the risk for cesarean delivery. In addition, women who underwent labor induction within the first 30 to 36 hours had a shorter prelabor rupture of membranes to delivery time and a shorter total maternal hospital stay when compared with those managed expectantly at the same time interval. Among women managed expectantly, less than two-thirds (64%; 1365/2120) experienced a spontaneous onset of labor within the first 24 hours following prelabor rupture of membranes.

CONCLUSION

These findings suggest that immediate labor induction seems to be the optimal management strategy to minimize neonatal and maternal morbidity in the setting of prelabor rupture of membranes at term gestations. In cases for which immediate induction is not feasible, labor induction remains the preferred option over expectant management if performed within the first 15 to 20 hours after prelabor rupture of membranes.

Risk of stillbirth in singleton fetuses with advancing gestational age at term: A 10-year experience of late third trimester prenatal screenings of 50,000 deliveries in a referral center in northern Italy

BACKGROUND

The risk of intrauterine death (IUD) at term varies from less than one to up to three cases per 1,000 ongoing pregnancies. The cause of death is often largely undefined. Protocols and criteria to prevent and define the rates and causes of stillbirth are the subjects of important scientific and clinical debates. We examined the gestational age and rate of stillbirth at term in a 10-year period at our maternity hub to evaluate the possible favorable impact of a surveillance protocol on maternal and fetal well-being and growth.

METHODS AND FINDINGS

Our cohort included all women with singleton pregnancies resulting in early term to late term birth at our maternity hub between 2010 and 2020, with the exclusion of fetal anomalies. As per our protocol for monitoring term pregnancies, all women underwent near term to early term maternal and fetal well-being and growth surveillance. If risk factors were identified, outpatient monitoring was initiated and early- or full-term induction was indicated. Labor was induced at late term (41+0-41+4 weeks of gestation), if it did not occur spontaneously. We retrospectively collected, verified, and analyzed all cases of stillbirth at term. The incidence of stillbirth at each week of gestation, was calculated by dividing the number of stillbirths observed that week by the number of women with ongoing pregnancies in that same week. The overall rate of stillbirth per 1000 was also calculated for the entire cohort. Fetal and maternal variables were analyzed to assess the possible causes of death.

RESULTS

A total of 57,561 women were included in our study, of which 28 cases of stillbirth (overall rate, 0.48 per 1000 ongoing pregnancies; 95% CI: 0.30-0.70) were identified. The incidence of stillbirth in the ongoing pregnancies measured at 37, 38, 39, 40, and 41 weeks of gestation was 0.16, 0.30, 0.11, 0.29, and 0.0 per 1000, respectively. Only three cases occurred after 40+0 weeks of gestation. Six patients had an undetected small for gestational age fetus. The identified causes included placental conditions (n = 8), umbilical cord conditions (n = 7), and chorioamnionitis (n = 4). Furthermore, the cases of stillbirth included one undetected fetal abnormality (n = 1). The cause of fetal death remained unknown in eight cases.

CONCLUSIONS

In a referral center with an active universal screening protocol for maternal and fetal prenatal surveillance at near and early term, the rate of stillbirth was 0.48 per 1000 in singleton pregnancies at term in a large, unselected population. The highest incidence of stillbirth was observed at 38 weeks of gestation. The vast majority of stillbirth cases occurred before 39 weeks of gestation and 6 of 28 cases were SGA, and the median percentile of the remaining case was the 35th.

Early-Onset Sepsis in Newborns

Early-onset sepsis can cause significant morbidity and mortality in newborn infants. Risk factors for sepsis include birth to mothers with inadequately treated maternal group B Streptococcus colonization, intra-amniotic infection, maternal temperature greater than 100.4°F (>38°C), rupture of membranes greater than 18 hours, and preterm labor. The organisms that most commonly cause early-onset sepsis include group B Streptococcus, Escherichia coli, and viridans streptococci. Infants often present within the first 24 hours after birth with clinical signs of sepsis, with respiratory distress as the most common presenting symptom. However, infants can also have respiratory distress from noninfectious etiologies. Therefore, when physicians are faced with asymptomatic infants with risk factors or infants with respiratory distress without risk factors, there is a delicate balance between empirically treating with antibiotics and observing these infants without treating.

A nationwide study of obstetric management and outcomes in premature rupture of membrane at term: Report from the Perinatology Committee, Japan Society of Obstetrics and Gynecology, 2017-2018

AIM

This nationwide study aimed to investigate the practical management of term premature rupture of membrane (PROM) and its relationship with maternal and neonatal outcomes.

METHODS

We conducted a questionnaire survey of 415 facilities participating in the Japan Perinatal Registry Network of the Japan Society of Obstetrics and Gynecology in 2016. The patients were women expecting vaginal birth after PROM at term without clinical chorioamnionitis. We classified the facilities into three groups based on duration of the expectant management after PROM (within 24, 24, and 48 h). Furthermore, we analyzed the association between perinatal outcomes and management protocol using the Japan Perinatal Registry Network Database 2016.

RESULTS

Of 415 facilities, 346 (83.4%) completed and returned the survey. Among 231 facilities with management protocols, an interval of 3 days from PROM to delivery was acceptable in 167 facilities (72.3%). One hundred forty-nine facilities (64.5%) responded that they did not perform mechanical cervical dilation, and 90 (39.0%) used oxytocin as a uterotonic irrespective of cervical maturation. The number of hospitals that had a policy to administer antibiotics to Group B streptococcus-positive patients was 211 (91.3%). Neonatal outcomes at birth and the frequency of cesarean section and postpartum fever did not differ among the three groups.

CONCLUSIONS

Most facilities in the Japan Perinatal Registry Network managed women at term to delivery within 3 days after PROM with attention to bacterial infection. Expectant management up to 48 h after PROM did not increase the risk of postpartum fever, compared to labor induction immediately after PROM.

Guideline No. 432a: Cervical Ripening and Induction of Labour - General Information

OBJECTIVE

This guideline presents evidence and recommendations for cervical ripening and induction of labour. It aims to provide information to birth attendants and pregnant individuals on optimal perinatal care while avoiding unnecessary obstetrical intervention.

TARGET POPULATION

All pregnant patients.

BENEFITS, HARMS, AND COSTS

Consistent interprofessional use of the guideline, appropriate equipment, and trained professional staff enhance safe intrapartum care. Pregnant individuals and their support person(s) should be informed of the benefits and risks of induction of labour.

EVIDENCE

Literature published to March 2022 was reviewed. PubMed, CINAHL, and the Cochrane Library were used to search for systematic reviews, randomized controlled trials, and observational studies on cervical ripening and induction of labour. Grey (unpublished) literature was identified by searching the websites of health technology assessment and health technology related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All providers of obstetrical care.

RECOMMANDATIONS

Directive clinique no 432a : Maturation cervicale et déclenchement artificiel du travail - Information générale

OBJECTIF

Présenter des données probantes et des recommandations sur la maturation cervicale et le déclenchement artificiel du travail. Fournir de l'information aux professionnels accoucheurs et aux personnes enceintes sur les soins périnataux optimaux et la prévention des interventions obstétricales inutiles.

POPULATION CIBLE

Toutes les patientes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en application interprofessionnelle et cohérente de la présente directive, l'équipement adéquat et le personnel compétent améliorent la sécurité des soins per partum. Les personnes enceintes et leurs personnes de soutien doivent être informées des risques et bénéfices du déclenchement artificiel du travail. DONNéES PROBANTES: La littérature publiée jusqu'en mars 2022 a été passée en revue. Une recherche a été effectuée dans les bases de données PubMed, CINAHL et Cochrane Library pour répertorier des revues systématiques, des essais cliniques randomisés et des études observationnelles sur la maturation cervicale et le déclenchement artificiel du travail. La littérature grise (non publiée) a été obtenue à l'aide de recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins obstétricaux.

RECOMMANDATIONS

A Randomised Controlled Trial Comparing Induction of Labour with the Propess Vaginal System to the Prostin Vaginal Tablet in Premature Rupture of Membranes at Term

Aim: To compare the perinatal outcome and delivery intervals after the induction of labour with the Prostin vaginal tablet versus the Propess vaginal system in pregnant women with term-PROM. Design: One centre paralleled randomised controlled trial with a computer-generated table to allocate treatments. Setting: University Medical Centre in Slovenia. Participants: A total of 205 singleton healthy pregnant women with term-PROM. Intervention: Induction of labour with the Propess vaginal system (intervention group) versus Prostin tablets (control group). Main outcomes: The rate of failed inductions, complications in labour, time intervals between the PROM, induction, the beginning of the active phase, and delivery. Results: A total of 104 patients received Prostin, and 101 patients received Propess. Induction failure rates in the Prostin and the Propess groups were 8/104 (7.7%) and 5/101 (5.0%), respectively (p = 0.80). Delivery abnormalities were uncommon and comparable across the groups. The rates of caesarean sections in the Prostin and Propess groups were 4/96 (4.2%) and 6/96 (6.3%), respectively. The delivery intervals were comparable across the groups. Conclusions: In term-PROM pregnancies, the Propess vaginal system is a safe and effective option for inducing labour.

Perinatal outcome and risk factors of precipitate labor in term primipara: an analysis of 381 cases

OBJECTIVE

To investigate the perinatal outcome and risk factors of precipitate labor in term primipara.

METHODS

A total of 6951 full-term singleton primiparas with cephalic vaginal delivery in Women's Hospital, Zhejiang University School of Medicine from January 2020 to December 2020 were enrolled, among whom 381 cases of precipitate labor were classified as the precipitate labor group and 762 cases of normal labor were randomly selected as the control group. The perinatal outcomes of the two groups were compared, and the risk factors of precipitate labor were analyzed by multivariate logistic regression.

RESULTS

The incidence of precipitate labor in full-term, singleton pregnancy and cephalic primiparas was 5.48% (381/6951). The durations of the first and second stages of labor in the precipitate labor group were significantly shorter than that in the control group ( P<0.01); while there was no significant difference in the duration of the third stage of labor between the two groups ( P>0.05). Compared with the control group, the incidence of soft birth canal laceration in the precipitate labor group was increased ( P<0.01). However, there was no significant difference in postpartum hemorrhage and neonatal related perinatal outcomes between the two groups (all P>0.05). Multivariate logistic regression analysis showed that maternal height ( OR=1.038, 95% CI: 1.010-1.067, P<0.01), gestational age at delivery ( OR=0.716, 95% CI: 0.618-0.829, P<0.01), late miscarriage ( OR=1.986, 95% CI: 1.065-3.702, P<0.05), membrane rupture before labor ( OR=1.802, 95% CI: 1.350-2.406, P<0.01), labor induction by transcervical balloon ( OR=3.230, 95% CI: 2.027-5.147, P<0.01), labor induction by propess ( OR=2.332, 95% CI: 1.632-3.334, P<0.01) and labor induction by oxytocin ( OR=0.291, 95% CI: 0.219-0.386, P<0.01) were independently associated with precipitate labor.

CONCLUSIONS

The incidence of precipitate labor in full-term, singleton pregnancy was not low. Precipitate labor could lead to a significant increase in perineal laceration. Maternal height, history of late miscarriage, membrane rupture before labor and labor induction by transcervical balloon, labor induction by propess are risk factors, while labor induction by oxytocin and late gestational time of delivery are protective factors for precipitate labor in term primipara.

Comparative study of dinoprostone and misoprostol for induction of labor in patients with premature rupture of membranes after 35 weeks

The modalities of induction of labor in the event of premature rupture of membranes are controversial. The main purpose of this study was to compare the modalities of delivery after the use of dinoprostone or misoprostol for labor induction in the preterm rupture of membranes after 35 weeks in women with an unfavorable cervix. We then studied maternal and fetal morbidity for the two drugs. Retrospective, single-center, comparative cohort study in a level 3 maternity unit in France from 2009 to 2018 comparing vaginal administration of misoprostol 50 µg every six hours (maximum 150 µg) and administration of dinoprostone 10 mg, a slow-release vaginal insert, for 24 h (maximum 20 mg), for labor induction in the preterm rupture of membranes after 35 weeks in women with an unfavorable cervix (Bishop score < 6). We included 904 patients, 656 in the misoprostol group and 248 in the dinoprostone group. Vaginal delivery rate was significantly higher in the dinoprostone group (89% vs. 82%, p = 0.016). There were more cesarean sections for abnormal fetal heart rate in the misoprostol group (p = 0.005). The time interval from induction to the beginning of the active phase of labor and the duration of labor were shorter in the misoprostol group than in the dinoprostone group (437 min vs. 719 min, p < 0.001 and 335 min vs. 381 min, p = 0.0023, respectively). Maternal and neonatal outcomes were not significantly different in the two groups. Vaginal dinoprostone used for labor induction in preterm rupture of membranes seems to be more effective for vaginal delivery than vaginal misoprostol (50 µg).

Cross-Cultural Adaptation and Psychometric Properties of the French Version of the EXIT to Measure Women’s Experiences of Induction of Labor

Background: In France, more than 20% of women require induction of labor (IOL), which can be psychologically and emotionally challenging for patients. It is important to assess how they feel about their IOL experiences. Our aim was to cross-culturally adapt and evaluate the psychometric properties of a French version of the EXIT to assess women’s experiences of IOL. Methods: The EXIT was cross-culturally adapted by conducting forward and backward translations following international guidelines. A cross-sectional study was conducted to assess the psychometric properties of the ten French EXIT items: data completeness, factor analysis, internal consistency, score distribution, floor and ceiling effects, inter-subscale correlations, convergent validity, and test–retest reliability. Results: The EXIT was successfully cross-culturally adapted to the French context and any IOL method. The results obtained from 163 patients requiring IOL showed good acceptability. Exploratory factor analysis resulted in a three-factor solution with subscales reflecting the experiential aspects of time taken to give birth, discomfort with IOL, and subsequent contractions. Good internal consistency (Cronbach’s alpha or Spearman correlation coefficients ranging from 0.55 to 0.84) and good test–retest reliability (intraclass correlation coefficients ranging from 0.66 to 0.85) for the three identified subscales were found. Conclusions: The ten-item French EXIT is a valid and reliable instrument for the self-assessment of women’s experiences of IOL in the three weeks following delivery for any method of IOL used. As a patient-reported outcome measure, it would allow the comparison of experiential outcomes across IOL studies in order to include women’s preferences in decisions regarding their care.

Adoption of Consensus Guidelines for Safe Prevention of the Primary Cesarean Delivery by Freestanding Birth Centers

INTRODUCTION

Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results.

METHODS

Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry.

RESULTS

A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P < .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) DISCUSSION: We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

Use of Vaginal Dinoprostone (PGE2) in Patients with Premature Rupture of Membranes (PROM) Undergoing Induction of Labor: A Comparative Study

Purpose: To evaluate the effect and safety of vaginal dinoprostone in pregnant women with PROM who undergo induction of labor (IoL). Materials and Methods: Prospective observational study conducted at La Mancha Centro hospital from 1 February 2019, to 30 August 2020. Obstetric and neonatal variables of 94 pregnant women with PROM who underwent IoL with vaginal dinoprostone were analyzed, and the results were compared with 330 patients without PROM who also underwent IoL. Bivariate and multivariate analyses were performed using binary and multiple linear regression. Results: A total of 424 women were included in this study. A greater response to cervical ripening (Bishop score > 6) with PGE2 was observed in the PROM group (odds ratio (OR) 2.73, 95% confidence interval (CI) 1.50−4.99, p = 0.001), as well as a shorter total duration of IoL (mean difference (MD) 2823.37 min (min), 95% CI 1257.30−4389.43, p < 0.001). Cesarean sections were performed in 28.7% (n = 27) of patients in the PROM group vs. 34.2% (n = 113) of patients in the non-PROM group, with no significant differences (OR 0.87%, 95% CI 0.47−1.60, p = 0.652). There were no significant differences in changes in the cardiotocographic record (CTG), postpartum hemorrhage (PPH), uterine rupture, or adverse neonatal outcomes between the two groups. Conclusions: The use of vaginal dinoprostone in pregnant women undergoing IoL with PROM is safe for the mother and the fetus, shortens the total delivery time, and does not increase the risk of cesarean section compared with pregnant women undergoing IoL without PROM.

Double Balloon Catheter (Plus Oxytocin) versus Dinoprostone Vaginal Insert for Term Rupture of Membranes: A Randomized Controlled Trial (RUBAPRO)

Background: The aim of this study is to demonstrate that a double balloon catheter combined with oxytocin decreases time between induction of labor and delivery (TID) as compared to a vaginal dinoprostone insert in cases of premature rupture of membranes at term. Methods: This is a prospective, randomized, controlled trial including patient undergoing labor induction for PROM at term with an unfavorable cervix in Clermont-Ferrand university hospital. We compared the double balloon catheter over a period of 12 h with adjunction of oxytocin 6 h after catheter insertion versus dinoprostone vaginal insert. After device ablation, cervical ripening continued only with oxytocin. The main outcome was TID. Secondary outcomes concerned delivery mode, as well as maternal and fetal outcome, and were adjusted for parity. Results: 40 patients per group were randomized. Each group had similar baseline characteristics. The study failed to demonstrate reduced TID (16.2 versus 20.2 h, ES = 0.16 (−0.27 to 0.60), p = 0.12) in the catheter group versus dinoprostone except in nulliparous women (17.0 versus 26.5 h, ES = 0.62 (0.10 to 1.14), p = 0.006). The rate of vaginal delivery <24 h significantly increased with combined induction (88.5% versus 66.6%, p = 0.03). No statistical difference was observed concerning caesarean rate (12.5% versus 17.5%, p > 0.05), chorioamnionitis (0% versus 2.5%, p = 1), postpartum endometritis, or maternal or neonatal outcomes. Procedure-related pain and tolerance to devices were found to be similar for the two methods. Interpretation: The double balloon catheter combined with oxytocin is an alternative for cervical ripening in case of PROM at term, and may reduce TID in nulliparous women.

Prelabor rupture of membranes at term: A possible hematological triage in addition to vagino-rectal beta-hemolytic streptococcus screening for early labor induction

Introduction

A potential complication of term prelabor rupture of membranes (term PROM) is chorioamnionitis with an increased burden on neonatal outcomes of chronic lung disease and cerebral palsy. The purpose of the study was to analyze the efficacy of a standing clinical protocol designed to identify women with term PROM at low risk for chorioamnionitis, who may benefit from expectant management, and those at a higher risk for chorioamnionitis, who may benefit from early induction.

Material and methods

This retrospective study enrolled all consecutive singleton pregnant women with term PROM. Subjects included women with at least one of the following factors: white blood cell count ≥ 15×100/μL, C-reactive protein ≥ 1.5 mg/dL, or positive vaginal swab for beta-hemolytic streptococcus. These women comprised the high risk (HR) group and underwent immediate induction of labor by the administration of intravaginal dinoprostone. Women with none of the above factors and those with a low risk for chorioamnionitis waited for up to 24 hours for spontaneous onset of labor and comprised the low-risk (LR) group.

Results

Of the 884 consecutive patients recruited, 65 fulfilled the criteria for HR chorioamnionitis and underwent immediate induction, while 819 were admitted for expectant management. Chorioamnionitis and Cesarean section rates were not significantly different between the HR and LR groups. However, the prevalence of maternal fever (7.7% vs. 2.9%; p = 0.04) and meconium-stained amniotic fluid was significantly higher in the HR group than in LR group (6.1% vs. 2.2%; p = 0.04). This study found an overall incidence of 4.2% for chorioamnionitis, 10.9% for Cesarean section, 0.5% for umbilical artery blood pH < 7.10, and 1.9% for admission to the neonatal intensive care unit. Furthermore, no confirmed cases of neonatal sepsis were encountered.

Conclusions

A clinical protocol designed to manage, by immediate induction, only those women with term PROM who presented with High Risk factors for infection/inflammation achieved similar maternal and perinatal outcomes between such women and women without any risks who received expectant management. This reduced the need for universal induction of term PROM patients, thereby reducing the incidence of maternal and fetal complications without increasing the rate of Cesarean sections.

Pre-induction cervical ripening with different initial doses of intravaginal misoprostol: time to delivery and peri-natal outcomes

From 2016 to 2018, a total of 300 pregnant women underwent induction of labour. Those women were allocated in two groups according to the initial dose of misoprostol. Group I (150 women) received intravaginally 50 µg misoprostol followed by 25 µg every four hours, up to a maximum of four doses whereas in group II (150 women) the initial dose was 25 μg intravaginal followed by the same dose every four hours up to a maximum of four doses. Women with previous uterine scar, abnormal foetal heart rate, severe foetal malformation, foetal growth restriction or multiple pregnancy were excluded. The aim of study was to compare the effectiveness (hours until delivery) and perinatal outcomes of both schemes of cervical ripening. Initial doses of 50 μg of misoprostol reduced the time until delivery (17.65 ± 8.2 hours vs. 20.85 ± 9.3 hours; p=.007) and the need of oxytocin (34.6% vs. 46.67%; p=.046), compared to the use of 25 μg misoprostol in all doses. No differences were observed regarding perinatal outcomes.In conclusion, starting with 50 µg of misoprostol in the first dose reduced time to vaginal delivery and decreased the use of oxytocin without worse perinatal outcomes.Impact StatementWhat is already known on this subject? The rate of labour induction is increasing. Mechanical and medical methods try to establish the active phase of labour as quickly and safely as possible. For this reason, there are numerous studies assessing different protocols, dosages and indications.What do the results of this study add? Despite the numerous studies, due to ethical restrictions, it is difficult to carry out prospective studies. For this reason, studies like this help to establish the most appropriate dose of misoprostol in two of the most common indications for induction of labour. We demonstrated that increasing initial doses up to 50 mg of misoprostol are safer and more effective.What are the implications of these findings for clinical practice and/or further research? This study could be useful for future prospective and randomised studies as well for including these data in a meta-analysis. In addition, these results may update the clinical protocols and reduce hospital stay without worse perinatal outcomes.

Term Neonatal Complications During the Second Localized COVID-19 Lockdown and Prolonged Premature Rupture of Membranes at Home Among Nulliparas With Reference Interval for Maternal C-Reactive Protein: A Retrospective Cohort Study

OBJECTIVE

The COVID-19 lockdown extended premature rupture of membranes (PROM) expectant time among nulliparas and increased the risk of term neonatal complications. This study investigated the impact of term nulliparas with PROM delays at home on neonatal outcomes during the COVID-19 lockdown period, considering the clinical diagnostic application of maternal C-reactive protein (CRP).

METHODS

This study collected 505 term nulliparous women who underwent PROM at home from five provinces in a non-designated hospital of China in 2020. We analyzed PROM maternal information at home and neonatal complications in the COVID-19 regional lockdown and compared related information in the national lockdown. Poisson regression models estimated the correlation of PROM management at home, maternal CRP, and neonatal morbidity. We constructed two diagnostic models: the CRP univariate model, and an assessed cut-off value of CRP in the combined model (CRP with PROM waiting time at home).

RESULTS

In the regional lockdown, PROM latency at home and the severity of neonatal complications were extended and increased lower than in the nationwide lockdown, but term neonatal morbidity was not reduced in the COVID-19 localized lockdown. Prolonged waiting time at home (≥8.17 h) was associated with increasing maternal CRP values and neonatal morbidity (adjusted risk ratio 2.53, 95% CI, 1.43 to 4.50, p for trend <0.001) in the regional lockdown period. In the combined model, CRP ≥7 mg/L with PROM latency ≥8.17 h at home showed higher diagnostic sensitivity and AUC than only CRP for initial assessing the risk of adverse neonatal complications in COVID-19 regional lockdowns (AUC, 0.714 vs. 0.534; sensitivity, 0.631 vs. 0.156).

CONCLUSION

The impact of the acute COVID-19 national blockade on the PROM newborns' health could continue to the COVID-19 easing period. Maternal CRP reference interval (≥7 mg/L) would effectively assess the risk of term neonatal morbidity when nulliparas underwent prolonged PROM expectant at home (≥8.17 h) during the second COVID-19 lockdown.

Can we improve our ability to interpret category II fetal heart rate tracings using additional clinical parameters?

OBJECTIVES

This study examined predictive factors, in addition to Category II Fetal Herat Rate (FHR) monitoring that might imply fetal acidosis and risk of asphyxia.

METHODS

This retrospective cohort study compared three groups of patients with Category II FHR monitoring indicating need for imminent delivery. Groups were divided based on fetal cord blood pH: pH≤7.0, 7.0<pH<7.2 and pH≥7.2. Demographics, medical history, delivery data and early neonatal outcomes were reviewed.

RESULTS

The cohort included 417 women. Nine (2.2%) had cord pH≤7.0, 105 (25.2%) pH 7.0 to 7.2 and 303 (72.6%) ad pH≥7.2. Background characteristics, pregnancy follow-up and intrauterine fetal evaluation prior to delivery were similar in all groups. As expected, more patients in the low pH group had cesarean section (55.6%), than vaginal delivery or vacuum extraction (p=0.02). Five-minute Apgar scores were similar in all groups.

CONCLUSIONS

This retrospective study did not detect a specific parameter that could help predict the prognosis of fetal acidosis and risk of asphyxia. As we only included patients with a Category II tracing that was worrisome enough to lead to imminent delivery, it is reasonable to believe that this is due to patient selection, meaning that when the Category II FHR results in decision for prompt delivery, there is no added value in additional clinical characteristics. The evaluation should be expanded to all patients with Category II tracing for better interpretation tools for Category II FHR monitors, as well as a larger study population.

Chorioamnionitis after premature rupture of membranes in nulliparas undergoing labor induction: prostaglandin E2 vs. oxytocin

OBJECTIVES

To assess the risk of chorioamnionitis in nulliparous, term, singleton, vertex (NTSV) pregnancies with premature rupture of membranes (PROM) and an unfavorable cervix undergoing labor induction with either prostaglandin E2 (PGE2) or oxytocin only.

METHODS

Retrospective cohort of NTSV pregnancies presenting with PROM who underwent labor induction with either PGE2 (n=94) or oxytocin (n=181) between October 2015 and March 2019. The primary outcome of chorioamnionitis was compared between the two groups. Statistical analysis included Chi-squared and Wilcoxon rank-sum tests, as well as logistic regression. For time to delivery, a Cox proportional hazard regression was used to determine the hazard ratio (HR) and adjusted HR (aHR).

RESULTS

Baseline characteristics were similar between the two groups. Cervical ripening with PGE2 was associated with an increased rate of chorioamnionitis (18.1 vs. 6.1%; aOR 4.14, p=0.001), increased neonatal intensive care unit admissions (20.2 vs. 9.9%; aOR 2.4, p=0.02), longer time interval from PROM to delivery (24.4 vs. 17.9 h; aHR 0.56, p=<0.0001), and lower incidence of meconium (7.4 vs. 14.4%; aOR 0.26, p=0.01), compared to the oxytocin group.

CONCLUSIONS

Based on our data, the use of oxytocin appears both superior and safer compared to PGE2 in NTSV pregnancies with PROM undergoing labor induction.

Term prelabor rupture of the membranes with unfavorable cervix: Frequency and factors associated with spontaneous onset of labor after two days of expectant management

INTRODUCTION

In case of term prelabor rupture of membranes (PROM), expectant management is a reasonable option. We aimed at assessing the frequency of spontaneous onset of labor after two days of term PROM and its associated factors.

MATERIAL AND METHODS

Women delivering at a tertiary center of a singleton in cephalic presentation, after a term PROM with an unfavorable cervix and with an expectant management period of at least two days were included during a 2-year period. Women were excluded in case of induction of labor before or at day 2(D2) or of spontaneous labor before D2. The frequency of spontaneous labor was assessed, then maternal characteristics at admission and at D2 were compared between women with a spontaneous onset of labor before D3, and women with an induced labor at D3. The maternal and neonatal outcomes were compared between the two groups. The factors associated with spontaneous labor in univariate analysis were tested in multivariable analysis.

RESULTS

Among the 11 608 women delivering at term, 933(8.4%) had a term PROM. Among them, 191 had an unfavorable cervix after D2 including 86(45%) women with a spontaneous labor onset between D2 and D3 and 105(55%) induced at D3. Maternal age below 35 years (reference ≥35years) and Bishop score of 3,4 and 5,6 at D2 (reference score 0-2) were significantly associated with spontaneous onset of labor, respectively aOR 2.62; 95%CI[1.26-5.45], aOR 2.38; 95%CI[1.18-4.78] and aOR 10.16; 95%CI[3.67-28.15].

DISCUSSION

In women with a term PROM and an unfavorable cervix, spontaneous labor still occurs in nearly half of women undelivered after two days of expectant management.

Outpatient labour induction

The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18 h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.

Preterm and term prelabour rupture of membranes: A review of timing and methods of labour induction

Prelabour rupture of membranes (PROM) exposes both foetuses and mothers to the risk of infection. Induction of labour has been proposed to reduce this risk, but its neonatal and maternal risks and benefits must be balanced against those of expectant management (EM). Recent randomized studies of preterm PROM show that EM until 37 weeks of gestation is associated with lower overall neonatal morbidity. In term PROM, active management is associated with a shorter birth interval but not with lower rates of neonatal infection. Similar maternal and neonatal outcomes are reported regardless of whether induction uses oxytocin, PGE2, or oral misoprostol.

Current and Emerging Strategies for Prediction and Diagnosis of Prelabour Rupture of the Membranes: A Narrative Review

Prelabour rupture of membranes (PROM) refers to the disruption of foetal membranes before the onset of labour, resulting in the leakage of amniotic fluid. PROM complicates 3% and 8% of preterm and term pregnancies, respectively. Accurate and timely diagnosis is crucial for effective management to prevent adverse maternal- and foetal-outcomes. The diagnosis of equivocal PROM cases with traditional methods often becomes challenging in current obstetrics practice; therefore, various novel biochemical markers have emerged as promising diagnostic tools. This narrative review is sought to review the published data to understand the current and emerging trends in diagnostic modalities in term and preterm pregnancies complicated with PROM and the potential role of various markers for predicting preterm PROM (pPROM) and chorioamnionitis in women with pPROM.

Prevalence of uterine rupture among women with one prior low transverse cesarean and women with unscarred uterus undergoing labor induction with PGE2: A systematic review and meta-analysis

BACKGROUND

As uterine rupture may affect as many as 11/1000 women with 1 prior cesarean birth and 5/10.000 women with unscarred uterus undergoing labor induction, we intended to estimate the prevalence of such rare outcome when PGE2 is used for cervical ripening and labor induction.

METHODS

We searched MEDLINE, ClinicalTrials.gov and the Cochrane library up to September 1st 2020. Retrospective and prospective cohort studies, as well as randomized controlled trials (RCTs) on singleton viable pregnancies receiving PGE2 for cervical ripening and labor induction were reviewed. Prevalence of uterine rupture was meta-analyzed with Freeman-Tukey double arcsine transformation among women with 1 prior low transverse cesarean section and women with unscarred uterus.

RESULTS

We reviewed 956 full text articles to include 69 studies. The pooled prevalence rate of uterine rupture is estimated to range between 2 and 9 out of 1000 women with 1 prior low transverse cesarean (5/1000; 95%CI 2-9/1000, 122/9000). The prevalence of uterine rupture among women with unscarred uterus is extremely low, reaching at most 0.7/100.000 (<1/100.000.000; 95%CI <1/100.000.000-0.7/100.000, 8/17.684).

CONCLUSIONS

Uterine rupture is a rare event during cervical ripening and labor induction with PGE2.

Induction within or after 12 hours of ≥36 weeks' prelabor rupture of membranes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the incidence of chorioamnionitis in women with singleton gestations with ≥36 weeks' prelabor rupture of membranes induced with oxytocin within or after 12 hours of prelabor rupture of membranes.

DATA SOURCES

The search was conducted using MEDLINE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and Cochrane Library as electronic databases from their inception to May 2020.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials of women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks comparing induction of labor with oxytocin either ≤12 hours after prelabor rupture of membranes or >12 hours after prelabor rupture of membranes (expectant management group).

STUDY APPRAISAL AND SYNTHESIS METHODS

The risk of bias in each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. All analyses were done using an intention-to-treat approach, evaluating women according to the treatment group to which they were randomly allocated in the original trials. The primary outcome was the incidence of chorioamnionitis.

RESULTS

After exclusions, 9 randomized controlled trials including 3759 women were analyzed. Women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks who have induction of labor ≤12 hours after prelabor rupture of membranes have shorter time between prelabor rupture of membranes and delivery (-12.68 hours; 95% confidence interval, -16.15 to -9.21) and higher chance of delivering within 24 hours of prelabor rupture of membranes (91% vs 46%; relative risk, 1.93; 95% confidence interval, 1.59-2.35). Cesarean and operative vaginal deliveries were not significantly different between the groups. Induction of labor ≤12 hours after prelabor rupture of membranes was also associated with significantly fewer incidences of chorioamnionitis (5.3% vs 9.9%; relative risk, 0.62; 95% confidence interval, 0.40-0.97), endometritis (2.4% vs 4.2%; relative risk, 0.59; 95% confidence interval, 0.40-0.87), neonatal sepsis (6.1% vs 11.8%; relative risk, 0.46; 95% confidence interval, 0.27-0.79), and admission to neonatal intensive care unit (6.4% vs 12.0%; relative risk, 0.54; 95% confidence interval, 0.43-0.69) compared with women managed expectantly, usually at >24 hours. The subgroup analysis of 3323 women with induction of labor at ≤6 hours showed similar results, including similar significant reductions in chorioamnionitis, endometritis, neonatal sepsis, and admission to neonatal intensive care unit.

CONCLUSION

Women with symptoms of prelabor rupture of membranes at ≥36 weeks should be evaluated promptly, and if prelabor rupture of membranes is confirmed, they should have induction of labor within 12 hours and perhaps even within 6 hours since the first symptom of prelabor rupture of membranes. This management is associated with significantly less morbidity, especially in terms of infections, for both the mother and the baby, with no evidence of any harm.

Outpatient Expectant Management of Term Prelabor Rupture of Membranes: A Retrospective Cohort Study

OBJECTIVE

To examine outcomes among women with prelabor rupture of membranes (PROM) who declined induction and chose outpatient expectant management compared with those admitted for induction.

STUDY DESIGN

This is a retrospective cohort study of term women with singleton, vertex-presenting fetuses who presented with PROM between July 2016 and June 2017 and were eligible for outpatient expectant management (n = 166). The primary outcomes were time from PROM to delivery and time from admission to delivery. Maternal and neonatal outcomes were also compared between groups. Multivariable linear regressions were used to assess time differences between groups, adjusting for known maternal and pregnancy characteristics.

RESULTS

Compared with admitted patients, women managed expectantly at home had significantly longer PROM to delivery intervals (median 29.2 vs. 17 hours, p < 0.001), but were more likely to deliver within 24 hours of admission (95.1 vs. 82.9%, p = 0.004). In the adjusted analysis, PROM to delivery was 7 hours longer (95% confidence interval [CI]: 3.9-10.0) and admission to delivery was 5.3 hours shorter (95% CI: 2.8-7.7) in the outpatient expectant management cohort. There were no differences in secondary outcomes.

CONCLUSION

Outpatient management of term PROM is associated with longer PROM to delivery intervals, but shorter admission to delivery intervals.

Neonatal outcomes and risk of neonatal sepsis in an expectantly managed cohort of late preterm prelabor rupture of membranes

OBJECTIVE

Expectant management in patients with prelabor preterm rupture of membranes between between 34^0/7 and 36 ^6/7 weeks (late preterm pPROM or LpPROM) has been shown to decrease the burden of prematurity, when compared to immediate delivery. As the severity of prematurity depends on gestational age (GA) at PROM, and PROM to delivery interval, we first investigated how such variables affect neonatal outcomes (NO). Second, we assessed the risk of neonatal sepsis.

STUDY DESIGN

retrospective cohort study on neonatal morbidity among singleton infants born to expectantly managed mothers with LpPROM in five hospitals affiliated with three Italian academic institutions. The primary NO was a composite of neonatal death, non-invasive (cPAP) or invasive (mechanical ventilation) respiratory support, hypoglycemia (< 44 mg/dl needing therapy), newborn sepsis, confirmed seizures, stroke, intraventricular hemorrhage (IVH), basal nuclei anomalies, cardiopulmonary resuscitation, umbilical-cord-blood arterial pH < 7.0 or base excess < -12.5, and prolonged hospitalization (≥ 5 days). Univariate analysis described differences in the population according to GA at delivery. Multivariate logistic regression was then used to investigate the effects of GA at PROM, and PROM to delivery interval on the NO.

RESULTS

258/606 (42.6 %) women with LpPROM were expectantly managed, as they did not deliver within the first 24 h. The median latency duration was 2 (95 %CI 1-3) days, having no effect on neonatal morbidity on multivariate analysis. Multivariate analysis also showed increased risks of adverse NO among PROM at 34 (OR 2.3 95 %CI 1.03-5.1) but not at 35 weeks when compared to 36 weeks, and among women receiving antenatal corticosteroids (OR 3.6 95 %CI 1.3-9.7), while antibiotic treatment showed a non-significant protective effect (OR 0.2 95 %CI 0.04-1.02). Prevalence of neonatal sepsis was 0.8 % (2/258) CONCLUSION: Expectant management of LpPROM should be encouraged especially between 34⁺⁰ and 34⁺⁶ weeks', when the burden of prematurity is the greatest. Antibiotics may have beneficial effects, while careful consideration should be given to antenatal corticosteroids until future studies specifically address LpPROM.

Oxytocin Compared to Buccal Misoprostol for Induction of Labor after Term Prelabor Rupture of Membranes

OBJECTIVE

This study was aimed to determine if admission-to-delivery times vary between term nulliparous women with prelabor rupture of membranes (PROM) who initially receive oxytocin compared with buccal misoprostol for labor induction.

STUDY DESIGN

This is a retrospective cohort of 130 term, nulliparous women with PROM and cervical dilation of ≤2 cm who underwent induction of labor with intravenous oxytocin or buccal misoprostol. The primary outcome was time from admission to delivery. Linear regressions with log transformation were used to estimate the effect of induction agent on time to delivery.

RESULTS

Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (16.9 vs. 19.9 hours, p = 0.013). There were no significant differences in secondary outcomes between the groups. In the adjusted model, women who received misoprostol had a 22% longer time from admission to delivery (95% CI 5.0-42.0%) compared with women receiving oxytocin.

CONCLUSION

In term nulliparous patients with PROM, intravenous oxytocin is associated with faster admission-to-delivery times than buccal misoprostol.

Outcomes of Expectant Management of Term Prelabor Rupture of Membranes

OBJECTIVE

To assess rates of induction/augmentation of labor, maternal infection, neonatal outcomes, and time to birth when women were expectantly managed after term prelabor rupture of membranes (PROM) at home or in the hospital.

DESIGN

Retrospective, descriptive study based on a review of data from a hospital midwifery service database and chart review.

SETTING

A large Midwest hospital with 4,700 births annually.

PARTICIPANTS

We used the cases of women who received midwifery care, experienced term PROM, and had singleton fetuses in the vertex position.

METHODS

We conducted an analysis of maternal and neonatal outcomes with term PROM using data from a midwifery service quality improvement database. We compared characteristics and outcomes between management plans (immediate induction, expectant hospital, and expectant home) using chi-square, analysis of variance, and independent t-tests.

RESULTS

PROM occurred in 281 (12%) of the 2,357 women cared for by the midwifery service between January 2016 and December 2018. One hundred fifty women (53.3%) opted to wait for labor onset at home, 102 (36.3%) were expectantly managed in the hospital, 21 (7.5%) were admitted for immediate induction of labor, and 8 (2.8%) were admitted for immediate cesarean birth. The rate of spontaneous labor onset was not significantly different between the two expectant management groups or between nulliparous and multiparous women. A total of 88 (34.9%) women who were expectantly managed ultimately had their labors induced. Rates of chorioamnionitis and endometritis were not significantly different between the expectant management groups in this study or compared with national averages. There was no difference in NICU admissions or Apgar scores below 7. The mean time from PROM to birth was significantly shorter in the expectant management in hospital group (27.3 hours) than in the expectant management at home group (33.5 hours).

CONCLUSION

Expectant management at home or in the hospital is appropriate for low-risk pregnant women with term PROM. Women for whom this option is appropriate include those with term singleton fetuses in vertex presentation with reassuring fetal heart rates and confirmed clear amniotic fluid. Acceptable time frames for home management include up to 24 hours for women with negative group B streptococcus cultures and up to 12 hours for those with positive cultures.

Labour Management in Trial of Labour After Cesarean Delivery (TOLAC): A Gap Analysis and Quality Improvement Initiative

OBJECTIVE

This quality improvement (QI) initiative was designed to identify gaps between evidence-based or hospital recommendations for trial of labour after cesarean delivery (TOLAC) labour management and clinical practice.

METHODS

Viable, singleton pregnancies from January 1, 2016, to December 31, 2018, undergoing TOLAC were extracted from the electronic medical record. Sixty randomly selected charts were reviewed for (1) consent, (2) induction methods, (3) oxytocin use, (4) continuous fetal monitoring, (5) admission indication, (6) examination regularity, (7) duration of dystocia before decision to perform cesarean delivery (CD), and (8) maternal complications.

RESULTS

The institutional vaginal birth after cesarean rate was 71%. Documented consent to TOLAC on admission was present in 50% of cases. Oxytocin augmentation was used in 38% of cases, and the median maximum dose was 4 mU/min (interquartile range [IQR] 3-7.5 mU/min). Delays in initiating oxytocin were identified in 47% of those patients. Decisions to deliver by cesarean were made after a median time of 5 hours and 40 minutes (IQR 3 hours and 30 minutes to 6 hours and 35 minutes) of failure to progress despite adequate contractions. After this decision, median time to delivery was 1 hour and 11 minutes (IQR 57 minutes to 2 hours and 16 minutes). Complications included postpartum hemorrhage (5%) and chorioamnionitis (6.7%). Surgical injury occurred in 10% of intrapartum CD. Peripartum complications were associated with delay in oxytocin implementation (χ² (1) = 9.80; P < 0.001) in secondary analysis.

CONCLUSION

Areas for QI were identified in (1) consent, (2) duration of dystocia before decision to proceed with CD and delay to CD, and (3) peripartum complications. We recognize the potential use of this as a tool to identify areas for QI and prospective study.

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.

Timing of induction for term prelabor rupture of membranes and intravenous antibiotics

BACKGROUND

Induction of labor usually within 24 hours is recommended for term prelabor rupture of membranes. It is still unclear when within the 24 hours induction of labor for term prelabor rupture of membranes should be initiated. Antibiotic prophylaxis for group B Streptococcus is usually recommended for prolonged prelabor rupture of membranes.

OBJECTIVE

The aim of our study was to evaluate whether induction of labor at ≤6 hours from prelabor rupture of membranes with intravenous oxytocin in singleton pregnancies at ≥37 weeks' gestation without regular uterine contractions reduces the administration of intravenous antibiotic agents.

STUDY DESIGN

This was a retrospective cohort study including all women with prelabor rupture of membranes at ≥37 weeks' gestation and without regular uterine contractions in which labor was induced using intravenous oxytocin. Women were divided into 2 groups according to the timing of induction (≤6 hours vs >6 hours after prelabor rupture of membranes).

RESULTS

A total of 166 women with term prelabor rupture of membranes were included, 53 of whom (31.9%) were induced within 6 hours of prelabor rupture of membranes and 113 (68.1%) were induced after 6 hours. There were no differences in demographic characteristics and risk factors for term prelabor rupture of membranes between the 2 groups. Women who underwent induction of labor at ≤6 hours were significantly less exposed to intravenous antibiotic prophylaxis compared with women induced at >6 hours (36% vs 80.5%, respectively; odds ratio, 0.14; 95% confidence interval, 0.07-0.28). Furthermore, for women induced within 6 hours after prelabor rupture of membranes, the chances of delivering at <12 or <24 hours were increased, nonreassuring cardiotocogram significantly less common, and hospital stay significantly shorter. No differences were found in regard to neonatal outcomes.

CONCLUSION

Induction of labor at ≤6 hours with intravenous oxytocin after term prelabor rupture of membranes is significantly associated with lesser use of antibiotic agents, shorter latency to delivery, lower incidence of nonreassuring cardiotocogram, and shorter hospital stay than induction of labor at >6 hours after prelabor rupture of membranes.