The impact of digital cervical examination on expectantly managed preterm rupture of membranes

FIGO good practice recommendations for preterm labor and preterm prelabor rupture of membranes: Prep-for-Labor triage to minimize risks and maximize favorable outcomes

Preterm labor occurs in around 10% of pregnancies worldwide. Once diagnosed, significant efforts must be made to reduce the likelihood of morbidity and mortality associated with preterm birth. In high-resource settings, access to hospitals with a neonatal intensive care unit (NICU) is readily available, whereas access to NICU care is limited in low- and middle-income countries (LMICs) and many rural settings. Use of FIGO's Prep-for-Labor triage method rapidly identifies low- and high-risk patients with preterm labor to enable clinicians to decide whether the patient can be managed on site or if transfer to a level II-IV facility is needed. The management steps described in this paper aim to minimize the morbidity and mortality associated with preterm labor and in the setting of preterm labor with preterm premature rupture of membranes (PPROM). The methods for accurate diagnosis of PPROM and chorioamnionitis are described. When the risk of preterm birth is high, antenatal corticosteroids should be administered for lung maturation combined with limited tocolysis for 48 hours to permit the corticosteroid course to be completed. Magnesium sulfate is also administered for fetal neuroprotection. Implementation of FIGO's Prep-for-Labor triage method in an LMIC setting will help improve maternal and neonatal outcomes.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, September 2022) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and on the Management of Preterm Premature Rupture of Membranes

Aim The revision of this guideline was coordinated by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (OEGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of the guideline is to improve the prediction, prevention and management of preterm birth based on evidence from the current literature, the experience of members of the guidelines commission, and the viewpoint of self-help organizations. Methods The members of the contributing professional societies and organizations developed recommendations and statements based on international literature. The recommendations and statements were presented and adopted using a formal process (structured consensus conferences with neutral moderation, written Delphi vote). Recommendations Part 2 of this short version of the guideline presents statements and recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Directive clinique no 430 : Diagnostic et prise en charge de la rupture prématurée des membranes avant terme

OBJECTIF

Fournir des directives claires et concises pour le diagnostic et la prise en charge de la rupture prématurée des membranes avant terme (RPMAT).

POPULATION CIBLE

Toute patiente manifestant une rupture prématurée des membranes avant 37 semaines d'aménorrhée. BéNéFICES, RISQUES ET COûTS: La présente directive clinique vise à fournir les premières recommandations générales canadiennes sur la prise en charge de la rupture des membranes avant terme. Elle repose sur un examen complet et à jour des données probantes sur le diagnostic de la rupture et sur la prise en charge, le bon moment et les modes d'accouchement. DONNéES PROBANTES: Des recherches ont été effectuées dans PubMed-Medline et Cochrane en 2021 en utilisant les termes suivants : preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, PAMG-1, IGFBP-1 test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des directives cliniques et des études observationnelles. D'autres publications pertinentes ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. 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 (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins de santé prénatale ou périnatale. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guideline No. 430: Diagnosis and management of preterm prelabour rupture of membranes

OBJECTIVE

To provide clear and concise guidelines for the diagnosis and management of preterm prelabour rupture of membranes (PPROM) TARGET POPULATION: All patients with PPROM <37 weeks gestation BENEFITS, HARMS, AND COSTS: This guideline aims to provide the first Canadian general guideline on the management of preterm membrane rupture. It includes a comprehensive and up-to-date review of the evidence on the diagnosis, management, timing and method of delivery.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane in 2021: preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, placental alpha microglobulin-1 (PAMG-1) test, insulin-like growth factor-binding protein-1 (IGFBP-1) test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/ antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/Neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Articles included were randomized controlled trials, meta-analyses, systematic reviews, guidelines, and observational studies. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

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 Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All prenatal and perinatal health care providers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Infectious morbidity of speculum versus digital examinations in preterm prelabor rupture of membranes: a systematic review and meta-analysis

OBJECTIVE

To estimate the effect of speculum examination only versus digital cervical examination on maternal infectious morbidity in women with preterm prelabor rupture of membranes by performing a systematic review and meta-analysis.

MATERIALS AND METHODS

We explored MEDLINE, Scopus, Embase, CINAHL, ClinicalTrials.gov and Cochrane Central Register of Controlled Trials for studies comparing the rate of a composite maternal infectious morbidity (either chorioamnionitis, endometritis or both) in women with preterm prelabor rupture of membranes that underwent a speculum only versus digital cervical examination at the time of diagnosis. Two reviewers separately ascertained studies, obtained data, and gauged study quality. The rate of a composite maternal infectious morbidity (either chorioamnionitis, endometritis or both) were compared and odds ratios (ORs) with 95% confidence intervals (CIs) were estimated.

RESULTS

Four cohort studies, reporting on 1213 women were identified. The median point prevalence of the composite maternal infectious morbidity was 26% (interquartile range 15-35%) in women who had a speculum examination only compared to 33% (interquartile range 22-42%) in women who underwent a digital examination. The overall maternal composite infectious morbidity rate in women that had a speculum examination only was less compared to women that had undergone a digital examination (pooled OR 0.75, 95% CI 0.58-0.98, I² 17%). The weighted mean length of latency in women with preterm prelabor rupture of membranes was longer in individuals evaluated by speculum only versus digital examination, 6.6 d versus 2.9 d (mean difference 4.5 d, 95% CI 1.4 to 7.8, I² 99%).

CONCLUSION

Speculum examination only in women with preterm prelabor rupture of membranes is associated with less maternal infectious morbidity and longer latency periods.

Incremental risk of clinical chorioamnionitis associated with cervical examination

BACKGROUND

Clinical chorioamnionitis is associated with significant maternal and neonatal morbidity, yet there is no clear evidence on the association between cervical examinations and infection.

OBJECTIVE

We sought to assess the association between the number of cervical examinations performed during term labor management and the risk of clinical chorioamnionitis.

STUDY DESIGN

This is a retrospective cohort study of term (≥37 weeks of gestation), singleton pregnancies who labored at our tertiary care center from 2014 to 2018. The primary outcome of clinical chorioamnionitis was defined as maternal intrapartum fever (single oral temperature of >39°C or 38°C-38.9°C for 30 minutes) and 1 or more of the following: maternal leukocytosis, purulent cervical drainage, or fetal tachycardia. The primary exposure was the number of digital cervical exams documented in the medical record. Log-binomial regression was used to model the effect of cervical examinations on the risk of clinical chorioamnionitis while adjusting for potential confounders.

RESULTS

A total of 20,029 individuals met the inclusion criteria and 1028 (5%) patients experienced clinical chorioamnionitis. The number of cervical exams was associated with increased risk of developing infection after adjusting for potential confounders. Individuals with ≥8 cervical exams had 1.7 times the risk of developing clinical chorioamnionitis compared with those with 1 to 3 exams. Prolonged rupture time, nulliparity, Black race, Medicaid insurance, higher gestational age, and higher body mass index were associated with increased risk of clinical chorioamnionitis, whereas smoking and group B Streptococcus colonization were associated with a lower risk.

CONCLUSION

Our study found that the number of cervical exams performed during labor is an independent risk factor for developing clinical chorioamnionitis. Unnecessary cervical exams should be avoided during labor management at term.

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.

Usefulness of an Intrapartum Ultrasound Simulator (IUSim™) for Midwife Training: Results from an RCT

INTRODUCTION

We conducted a randomized study to determine whether a training session on a dedicated simulator (IUSim™) would facilitate the midwives in learning the technique of transperineal intrapartum ultrasound.

METHODS

Following a 30-min multimedia presentation including images and videos on how to obtain and measure the angle of progression (AoP) and the head-perineum distance (HPD), 6 midwives with no prior experience in intrapartum ultrasound were randomly split into 2 groups: 3 of them were assigned to the "training group" and 3 to the "control group." The midwives belonging to the former group were taught to measure the 2 sonographic parameters during a 3-h practical session conducted on IUSim™ under the supervision of an expert obstetrician. In the following 3 months, all the 6 midwives were asked to independently perform transperineal ultrasound during their clinical practice and to measure on the acquired images either the AoP or the HPD. The sonographic images were examined in blind by the teaching obstetrician who assigned a 0-3 score to the image quality (IQS) and to the measurement quality (MQS).

RESULTS

A total of 48 ultrasound images (24 patients) from 5 midwives were acquired and included in the study analysis. A midwife of the "training group" declined participation after the practical session. Independently from the randomization group, the image quality score (IQS + MQS) was significantly higher for the HPD compared with the AoP (2.5 ± 0.66 vs. 1.79 ± 1.14; p = 0.01). In the training group, the MQS of either AoP (2.66 ± 0.5 vs.1.46 ± 1.45. p = 0.038) and the HPD (2.9 ± 0.33 vs. 1.87 ± 0.83 p = 0.002) was significantly higher in comparison with the control group, while the IQS of both measurements was comparable between the 2 groups (1.91 ± 1.24 vs. 2.25 ± 0.865; p = 0.28).

CONCLUSION

The use of a dedicated simulator may facilitate the midwives in learning how to measure the AoP and the HPD on transperineal ultrasound images.

Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217

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

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Preterm Premature Rupture of Membranes: A Review of 3 National Guidelines

Importance

Preterm premature rupture of membranes (PPROM) is a major cause of perinatal mortality and morbidity.

Objective

The aim of this study was to compare recommendations from published national guidelines for pregnancies complicated with PPROM.

Evidence Acquisition

A descriptive review of 3 national guidelines on PPROM was performed: the Royal College of Obstetricians and Gynaecologists on "Preterm Prelabour Rupture of Membranes," the American College of Obstetricians and Gynecologists on "Premature Rupture of Membranes," and the Society of Obstetricians and Gynaecologists of Canada on "Antibiotic Therapy in Preterm Premature Rupture of the Membranes." Guidelines were compared in the diagnosis and management of PPROM. Recommendations and strength of evidence were reviewed based on each guideline's method of reporting. The references were compared with regard to their total number, total number of randomized controlled trials, Cochrane reviews, and systematic reviews/meta-analyses cited.

Results

The variations stated on the guidelines reflect the heterogeneity of the literature contributing to the guidelines and challenges of diagnosing and managing cases of PPROM.

Conclusions

An improved international guideline may improve safety and outcomes in pregnant women with PPROM.

[Management of preterm premature rupture of membranes (except for antibiotherapy): CNGOF preterm premature rupture of membranes guidelines]

OBJECTIVE

To review the different parts of therapeutic management of viable preterm premature rupture of membranes (PPROM), except the antibiotherapy and birth modalities.

METHODS

The Medline, Cochrane Library, and Google Scholar databases over a period from 1980 to September 2018 have been consulted.

RESULTS

When the diagnostic of viable PPROM is reached, the woman should be hospitalized and signs of intrauterine infection (IUI) should be sought (Professional consensus). If cervical assessment appears necessary, speculum, digital examination or cervical ultrasound may be performed (Professional consensus). It is recommended to limit cervical evaluation regardless of the method used (Professional consensus). Initial ultrasound is recommended to determine the fetal presentation, locate the placenta, estimate the fetal weight and the residual amniotic fluid volume (Professional consensus). Performing vaginal and urinary bacteriological sampling at admission is recommended before any antibiotic (Professional consensus). In the case of positive vaginal culture, an antibiogram is necessary since it can guide antibiotherapy in the case of IUI and early onset neonatal bacterial sepsis (Professional consensus). In absence of demonstrated neonatal benefit, there is insufficient evidence to recommend or to not recommend initial tocolysis in PPROM (Grade C). If tocolysis was administered, it is recommended not to prolong it for more than 48hours (Grade C). Antenatal corticosteroid administration is recommended before 34 weeks of gestation (WG) (Grade A) and magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 WG (Grade A). Vitamin supplementation (vitamins C and E) is not recommended (Professional consensus), and it is recommended not to impose strict bed rest in case of PPROM (Professional consensus). In case of clinical signs of IUI with cerclage, it is recommended to remove the cerclage immediately (Professional consensus). The home care management of clinically stable PPROM after 48hours of hospital observation can be considered (Professional consensus). During the monitoring of a PPROM, it is recommended to identify elements relating to the diagnosis of IUI (Professional consensus).

CONCLUSION

The level of evidence and scientific data in the literature concerning the management (except antibiotics) of PPROM are low. Initial management of viable PPROM requires hospitalization. The main objectives of the management are the detection and medical care of maternal and fetal complications.

ACOG Practice Bulletin No. 188: Prelabor Rupture of Membranes

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm prelabor rupture of membranes (also referred to as premature rupture of membranes) (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

Practice Bulletin No. 172: Premature Rupture of Membranes

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm premature rupture of membranes (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

The predictive value of lactate levels in vaginal fluid on the latent period in pregnant women with preterm premature rupture of membranes

The aim of the present study was to investigate the relationship between lactate level in vaginal fluid and the latent phase of labour in pregnancies complicated by preterm premature rupture of membranes (PPROM). Seventy pregnant women with PPROM during 28-34 weeks' gestation were selected for this prospective observational study. All subjects underwent a pelvic examination involving the insertion of a vaginal speculum, and lactate levels were measured in vaginal fluid samples. The relationship between the lactate levels in the vaginal fluid and the latent phase of the labour was analysed using a logistic regression test. Of the patients, 48 (68.6%) had a latent period of 48 h or less, and 22 patients (31.4%) had a latent period longer than 48 h. The median lactate level was 3.81 mmol/L in patients with a latent period ≤ 48 h, and 3.36 mmol/L in patients with a latent period > 48 h. The lactate level in vaginal fluid was not found to be distinctive in the differentiation of patients according to the duration of the latent phase (receiver operating characteristic or ROC: 0.509; 95% confidence interval or CI: 0.361-0.657; p = 0.904). There was no significant correlation between the lactate level in the vaginal fluid and the transition from the latent phase to the active phase of labour in pregnancies complicated by PPROM.

[Preterm rupture of membranes: Is home care a safe management?]

OBJECTIVE

Compare the maternal and neonatal outcomes in pregnancies complicated by preterm prelabour rupture of membranes (PPROM), which were managed either at home (HAD) or hospital (HC).

MATERIALS AND METHODS

Retrospective study in two level III maternities during 2 years. Inclusion criteria in HAD were: singleton pregnancy, PPROM between 24 and 35 weeks of gestation, absence of chorioamnionitis, clinical stability at D7 of the rupture, cervical dilatation <3 cm, patient residing in the geographic area.

RESULTS

Thirty-two patients were included in the HAD group and 24 in the HC group. Our populations were similar in the 2 groups. The duration of latency was longer in the HAD group than in the HC group (27.5 d [20-37] versus 16.5 d [12.5 to 29.5]; P=0.026). Patients in the HAD group received fewer antibiotics with a similar rate of chorioamnionitis. No difference in terms of obstetrical and neonatal outcomes was observed. Number of days in neonatal resuscitation was lower in the HAD group than in the HC group (12.5 d [10-22] versus 43 d [20-52]; P=0.003).

CONCLUSION

HAD seems to be an alternative to continuous hospitalization for patients followed for PPROM between 24 and 35 weeks. A randomized study with a larger number of patients, including other data such as maternal satisfaction and cost analysis, would be interesting to confirm those preliminary results.

Neonatal morbidity mortality outcomes in pre-term premature rupture of membranes

We present a retrospective review of 228 pre-term premature rupture of membranes (PPROM) singleton pregnancies followed-up in our clinic between 1996 and 2005. The most common neonatal morbidities in PPROM cases are respiratory distress syndrome (RDS), sepsis and intraventricular haemorrhage (IVH). The route of delivery does not affect newborn intensive care unit (NICU) requirements, perinatal asphyxia, sepsis and IVH rates in PPROM cases. NICU and PPV requirements, RDS, sepsis and IVH rates increase if the Apgar score is < 5. Neonatal morbidity and mortality rates increase as the latent period lengthens. C reactive protein (CRP) on admission, last CRP, birth weight and the 5 min Apgar score was found to be associated with NICU requirements; only the 5 min Apgar score was found to be associated with RDS; and last leukocyte count and maternal haemotocrit was found to be associated with sepsis and pneumonia, independently. In PPROM cases, CRP on admission, last CRP, birth weight, the 5 min Apgar score, last leukocyte count and maternal haemotocrit, should be considered to predict neonatal outcomes.

Practice bulletins No. 139: premature rupture of membranes

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (). Preterm premature rupture of membranes (PROM) complicates approximately 3% of all pregnancies in the United States (). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

[Rupture of membranes: pathophysiology, diagnosis, consequences and management]

Rupture of membranes (ROM) depends on mechanical stretch, extracellular matrix components imbalance and increased apoptosis. It occurs in 2 to 3% of all pregnancies before 37 weeks' gestation (WG) and in up to 10% at term. Main consequences are labor induction and risk of maternal-fetal infection. ROM is associated with one third of preterm births and about 20% of perinatal mortality. This review deals with recent knowledge concerning ROM including diagnosis and management. In many cases, ROM is easily identified by clinical examination. In other cases, the use of vaginal pH appears to be less efficient than the use of immunochromatographic strips based on IGFBP-1 or PAMG-1 detection. Before 34WG, conservative management consists in in utero transfer, antibioprophylaxis and corticosteroids. After 37WG, delivery is the most appropriate option. Between 34 and 37WG, recent studies demonstrate that induction of labour does not improve pregnancy outcomes. Therefore, expectant management can be the first option between 34 and 37WG when no active infection is suspected especially in case of unfavourable cervix.

Number of cervical examinations and risk of intrapartum maternal fever

OBJECTIVE

To estimate the association between number of cervical examinations and risk of maternal fever during term labor and delivery.

METHODS

Within a 4-year retrospective cohort study of all consecutive term (37 weeks of gestation or more) singleton deliveries reaching the second stage of labor, we identified women who developed an intrapartum fever and compared them with women who remained afebrile through 6 hours postpartum. Primary exposure was number of digital cervical examinations. Extensive data were collected from the medical record, including obstetric and medical history, cervical examinations and timing, admitting diagnoses, and outcomes. Time-to-event analyses were used to account for length of labor. Cox proportional hazard models were developed adjusting for potentially confounding factors.

RESULTS

Of 2,395 women who were afebrile at admission, 174 (7.2%) developed an intrapartum fever. Women were examined one to 14 times. There was no significant association between increasing number of examinations and risk of fever. Even for the 505 women who had more than seven examinations during labor, there was no statistically significant increased risk of fever (hazard ratio 0.9, 95% confidence interval 0.4-2.0) compared with those with one to three examinations. Subanalyses by labor type and examinations after rupture of membranes also showed no significant association between number of cervical examinations and risk of intrapartum fever.

CONCLUSION

During term labor management, maternal fever risk is not significantly increased by the number of cervical examinations.

LEVEL OF EVIDENCE

II.

Prediction of imminent preterm delivery in women with preterm premature rupture of membranes

AIMS

To develop a model based on non-invasive clinical parameters to predict the probability of imminent preterm delivery (delivery within 48 h) in women with preterm premature rupture of membranes (PPROM), and to determine if additional invasive test results improve the prediction of imminent delivery based on the non-invasive model.

METHODS

Transvaginal ultrasonographic assessment of cervical length was performed and maternal serum C-reactive protein (CRP) and white blood cell (WBC) count were determined immediately after amniocentesis in 102 consecutive women with PPROM at 23-33+6 weeks. Amniotic fluid (AF) obtained by amniocentesis was cultured and interleukin-6 (IL-6) levels and WBC counts were determined.

RESULTS

Serum CRP, cervical length, and gestational age were chosen for the non-invasive model (model 1), which has an area under the curve (AUC) of 0.804. When adding AF IL-6 as an invasive marker to the non-invasive model, serum CRP was excluded from the final model (model 2) as not significant, whereas AF IL-6, cervical length, and gestational age remained in model 2. No significant difference in AUC was found between models 1 and 2.

CONCLUSIONS

The non-invasive model based on cervical length, gestational age, and serum CRP is highly predictive of imminent delivery in women with PPROM. However, invasive test results did not add predictive information to the non-invasive model in this setting.

Microbiologic and histologic characteristics of the extremely preterm infant's placenta predict white matter damage and later cerebral palsy. the ELGAN study

Inflammatory phenomena seem to contribute to the occurrence of perinatal cerebral white matter damage and CP. The stimulus that initiates the inflammation remains obscure. One thousand two hundred forty-six infants born before the 28th postmenstrual week had a protocol ultrasound scan of the brain read concordantly by two independent sonologists. Eight hundred ninety-nine of the children had a neurologic examination at approximately 24-mo postterm equivalent. The placenta of each child had been biopsied under sterile conditions and later cultured. Histologic slides of the placenta were examined specifically for this study. Recovery of a single microorganism predicted an echolucent lesion, whereas polymicrobial cultures and recovery of skin flora predicted both ventriculomegaly and an echolucent lesion. Diparetic CP was predicted by recovery of a single microorganism, multiple organisms, and skin flora. Histologic inflammation predicted ventriculomegaly and diparetic CP. The risk of ventriculomegaly associated with organism recovery was heightened when accompanied by histologic inflammation, but the risk of diparetic CP was not. Low-virulence microorganisms isolated from the placenta, including common skin microflora, predict ultrasound lesions of the brain and diparetic CP in the very preterm infant. Organism recovery does not seem to be needed for placenta inflammation to predict diparetic CP.

Late preterm gestation: physiology of labor and implications for delivery

The late preterm infant represents a significant portion of preterm deliveries. Historically, this cohort has been referred to as near-term, which may not address adequately the increased perinatal morbidity these neonates experience. The changing demographics of pregnant women also are increasing the number of inductions in this gestational age group. More women with chronic hypertension, diabetes, and other chronic medical problems are getting pregnant, and often these pregnancies may require induction during this gestational age. The increasing numbers of multi-fetal gestations also have an average gestational age at delivery in this range of 34 to 36.6 weeks. Preeclampsia is another factor that can lead to delivery and induction during this gestational age. This article discusses some of the physiologic causes behind late preterm deliveries.

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

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

Preterm premature rupture of membranes: diagnosis, evaluation and management strategies

Preterm premature rupture of the membranes (PPROM) is responsible for one-third of all preterm births and affects 120,000 pregnancies in the United States each year. Effective treatment relies on accurate diagnosis and is gestational age dependent. The diagnosis of PPROM is made by a combination of clinical suspicion, patient history and some simple tests. PPROM is associated with significant maternal and neonatal morbidity and mortality from infection, umbilical cord compression, placental abruption and preterm birth. Subclinical intrauterine infection has been implicated as a major aetiological factor in the pathogenesis and subsequent maternal and neonatal morbidity associated with PPROM. The frequency of positive cultures obtained by transabdominal amniocentesis at the time of presentation with PPROM in the absence of labour is 25-40%. The majority of amniotic fluid infection in the setting of PPROM does not produce the signs and symptoms traditionally used as diagnostic criteria for clinical chorioamnionitis. Any evidence of infection by amniocentesis should be considered carefully as an indication for delivery. Documentation of amniotic fluid infection in women who present with PPROM enables us to triage our therapeutic decision making rationally. In PPROM, the optimal interval for delivery occurs when the risks of immaturity are outweighed by the risks of pregnancy prolongation (infection, abruption and cord accident). Lung maturity assessment may be a useful guide when planning delivery in the 32- to 34-week interval. A gestational age approach to therapy is important and should be adjusted for each hospital's neonatal intensive care unit. Antenatal antibiotics and corticosteroid therapies have clear benefits and should be offered to all women without contraindications. During conservative management, women should be monitored closely for placental abruption, infection, labour and a non-reassuring fetal status. Women with PPROM after 32 weeks of gestation should be considered for delivery, and after 34 weeks the benefits of delivery clearly outweigh the risks.

Streptococcus porcinus as a cause of spontaneous preterm human stillbirth

We report, to our knowledge, on the first case of a woman suffering stillbirth due to Streptococcus porcinus on the basis of microbiologic and histologic data.

Preterm premature rupture of the membranes: diagnosis and management

Preterm premature rupture of the membranes (preterm PROM) is a common and significant cause of preterm birth and perinatal morbidity and mortality. The obstetric caregiver has the opportunity significantly to alter pregnancy and perinatal outcome for women suffering from this complication. Although management is often predetermined by the presence of clinical infection, vaginal bleeding, labor, or nonreassuring fetal heart-rate pattern on admission, a gestational age-based approach to the management of the stable patient with preterm PROM offers the potential to reduce perinatal infectious and gestational age-dependent morbidity for patients who are amenable to conservative management.

An Evidence-Based Approach to the Evaluation and Treatment of Premature Rupture of Membranes: Part I

Preterm premature rupture of membranes (PPROM) occurs in 3% of pregnancies and is responsible for one third of all preterm births. PPROM will affect 120,000 women in the United States each year. It is associated with significant maternal, fetal, and neonatal morbidity and mortality resulting from infection, umbilical cord compression, abruptio placentae, and prematurity. The etiology is multifactorial, but the most significant risk factors are previous preterm birth and previous preterm premature rupture of membranes. Accurate diagnosis is extremely important to assure proper treatment. Evaluation is based on patient history and clinical examination. This review presents the available evidence and grades it according to the U.S. Preventative Task Force recommendations. In part I of this review, the definition, pathophysiology, and methods of PPROM diagnosis are presented. In part II, the management, treatment, neonatal outcome, and the maternal and fetal evaluation of women with PPROM in the presence of cerclage and medical complications is reviewed.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to define the term: preterm premature rupture of membranes, to list the factors associated with premature rupture of membranes, and to outline the tests available for the diagnosis of intra-amniotic infection.

Increased rates of chorioamnionitis with extra-amniotic saline infusion method of labor induction

OBJECTIVE

Extra-amniotic saline infusion has been shown to be equal to or more efficacious than misoprostol, laminaria, dinoprostone, and prostaglandin estradiol for cervical ripening and labor induction. Because of the introduction of a foreign body into the uterus, extra-amniotic saline infusion may potentially cause increased rates of chorioamnionitis. This study examines the risk of chorioamnionitis with extra-amniotic saline infusion compared with other methods of induction and spontaneous labor.

METHODS

A retrospective analysis was performed based on deliveries at Bellevue Hospital Center, a tertiary-care facility, from August 2000 to December 2002. Three groups were identified: extra-amniotic saline infusion, other methods of induction, and spontaneous labor. Differences in chorioamnionitis rates were analyzed by using analysis of variance and multivariable logistic regression as appropriate.

RESULTS

There were 625 charts evaluated: 171 extra-amniotic saline infusion, 190 other, and 264 with spontaneous labor. The rates of chorioamnionitis were 26.9%, 17.9%, and 13.3%, respectively. After adjusting for confounding variables, such as instrumentation, length of rupture, and number of exams, subjects who were induced with extra-amniotic saline infusion were significantly more likely to develop chorioamnionitis (relative risk = 2.2; 95% confidence interval 1.4, 4.0; P =.006).

CONCLUSION

Extra-amniotic saline infusion may be associated with a greater risk of chorioamnionitis when compared with other methods of labor induction. Given the increased risk of chorioamnionitis associated with extra-amniotic saline infusion, its use should be in the context of a careful assessment of the risks and benefits of various methods of labor induction.

LEVEL OF EVIDENCE

II-2

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

Preterm premature rupture of the membranes (pPROM) is responsible for approximately one third of the over 450,000 preterm births occurring in the United States annually. In this manuscript, we summarize the outcomes and analyses related to the National Institute of Child Health and Human Development Maternal Fetal Medicine Units Network (NICHD-MFMU) network multicenter trial of antibiotics to reduce infant morbidity after pPROM. Based on evident reduction in gestational age dependent and infectious infant morbidity, we provide the rationale for aggressive intravenous and oral, broad spectrum Ampicillin/Amoxicillin, and Erythromycin therapy during conservative management of pPROM before 32 weeks' gestation. We further review the histopathologic correlates to pPROM, to antibiotic treatment, and to perinatal outcome, and discuss the relationships between maternal and neonatal cytokine levels intercellular adhesion molecule, and other clinical and plasma markers regarding perinatal morbidity. The use and limitations of ultrasound and vaginally collected amniotic fluid pulmonary maturity assessment are discussed.

[Prediction of the latency period by cervical ultrasonography in premature rupture of the membranes before term]

OBJECTIVE

To assess the value of ultrasonographic measurement of cervical length for predicting the duration of the latency period from admission to delivery in women with preterm premature rupture of the membranes (PROM).

METHOD

Prospective study in 88 women with preterm PROM before 34 weeks of amenorrhea. The median gestational age at admission was of 30.1 weeks. The clinical management included: no digital examination of the uterine cervix, antenatal corticosteroids, antibiotics (amoxicillin & clavulanic acid) for 7 days, and hoding back until 34 weeks. Cervical length at admission was determined with transvaginal ultrasonography. The duration of the latency period was studied in relation with cervical length, serum C-reactive protein (CRP) level and white blood cell (WBC) count at admission.

RESULTS

The median latency period was longer in women with a cervical length > or = 25 mm (10 vs 5 days; p = 0.04), but this was not associated with a significant increase in birth weight. The median latency period was also longer in women with CRP < 20 mg/l (10 vs 3 days; p < 0.001) and this was associated with a significant increase in birth weight (1716 +/- 549 vs 1201 +/- 485 g; p < 0.01). Moreover, increased CRP levels were more frequent in women with a cervical length < 25 mm, and cervical length was no more predictive of the duration of the latency period in the subgroup of women with CRP < 20 mg/l and WBC < 20,000 cells/mm3.

CONCLUSION

In women with preterm PROM, the latency period from admission to delivery is shorter when cervical length is < 25 mm. However, the clinical value of transvaginal ultrasonography is limited in comparison with serum CRP.

Management of premature rupture of membranes

The management of patients with PROM, regardless of gestational age, remains controversial. Generally, when patients are in labor, have infection, or there is irreversible fetal distress, there are few options other than delivery. For those not in labor, especially in premature gestational ages, the complexities of the many combinations of decisions to be made regarding the best methods for evaluating patients, prolonging gestation, reducing complications of prematurity, and choosing the timing and route of delivery make studying and solving the problem of the best option for management difficult at best. The administration of corticosteroids and broad-spectrum antibiotics of those patients in the very early premature gestational age groups has now been shown clearly to improve outcome. Beyond that, the remainder of these problems are somewhat unresolved and several reasonable options often exist and are likely to remain so for some time to come.