An aggressive interventional protocol for early midtrimester premature rupture of the membranes using gelatin sponge for cervical plugging

Management and Interventions in Previable and Periviable Preterm Premature Rupture of Membranes: A Review

Importance

Periviable and previable premature rupture of membranes (pPPROM) occurs in <1% of pregnancies but can have devastating consequences for the mother and the fetus. Understanding risk factors, possible interventions, and both maternal and neonatal outcomes will improve the counseling and care provided for these patients.

Objective

The aim of this review is to describe the etiology, risk factors, management strategies, neonatal and maternal outcomes, and recurrence risk for patients experiencing pPPROM.

Evidence Acquisition

A PubMed, Web of Science, and CINAHL search was undertaken with unlimited years searched. The search terms used included "previable" OR "periviable" AND "fetal membranes" OR "premature rupture" OR "PROM" OR "PPROM." The search was limited to English language.

Results

There were 181 articles identified, with 41 being the basis of review. Multiple risk factors for pPPROM have been identified, but their predictive value remains low. Interventions that are typically used once the fetus reaches 23 to 24 weeks of gestation have not been shown to improve outcomes when used in the previable and periviable stage. Neonatal outcomes have improved over time, but survival without severe morbidity remains low. Later gestational age at the time of pPPROM and longer latency period have been shown to be associated with improved outcomes.

Conclusions and Relevance

Periviable and previable premature rupture of membranes are uncommon pregnancy events, but neonatal outcomes remain poor, and routine interventions for PPROM >24 weeks of gestation have not proven beneficial. The 2 most reliable prognostic indicators are gestational age at time of pPPROM and length of the latency period.

Application of Tissue Engineering and Regenerative Medicine in Prelabor Rupture of Membranes: a Review of the Current Evidence

Preterm prelabor rupture of membranes (PPROM) is the main cause of preterm delivery, resulting in increased perinatal morbidity and mortality. Several techniques have been studied for the healing of ruptured membranes, with some success. Before new techniques using tissue/organ engineering are applied in clinical practice, these techniques must be validated in clinical trials. To address this issue, the objective of this study was to summarize the current literature on interventions to seal or heal the amniotic membranes after PPROM. An electronic search was conducted using the keywords "fetal membranes," "premature rupture," "amnion," "tissue engineering," "fibrin tissue adhesive," "regenerative medicine," "tissue adhesive," "wound healing," and "fetoscopy" through the MEDLINE, Embase, and Cochrane CENTRAL databases, with the limitation of English-language studies. Through a review of the identified studies, it was found that spontaneous healing of the fetal membrane has not been successful. Several efforts have been made to seal membranes before or after rupture using different methods, including amniopatches, collagen, tissue patches, fibrin sealant, mussel-mimetic sealant, engineered cell matrix, and immunological supplements. However, most studies have been conducted in ex vivo or in vivo settings, so the safety and applicability of these techniques to spontaneous rupture of membranes in clinical settings have not been sufficiently tested. Overall, the current evidence is limited regarding the safety and effectiveness of interventions against PPROM.

Amnion-Analogous Medical Device for Fetal Membrane Healing: A Preclinical Long-Term Study

Although recent invasive fetal surgeries have improved fetal outcomes, fetal membrane rupture remains a major complication, leading to premature delivery, thus undermining the complete benefits of such procedures. A biocompatible amnion-analogous medical device (AMED) consisting of polycaprolactone framework and decellularized amniotic membrane (dAM)-derived hydrogel for restoration of amniotic membrane defect is developed using 3D printing technology. Its efficacy on healing iatrogenic fetal membrane defects in vitro is evaluated, showing that the dAM gel contains migratory and proliferative properties. The fetoscope feasibility of the developed AMED is assessed using a pregnant swine model. All animals had successfully recovered from anesthesia and the fetoscopic procedure and maintained a healthy condition until the end of the pregnancy. AMED exhibits superior surgical handling characteristics and is easy to manufacture, nonimmunogenic, biocompatible, and suitable for storage and transport for off-the-shelf use; hence, it can be used in successfully sealing defect sites, thus improving the preservation of the amniotic fluid, which in turn improves fetal survival and development.

Perinatal outcomes after previable preterm premature rupture of membranes before 24 weeks of gestation

OBJECTIVE

A current descriptive assessment of perinatal outcomes in pregnancies complicated by previable preterm premature rupture of membranes (pPPROM) at <24 weeks of gestation, after expectant treatment.

STUDY DESIGN

Maternal and short-term neonatal data were collected for patients with pPPROM.

RESULTS

Seventy-three patients with 93 fetuses were hospitalized with pPPROM at 15-24 weeks' gestation. Among these patients, 27.4% (n=20) chose pregnancy termination, 27.4% (n=20) miscarried and 45.2% (n=33) proceeded to live births. After a median latency period of 38 days, ranging from 1 to 126 days, 24 singletons and 20 multiples were live-born, of whom 79.5% (n=35) survived the perinatal period. The main neonatal sequelae were pulmonary hypoplasia (29.5%; n=13), connatal infection (56.8%; n=25), intraventricular hemorrhage (25%; n=11; resulting in five neonatal deaths) and Potter's syndrome (15.9%; n=7). Nine newborns died, within an average of 2.8 days (range, 1-10 days). The overall neonatal survival rate was 51.5% - including miscarriages but not elective terminations. The intact survival rate was 45.5% of all live-born neonates.

CONCLUSIONS

Even with limited treatment options, overall neonatal survival is increasing. However, neonatal mortality and morbidity rates remain high. The gestational age at membrane rupture does not predict neonatal outcome.

Prenatal incarceration of caput succedaneum: A case report

Caput succedaneum is relatively common at birth but infrequently diagnosed in utero. We report the first case of a prenatal incarcerated caput succedaneum after cervical cerclage in a patient with premature rupture of the membranes (PPROM). A 41-year-old woman was referred and admitted to our hospital due to PPROM at 19 wk of gestation. Aggressive therapy, including amnioinfusion, cervical cerclage, and administration of antibiotics and tocolysis, was initiated. At 24 wk of gestation, a thumb tip-sized and polyp-like mass, which was irreducible, was delineated with a vaginal examination, vaginal speculum, and transvaginal ultrasonography, leading to the diagnosis of incarcerated caput succedaneum. Under general anesthesia, the incarcerated caput succedaneum was repositioned with fingers after cutting the string to avoid necrosis, and then, placement of a McDonald cervical cerclage was undertaken again. At 26 wk of gestation, she delivered a 678 g girl through an emergency cesarean section performed due to profuse bleeding and prolonged decelerations. A slight bulge with hair was observed on the head by palpation at birth. Cephalic ultrasonography, X-ray, magnetic resonance imaging and electroencephalogram confirmed no abnormality. Although the baby needed oxygen (0.2 L/min) at the time of hospital discharge, she has grown favorably at three years of corrected age.

Pulmonary effects of prolonged oligohydramnios following mid-trimester rupture of the membranes--antenatal and postnatal management

Mid-trimester, preterm prelabour rupture of the membranes (PPROM) with prolonged oligohydramnios remains a challenge for both obstetricians and neonatologists. Although survival rates have improved, morbidity remains common particularly due to pulmonary insufficiency and pulmonary hypertension. The aetiology of abnormal lung development is unknown but may depend critically on pulmonary vascular development. Antenatal evaluation of at-risk foetuses by three-dimensional ultrasound and MRI is possible but the techniques need to be further assessed. Antenatal corticosteroids given in cases of PPROM reduce the incidence of neonatal death, respiratory distress syndrome, intraventricular haemorrhage and necrotising enterocolitis without increasing maternal or neonatal infection. The true risk-benefit ratio of antibiotics, tocolysis and strategies to normalise amniotic fluid volume remains less clear. There is no consensus regarding the optimal ventilation strategy to support infants with pulmonary insufficiency following PPROM, and further work is required to determine whether and which pulmonary vasodilators improve long-term outcome in these infants.

Laser therapy for twin-to-twin transfusion syndrome (TTTS)

Monochorionic twins are subjected to specific complications which originate in either imbalance or abnormality of the single placenta serving two twins including twin-to-twin transfusion syndrome. The diagnosis is well established in overt clinical forms with the association of polyuric polyhydramnios and oliguric oligohydramnios. The best treatment of cases presenting before 26 weeks of gestion is fetoscopic laser ablation of the intertwin anastomoses on the chorionic plate. Although subjected to subtle variations, the core technique follows robust guidelines which could help understanding and acquiring the required skills and experience to perform this procedure. However appropriate and tailored hands-on training and appropriate perinatal set-up are critical not only for surgical management but also for the follow-up and management of related complications.

The management of preterm premature rupture of the membranes near the limit of fetal viability

Preterm premature rupture of the membranes near the limit of fetal viability is an uncommon complication of pregnancy, affecting approximately 4 in 1000 gravidas. However, maternal, fetal, and neonatal complications resulting from this condition are significant and include chorioamnionitis, pulmonary hypoplasia, restriction deformities, fetal loss, and complications of extreme prematurity among surviving infants. In this article, we review the literature regarding pregnancy outcomes after preterm premature rupture of the membranes near the limit of viability, and the data on traditional and nontraditional interventions to improve outcomes. An approach to patients who present with preterm premature rupture of the membranes near the limit of viability will be proposed.

Treatment with amniopatch of premature rupture of membranes after first-trimester chorionic villus sampling

OBJECTIVE

To assess the amniopatch procedure when premature rupture of membranes occurs after first-trimester chorionic villus sampling (CVS).

STUDY DESIGN

From May 2001 to June 2004, the amniopatch procedure was offered in cases of premature rupture of membranes after CVS when severe oligohydramnios was present (largest vertical pocket < 2 cm) and persistent (more than 1 week).

RESULTS

The amniopatch was placed in five pregnancies at 12-18 weeks of gestation, resulting in amniotic fluid restoration in all but one pregnancy. In three pregnancies, fetal demise was observed at 1, 2 and 36 days after the procedure. The last procedure resulted in a healthy newborn.

CONCLUSION

Although the amniopatch restored normal amniotic fluid levels in all cases, 4 of the 5 cases resulted in fetal demise.

Manufacture of a Cell-free Amnion Matrix Scaffold that Supports Amnion Cell Outgrowth In Vitro

We manufactured a cell-free extracellular matrix scaffolds in order to obtain a support material for amnion cell outgrowth, eventually being used for repair of prematurely ruptured fetal membrane. Human preterm or term amnion tissue was separated into its collagenous extracellular matrix and cell components. The acellular scaffold was explored for its capacity to support regrowth of isolated human amnion epithelial or mesenchymal cells in vitro. The outgrowth of amnion cells on and in the scaffold was investigated by scanning and transmission electron microscopy, and confocal laser scanning microscopy. Cell-free amnion matrix scaffolds demonstrated a porous collagen fiber network similar as in native amnion. Inoculation of acellular amnion scaffolds with human amnion cells revealed that its property to support amnion cell outgrowth was retained. Amnion epithelial and mesenchymal cells were found to grow into dense layers on the surface of the scaffold within 3-4 days and 7-8 days, respectively, and to some extent, invaded the scaffold during the culture period. Manufactured acellular amnion matrix retains structural and functional properties required for cell outgrowth in vitro. It may become useful to repair prematurely ruptured fetal membranes.

Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence

In view of the important protective role of the fetal membranes, wound sealing, tissue regeneration, or wound healing could be life saving in cases of preterm premature rupture of the membranes. Although many investigators are studying the causes of preterm premature rupture of membranes, the emphasis has not been on the wound healing capacity of the fetal membranes. In this review, the relevant literature on the pathophysiologic condition that leads to preterm premature rupture of membranes will be summarized to emphasize a continuum of events between rupture and repair. We will present the current knowledge on fetal membrane wound healing and discuss the clinical implications of these findings. We will critically discuss recent experimental interventions in women to seal or heal the fetal membranes after preterm premature rupture of membranes.

Predictors of perinatal survival in a cohort of pregnancies with severe oligohydramnios due to premature rupture of membranes at <26 weeks managed with serial amnioinfusions

OBJECTIVE

To evaluate whether successful amnioinfusion is an independent predictor of perinatal survival in a cohort of cases with extreme and persistent oligohydramnios due to preterm premature rupture of membranes (pPROM) who reached viability and were managed with serial amnioinfusions.

STUDY DESIGN

We included all consecutive singleton pregnancies with pPROM at <26 weeks and oligohydramnios lasting >4 days between 1/1991 and 12/2001 and who consented to undergo amnioinfusion (n=77). Women received serial transabdominal amnioinfusions in an attempt to maintain a pocket of fluid >2 cm. The procedure was deemed successful if the median deepest pocket of fluid during the latency period was >2 cm. Excluded were miscarriages (n=10), fetal deaths before viability (24 weeks) (n=15), and cases that did not develop oligohydramnios (n=17). Prenatal predictors of outcome were compared between cases who survived the perinatal period and those who did not using Wilcoxon rank-sum test, Fisher's exact test and stepwise logistic regression analysis, with a two-tailed P<0.05 considered significant.

RESULTS

Of the 35 patients fulfilling the study criteria, 20 (57%) survived the perinatal period. Perinatal survivors had similar gestational age at pPROM (P=0.68) and at first amnioinfusion (P=0.53) as those who died in the perinatal period, but longer latency (P=0.013). Consequently, median gestational age at delivery [29.2 (25.4-35.3) weeks versus 26.1 (24.0-34.0) weeks, P<0.001] and median birth weight [1220 (650-2240) g versus 863 (520-2200) g, P=0.001] were significantly greater among survivors than among those who died. Significant predictors of survival at univariate analysis were entered into a stepwise logistic regression analysis in the chronological order in which they normally occur. The analysis demonstrated that successful amnioinfusion (OR=6.9, 95% CI 1.2-40.4) and administration of steroids (OR=14.6, 95% CI 1.5-144.1) were independent and significant predictors of perinatal survival.

CONCLUSION

In a cohort of women with pPROM at <26 weeks and severe oligohydramnios managed with serial amnioinfusions, successful procedures and prenatal administration of corticosteroids are the only independent predictors of perinatal survival.

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.

Outcomes after expectant management of extremely preterm premature rupture of the membranes

OBJECTIVE

This study was undertaken to assess contemporary outcomes in pregnancies managed expectantly after extremely preterm premature (< or =24 weeks) premature rupture of the membranes (EPPROM).

STUDY DESIGN

We queried antepartum and ultrasound databases for patients with EPPROM. Data on pregnancy outcome and short-term neonatal outcomes were collected.

RESULTS

Forty-six patients with EPPROM were studied. Patients were hospitalized at 24 weeks' gestation and given antibiotics and antenatal steroids. Median gestational age at PPROM was 22.0 weeks (range 16.9-24 weeks); 43 (93%) elected expectant management, 2 of whom later had an intrauterine fetal death. Median latency period to delivery was 13 days (range 0-96 days), with mean gestational age at delivery of 25.8+/-3.4 weeks. Overall survival was 47% (27 of 57 infants), after a median hospital stay of 71 days (range 17-209 days). Ten (37%) of the survivors have serious sequelae.

CONCLUSION

Although significant pregnancy prolongation after previable PPROM occurs in many cases, neonatal outcomes remain poor.