Comparison between maternal and neonatal outcome of PPROM in the cases of amniotic fluid index (AFI) of more and less than 5 cm

Predicting previable preterm premature rupture of membranes (pPPROM) before 24 weeks: maternal and fetal/neonatal risk factors for survival

We sought to compare maternal and neonatal risk factors in cases with previable premature rupture of membranes (pPPROM, between 14-24 weeks) for optimal counselling. Therefore, 192 pregnancies of 485 cases which met selection criteria and agreed to follow-up were retrospectively analysed. Mean gestational age at pPPROM was 20.45 weeks. Live births occurred in 171 cases, but 67 (39.2%) of them died in the neonatal period (neonatal death group) and 104 cases (60.8%) constituted surviving neonate group. Of the surviving neonates, 37 (33.7%) experienced at least one complication. Most seen maternal complications were chorioamnionitis (24.48%) and placental abruption (8.33%). Although amniotic fluid volume, length of pPPROM period, completing antibiotherapy and CRP values were significant, amniotic fluid volume and length of pPPROM showed also significance for multivariate regression analysis for maternal risk factors. Risk factors for birth were gestational age at pPPROM, gestational age at birth, new-born weight at birth, 1^st and 5^th minute Apgar scores, umbilical cord pH value and need for neonatal resuscitation. Furthermore, development of respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage and retinopathy of premature were additional risk factors for neonate. Of them, gestational age at birth, new-born weight at birth, respiratory distress syndrome and retinopathy of prematurity were also significant in multivariate regression analysis.Impact StatementWhat is already known on this subject? Management of previable premature rupture of membranes is controversial and there is no definite consensus on the approach. The factor that best predicts neonatal survival is the gestational age at birth (Deutsch et al. 2010).What do the results of this study add? Appropriate counselling for pPPROM cases is important especially during antenatal period (maternal factors) and postpartum period (neonatal factors). Maternal infection risk is increased with an increased latency period of PPROM. As the gestational age at birth increases, the survival rate increases and neonatal complication rates decrease. Other important determinants of neonatal survival and well-being are the presence of oligo-anhydramnios and latency period of previable PPROM to delivery.What are the implications of these findings for clinical practice and/or further research? Counselling the patient with previable PPROM about pregnancy complications and paediatric outcome is challenging because of the small size, different gestational age ranges, and retrospective nature of the multiple studies on this subject. The most important feature of our study was the relatively high number of patients compared to other series. Thus, we can counsel pregnant women with PPROM prior to 24 weeks of gestation about the maternal antenatal factors and neonatal postnatal factors with related outcomes and help make an informed decision regarding termination or conservative follow-up. Nevertheless, there is a need for larger multicentric prospective studies to validate our data and to establish the prognosis of previable PPROM for both mother and foetus.

Clinical Significance of Oligohydramnios in Patients with Preterm Premature Rupture of Membranes

Background. Preterm premature rupture of membranes (PPROM) is one of the main causes of perinatal morbidity and mortality. Associated oligohydramnios may further exacerbate the condition leading to intra-amniotic inflammation and adverse obstetric and perinatal outcomes in preterm labor.

Aim of the research. To determine an impact of oligohydramnios on patients with preterm premature rupture of membranes.

Materials and methods. We performed a retrospective analysis of two groups of patients with PPROM: 56 patients with oligohydramnios were included in the main group, 111 patients without oligohydramnios were included in the control group. The gestational age varied from 24+0 weeks to 33+6 weeks. Amniotic fluid index, endocervical culture, leukogram and neutrophil-to-lymphocyte ratio (NLR), serum procalcitonin and C-reactive protein levels were assessed in all participants.

Results. We witnessed a plethora of consequences in the group of women with PPROM and oligohydramnios: shorter latent phase, higher incidence of clinical chorioamnionitis, antenatal fetal distress, higher levels of C-reactive protein, leukocytes, neutrophils and NLR, lower level of lymphocytes, and increased growth of potentially pathogenic cervical flora. Moreover, the patients with oligohydramnios demonstrated a significantly higher rate of cesarean delivery. The combination of PPROM and oligohydramnios also take a toll on the condition of the newborns: they have lower 5-minute Apgar score and higher prevalence of respiratory distress syndrome, congenital pneumonia, and necrotizing enterocolitis. Furthermore, newborns from the main group are more likely to be admitted to the neonatal intensive care unit, compared with newborns from the control group.

Conclusion. Oligohydramnios in PPROM is associated with a dramatic rise of numerous complications affecting both the women and the newborns. 

<p>What is the Impact of Abnormal Amniotic Fluid Volumes on Perinatal Outcomes in Normal Compared with At-Risk Pregnancies?</p>

Objective

Assessing amniotic fluid volume is an integral part of obstetric practice. Data are sparse on at-risk pregnancy and amniotic fluid volumes. The aim of our study was to determine if there is a difference in perinatal outcomes based on complications of pregnancy and amniotic fluid volumes. We hypothesized that at-risk pregnancies with abnormal amniotic fluid volumes would have worse perinatal outcomes than normal pregnancies with abnormal amniotic fluid volumes.

Study Design

This retrospective cohort study evaluated both normal and at-risk singleton pregnancies with intact membranes on admission for delivery. Amniotic fluid volumes were estimated using both the amniotic fluid index (AFI) and single deepest pocket (SDP) techniques. All sonograms were performed by trained ultrasound technicians or obstetrician/gynecologists. We placed 3365 women into 6 separate groups (at-risk versus normal, then further stratified by oligohydramnios by SDP, normal fluid, or polyhydramnios by AFI).

Results

At-risk pregnancies with normal fluid and at-risk pregnancies with polyhydramnios have significantly increased risk of neonatal intensive care unit (NICU) admission [OR 2.06 (95% CI 1.63,2.60), OR 2.74 (95% CI 1.54, 4.87)]. Birthweight is significantly higher in at-risk and normal pregnancies with polyhydramnios than those with normal pregnancies and normal fluid (p<0.0001). Birthweight is significantly lower in at-risk pregnancies with oligohydramnios (p<0.0001). There were no significant differences in need for amnioinfusion in labor, variables or lates influencing delivery, meconium staining, or umbilical artery pH <7.1.

Conclusion

Our study attempted to further define risk of adverse pregnancy outcomes by defining the pregnancy as normal or at-risk and amniotic fluid volumes. Contrary to our hypothesis, we did not find an increased risk of many of the adverse perinatal outcomes we studied amongst at-risk pregnancies with abnormal fluid. There was an increased risk of NICU admission associated with polyhydramnios in normal and at-risk pregnancies.

Can maternal characteristics on admission for preterm prelabor rupture of membranes predict pregnancy latency?

BACKGROUND

Latency duration after preterm prelabor rupture of membranes has been an area of investigation for many years. Previously described factors associated with latency include gestational age at the time of rupture, cervical dilation of >1 cm, vaginal bleeding at the time of presentation, and oligohydramnios. However, little is known about the impact of composite maternal factors and presenting symptoms on the duration or prediction of the latency period.

OBJECTIVE

This study aimed to determine whether maternal factors and subjective presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes.

STUDY DESIGN

This is a retrospective observational study of singleton pregnancies complicated by preterm prelabor rupture of membranes for over 3 years at a single institution utilizing a uniform management protocol. Maternal demographics, obstetrical data, maternal subjective symptoms and physical examination findings on admission, amniotic fluid volume assessment, presence of contractions, and maternal perception of feeling unwell were collected and analyzed. Clinical characteristics were summarized with mean and standard deviation for continuous measures and frequency and percentages for categorical variables. For skewed variables, medians with 25th and 75th percentiles were reported. Cumulative latency duration (ie, survival time) was estimated with a Kaplan-Meier model. Multivariable Cox proportional hazards regression model with backward variable selection was used to determine the effects of maternal factors on latency duration.

RESULTS

Of the 212 patients available for analysis, there was a considerable variability in the latency duration with values ranging between 0 and 119 days. Factors related to latency duration included maternal age, parity, gestational age at rupture, cervical dilation, amniotic fluid volume, and contractions. Advancing maternal age (P=.012), increased gestational age at rupture (P<.0001), cervical dilation of ≥3 (vs 0; P<.0001), anhydramnios or oligohydramnios (vs normal amniotic fluid; P<.0001), cramping (P=.012), and painful contractions (P=.015) were associated with a shorter latency duration. Utilizing these statistically significant factors, we constructed a nomogram to predict latency for 1-day, 1-week, and overall median latency duration.

CONCLUSION

Maternal factors and presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes. We created a nomogram for clinical use that provides a visual display of the probability of pregnancy latency. This tool may be useful for counseling and providing additional information on expectations for providers and patients with pregnancies complicated by preterm prelabor rupture of membranes.

Amniotic fluid volume at presentation with early preterm prelabor rupture of membranes and association with severe neonatal respiratory morbidity

OBJECTIVE

Amniotic fluid volume (AFV) plays an important role in early fetal lung development, and oligohydramnios in early pregnancy is associated with pulmonary hypoplasia. The aim of this study was to evaluate the association between AFV at the time of presentation with early preterm prelabor rupture of membranes (PPROM) and severe neonatal respiratory morbidity and other adverse pregnancy outcomes.

METHODS

This was a retrospective study of all women with a singleton pregnancy, admitted to a single tertiary referral center between 2004 and 2014, for expectant management of PPROM at 20 + 0 to 28 + 6 weeks' gestation. The primary exposure was AFV at presentation, classified according to sonographic maximum vertical pocket (MVP) as: normal AFV (> 2 cm), oligohydramnios (≤ 2 cm and > 1 cm) or severe oligohydramnios (≤ 1 cm). The primary outcome was a composite variable of severe respiratory morbidity, defined as either of the following: (1) need for respiratory support in the form of mechanical ventilation using an endotracheal tube for ≥ 72 h and need for surfactant; or (2) bronchopulmonary dysplasia, defined as requirement for oxygen at postmenstrual age of 36 weeks or at the time of transfer to a Level-II facility. Adjusted odds ratios (aOR) and 95% CI for the primary and secondary outcomes were calculated for each AFV-at-presentation group (using normal AFV as the reference), adjusting for gestational age (GA) at PPROM, latency period, birth weight, mode of delivery and chorioamnionitis.

RESULTS

In total, 580 women were included, of whom 304 (52.4%) had normal AFV, 161 (27.8%) had oligohydramnios and 115 (19.8%) had severe oligohydramnios at presentation. The rates of severe respiratory morbidity were 16.1%, 26.7% and 45.2%, respectively. Compared with normal AFV at presentation, oligohydramnios (aOR, 3.27; 95% CI, 1.84-5.84) and severe oligohydramnios (aOR, 4.11; 95% CI, 2.26-7.56) at presentation were associated independently with severe respiratory morbidity. Other variables that were associated independently with the primary outcome were GA at PPROM (aOR, 0.54; 95% CI, 0.43-0.69), latency period (aOR, 0.94; 95% CI, 0.91-0.98) and Cesarean delivery (aOR, 2.01; 95% CI, 1.21-3.32).

CONCLUSIONS

In women with early PPROM, AFV at presentation, as assessed by the MVP on ultrasound examination, is associated independently with severe neonatal respiratory morbidity. This information may be taken into consideration when counseling women with early PPROM regarding neonatal outcome and management options. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Continuous amnioinfusion for treatment of mid-trimester preterm premature rupture of membranes with oligoamnios

AIM

Given the scarcity of relevant reports, this study aimed to elucidate whether pregnancy can be prolonged by maintaining the amniotic fluid volume with continuous transabdominal amnioinfusion (TA) for patients with mid-trimester preterm premature rupture of membranes (PPROM) and oligoamnios.

METHODS

We retrospectively examined patients who were managed during hospitalization at our department after developing PPROM between week 22 day 0 and week 25 day 6 of gestation and subsequent oligoamnios (amniotic fluid index [AFI] <5 cm) within 7 days after PPROM onset. Cases between 2006 and 2011 comprised the conventional management group (n = 14); cases administered continuous TA between 2012 and 2017 comprised the continuous TA group (n = 14). The primary outcome was the number of days between PPROM and delivery. The secondary outcomes were the proportion of normal amniotic fluid volume (AFI ≥ 5 cm) maintained between PPROM and delivery and the perinatal prognosis for the mother and infant.

RESULTS

The continuous TA group had significantly more days between PPROM and delivery and a significantly higher proportion of days that a normal amniotic fluid volume was maintained during that period, regardless of antimicrobial agents administered. Although no significant differences in the perinatal prognosis of disease were found between groups, there was a decreasing trend of composite perinatal mortality and morbidity, and the incidence rates were reduced by half.

CONCLUSION

Continuous TA for PPROM with oligoamnios may allow significant prolongation of the gestation period while maintaining the amniotic fluid volume and may lead to improved perinatal prognosis.

Factors associated with neonatal outcomes in preterm prelabor rupture of membranes after cervical cerclage

OBJECTIVE

To evaluate risk factors associated with neonatal morbidity and mortality in pregnant women with preterm prelabor rupture of membranes (PPROM) after cervical cerclage.

METHODS

A retrospective cohort study of singleton pregnancies with cervical insufficiency was conducted at a tertiary referral center in Taiwan from May 1, 2000 to July 31, 2017. Patients with PPROM after cerclage and delivered between 20 0/7 days and 36 6/7 days were recruited. Logistic and linear regression analyses were performed to evaluate various risk factors.

RESULTS

Overall, 109 women were included. Mothers with a higher white blood cell count, a higher C-reactive protein (CRP) level, a lower amniotic fluid index, and chorioamnionitis were significantly associated with neonatal morbidity. Neonatal mortality was related to oligohydramnios (adjusted odds ratio [aOR] 2.98, 95% confidence interval [CI] 1.11-8.01) and chorioamnionitis (aOR 3.17, 95% CI 1.03-9.69). An elevated CRP level was associated with a shorter PPROM to delivery latency (adjusted B -16.64, 95% CI -29.88 to -3.41), but cerclage retention more than 12 hours after PPROM was associated with a prolonged latency (adjusted B 17.21, 95% CI 3.25-31.18).

CONCLUSION

Oligohydramnios and chorioamnionitis are associated with neonatal mortality.

Epidemiological profile of patients with preterm premature rupture of membranes at a tertiary hospital in São Paulo, Brazil

OBJECTIVE

To perform a descriptive analysis of preterm premature rupture of membranes (PPROM) cases attended in a tertiary hospital.

METHOD

Retrospective analysis of medical records and laboratory tests of patients admitted to a Brazilian tertiary hospital between 2006 and 2011, with a confirmed diagnosis of PPROM and gestational age (GA) at delivery <37 weeks.

RESULTS

A total of 299 pregnant women were included in the study. Nine patients evolved to abortion, and 290 pregnant women remained for the final analysis. There was initial diagnostic doubt in 17.6% of the cases. The oligohydramnios rate [amniotic fluid index (AFI) <5] was 27.9% on admission. Chorioamnionitis was initially diagnosed in 10.8% of the patients and was retrospectively confirmed in 22.9% of the samples. The latency period had a mean of 9.1 days. The main reasons for interruption were premature labor (55.2%), GA ≥36 weeks (27.2%), and fetal distress (6.9%). The delivery method was cesarean section in 55% of cases. The mean birth weight was 2,124 grams, and 67% of the neonates had a low birth weight (<2500 g). The GA at delivery averaged 33.5 weeks. The stillbirth rate was 5.3%, and the early neonatal mortality rate was 5.6%. There were complications at delivery in 18% of mothers.

CONCLUSION

In one of the few Brazilian reports on the epidemiological profile of PPROM, with GA until 37 weeks and intercurrences generally excluded from assessments (such as twinning and fetal malformations), there is a favorable evolution, with an acceptable rate of complications.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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