Outcome of dichorionic diamniotic twin pregnancies with spontaneous PPROM before 24 weeks’ gestation

Periviable Premature Rupture of Membranes-Maternal and Neonatal Risks: A Systematic Review and Meta-analysis

OBJECTIVE

 Periviable premature rupture of membranes (PROM) counseling should describe maternal and neonatal outcomes associated with both immediate delivery and expectant management. Unfortunately, most published data focuses on neonatal outcomes and maternal risk estimates vary widely. We performed a meta-analysis to describe outcomes associated with expectant management compared with immediate delivery of periviable PROM.

STUDY DESIGN

 We performed a search on PubMed, MEDLINE, Web of Science, PROSPERO, Cochrane library, and ClinicalTrials.gov utilizing a combination of key terms. Published clinical trials and observational cohorts were included if published after 2000. Publications were selected if they included maternal and/or neonatal outcomes for both expectant management and immediate delivery. Gestational age range was limited from 14 to 25 weeks. The primary outcome was maternal sepsis. Secondary outcomes included chorioamnionitis, hemorrhage, laparotomy, and neonatal survival. Pooled risk differences (RDs) were calculated for each outcome using a random-effects model. Publication bias was assessed using funnel plots and Harbord test.

RESULTS

 A total of 2,550 studies were screened. After removal of duplicates and filtering by abstract, 44 manuscripts were reviewed. A total of five publications met inclusion for analysis: four retrospective and one prospective. Overall, 364 (68.0%) women underwent expectant management and 171 (32.0%) underwent immediate delivery. Maternal sepsis was significantly more frequent in the expectant group (RD, 4%; 95% confidence interval, 2-7%) as was chorioamnionitis (RD: 30%; p < 0.01) and any laparotomy (RD: 28%; p < 0.01). Neonatal survival in the expectant group was 39% compared with 0% in the immediate group (p < 0.01).

CONCLUSION

 Women who undergo expectant management following periviable rupture of membranes experience significantly increased risks of sepsis, chorioamnionitis, and laparotomy. Overall, 39% of neonates survive to discharge. Knowledge of these risks is critical to counseling patients with this diagnosis.

KEY POINTS

· Expectant management associated with 4% increased risk of sepsis.. · Expectant management associated with 30% increased risk of chorioamnionitis.. · A total of 39% of neonates survived to discharge with expectant management..

Selective feticide in dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane before 24 weeks may be a safe therapeutic alternative to ongoing pregnancy

BACKGROUND

To date, there are no clinical guidelines for dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane (PV-ROM) before 24 weeks of gestation. The typical management options including expectant management and/or pregnant termination, induce the risks of fetal mortality and morbidity.

OBJECTIVE

To explore the feasibility selective feticide in DCDA twins complicated with PV-ROM.

STUDY DESIGN

A Retrospective cohort study, enrolling 28 DCDA twins suffering from PV-ROM in a tertiary medical center from Jan 01 2012 to Jan 01 2022. The obstetric outcome was compared between selective feticide group and expectant management group.

RESULTS

There were 12 cases managed expectantly and 16 underwent selective feticide. More cases suffered from oligohydramnios in expectant management group compared to selective feticide group (P = 0.008). Among 13 cases with ROM of upper sac, the mean gestational age at delivery was (33.9 ± 4.9) weeks in the selective feticide group, which was significantly higher than that in the expectant management (P = 0.038). Five fetuses (83.3%) with selective feticide delivered after 32 weeks, whereas only one (14.3%) case in expectant management group (P = 0.029). However, in the subgroup with ROM of lower sac, no significant difference of the mean gestation age at delivery between groups and none of cases delivered after 32 weeks.

CONCLUSION

There was a trend towards an increase in latency interval in DCDA twins with PV-ROM following selective feticide, compared to that with expectant management. Furthermore, selective feticide in cases with PV-ROM of upper sac has a favorable outcome.

Preterm Prelabour Rupture of Membranes before Viability in Twin Pregnancies: What Can We Expect?

Preterm prelabour rupture of membranes (PPROMs) before viability carries significant perinatal mortality and morbidity. Clinical management and prenatal counselling are a challenge, especially in twin pregnancies, due to scarce evidence on how previable PPROM affects this population. The aim of this study was to describe pregnancy outcomes of twin pregnancies complicated with previable PPROM and evaluate potential prognostic factors that may predict perinatal mortality. A retrospective cohort including dichorionic and monochorionic diamniotic twin pregnancies complicated with PPROM before 24 + 0 weeks of pregnancy was evaluated. Perinatal outcomes of pregnancies managed expectantly were described. Factors predicting perinatal mortality or reaching periviability (defined from 23 + 0 weeks onwards) were evaluated. Of the 45 patients included, 7 (15.6%) spontaneously delivered within the first 24 h after diagnosis. Two patients (5.3%) requested selective termination of the affected twin. In the 36 ongoing pregnancies that opted for expectant management, the overall survival rate was 35/72 (48.6%). There were 25/36 (69.4%) patients who delivered after 23 + 0 weeks of pregnancy. When periviability was achieved, neonatal survival increased up to 35/44 (79.5%). Gestational age at delivery was the only independent risk factor of perinatal mortality. The overall survival rate of twin pregnancies complicated with previable PPROM is poor but similar to singletons. No prognostic factors, apart from achieving periviability, were identified as individual predictors of perinatal mortality.

Effect of gestational age at laser therapy on perinatal outcome in monochorionic diamniotic pregnancies affected by twin-to-twin transfusion syndrome

OBJECTIVE

To evaluate the effect of gestational age at laser therapy for twin-to-twin transfusion syndrome (TTTS) on perinatal outcome.

DESIGN AND SETTINGS

Single retrospective observational cohort.

POPULATION

All consecutive pregnancies affected by TTTS and referred to our department between January 2013 and August 2020.

METHODS

Gestational age was modelled both as a categorical and as a continuous variable. Log-binomial regression was used to estimate the odds ratios (crude and adjusted for placental location, Quintero stage and cervical length) as well as the adjusted predicted probability of survival and fetal loss according to gestational age at laser therapy.

MAIN OUTCOMES

Fetal and neonatal survival, preterm prelabour rupture of membranes (PPROM).

RESULTS

Of the 503 pregnancies referred for TTTS, 431 were treated by laser therapy. Gestational age at laser therapy was positively and significantly associated with the overall survival at birth and at discharge (adjusted odds ratio [aOR] 1.12, 95% CI 1.05-1.19), as with a reduction in double fetal loss (aOR 0.81, 95% CI 0.71-0.92). Conversely, the rate of PPROM before 24 weeks was significantly higher in early cases (32% of PPROM <24 weeks when laser therapy was performed before 17 weeks versus 1.5% after 22 weeks, p < 0.001, aOR 0.60, 95% CI 0.48-0.72). Among the survivors, preterm birth before 28 weeks was significantly related to the gestational age at laser (OR 0.91, 95% CI 0.84-0.99), resulting in a significant impact on neonatal morbidity (OR 0.91, 95% CI 0.85-0.97).

CONCLUSION

Our results suggest a significant and independent impact of the gestational age at laser surgery on perinatal survival, PPROM and neonatal morbidity.

Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies

Two unique aspects of antenatal care occur in the setting of fetal surgery and multiple gestations. As fetal interventions increase, so do the number of cases of iatrogenic preterm prelabor rupture of membranes (PPROM). Because of the amniotic sac's inability to heal, the risk of PPROM after surgery is directly correlated with the number of interventions, the size of the defect, and the surgery performed. Higher order gestations also carry an increased risk of PPROM. This paper reviews the risks and management of PPROM in the setting of the various prenatal interventions as well as in the setting of multiple gestations.

Risk factors and maternal outcomes following preterm premature rupture of membrane in the second trimester of gestation

PURPOSE

To characterize the population of women who underwent mid-trimester preterm premature rupture of membrane (PPROM) in a country where mid-trimester abortions are legal and available.

METHODS

A retrospective cross-sectional cohort study was conducted at a tertiary referral hospital, during 2013-2016. Mid-trimester defined as gestational age 13 + 0 to 23 + 6 weeks. Rupture of membrane was defined by documentation of fluid passing through the cervix on sterile speculum examination, and a positive Nitrazine (Bristol-Myers Squibb, Princeton, NJ) or erning test. All records were evaluated for medical history, laboratory data, postnatal examination, and autopsy findings, and a database was constructed.

RESULTS

A total of 61 women were hospitalized for mid-trimester PPROM during the study period. Mean maternal age was 32 ± 5.98, range 20-45 years old. The majority (50, 82%) of patients decided to terminate their pregnancy before reaching the limit of viability at 24 weeks gestation. The overall prognosis of pregnancies reaching term was better than expected, with six (9.8%) patients delivering live babies and four of them born at term (36 ± 5 to 40 ± 6 weeks gestation), all after PPROM following amniocentesis or selective fetal reduction. A total of 60% of women with hypothyroidism had unbalanced TSH levels above 4.0 mIU/L prior to their pregnancy. A notable number of women (15, 24.6%) had PPROM following a pregnancy achieved by assisted reproductive technology (ART).

CONCLUSIONS

Most women with diagnosed mid-trimester PPROM opted for pregnancy termination before the limit of viability when granted the choice. Possible risk factors for early PPROM are unbalanced hypothyroidism and ART. PPROM following amniocentesis can in some cases reseal and reach term, suggesting conservative treatment is a reasonable management for those cases.