The effects of latency period in PPROM cases managed expectantly

The role of D-dimer changes in predicting delivery time in preterm premature rupture of membranes: a retrospective analysis

INTRODUCTION

Pregnancy induces a hypercoagulable state, characterized by increased coagulation factors and decreased anticoagulants, alongside ongoing fibrinolysis marked by elevated D-dimer (DD) levels. Reference values for DD in pregnancy often exceed the non-pregnant cutoff due to these changes. Elevated DD levels are common in late pregnancy and may correlate with complications such as gestational diabetes, hypertension, and preterm delivery, particularly in cases of preterm premature rupture of membranes (PPROM). This study investigates the association between DD levels, the duration from PPROM diagnosis to delivery, and neonatal outcomes.

METHODS

This retrospective study was conducted at the Department of Perinatology, Etlik City Hospital, Ankara, Turkey, from October 2022 to May 2023. Eighty patients with PPROM between 24 and 36 weeks of gestation were included. Routine blood tests and coagulation parameters, including DD, were monitored every other day for 2 weeks. Patients were classified into two subgroups based on whether labor occurred within 7 days of PPROM diagnosis. Statistical analyses included the Mann-Whitney U test, Student's t test, Chi-square test, Friedman test, Durbin-Conover test, generalized estimating equations (GEE), and ROC analysis.

RESULTS

Gestational age at admission was significantly lower in patients who delivered later than 7 days post-PPROM. Significant differences were observed in ultrasonographic measurements, with larger fetal parameters in the early delivery group. Higher DD levels at the third follow-up correlated with shorter durations to delivery (p = 0.021). Longitudinal analysis showed significant fluctuations in DD levels over time, particularly near delivery. The GEE analysis demonstrated a strong inverse relationship between DD levels and time to delivery (p = 0.004), supported by ROC analysis (AUROC = 0.811).

CONCLUSIONS

Elevated DD levels are associated with shorter durations from PPROM diagnosis to delivery, indicating their potential utility in predicting labor onset. Monitoring DD levels may help in clinical decision-making for managing PPROM, including planning neonatal care and timing of interventions.

Association between Gestational Age and Perinatal Outcomes in Women with Late Preterm Premature Rupture of Membranes

OBJECTIVE

 The American College of Obstetricians and Gynecologists (ACOG) suggests expectant management until 34 weeks for patients with preterm premature rupture of membranes (PPROM). New data suggest extending to 37 weeks might enhance neonatal outcomes, reducing prematurity-linked issues. This study aims to assess adverse neonatal outcomes across gestational ages in women with PPROM.

STUDY DESIGN

 A retrospective cohort study was performed using linked vital statistics and the International Classification of Diseases, Ninth Revision data. Gestational age at delivery ranged from 32 to 36 weeks. Outcomes include neonatal intensive care unit (NICU) admission >24 hours, neonatal sepsis, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. Multivariate regression analyses and chi-square tests were employed for statistical comparisons.

RESULTS

 In this cohort of 28,891 deliveries, there was a statistically significant decline in all studied adverse neonatal outcomes with increasing gestational age, without an increase in neonatal sepsis. At 32 weeks, 93% of newborns were in the NICU >24 hours compared with 81% at 34 weeks and 22% at 36 weeks (p < 0.001). At 32 weeks, 20% had neonatal sepsis compared with 11% at 34 weeks and 3% at 36 weeks (p < 0.001). At 32 weeks, 67% had respiratory distress syndrome compared with 44% at 34 weeks and 12% at 36 weeks (p < 0.001).

CONCLUSION

 In the setting of PPROM, later gestational age at delivery is associated with decreased rates of adverse neonatal outcomes without an increase in neonatal sepsis.

KEY POINTS

· The ACOG recommends expectant management until 34 weeks for patients with PPROM.. · However, expectant management to 37 weeks might improve neonatal outcomes.. · Later gestational age at delivery was associated with decreased rates of adverse neonatal outcomes.. · Later gestational age at delivery was not associated with an increase in neonatal sepsis.. · The management of PPROM is complex and should be individualized..

Comparison of the Fetomaternal Outcome in Women With Preterm Premature Rupture of Membranes on Expectant Management Versus Delivery at 34 Weeks

CONTEXT

This study aimed to study feto-maternal outcomes in women with preterm prelabor rupture of membranes (PTPROM) on expectant management versus delivery at 34 weeks of gestation and correlate the period of latency and inflammatory markers with delivery outcomes. We have chosen this research topic as there is a paucity of specific guidelines regarding the optimal period of gestation for delivering women with PTPROM.

AIM

The study correlated the feto-maternal outcomes in women with PTPROM on expectant management till 37 weeks versus delivery at 34 weeks with a period of latency and maternal inflammatory markers.

METHODS AND MATERIALS

This was a prospective observational study conducted on 262 women with PTPROM from 28-33+6 weeks of gestation. Women were monitored till 37 weeks with biweekly total leukocyte count and weekly C-reactive protein, urine routine microscopy, urine culture, high vaginal culture sensitivity, and ultrasound. Women were monitored expectantly till 37 weeks. However, intervention was done at any time during the feto-maternal compromise. There were 52 women who delivered <34 weeks and 210 women who delivered ≥34 weeks. Feto-maternal outcomes were documented. Group A was assigned to women who delivered before 34 weeks and Group B was assigned to women who delivered after 34 weeks. Statistical analysis was done using SPSS software. A p-value <0.05 was considered significant.

RESULTS

Among the study group, 238 (90.8%) women were managed expectantly while 24(9.1%) required intervention. A latency of 3-4 weeks was observed in 131(50%) women. Chorioamnionitis developed in 7 women (4.4%) in group A and 13 women (4.9%) in group B. Neonates developed sepsis in 5.7% in group A and 5.8 % in group B and were comparable in both the groups (p=1.000). Early neonatal death (END) occurred in 10 (3.8%) among which seven died because of low birth weight (LBW), two due to sepsis, and one due to respiratory distress. LBW was significantly associated with END (p<0.001) Conclusion: Expectant management beyond 34 weeks with close monitoring can improve neonatal outcomes without increasing maternal morbidity in women with PTPROM.

Maternal and Perinatal Outcomes in Singleton Nulliparous Spontaneous Preterm Birth with and without Preterm Premature Rupture of Membranes-A National Population-Based Cohort Study

OBJECTIVE

Preterm birth (PTB, birth before 37 gestational weeks) is the leading cause of neonatal death and a major challenge for obstetric and neonatal care. About two-thirds of PTBs are spontaneous PTB (sPTB), of which approximately 30% start with preterm premature rupture of membranes (PPROM). The aim of the study was to investigate risk factors and maternal and perinatal outcomes in sPTB with and without PPROM.

STUDY DESIGN

This is a national population-based cohort study including all singleton pregnancies in nulliparous women with spontaneous onset of labor and vaginal births (n = 266,968) registered in the Swedish Medical Birth Register 2005 to 2014. sPTB with PPROM (sPTB-PPROM) and sPTB without PPROM were compared regarding risk factors and maternal and perinatal outcomes. Logistic regression was used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Adjustments were made for maternal age, body mass index, country of birth, smoking, chronic hypertension, pregestational and gestational diabetes, and gestational length.

RESULTS

sPTB-PPROM (n = 5,037), compared with sPTB without PPROM (n = 8,426), was more common in women with previous spontaneous abortions, prepregnancy urinary tract infections, chronic hypertension, and gestational diabetes and had a higher risk of postpartum endometritis (aOR: 2.78, 95% CI: 1.55-5.00). Infants born to women with sPTB-PPROM had a lower risk of birth asphyxia (aOR: 0.60, 95% CI: 0.43-0.83), respiratory distress syndrome (aOR: 0.86, 95% CI: 0.70-1.00), retinopathy of prematurity (aOR: 0.93, 95% CI: 0.92-0.94), necrotizing enterocolitis (aOR: 0.95, 95% CI: 0.94-0.96), and higher risk of hypoglycemia (aOR: 1.14, 95% CI: 1.01-1.28), and hyperbilirubinemia (aOR: 1.28, 95% CI: 1.19-1.38) compared with infants born to sPTB without PPROM.

CONCLUSION

Our findings of risk factors and distinct differences in adverse outcomes after sPTB-PPROM compared with sPTB without PPROM are of vital importance and might serve as a basis when elaborating programs for the prevention and management of PPROM.

KEY POINTS

· This is a large cohort study of spontaneous preterm birth (sPTB).. · Singleton nulliparous sPTB with/without preterm premature rupture of membrane (PPROM) were studied.. · Distinct differences in adverse perinatal outcomes in sPTB with and without PPROM were observed..

Conservative management of preterm premature rupture of membranes < 30 weeks of gestational age: Effectiveness of clinical guidelines implementation strategies

Objective

To compare obstetrical and neonatal outcomes in patients with p-PROM (preterm premature rupture of membranes) at less than 30 weeks of gestational age before and after the application of protocols developed on the basis of international guidelines and to identify local barriers and strategies for their implementation.

Study design

Single and twin pregnancies with p-PROM < 30 weeks of gestation without signs of infection were retrospectively collected. The population was divided in two groups. Group A contained patients treated before the introduction of the protocol, hospitalized from the day of the p-PROM to delivery and treated according to clinicians' practice. Group B included patients managed according to a standardized protocol, treated with home care management under strict surveillance, after 48 h of hospitalization.

Results

19 women with 21 newborns in group A and 22 women with 26 newborns in group B were enrolled. Maternal characteristics and p-PROM gestational age were comparable. In group A we observed minor latency time from diagnosis to delivery (1.6 vs 6.5 weeks, p < 0.001) with lower gestational age at delivery (25.8 ± 2 vs 30.7 ± 4.2 weeks, p = 0.00) and lower newborn weight (859 ± 268 vs 1511 ± 917 g, p = 0.002). Concerning neonatal outcomes, in group A there were lower Apgar score at 1 min (4.0 ± 2.1vs 6.3 ± 2, p = 004), longer hospitalization (42 ± 38 vs 68 ± 38 days, p = 0.05) and, even if non statistically significant, major rate of neonatal mortality (11,5% vs 19%, p = 1.00) and of neonatal complications (need of neonatal intensive care unit, sepsis, bronchopulmonary dysplasia, retinopathy of prematurity, mechanical ventilation). Postnatal follow-up showed comparable outcomes at 24 months of correct age.

Conclusions

Educational and interdisciplinary meetings, along with group performance audit and standardization of procedures are successful strategies to implement guidelines application. Applying this strategy, we developed a protocol according to international guidelines for the treatment of early onset p-PROM based on a standardized conservative management at home, achieving better results compared to hospital management in terms of latency, gestational age at delivery, neonatal weight and neonatal hospitalization.

Risk factors associated with shortened latency before delivery in outpatients managed for preterm prelabor rupture of membranes

INTRODUCTION

Preterm prelabor rupture of membranes (PPROM) occurs in 3% of pregnancies and is the main cause (~30%) of premature delivery. Home care seems to be a safe alternative for the management of patients with PPROM, who have a longer latency than those with PPROM managed with conventional hospitalization. We aimed to identify the risk factors associated with a shortened latency before delivery in women with PPROM managed as outpatients.

MATERIAL AND METHODS

The design was a retrospective cohort study and the setting was a Monocentric Tertiary centre (Lille University Hospital, France) from 2009 to 2018. All consecutive patients in home care after PPROM at 24-36 weeks were included. For the main outcome measure we calculated the latency ratio for each patient as the ratio of the real latency period to the expected latency period, expressed as a percentage. The risk factors influencing this latency ratio were evaluated.

RESULTS

A total of 234 patients were managed at home after PPROM. Mean latency was 35.5 ± 20.7 days, corresponding to an 80% latency ratio. In 196 (83.8%) patients the length of home care was more than 7 days. A lower latency ratio was significantly associated with oligohydramnios (p < 0.001), gestational age at PPROM (p = 0.006), leukocyte count at PPROM more than 12 × 10⁹ /L (p = 0.025), and C-reactive protein concentration more than 5 mg/L at 7 days after PPROM (p = 0.046). Cervical length was not associated with a lower latency ratio.

CONCLUSIONS

Women with PPROM managed with home care are stable. The main risk factor associated with a reduced latency is oligohydramnios. Outpatients with oligohydramnios should be informed of the probability of a shortened latency period.

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

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

Transabdominal amniocentesis in expectant management of preterm premature rupture of membranes: A single center prospective study

AIMS

The aim of this study was to evaluate the role of IL-6 point-of-care test in amniotic fluid obtained from serial amniocentesis in expectantly managed women with PPROM between 24 and 34 weeks of gestation.

METHODS

We conducted a prospective observational cohort study which included 62 pregnant women with PPROM in gestational weeks between 22+0 and 34+0. Women aged >18 years were eligible if they presented with PPROM and a singleton pregnancy. Only women who delivered at >24.0 weeks were included in the study. In all women, the maternal blood sampling and a transabdominal amniocentesis were performed at the time of admission prior to the administration of corticosteroids, antibiotics, or tocolytics, to rule out signs of chorioamnionitis. Maternal temperature, maternal serum C-reactive protein (CRP) and white blood cell (WBC) counts were assayed every subsequent day until delivery. Amniotic fluid was used for the clinical assessment (IL-6 point-of-care test, identification of microorganisms in the amniotic fluid. After one week of expectant management of PPROM, second amniocentesis with amniotic fluid sampling was performed in patients who did not deliver. For all newborns, medical records regarding neonatal morbidity and mortality were reviewed.

RESULTS

In total, 62 women aged 19 to 41 years were recruited in the study. The mean gestational age at the time of PPROM was 31+0, the mean gestational age at labor was 32+1, and the median time from PPROM to childbirth was 112 h. IL-6 point-of-care test values above 1,000 pg/mL (positive Il-6 AMC) were found in 12 women (19.4%) with median interval from PPROM to childbirth 56 h (min-max: 6.4-288). IL-6 point-of-care test values below 1,000 pg/mL (negative Il-6 AMC) were found in 51 women (81.0%). The neonatal mortality rate was 1.9% and was associated with prematurity.

CONCLUSION

The major clinical finding of our study is that serial transabdominal amniocentesis with Il-6 point-of-care test helps to identify a high inflammatory status in amniotic fluid in women with PPROM. Subsequent expectant management of women with PPROM does not lead to worsening of short-term neonatal outcomes.

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.