ACOG Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 80: premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists

Intrapartum pyrexia, cardiotocography traces and histologic chorioamnionitis: a case-control study

OBJECTIVES

To compare characteristics of labor, cardiotocography traces, and maternal and neonatal outcomes, in a cohort of pregnancies at term complicated by maternal intrapartum pyrexia, with or without a histologic diagnosis of chorioamnionitis.

METHODS

This is a retrospective case-control study including pregnancies at term with detection of maternal intrapartum pyrexia, delivered between January 2020 and June 2021. Cardiotocography traces were entirely evaluated, since admission till delivery, and classified according to the International Federation of Obstetrics and Gynecology (FIGO) guideline. Maternal and neonatal outcomes were also recorded as secondary outcomes. Placentas have been studied according to the Amniotic Fluid Infection Nosology Committee.

RESULTS

Forty four patients met the inclusion criteria and were included in the study cohort. There was a significant association between the use of oxytocin augmentation in labor and the histologic diagnosis of chorioamnionitis. A significative recurrence of loss and/or absence of accelerations at the point of pyrexia was also documented in women with histological chorioamnionitis compared to the others.

CONCLUSIONS

Chorioamnionitis appears to be associated with myometrial disfunction, as suggested by the increased use of oxytocin augmentation during active labor of women at term with intrapartum pyrexia and histologic diagnosis of chorioamnionitis.

Association of clinical signs of chorioamnionitis with histological chorioamnionitis and neonatal outcomes in women with premature rupture of membranes

Background

Premature rupture of membrane (PROM), especially when preterm or prolonged is associated with an increased risk of chorioamnionitis with its attendant feto-maternal complications.

Aim

The study was aimed to determine the association of clinical signs of chorioamnionitis with histological chorioamnionitis and neonatal outcomes in women with PROM.

Materials and Methods

Eligible participants with clinical diagnosis of PROM at gestational age of ≥28 weeks managed between December 2018 and June 2019 were consecutively recruited. Their sociodemographic characteristics, obstetrics history, and evidence of clinical chorioamnionitis using the Gibb's criteria were obtained. Following delivery, chorioamnionitis was histologically confirmed. Primary outcome measure was the proportion of women with PROM and histological chorioamnionitis that were detected clinically.

Results

Of the 136 participants analyzed, 108 (79.4%) had term PROM, while 28 (20.6%) had preterm PROM (<37 weeks). The prevalence of histological chorioamnionitis was 50.0% compared to 16.2% using clinical indicators of infection. Histological chorioamnionitis was almost two times higher in preterm than term PROM (71.4% vs 38.9%). About two-third (67.6%) of the chorioamnionitis identified histologically were missed using clinical signs of chorioamnionitis. Clinical signs of chorioamnionitis had specificity of 100.0%, but low sensitivity (35.5%) and accuracy of 70.6%. A combination of three symptoms, maternal pyrexia and tachycardia, and fetal tachycardia appears to be the most reliable clinical indicator of chorioamnionitis in women with preterm PROM. There was a significant association between low birth weight, low Apgar score, NICU admission, and the presence of histological chorioamnionitis in women that had PROM.

Conclusion

Clinical signs of chorioamnionitis have a low sensitivity and are not very accuracy in diagnosing chorioamnionitis in women with PROM.

Active versus expectant management for premature rupture of membranes at term: A randomized, controlled study

OBJECTIVE

To compare the effects on feto-maternal outcomes of expectant versus active management for premature rupture of membranes (PROM) at term.

METHODS

This was a prospective randomized (1:1) controlled study involving 86 pregnant-women who received either expectant management (n = 43) or active management with misoprostol (n = 43) for PROM at term. Primary outcome was route of delivery. Secondary outcomes were: PROM to presentation interval; latency period; PROM to delivery interval; recruitment to delivery interval; labour and delivery complications.

RESULTS

Baseline-characteristics were similar between groups. There was no significant difference between active and expectant groups in mean PROM to presentation/admission, or PROM to delivery. However, mean latency period (11.1 ± 7.3 hours vs 8.8 ± 5.5 hours) and mean recruitment to delivery intervals after PROM (14.7 ± 5.2 hours vs 11.8 ± 5.0 hours) were significantly shorter for the active group compared with the expectant group. Although the rate of caesarean section was less in expectant management group (21%) compared with the active management group (30%), the difference was not statistically significant. There were no significant differences between groups in delivery or perinatal complications.

CONCLUSION

Active and expectant management for PROM at term gave comparable outcomes in terms of methods of delivery and complications. However, active management significantly shortened the latency period and induction to delivery intervals compared with expectant management.Trial-Registration: Pan-African-trial-registry-(PACTR)-approval-number PACTR202206797734088.

Optimal timing of labor induction after prelabor rupture of membranes at term: a secondary analysis of the TERMPROM study

BACKGROUND

In the case of prelabor rupture of membranes at term, the risk for neonatal and maternal infectious morbidity increases progressively with time from prelabor rupture of membranes. Although most studies identified a benefit associated with early induction within the first 24 hours following term prelabor rupture of membranes, there is currently no precise data regarding how early should induction be scheduled.

OBJECTIVE

This study aimed to identify the optimal timing of labor induction among women with term prelabor rupture of membranes by comparing the maternal and neonatal outcomes associated with labor induction with those of expectant management at any given 1-hour interval following prelabor rupture of membranes.

STUDY DESIGN

This was a secondary analysis of data from the TERMPROM trial, an international, multicenter, randomized clinical trial on immediate delivery vs expectant management of women with prelaor rupture of membranes at term (≥37+0/7 weeks' gestation). We considered all participants as a single cohort of women with term prelabor rupture of membranes, irrespective of the original randomized study group allocation. For each given 1-hour time interval within the first 36 hours following prelabor rupture of membranes, we compared the outcomes of subjects for whom labor induction was initiated during this interval with those of subjects managed expectantly at the same time interval. The primary neonatal outcome was a composite of neonatal infection and admission to the neonatal intensive care unit. The primary maternal outcomes included maternal infection (clinical chorioamnionitis or postpartum fever) and cesarean delivery.

RESULTS

Of the 4742 subjects who met the study criteria, 2622 underwent labor induction, and 2120 experienced a spontaneous onset of labor. The rates of the neonatal composite outcome, neonatal admission to intensive care unit, and maternal infection increased progressively with time after prelabor rupture of membranes. The risk for these outcomes was lower among women who underwent induction when compared with those managed expectantly within the first 15 to 20 hours after prelabor rupture of membranes without affecting the risk for cesarean delivery. In addition, women who underwent labor induction within the first 30 to 36 hours had a shorter prelabor rupture of membranes to delivery time and a shorter total maternal hospital stay when compared with those managed expectantly at the same time interval. Among women managed expectantly, less than two-thirds (64%; 1365/2120) experienced a spontaneous onset of labor within the first 24 hours following prelabor rupture of membranes.

CONCLUSION

These findings suggest that immediate labor induction seems to be the optimal management strategy to minimize neonatal and maternal morbidity in the setting of prelabor rupture of membranes at term gestations. In cases for which immediate induction is not feasible, labor induction remains the preferred option over expectant management if performed within the first 15 to 20 hours after prelabor rupture of membranes.

The serotonin reuptake inhibitor fluoxetine induces human fetal membrane sterile inflammation through p38 MAPK activation

Serotonin Reuptake Inhibitors (SRIs) are often used as first line therapy for depression and other psychiatric disorders. SRI use during pregnancy is associated with preterm premature rupture of membranes (PPROM) and subsequent preterm birth. The objective of this study was to investigate the mechanism(s) responsible for SRI-associated PPROM. Putative mechanisms underlying PPROM include fetal membrane (FM) inflammation, increased apoptosis, and/or accelerated senescence, the later which may be reversed by statins. Human FM explants from normal term deliveries without labor, infection, or antidepressant use were treated with or without the SRI, fluoxetine (FLX), either alone or in the presence of a p38 MAPK inhibitor or the statins, simvastatin or rosuvastatin. FMs were also collected from women either unexposed or exposed to FLX during pregnancy. FLX significantly increased FM p38 MAPK activity and secretion of inflammatory IL-6. Inhibition of p38 MAPK reduced FM IL-6 secretion in response to FLX. Statins did not reduce the SRI-induced FM IL-6 production. FMs from women exposed to FLX during pregnancy expressed elevated levels of p38 MAPK activity compared to matched unexposed women. FMs exposed to FLX did not exhibit signs of increased apoptosis and/or accelerated senescence. These results indicate that the SRI, FLX, may induce sterile FM inflammation during pregnancy through activation of the p38 MAPK pathway, and in the absence of apoptosis and senescence. These findings may better inform clinicians and patients as they weigh the risks and benefits of SRI antidepressant treatment during pregnancy.

The efficacy and safety of vitamin C administration to women with history of premature preterm rupture of membrane in prevention of such event in current pregnancy: Randomized controlled clinical trial

BACKGROUND

When rupture of membrane happens before onset of labor, the condition in obstetric practice is defined as "Prelabor rupture of membranes (PROM)" leading to leakage of amniotic fluid through ruptured chorioamniotic membranes and the conditions happens before 37 weeks of pregnancy the term "preterm PROM (PPROM)" is applied. Lack of vitamin C has been suggested as a predisposing factor and vitamin C supplementation has been suggested as a preventive measure.

AIM OF THE STUDY

This study was aimed to determine the efficacy and safety of administration of vitamin C women with history of premature preterm rupture of membrane in prevention of such event in current pregnancy.

PATIENTS AND METHODS

The present randomized controlled clinical trial was performed in Maternity and Children Teaching Hospital in Al-Diwaniyah province in Iraq. It included 100 women with previous history of premature preborn rupture of membrane who were randomly allocated into two groups. The first group, the study group included 55 women who received vitamin C supplementation orally staring from 14 weeks gestation and the second group, the reference group was the placebo group (n = 45). Data regarding age, previous abortion, body mass index, number of previous pregnancies and previous abortions were obtained and outcome variables included gestational age at which rupture of membrane happened, gestational age at which delivery happened and birth weight were collected.

RESULTS

Vitamin C was able to significantly increase the GA at rupture or membrane (p = 0.033), form 29.00 ± 2.92 weeks to 30.11 ± 2.21 weeks. Vitamin C was also able to significantly increase the GA at birth (p = 0.019), form 32.04 ± 2.88 weeks to 33.31 ± 2.43 weeks. In addition, Vitamin C was also able to significantly increase the birth weight (p = 0.019) from 1951.10 ± 869.72 gram to 2409.10 ± 613.44 gram.

CONCLUSION

Vitamin C Administration to women with previous history of Premature Preterm Rupture of Membrane is efficient and safe in prevention of such event in current pregnancy.

Different azithromycin protocols for management of preterm prelabour rupture of membranes: a randomized clinical trial

BACKGROUND

Preterm prelabor rupture of membranes is associated with polymicrobial infection; hence broad-spectrum antibiotics are recommended. Nowadays, Azithromycin is used instead of Erythromycin due to erythromycin shortages, its ease of administration, decreased cost, and better side effect profile. This study aimed to evaluate the efficacy of different azithromycin protocols for the conservative management of preterm prelabor rupture of membranes.

METHODS

It was a single-blinded randomized clinical trial including pregnant women at 24-36⁺⁶ weeks with viable singleton pregnancies and confirmed preterm prelabor rupture of membranes from January 01, 2020, to June 01, 2021. The participants were randomized into two groups: Group I was made of women who received Azithromycin 1000 mg PO once, and Group II of women who received Azithromycin 500 mg PO once, followed by Azithromycin 250 mg PO daily for four days. The primary study outcome was the length of the latency period from the diagnosis of preterm prelabor rupture of membranes to delivery (days).

RESULTS

The latency period in group I was significantly higher than that in Group II (5.80 ± 5.44 days vs. 2.88 ± 2.37; respectively, p = 0.0001). The mean gestational age at the time of delivery was significantly higher in Group I (p = 0.0001). However, postpartum endometritis and respiratory distress syndrome (RDS) rates were significantly higher in Group II (p = 0.003 and p = 0.0001, respectively).

CONCLUSION

The higher dose of Azithromycin was associated with better maternal and neonatal outcomes.

TRIAL REGISTRATION

Clinical trial identification number: Clinical trial.gov: NCT04202380 (17/ 12/ 2019). Date of registration: 1/1 /2020. Date of initial participant enrollment30 /1/2020. URL of the registration site: https://www.

CLINICALTRIALS

gov/ct2/show/NCT04202380.

Inflammatory Proteins in the Amniotic Fluid, Plasma, and Cervicovaginal Fluid for the Prediction of Intra-Amniotic Infection/Inflammation and Imminent Preterm Birth in Preterm Labor

OBJECTIVE

This study was aimed to develop models using multiple cytokine/chemokine levels in cervicovaginal fluid (CVF) and plasma and widely used noninvasive parameters that have better accuracy for predicting intra-amniotic infection and/or inflammation (IAI) and imminent spontaneous preterm delivery (SPTD, ≤48 hours) in women with preterm labor (PTL).

STUDY DESIGN

This was a retrospective cohort study of 95 singleton pregnant women with PTL (23-34 weeks) who underwent amniocentesis. Both CVF and plasma samples were obtained at the time of amniocentesis, and serum C-reactive protein (CRP) levels were measured. The amniotic fluid (AF), CVF, and plasma samples were assayed for interleukin (IL)-6, IL-8, IL-10, monocyte chemotactic protein-1 (MCP-1), and macrophage inflammatory protein-1β (MIP-1β) levels using a multiplex immunoassay kit.

RESULTS

The levels of most cytokines/chemokines measured in the AF and CVF were significantly higher in the women with than in those without IAI and imminent SPTD, whereas only high-plasma IL-10 level showed a significant association with imminent SPTD. In predicting IAI, proteins in AF had significantly higher areas under the curves (AUCs) than those in CVF and plasma. However, for predicting imminent SPTD, no significant differences in the AUCs of the outcome-associated proteins were observed among the measurements in AF, CVF, and maternal plasma. By using stepwise regression analyses, noninvasive models (using protein levels in CVF and baseline clinical parameters) were developed for the prediction of IAI and imminent SPTD. The AUC of these noninvasive models were similar to those of the invasive models (using AF protein levels and baseline clinical parameters).

CONCLUSION

Noninvasive models based on CVF cytokine/chemokine levels and widely used noninvasive parameters (especially CRP) act as good indicators for predicting the risk of IAI and imminent SPTD in women with PTL. Evaluation of cytokine/chemokine levels in plasma samples did not add valuable information regarding the two outcome measures in the PTL setting.

KEY POINTS

· Markers in either CVF or plasma alone did not have sufficient accuracy for predicting IAI and SPTD.. · Noninvasive models using CVF cytokine and CRP act as effective tools for predicting two outcomes.. · Evaluation of cytokine level in plasma did not add valuable information regarding two outcomes..

Suspected clinical chorioamnionitis with peak intrapartum temperature <380C: the prevalence of confirmed chorioamnionitis and short term neonatal outcome

Background

Chorioamnionitis (CA) affects up to 3.9% of all deliveries worldwide and is one of the leading causes of early-onset neonatal sepsis. Fever≥38⁰C is an essential criterion for the diagnosis of clinical CA. Obstetricians frequently take the maternal risk factors into consideration, and many mothers are treated as CA even with peak intrapartum temperature (PIT) between 37.6⁰C to 37.9⁰C if they have other clinical signs and risk factors.

Aim

To estimate the prevalence of confirmed chorioamnionitis and adverse neonatal outcomes among those mothers with PIT below 38⁰C.

Materials and methods

Retrospective chart review among mothers delivered at Al-Wakra Hospital, Qatar, between1^stJanuary2016 to 31^stDecember 2019 with a clinical suspicion of CA.

Results

Among 21,471 mothers, 442 were suspected of having CA (2.06%, 95% CI 1.88 to 2.26%). After exclusions, 415 were included in the study, 203(48.9%) mothers had PIT between 37.6-37.9⁰C. There was no significant difference in the rate of confirmed CA between the low (<38⁰C) and higher (≥38⁰C) temperature groups (25.4%Vs.31.3%, OR0.75, 95%CI0.46-1.25 , p.262). More patients in the low-temperature group received paracetamol for PIT between 37.6 to 37.9 ⁰C, while it was less frequently used for such milder elevation in higher temperature group (88.2%Vs.38.9%, OR11.69, 95% CI 6.46-2.15, p <.001).

Conclusion

The incidence of suspected clinical CA in our institution was within the international rates. Although nearly half of the mothers with suspected clinical CA had peak temperature below the recommended diagnostic criteria, the rate of confirmed CA and neonatal outcome was not significantly different from those with PIT≥38⁰C. Early antipyretic use might have affected further elevation of temperature.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03239-9.

Risk factors and clinical characteristics for bronchopulmonary dysplasia associated pulmonary hypertension in very-low-birth-weight infants

BACKGROUND

Pulmonary hypertension (PH) is a common complication of bronchopulmonary dysplasia (BPD) in very-low-birth-weight infants (VLBWIs). Although recent studies have increased awareness that PH contributes significantly to the high morbidity and mortality of BPD, the risk factors and clinical characteristics for PH in VLBWIs are little known.

OBJECTIVES

To investigate the risk factors and clinical characteristics for BPD-associated pulmonary hypertension (BPD-PH) in VLBWIs.

METHODS

A retrospective case-control observational study of VLBWIs with BPD admitted to a neonatal intensive care unit (NICU) over 4 years. According to echocardiograms confirming elevated pulmonary artery pressure after 28 days after birth, we divided BPD infants into PH group (n = 18) and non-PH group (n = 65). We compared pre- and postnatal characteristics between VLBWIs with or without PH. Multivariable logistic regression analysis was conducted with backward selection.

RESULTS

A total of 83 infants with BPD were divided into PH group (n = 18) or non-PH group (n = 65). The average birth weight of the infants with BPD was 1078.1 g. Compared with those infants of the non-PH group, the birth weight of BPD-PH infants was significantly lower (968.1 ± 187.7 vs. 1108.5 ± 185.8, P = 0.006). Infants in the PH group had a higher incidence of patent ductus arteriosus (PDA) and underwent longer durations of oxygen therapy and mechanical ventilation compared to those in the non-PH group. In all subjects, birth weight (OR 0.995; 95% CI 0.991-0.999; P = 0.025) and PDA (OR 13.355; 95% CI 2.950-60.469; P = 0.001) were found to be specific risk factors for BPD-PH in this cohort.

CONCLUSIONS

The study shows PDA and birth weight are specific risk factors for BPD-PH in VLBWIs.

Acute associations between air pollution on premature rupture of membranes in Hefei, China

Numerous studies had focused on the association between air pollution and health outcomes in recent years. However, little evidence is available on associations between air pollutants and premature rupture of membranes (PROM). Therefore, we performed time-series analysis to evaluate the association between PROM and air pollution. The daily average concentrations of PM_2.5, SO₂ and NO₂ were 54.58 μg/m³, 13.06 μg/m³ and 46.09 μg/m³, respectively, and daily maximum 8-h average O₃ concentration was 95.67 μg/m³. The strongest effects of SO₂, NO₂ and O₃ were found in lag4, lag06 and lag09, and an increase of 10 μg/m³ in SO₂, NO₂ and O₃ was corresponding to increase in incidence of PROM of 8.74% (95% CI 2.12-15.79%), 3.09% (95% CI 0.64-5.59%) and 1.68% (95% CI 0.28-3.09%), respectively. There were no significant effects of PM_2.5 on PROM. Season-specific analyses found that the effects of PM_2.5, SO₂ and O₃ on PROM were more obvious in cold season, but the statistically significant effect of NO₂ was observed in warm season. We also found the modifying effects by maternal age on PROM, and we found that the effects of SO₂ and NO₂ on PROM were higher among younger mothers (< 35 years) than advanced age mothers (≥ 35 years); however, ≥ 35 years group were more vulnerable to O₃ than < 35 years group. This study indicates that air pollution exposure is an important risk factor for PROM and we wish this study could provide evidence to local government to take rigid approaches to control emissions of air pollutants.

Risk factors of uterine contraction after ureteroscopy in pregnant women with renal colic

Background

Ureteroscopy is widely applied in pregnant women with renal colic, but such patients are easy to experience uterine contraction after surgery. There are many factors which may affect uterine contraction, this study aims to explore the risk factors of uterine contraction triggered by ureteroscopy in pregnant women with renal colic.

Methods

One hundred and one pregnant women were retrospectively analyzed, the patients were hospitalized because of severe renal colic. All patients received ureteroscopy during which double J catheters were inserted into ureters for drainage. Patients received other medical treatments individually according to their condition and uterine contractions were detected by EHG within 12 h after operation. Patients were classified as group A (uterine contraction) and group B (no uterine contraction) according to the presence or absence of continuously regular uterine contraction. Clinical characteristics were collected for further analysis, including history of childbirth, anesthesia method, application of phloroglucinol or not, operation time, Oxygen inhalation or not, pain relief or not after surgery, systemic inflammatory response syndrome (SIRS) occurred or not. A binary logistic regression analysis model was established to explore whether such clinical characteristics were relevant to uterine contraction after ureteroscopy.

Results

Continuously regular uterine contraction presented in 46 pregnant women within 12 h after ureteroscopy, making the incidence of uterine contraction as high as 45.54%. The presence of uterine contraction was related to the following factors(P < 0.05): history of childbirth (primipara versus multipara)(OR 6.593, 95% CI 2.231–19.490), operation time (each quarter additional) (OR 2.385, 95% CI 1.342–4.238), application of phloroglucinol (yes versus not) (OR 6.959, 95% CI 1.416–34.194), pain relief after surgery(yes versus not)(OR 6.707, 95% CI 1.978–22.738), SIRS occurred after surgery (yes versus not) (OR 0.099, 95% CI 0.014–0.713).

Conclusion

Continuously regular uterine contraction is easy to occur within 12 h after ureteroscopy in pregnant women. SIRS occurred after surgery is a risk factor for uterine contraction; on the contrary, no history of childbirth, shorter operation time, application of phloroglucinol, pain relief after surgery are protective factors.

Interleukin-6 in Amniotic Fluid: A Reliable Marker for Adverse Outcomes in Women in Preterm Labor and Intact Membranes

INTRODUCTION

Amniotic fluid (AF) interleukin-6 (IL-6) concentration has been associated to preterm delivery and perinatal morbidity and mortality in women with preterm labor and intact membranes. Nevertheless, the clinical significance of this biomarker of intra-amniotic inflammation (IAI) is still unclear due in part to the paucity of large studies.

METHODS

AF IL-6 concentrations were determined in 452 consecutive women with preterm labor and intact membranes, categorized into 3 groups: 302 without IAI (IL-6 of <2.6 ng/mL), 64 with mild IAI (IL-6 of 2.6-11.2 ng/mL), and 86 with severe IAI (IL-6 of ≥11.3 ng/mL).

RESULTS

The severe IAI group had a short pregnancy duration from amniocentesis to delivery (median 3 days) than in without IAI group (median 45 days); meanwhile, the mild IAI group had a latency that was intermediate to the severe and without IAI groups (median 9.5 days). As compared to women without IAI, women with mild and severe IAI had higher rates of preterm delivery at both <34 and <37 weeks of gestation and perinatal morbidity and mortality. Furthermore, the risk of various individual adverse outcomes (short latency from amniocentesis to delivery [at ≤3 days, ≤7 days, and ≤14 days], preterm delivery at both <34 and <37 weeks of gestation, histologic chorioamnionitis, respiratory distress syndrome, and congenital sepsis) was higher in women with severe IAI (OR ≥ 2.8), compared with women without IAI.

CONCLUSIONS

AF IL-6 concentrations appear to be suitable marker to assess the degree of IAI and are associated with increased risk of adverse outcomes.

Neonatal outcomes and risk of neonatal sepsis in an expectantly managed cohort of late preterm prelabor rupture of membranes

OBJECTIVE

Expectant management in patients with prelabor preterm rupture of membranes between between 34^0/7 and 36 ^6/7 weeks (late preterm pPROM or LpPROM) has been shown to decrease the burden of prematurity, when compared to immediate delivery. As the severity of prematurity depends on gestational age (GA) at PROM, and PROM to delivery interval, we first investigated how such variables affect neonatal outcomes (NO). Second, we assessed the risk of neonatal sepsis.

STUDY DESIGN

retrospective cohort study on neonatal morbidity among singleton infants born to expectantly managed mothers with LpPROM in five hospitals affiliated with three Italian academic institutions. The primary NO was a composite of neonatal death, non-invasive (cPAP) or invasive (mechanical ventilation) respiratory support, hypoglycemia (< 44 mg/dl needing therapy), newborn sepsis, confirmed seizures, stroke, intraventricular hemorrhage (IVH), basal nuclei anomalies, cardiopulmonary resuscitation, umbilical-cord-blood arterial pH < 7.0 or base excess < -12.5, and prolonged hospitalization (≥ 5 days). Univariate analysis described differences in the population according to GA at delivery. Multivariate logistic regression was then used to investigate the effects of GA at PROM, and PROM to delivery interval on the NO.

RESULTS

258/606 (42.6 %) women with LpPROM were expectantly managed, as they did not deliver within the first 24 h. The median latency duration was 2 (95 %CI 1-3) days, having no effect on neonatal morbidity on multivariate analysis. Multivariate analysis also showed increased risks of adverse NO among PROM at 34 (OR 2.3 95 %CI 1.03-5.1) but not at 35 weeks when compared to 36 weeks, and among women receiving antenatal corticosteroids (OR 3.6 95 %CI 1.3-9.7), while antibiotic treatment showed a non-significant protective effect (OR 0.2 95 %CI 0.04-1.02). Prevalence of neonatal sepsis was 0.8 % (2/258) CONCLUSION: Expectant management of LpPROM should be encouraged especially between 34⁺⁰ and 34⁺⁶ weeks', when the burden of prematurity is the greatest. Antibiotics may have beneficial effects, while careful consideration should be given to antenatal corticosteroids until future studies specifically address LpPROM.

Maternal serum procalcitonin levels in prediction of chorioamnionitis in women with preterm premature rupture of membranes

INTRODUCTION

Chorioamnionitis is one of the most important maternal complications in the expectant management of patients with preterm premature rupture of membranes (PPROM). Procalcitonin (proCT), the precursor of the hormone calcitonin, is used to differentiate bacterial infections from non-bacterial ones. The objective of the study was to determine the efficacy of maternal serum procalcitonin levels in the early prediction of chorioamnionitis in women with PPROM.

MATERIAL AND METHODS

The study was conducted in 76 pregnant women hospitalized due to PPROM at the maternal-fetal medicine unit of a tertiary center in Istanbul. Patients were followed up with white blood cell (WBC), C-reactive protein (CRP) and proCT levels every 2 days. The values of investigated parameters were recorded at the diagnosis of PPROM and at the time of delivery. The maximum values during the follow-up period were also recorded.

RESULTS

Out of the 76 patients with PPROM, 15 (19.73%) developed clinical chorioamnionitis. No significant difference could be detected in the gravidity, parity, duration of hospitalization and gestational week at diagnosis between those patients who developed clinical chorioamnionitis and those who did not. The WBC at the time of hospital admittance and before delivery, and CRP levels before delivery were statistically higher in the chorioamnionitis group (p < 0.05). No difference in the proCT levels could be detected either at the time of hospital admittance or before delivery between the two groups.

CONCLUSIONS

Maternal proCT was not found to be predictive of chorioamnionitis. However, since there are reports in the literature that contradict these results, further studies are warranted to determine the true efficacy of proCT in the prediction of clinical chorioamnionitis.

Pretransplant ascites and encephalopathy and their influence on survival and liver graft rejection in alcoholic cirrhosis disease

INTRODUCTION

The Child-Pugh and model for end-stage liver disease (MELD) scores are widely used to predict the outcomes of liver transplant (LT). Both have similar prognostic values in most cases, although their benefits might differ in some specific conditions. The aim of our study was to analyze the influence of pre-transplant ascites and encephalopathy in post-transplant liver rejection development and survival in alcohol cirrhosis (AC) patients undergoing LT to determine the usefulness of the Child-Pugh score for the assessment of prognosis in such patients.

MATERIAL AND METHODS

Two hundred and eighty-one AC patients, classified according to viral infections and pre-transplant complications, were analyzed. Acute (AR) and chronic (CR) liver rejections and Child-Pugh, MELD and albumin-bilirubin (ALBI) scores were studied in all cases.

RESULTS

Similar AC rejection percentages were observed in ascites or encephalopathy groups (18.5% and 16.5%, p = 0.735), although a higher but not statistically significant AC rate was observed in patients with grade III ascites (p = 0.777) and with grade II encephalopathy (p = 0.089). Chronic rejection was only developed by 9.1% of AC patients, regardless of the presence of ascites (6.2%) or encephalopathy (5.5%). The presence of ascites and encephalopathy complications did not seem to influence post-transplant survival. Neither the Child-Pugh nor the ALBI score can be considered the best for predicting patient survival in the short or long term.

CONCLUSIONS

Ascites and encephalopathy do not seem to influence AC or CR in patient survival, regardless of the presence of viral infections, so in our study neither the Child-Pugh nor ALBI score seems to be the best score to predict the outcomes of these patients.

A protein microarray analysis of amniotic fluid proteins for the prediction of spontaneous preterm delivery in women with preterm premature rupture of membranes at 23 to 30 weeks of gestation

Objective

We sought to identify novel biomarkers in the amniotic fluid (AF) related to imminent spontaneous preterm delivery (SPTD) (≤ 14 days after sampling) in women with early preterm premature rupture of membranes (PPROM), using a protein microarray.

Method

This was a retrospective cohort study of a total of 88 singleton pregnant women with PPROM (23+0 to 30+6 weeks) who underwent amniocentesis. A nested case-control study for biomarker discovery was conducted using pooled AF samples from controls (non-imminent delivery, n = 15) and cases (imminent SPTD, n = 15), which were analyzed using an antibody microarray. Quantitative validation of four candidate proteins was performed, using ELISA, in the total cohort (n = 88). IL-8, MMP-9, and Fas levels were additionally measured for the comparison and to examine association of SPTD with the etiologic factors of PPROM.

Results

Of all the proteins studied in the protein microarray, four showed significant intergroup differences. Analyses of the total cohort by ELISA confirmed the significantly elevated concentrations of AF lipocalin-2, MMP-9, and S100 A8/A9, but not of endostatin and Fas, in women who delivered within 14 days of sampling. For inflammatory proteins showing a significant association, the odds of SPTD within 14 days increased significantly with an increase in baseline AF levels of the proteins (P for trend <0.05 for each) in each quartile, especially in the 3rd and 4th quartile.

Conclusions

We identified several potential novel biomarkers (i.e., lipocalin-2, MMP-9, and S100 A8/A9) related to SPTD within 14 days of sampling, all of which are inflammation-related molecules. Furthermore, the SPTD risk increased with increasing quartiles of each of these inflammatory proteins, especially the 3rd and 4th quartile of each protein. The present findings may highlight the importance of inflammatory mechanisms and the degree of activated inflammatory response in developing SPTD in early PPROM.

Respiratory Severity Score with Regard to Birthweight during the Early Days of Life for Predicting Pulmonary Hypertension in Preterm Infants

OBJECTIVE

The respiratory severity score (RSS) has been demonstrated to be associated with the oxygenation index in intubated newborn infants. We aimed to evaluate the usefulness of RSS with regard to birthweight (BW) in preterm infants for predicting an association with future pulmonary hypertension (PH).

METHODS

Preterm infants with <30 weeks' gestation and <1250 g BW were reviewed and grouped into two (PH vs. no PH). Basic perinatal characteristics, comorbidities and parameters reflecting lung condition, including duration of invasive mechanical ventilator care, were compared. Respiratory support parameters (FiO2, RSS and RSS/kg) during the first 5 days of birth (0-120 h) were compared between the groups, and receiver operating characteristics curves were produced to evaluate the association with PH.

RESULTS

RSS/kg, of the three respiratory support parameters, demonstrated significantly higher values in the PH group in the early days of life. Particularly, RSS/kg at day 2 of life had the greatest area under the curve [0.762, 95% confidence interval (CI) 0.655-0.869, p < 0.001] and maintained statistical significance [odds ratio (OR) 1.352, 95% CI 1.055-1.732, p = 0.017] in the multivariable analysis for a potential association with PH, along with gestational age (OR 0.996, 95% CI 0.993-0.999, p = 0.015) and preterm premature rupture of membrane >18 h (OR 4.907, 95% CI 1.436-16.765, p = 0.011).

CONCLUSION

RSS/kg is a potential marker associated with the development of PH. Future studies could verify its usefulness as a reliable surrogate for predicting respiratory morbidity in clinical settings.

Achieving Country-Wide Scale for Helping Babies Breathe and Helping Babies Survive

Helping Babies Breathe (HBB) was piloted in 2009 as a program targeted to reduce neonatal mortality (NM). The program has morphed into a suite of programs termed Helping Babies Survive that includes Essential Care for Every Baby. Since 2010, the HBB and Helping Babies Survive training programs have been taught to >850 000 providers in 80 countries. Initial HBB training is associated with a significant improvement in knowledge and skills. However, at refresher training, there is a knowledge-skill gap evident, with a falloff in skills. Accumulating evidence supports the role for frequent refresher resuscitation training in facilitating skills retention. Beyond skill acquisition, HBB has been associated with a significant reduction in early NM (<24 hours) and fresh stillbirth rates. To evaluate the large-scale impact of the growth of skilled birth attendants, we analyzed NM rates in sub-Saharan Africa (n = 11) and Nepal (as areas of growing HBB implementation). All have revealed a consistent reduction in NM at 28 days between 2009 and 2018; a mean reduction of 5.34%. The number of skilled birth attendants, an indirect measure of HBB sustained rollout, reveals significant correlation with NM, fresh stillbirth, and perinatal mortality rates, highlighting HBB's success and the need for continued efforts to train frontline providers. A novel live newborn resuscitation trainer as well as a novel app (HBB Prompt) have been developed, increasing knowledge and skills while providing simulation-based repeated practice. Ongoing challenges in sustaining resources (financial and other) for newborn programming emphasize the need for innovative implementation strategies and training tools.

Maternal risk score for the prediction of fetal inflammatory response syndrome after preterm premature rupture of membranes

AIM

Preterm premature rupture of membranes (PPROM) is common in preterm births. Fetal inflammatory response syndrome (FIRS) is present in nearly 50% of PPROM cases. We created a risk score to predict FIRS using maternal factors after PPROM.

METHODS

We conducted a retrospective study of singleton pregnancies complicated by PPROM that resulted in delivery at 23-35 weeks of gestation. Antepartum maternal factors and umbilical cord blood interleukin-6 (IL-6) data were analyzed. FIRS was defined as IL-6 > 11 pg/mL.

RESULTS

Umbilical cord blood IL-6 and maternal blood data within 24 h before parturition were available for 158 cases; 66 were diagnosed with FIRS (41.8%; median IL-6, 57.55 pg/mL). We created a risk score (FIRS score) comprising expected delivery weeks (≤30 weeks), maternal C-reactive protein (≥1.2 mg/dL), maternal white blood cell count (≥13 000/μL), corticosteroid use (none) and PROM latency period (≥3 days) from the multivariate logistic regression model predicting FIRS. Receiver operating characteristic curve analysis of the score produced the following results: area under the curve, 0.82; 95% CI, 0.76-0.89; cut-off value, 7.5; sensitivity, 89%; specificity, 63%; positive predictive value, 63% and negative predictive value, 89%. The probability of FIRS according to the categories of the FIRS score was 11% for those with a score of 0-7, 50% for a score of 8-15, and 88% for a score of 16-22.

CONCLUSION

The devised maternal risk score could predict FIRS and be helpful to decide the delivery timing for the cases of PPROM.

Term prelabor rupture of membranes: Foley catheter versus dinoprostone as ripening agent

INTRODUCTION

Term prelabor rupture of membranes (TPROM) occurs in approximately 8 % of pregnancies. This condition regularly requires medical intervention such as induction of labor. The actual data concerning cervical ripening in case of TPROM does not favor any of the available techniques. This is the first study comparing dinoprostone versus Foley catheter for cervical ripening in TPROM.

MATERIALS AND METHODS

We conducted a retrospective before-after study. We enrolled all the patients with confirmed TPROM after 37 weeks of gestation (WG) who required cervical ripening. Women were included if they had a singleton fetus in cephalic presentation, with unfavorable cervix (Bishop ≤ 6). Patients were excluded if they had a previous uterine surgery, a multiple pregnancy, contraindication to vaginal delivery, spontaneous labor or favorable cervix (Bishop > 6). During the first period (2015), the protocol of cervical ripening involved dinoprostone (prostaglandins E2) by vaginal administration (vaginal gel or pessary). During the second period (2016-2017), the protocol of cervical ripening involved Foley catheter (FC). The primary outcome was the rate of cesarean section.

RESULTS

Two hundred and thirty-eight patients were included for the analysis: 131 in the first period (dinoprostone group) and 107 in the second period (foley catheter group). There was no significant difference between the two groups regarding the mode of delivery (cesarean section: 206 % vs 13 %, p = 016). Concerning tolerance, the were no difference in the rates of postpartum hemorrhage, maternal per-partum fever and endometrisis. Neonatal outcomes were similar between the two groups. The induction to delivery interval was lower with dinoprostone (20,3 h versus 26,0 h, p = 0001). The mean duration of labor was also significantly different (6,9 h for dinoprostone group versus 8,7 h for FC group, p = 001).

CONCLUSION

Cervical ripening in case of TPROM after 37 W G with Foley catheter seems to be a safe technique with similar outcomes to prostaglandins regarding the mode of delivery.

Can vitamin C and interleukin 6 levels predict preterm premature rupture of membranes: evaluating possibilities in North Indian population

Objective

We aimed to evaluate the relation between plasma ascorbic acid levels and the occurrence of preterm premature rupture of membranes (PPROM) and whether patients with ascorbic acid deficiency have predisposition to microbial invasion, as revealed by serum interleukin-6 (IL-6) levels and confirmed by placental culture sensitivity evaluation.

Methods

This controlled study involved 50 women with PPROM at gestational age between 28 and 36.6 weeks. Fifty patients with uncomplicated pregnancy and intact membranes were observed as control group. Serum ascorbic acid and IL-6 levels were evaluated for PPROM group subjects and controls, matched by their gestational age and body mass index. Repeat samples for IL-6 were taken after 48 hours of admission in PROM group subjects and at the onset of labor in controls. Placental membranes were sent for culture sensitivity evaluation after delivery.

Results

The mean plasma level of ascorbic acid was 0.60±0.35 mg/dL and 1.18±0.43 mg/dL in the PPROM and control groups, respectively, showing significant difference. Plasma IL-6 level rose from 18.18±5.94 pg/mL to 34.32±7.31 pg/mL after 48 hours of admission in the PPROM group (P=0.000). Plasma IL-6 level in controls rose from 5.59±4.36 pg/mL at admission to 7.36±3.67 pg/mL at the onset of labor. Membrane culture test results were positive in a total of 40 samples, of which 37 samples were from the PPROM group subjects.

Conclusion

Vitamin C deficiency, when complemented with elevated serum IL-6 level, can predict susceptibility to PPROM in the third trimester; the risk increases in women with prior history of similar pathology.

Maternal Serum Haptoglobin Levels as a Marker of Preterm Premature Rupture of Membranes

OBJECTIVE

We aimed to investigate the prognostic value of maternal serum haptoglobin levels in patients presenting with preterm premature rupture of fetal membranes (PPROM) during the second and the third trimesters of pregnancy.

METHODS

In this case control study, 60 patients were recruited (30 pregnant women with PPROM between 26-34 weeks of gestation and 30 healthy, gestational-age-matched pregnant women without PPROM). White blood cell count (WBC), interleukin 6 (IL-6), C-reactive protein (CRP), sedimentation rate, and haptoglobin levels were measured.

RESULTS

The mean age, gestational week, gravida, and parity of the 2 groups were statistically comparable (P>0.001). There was a statistically significant difference between the 2 groups in terms of haptoglobin values (p<0.001). The mean haptoglobin level was 115.5+33.1(mg/dl) in the PPROM group and 66.5+42.6 (mg/dl) in the control group. ROC curve analysis was performed to determine whether the level of haptoglobin alone could diagnose PPROM as an independent marker. It was shown that the level of 94.5 mg/dL for haptoglobin could indicate the diagnosis of PPROM with 80% sensitivity and specificity CONCLUSION: Maternal serum haptoglobin levels may be a diagnostic marker for suspected PPROM cases when membrane rupture diagnosis is not accurate based on physical examination and other diagnostic tests.

Pregnancy outcome among women with drug dependence: A population-based cohort study of 14 million births

OBJECTIVE

Drug dependence is on the rise worldwide. The purpose of this study is to examine the association between drug dependency in pregnancy (DDP) and maternal and newborn outcomes.

METHODS

We carried out a population-based retrospective cohort study evaluating DDP using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2014. DDP was identified using ICD-9 coding. The associations between DDP and maternal and newborn outcomes were estimated using multivariate logistic regression analyses to estimate adjusted odds ratios and 95 % confidence intervals.

RESULTS

Among 14,513,587 deliveries, 50,570 were to mothers with DDP for an overall prevalence of 35 cases/10,000 deliveries. The rate of pregnancies to drug-dependent women increased during the 15-year study period, from approximately 25/10,000 in 1999 to 69/10,000 in 2014. Women with DDP were younger in age, users of tobacco, and in lower income quartiles with more pre-existing health conditions, such as diabetes and hypertension. DDP was associated with greater risk of venous thromboembolism (OR 1.60; 95 % CI, 1.45-1.76), sepsis (OR 2.94; 95 % CI, 2.48-3.49), and maternal death (OR 2.77; 95 % CI, 1.88-4.08). Neonates born to mothers with drug dependence were at higher risk of prematurity (OR 1.37; 95 % CI, 1.33-1.41), intrauterine growth restriction (OR 1.60; 95 % CI, 1.54-1.67), and intrauterine fetal death (OR 1.27; 95 % CI, 1.16-1.40).

CONCLUSION

DDP is increasing in frequency and it is associated with maternal and newborn deaths and adverse events. Further research and public health initiatives should be undertaken to address prevention, screening, and treatment.

Complement and other immune-related factors in cervicovaginal fluid associated with intra-amniotic infection/inflammation and spontaneous preterm delivery in women with preterm labor

PURPOSE

To investigate whether complement and other immune-related proteins in cervicovaginal fluid (CVF) can predict intra-amniotic infection and/or inflammation (IAI) and spontaneous preterm delivery (SPTD, < 34.0 weeks) in women with preterm labor (PTL) and to compare the predictive abilities of these biomarkers with that of amniotic fluid (AF) white blood cells (WBCs).

METHODS

We designed a retrospective cohort study of 145 women with PTL at 23.0-33.6 weeks who underwent amniocentesis. AF was cultured and assayed for WBC count and interleukin-6 (IL-6). CVF samples were obtained at the time of amniocentesis. CVF was assayed for complement C3a and C5a, IGFBP-1, and MMP-9 by ELISA.

RESULTS

In the multivariate analysis, elevated CVF levels of C5a and IGFBP-1 were significantly associated with IAI and SPTD at < 34 weeks, while those of C3a were associated with IAI, but not SPTD, even after adjusting for other baseline confounders. For C3a, C5a, and IGFBP-1 in the CVF, area under the curve (AUC) values were statistically similar to that of AF WBCs for detecting IAI, whereas these CVF biomarkers had similar or higher AUC values than AF WBCs for predicting SPTD at < 34 weeks. However, univariate analysis showed no significant correlation between high CVF MMP-9 and IAI or SPTD at < 34 weeks.

CONCLUSIONS

In women with PTL, the CVF levels of C3a, C5a, and IGFBP-1 may be useful as novel non-invasive predictors of IAI and SPTD at < 34 weeks. These biomarkers (especially IGFBP-1) have similar or better diagnostic performance compared to AF WBCs.

Comparison of the accuracy and reliability of the AmniSure, AMNIOQUICK, and AL-SENSE tests for early diagnosis of premature rupture of membranes

OBJECTIVE

To compare the accuracy and reliability of the AmniSure, AMNIOQUICK, and AL-SENSE tests with conventional tests to diagnose suspected premature rupture of membranes (PROM).

METHODS

A prospective cohort study of 60 pregnant women at 25-36 weeks of pregnancy with suspected PROM was conducted between January and April 2015. AmniSure (Qiagen Sciences LLC, Germantown, MD, USA), AMNIOQUICK (BIOSYNEX, Strasbourg, France), and AL-SENSE (Common Sense Ltd, Caesarea, Israel) tests were performed after conventional tests (ultrasonography, pooling, nitrazine, and fern tests) and women were followed-up for 7 days. Sensitivity, specificity, and diagnostic accuracy, among others, were assessed and compared.

RESULTS

For women with a confirmed diagnosis of PROM, the sensitivity and specificity of conventional tests were 93.7% and 100.0%, respectively; diagnostic accuracy was 98.3%. Sensitivity, specificity, and diagnostic accuracy were all 100.0% for AmniSure. Sensitivity, specificity, and diagnostic accuracy for AMNIOQUICK were 75.0%, 97.7%, and 91.6%, respectively. Sensitivity, specificity, and diagnostic accuracy were 75.0%, 86.3%, 83.3%, respectively, for the AL-SENSE pad test.

CONCLUSION

The AmniSure test was most sensitive and specific for diagnosing PROM compared with the other tests and is reliable and usable.

Identification of Cultivable Bacteria in Amniotic Fluid Using Cervicovaginal Fluid Protein Microarray in Preterm Premature Rupture of Membranes

We aimed to identify cervicovaginal fluid (CVF) protein biomarkers of microbial invasion of the amniotic cavity (MIAC) in women with preterm premature rupture of membranes (PPROM), using an antibody microarray. This retrospective cohort study included 99 consecutive women with singleton pregnancies and PPROM (23-33 weeks) who underwent amniocentesis and who gave CVF samples. CVF proteomes from the MIAC (n = 20) versus non-MIAC groups (n = 20) were comparatively profiled by an antibody microarray using a nested case-control study design. The seven candidate biomarkers of interest were validated in the total cohort (n = 99) by enzyme-linked immunosorbent assays (ELISA). For comparison with candidate markers, amniotic fluid (AF) white blood cell (WBC) count was also measured. The primary outcome measure was MIAC (defined as positive AF culture). Thirty of the proteins studied exhibited significant intergroup differences. Measurements of the total cohort with ELISA confirmed a significant increase in the levels of CVF IL-8, lipocalin-2, MIP-1α, MMP-9, and TIMP-1 in women with MIAC, independent of gestational age at sampling. A combined, non-invasive model was developed by using a stepwise regression procedure, which included CVF IL-8 and CVF MMP-9 (area under the curve [AUC] = 0.763), and this AUC was comparable with the AUC of AF WBC. Using protein-antibody microarray technology, we found several novel, independent, non-invasive biomarkers to identify MIAC in women with PPROM: IL-8, lipocalin-2, MIP-1α, MMP-9, and TIMP-1. Furthermore, the combined non-invasive model (IL-8 and MMP-9) was a useful independent predictor for MIAC with good discriminatory power, similar to AF WBC count.

Factors associated with development of early and late pulmonary hypertension in preterm infants with bronchopulmonary dysplasia

OBJECTIVE

To investigate factors associated with development of early and late pulmonary hypertension (E/LPH) in preterm infants with bronchopulmonary dysplasia (BPD).

STUDY DESIGN

A retrospective case-control observational study of preterm infants with BPD admitted to a level IV referral neonatal intensive care unit over 5 years. We compared pre- and postnatal characteristics between infants with or without BPD-associated EPH and LPH.

RESULTS

Fifty-nine out of 220 infants (26.8%) had LPH, while 85 out of 193 neonates (44%) had EPH. On multiple logistic regression, novel factors associated with development of BPD-LPH included presence of maternal diabetes, EPH, tracheostomy, tracheitis, intraventricular hemorrhage (IVH, grade ≥3) and systemic steroid use. For EPH, these were maternal diabetes, IVH grade ≥3, high frequency ventilator use, and absence of maternal antibiotics use.

CONCLUSION

We identified novel factors and confirmed previously established factors with development of LPH and EPH, which can help develop a screening strategy in BPD patients.

Should clinical suspicion shift to ampicillin resistance organisms in certain preterm premature rupture of membranes scenarios?: Case of early-onset sepsis caused by E coli

This case highlights the importance antibiotic stewardship, including reexamining current regimens use for intrapartum antibiotic prophylaxis, which may be accountable for the shift in organism responsible for some cases of early-onset sepsis.

Preterm Premature Rupture of Membranes in Twins: Comparison of Rupture in the Presenting Versus Non-presenting Sac

OBJECTIVE

This study sought to compare the latency from membrane rupture to delivery and subsequent neonatal outcomes in twin gestations complicated by preterm premature rupture of membranes (PPROM) of the presenting versus non-presenting sac.

METHODS

This was a retrospective study of twin pregnancies over a 7-year period diagnosed with PPROM between 12 and 37 weeks gestation with a latency period to delivery of >24 hours. The ruptured sac was identified by ultrasound scan. The study compared the latency period from PPROM to delivery and subsequent neonatal morbidity and mortality resulting from rupture of the presenting versus non-presenting sac. Obstetric and neonatal outcomes were evaluated using a matched-cohort subset analysis (Canadian Task Force Classification II-2).

RESULTS

During the study period, 77 twin pregnancies diagnosed with PPROM satisfied the inclusion criteria. The mean latency periods from PPROM to delivery were 10.1 days (n = 7) when the presenting sac ruptured and 41.3 days (n = 10) when the non-presenting sac ruptured (P < 0.05). Neonatal death was higher with PPROM of the presenting than the non-presenting sac (21.4% vs. 0%, respectively; P = 0.05). Neonates were more likely to be affected by retinopathy of prematurity (57% vs. 19%; P < 0.05) but less likely to have persistent pulmonary hypertension of the newborn (0% vs. 25%; P < 0.05) when the rupture occurred in the presenting sac. The rates of other neonatal adverse outcomes were similar between the two groups.

CONCLUSIONS

In twin gestations there is a longer latency from PPROM to delivery and fewer neonatal complications when rupture occurs in the non-presenting rather than the presenting sac.

Labor induction in term nulliparous women with premature rupture of membranes: oxytocin versus dinoprostone

INTRODUCTION

Premature rupture of the membranes (PROM) refers to rupture of the fetal membranes prior to the onset of regular uterine contractions. Premature rupture of the membranes continues to be one of the most vexing issues of obstetrics due to increased maternal and fetal morbidity and mortality. Many studies have focused on how management should be in these cases. The purpose of this study was to investigate whether dinoprostone (PGE2 analogue) administration is necessary for cervical ripening and labor induction in term women with premature rupture of membranes (PROM) and to compare maternal and neonatal outcomes between oxytocin usage and dinoprostone usage in PROM.

MATERIAL AND METHODS

A total of 224 nulliparous singleton pregnant women at term, with PROM ≥ 12 h, vertex presentations, no prior uterine surgery, reactive non-stress test and Bishop scores ≤ 6 (unfavorable cervixes) were reviewed. Participants were divided into two groups as oxytocin and dinoprostone groups. The primary outcome was vaginal delivery within 24 h.

RESULTS

The women in the oxytocin group were significantly younger than in the dinoprostone group (22.85 ±4.10 years vs. 25.99 ±4.94 years; p = 0.001). There were significant differences in vaginal delivery rates within 24 h. It was 72 of 112 (64.3%) vs. 53 of 112 (47.3%), p = 0.023 for oxytocin and dinoprostone groups, respectively.

CONCLUSIONS

Vaginal dinoprostone appears to be a relatively inefficient method of inducing labor compared with oxytocin in term pregnancies with PROM and unfavorable cervixes. However, dinoprostone may maintain uterine contractions as effectively as oxytocin once uterine contractions are established.

Can we predict preterm delivery in patients with premature rupture of membranes?

PURPOSE

To characterize the parameters that predict preterm delivery in patients with preterm, premature rupture of membranes.

METHODS

This retrospective cohort study included women diagnosed with preterm premature rupture of membranes at 24-34 weeks gestation. Demographics, medical history, laboratory tests, and delivery data were reviewed.

RESULTS

Among 258 patients with preterm, premature rupture of membranes during the study period, 141 (54.7%) met the inclusion criteria. Therefore, the final cohort included 141 (54.78%) women, among whom, 32 (22.7%) delivered within the first 24 h of ROM and 109 (77.3%) delivered after 24 h. Univariant analysis revealed that advanced gestational age at the time of preterm, premature rupture of membranes, larger cervical dilation and leukocyte count at admission had significant effects on the likelihood of labor within 24 h. Analysis of the differences between each patient at admission to 24 h before labor in heart rate, temperature (fever), leukocyte counts and amniotic fluid color revealed significant changes in heart rate (P < 0.001), leukocyte count (P < 0.001) and in amniotic fluid from clean to meconium or bloody (P < 0.001). There was no significant change in elevated temperature (P = 0.065).

CONCLUSIONS

Our findings indicate that minimal changes in heart rate, body temperature (fever), leukocyte count and amniotic fluid color, within normal ranges, appear 24 h before delivery, among women with preterm, premature rupture of membranes and prolonged latency period. Increased attention to these changes might enable better follow-up and timing of delivery for patients with preterm, premature rupture of membranes before 34 weeks gestation.

Outpatient versus inpatient care for preterm premature rupture of membranes before 34 weeks of gestation

Preterm premature rupture of membranes (PPROM) is associated with an increased risk of serious maternal, fetal, and neonatal morbidities. We compared neonatal outcomes of women with PPROM before 34⁺⁰ weeks of gestation according to inpatient or outpatient management policy. 587 women with PPROM >48 hours, 246 (41.9%) in the group with an inpatient care policy (ICP) and 341 (58.1%) in the group with an outpatient care policy (OCP), were identified in France, from 2009 to 2012. Neonatal outcomes were compared between the two groups using logistic regression. A second analysis was performed to compare inpatient care and effective outpatient care (discharge from hospital) through propensity score matching. The outcome was a neonatal composite variable including one or more of the neonatal morbidity complications. The perinatal composite outcome was 14.6% with the ICP and 15.5% with the OCP (p = 0.76). After using the 1:1 ratio propensity score matching, effective outpatient care was not associated with a significantly higher risk of the perinatal composite outcome (OR 0.88, CI 0.35 to 2.25; p = 0.80) compared with inpatient care. Outpatient care is not associated with an increased rate of obstetric or neonatal complications and can be an alternative to hospital care for women with uncomplicated PPROM.

Urinary profiles associated with bacterial metabolites from asymptomatic pregnant women with at term or preterm premature rupture of membranes: a pilot study

Objective: Premature rupture of membranes (PROM) and preterm premature rupture of membranes (pPROM) are frequent conditions with a not fully understood multifactorial etiology. It has been suggested that infection may be the leading cause of pPROM. Metabolomics is nowadays recognized as a successful and versatile approach for the investigation of several pathological conditions, including pregnancy-related ones. However, collecting samples such as fetal fluids or placenta poses a limit on the clinical application of this strategy. Therefore, the aim of this study was to detect urinary metabolites that could be associated with bacterial infection in PROM and pPROM and to understand its role in these different conditions, using readily available samples such as urines.Methods: Urine samples were collected from pregnant women who experienced rupture of membranes: (1) at term (≥37 weeks) not in labor (NLPROM); (2) at term in labor (LPROM); (3) preterm (<37 weeks) not in labor (pPROM). Samples were analyzed using a GC-MS platform. Student's t-test, Pearson correlation coefficient, principal component analysis (PCA), and partial least squares discriminant analysis (PLS-DA) were applied to observe differences between groups.Results: Results showed that lactic acid, erythritol, and ethanolamine levels were significantly higher in pPROM than in PROM (NLPROM + LPROM considered as one single group). These three metabolites might be associated with bacterial infections since they derive from bacterial metabolic processes and environments.Conclusions: This study might be useful to understand the mechanisms underlying the etiology of pPROM and PROM, and urine samples might represent a useful and readily available sample to discriminate preterm high-risk women.

Determinants of premature rupture of membrane in Southern Ethiopia, 2017: case control study design

OBJECTIVE

To identify the determinants of term premature rupture of membrane in Southern Ethiopia public hospitals, 2017.

RESULTS

Seventy-five cases and 223 controls women were enrolled for the study. Two hundred eighty-four (95.3%) participants were admitted at the gestational age of above 40, and the rest, 14 (4.7%), were admitted at 37-40 weeks of gestation. The current study identified wealth index and inter-birth interval as preventive predictors, but smoking and hypertension during pregnancy were identified as positive determinants of premature rupture of membrane. This finding is supported by multiple logistic regression analysis result of wealth index (AOR: 0.102, 95% CI [0.033, 0.315]), inter-birth interval (AOR: 0.251, 95% CI [0.129, 0 0.488]), smoking (AOR: 17.053, 95% CI [2.145, 135.6]), and hypertension (AOR: 8.92, 95% CI (1.91, 41.605]). The association between PROM and its determinants indicated that evidence-based interventions should be needed and designed to have very high wealth index, and optimal interbirth interval, and prevent smoking and hypertension during pregnancy to decrease PROM occurrence in the study settings. Hence, we recommended that integration of prevention mechanism of modifiable determinants to the obstetrics health care system will reduce premature ruptures of a membrane.

Enterobacteria vaginal colonization among patients with preterm premature rupture of membranes from 24 to 34 weeks of gestation and neonatal infection risk

AIM

Premature rupture of membranes (PROM) increases the neonatal morbidity and mortality, because of its association with a high risk of prematurity and infection. The group B streptococcus (GBS) prophylaxis using amoxicillin doesn't seem to be adapted to the emergence of new bacteria found in vaginal samples (VS). Our study aim was to assess, for PROM occurring at 23-34 weeks' gestation (WG), if the presence of ampicillin-resistant enterobacteria in the vaginal microbiome is predictive of an increased risk of early-onset neonatal infection.

MATERIAL AND METHODS

We conducted a prospective, observational, single-center study at the Nice Academic Hospital (level 3 maternity ward), between March 16, 2014 and May 3, 2015, that evaluated patients with preterm PROM (24-34 WG). Two groups were constituted according to the VS bacteria isolates and the amoxycillin-resistant enterobacteria found. Two groups of newborns were constituted depending on the suspicion of perinatal maternal-fetal bacterial infection (MFI). An intent-to-treat analysis was performed.

RESULTS

Among the 67 patients included, 12 newborns presented a strong MFI suspicion, 83% of which were associated to the group of patients with untreated or amoxycillin-resistant enterobacteria VS isolates.

CONCLUSION

Our study showed that vaginal colonization of untreated or amoxycillin-resistant enterobacteria constitutes a major risk factor of neonatal infection.

Association of histological chorioamnionitis and magnesium sulfate treatment in singleton and dichorionic twin pregnancies with preterm premature rupture of membranes: preliminary observations

Objective To evaluate the possible association between antenatal magnesium sulfate treatment with histological chorioamnionitis in patients with singleton or dichorionic twins that had preterm premature rupture of the membranes. Methods This was an observational study performed in patients admitted to the hospital with rupture of membranes before 34 weeks' gestation. The primary outcome was histological chorioamnionitis and the primary predictor was antenatal magnesium sulfate treatment. A logistic regression model was used without consideration of other antenatal medical treatments. Results Among 107 patients with preterm deliveries, 57 were admitted to the hospital before 34 weeks' gestation with preterm premature rupture of membranes. Fifty-cases were excluded from the analysis because they were admitted after 34 weeks' gestation, delivered before 24 weeks' gestation or had intrauterine fetal demise or monochorionic twins. The logistic regression analysis adjusting for maternal age, gravidity, parity, multiple gestation, gestational age at delivery, and birthweight, indicated that patients with singleton pregnancies and histological chorioamnionitis had received magnesium sulfate antenatally more frequently (χ2=6.46; P=0.01). The association between histological chorioamnionitis and magnesium sulfate treatment was not found among patients with dichorionic twin pregnancies with one intact gestational sac. Conclusions In this cohort of patients with preterm premature rupture of membranes admitted to the hospital before 34 week's gestation, those with singleton pregnancies treated antenatally with magnesium sulfate for neonatal neuroprotection had a greater rate of histological chorioamnionitis.

Maternal lead exposure and premature rupture of membranes: a birth cohort study in China

OBJECTIVES

Maternal exposure to lead (Pb) has been suggested to correlate with adverse birth outcomes, but evidence supporting an association between Pb exposure and premature rupture of membranes (PROM) is limited. The aim of our study was to investigate whether maternal Pb exposure was associated with PROM and preterm PROM.

DESIGN

Cross-sectional cohort study.

STUDY POPULATION

The present study involved 7290 pregnant women from the Healthy Baby Cohort in Wuhan, China, during 2012-2014.

MAIN OUTCOME MEASURES

PROM was defined as spontaneous rupture of amniotic membranes before the onset of labour and was determined with a pH ≥6.5 for vaginal fluid. Maternal urinary Pb level was adjusted by creatinine concentration, and its relationship with PROM was analysed by logistic regression.

RESULTS

The IQR of maternal urinary Pb concentrations of the study population was 2.30-5.64 µg/g creatinine with a median of 3.44 µg/g creatinine. Increased risk of PROM was significantly associated with elevated levels of Pb in maternal urine (adjusted OR 1.23, 95% CI 1.0 to 1.47 for the medium tertile; adjusted OR 1.51, 95% CI 1.27 to 1.80 for the highest tertile). The risk of preterm PROM associated with Pb levels was significantly higher when compared with the lowest tertile (adjusted OR 1.24, 95% CI 0.80 to 1.92 for the medium tertile; adjusted OR 1.73, 95% CI 1.15 to 2.60 for the highest tertile). In addition, the relationship between Pb and PROM was more pronounced among primiparous women than multiparous women (p for interaction <0.01).

CONCLUSIONS

Our study found that higher levels of maternal Pb exposure was associated with increased risk of PROM, indicating that exposure to Pb during pregnancy may be an important risk factor for PROM.

Vitamin D-binding protein in cervicovaginal fluid as a non-invasive predictor of intra-amniotic infection and impending preterm delivery in women with preterm labor or preterm premature rupture of membranes

Objective

To determine whether vitamin D-binding protein (VDBP) in cervicovaginal fluid (CVF) is independently predictive of intra-amniotic infection and imminent spontaneous preterm delivery (SPTD, delivery within 48 hours) in women with preterm labor with intact membranes (PTL) or preterm premature rupture of membranes (PPROM).

Method

This was a single-center retrospective cohort study. CVF samples for VDBP assays were obtained along with serum C-reactive protein (CRP) levels immediately after amniocentesis in consecutive women with PTL (n = 148) or PPROM (n = 103) between 23.0 and 34.0 weeks of gestation. VDBP levels in CVF were determined by enzyme-linked immunosorbent assay kits. The primary outcome measures were intra-amniotic infection [defined as positive amniotic fluid (AF) culture] and SPTD within 48 hours after sampling.

Results

In the multivariable analysis, elevated VDBP levels in CVF samples of PTL women were significantly associated with intra-amniotic infection and imminent preterm delivery, even after adjusting for potential confounders (e.g., gestational age at sampling, parity, and serum CRP). However, these relationships were not found in women with PPROM. In women with PTL, the areas under receiver operating characteristic curves of CVF VDBP level for predicting intra-amniotic infection and imminent preterm delivery were 0.66 and 0.71, with cut-off values of 1.76 μg/mL (sensitivity of 64.3% and specificity of 78.4%) and 1.37 μg/mL (sensitivity of 65.4% and specificity of 72.6%), respectively. The CVF VDBP levels were significantly higher in women with PPROM than in those with PTL.

Conclusions

VDBP in the CVF independently predicts intra-amniotic infection and imminent preterm delivery in women with PTL, whereas in women with PPROM, an elevated VDBP level in CVF is not associated with increased risks of these two outcome variables.

Plasma inflammatory and immune proteins as predictors of intra-amniotic infection and spontaneous preterm delivery in women with preterm labor: a retrospective study

Background

We investigated whether various inflammatory and immune proteins in plasma predict intra-amniotic infection and imminent preterm delivery in women with preterm labor and compared their predictive ability with that of amniotic fluid (AF) interleukin (IL)-6 and serum C-reactive protein (CRP).

Methods

This retrospective cohort study included 173 consecutive women with preterm labor who underwent amniocentesis for diagnosis of infection and/or inflammation in the AF. The AF was cultured, and assayed for IL-6. CRP levels and cervical length by transvaginal ultrasound were measured at the time of amniocentesis. The stored maternal plasma was assayed for IL-6, matrix metalloproteinase (MMP)-9, and complements C3a and C5a using ELISA kits. The primary and secondary outcome criteria were positive AF cultures and spontaneous preterm delivery (SPTD) within 48 h, respectively. Univariate, multivariate, and receiver operating characteristic analysis were used for the statistical analysis.

Results

In bivariate analyses, elevated plasma IL-6 level was significantly associated with intra-amniotic infection and imminent preterm delivery, whereas elevated plasma levels of MMP-9, C3a, and C5a were not associated with these two outcomes. On multivariate analyses, an elevated plasma IL-6 level was significantly associated with intra-amniotic infection and imminent preterm delivery after adjusting for confounders, including high serum CRP levels and short cervical length. In predicting intra-amniotic infection, the area under the curve (AUC) was significantly lower for plasma IL-6 than for AF IL-6 but was similar to that for serum CRP. Differences in the AUCs between plasma IL-6, AF IL-6, and serum CRP were not statistically significant in predicting imminent preterm delivery.

Conclusions

Maternal plasma IL-6 independently predicts intra-amniotic infection in women with preterm labor; however, it has worse diagnostic performance than that of AF IL-6 and similar performance to that of serum CRP. To predict imminent preterm delivery, plasma IL-6 had an overall diagnostic performance similar to that of AF IL-6 and serum CRP. Plasma MMP-9, C3a, and C5a levels could not predict intra-amniotic infection or imminent preterm delivery.

Maternal blood endotoxin activity in pregnancies complicated by preterm premature rupture of membranes

Objective: To compare maternal blood endotoxin activity (EA) in women with preterm premature rupture of membranes (PPROM) with gestational age (GA) matched controls; to evaluate serial EA till birth in PPROM and its correlation with latency to delivery. Methods: We followed singleton preterm pregnancies from admission with PPROM until birth. Uncomplicated, GA-matched pregnancies served as controls. Demographics, birth and neonatal outcomes were collected. EA (EAA™) was assessed serially in PPROM and at study entry in controls. EA was compared using Mann Whitney and Wilcoxon tests, p value <.05 was considered significant. Results: We recruited 20 cases of PPROM and 20 controls. Demographics were similar between groups. Mean GA of PPROM was 29.0 ± 2.2 weeks and median latency was 7.5 (IQR 14.1) weeks. Median EA at admission following PPROM was significantly elevated over controls (0.43 (0.18) versus 0.36 (0.2); p < .02). Overall there was no difference in median EA at admission and in labor (0.43 (0.18) versus 0.33 (0.21); p = .2) following PPROM. However, on comparing cases with latency to delivery ≤7 days (n = 10) versus >7 days (n = 10), there was a significant drop in EA in the latter group (0.44 (0.2) versus 0.34 (0.2); p < .004). Conclusions: EA in PPROM represents a promising biomarker in predicting the clinical evolution of preterm birth.

Acute Associations Between Outdoor Temperature and Premature Rupture of Membranes

BACKGROUND

Extreme ambient temperatures have been linked to preterm birth. Preterm premature rupture of membranes is a common precursor to preterm birth but is rarely studied in relation to temperature.

METHODS

We linked 15,381 singleton pregnancies with premature rupture of membranes from a nationwide US obstetrics cohort (2002-2008) to local temperature. Case-crossover analyses compared daily temperature during the week preceding delivery and the day of delivery to 2 control periods, before and after the case period. Conditional logistic regression models calculated the odds ratio (OR) and 95% confidence intervals (CIs) of preterm and term premature rupture of membranes for a 1°C increase in temperature during the warm (May-September) and cold (October-April) season separately after adjusting for humidity, barometric pressure, ozone, and particulate matter.

RESULTS

During the warm season, 1°C increase during the week before delivery was associated with a 5% (95% CI, 3%, 6%) increased preterm premature rupture of membranes risk, and a 4% (95% CI, 3%, 5%) increased term premature rupture of membranes risk. During the cold season, 1°C increase was associated with a 2% decreased risk for both preterm (95% CI, 1%, 3%) and term premature rupture of membranes (95% CI, 1%, 3%). The day-specific associations for the week before delivery were similar, but somewhat stronger for days closer to delivery.

CONCLUSIONS

Relatively small ambient temperature changes were associated with the risk of both preterm and term premature of membranes. Given the adverse consequences of premature rupture of membranes and concerns over global climate change, these findings merit further investigation. See video abstract at, http://links.lww.com/EDE/B312.

PROM and Labour Effects on Urinary Metabolome: A Pilot Study

Since pathologies and complications occurring during pregnancy and/or during labour may cause adverse outcomes for both newborns and mothers, there is a growing interest in metabolomic applications on pregnancy investigation. In fact, metabolomics has proved to be an efficient strategy for the description of several perinatal conditions. In particular, this study focuses on premature rupture of membranes (PROM) in pregnancy at term. For this project, urine samples were collected at three different clinical conditions: out of labour before PROM occurrence (Ph1), out of labour with PROM (Ph2), and during labour with PROM (Ph3). GC-MS analysis, followed by univariate and multivariate statistical analysis, was able to discriminate among the different classes, highlighting the metabolites most involved in the discrimination.

Management of premature rupture of membranes at term: the need to correct a recurring mistake in articles, chapters, and recommendations of professional organizations

Recommendations about the management of premature rupture of membranes at term are based, in part, on a large, randomized controlled trial published in 1996: the TERMPROM trial. The original article contained an error in Table 1, in which "Interval from membrane rupture to delivery" was listed instead of "Interval from membrane rupture to study entry." While the authors and journal corrected this error, the mistake published in the original paper has made its way into subsequent publications and even in guidelines or practice bulletins issued by professional organizations, textbooks, and other publications around the world. The mistake, that half of women with premature rupture of membranes at term who were managed expectantly delivered within 5 hours and 95% delivered within 28 hours of membrane rupture, should be replaced with the actual fact that half of women with premature rupture of membranes at term who were managed expectantly delivered within 33 hours, and 95% delivered within 94-107 hours of membrane rupture. Correcting this error in contemporary health care information and publications is important to counsel patients accurately and to optimize the clinical care of women with premature rupture of membranes at term.

32-week premature rupture of membranes caused by oropharyngeal microbiota

Introduction. Preterm premature rupture of membranes (PPROM) usually has a multifactorial etiology that is often unknown, although the most frequently reported cause is infection by group B Streptococcus. Therefore, the etiology of PPROM, although probably infectious, remains unknown in most cases. This case describes a PPROM caused by infection from oropharyngeal microbiota.

Case presentation. We report the case of a 26-yr-old pregnant woman. The gestational age was 32 weeks+5 days. Examinations in the emergency department revealed the release of clear amniotic fluid and a closed multiparous cervix with a length of 22 mm. Endocervical culture evidenced the growth of Staphylococcus aureus, serogroup B Neisseria meningitidis and Haemophilus influenzae.

Conclusion. Preventive antibiotic therapy should consider: opportunistic infections by normal genital microbiota, infections due to sexual activity, opportunist microorganisms derived from oral sex, and the hematogenous spread of oral bacteria.