Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217

Uncertain prelabor rupture of membranes at term and associated delivery outcomes

OBJECTIVE

To determine whether equivocal prelabor rupture of membranes (PROM) cases are associated with adverse outcomes.

METHODS

A retrospective study was conducted in a tertiary medical center between July 2012 and March 2022. The cohort comprised all women diagnosed with term PROM (≥37 gestational weeks), divided into two groups. (1) Certain PROM-suggestive history of a watery vaginal discharge confirmed by visualization of fluid leaking from the cervix or pooling in the vagina on speculum examination. (2) Uncertain PROM-suggestive history of a watery vaginal discharge not supported by speculum examination. All patients were hospitalized and gave birth spontaneously or following either expectant management for up to 24 h from PROM or induction. The primary outcome measure was cesarean delivery (CD) rate. Secondary outcome measures were adverse maternal/neonatal events.

RESULTS

Of the 2012 women included in the study, 1750 had certain PROM and 262 uncertain PROM. CD rate was 5.8% in the certain PROM group and 8.8% in the uncertain PROM group; the difference was not statistically significant (P = 0.074). There was a significant between-group difference in the rate of CD due to failed induction on univariate analysis (0.69% vs 2.67%, respectively, P = 0.007), but it was not maintained on multivariate logistic regression (odds ratio 0.37, 95% confidence interval: 0.12-1.17). Other maternal and neonatal outcomes were similar in the two groups.

CONCLUSION

Our findings indicate that following the same management guidelines for equivocal cases of ruptured membranes as for confirmed cases of term PROM did not compromise maternal or fetal outcomes.

Perinatal Outcomes of Late Preterm Rupture of Membranes with or without Latency Antibiotics

OBJECTIVE

 This study aimed to examine whether the addition of latency antibiotics in late preterm rupture of membranes (ROM) decreases neonatal infection and increases latency.

STUDY DESIGN

 This retrospective two-center study was conducted at Holy Family Hospital (HFH) in Nazareth and Emek Medical Center (EMC) in Afula, on data collected between January 2017 and April 2023. HFH is the smaller institution. EMC and HFH implement similar policies regarding ROM at 340/7 to 366/7 weeks' gestation; the only difference is that a 10-day course of latency antibiotics is implemented at EMC. All women with ROM between 340/7 and 366/7 weeks' gestation who were admitted to one of the centers during the study period, and had a live fetus without major malformations, were included. The primary outcome was neonatal sepsis rate. Secondary outcomes included a composite of neonatal sepsis, mechanical ventilation ≥24 hours, and perinatal death. Additionally, gestational age at delivery and delivery mode were examined.

RESULTS

 Overall, 721 neonates were delivered during the study period: 534 at EMC (where latency antibiotics were administered) and 187 at HFH. The gestational age at ROM was similar (35.8 and 35.9 weeks, respectively, p = 0.14). Neonatal sepsis occurred in six (1.1%) neonates at EMC and one (0.5%) neonate at HFH (adjusted p = 0.71; OR: 1.69; 95% Confidence Interval [CI]: 0.11-27.14). The composite secondary outcome occurred in nine (1.7%) and three (1.6%) neonates at EMC and HFH, respectively (adjusted p = 0.71; OR: 0.73; 95% CI: 0.14-3.83). The gestational age at delivery was 36.1 and 36.2 weeks at EMC and HFH, respectively (mean difference: 5 h; adjusted p = 0.02). The cesarean delivery rate was 24.7% and 19.3% at EMC and HFH, respectively (adjusted p = 0.96).

CONCLUSION

 Latency antibiotics administered to women admitted with ROM between 340/7 and 366/7 weeks' gestation did not decrease the rate of neonatal sepsis.

KEY POINTS

· Latency antibiotics in late preterm ROM does not decrease neonatal sepsis.. · Latency antibiotics in late preterm ROM does not prolong gestational age at delivery.. · Latency antibiotics in late preterm ROM does not affect the mode of delivery..

Exposure to mixtures of PM2.5 components and term premature rupture of membranes: a case-crossover study in Shijiazhuang, China

This study aims to explore the acute effects of short-term exposure to PM2.5 components and their mixture on PROM. Counts of hospital admissions due to PROM were collected at the Fourth Hospital of Shijiazhuang. The associations between the PROM and PM2.5 components was examined using a time-stratified case-crossover approach. The overall effects of components on TPROM were examined using the BKMR. During the study period 30,709 cases of PROMwere identified. The relative risks and the 95% CI of TPROM were 1.013 (1.002, 1.028) and 1.015 (1.003, 1.028) associated with per interquartile range increase in nitrate and ammonium ion on the current day and they were 1.007 (1.001, 1.013) and 1.003 (1.000, 1.005) on the previous day. The results from the BKMR models showed a higher risk of TPROM was associated with exposure to mixtures, in which, nitrate and organic matter were the main contributors to the overall effect.

Society for Maternal-Fetal Medicine Consult Series #71: Management of previable and periviable preterm prelabor rupture of membranes

Previable and periviable preterm prelabor rupture of membranes are challenging obstetrical complications to manage given the substantial risk of maternal morbidity and mortality, with no guarantee of fetal benefit. The following are the Society for Maternal-Fetal Medicine recommendations for the management of previable and periviable preterm prelabor rupture of membranes before the period when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient: (1) we recommend that pregnant patients with previable and periviable preterm prelabor rupture of membranes receive individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management to guide an informed decision; all patients with previable and periviable preterm prelabor rupture of membranes should be offered abortion care, and expectant management can also be offered in the absence of contraindications (GRADE 1C); (2) we recommend antibiotics for pregnant individuals who choose expectant management after preterm prelabor rupture of membranes at ≥24 0/7 weeks of gestation (GRADE 1B); (3) antibiotics can be considered after preterm prelabor rupture of membranes at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C); (4) administration of antenatal corticosteroids and magnesium sulfate is not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (GRADE 1B); (5) serial amnioinfusions and amniopatch are considered investigational and should be used only in a clinical trial setting; they are not recommended for routine care of previable and periviable preterm prelabor rupture of membranes (GRADE 1B); (6) cerclage management after previable or periviable preterm prelabor rupture of membranes is similar to cerclage management after preterm prelabor rupture of membranes at later gestational ages; it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making (GRADE 2C); and (7) in subsequent pregnancies after a history of previable or periviable preterm prelabor rupture of membranes, we recommend following guidelines for management of pregnant persons with a previous spontaneous preterm birth (GRADE 1C).

Prediction and prevention of preterm birth: Quality assessment and systematic review of clinical practice guidelines using the AGREE II framework

BACKGROUND

Prediction of pregnancies at risk of preterm birth (PTB) may allow targeted prevention strategies.

OBJECTIVES

To assess quality of clinical practice guidelines (CPGs) and identify areas of agreement and contention in prediction and prevention of spontaneous PTB.

SEARCH STRATEGY

We searched for CPGs regarding PTB prediction and prevention in asymptomatic singleton pregnancies without language restriction in January 2024.

SELECTION CRITERIA

CPGs included were published between July 2017 and December 2023 and contained statements intended to direct clinical practice.

DATA COLLECTION AND ANALYSIS

CPG quality was assessed using the AGREE-II tool. Recommendations were extracted and grouped under domains of prediction and prevention, in general populations and high-risk groups.

MAIN RESULTS

We included 37 CPGs from 20 organizations; all were of moderate or high quality overall. There was consensus in prediction of PTB by identification of risk factors and cervical length screening in high-risk pregnancies and prevention of PTB by universal screening and treatment for asymptomatic bacteriuria, screening and treatment for BV in high-risk pregnancies, and use of preventative progesterone and cerclage. Areas of contention or limited consensus were the role of PTB clinics, universal cervical length measurement, biomarkers and cervical pessaries.

CONCLUSIONS

This review identified strengths and limitations of current PTB CPGs, and areas for future research.

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.

A real-world study on the treatment of extremely preterm infants: a multi-center study in southwest area of Fujian Province in China

BACKGROUND

Due to regional and cultural differences, the current status of extremely preterm infants(EPIs) treatment across different areas of mainland China remains unclear. This study investigated the survival rate and incidence of major diseases among EPIs in the southwest area of Fujian province.

METHOD

This retrospective and multicenter study collected perinatal data from EPIs with gestational ages between 22-27+ 6w and born in the southwest area of Fujian province. The study population was divided into 6 groups based on gestational age at delivery. The primary outcome was the survival status at ordered hospital discharge or correct gestational age of 40 weeks, and the secondary outcome was the incidence of major diseases. The study analyzed the actual survival status of EPIs in the area.

RESULT

A total of 2004 preterm infants with gestational ages of 22-27+ 6 weeks were enrolled in this study. Among them, 1535 cases (76.6%) were born in the delivery room but did not survive, 469 cases (23.4%) were transferred to the neonatal department for treatment, 101 cases (5.0%) received partial treatment, and 368 cases (18.4%) received complete treatment. The overall all-cause mortality rate was 84.4% (1691/2004). The survival rate and survival rate without major serious disease for EPIs who received complete treatment were 85.1% (313/368) and 31.5% (116/318), respectively. The survival rates for gestational ages 22-22+ 6w, 23-23+ 6w, 24-24+ 6w, 25-25+ 6w, 26-26+ 6w, and 27-27+ 6w were 0%, 0%, 59.1% (13/22), 83% (39/47), 88.8% (87/98), and 89.7% (174/198), respectively. The survival rates without major serious disease were 0%, 0%, 9.1% (2/22), 19.1% (9/47), 27.6% (27/98), and 40.2% (78/194), respectively.

CONCLUSION

The all-cause mortality of EPIs in the southwest area of Fujian Province remains high, with a significant number of infants were given up after birth in the delivery room being the main influencing factor. The survival rate of EPIs who received complete treatment at 25-27 weeks in the NICU was similar to that in developed countries. However, the survival rate without major serious disease was significantly lower compared to high-income countries.

Use of vaginal dinoprostone for women with term prelabor rupture of membranes and an unfavorable cervix within 6 h versus within 6-24 h

BACKGROUND

Most guidelines propose inducing labor within 24 h following term (37 or more weeks of gestation) prelabor rupture of membranes (PROM). However, the exact timing for initiating induction within the 24 h period remains unknown. This study aims to comparatively assess the efficacy and safety of the use of vaginal dinoprostone within 6 h versus within 6-24 h for singleton pregnancies with PROM and an unfavorable cervix (Bishop score < 6).

METHODS

This was a retrospective cohort study including singleton pregnancies with PROM and an unfavorable cervix (Bishop score < 6) in which labor was induced using vaginal dinoprostone. Women were divided into two groups according to the timing of the use of induction (within 6 h versus within 6-24 h after PROM). Baseline maternal data, maternal and neonatal outcomes were recorded for statistical analysis.

RESULTS

450 women were included, 146 (32.4%) of whom were induced within 6 h of PROM and 304 (67.6%) were induced within 6-24 h. Cesarean delivery rate (15.8% versus 29.3%, p = 0.002) and nonreassuring fetal heart rate tracing (4.8% versus 10.5%, p = 0.043) in group with vaginal dinoprostone within 6 h were significantly lower than those in group with vaginal dinoprostone within 6-24 h. There was no significant differences in terms of duration from IOL to vaginal delivery.

CONCLUSION

Induction of labor within 6 h with vaginal dinoprostone after PROM for singleton pregnancies with an unfavorable cervix (Bishop score < 6) significantly associated with less cesarean section, less nonreassuring fetal heart rate tracing, compared to induction of labor within 6-24 h after PROM.

A phase II, multicenter, nonblinded, randomized controlled trial for evaluating protective effects of ABPC/SBT plus, azithromycin versus erythromycin, in pregnant women with pPROM occurring at <28 weeks of gestation on the development of BPD in neonates: Study protocol

This is a protocol for PPROM-AZM Study, phase II, nonblinded, randomized controlled trial. Bronchopulmonary dysplasia (BPD) at a postmenstrual age of 36 weeks (BPD36) is often observed in infants with preterm premature rupture of the membranes (pPROM). A regimen of ampicillin (ABPC) intravenous infusion for 2 days and subsequent amoxicillin (AMPC) oral administration for 5 days plus erythromycin (EM) intravenous infusion for 2 days followed by EM oral administration for 5 days is standard treatment for pPROM. However, the effect on the prevention of moderate/severe BPD36 using the standard treatment has not been confirmed. Recently, it is reported that ampicillin/sulbactam (ABPC/SBT) plus azithromycin (AZM) was effective for the prevention of moderate/severe BPD36 in pPROM patients with amniotic infection of Ureaplasma species. Therefore, our aim is to evaluate the occurrence rate of the composite outcome of "incidence rate of either moderate/severe BPD36 or intrauterine fetal death, and infantile death at or less than 36 weeks 0 days" comparing subjects to receive ABPC/SBT for 14 days plus AZM for 14 days (intervention group) and those to receive ABPC/SBT for 14 days plus EM for 14 days (control group), in a total of 100 subjects (women with pPROM occurring at 22-27 weeks of gestation) in Japan. The recruit of subjects was started on April 2022, and collection in on-going. We also investigate the association between the detection of Ureaplasma species and occurrence of BPD36. In addition, information on any adverse events for the mother and fetus and serious adverse events for infants are collected during the observation period. We allocate patients at a rate of 1:1 considering two stratification factors: onset of pPROM (22-23 or 24-27 weeks) and presence/absence of a hospital policy for early neonatal administration of caffeine. Trial registration: The trial number in the Japan Registry of Clinical Trials is jRCTs031210631.

The impact of premature rupture of membrane on neonatal outcomes in infants born at 34 weeks gestation or later

BACKGROUND

Premature rupture of membranes (PROMs) is a known risk for adverse neonatal outcomes, often leading to neonatal hospitalization due to suspected perinatal infection or other issues. This study assesses PROM's clinical impact on neonatal outcomes in infants born at 34 weeks of gestation or later.

METHODS

We studied hospitalized neonates born between December 2018 and November 2019, with gestational ages of 34 weeks or more and PROM diagnosis. We extracted patient data from clinical records, including demographics, maternal history, medical profiles, and neonatal outcomes. Neonates were categorized based on symptoms, PROM duration, neonatal intensive care unit (NICU) stay, and respiratory support. Data underwent thematic analysis.

RESULTS

Of 275 neonates, the average PROM duration was 7.9 ± 8.1 hours, with 247 cases (89.8%) showing symptoms. Among them, 34 (12.4%) had PROM lasting over 18 hours, 48 (17.5%) were born prematurely, and 79 (28.7%) required intensive care. Symptomatic neonates had significantly higher rates of needing intensive care, respiratory support, prolonged antibiotics, and extended hospitalization ( p < 0.05). NICU stays (≥3 days) were significantly associated with prematurity (odds ratio [OR] = 5.49; 95% CI, 2.39-12.60) and an initial pH level <7.25 (OR = 3.35; 95% CI, 1.46-7.68). Extended respiratory support (≥3 days) was significantly correlated with tocolysis ≥7 days (OR = 13.20; 95% CI, 3.94-44.20), Apgar score <7 at 1 minute after birth (OR = 4.28; 95% CI, 1.67-10.97), and inadequate intrapartum antibiotic prophylaxis (IAP) (OR = 2.34; 95% CI, 1.04-5.23).

CONCLUSION

Neonates born at or after 34 weeks of gestation with PROM should undergo vigilant monitoring if early symptoms (<24 hours) manifest. Risk factors for requiring NICU care or extended respiratory support (≥3 days) include prematurity, low initial pH (<7.25), prolonged tocolysis requirement (≥7 days), an Apgar score below 7 at 1 minute, and inadequate IAP.

Relationship between first trimester physical activity and premature rupture of membranes: a birth cohort study in Chinese women

OBJECTIVE

This study aimed to examine prospective associations of different intensity levels and types of physical activity (PA) in early pregnancy with premature rupture of membranes (PROM) among Chinese pregnant women.

METHODS

A total of 6284 pregnant women were included from the Tongji-Shuangliu Birth Cohort. Household/caregiving, occupational, sports/exercise and transportation activities during early pregnancy were investigated by the pregnancy physical activity questionnaire (PPAQ), and the diagnosis of PROM was ascertained during the whole pregnancy. Multivariate logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence interval (CI) for the associations between PA and PROM.

RESULTS

Among the 6284 pregnant women, 1246 were identified to have PROM (19.8%). Women undertaking the highest level (3 third tertile) of PA during pregnancy appeared to have a lower risk of PROM [OR = 0.68, 95%CI 0.58-0.80) when compared to those at the lowest tertile of PA. Similarly, women with increased levels of light intensity activity, moderate-vigorous intensive, household/caregiving activity and meeting exercise guidelines during pregnancy were associated with reduced risks of PROM (OR = 0.69, 95% CI 0.59-0.81, OR = 0.70, 95% CI 0.60-0.82, OR = 0.62, 95% CI 0.53-0.73 and OR = 0.82, 95% CI 0.70-0.97, respectively).

CONCLUSIONS

High levels of PA of different intensities and PA of household/caregiving activities and meeting exercise guidelines during the first trimester were associated with a lower incidence of PROM.

TRIAL REGISTRATION

The data of human participants in this study were conducted in accordance with the Helsinki Declaration. This study has been approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China ([2017] No. S225). All participants provided written informed consent prior to enrollment. A statement to confirm that all methods were carried out in accordance with relevant guidelines and regulations.

The vaginal immunoproteome for the prediction of spontaneous preterm birth: A retrospective longitudinal study

Background

Preterm birth is the leading cause of neonatal morbidity and mortality worldwide. Most cases of preterm birth occur spontaneously and result from preterm labor with intact (spontaneous preterm labor [sPTL]) or ruptured (preterm prelabor rupture of membranes [PPROM]) membranes. The prediction of spontaneous preterm birth (sPTB) remains underpowered due to its syndromic nature and the dearth of independent analyses of the vaginal host immune response. Thus, we conducted the largest longitudinal investigation targeting vaginal immune mediators, referred to herein as the immunoproteome, in a population at high risk for sPTB.

Methods

Vaginal swabs were collected across gestation from pregnant women who ultimately underwent term birth, sPTL, or PPROM. Cytokines, chemokines, growth factors, and antimicrobial peptides in the samples were quantified via specific and sensitive immunoassays. Predictive models were constructed from immune mediator concentrations.

Results

Throughout uncomplicated gestation, the vaginal immunoproteome harbors a cytokine network with a homeostatic profile. Yet, the vaginal immunoproteome is skewed toward a pro-inflammatory state in pregnant women who ultimately experience sPTL and PPROM. Such an inflammatory profile includes increased monocyte chemoattractants, cytokines indicative of macrophage and T-cell activation, and reduced antimicrobial proteins/peptides. The vaginal immunoproteome has improved predictive value over maternal characteristics alone for identifying women at risk for early (<34 weeks) sPTB.

Conclusions

The vaginal immunoproteome undergoes homeostatic changes throughout gestation and deviations from this shift are associated with sPTB. Furthermore, the vaginal immunoproteome can be leveraged as a potential biomarker for early sPTB, a subset of sPTB associated with extremely adverse neonatal outcomes.

Funding

This research was conducted by the Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS) under contract HHSN275201300006C. ALT, KRT, and NGL were supported by the Wayne State University Perinatal Initiative in Maternal, Perinatal and Child Health.

Nulliparas at Term with Premature Rupture of Membranes and an Unfavorable Cervix: Labor Induction with Prostaglandin or Oxytocin? A Retrospective Matched Case Study

Background: Induction of labor (IOL) in nulliparas with premature rupture of membranes (PROM) and an unfavorable cervix at term poses challenges. Our study sought to investigate the impact of prostaglandin E2 (PGE2) compared to oxytocin on the duration of IOL in this specific group of parturients. Methods: This was retrospective matched-case study. All nulliparas with term PROM who underwent induction between January 2006 to April 2023 at Shaare Zedek Medical Center were identified. Cases induced by either PGE2 or oxytocin were matched by the following criteria: (1) time from PROM to IOL; (2) modified Bishop score prior to IOL ≤ 5; (3) newborn birthweight; and (4) vertex position. The primary outcome was time from IOL to delivery. Results: Ninety-five matched cases were identified. All had a modified Bishop score ≤ 5. Maternal age (26 ± 4.7 years old, p = 0.203) and gestational age at delivery (38.6 ± 0.6, p = 0.701) were similar between the groups. Matched factors including time from PROM to IOL (23.5 ± 19.2 versus 24.3 ± 21.4 p = 0.780), birth weight of the newborn (3111 g versus 3101 g, p = 0.842), and occiput anterior position (present on 98% in both groups p = 0.687) were similar. Time from IOL to delivery was significantly shorter by 3 h and 36 min in the group induced with oxytocin than in the group induced with PGE2 (p = 0.025). Within 24 h, 55 (58%) of those induced with PGE2 delivered, compared to 72 (76%) of those induced with oxytocin, (p = 0.033). The cesarean delivery rates [18 (19%) versus 17 (18%)], blood transfusion rates [2 (2%) versus 3 (3%)], and Apgar scores (8.8 versus 8.9) were similar between the groups (PGE2 versus oxytocin, respectively), p ≥ 0.387. Conclusions: Induction with oxytocin, among nulliparas with term PROM and an unfavorable cervix, was associated with a shorter time from IOL to delivery and a higher rate of vaginal delivery within 24 h, with no difference in short-term maternal or neonatal adverse outcomes.

Maternal and fetal outcomes of pregnancy in women with primary systemic vasculitis: A single-center cohort study of 20 patients and 30 pregnancies

OBJECTIVES

To analyze pregnancy outcomes of patients with primary systemic vasculitis followed in a third-level referral center.

METHODS

Retrospective cohort study of all pregnant women with systemic vasculitis followed between 2009 and 2022 at the High-Risk Pregnancy Clinic of the Department of Systemic Autoimmune Diseases of the Hospital Clínic, Barcelona.

RESULTS

Twenty women with primary vasculitis were identified, with a total of 30 pregnancies. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (n = 7) and Behçet disease (n = 4) were the most frequent types of vasculitis. All women had the diagnosis of vasculitis before pregnancy, with a median time between disease diagnosis and pregnancy of 5.8 years (range: 2 months-29 years). Most were in remission at conception (76.7 %). During pregnancy, a vasculitis flare occurred in 4 (13.3 %) patients (one each with Takayasu arteritis, eosinophilic granulomatosis with polyangiitis [EGPA], IgA vasculitis [IgAV], and Behçet disease [BD]). Four (16.7 %) of the successful pregnancies had post-partum relapses (one each with EGPA, granulomatosis with polyangiitis, IgAV, and BD). Eighty percent of pregnancies resulted in live babies. In four cases (13.3 %), medical termination of pregnancy was decided, considering the mother or baby health risk. There were two spontaneous miscarriages, and no stillbirths or neonatal deaths. Preeclampsia was the most frequent maternal complication (25 %). Newborns were preterm in 24 % and low birthweight in 20 % of cases. No maternal deaths occurred.

CONCLUSIONS

This cohort study shows that vasculitis relapses during pregnancy and post-partum, together with other pregnancy complications, occur in a considerable number of patients with systemic vasculitides, although a final good pregnancy outcome can be expected in most cases. These findings emphasize the convenience of managing these special situations in expert reference centers.

Variation in clinical practice guideline recommendations for medication use in pregnancy in Australia: A systematic review

BACKGROUND

Medication use in pregnancy is common; however, it is unknown if clinical practice guideline (CPG) prescribing recommendations referred to in Australia at the state, national and international level are consistent.

AIMS

This systematic review aimed to: (1) identify sources of CPGs that inform prescribing during pregnancy in Australia; (2) assess CPG quality; and (3) evaluate variation within CPG recommendations for medication use in three common conditions in pregnancy: prophylactic antibiotics following premature rupture of membranes (PROM) at term, antidepressants in pregnancy and metformin in gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

A literature search was conducted across PubMed, Scopus and EMBASE databases. Grey literature was identified through publicly available Australian policy statements. Prescribing recommendations for prophylactic antibiotics following PROM at term, antidepressants in pregnancy and metformin in GDM, were compared at the state, national and international levels. CPG quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

RESULTS

We identified 39 CPG sources that inform prescribing during pregnancy in Australia. CPG quality varied between resources. There was minor variation in recommendations for antibiotic prophylaxis in PROM at term. Recommendations regarding metformin use in GDM were also variable, with CPGs either recommending its use as a first-line agent when lifestyle modifications are not effective or when insulin therapy is not practicable. Recommendations for antidepressant use were consistent across CPGs analysed.

CONCLUSION

Multiple CPGs exist to inform prescribing during pregnancy in Australia, with variation present within CPG quality and recommendations. These findings offer insight into potential sources of variation in maternal and neonatal health outcomes.

Predictors of Breastfeeding among Patients Admitted with Preterm Prelabor Rupture of Membranes

OBJECTIVE

 We sought to describe rates of breastmilk feeding (BF) at hospital discharge and 6 weeks postpartum and to identify risk factors for noninitiation or cessation among pregnancies complicated by preterm prelabor rupture of membranes (PPROM).

STUDY DESIGN

 Retrospective cohort study of pregnant persons with PPROM admitted to a single tertiary center (2013-2019). Patients with deliveries complicated by intrauterine or neonatal demise or with incomplete BF data were excluded. Demographic, antepartum, and delivery characteristics were evaluated. Primary analysis identified rate of BF initiation at maternal discharge and factors associated with noninitiation. Secondary analysis evaluated BF continuation and factors associated with cessation at 6 weeks postpartum. Bivariate statistics were used to compare characteristics and logistic regression was used to estimate adjusted odds ratios (aOR).

RESULTS

 Of 397 patients with PPROM, 342(86%) initiated BF prior to discharge. Those reporting tobacco use in pregnancy were less likely to initiate BF (aOR: 0.32; 95% confidence interval [CI]: 0.16, 0.64). In contrast, private insurance (aOR: 2.53; 95% CI: 1.19, 5.37) and pregnancy latency ≥ 14 days (aOR: 3.02; 95% CI: 1.09, 8.38) were associated with BF initiation at hospital discharge. Of the 293 patients with postpartum follow-up, only 214 (73%) had BF continuation at 6 weeks postpartum. Maternal age <20 years (aOR: 0.07; 95% CI: 0.01, 0.68) and multiparity (aOR: 0.54; 95% CI: 0.29, 0.99) were associated with BF cessation. Patients with private insurance were observed to have increased odds of BF continuation (aOR: 2.10; 95% CI: 1.07, 4.12).

CONCLUSION

 Among patients with PPROM, tobacco use may be associated with noninitiation of BF prior to discharge, whereas age < 20 years and multiparity were associated with cessation by 6 weeks postpartum. Longer pregnancy latency ≥ 14 days was associated with BF initiation prior to discharge. Private insurance was associated with increased rates of BF initiation and continuation postpartum. BF education and support should be offered to all patients admitted for PPROM.

KEY POINTS

· Tobacco use may be associated with BF noninitiation.. · Young age and multiparity are linked with BF cessation.. · Private insurance resulted in BF initiation and continuation..

The Role of Cerclage in Subsequent Pregnancy following Previable Prelabor Rupture of Membranes

OBJECTIVE

This study aimed to ascertain the outcomes associated with a cervical cerclage among individuals with a history of previable prelabor rupture of membranes (PROM).

STUDY DESIGN

This study was a retrospective cohort study conducted at a single tertiary center between 2011 and 2021. We included individuals with a history of previable (before 24 weeks) PROM and the subsequent viable pregnancy. Women with multifetal gestation, preterm birth (PTB) or cerclage in previous gestation, or abdominal cerclage after trachelectomy were excluded. Primary outcome was PTB rate (delivery <37 weeks). Recurrence of preterm PROM and adverse composite maternal and neonatal outcomes (CMO and CNO) were evaluated as secondary outcomes. CMO included any of the following: suspected chorioamnionitis, endometritis, red blood cell transfusion, uterine rupture, unplanned hysterectomy, or death. CNO included any of the following: previable PTB (<24 weeks of gestation), bronchopulmonary dysplasia, grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, mechanical ventilation, seizures, hypoxic ischemic encephalopathy, or death.

RESULTS

During the study period, 118 individuals had a history of previable PROM and a documented subsequent pregnancy, out of which 74 (62.7%) met inclusion criteria. Nineteen (25.7%) of eligible individuals underwent a cerclage for prior previable PROM and were compared with controls (n = 55, 74.3%). Women who underwent a cerclage had higher rates of PTB < 37 weeks (63.2 vs. 10.9%, p < 0.001; odds ratio [OR]: 14.00, 95% confidence interval [CI]: 3.97-49.35) and < 34 weeks (21.1 vs. 3.6%, p = 0.03; OR: 7.07, 95% CI: 1.18-42.39) compared with those without cerclage. Furthermore, recurrent preterm PROM and previable PTB rates were higher among patients who underwent cerclage. The survival curve further indicated that individuals with cerclage delivered earlier. CMO and CNO rates were similar in those with and without cerclage.

CONCLUSION

Cerclage placement in individuals with prior previable PROM was associated with higher rates of recurrent preterm PROM and PTB.

KEY POINTS

· The management of individuals in a subsequent pregnancy following previable PROM is a conundrum.. · Cerclage following previable PROM is associated with higher rates of recurrent preterm PROM and PTB.. · Composite maternal and neonatal outcome rates were similar in those with and without cerclage..

Postpartum Necrotizing Myositis With Endometrial Prolapse

BACKGROUND

Postpartum necrotizing myositis is a rare condition, typically presenting as a complication after uterine artery embolization or uterine compression suturing. Uterine ischemia can cause endometrial necrosis and even myometrial necrosis, which can lead to systemic infection. If a systemic infection is not promptly and actively treated, it may pose significant risk.

CASE

A 35-year-old patient who had undergone bilateral uterine artery ligation, modified B-Lynch suture, and multiple compression sutures due to refractory postpartum hemorrhage frequently presented to clinic after postpartum discharge due to persistent fever and vaginal discharge. A bag-like prolapse from the vagina measuring 10×5 cm, accompanied by purulent discharge, was noted 78 days postsurgery. Subsequent pelvic magnetic resonance imaging revealed a uterine basal abscess and postpartum necrotizing myositis; an emergency laparoscopic supracervical hysterectomy was performed, with postoperative pathology confirming the diagnosis. After the patient's discharge, she was readmitted for inpatient treatment of a pelvic abscess.

CONCLUSIONS

Although rare, postpartum necrotizing myositis should be considered in postpartum patients presenting with fever, abdominal pain, severe infection symptoms, and abnormal vaginal discharge. Culture and sensitivity testing are recommended to direct appropriate antibiotic therapy.

Maternal biomarkers in predicting neonatal sepsis after preterm premature rupture of membranes in preterm infants

AIM

This retrospective cohort study aimed to assess the utility of maternal C-reactive protein (CRP) and leukocyte levels in predicting neonatal sepsis after preterm premature rupture of membranes (pPROM).

METHODS

We conducted a retrospective cohort study (2009-2021), encompassing preterm infants born ≤29 + 6 weeks of gestation following pPROM. The primary outcome was early-onset neonatal sepsis within the initial 72 h of life.

RESULTS

We analysed data from 706 patients with a median gestational age at pPROM of 25.1 weeks and a median gestational age at birth of 26.4 weeks. Overall survival rate was 86.1%, with 65.7% survival without severe morbidities. These rates were significantly worse in preterm infants with sepsis. Maternal CRP and leukocyte levels correlated significantly with neonatal infection markers and sepsis. However, their predictive values, correlation coefficients, and area under the curve values were generally low. Using maternal CRP ≥2 mg/dL to predict neonatal sepsis yielded a positive predictive value of 18.5%, negative predictive value of 91.5%, AUC of 0.589, 45.5% sensitivity, and 74.5% specificity.

CONCLUSION

Maternal CRP and leukocyte levels were ineffective as a tool for predicting early-onset neonatal sepsis following early pPROM. Consequently, these biomarkers lack the reliability required for clinical decision-making in this context.

Non-invasive prediction model of histologic chorioamnionitis with preterm prelabour rupture of membranes

BACKGROUND

The aim of this study is to identify risk factors associated with histological chorioamnionitis (HCA) and develop a predictive model for antepartum assessment of the risk of PPROM with HCA.

METHODS

This study retrospectively analyzed pregnant women who experienced PPROM between 25 + 0 and 35 + 0 weeks of gestational age. The women were divided into two groups based on the presence or absence of HCA. Univariate and multivariate logistic regression analyses were conducted to identify maternal risk factors and develop a clinical prediction model for HCA. The model's discrimination and consistency were evaluated using receiver operating characteristic (ROC) and calibration curves.

RESULTS

Seventeen thousand one hundred forty-six (17,146) pregnant women were screened, and 726 (4.23 %) had PPROM. Out of the 286 subjects with PPROM, 160 developed HCA. The maternal age of these subjects ranged from 18 to 43 years (30.0 ± 5.4), while their gestational age (GA) ranged from 25 + 0 to 35 + 0 weeks (31.6 ± 2.0). The average GA at delivery was 32.2 ± 2.0 (weeks).Compared with the non-HCA group, the expectant time > 48 h, GA at delivery > 32 weeks, twin pregnancy, HGB (<110 g/Lg/L), degree of LGB (IIb-III), and WBC (>9.5 × 109 /L) were significantly more than in the PPROM with HCA group. The results show that the best model was obtained by leave-one-out logistic regression (AUC = 0.785, CA = 0.741, F1 = 0.739, Precision = 0.740, Recall = 0.741). In the validation set, logistic regression also achieved good results (AUC = 0.710, CA = 0.671, F1 = 0.654, Precision = 0.683, Recall = 0.671). Combining the previous analysis, we found that the prognostic model constructed using the core six features had the best predictive effect.

CONCLUSIONS

Six features were associated with the occurrence of chorioamnionitis. These features were used to construct a diagnostic model that can accurately predict the probability of chorioamnionitis occurrence and provide a beneficial tool for the prevention and management of PPROM with HCA.

Ureaplasma and Mycoplasma Screening for Pregnant Individuals Who Are at High Risk for Preterm Birth

OBJECTIVE

This study aimed to examine gestational age at delivery according to Ureaplasma/Mycoplasma cervical culture results and whether pregnant individuals received antibiotics.

STUDY DESIGN

A retrospective cohort study at a single academic institution where all pregnant individuals with risk factors for preterm birth including those with a history of preterm birth, recurrent pregnancy loss, or pregnancy requiring cervical cerclage were included. We plotted Kaplan-Meier curves to investigate the association between the gestational age at delivery and Ureaplasma culture results (negative; positive and treated; or positive but did not receive the treatment). A Cox proportional regression model was used to calculate hazard ratio (HR) with 95% confidence intervals (95% CI), controlling for confounders. The main outcome was age at delivery. Analyses were repeated for Mycoplasma culture.

RESULTS

Of 607 individuals, 258 (42.5%) had a negative Ureaplasma culture, 308 (50.7%) had a positive Ureaplasma culture and received treatment, and 41 (6.8%) had a positive Ureaplasma culture and did not receive treatment. Compared with those who had a positive Ureaplasma culture but did not receive treatment, those who had a negative Ureaplasma culture did not have a decreased risk (HR: 1.03; 95% CI: 0.74-1.44). Compared with those who had a positive Ureaplasma culture but did not receive treatment, those who had a positive Ureaplasma culture and received treatment did not have a decreased risk (HR: 0.91; 95% CI: 0.66-1.27). The treatment failure rate of Ureaplasma after treatment was 78.6% (95% CI: 72.8-83.7%). Overall, the findings of Mycoplasma were similar.

CONCLUSION

Routine ureaplasma/mycoplasma cervical culture is not recommended for pregnant individuals who are at high risk for preterm birth.

KEY POINTS

· Ureaplasma/mycoplasma species are isolated in patients with preterm birth.. · High ureaplasma/mycoplasma recurrence rate despite treatment with antibiotics.. · Treatment of patient and partner did not improve gestational age at delivery..

Tocolysis after preterm prelabor rupture of membranes and 5-year outcomes: a population-based cohort study

BACKGROUND

The administration of tocolytics after preterm prelabor rupture of membranes remains a controversial practice. In theory, reducing uterine contractility should delay delivery and allow for optimal antenatal management, thereby reducing the risks for prematurity and adverse consequences over the life course. However, tocolysis may be associated with neonatal death or long-term adverse neurodevelopmental outcomes, mainly related to prolonged fetal exposure to intrauterine infection or inflammation. In a previous study, we showed that tocolysis administration was not associated with short-term benefits. There are currently no data available to evaluate the impact of tocolysis on neurodevelopmental outcomes in school-aged children born prematurely in this clinical setting.

OBJECTIVE

This study aimed to investigate whether tocolysis administered after preterm prelabor rupture of membranes is associated with neurodevelopmental outcomes at 5.5 years of age.

STUDY DESIGN

We used data from a prospective, population-based cohort study of preterm births recruited in 2011 (referred to as the EPIPAGE-2 study) and for whom the results of a comprehensive medical and neurodevelopmental assessment of the infant at age 5.5 years were available. We included pregnant individuals with preterm prelabor rupture of membranes at 24 to 32 weeks' gestation in singleton pregnancies with a live fetus at the time of rupture, birth at 24 to 34 weeks' gestation, and participation of the infant in an assessment at 5.5 years of age. Exposure was the administration of any tocolytic treatment after preterm prelabor rupture of membranes. The main outcome was survival without moderate to severe neurodevelopmental disabilities at 5.5 years of age. Secondary outcomes included survival without any neurodevelopmental disabilities, cerebral palsy, full-scale intelligence quotient, developmental coordination disorders, and behavioral difficulties. A propensity-score analysis was used to minimize the indication bias in the estimation of the treatment effect on outcomes.

RESULTS

Overall, 596 of 803 pregnant individuals (73.4%) received tocolytics after preterm prelabor rupture of membranes. At the 5.5-year follow-up, 82.7% and 82.5% of the children in the tocolysis and no tocolysis groups, respectively, were alive without moderate to severe neurodevelopmental disabilities; 52.7% and 51.1%, respectively, were alive without any neurodevelopmental disabilities. After applying multiple imputations and inverse probability of treatment weighting, we found no association between the exposure to tocolytics and survival without moderate to severe neurodevelopmental disabilities (odds ratio, 0.93; 95% confidence interval, 0.55-1.60), survival without any neurodevelopmental disabilities (odds ratio, 1.02; 95% confidence interval, 0.65-1.61), or any of the other outcomes.

CONCLUSION

There was no difference in the neurodevelopmental outcomes at age 5.5 years among children with and without antenatal exposure to tocolysis after preterm prelabor rupture of membranes. To date, the health benefits of tocolytics remain unproven, both in the short- and long-term.

Investigation of the frequency and relationship between trichomonas infection in the preterm delivery (a case-control study in Amir Al-Momenin Hospital, Semnan)

Introduction and Purpose

Preterm delivery is a common complication during pregnancy periods and imposes a high cost on the healthcare system due to the care needs of premature babies. Sexually transmitted infections are one of the effective factors in the occurrence of preterm delivery and the diagnosis and treatment of these infections are effective in reducing complications and preventing preterm delivery. In this study, the role of Trichomonas vaginalis (T. vaginalis [TV]) infection in preterm delivery has been evaluated.

Methods

In a prospective case-control study, women with preterm birth were assigned to the case group, and women with full-term delivery on the same day were also assigned randomly to the control group. After receiving the history and physical examination, a sample was taken from the cervix for TV culture. The data were included in the SPSS version 23 software. A significance level of less than 0.05 was considered.

Findings

The overall prevalence of this infection was 10%. The prevalence of chlamydial infection was 2% among mothers with full-term delivery and 16.4% among mothers with premature birth, and there was a significant difference between the two groups (P = 0.021). The logistic regression analysis to determine the effect of Trichomonas infection on premature birth showed that there was the probability of the occurrence of premature delivery increases in mothers with trichomoniasis infection with lower age, higher body mass index, the presence of underlying disease, lower educational level, housewives, lower parity and gravity and having a history of fetus abortion more than 13 times with its occurrence probability occurs in mothers without Trichomonas infection (P = 0.046, Exp (β) =13.266).

Conclusion

According to the present results, TV screening for pregnant women, especially in high-risk groups, is emphasized to reduce the incidence of preterm delivery and related complications, especially neonatal complications.

Prelabour rupture of the membranes at term: antibiotic overuse in Italy

BACKGROUND

The proper management of women with premature rupture of membrane (PROM) and not spontaneously entering in labour remains controversial. The aim of this study was to identify the current management for women with PROM at term according to the Group B Streptococcus (GBS) status across different Italian hospitals.

METHODS

Anonymous online survey evaluating: the current practice of women with PROM in terms of management (expectant management vs. induction of labour) and antibiotic prophylaxis according to GBS status.

RESULTS

In case of negative GBS status, the 82.4% of respondents wait until 24 hours before labour induction. Antibiotics are administered for prophylaxis in 35.3%, 27.5% and 2% at 18, 12 and 24 hours respectively. The remaining 35.3% of respondents are divided between those using antibiotics only with signs of infections or according to different risk factors (i.e. meconium-stained amniotic fluid or suspected infection). Neonates born from a mother with negative GBS status almost never (90.2%) receive prophylactic antibiotics. In case of positive GBS status, induction is started as soon as possible by 49.1% of respondents; the remnants choose to wait 6 (15.7%), 12 (17.6%), 18 (3.9%) and 24 (13.7%) hours. Antibiotics are administered as soon as possible by 78.4% of clinicians. In the neonates, 51% of neonatologist administer antibiotics upon clinical indications (suspected sepsis); 15.7% use antibiotics routinely or with a short interval between maternal antibiotics and delivery (17.6%).

CONCLUSIONS

The management after PROM is highly heterogeneous with an inappropriate extension of antibiotic prophylaxis in cases with negative GBS status.

Peripartum Pharmacotherapy: A Pharmacist's Guide

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

Perinatal outcomes following abdominoplasty: a retrospective study and review of current literature

BACKGROUND

Abdominoplasty surgery is a common body contouring surgery to remove excess fat and skin and restore weakened or separated abdominal muscles caused by aging, pregnancy, or weight fluctuations. There is limited literature regarding patient and pregnancy outcomes after abdominoplasty.

OBJECTIVE

This study aimed to determine whether there was a correlation between adverse pregnancy outcomes and history of abdominoplasty.

STUDY DESIGN

Our study used a large federated deidentified national health research network with data sourced from 68 healthcare organizations within the United States (TriNetX; data accessed on August 19, 2022). All patients with a record of pregnancy were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, codes and were grouped into those with a history of abdominoplasty and those without. This study evaluated the perinatal outcomes of fetal growth restriction, abnormal umbilical artery Dopplers, gestational hypertension, preeclampsia, preterm delivery, preterm premature rupture of membranes, gestational diabetes mellitus, macrosomia, stillbirth, abnormal placentation, and wound disruption or infection occurring during a patient's pregnancy after abdominoplasty. Propensity matching was performed to account for potential confounders. An alpha level of <.05 was considered statistically significant.

RESULTS

Of the 44,737 patients meeting our criteria, 304 had a history of abdominoplasty, whereas 44,433 did not (control). Our study found that patients with a history of abdominoplasty had significantly higher gravidity, were largely located in the Southern and Midwest region, and had higher counts of vaginal deliveries and cesarean deliveries than the control cohort (Table 1). After propensity score matching, our study found a lower risk of preeclampsia and preterm premature rupture of membranes in patients with abdominoplasty (odds ratio, 0.46; 95% confidence interval, 0.32-0.67; P<.0001) (Table 2). Furthermore, abdominoplasty was associated with an increased risk of preterm delivery (odds ratio, 2.15; 95% confidence interval, 1.48-3.13; P=.0002) (Table 2). Lastly, this study did not find significant differences in the other perinatal outcomes (Table 2).

CONCLUSION

Our data suggest that abdominoplasty may be associated with a relative increase in the rates of preterm delivery and cesarean delivery and that other perinatal outcomes are not increased. This provides evidence that future desire for pregnancy need not be a relative contraindication to abdominoplasty.

Risk factors for premature rupture of membranes in pregnant women: a systematic review and meta-analysis

OBJECTIVE

To identify risk factors for premature rupture of membranes (PROM) in pregnant women.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Web of Science, PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, Chinese Scientific Journal Database (VIP) and China Biology Medicine Disc were searched from inception to October 2022.

ELIGIBILITY CRITERIA

Cross-sectional, case-control and cohort studies published in English or Chinese that reported the risk factors for PROM were eligible for inclusion.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data and evaluated the risk of bias using the Newcastle-Ottawa Scale and American Agency for Healthcare Research and Quality tools. Analyses were performed using RevMan 5.4 software, and heterogeneity was assessed using χ2 tests and I2 statistics. The sensitivity analyses included a methodological transition between fixed-effect and random-effect models and the systematic stepwise exclusion of studies.

RESULTS

A total of 21 studies involving 18 174 participants with 18 risk factors were included. The significant risk factors were low Body Mass Index (BMI) (OR 2.18, 95% CI 1.32 to 3.61), interpregnancy interval (IPI) <2 years (OR 2.99, 95% CI 1.98 to 4.50), previous abortion (OR 2.35, 95% CI 1.76 to 3.14), previous preterm birth (OR 5.72, 95% CI 3.44 to 9.50), prior PROM (OR 3.95, 95% CI 2.48 to 6.28), history of caesarean section (OR 3.06, 95% CI 1.72 to 5.43), gestational hypertension (OR 3.84, 95% CI 2.36 to 6.24), gestational diabetes mellitus (GDM) (OR 2.16, 95% CI 1.44 to 3.23), abnormal vaginal discharge (OR 2.17, 95% CI 1.45 to 3.27), reproductive tract infection (OR 2.16, 95% CI 1.70 to 2.75), malpresentation (OR 2.26, 95% CI 1.78 to 2.85) and increased abdominal pressure (OR 1.45, 95% CI 1.07 to 1.97). The sensitivity analysis showed that the pooled estimates were stable.

CONCLUSIONS

This meta-analysis indicated that low BMI, IPI <2 years, previous abortion, previous preterm birth, prior PROM, history of caesarean section, gestational hypertension, GDM, abnormal vaginal discharge, reproductive tract infection, malpresentation and increased abdominal pressure might be associated with a greater risk of PROM. Associations between smoking status, short cervical length, fine particulate matter (PM2.5) and PROM require further investigation.

PROSPERO REGISTRATION NUMBER

CRD42022381485.

Vaginal delivery of triplets after emergency transvaginal cerclage: A case report and literature review

RATIONALE

To report a peculiar case of vaginal delivery of a triplet after emergency transvaginal cerclage and to find a way to optimize some extreme situations encountered in clinical practice after evaluating feasibility.

PATIENT CONCERNS

A 33-year-old gravida 6, para 0050 woman at 21 + 6 weeks of gestation was referred to the obstetric department for opening of the cervical canal. An emergency McDonald cerclage was performed at 22 weeks of gestation after a comprehensive assessment, and the pregnancy ended with vaginal delivery at 24 + 6 weeks of gestation. The postpartum period was normal, and the newborns were discharged to home care after treatment in the neonatal intensive care unit.

INTERVENTIONS

After discussing the risks, the patient requested emergency transvaginal McDonald cerclage at 22 weeks of gestation.

OUTCOMES

Emergency McDonald cerclage was performed at 22 weeks of gestation, and the pregnancy ended with vaginal delivery at 24 + 6/25 weeks of gestation, successfully prolonging gestation by 20/21 days. The postpartum period had no exceptional circumstances, and newborns were discharged to home care after treatment in the neonatal intensive care unit for 104/98/104 days.

LESSONS

Emergency cerclage seems to be impossible in multiple pregnancies. However, in this case, after a comprehensive assessment, it was feasible to extend the gestational age by emergency cerclage, and prompt and accurate evaluation is important to avoid complications and individualize the following management. In this case, we may find a way to optimize some extreme situations encountered in clinical practice and offer a glimmer of hope for families challenged with multiple pregnancies at risk of preterm delivery. However, more high-quality studies are needed to prove the effectiveness and safety of emergency cerclages in triplets.

Risk of adverse perinatal outcomes among women with clinical and subclinical histopathological chorioamnionitis

Introduction

Histologic chorioamnionitis (HCA) is a placental inflammatory condition associated with adverse perinatal outcomes (APOs). This historical cohort study explores the risk of APOs in pregnant women with HCA and compares the impact of clinical chorioamnionitis (CCA) with subclinical chorioamnionitis (SCCA).

Methodology

Placentas were evaluated by a perinatal pathologist tand all women with HCA were included. Two groups were integrated: (1) women with clinical chorioamnionitis (CCA) and (2) women with subclinical chorioamnionitis (SCCA). Additionally, we conducted a secondary analysis to compare the prevalence of APOs among stage 1, 2 and 3 of HCA and the risk of APOs between grades 1 and 2 of HCA. The APOs analyzed were preterm birth, stillbirth, neonatal weight < 1,500 g, neonatal sepsis. Relative risk with 95% confidence interval was calculated.

Results

The study included 41 cases of CCA and 270 cases of SCCA. The mean gestational age at diagnosis and birth was 30.2 ± 5.4 weeks and 32.5 ± 5.1 weeks, for group 1 and 2, respectively. The study also found that women with HCA stage 3 and grade 2 had a higher prevalence and risk of adverse perinatal outcomes.

Discussion

The findings of this study suggest the importance of placental histological study to excluded SCCA, which represents a significant risk to both maternal and neonatal health, contributing to high morbidity and mortality.

The impact of gestational weeks of Coronavirus disease 2019 (COVID-19) infection on perinatal outcomes

BACKGROUND

To evaluate the relationship between coronavirus disease 2019 (COVID-19) infection at different time points during pregnancy and perinatal outcomes.

METHODS

This retrospective study included 611 women who hospitalized for delivery between December 7 and April 30, 2023. Based on the different pregnancy weeks infected with COVID-19, the participants were divided into four groups: Group 1 (14-27+6 weeks gestation), Group 2 (28-36+6 weeks gestation), Group 3 (37-39+6 weeks gestation), and Group 4 (≥ 40 weeks gestation). Data including maternal demographic characteristics, clinical profiles, and perinatal outcomes were analyzed.

RESULTS

There were no significant differences in maternal demographic characteristics among the four groups (P > 0.05). Compared to Groups 3 and 4, a higher rate of fever was noted in Groups 1 and 2 (P < 0.05). The frequency of preeclampsia and gestational diabetes mellitus showed a decreasing trend as pregnancy progressing (P < 0.05). Preterm delivery and neonatal intensive care unit admission were more frequently observed in Groups 1 and 2 than in Groups 3 and 4 (P < 0.05). Multivariate logistic regression analysis demonstrated that the timing of gestation in which COVID-19 was infected was not associated with preterm delivery and neonatal intensive care unit admission (P > 0.05), whereas gestational age at COVID-19 infection was negatively associated with the occurrence of preeclampsia and gestational diabetes mellitus (P < 0.05).

CONCLUSIONS

Gestational age at COVID-19 infection is a simple parameter that predicts adverse perinatal outcomes to aid clinicians in determining to provide early enhanced prenatal care and increased monitoring to reduce maternal complications.

Latency Antibiotics in Preterm Prelabor Rupture of Membranes: A Comparison of Azithromycin Regimens

BACKGROUND

Treatment with antibiotics at the time of preterm prelabor rupture of membranes (PPROM) has been shown to prolong pregnancy. Due to the recurrent shortage of erythromycin, azithromycin has been substituted in the traditional regimen; however, there are little data on optimal dosing.

OBJECTIVE

The objective of this study was to determine whether there is a difference in latency from onset of PPROM to delivery in patients who received a single dose of azithromycin compared with a 5-day course.

METHODS

This was a single-center, multisite, retrospective, IRB approved analysis of patients admitted with a diagnosis of PPROM. Patients were included if rupture occurred between 22 0/7 and 33 6/7 weeks of gestation and received either a single dose or a 5-day course of azithromycin along with a beta lactam.

RESULTS

A total of 376 patients were reviewed with 296 patients included in the final analysis. There was no statistical difference in the primary outcome of latency days in patients who received the 5-day versus the single-dose course (4 vs 5 days, P = 0.641). There was a significantly higher rate of histologic chorioamnionitis in the single-dose course of azithromycin (46.4% vs 62.6%, P = 0.006).

CONCLUSIONS AND RELEVANCE

There was no difference in latency for patients who received a 5-day course of azithromycin versus a single dose for the treatment of PPROM. A higher rate of histologic chorioamnionitis was observed in those who received the single-day course. Prospective follow-up studies are needed to confirm these findings.

Prenatal amoxicillin exposure induces developmental toxicity in fetal mice and its characteristics

Amoxicillin, a widely used antibiotic in human and veterinary pharmaceuticals, is now considered as an "emerging contaminant" because it exists widespreadly in the environment and brings a series of adverse outcomes. Currently, systematic studies about the developmental toxicity of amoxicillin are still lacking. We explored the potential effects of amoxicillin exposure on pregnancy outcomes, maternal/fetal serum phenotypes, and fetal multiple organ development in mice, at different doses (75, 150, 300 mg/(kg·day)) during late-pregnancy, or at a dose of 300 mg/(kg·day) during different stages (mid-/late-pregnancy) and courses (single-/multi-course). Results showed that prenatal amoxicillin exposure (PAmE) had no significant influence on the body weights of dams, but it could inhibit the physical development and reduce the survival rate of fetuses, especially during the mid-pregnancy. Meanwhile, PAmE altered multiple maternal/fetal serum phenotypes, especially in fetuses. Fetal multi-organ function results showed that PAmE inhibited testicular/adrenal steroid synthesis, long bone/cartilage and hippocampal development, and enhanced ovarian steroid synthesis and hepatic glycogenesis/lipogenesis, and the order of severity might be gonad (testis, ovary) > liver > others. Further analysis found that PAmE-induced multi-organ developmental and functional alterations had differences in stages, courses and fetal gender, and the most obvious changes might be in high-dose, late-pregnancy and multi-course, but there was no typical rule of a dose-response relationship. In conclusion, this study confirmed that PAmE could cause abnormal development and multi-organ function alterations, which deepens our understanding of the risk of PAmE and provides an experimental basis for further exploration of the long-term harm.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Significance of cervical secretion culture in predicting maternal and fetal outcome in pregnant women with premature rupture of membranes: a retrospective cohort study

Background: To investigate the clinical value of cervical secretion culture in pregnant women with premature rupture of membranes (PROM) in predicting maternal and fetal outcomes. Methods: We retrospectively reviewed clinical records of pregnant women who underwent obstetric examination and delivered in Fujian Maternal and Child Healthcare from December 2013 to December 2016. Pregnant women with a clear diagnosis of PROM, who underwent cervical secretion culture immediately after hospital admission were selected for the study. The primary outcome was the occurrence of chorioamnionitis. The secondary outcome was neonatal admission to the neonatal intensive care unit (NICU). Correlation between maternal and fetal outcomes and the results of the cervical secretion culture was analyzed by one-way analysis and multifactorial analysis, respectively. The predictive efficacy of cervical secretion culture was evaluated using receiver operating characteristic curve (ROC), area under the curve (AUC) and the integrated discrimination improvement (IDI). Results: A total of 7,727 pregnant women with PROM were included in the study. Of them, 1812 had positive cervical secretion cultures (635 positive for mycoplasma infection, 475 for bacterial, 637 for fungal, and 65 for chlamydial infections). Pregnant women with positive mycoplasma and bacterial cultures had higher rates of developing chorioamnionitis compared to women with negative cervical secretion cultures (9%, 12% vs. 1%, respectively). Similarly, positive mycoplasma and bacterial cultures were associated with higher rate of the preterm (before 34 weeks) labor (3%, 3% vs. 1% in women with negative cultures, respectively), and neonatal admission to the NICU (9%, 11% vs. 7%, respectively). After adjusting for various confounding factors, our analysis demonstrated that a positive cervical secretion culture for mycoplasma or bacterial pathogens remained an independent risk factor for chorioamnionitis. Cervical secretion culture outcome was less effective in predicting chorioamnionitis (AUC 0.569) compared to white blood count (WBC) (AUC 0.626) and C-reactive protein (CRP) levels (AUC 0.605). The IDI of the combined predictive model incorporating WBC, CRP, maternal fever and cervical secretion culture results was 0.0029. Conclusion: Positive cervical secretion cultures, especially for mycoplasma and bacteria, are associated with higher incidence of adverse maternal and fetal outcomes. However, the predictive value of this test is poor, and cannot be efficiently used for predicting chorioamnionitis.

Preterm premature rupture of the membranes (PPROM): a study of patient experiences and support needs

BACKGROUND

Preterm prelabour rupture of membranes (PPROM) is a common obstetric condition but outcomes can vary depending on gestation. Significant maternal and foetal complications occur including preterm birth, infection, abruption, cord prolapse, pulmonary hypoplasia and even death. Although the need for psychological support is recognised it is unclear how much is actually offered to women and their families. This study aimed to survey the views of women and their families who have undergone PPROM in order to understand the care and psychological burden these families face.

METHODS

An online survey was conducted, recruiting women via social media with collaboration from the patient advocacy support group Little Heartbeats. Responses were collated where fields were binary or mean and standard deviations calculated. Framework analysis was used to identify and analyse themes in free text responses.

RESULTS

180PPROM pregnancies were described from 177 respondents. Although carewas variable and respondents were from across the world there werecommon themes. Five themes were highlighted which were: a lack ofbalanced information regarding the condition, support in decisionmaking and support with the process, specific psychological supportand ongoing psychological consequences of PPROM.

CONCLUSION

This survey highlights areas in which care needs to be improved for women with PPROM. Previous studies have shown that providing good care during the antenatal period reduces long-term psychological morbidity for the whole family. The need for support, with regard both to information provided to women and their families and their psychological support needs to be addressed urgently.

Recent Advances and Challenges in the Early Diagnosis and Treatment of Preterm Labor

Preterm birth (PTB) is the primary cause of neonatal mortality and long-term disabilities. The unknown mechanism behind PTB makes diagnosis difficult, yet early detection is necessary for controlling and averting related consequences. The primary focus of this work is to provide an overview of the known risk factors associated with preterm labor and the conventional and advanced procedures for early detection of PTB, including multi-omics and artificial intelligence/machine learning (AI/ML)- based approaches. It also discusses the principles of detecting various proteomic biomarkers based on lateral flow immunoassay and microfluidic chips, along with the commercially available point-of-care testing (POCT) devices and associated challenges. After briefing the therapeutic and preventive measures of PTB, this review summarizes with an outlook.

Timing of antibiotic prophylaxis in term prelabor rupture of membranes: A retrospective cohort study using propensity-score matching

OBJECTIVE

To assess whether earlier administration of antibiotic prophylaxis after prelabor rupture of membranes (PROM) at term would decrease the incidence of maternal and neonatal infections.

METHODS

This is a retrospective cohort study comparing women with term PROM who were initiated antibiotic prophylaxis within or after 6 h, and within or after 12 h from PROM to delivery during January 2019 to December 2021. Women with term PROM receiving cephalosporin and without contraindications to vaginal delivery or confirmed or suspected infection were included in the study. The primary outcome was puerperal infection, which refers to the reproductive tract infection occurring within 42 days of delivery. The type of pharmacoeconomic evaluation was selected based on the results of compared effectiveness between the early group and the late group. Propensity-score matching (PSM) was used to adjust confounding. Subgroup and sensitivity analyses were used to verify the robustness of results.

RESULTS

We enrolled 5353 women with term PROM, including 4331 initiated with antibiotic within 6 h, 1022 after 6 h, 5077 within 12 h, and 276 after 12 h. After PSM, no significant difference was observed in the baseline characteristics of the groups. There was no statistical difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in puerperal infection (4.6% vs. 4.3%, P = 0.826; 2.9% vs. 4.6%, P = 0.471, respectively), total maternal infection, neonatal sepsis, and total neonatal infection. Cost-minimization analysis showed there was no significant difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in direct medical costs.

CONCLUSION

This study showed that there was no statistical difference in the efficacy and economy of antibiotic prophylaxis used within 6-12 h after rupture of membranes versus after 6-12 h in women with term PROM.

Associations between individual and structural level racism and gestational age at birth in the Nulliparous Pregnancy Outcomes Study: Monitoring mothers-to-be

The purpose of this study was to investigate the associations between multilevel racism and gestational age at birth among nulliparous non-Hispanic Black, non-Hispanic White and Hispanic women. We conducted a secondary analysis of data of the nuMoM2b Study (2010-2013) to examine the associations between individual and structural-level experiences of racism and discrimination and gestational age at birth among nulliparous women (n=7,732) at eight sites across the U.S. Measures included the individual Experiences of Discrimination (EOD) scale and the Index of Concentration (ICE) at the Extremes to measure structural racism. After adjustment,we observed a significant individual and structural racism interaction on gestational length (p=0.03). In subgroup analyses, we found that among these with high EOD scores, women who were from households concentrated in the more privileged group had significantly longer gestations (β = 1.07, 95% CI: 0.24, 1.90). Women who reported higher EOD scores and more economic privilege had longer gestations, demonstrating the moderating effect of ICE as a measure of structural racism. In conclusion, ICE may represent a modifiable factor in the prevention of adverse birth outcomes in nulliparas.

Predictors and perinatal outcomes of pre-labor rupture of membrane among pregnant women admitted to Hiwot Fana Comprehensive Specialized University Hospital, Eastern Ethiopia: a retrospective study

Background

Pre-labor rupture of membrane (PROM) refers to a membrane rupture that occurs after the 28th week of pregnancy but before the start of labor. If not appropriately managed, it poses a significant risk to the health of the mother and fetus. However, information on the magnitude of PROM, contributing factors, and its perinatal outcomes was limited in Eastern Ethiopia. This study assessed the prevalence, predictors, and perinatal outcomes of PROM among pregnant women admitted to Hiwot Fana Comprehensive Specialized University Hospital (HFCSUH) in Eastern Ethiopia so as to guide specific preventive measures.

Methods

A hospital-based retrospective cross-sectional study was carried out from May 15 to June 14, 2022, and data were gathered by reviewing the chart records of 424 pregnant women who were admitted to maternity and labor wards in the previous two years, from January 1, 2019 to December 31, 2020. Records were chosen using a simple random sampling method. Mother's socio-demographic traits, previous obstetric and gynecologic history, current pregnancy history, habit-related history (khat chewing), ultrasound findings, laboratory investigations, mode of delivery, maternal and perinatal outcomes were extracted from the maternal charts. Bi-variable and multivariable logistic regression analyses were performed to identify predictors of pre-labor membrane rupture. The association between the explanatory and outcome variables was expressed using an adjusted odds ratio with a 95% confidence interval.

Results

The prevalence of pre-labor membrane rupture was 16.27% with 95% CI: (13.05-20.11). Among 69 women who experienced pre-labor rupture of membrane, 50 (72.5%) of them had adverse perinatal outcomes. Of all 69 neonates 17 (24.64%) were delivered with low birth weight and 20 (29%) of them were born preterm. The overall perinatal mortality rate was 10.1% or 101 per 1,000 live births. History of abortion [AOR = 2.61; 95% CI (1.09, 6.24)], urinary tract infection [AOR = 2.59; 95% CI (1.23, 5.42)], antepartum hemorrhage [AOR = 3.35; 95% CI (1.38, 8.13)], and khat chewing (a leafy plant which contains psychoactive chemical) in the current pregnancy [AOR = 2.63; 95% CI (1.49, 4.63)] were all significantly associated with pre-labor rupture of membrane.

Conclusion

In this study, the magnitude of pre-labor membrane rupture was relatively high compared to the global rate. Prenatal risk identification and early detection of complications among mothers with a history of abortion, antepartum hemorrhage, urinary tract infection, and counseling on the effects of khat chewing during pregnancy are crucial to reduce the likelihood of pre-labor membrane rupture and its adverse perinatal outcome.

Soluble urokinase plasminogen activator receptor in vaginally collected amniotic fluid predicting fetal inflammatory response syndrome: a prospective cohort study

BACKGROUND

Improving noninvasive antenatal diagnosis of fetal inflammatory response syndrome (FIRS) can assist in the evaluation of prenatal risk and reduce perinatal outcomes. This study aimed to determine whether soluble urokinase-type plasminogen activator receptor (suPAR) in vaginally collected amniotic fluid is significant in identifying FIRS after preterm premature rupture of membranes before 34 weeks of gestation.

METHODS

This was a prospective cohort study of 114 pregnant women and their newborns after preterm premature rupture of membranes at 22-34+6 weeks of gestation. SuPAR was evaluated using an enzyme-linked immunosorbent assay in vaginally collected amniotic fluid. Patients were classified according to the presence or absence of FIRS. FIRS was defined by umbilical cord blood interleukin-6 level > 11 pg/mL or histological funisitis. The data were analyzed using the R package (R-4.0.5).

RESULTS

SuPAR was detected in all amniotic fluid samples with a median of 26.23 ng/mL (interquartile range (IQR), 15.19-51.14). The median level of suPAR was higher in the FIRS group than in the non-FIRS group, 32.36 ng/mL (IQR, 17.27-84.16) vs. 20.46 ng/mL (IQR, 11.49-36.63) (P = 0.01), respectively. The presence of histological chorioamnionitis significantly increased the suPAR concentration in the FIRS group (P < 0.001). The areas under the curve for FIRS and FIRS with histological chorioamnionitis were 0.65 and 0.74, respectively, with an optimum cutoff value of 27.60 ng/mL. Controlling for gestational age, the cutoff of suPAR more than 27.60 ng/mL predicted threefold higher odds for FIRS and sixfold higher odds for FIRS with histologic chorioamnionitis.

CONCLUSION

Soluble urokinase-type plasminogen activator receptor in vaginally obtained amniotic fluid may assist in evaluating prenatal risk of FIRS in patients after preterm premature rupture of membranes before 34 weeks of gestation.

Deciphering maternal-fetal cross-talk in the human placenta during parturition using single-cell RNA sequencing

Labor is a complex physiological process requiring a well-orchestrated dialogue between the mother and fetus. However, the cellular contributions and communications that facilitate maternal-fetal cross-talk in labor have not been fully elucidated. Here, single-cell RNA sequencing (scRNA-seq) was applied to decipher maternal-fetal signaling in the human placenta during term labor. First, a single-cell atlas of the human placenta was established, demonstrating that maternal and fetal cell types underwent changes in transcriptomic activity during labor. Cell types most affected by labor were fetal stromal and maternal decidual cells in the chorioamniotic membranes (CAMs) and maternal and fetal myeloid cells in the placenta. Cell-cell interaction analyses showed that CAM and placental cell types participated in labor-driven maternal and fetal signaling, including the collagen, C-X-C motif ligand (CXCL), tumor necrosis factor (TNF), galectin, and interleukin-6 (IL-6) pathways. Integration of scRNA-seq data with publicly available bulk transcriptomic data showed that placenta-derived scRNA-seq signatures could be monitored in the maternal circulation throughout gestation and in labor. Moreover, comparative analysis revealed that placenta-derived signatures in term labor were mirrored by those in spontaneous preterm labor and birth. Furthermore, we demonstrated that early in gestation, labor-specific, placenta-derived signatures could be detected in the circulation of women destined to undergo spontaneous preterm birth, with either intact or prelabor ruptured membranes. Collectively, our findings provide insight into the maternal-fetal cross-talk of human parturition and suggest that placenta-derived single-cell signatures can aid in the development of noninvasive biomarkers for the prediction of preterm birth.

Analysis of cases of premature rupture of membranes and preterm births to identify effective management measures to prevent them

OBJECTIVE

Aim: Based on retrospective analysis recognize the key factors of development of premature childbirth and elaborate highly specific criteria for individual prognosis to improve perinatal outcomes.

PATIENTS AND METHODS

Materials and Methods: A retrospective analysis of the birth histories of 250 women and their newborns with spontaneous preterm births at 22-36 weeks was conducted using archival data from the department for pregnant women with obstetric pathology of the State Institution "Institute of Pediatrics, Obstetrics and Gynecology named by academician OM Lukianova of the National Academy of Medical Sciences of Ukraine".

RESULTS

Results: Important risk factors for premature rupture of membranes (PROM) in preterm pregnancy include the presence of sexually transmitted diseases (χ2=31.188, p=0.001), bacterial vaginosis (χ2=30.913, p=0.0001), a history of abortion and/or preterm birth (χ2=16.62, p=0.0002), SARS during pregnancy (χ2=16.444, p=0.0002), chronic adnexitis in anamnesis (χ2=11.522, p=0.0031), inflammatory cervical disease (χ2=11.437, p=0.0032), anaemia (χ2=10.815, p=0.0044), isthmic-cervical insufficiency (ІСІ) (χ2=10.345, p=0.0057), chronic pyelonephritis with exacerbation (χ2=9.16, p=0.01), smoking during pregnancy (χ2=10.815, p=0.0044).

CONCLUSION

Conclusions: The results of a retrospective analysis of 250 cases of preterm birth at 22 to 36 weeks allowed us to identify ways to effectively use existing diagnostic measures to determine readiness for pregnancy and the possibility of prolonging pregnancy to the viability of the newborn. Ways to improve the prevention of preterm birth and the design of further research were identified.

Ambulation for latency during expectant management of preterm prelabor rupture of membranes: a randomized controlled trial (AMBLE)

BACKGROUND

Individuals hospitalized with preterm prelabor rupture of membranes are often advised to limit their activity or adhere to bed rest. Some evidence suggests that greater activity is associated with longer latency and improved outcomes, but no high-quality evidence from a randomized controlled trial exists.

OBJECTIVE

This study aimed to evaluate whether encouragement to ambulate at least 2000 steps daily affects latency among individuals with preterm prelabor rupture of membranes compared with usual care.

STUDY DESIGN

This was a multisite unblinded, 2-arm randomized trial of individuals at 23 0/7 to 35 0/7 weeks of gestation undergoing inpatient expectant management of preterm prelabor rupture of membranes with planned delivery at least 7 days away. Each participant wore a Fitbit Inspire that tracked steps. The intervention arm was encouraged (verbal and Fitbit-based reminders) to reach a goal of 2000 steps per day. The usual-care arm was allowed ad libitum activity with no step goal or reminders. The primary outcome was latency (days) from randomization to delivery. Secondary analyses included composite neonatal and maternal clinical outcomes and maternal mental health survey results. Statistical analyses were conducted with an intent-to-treat approach under a Bayesian framework using neutral priors (a priori assumed 50:50 likelihood of longer latency in either arm). A total of 100 participants were required to have 80% power to demonstrate a 4-day difference in latency with 75% certainty (Bayesian probability).

RESULTS

Among 163 eligible individuals, 100 (61%) were randomized, and after loss to follow-up, 95 were analyzed. Gestational age at randomization was 29 3/7 weeks (interquartile range, 26 2/7 to 31 5/7) in the intervention arm and 27 4/7 weeks (interquartile range, 25 4/7 to 29 6/7) in the usual-care arm. Median step counts were 1690 per day in the intervention arm (interquartile range, 1031-2641) and 1338 per day in the usual-care arm (interquartile range, 784-1913). Median days of latency were 9 days in the intervention arm (interquartile range, 4-17) and 6 days in the usual-care arm (interquartile range, 2-14). The primary analysis indicated a 65% posterior probability that the intervention increased latency relative to usual care (posterior relative risk, 1.09; 95% credible interval, 0.70-1.71). The relative risk was 0.55 (95% credible interval, 0.32-0.82) for the composite neonatal adverse outcome, with 99% posterior probability of intervention benefit, and was 0.94 (95% credible interval, 0.72-1.20) for the composite maternal adverse outcome, with 70% posterior probability of intervention benefit. There was a 94% posterior probability of the intervention arm having a greater decrease in maternal stress score from baseline to before delivery compared with the usual-care arm (mean arm difference, 3.24 points [95% credible interval, -7.23 to 0.79]). Adjustment for gestational age at randomization had minimal impact on secondary outcome results.

CONCLUSION

Individuals with preterm prelabor rupture of membranes randomized to encouragement to ambulate had a longer latency to delivery and improved neonatal and mental health outcomes, with similar maternal clinical outcomes compared with usual care.

Pre-labour Rupture of Membranes at Term in Women With Gestational Diabetes and the Risk of Neonatal Hypoglycemia

OBJECTIVES

The management for improving maternal and neonatal outcomes of women with gestational diabetes mellitus (GDM) arriving at the delivery ward with pre-labour rupture of membranes (PROM) has not been elucidated. We tested the hypothesis that prolonged PROM in women with GDM would result in higher rates of neonatal hypoglycemia.

METHODS

We retrospectively enrolled women with diet or insulin-controlled GDM who presented with spontaneous clear PROM. Each woman was allocated into one of two groups based on the PROM-delivery time: <18 hours (group 1) and ≥18 hours (group 2). The primary outcome was the incidence of neonatal hypoglycemia, defined as glucose <40 mg/dL (2.2 mmol/L) within 24 hours of birth.

RESULTS

We ultimately analyzed 631 cases of GDM (6.7%), 371 with PROM-delivery <18 hours, and 260 with PROM-delivery ≥18 hours. The incidence of neonatal hypoglycemia did not differ between the two groups, reaching 7.3%. Women in group 2 were at increased risk of both cesarean delivery (20% vs. 12.4%, P < 0.01) and maternal chorioamnionitis morbidity (6.5% vs. 1.3%, P < 0.001).

CONCLUSIONS

In a sub-group of women with GDM, a PROM-delivery time ≥18 hours is not associated with higher rates of neonatal hypoglycemia, but higher rates of chorioamnionitis and cesarean delivery were noted. Therefore, we suggest consideration for early delivery when managing women with GDM and PROM.

Relationship between vaginal microbiota and chorioamnionitis: A prospective cohort study

OBJECTIVE

This study aimed to determine the association between vaginal microbiota and chorioamnionitis and its predictive value.

METHODS

Thirty pregnant women in their third trimester were prospectively recruited. The participants were categorized into three groups based on their clinical manifestations and placental pathology: the clinical chorioamnionitis group (IP group), the asymptomatic histological chorioamnionitis group (CP group), and the healthy control group (CN group). Basic data and medical history were collected from each participant. Vaginal samples were collected before delivery and analyzed using microbial diversity sequencing.

RESULTS

No significant differences were observed in age, body mass index, and education among the groups (P > 0.05). However, the IP group exhibited higher rates of low birth weight (60 % vs 20 % vs 0 %, P = 0.008) and respiratory distress syndrome (50 % vs 20 % vs 0 %, P = 0.003) compared with the CP and CN groups. The Shannon index [2.09 (1.16-3.86) vs 0.84 (0.19-1.11) vs 0.44 (0.25-0.85), P = 0.009] and Simpson index [0.70 (0.41-0.81) vs 0.26 (0.04-0.39) vs 0.11 (0.05-0.29), P = 0.010] in the IP group were higher than those in the CN and CP groups. β diversity analysis indicated that the microbial community structure differed among the three groups, with a 14.1 % variation associated with group differences (P = 0.002). At the genus level, the random forest model revealed that Lactobacillus, Dialister, Prevotella, Ligilactobacillus, and Anaerococcus had Gini indexes higher than 1. Further, linear discriminant analysis (LDA) demonstrated that the abundance of Lactobacillus crispatus in the IP group was lower than in the CN group (LDA >4.0, mean relative abundance 9.19 % vs 54.40 %, P = 0.031). The logistic regression analysis indicated that a decreased abundance of L. crispatus was associated with an increased risk of clinical chorioamnionitis.

CONCLUSIONS

The reduction of L. crispatus and increasing trend of specific anaerobic groups are associated with the onset of chorioamnionitis, suggesting their potential value in chorioamnionitis identification. The vaginal microbiota could serve as a useful biomarker for predicting future disease and tailoring surveillance efforts. Additionally, it may present a viable target for developing prevention and therapeutic strategies.

Pregnancy-Related Complications During the COVID-19 Pandemic in Iran

BACKGROUND

The COVID-19 pandemic has profoundly affected healthcare systems worldwide, with significant collateral damage to vulnerable populations, including the perinatal population. This study sought to compare pregnancy-related complications before and during the COVID-19 pandemic in Iran.

METHODS

This retrospective data analysis was performed from February 20 to August 20, 2019 (prior to the onset of the COVID-19 pandemic) and from February 20 to August 20, 2020 (during the pandemic), encompassing the initial wave of the pandemic and the subsequent lockdown. To collect data, we utilized the medical records of 168,358 women obtained from the Iranian Maternal and Neonatal Network, which is a comprehensive electronic health record database management system specifically designed to store information pertaining to maternal and neonatal health.

RESULTS

A total of 168,358 medical records were analyzed, with 87388 (51.9%) and 80970 (48.1%) before and during the pandemic, respectively. The occurrence of pregnancy complications was found to be significantly more frequent during the pandemic compared to the pre-pandemic period. Notably, there was a higher likelihood of experiencing preeclampsia (odds ratio [OR]=1.14, 95% confidence interval [CI]: 1.07‒1.22, P=0.0001) and gestational diabetes (OR=1.14, 95% CI: 1.09‒1.19, P=0.0001) during the pandemic. Furthermore, cesarean section (CS) became more prevalent during the pandemic in comparison to vaginal delivery (OR=1.19, 95% CI: 1.17‒-1.22, P=0.0001).

CONCLUSION

Our findings demonstrated a significant association between the COVID-19 pandemic and an escalation in adverse pregnancy outcomes, notably preeclampsia, gestational diabetes, and CS deliveries. However, further research is warranted to gain a richer understanding of the intricate interplay between the COVID-19 pandemic and pregnancy complications. This is particularly crucial in light of the evolving landscape of new coronavirus variants.

Optimizing the timing of antenatal corticosteroid administration prior to anticipated preterm birth: A retrospective cohort study

OBJECTIVE

To examine suboptimal antenatal corticosteroid (ACS) administration based on indications and maternal-obstetrical factors.

METHODS

Women who prematurely delivered (24 + 0 to 36 + 6 gestational weeks) a viable neonate following ACS treatment between 2012 and 2019 were identified by a retrospective database review. The cohort was divided into patients in whom ACS administration was optimally timed (≥24 h to ≤7 days) or suboptimally timed (>7 days). The groups were compared for ACS indications and maternal, obstetrical, and neonatal parameters.

RESULTS

The cohort included 399 women. ACS timing was optimal in 233 patients (58%) and was associated with nulliparity (109 [46.8%] vs. 54 [32.5%], P = 0.004) and preterm premature rupture of membranes (89 [38.2%] vs. 45 [27.1%], P = 0.021). Suboptimal timing was associated with chronic hypertension (22 [9.4%] vs. 36 [21.7%], P < 0.001) and asymptomatic cervical shortening (23 [9.9%] vs. 26 [15.7%], P = 0.020). Optimal ACS timing was associated with higher neonatal intensive care unit admission (135 [58%] vs. 71 [42.8%], P = 0.003). On multivariate analysis, the adjusted odds ratio (aOR) of neonatal intensive care unit admission was 0.69 (95% confidence interval [CI], 0.58-0.83, P < 0.001) and 0.99 (95% CI, 0.99-1, P = 0.003) when adjusted for gestational age and birth weight, respectively. When adjusting for maternal age, the aOR for suboptimal ACS administraion due to chronic hypertension was 2.65 (95% CI, 1.49-4.72; P < 0.001).

CONCLUSION

Optimal timing of ACS varies based on different maternal characteristics and clinical indications. In the presence of certain parameters physicians tend to administer ACS suboptimally, diminishing its beneficial effect.

The optimal induction timing in prelabor rupture of membranes: a retrospective study

OBJECTIVE

Term prelabour rupture of membrane (PROM) occurs in 8% of term deliveries, but it is unclear when to initiate induction. Our objective was to assess the optimal timing of oxytocin induction in the management of term PROM in terms of maternal and neonatal outcomes.

METHODS

A retrospective cohort study was performed at a single tertiary care center from 2010 to 2020. All singleton pregnancies with PROM beyond 37 weeks gestation, without regular uterine contractions, were included. Eligible women were divided into three groups according to the timing of oxytocin induction (≤12; 12-24; ≥24 h) following PROM.

RESULTS

Of 9,443 women presented with the term PROM, 1676 were included. They were classified according to the timing of oxytocin induction initiation following PROM: 1,127 within 12 h; 285 within 12-24 h; 264 after 24 h. There were no significant differences in baseline demographic characteristics between groups. Women who presented at our emergency department were induced earlier delivered significantly sooner than those who received oxytocin later (45 vs. 28.2 vs. 23.2 h, respectively, p < .001. Maternal infection rate was similar and unrelated to oxytocin starting time. Induction at <12 h from PROM was associated with reduced rate of antibiotic administration compared with other timings (26.8% vs. 38.6% vs. 33.33%, respectively; p < .001), and the same was found for neonatal composite adverse outcomes (RR = 1.27, p = .0307).

CONCLUSION

In term PROM, early induction (within 12 h of PROM) may be recommended to reduce the time-do-delivery interval and increase the delivery rate within 24 h. It may be of economic significance and improve women satisfaction. Furthermore, early induction may also improve neonatal outcomes, without worsening maternal outcomes.

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

Importance

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

Objective

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

Evidence Acquisition

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

Results

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

Conclusions and Relevance

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

Term prelabor rupture of membranes: immediate induction is the optimal management

Term prelabor rupture of membranes, defined as rupture of membranes before the onset of labor at ≥37 weeks of gestation, is a common obstetrical event occurring in 8% of pregnancies. However, most relevant guidelines are inconclusive regarding the management of this condition and the optimal timing of induction of labor. Here, we present evidence from randomized controlled trials and a recent meta-analysis indicating that an immediate induction of labor in term premature rupture of membranes is associated with several maternal and neonatal benefits compared with expectant management, without increasing the risk of cesarean delivery. Given these findings, we strongly believe that immediate induction of labor is the optimal management strategy in case of term prelabor rupture of membranes.