Adverse respiratory outcome after premature rupture of membranes before viability

Respiratory outcomes of neonates born after previable premature rupture of membranes and treated with gentle ventilation

OBJECTIVE

We aim to describe neonatal respiratory outcomes following previable preterm premature rupture of membranes(PPROM) when gentle ventilation is utilized. We also report maternal morbidity and mortality.

STUDY DESIGN

This is a retrospective single-center cohort study of infants delivered between 2016 and 2020 that included infants born at ≥23 weeks without major congenital anomaly after a pregnancy complicated with PPROM before 23 weeks gestation. Statistical analysis utilized unpaired Student's t-test or Mann-Whitney U-test when appropriate.

RESULTS

35 infants from 33 pregnancies were included. 91.4% of infants survived until discharge and 12.1% developed Bronchopulmonary Dysplasia (BPD). Those who developed BPD had significantly lower amniotic fluid levels prior to delivery (p < 0.05). There was no significant maternal morbidity or mortality in this cohort.

CONCLUSION

This cohort had high survival and low rates of respiratory morbidities. This suggests the use of gentle ventilation might be the optimal strategy for patients born after previable PPROM.

Value of fetal echocardiographic examination in pregnancies complicated by preterm premature rupture of membranes

OBJECTIVES

Cardiopulmonary and infectious complications are more common in preterm newborns after preterm premature rupture of membranes (pPROM). Fetal echocardiography may be helpful in predicting neonatal condition. Our aim was to assess the cardiovascular changes in fetuses from pregnancies complicated by pPROM and possible utility in predicting the intrauterine or neonatal infection, and neonatal heart failure (HF).

METHODS

It was a prospective study enrolling 46 women with singleton pregnancies complicated by pPROM between 18+0 and 33+6 weeks of gestation and followed until delivery. 46 women with uncomplicated pregnancies served as a control group. Fetal echocardiographic examinations with the assessment of cardiac structure and function (including pulmonary circulation) were performed in all patients.

RESULTS

Mean gestational age of pPROM patients was 26 weeks. Parameters suggesting impaired cardiac function in fetuses from pPROM were: higher right ventricle Tei index (0.48 vs. 0.42 p<0.001), lower blood flow velocity in Ao z-score (0.14 vs. 0.84 p=0.005), lower cardiovascular profile score (CVPS), higher rate of tricuspid regurgitation (18.2 % vs. 4.4 % p=0.04) and pericardial effusion (32.6 vs. 0 %). Intrauterine infection was diagnosed in 18 patients (39 %). 4 (8.7 %) newborns met the criteria of early onset sepsis (EOS). HF was diagnosed in 9 newborns. In fetal echocardiographic examination HF group had shorter mitral valve inflow time and higher left ventricle Tei index (0.58 vs. 0.49 p=0.007).

CONCLUSIONS

Worse cardiac function was observed in fetuses from pPROM compared to fetuses from uncomplicated pregnancies.

Maternal features at time of preterm prelabor rupture of membranes and short-term neonatal outcomes

Objective: The objective of this study was to assess if maternal and obstetric characteristics other than gestational age at the time of rupture impact short-term neonatal outcomes.Methods: This is a retrospective observational study from a single tertiary care referral center. This study reviewed women with a singleton pregnancy complicated by preterm prelabor rupture of membranes over a 3-year period from May of 2014 through May of 2017. Maternal characteristics and short term neonatal outcomes were collected.Results: We identified 210 pregnancies complicated by preterm prelabor rupture of membranes. Eighteen of these patients had rupture of membranes prior to viability. Of the maternal characteristics at time of admission studied, gestational age at rupture and race influenced short term neonatal outcomes. Women who identified as race other than white had neonates with lower rates of intubation than neonates born to white patients. Gestational age at rupture significantly influenced the neonatal intensive care unit length of stay. Each additional week gained before rupture occurred was associated with a 17.1% decrease in length of stay. Maternal age, gravidity, parity, body mass index, single deepest pocket, and amniotic fluid index did not influence short term neonatal outcomes.Conclusions: Gestational age at rupture of membranes is the most predictive factor associated with short term neonatal outcomes. Race may also influence short term neonatal outcomes. Other maternal characteristics do not seem to influence short term neonatal outcomes. This information can assist with patient counseling on admission for preterm prelabor rupture of membranes and expected neonatal course.

First-Trimester Prediction of Preterm Prelabour Rupture of Membranes

BACKGROUND

Preterm prelabour rupture of membranes (PPRoM) is commonly associated with preterm delivery and affects up to 3% of all pregnancies. It is associated with high rates of morbidity and mortality for the mother and the newborn.

OBJECTIVES

To identify risk factors for PPRoM and develop a model for first-trimester prediction of risk of PPRoM.

METHODS

A retrospective analysis of a series of women who had first-trimester (11-13+6 weeks) screening for aneuploidy and pre-eclampsia and delivered in the same institution was performed. Univariate and multivariate logistic regression analyses were used to identify maternal and pregnancy factors and then develop a clinical prediction model for PPRoM.

RESULTS

10,280 women were screened between April 2010 and October 2016. 144 (1.4%) had PPRoM. Maternal factors predictive of PPRoM included nulliparity (parous women, OR 0.53; 95% CI 0.4-0.8), pre-existing diabetes mellitus (DM) (Type 1 DM, OR 6.7; 95% CI 2.3-19.4, Type 2 DM, OR 5.3; 95% CI 1.6-18.3), maternal age group (p = 0.004), and BMI category (p = 0.012). Uterine artery pulsatility index (UAPI) and biochemical parameters (PAPP-A, free βHCG) did not reach statistical significance. The predictive model had moderate efficacy with an area under the ROC curve of 0.67.

CONCLUSIONS

Several maternal characteristics collected during first-trimester screening predict PPRoM. Biomarkers currently measured during first-trimester screening (PAPP-A, βHCG, and UAPI) do not predict PPRoM. Whilst a predictive model can be generated with information currently collected at 11-13+6 weeks, this has only modest screening performance. First-trimester screening provides a structured framework where other predictors could improve model performance, and future studies should focus on the addition of other risk factors and biomarkers that may improve screening efficacy.

Preterm prelabor rupture of membranes prior to early preterm delivery elevates the risk of later respiratory-related hospitalizations in the offspring

OBJECTIVE

Preterm prelabor rupture of membranes (PPROM) precedes 30%-40% of all preterm births. Early preterm delivery (<34 gestation weeks) is a well-established risk factor for short- and long-term respiratory morbidity in the offspring. We aimed to ascertain whether the presence of PPROM, before early preterm delivery, independently impacts long-term respiratory hospitalizations in the offspring.

STUDY DESIGN

A population-based retrospective cohort analysis was performed including all singleton early preterm deliveries. Exposure was defined as the presence of PPROM. Hospitalizations of the offspring up to the age of 18 years involving respiratory-related morbidity were evaluated. A Kaplan-Meier survival curve and multivariable Cox regression model were used to assess the association.

RESULTS

During the study period, 3309 early preterm deliveries met the inclusion criteria. In 22.4% of cases (n = 742), PPROM was documented. Rates of respiratory-related hospitalizations of the offspring up to the age of 18 years were significantly higher in the exposed group (12.5% vs 9.4% in the unexposed group, P = .023). The survival curve demonstrated significantly higher cumulative incidence of respiratory hospitalizations in the exposed group (logrank P = .018). In the Cox regression model controlled for gestational age, and other clinically relevant confounders - PPROM before early preterm deliveries was independently associated with an increased risk for long-term childhood respiratory-related hospitalizations in the offspring (adjusted hazard ratio 1.40, 95% confidence interval, 1.05-1.87, P = .021).

CONCLUSION

Fetal exposure to PPROM before early preterm delivery was associated with an increased risk for long-term respiratory hospitalizations in the offspring.

Does low dose aspirin prescribed for risk of early onset preeclampsia reduce the prevalence of preterm prelabor rupture of membranes?

Background: Placental dysfunction, inflammation and degradation of fetal membranes has been hypothesized as a cause of preterm prelabor of rupture of membranes.Objective: To examine the effect of aspirin, an anti-inflammatory agent, on the prevalence of preterm prelabor rupture of membranes (PPRoMs).Methods: A retrospective analysis was conducted to examine the effect of aspirin on the prevalence of PPRoM. Aspirin (150 mg, nocte) was prescribed to women who were identified through a screening program at 11-13⁺⁶ weeks' gestation as being at high risk for developing early-onset preeclampsia. Women who were at low risk for developing preeclampsia did not receive aspirin. The prevalence of PPRoM was compared with an observational cohort.Results: In the observational cohort, there were 3027 women, including 32 (1.1%) cases of PPRoM. The prevalence of PPRoM in the high risk group was 3.1% (4/128) and was statistically significantly higher compared to the low risk group (1.0%) (28/2899). The relative risk was 3.02 (95% CI 1.2-7.7; p= .04). In the interventional cohort, there were 7280 women, with 114 (1.6%) cases of PPRoM. The prevalence of PPRoM in the high risk group who were treated with aspirin was 1.8% (14/766) compared to 1.5% (100/6516) in the low risk group (p= .54). The prevalence of PPRoM in high risk patients in the observational group (who did not receive aspirin) compared with the high risk patients in the interventional group (who were treated with aspirin) was not statistically significant (p= .31).Conclusions: PPRoM is significantly associated with a description of high risk for ePET; although, this algorithm is not a good screening tool for predicting PPRoM. Aspirin treatment of women deemed high risk for ePET is safe in the context of PPRoM and there may be some reduction in prevalence of PPRoM in treated high risk women; although, this study was not powered to demonstrate a small reduction in the prevalence of PPRoM. The findings merit further investigation through a larger prospective study with adequate sample size.

Outcome at Two Years of Very Preterm Infants Born after Rupture of Membranes before Viability

Purpose

To compare the respiratory and neurological outcomes at two years of age of preterm children born before 33 weeks of gestation (WG) after early preterm premature rupture of membranes (EPPROM) between 14 and 24 WG with preterm children without EPPROM.

Design and Patients

This single-center case-control retrospective study was conducted at Rouen University Hospital between 1^st January 2000 and 31^st December 2010. All the cases with EPPROM born from 26WG to 32WG were included. Each newborn was matched by sex, gestational age (GA) and year of birth to two very preterm children, born without EPPROM. At two years of corrected age, motor and cognitive abilities were assessed by routine score based on the Amiel-Tison and Denver developmental scales.

Results

Ninety-four cases with EPPROM before 24WG have been included. The 31 children born from 26WG to 32WG were matched with 62 controls. The EPPROM group had poorer clinical evaluation at one year for motor (p = 0.003) and cognitive developmental scores (p = 0.016). Neuromotor rehabilitation was performed more often (p = 0.013). However, there was no difference at 2 years of age. Children born after EPPROM were hospitalized more often for bronchiolitis (p<0.001) during their first 2 years, which correlates with increased incidence of pneumothorax (p = 0.017), pulmonary hypoplasia (p = 0.004) and bronchopulmonary dysplasia (p = 0.005) during neonatal period.

Conclusion

At two years, despite an increase in severe bronchiolitis and the need for more neuromotor rehabilitation during the first month of the life after discharge, there was no difference in neurological outcomes in the very preterm children of the EPPROM group compared to those born at a similar GA without EPPROM.

Neonatal outcomes after prelabour rupture of membranes before 24 weeks' gestation

AIM

The aim of this study was to determine neonatal outcomes in pregnancies complicated by prelabour rupture of membranes (PROM) before 24 weeks' gestation.

METHODS

We performed a retrospective review of medical records over a 5-year period (2007-2011) at Mater Health Services, South Brisbane, Australia. Data relating to the antenatal and perinatal course of pregnancies complicated by PROM before 24 weeks' gestation were collected. Data were also collected on neonatal diagnoses, management and outcomes for all liveborn infants resulting from these pregnancies.

RESULTS

One hundred and six pregnancies were complicated by PROM before 24 weeks' gestation. Thirty-three (31%) of these pregnancies resulted in delivery at pre-viable gestations (<23 weeks). There were 36 (37%) infants who survived to hospital discharge. At discharge, 47% of infants had chronic lung disease, with 81% of this group requiring supplemental oxygen at home.

CONCLUSIONS

Almost one-third of pregnancies complicated by PROM before 24 weeks resulted in pre-viable preterm delivery. In pregnancies continuing to a viable gestation, there remained a significant risk of neonatal mortality and morbidity, primarily due to respiratory disease.

Determinants of low APGAR score among preeclamptic deliveries in Cipto Mangunkusumo Hospital: a retrospective cohort study in 2014

Background: Preeclampsia has great implication on adverse neonatal outcome. Appearance, pulse, grimace, activity, respiration (APGAR) score at 1 or 5 minutes is one of the indicators of physiologic maturity of the infant. Therefore, the aim of this study was to know the correlation of APGAR score in preeclamptic deliveries with its risk factors. Methods: This study was a retrospective cohort. Data were collected from January to December 2013 including all preeclamptic women with singleton live pregnancies who delivered their babies in Cipto Mangunkusumo Hospital, Jakarta. The primary outcome was APGAR score. There were some determinants conducted in this study. Binary logistic was used as multivariate analysis to analyze the correlation between APGAR score and risk factors of preeclampsia, data were analyzed using chi square test. Results: Out of 450 preeclamptic women, 446 of them met the inclusion criteria. Low APGAR scores at 1 and 5 minutes were found in 19% (86/446) and 5.4% (24/446) of neonates respectively. Early onset of preeclampsia (adjusted OR = 4.577; 95% CI = 2.147 - 9.757), white blood cell ≥ 15,000/μL (adjusted OR = 3.315; 95% CI = 1.738 – 6.324), HELLP syndrome (adjusted OR = 2.00; 95% CI = 1.38 – 2.91) were independent risk factors for having infant with low APGAR score at 1 minute. Meanwhile, there was no significant risk factors at 5 minutes APGAR score after adjustment.Conclusion: Leukocytosis, early onset preeclampsia, preterm birth, and thrombocytopenia, severity of preeclampsia, and HELLP syndrome are independent risks of having infant born with low APGAR score at 1 minute in preeclamptic deliveries.

Preterm prelabor rupture of membranes and outcome of very-low-birth-weight infants in the German Neonatal Network

OBJECTIVE

It was the aim of our study to evaluate the independent effect of preterm prelabor rupture of membranes (PPROM) as a cause of preterm delivery on mortality during primary hospital stay and significant morbidities in very-low-birth-weight (VLBW) infants < 32 weeks of gestation.

DESIGN

Observational, epidemiological study design.

SETTING

Population-based cohort, German Neonatal Network (GNN).

POPULATION

6102 VLBW infants were enrolled in GNN from 2009-2012, n=4120 fulfilled criteria for primary analysis (< 32 gestational weeks, no pre-eclampsia, HELLP (highly elevated liver enzymes and low platelets syndrome) or placental abruption as cause of preterm birth).

METHODS

Multivariable logistic regression analyses included PPROM as potential risk factors for adverse outcomes and well established items such as gestational age in weeks, birth weight, antenatal steroids, center, inborn delivery, multiple birth, gender and being small-for-gestational-age.

RESULTS

PPROM as cause of preterm delivery had no independent effect on the risk of early-onset sepsis, clinical sepsis and blood-culture proven sepsis, while gestational age proved to be the most important contributor to sepsis risk. The diagnosis of PPROM was associated with an increased risk for bronchopulmonary dysplasia (BPD; OR: 1.25, 95% CI: 1.02-1.55, p=0.03) but not with other major outcomes.

CONCLUSIONS

The diagnosis of PPROM per se is not associated with adverse outcome in VLBW infants < 32 weeks apart from a moderately increased risk for BPD. Randomized controlled trials with primary neonatal outcomes are needed to determine which subgroup of VLBW infants benefit from expectant or intentional management of PPROM.