Perinatal Outcome in Pregnancies with Extreme Preterm Premature Rupture of Membranes (Mid-Trimester PROM)

A systematic review of biomarkers associated with maternal infection in pregnant and postpartum women

BACKGROUND

Serum biomarkers are commonly used to support the diagnosis of infection in non-pregnant patients whose clinical presentation suggests infection. The utility of serum biomarkers for infection in pregnant and postpartum women is uncertain.

SEARCH STRATEGY

PubMed, CINAHL, EMBASE, ClinicalTrials.gov, Cochrane Library, CINAHL, and SCOPUS were searched from inception to February 2020.

SELECTION CRITERIA

Full-text manuscripts in English were included if they reported the measurement of maternal serum biomarkers-and included a control group-to identify infection in pregnant and postpartum women.

DATA COLLECTION AND ANALYSIS

two authors independently screened manuscripts, extracted data, and assessed methodologic quality.

MAIN RESULTS

Interleukin-6 (IL-6), C-reactive protein, procalcitonin, insulin-like growth factor binding protein 1, tumor necrosis factor-α, calgranulin B, neopterin, and interferon-γ inducible protein 10 reliably indicated infection. Intercellular adhesion molecule 1, monocyte chemotactic and activating factor, soluble IL-6 receptor, and IL-8 were not useful markers in pregnant and postpartum women.

CONCLUSIONS

Findings suggest that certain biomarkers have diagnostic value when maternal infection is suspected, but also confirms limitations in this population.

Trends in obstetric management of extreme preterm birth at 23 to 27 weeks' gestation in a tertiary obstetric unit: A 10-year retrospective review

OBJECTIVE

To evaluate maternal and perinatal outcomes in deliveries from 23 + 0 to 26 + 6 weeks gestation in a tertiary hospital.

STUDY DESIGN

A 10-year retrospective analysis was performed which included all women who delivered between 23 + 0 and 26 + 6 weeks gestation in a tertiary obstetric unit from 01/01/2007 to 31/12/2017 inclusive. Data were collected from electronic patient records and individual chart reviews using predetermined variables.

RESULTS

340 women and 402 infants were included. 84 % (282/340) were singleton pregnancy and 17 % (59/340) had multiple pregnancies. 36.8 % (125/340) of women were delivered by Caesarean section, 11.2 % (14/125) had a classical caesarean section. The leading indications for delivery were preterm premature ruptured membranes (PPROM) 28.2 % (96/340), 8.5 % (29/340) severe pre-eclampsia (PET) and 5.6 % (19/340) were delivered for suspected placental abruption. Of all infants (N = 402), 18.9 % (76/402) were stillborn. 300 infants were admitted to the Neonatal Intensive Care Unit (NICU). The NICU survival to discharge rate was 83.7 % (251/300). The overall perinatal mortality rate (PNMR) was 328.4/1000 and a further late neonatal mortality of 47.3/1000 births. Notably, at the 23 week gestation NNDs are the major contributor to the PNMR and at later gestations stillbirths are the largest contributor.

CONCLUSION

Pregnant women delivering at extreme preterm gestations are at risk of maternal morbidity. Their infants have high rates of serious morbidity and mortality, with all survivors in this cohort affected by neonatal morbidity. Informed decision-making by providers and parents requires evidence based information on perceived outcomes, ideally individualized to the mother and pregnancy in question. Information from this retrospective cohort study can be used to counsel women and their families on potential morbidity and mortality and to manage expectations.

A retrospective cohort study of fetal assessment following preterm premature rupture of membranes

OBJECTIVE

To evaluate maternal and neonatal outcomes following management of preterm premature rupture of membranes (PPROM) by two fetal assessment strategies.

METHODS

In a retrospective cohort study performed at two hospitals in Philadelphia, Pennsylvania between July 2010 and June 2015, data were reviewed from 180 singleton pregnancies with PPROM at 23⁰ -33⁶  weeks of gestation that underwent expectant management. Outcomes were compared between continuous electronic fetal heart monitoring (EFM) with daily biophysical profile (BPP) ("continuous monitoring") and non-stress test (NST) three times per day ("periodic monitoring") using Mann-Whitney U and Fisher exact tests.

RESULTS

Overall, 119 (66.1%) pregnancies were assessed by continuous monitoring and 61 (33.9%) by periodic monitoring. There was no difference in frequency of intrauterine death between the continuous monitoring (1, 0.8%) and periodic monitoring (3, 4.9%) groups (OR, 0.16; 95% CI, 0.02-1.61). The continuous monitoring group was more likely to have an interventional (OR, 2.17; 95% CI, 1.06-4.44) or cesarean (OR 3.30, 95% CI 1.70-6.38) delivery.

CONCLUSION

Continuous EFM with daily BPP was associated with higher rates of intervention and cesarean delivery compared with periodic NST, but there was no difference in intrauterine or perinatal mortality.

Maternal and neonatal outcomes following expectant management of preterm prelabor rupture of membranes before viability

Purpose: To provide center-based outcome data on obstetric and neonatal complications arising from expectantly managed pregnancies affected by preterm prelabor rupture of membranes (PPROM) before viability.Materials and methods: We collected data on 130 consecutive pregnancies complicated by spontaneous rupture of membranes before 24 week's gestation, occurring over a 7-year period. These were women who delivered >24 h after membrane rupture, and had no signs of chorioamnionitis or advanced labor at admission. Women with amniocentesis-induced PPROM (n = 7) were analyzed separately. The descriptive statistics of obstetrics and neonatal outcomes were reported.Results: The overall neonatal survival to discharge rate was 33.8%. Stratification of patients into early (12 to 19⁺⁶ weeks' gestation) and late pre-viable PPROM (20 to 23⁺⁶ weeks' gestation) revealed a 3.6-fold increase in survival rate in the latter group (12.2% versus 43.8%, p < .001). Pre-viable PPROM following amniocentesis predicted a 100% survival outcome, however anhydramnios impacted negatively. The most common neonatal morbidities of those admitted to intensive care unit were respiratory distress syndrome (78.7%) and bronchopulmonary dysplasia (84.4%). The most common maternal morbidities affecting pre-viable PPROM were clinical chorioamnionitis (47.7%), histological chorioamnionitis (81.8%), retained products of conception (39.3%) and preterm labor (45.4%).Conclusions: Later gestational ages at PPROM were associated with better survival rates, however neonatal morbidity remained high. Women experiencing pre-viable PPROM following amniocentesis can be reassured, while those with anhydramnios at any time during the latency period should be adequately counseled regarding poorer outcomes.

Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability

AIM

To assess the contemporary maternal and neonatal outcomes following expectant management of preterm premature rupture of membranes (PPROM) prior to 24 weeks' gestation and to identify prognostic indicators of this morbid presentation.

METHODS

We performed a systematic review in the Pubmed and EMBASE databases to identify the primary (perinatal mortality, severe neonatal morbidity and serious maternal morbidity) and secondary (neonatal survival and morbidity) outcomes following expectant management of previable PPROM.

RESULTS

Mean latency between PPROM and delivery ranged between 20 and 43 days. Women with PPROM <24 weeks had an overall live birth rate of 63.6% and a survival-to-discharge rate of 44.9%. The common neonatal morbidities were respiratory distress syndrome, bronchopulmonary dysplasia and sepsis. The majority of neonatal deaths within 24 h post birth were associated with pulmonary hypoplasia, severe intraventricular haemorrhage and neonatal sepsis. The common maternal outcomes were chorioamnionitis and caesarean sections. The major predictors of neonatal survival were later gestational age at PPROM, adequate residual amniotic fluid levels, C-reactive protein <1 mg/dL within 24 h of admission and PPROM after invasive procedures.

CONCLUSION

Pregnancy latency and neonatal survival following previable PPROM has improved in recent years, although neonatal morbidity remains unchanged despite recent advances in obstetric and neonatal care. There is heterogeneity in management practices across centres worldwide.

Survival, morbidity, growth and developmental delay for babies born preterm in low and middle income countries - a systematic review of outcomes measured

BACKGROUND

Premature birth is the leading cause of neonatal death and second leading in children under 5. Information on outcomes of preterm babies surviving the early neonatal period is sparse although it is considered a major determinant of immediate and long-term morbidity.

METHODS

Systematic review of studies reporting outcomes for preterm babies in low and middle income settings was conducted using electronic databases, citation tracking, expert recommendations and "grey literature". Reviewers screened titles, abstracts and articles. Data was extracted using inclusion and exclusion criteria, study site and facilities, assessment methods and outcomes of mortality, morbidity, growth and development. The Child Health Epidemiology Reference Group criteria (CHERG) were used to assess quality.

FINDINGS

Of 197 eligible publications, few (10.7%) were high quality (CHERG). The majority (83.3%) report on the outcome of a sample of preterm babies at time of birth or admission. Only 16.0% studies report population-based data using standardised mortality definitions. In 50.5% of studies, gestational age assessment method was unclear. Only 15.8% followed-up infants for 2 years or more. Growth was reported using standardised definitions but recommended morbidity definitions were rarely used. The criteria for assessment of neurodevelopmental outcomes was variable with few standardised tools - Bayley II was used in approximately 33% of studies, few studies undertook sensory assessments.

CONCLUSIONS

To determine the relative contribution of preterm birth to the burden of disease in children and to inform the planning of healthcare interventions to address this burden, a renewed understanding of the assessment and documentation of outcomes for babies born preterm is needed. More studies assessing outcomes for preterm babies who survive the immediate newborn period are needed. More consistent use of data is vital with clear and aligned definitions of health outcomes in newborn (preterm or term) and intervention packages aimed to save lives and improve health.