Factors affecting the duration of the latency period in preterm premature rupture of membranes

Neonatal Survival and Outcomes following Periviable Rupture of Membranes

To clarify survival for infants affected by periviable prolonged preterm premature rupture of membranes (PPROM) in the military health system (MHS). To add to current literature on outcomes following expectant management, including long-term neurodevelopment outcomes.Retrospective matched cohort review of six level 3 military neonatal intensive care units (NICUs; 2010-2020). Cases were matched 1:1 with control infants, matched by location, gender, gestational age (within 1 week), birth weight (within 300 g), and rupture of membranes (ROM) within 24 hours of delivery. Follow-up data were obtained for each infant through 48 months' corrected age or age of last documented health visit in a military treatment facility.Forty-nine infants met inclusion criteria. Mean ROM for cohort infants was 20.7 weeks, with mean latency period of 34.6 days and mean gestational age at delivery of 25.7 weeks. Cohort infants had a mean birth weight of 919 g. Cohort survival to NICU discharge was 75.5 versus 77.6% of controls (p = 0.81). Statistically significant short-term outcomes: oligohydramnios or anhydramnios at delivery (p < 0.0001), pulmonary hypertension (p = 0.0003), and high-frequency ventilation (p = 0.004) were higher in cohort infants. No differences were found regarding rates of early sepsis, intraventricular hemorrhage, surgical necrotizing enterocolitis, oxygen at 36 weeks or at discharge. No statistical difference in long-term outcomes at 18 to 48 months of age or incidence of autism, cerebral palsy, attention deficit hyperactivity disorder, or asthma.Cohort survival to discharge in the MHS was 75.5%, higher than previously reported and not different from matched controls. Infants born after periviable PPROM should deliver at centers with access to high-frequency ventilation and ability to manage pulmonary hypertension. There was no difference in long-term neurodevelopment between the groups. · Survival to NICU discharge is similar between infants exposed to periviable PPROM and controls.. · Cohort survival to discharge was 75.5%, higher than previously reported in recent literature.. · Infant with periviable PPROM should delivery at centers capable of managing pulmonary complications..

[Impact of the mode of follow-up of preterm premature rupture of membranes before 36 weeks of gestation on the latency period]

INTRODUCTION

Preterm premature rupture of membranes (PPROM) is the main cause of premature delivery, complicating 1-3% of all pregnancies. Conventional hospitalization (CH) is the most frequent mode of follow-up, but homecare (HC) seems to be an alternative.

OBJECTIVES

Study of the impact of the monitoring mode on the duration of the latency period and on the latency ratio after PPROM, and analysis of the risk factors modifying this ratio.

METHODS

This was a bicentric retrospective cohort study here-abouts including patients who presented a PPROM between 24 and 36weeks of gestation from 2016 to 2018. Patients had a follow-up in HC at Lille University Hospital center (UHC) and in CH at Nantes UHC according to two different follow-up protocols. The latency ratio corresponded to the real latency period divided by the latency period to theoretical term.

RESULTS

We included 154 patients: 102 in HC and 52 in CH. The mean latency period was significantly higher in HC: 36.9±21.8 days, corresponding to an 85.5±23.7% latency ratio versus 20.2±12 days, corresponding to an 66.9±29.8% latency ratio in CH (P<0.001). The latency ratio in CH was correlated with term at PPROM (P=0.001).

CONCLUSIONS

The duration of the latency period seems prolonged for PPROM followed by HC management versus CH in selected populations. This study suggests a benefit to HC in stable patients.

Outpatient vs inpatient management of preterm prelabor rupture of membranes: A systematic review and meta-analysis

INTRODUCTION

To compare neonatal, obstetrical, and maternal outcomes associated with outpatient vs inpatient management of pregnancies with preterm prelabor rupture of membranes (PPROM).

MATERIAL AND METHODS

A search of MEDLINE, EMBASE, the Cochrane Database and Central Register from January 1, 1990 to July 31, 2023 identified randomized controlled trials (RCTs) and cohort studies comparing outpatient with inpatient management for pregnant persons diagnosed with PPROM before 37 weeks' gestation. No language restriction was applied. We applied a random effects model for meta-analysis. Trustworthiness was assessed using recently published guidance and Risk of bias using the RoB 2.0 tool for RCTs and ROBINS-I tool for cohort studies. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the certainty of evidence (COE). Outcomes of interest included perinatal mortality, neonatal morbidities, latency and gestational age at delivery, and maternal morbidities. RCTs and cohort studies were analyzed separately. This study was registered in the International Prospective Register of Systematic Reviewsr: CRD42022295275.

RESULTS

From 2825 records, two RCTs and 10 cohort studies involving 1876 patients were included in the review and meta-analysis. Outpatient management protocols varied but generally included brief initial hospitalization, strict eligibility criteria, and surveillance with laboratory and ultrasound investigations. Outpatient management showed lower rates of neonatal respiratory distress syndrome (cohort: RR 0.63 [0.52-0.77, very low COE]), longer latency to delivery (RCT: MD 7.43 days [1.14-13.72 days, moderate COE], cohort: MD 8.78 days [2.29-15.26 days, low COE]), higher gestational age at birth (cohort: MD 7.70 days [2.02-13.38 days, low COE]), lower rates of Apgar scores <7 at 5 min of life (cohort: RR 0.66 [0.50-0.89, very low COE]), and lower rates of histological chorioamnionitis (cohort: RR 0.74 [0.62-0.89, low COE]) without increased risks of adverse neonatal, obstetrical, or maternal outcomes.

CONCLUSIONS

Meta-analysis of data from RCTs and cohort studies with very low-to-moderate certainty of evidence indicates that further high-quality research is needed to evaluate the safety and potential benefits of outpatient management for selected PPROM cases, given the moderate-to-high risk of bias in the included studies.

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).

Statement of the Obstetrics and Prenatal Medicine Working Group (AGG - Preterm Birth Section) on "Outpatient Management for Pregnant Women with Preterm Premature Rupture of Membranes (PPROM)"

Preterm premature rupture of membranes (PPROM) is one of the leading causes of perinatal morbidity and mortality. After a PPROM, more than 50% of pregnant women are delivered within 7 days. Fetal and maternal risks are primarily due to infection and inflammation, placental abruption, umbilical cord complications and preterm birth. Standard care usually consists of an expectant approach. Management includes the administration of antenatal steroids and antibiotic therapy. Patients with PPROM require close monitoring. The management of pregnant women with PPROM (inpatient vs. outpatient) is still the subject of controversial debate. The international guidelines also do not offer a clear stance. The statement presented here discusses the current state of knowledge.

Administration of Antenatal Corticosteroids: Optimal Timing

The effectiveness of antenatal corticosteroids (ACS) in significantly reducing respiratory distress syndrome (RDS) depends crucially on the timing. It is successful if delivery takes place between 24 hours and seven days following administration; after this period, the side effects seem to predominate. In addition, an increased rate of mental impairment and behavioral disorders are observed in children born full-term after ACS administration. The optimal timing of ACS administration depends crucially on the given indication; to date, it has been achieved in only 25-40% of cases. ACS administration is always indicated in PPROM, in severe early pre-eclampsia, in fetal IUGR with zero or reverse flow in the umbilical artery, in placenta previa with bleeding, and in patients experiencing premature labor with a cervical length < 15 mm. The risk of women with asymptomatic cervical insufficiency giving birth within seven days is very low. In this case, ACS should not be administered even if the patient's cervical length is less than 15 mm, provided that the cervix is closed and there are no other risk factors for a premature birth. The development of further diagnostic methods with improved power to predict premature birth is urgently needed in order to optimize the timing of ACS administration in this patient population. Caution when administering ACS is also indicated in women experiencing premature labor who have a cervical length ≥ 15 mm. Further studies using amniocentesis are needed in order to identify the patient population with microbial invasion of the amniotic cavity/intra-amniotic infection (MIAC/IAI), and to define threshold values at which delivery is indicated. ACS administration is not performed as an emergency measure, usually not even before transfer to a perinatal center. Therefore, whenever possible, the indication for ACS administration should be determined by a clinician who is highly experienced in perinatology.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, September 2022) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and on the Management of Preterm Premature Rupture of Membranes

Aim The revision of this guideline was coordinated by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (OEGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of the guideline is to improve the prediction, prevention and management of preterm birth based on evidence from the current literature, the experience of members of the guidelines commission, and the viewpoint of self-help organizations. Methods The members of the contributing professional societies and organizations developed recommendations and statements based on international literature. The recommendations and statements were presented and adopted using a formal process (structured consensus conferences with neutral moderation, written Delphi vote). Recommendations Part 2 of this short version of the guideline presents statements and recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Antibiotics in Labor and Delivery

Infections are common in obstetric care and often require specific antibiotics, depending on the infection site and prevailing organisms. Summaries of antibiotic recommendations and treatment algorithms are provided for the following conditions: routine labor, group B streptococcus prophylaxis, preterm prelabor rupture of membranes, operative vaginal delivery, cesarean delivery, obstetric anal sphincter lacerations, chorioamnionitis, postpartum endometritis, infections of the urinary tract, and bacterial endocarditis prophylaxis.

Role of cervical sliding sign in predicting preterm delivery in pregnancies complicated with preterm premature rupture of membranes

OBJECTIVE

To investigate the effect of cervical sliding sign (CSS) to predict preterm delivery in patients with premature rupture of membranes.

METHODS

This prospective cohort study included 88 pregnant women between 24^0/7 and 36^6/7  weeks of gestation who were complicated with preterm premature rupture of membranes (PPROM) between June 2020 and January 2022. We measured the cervical length (CL) and applied pressure to the anterior fornix of the cervix with the transvaginal probe to investigate the CSS, which is defined as the sliding of the anterior lip of the cervix on the posterior lip.

RESULTS

The time between PPROM and delivery was significantly shorter in the CSS+ group (P < 0.001). Receiver operating characteristic curve analysis was performed for CSS with regard to predicting delivery within 7 days following PPROM (area under the curve, 0.749 [95% confidence interval, 0.642-0.857], P < 0.001). On logistic regression analysis, CL <25 mm increased the predictive accuracy of delivery within 7 days following PPROM 1.91-fold, and CSS increased the predictive accuracy of delivery within 7 days following PPROM 10.71-fold.

CONCLUSION

CSS is an effective sonographic marker in predicting preterm delivery and provides better information of oncoming preterm delivery in patients with PPROM than CL measurement.

Latency Period after Preterm Premature Rupture of Membranes: Singletons versus Twins

OBJECTIVE

Several studies have evaluated the differences in duration of latency and clinical outcomes between singleton and twin pregnancies after preterm premature rupture of membranes (PPROM); however, these data are limited to single-institution analyses and based on small sample sizes. The aim of this study was to assess differences in latency and clinical outcomes in singletons versus twin gestations affected by PPROM in a large, diverse cohort of women.

STUDY DESIGN

This is a secondary analysis of a multicenter trial of magnesium for neuroprotection in women at high risk of preterm birth. Our study included women with PPROM ≥ 24 weeks with singleton and twin gestations. We compared singleton versus twin gestation and our primary outcome was duration of latency after PPROM. Secondary outcomes included selected perinatal and neonatal outcomes including long-term neurodevelopmental outcomes. We fit a linear regression model to assess independent risk factors for latency duration.

RESULTS

Our study included 1,753 women, 1,602 singleton gestations (91%) and 151 twin gestations (9%). The median latency period was significantly shorter in twins (4 [interquartile range, IQR: 1-10] vs. 7 [IQR: 3-16] days, p < 0.001) and gestational age at delivery was significantly earlier (29.3 vs. 30.1 weeks, p = 0.001). Twins were more likely to develop neonatal sepsis (20.1 vs. 13.4%, p = 0.004), but rates of chorioamnionitis and abruption did not differ. Twins were more likely to suffer from adverse short-term neonatal outcomes, had higher rates of neonatal demise (7.9 vs. 3.8%, p = 0.002), and had higher rates of cerebral palsy (7.3 vs. 3.7, p = 0.005). When adjusting for confounders, twin gestation remained an independent risk factor for shorter latency (p < 0.001).

CONCLUSION

Twin gestations affected by PPROM had shorter latency, earlier delivery, and higher rates of short- and long-term morbidity. Despite having longer latency, singleton gestations did not have higher rates of complications associated with expectant management.

KEY POINTS

· Twins affected by PPROM had shorter latency duration and earlier gestational at delivery.. · Twins with PPROM had higher rates of both short- and long-term perinatal morbidity.. · Rates of chorioamnionitis and abruption did not differ between twins and singletons with PPROM..

Directive clinique no 430 : Diagnostic et prise en charge de la rupture prématurée des membranes avant terme

OBJECTIF

Fournir des directives claires et concises pour le diagnostic et la prise en charge de la rupture prématurée des membranes avant terme (RPMAT).

POPULATION CIBLE

Toute patiente manifestant une rupture prématurée des membranes avant 37 semaines d'aménorrhée. BéNéFICES, RISQUES ET COûTS: La présente directive clinique vise à fournir les premières recommandations générales canadiennes sur la prise en charge de la rupture des membranes avant terme. Elle repose sur un examen complet et à jour des données probantes sur le diagnostic de la rupture et sur la prise en charge, le bon moment et les modes d'accouchement. DONNéES PROBANTES: Des recherches ont été effectuées dans PubMed-Medline et Cochrane en 2021 en utilisant les termes suivants : preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, PAMG-1, IGFBP-1 test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des directives cliniques et des études observationnelles. D'autres publications pertinentes ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins de santé prénatale ou périnatale. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guideline No. 430: Diagnosis and management of preterm prelabour rupture of membranes

OBJECTIVE

To provide clear and concise guidelines for the diagnosis and management of preterm prelabour rupture of membranes (PPROM) TARGET POPULATION: All patients with PPROM <37 weeks gestation BENEFITS, HARMS, AND COSTS: This guideline aims to provide the first Canadian general guideline on the management of preterm membrane rupture. It includes a comprehensive and up-to-date review of the evidence on the diagnosis, management, timing and method of delivery.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane in 2021: preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, placental alpha microglobulin-1 (PAMG-1) test, insulin-like growth factor-binding protein-1 (IGFBP-1) test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/ antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/Neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Articles included were randomized controlled trials, meta-analyses, systematic reviews, guidelines, and observational studies. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All prenatal and perinatal health care providers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

The Management of Pregnancy Complicated with the Previable Preterm and Preterm Premature Rupture of the Membranes: What about a Limit of Neonatal Viability?-A Review

Preterm premature rupture of the membranes (PPROM) at the limit of viability is associated with low neonatal survival rates and a high rate of neonatal complications in survivors. It carries a major risk of maternal morbidity and mortality. The limit of viability can be defined as the earliest stage of fetal maturity when a fetus has a reasonable chance, although not a high likelihood, for extra-uterine survival. The study reviews available data on preventing preterm delivery caused by the previable PPROM, pregnancy latency, therapeutic options including the use of antibiotics and steroids, neonatal outcomes, and future directions and opportunities.

Preterm Premature Rupture of Membranes – Inpatient Versus Outpatient Management: an Evidence-Based Review

According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the increasing burden on obstetric departments and the growing importance of satisfaction and right to self-determination in pregnant women, outpatient management in PPROM is a possible alternative to inpatient monitoring. The most important criterion for this approach is to ensure the safety of both the mother and the child. Due to the small number of cases (n = 116), two randomised controlled trials (RCTs) comparing inpatient and outpatient management were unable to draw any conclusions. By 2020, eight retrospective comparative studies (cohort/observational studies) yielded the following outcomes: no significant differences in the rate of maternal complications (e.g., chorioamnionitis, premature placental abruption, umbilical cord prolapse) and in neonatal morbidity, significantly prolonged latency period with higher gestational age at birth, higher birth weight of neonates, and significantly shorter length of stay of preterm infants in neonatal intensive care, shorter hospital stay of pregnant women, and lower treatment costs with outpatient management. Concerns regarding this approach are mainly related to unpredictable complications with the need for rapid obstetric interventions, which cannot be performed in time in an outpatient setting. Prerequisites for outpatient management are the compliance of the expectant mother, the adherence to strict selection criteria and the assurance of adequate monitoring at home. Future research should aim at more accurate risk assessment of obstetric complications through studies with higher case numbers and standardisation of outpatient management under evidence-based criteria.

Individualized treatment of preterm premature rupture of membranes to prolong the latency period, reduce the rate of preterm birth, and improve neonatal outcomes

BACKGROUND

Preterm premature rupture of membranes complicates approximately 3% of pregnancies. Currently, in the absence of chorioamnionitis or placental abruption, expectant management, including antenatal steroids for lung maturation and prophylactic antibiotic treatment, is recommended. The benefits of individualized management have not been adequately explored.

OBJECTIVE

This study aimed to compare the impact of 2 different management strategies of preterm premature rupture of membranes in 2 tertiary obstetrical centers on latency of >7 days, latency to birth, chorioamnionitis, funisitis, and short-term adverse maternal and neonatal outcomes.

STUDY DESIGN

This was a multicenter retrospective study of women with singleton pregnancies with preterm premature rupture of membranes from 23 0/7 to 33 6/7 weeks of gestation between 2014 and 2018 and undelivered within 24 hours after hospital admission managed at Sunnybrook Health Sciences Center, Toronto, Canada (standard management group), and BCNatal (Hospital Clínic of Barcelona and Hospital Sant Joan de Déu Barcelona), Barcelona, Spain (individualized management group), following local protocols. The standard management group received similar management for all patients, which included a standard antibiotic regimen and routine maternal and fetal surveillance, whereas the individualized management group received personalized management on the basis of amniocentesis at hospital admission (if possible), to rule out microbial invasion of the amniotic cavity and targeted treatment. The exclusion criteria were cervical dilatation >2 cm, active labor, contraindications to expectant management (acute chorioamnionitis, placental abruption, or abnormal fetal tracing), and major fetal anomalies. The primary outcome was latency of >7 days, and the secondary outcomes included latency to birth, chorioamnionitis, and short-term adverse maternal and neonatal outcomes. Statistical comparisons between groups were conducted with propensity score weighting.

RESULTS

A total of 513 pregnancies with preterm premature rupture of membranes were included in this study: 324 patients received standard management, and 189 patients received individualized management, wherein amniocentesis was performed in 112 cases (59.3%). After propensity score weighting, patients receiving individualized management had a higher latency of >7 days (76.0% vs 41.6%; P<.001) and latency to birth (18.1±14.7 vs 9.7±9.7 days; P<.001). Although a higher rate of clinical chorioamnionitis was suspected in the individualized management group than the standard group (34.5% vs 22.0%; P<.01), there was no difference between the groups in terms of histologic chorioamnionitis (67.2% vs 73.4%; P=.16), funisitis (57.6% vs 58.1%; P=.92), or composite infectious maternal outcomes (9.1% vs 7.9%; P=.64). Prolonged latency in the individualized management group was associated with a significant reduction of preterm birth at <32 weeks of gestation (72.1% vs 90.5%; P<.001), neonatal intensive care unit admission (75.6% vs 83.0%; P=.046), and neonatal respiratory support at 28 days of life (16.1% vs 26.1%; P<.01) compared with that in the standard management group. Moreover, prolonged latency was not associated with neonatal severe morbidity at discharge (survival without severe morbidity, 80.4% vs 73.5%; P=.09).

CONCLUSION

Individualized management of preterm premature rupture of membranes may prolong pregnancy and reduce preterm birth at <32 weeks of gestation, the need for neonatal support, and neonatal intensive care unit admissions, without an increase in histologic chorioamnionitis, funisitis, neonatal infection-related morbidity, and short-term adverse maternal and neonatal outcomes.

Infectious morbidity of speculum versus digital examinations in preterm prelabor rupture of membranes: a systematic review and meta-analysis

OBJECTIVE

To estimate the effect of speculum examination only versus digital cervical examination on maternal infectious morbidity in women with preterm prelabor rupture of membranes by performing a systematic review and meta-analysis.

MATERIALS AND METHODS

We explored MEDLINE, Scopus, Embase, CINAHL, ClinicalTrials.gov and Cochrane Central Register of Controlled Trials for studies comparing the rate of a composite maternal infectious morbidity (either chorioamnionitis, endometritis or both) in women with preterm prelabor rupture of membranes that underwent a speculum only versus digital cervical examination at the time of diagnosis. Two reviewers separately ascertained studies, obtained data, and gauged study quality. The rate of a composite maternal infectious morbidity (either chorioamnionitis, endometritis or both) were compared and odds ratios (ORs) with 95% confidence intervals (CIs) were estimated.

RESULTS

Four cohort studies, reporting on 1213 women were identified. The median point prevalence of the composite maternal infectious morbidity was 26% (interquartile range 15-35%) in women who had a speculum examination only compared to 33% (interquartile range 22-42%) in women who underwent a digital examination. The overall maternal composite infectious morbidity rate in women that had a speculum examination only was less compared to women that had undergone a digital examination (pooled OR 0.75, 95% CI 0.58-0.98, I² 17%). The weighted mean length of latency in women with preterm prelabor rupture of membranes was longer in individuals evaluated by speculum only versus digital examination, 6.6 d versus 2.9 d (mean difference 4.5 d, 95% CI 1.4 to 7.8, I² 99%).

CONCLUSION

Speculum examination only in women with preterm prelabor rupture of membranes is associated with less maternal infectious morbidity and longer latency periods.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal, perinatal and childhood outcomes of the PPROMEXIL-III cohort: Pregnancies complicated by previable prelabor rupture of membranes

OBJECTIVE

Perinatal mortality after previable prelabor rupture of membranes (previable PROM) might be underestimated as most studies exclude patients with poor prognosis, or solely include patients in tertiary-care centers. We aimed to report perinatal, neonatal and long-term outcomes in a consecutive series of women with pregnancies complicated by previable PROM.

STUDY DESIGN

We conducted a prospective cohort study including women with singleton pregnancies and previable PROM ≤ 23⁺⁶ weeks gestational age (GA) from one tertiary hospital and eight affiliated secondary hospitals in the region of Amsterdam, the Netherlands (June 2012 until January 2016, PPROMEXIL-III cohort). Exclusion criteria were signs of active labor before onset of PROM or fetal structural anomalies visible at ultrasound. We assessed perinatal mortality. Furthermore, outcomes were maternal, perinatal, neonatal and long-term child characteristics.

RESULTS

We included 98 pregnancies with previable PROM. Twelve women (12.2%) opted for termination of pregnancy, resulting in 86 pregnancies included in further analyses. Median GA at PROM was 20⁺² weeks (interquartile range (IQR) 17⁺⁶-22⁺⁰). Median GA at delivery was 22⁺⁶ weeks (IQR 20⁺¹-26⁺⁴). Delivery within 1 week occurred in 38.4% of women and 60.4% delivered before 24 weeks GA (viability). Perinatal mortality occurred in 73.3% of pregnancies. 23/33 (69.7%) live-born neonates survived to discharge, representing 26.7% of total. None of the children died after discharge. Developmental data at two and/or five years of age was available for 13/23 children (i.e. all children born before 32 weeks of gestation), with 69.2% of children reporting a normal neurodevelopment. However, more than half of children reported respiratory problems.

CONCLUSION

In women with previable PROM perinatal mortality was 73.3%, with a normal neurodevelopment in 69.2% of surviving children with follow-up data. Due to broad inclusion criteria, this cohort represents a population more generalizable to daily practice as compared to previous studies.

Factors associated with a latency < 7 days after preterm premature rupture of membranes between 22 and 32 weeks of gestation in singleton pregnancies

OBJECTIVE

To identify factors at admission associated with a latency < 7 days after Preterm premature rupture of membranes (PPROM) between 22 and 32 weeks of gestation in singleton pregnancies.

MATERIAL AND METHODS

A retrospective comparative study of all women with singleton pregnancies admitted for PPROM to an academic tertiary center during the 5-year period of 2015-2019. Women who gave birth < 7 days and ≥ 7 day after PPROM were compared. We determined risk at admission associated with a latency < 7 days after PPROM by logistic regression and identified high-risk subgroups by classification and regression tree (CART) analysis.

RESULTS

Among 174 eligible births, 76 (44%) women gave birth < 7 days after PPROM and 98 (56%) later. The two groups had similar maternal baseline and obstetric characteristics. In multivariate analysis, the following variables reported at admission were independently associated with a latency < 7 days: painful uterine contractions (aOR 3.9, 95%CI 1.1-7.4), cervical length < 20 mm (aOR 2.4, 95%CI 1.2-4.8), and C reactive protein ≥ 10 mg/L (aOR 2.4, 95% CI 1.3-4.8). Women with painful uterine contractions and cervical length at admission < 20 mm were at highest risk of latency < 7 days (rate: 91%). Conversely, the women at lowest risk were those without uterine contractions, with a cervical length ≥ 20 mm, and C-reactive protein < 10 mg/L at admission (rate: 22%).

CONCLUSION

Our results may be helpful in determining criteria at admission for selecting women eligible for outpatient care after an initial hospitalization.

Neonatal Outcomes according to the Latent Period from Membrane Rupture to Delivery among Extremely Preterm Infants Exposed to Preterm Premature Rupture of Membrane: a Nationwide Cohort Study

BACKGROUND

In accordance with the guidelines for the expectant management of women exposed to previable preterm premature rupture of membrane, we compared neonatal outcomes according to the latent period from membrane rupture to delivery among extremely preterm infants exposed to maternal preterm premature rupture of membrane using the Korean Neonatal Network database.

METHODS

Of the 3,305 extremely preterm infants born at 23-27 weeks' gestation between 2014 and 2017 who were registered in the Korean Neonatal Network, 1,464 infants were born to pregnant women who were exposed to preterm premature rupture of membrane. The short latency group was defined as infants born with a latent period between membrane rupture and delivery < 7 days (n = 450), whereas the prolonged latency group was defined as infants born with a latent period of ≥ 7 days (n = 434). Using well-established risk factors for adverse short-term outcomes, multivariate logistic regression analysis was performed to assess a prolonged latent period in preterm premature rupture of membrane as an independent risk factor for neonatal outcomes in extremely preterm infants exposed to preterm premature rupture of membrane.

RESULTS

The mean gestational age at membrane rupture in the prolonged latency group was significantly lower than that in the short latency group (22.7 ± 2.5 vs. 25.4 ± 1.3 weeks, P < 0.001). Nevertheless, the mean gestational age at delivery and birth weight were not significantly different between the two groups. The incidence of oligohydramnios and histologic chorioamnionitis in the prolonged latency group was significantly higher than that in the short latency group (38.7 [155/401] vs. 26.1 [105/403], 69.8 [270/384] vs. 61.0 [242/397], respectively, P < 0.05). The survival rate in the prolonged latency group did not differ from that in the short latency group (71.2 [309/434] vs. 73.3 [330/450], P = 0.478). Although the prolonged latency group was not associated with mortality during hospitalization in the multivariate logistic regression analysis, the prolonged latency group's early pulmonary hypertension and bronchopulmonary dysplasia rates were increased by 1.8 and 1.5 times, respectively.

CONCLUSION

A prolonged latent period of 7 days or more does not affect the survival rate but increases the risk of bronchopulmonary dysplasia occurrence among extremely preterm infants who are exposed to maternal preterm premature rupture of membrane.

Predictors of Short Latency Period Exceeding 48 h after Preterm Premature Rupture of Membranes

BACKGROUND

Preterm premature rupture of membranes (PPROM) is a complication responsible for a third of preterm births. Clinical management is initially hospital based, but homecare management is possible if patients are clinically stable 48 h after PPROM. This study set out to determine factors that are predictive of short latency (delivery ≤ 7 days) exceeding 48 h after PPROM, enabling estimation of the prevalence of maternal and neonatal complications and comparison of maternal and fetal outcomes between inpatient and outpatient management.

METHOD

This was a monocentric retrospective study conducted between 1 January 2010 and 28 February 2017 on all patients experiencing PPROM at 24 to 34 weeks + 6 days and who gave birth after 48 h. Maternal, obstetric, fetal, and neonatal variables were included in the data collected. The primary endpoint was latency, defined as the number of days between rupture of membranes and delivery.

RESULTS

170 consecutive patients were analyzed. Short latency could be predicted by the need for tocolysis, a cervical length less than 25 mm at admission and the existence of anamnios. Outpatient follow-up was not found to lead to increased maternal morbidity or neonatal mortality.

CONCLUSION

Our study highlights predictive factors of short latency exceeding 48 h after PPROM. Knowledge of these factors may provide justification for outpatient monitoring of patients presenting with a long cervix, absence of need for tocolysis and persistence of amniotic fluid and, thus, no risk factors after 48 h of admission.

Tocolytic Therapy in Preterm Premature Rupture of Membranes

"Trials evaluating tocolytic use in preterm premature rupture of membranes (PPROM) have been small and lacked adequate power to evaluate uncommon outcomes. There still is much controversy on the benefit, length of use, route, and drug of choice among clinicians treating patients with PPROM. Most professional medical societies would propose to consider the use of tocolytics for 48 hours to allow for corticosteroid administration or to allow for maternal transfer to a higher level of care. Longer treatment regimens may lead to adverse maternal and perinatal outcomes. Insufficient data are available to make stronger and more definitive recommendations."

Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217

Preterm birth occurs in approximately 10% of all births in the United States and is a major contributor to perinatal morbidity and mortality (). Prelabor rupture of membranes (PROM) that occurs preterm complicates approximately 2-3% of all pregnancies in the United States, representing a significant proportion of preterm births, whereas term PROM occurs in approximately 8% of pregnancies (). The optimal approach to assessment and treatment of women with term and preterm PROM remains challenging. Management decisions depend on gestational age and evaluation of the relative risks of delivery versus the risks (eg, infection, abruptio placentae, and umbilical cord accident) of expectant management when pregnancy is allowed to progress to a later gestational age. The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented. This Practice Bulletin is updated to include information about diagnosis of PROM, expectant management of PROM at term, and timing of delivery for patients with preterm PROM between 34 0/7 weeks of gestation and 36 6/7 weeks of gestation.

Can maternal characteristics on admission for preterm prelabor rupture of membranes predict pregnancy latency?

BACKGROUND

Latency duration after preterm prelabor rupture of membranes has been an area of investigation for many years. Previously described factors associated with latency include gestational age at the time of rupture, cervical dilation of >1 cm, vaginal bleeding at the time of presentation, and oligohydramnios. However, little is known about the impact of composite maternal factors and presenting symptoms on the duration or prediction of the latency period.

OBJECTIVE

This study aimed to determine whether maternal factors and subjective presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes.

STUDY DESIGN

This is a retrospective observational study of singleton pregnancies complicated by preterm prelabor rupture of membranes for over 3 years at a single institution utilizing a uniform management protocol. Maternal demographics, obstetrical data, maternal subjective symptoms and physical examination findings on admission, amniotic fluid volume assessment, presence of contractions, and maternal perception of feeling unwell were collected and analyzed. Clinical characteristics were summarized with mean and standard deviation for continuous measures and frequency and percentages for categorical variables. For skewed variables, medians with 25th and 75th percentiles were reported. Cumulative latency duration (ie, survival time) was estimated with a Kaplan-Meier model. Multivariable Cox proportional hazards regression model with backward variable selection was used to determine the effects of maternal factors on latency duration.

RESULTS

Of the 212 patients available for analysis, there was a considerable variability in the latency duration with values ranging between 0 and 119 days. Factors related to latency duration included maternal age, parity, gestational age at rupture, cervical dilation, amniotic fluid volume, and contractions. Advancing maternal age (P=.012), increased gestational age at rupture (P<.0001), cervical dilation of ≥3 (vs 0; P<.0001), anhydramnios or oligohydramnios (vs normal amniotic fluid; P<.0001), cramping (P=.012), and painful contractions (P=.015) were associated with a shorter latency duration. Utilizing these statistically significant factors, we constructed a nomogram to predict latency for 1-day, 1-week, and overall median latency duration.

CONCLUSION

Maternal factors and presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes. We created a nomogram for clinical use that provides a visual display of the probability of pregnancy latency. This tool may be useful for counseling and providing additional information on expectations for providers and patients with pregnancies complicated by preterm prelabor rupture of membranes.

Antenatal corticosteroids for pregnant women with COVID-19 infection and preterm prelabor rupture of membranes: a decision analysis

Background: While antenatal corticosteroids are routinely used to decrease adverse neonatal outcomes following preterm delivery, corticosteroids are also associated with worse outcomes in patients with viral respiratory infections. Currently in the setting of the COVID-19 pandemic, it is unclear whether antenatal corticosteroids for infant benefit outweigh the potential harm to a pregnant woman with a COVID-19 infection.Objective: To determine at which gestational ages administering antenatal corticosteroids is the optimal management strategy for hospitalized women with preterm prelabor rupture of membranes (PPROM) who have a COVID-19 infection.Methods: We designed a decision-analytic model to assess the maternal and infant outcomes associated with antenatal corticosteroid administration for risk of preterm delivery following rupture of membranes in the setting of a COVID-19 infection. We used a theoretical cohort of 10,000 women at each gestational age between 24 and 32 weeks who were hospitalized with PPROM and found to be COVID-19 positive. Maternal outcomes included intensive care unit admission and death related to COVID-19 infection. The infant outcomes of interest included respiratory distress syndrome, intraventricular hemorrhage, neurodevelopmental delay, and death, and were assessed along with maternal and infant quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were used to evaluate model assumptions.Results: In our theoretical cohort of 10,000 women with COVID-19 infection and preterm prelabor rupture of membrane between 24 and 32 weeks, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths at each gestational age. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths at each gestational age. Antenatal corticosteroid administration also resulted in fewer cases of respiratory distress syndrome, intraventricular hemorrhage, and infant death. Overall, we found that between 24 and 30 weeks of gestation, administering antenatal corticosteroids was the optimal management strategy as it resulted in higher combined QALYs than no corticosteroid use. For 31 and 32 weeks of gestation, antenatal corticosteroid administration resulted in lower combined QALYs. On sensitivity analyses, we found that with increasing gestational age, the probability which antenatal corticosteroids was the optimal management strategy decreased.Conclusion: Administration of antenatal corticosteroids was an effective management strategy compared to no corticosteroid administration at gestational ages less than 31 weeks. These results provide data for clinicians to utilize when counseling pregnant patients hospitalized with PPROM and have a COVID-19 infection.

A novel extended prophylactic antibiotic regimen in preterm pre-labor rupture of membranes: A randomized trial

OBJECTIVES

Prophylactic antibiotic use in preterm pre-labor rupture of membranes (PPROM) is associated with a significant reduction in intra-amniotic infection and improved neonatal outcome. However, data is insufficient to determine the optimal antibiotic regimen. Considering the rise in Escherichia coli and Klebsiella pneumonia early-onset sepsis rate and the emergence of ampicillin resistance, our aim is to compare the efficiency of two antibiotic regimens in prolonging pregnancy and reducing infectious morbidity.

DESIGN

This multicenter randomized unblinded controlled prospective trial compared two antibiotic prophylactic protocols in PPROM: ampicillin + roxithromycin vs. cefuroxime + roxithromycin in 84 women with PPROM, from 12/2015-12/2019.

RESULTS

The median latency period was significantly longer (p = 0.039) in the cefuroxime + roxithromycin group (4.63 [0.59-50.18] days) than in the ampicillin + roxithromycin group (2.3 [0.15-58.3] days). Neonatal admission to neonatal intensive care unit rate, hospitalization length, neonatal respiratory distress syndrome, neonatal fever, and need for respiratory support or mechanical ventilation, were similar between the groups. K. pneumonia cultures were significantly more frequent in the ampicillin + roxithromycin group. None of the cultures were group B Streptococcus positive.

CONCLUSIONS

To prolong latency period and reduce gram-negative early-onset sepsis, cefuroxime + roxithromycin is recommended as the first-line protocol in PPROM.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02819570.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Factors Associated with Previable Delivery following Second Trimester Rupture of Membranes

OBJECTIVE

To identify factors associated with previable delivery in second trimester preterm rupture of membranes (PROM).

STUDY DESIGN

We conducted a single-center retrospective cohort study of women with pregnancies complicated by second trimester PROM (14.0-21.9 weeks' gestation) from 2000 to 2015 who elected expectant pregnancy management and achieved at least 24 hours latency. Maternal characteristics and clinical factors were compared among pregnancies that reached viability (≥ 23.0 weeks) and pregnancies delivered before viability (< 23.0 weeks) using appropriate statistical methods.

RESULTS

Of 73 pregnancies complicated by second trimester PROM, 49 (67%) delivered before viability. Maternal race, history of preterm birth, and tobacco use were similar between women who delivered < 23 weeks versus ≥ 23 weeks. Gestational age at PROM, cervical dilation > 1cm, Group B streptococcus carrier status, bacterial vaginosis, and chlamydial infection during pregnancy were similar between groups. Median time to delivery was significantly shorter in women who delivered < 23 weeks compared with those who reached ≥ 23 weeks (6 vs. 46 days, p < 0.01).

CONCLUSION

Previable delivery occurred in the majority of women with second trimester PROM. No maternal or clinical factors were associated with delivery prior to viability. Counseling women with second trimester PROM should include the inability to determine which pregnancies will reach viability.

Macrolide antibiotics roxithromycin vs. azithromycin for preterm premature rupture of membranes: a retrospective comparison

PURPOSE

Prophylactic antibiotics to prolong latency and reduce the risk of neonatal and maternal infections are used for preterm premature rupture of membranes. This study compared outcomes between two macrolides: roxithromycin given twice a day for a week and azithromycin, given as a single dose, which is more convenient.

METHODS

Two local protocols were retrospectively compared: roxithromycin and ampicillin from July 2005 to May 2016, and azithromycin and ampicillin from May 2016 to May 2018. Inclusion criteria were singleton pregnancy, at 24-34 weeks of gestation upon admission with preterm premature rupture of membranes. Primary outcome was length of the latency period, defined as time from first antibiotic dose to 34 + 0 weeks, or spontaneous or indicated delivery prior to 34 + 0 weeks. Secondary outcomes were rates of chorioamnionitis, delivery mode, birth weight and Apgar scores.

RESULTS

A total of 207 women met inclusion criteria, of whom, 173 received penicillin and roxithromycin and 34 received penicillin and azithromycin. Baseline characteristics were similar between groups. The latent period was longer in the azithromycin group than in the roxithromycin group (14.09 ± 14.2 days and 7.87 ± 10.2 days, respectively, P = 0.003). Rates of chorioamnionitis, cesarean deliveries, Apgar scores and birth weights were similar between the groups.

CONCLUSIONS

Azithromycin compared to roxithromycin results in a longer latency period in the setting of preterm premature rupture of membranes at 24-34 weeks of gestation. Given its more convenient regimen and our results, it seems justified to use azithromycin as the first-line treatment for patients with preterm premature rupture of membranes.

Insulin-like growth factor binding protein-1 predicts preterm premature rupture of membranes in twin pregnancies

PURPOSE

Mechanisms leading to preterm premature rupture of membranes (PPROM) remain incompletely defined. Based on the elevated occurrence of PPROM in twin gestations and recent studies of the involvement of insulin-like growth factor binding protein-1 (IGFBP-1) in the inhibition of collagen production we hypothesized that serum IGFBP-1 levels might be predictive of susceptibility to PPROM in women with twins.

METHODS

In this prospective study peripheral blood was obtained from 58 women with twin gestations prior to 20 weeks gestation and sera analyzed by ELISA for concentrations of IGFBP-1. Demographic and clinical outcome data were subsequently obtained and associations between IGFBP-1 and PPROM were analyzed by the Mann-Whitney test and receiver operator curve (ROC) analysis.

RESULTS

Eight of our subjects developed PPROM. They did not differ from the other women in demographics, medical history or current pregnancy outcome parameters. However, median IGFBP-1 levels were higher in women who subsequently developed PPROM (59.3 ng/ml) than in the other women (46.6 ng/ml) (p = 0.042). Using a cutoff value of 53.9 ng/ml the circulating IGFBP-1 level predicted development of PPROM with a sensitivity of 74%, specificity of 75%, a negative predictive value of 97% and a positive predictive value of 20%.

CONCLUSIONS

Pending validation in larger studies the findings suggest that determination of serum IGFBP-1 levels in women with twin pregnancies may predict the later development of PPROM.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Amniotic fluid index, single deepest pocket and transvaginal cervical length: Parameter of predictive delivery latency in preterm premature rupture of membranes

OBJECTIVE

Prediction of delivery latency complicated with preterm premature rupture of membrane (PPROM) is crucial for reducing maternal and neonatal complications. Therefore, we investigated the correlations between latency period and cut-off values of ultrasonographic parameters, ultimately predicting delivery latency.

MATERIALS AND METHODS

The retrospective study was performed on 121 PPROM patients enrolled between March 2010 and July 2015. Parameters including amniotic fluid index (AFI), single deepest pocket (SDP) and transvaginal cervical length (TVCL) were measured in 99 singleton pregnancies with PPROM. Latency was defined as the period from sonographic measurements to delivery day. The parameters were analyzed independently by Wilcoxon rank sum test and Fisher's exact test. Cut-off values were determined using a receiver operating characteristic (ROC) curve.

RESULTS

In delivery latency within 3 days, AFI and SDP were decreased with significantly shorter TVCL. AFI and SDP had the highest sensitivity (82.2%) and SDP combined with TVCL showed the highest specificity (75.9%) in area under curve (AUC) value. The predicted median latency period was less than 2 days within the cutoff value of parameter (AFI ≤ 7.72, SDP ≤ 3.2 and TVCL ≤ 1.69).

CONCLUSION

AFI and SDP combined with TVCL could be useful predictive parameters of the latency interval from PPROM to delivery.

Prenatal Correction of X-Linked Hypohidrotic Ectodermal Dysplasia

Genetic deficiency of ectodysplasin A (EDA) causes X-linked hypohidrotic ectodermal dysplasia (XLHED), in which the development of sweat glands is irreversibly impaired, an condition that can lead to life-threatening hyperthermia. We observed normal development of mouse fetuses with Eda mutations after they had been exposed in utero to a recombinant protein that includes the receptor-binding domain of EDA. We administered this protein intraamniotically to two affected human twins at gestational weeks 26 and 31 and to a single affected human fetus at gestational week 26; the infants, born in week 33 (twins) and week 39 (singleton), were able to sweat normally, and XLHED-related illness had not developed by 14 to 22 months of age. (Funded by Edimer Pharmaceuticals and others.).

ACOG Practice Bulletin No. 188: Prelabor Rupture of Membranes

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm prelabor rupture of membranes (also referred to as premature rupture of membranes) (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

Practice Bulletin No. 172: Premature Rupture of Membranes

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm premature rupture of membranes (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

Perinatal Outcomes in Cephalic Compared With Noncephalic Singleton Presentation in the Setting of Preterm Premature Rupture of Membranes Before 32 Weeks of Gestation

OBJECTIVE

To investigate the relationship between fetal presentation at the time of admission for preterm premature rupture of membranes (PROM) and perinatal outcomes, including gestational latency, among women in a large and well-characterized population with preterm PROM at less than 32 weeks of gestation.

METHODS

This was a secondary analysis of data from women randomized to receive magnesium sulfate compared with placebo in the previously reported Maternal-Fetal Medicine Units Network Beneficial Effects of Antenatal Magnesium Sulfate (1997-2004) trial. Women with a singleton gestation and preterm PROM were included. Fetal presentation at the time of randomization was recorded. Associations of fetal position (cephalic compared with noncephalic) with perinatal outcomes were compared using χ, Fisher exact, and Wilcoxon rank-sum tests. Perinatal outcomes included gestational latency, abruption, and neonatal morbidity and mortality. Multivariable regression (logistic, linear, and Cox) analyses were used to adjust for potential confounding factors.

RESULTS

Of the 1,767 eligible women, 439 (24.5%) had a noncephalic presentation. Noncephalic presentation was associated with an earlier median gestational age at the time of preterm PROM (26.6 compared with 28.4 weeks of gestation, P<.001), but no difference in gestational latency (7.5 compared with 7.7 days, P=.7, adjusted hazard ratio 1.09, 95% confidence interval [CI] 0.97-1.23). There were no differences in odds of abruption or neonatal morbidity in multivariable analyses. However, even after controlling for potential confounding factors including gestational age at delivery and mode of delivery, odds of neonatal death before discharge was greater for noncephalic gestations (11.5% compared with 3.4%, P<.001; adjusted odds ratio 2.24, 95% CI 1.12-4.48).

CONCLUSION

Even after controlling for gestational age and route of delivery, noncephalic fetuses in the setting of preterm PROM are at greater risk of neonatal death.

The relationship between the latency period, infection markers, and oxidant and antioxidant states in women with preterm premature rupture of membranes

BACKGROUND

A major cause of perinatal morbidity and mortality has been reported to be preterm premature rupture of membranes (PPROM). Our objective was to evaluate oxidant-antioxidant balance, infection parameters, time interval between rupture of membranes and delivery (latency period), and the relationship among all these parameters.

METHODS

Seventy-five cases with PPROM between 24 and 34 gestational weeks were included in the study. A control group of 41 women who gave birth at term were considered as the control group. The relationship among maternal plasma total oxidative stress (TOS), malondialdehyde (MDA), total antioxidant status (TAS), leukocyte counts, CRP, vitamin C and E levels, gestational week, neonatal birthweight, and latency period was evaluated.

RESULTS

In cases with PPROM, rupture occurred at an average of 29.4 gestational weeks and premature babies were born at an average of 31.6 gestational weeks. The mortality rate of babies born to PPROM women was 18.7% (14/75) died at or following birth. In the PPROM group, TOS, MDA, and leukocyte counts were found to be significantly higher compared to the control group (p < 0.001). Besides, a significant negative correlation was detected among the latency period, TOS, CRP, and leukocyte counts (p < 0.05).

CONCLUSIONS

Appropriate treatment protocols that strengthen antioxidant defense systems and taking into consideration the signs of infection can decrease the incidence of PPROM and/or mortality rates of babies born to PPROM women.

Major determinants of survival and length of stay in the neonatal intensive care unit of newborns from women with premature preterm rupture of membranes

OBJECTIVE

To assess the predictors of outcome in terms of length of stay in the neonatal intensive care unit (NICU) and survival of neonates from women with preterm premature rupture of membranes (PPROM).

METHODS

A population-based retrospective study including 331 singleton pregnant women with PPROM at 24-34 gestational weeks between January 2013 and December 2015 was conducted. Gestational age at delivery, birth weight, route of delivery, newborn gender, maternal age, oligohydramnios, premature retinopathy (ROP), necrotising enterocolitis (NEC), sepsis, fetal growth retardation (FGR), intracranial hemorrhagia (ICH), bronchopulmonary dysplasia (BPD), respiratory distress syndrome (RDS), primary pulmonary hypertension (PPH), congenital cardiac disease (CCD), patent ductus arteriosus (PDA), use of cortisol (betamethasone) and maternal complications including gestational diabetes, preeclampsia and chorioamnionitis were used to predict neonatal outcomes in terms of length of stay in the NICU and survival.

RESULTS

In linear regression analyses, birth weight, ROP, CCD, BPD, PDA, NEC and preeclampsia were significant confounders for length of stay in the NICU. Among them, birth weight was the most powerful confounder for prolongation of the NICU stay (t: -6.43; p < 0.001). In multivariate logistic regression analyses, birth weight, PDA, ROP and PPH were significantly correlated with neonatal survival. PPH was the most powerful confounder in neonatal survival (β: 7.22; p = 0.005).

CONCLUSION

Prematurity-related complications are the most important problems for which precautions should be taken. Therefore, premature deliveries should be avoided to prevent infection and to prolong the latent period in cases of PPROM in order to decrease prematurity-related outcomes.

Antepartum and intrapartum interventions to prevent preterm birth and its sequelae

Preterm birth is the main cause of neonatal morbidity and mortality. This review provides an overview of antepartum and intrapartum management of threatened preterm birth. The most effective method to identify women at high risk of delivering within seven days is the combination of cervical length and fetal fibronectin test. Antenatal corticosteroids administered for 48 h improve neonatal outcome. Although tocolysis has been shown to prolong pregnancy, there is no evidence that tocolytic therapy improves neonatal outcomes. Intrapartum administration of magnesium sulfate improves neurologic outcomes, such as cerebral palsy and gross motor function. In women with preterm premature rupture of membranes, prophylactic antibiotic treatment with erythromycin improves short-term neonatal outcomes, but proof of long-term benefit is lacking. In threatened preterm birth with intact membranes, prophylactic antibiotic treatment is thought to be harmful. Critical appraisal of the long-term benefits and harms of all these treatments questions their use.

The predictive value of lactate levels in vaginal fluid on the latent period in pregnant women with preterm premature rupture of membranes

The aim of the present study was to investigate the relationship between lactate level in vaginal fluid and the latent phase of labour in pregnancies complicated by preterm premature rupture of membranes (PPROM). Seventy pregnant women with PPROM during 28-34 weeks' gestation were selected for this prospective observational study. All subjects underwent a pelvic examination involving the insertion of a vaginal speculum, and lactate levels were measured in vaginal fluid samples. The relationship between the lactate levels in the vaginal fluid and the latent phase of the labour was analysed using a logistic regression test. Of the patients, 48 (68.6%) had a latent period of 48 h or less, and 22 patients (31.4%) had a latent period longer than 48 h. The median lactate level was 3.81 mmol/L in patients with a latent period ≤ 48 h, and 3.36 mmol/L in patients with a latent period > 48 h. The lactate level in vaginal fluid was not found to be distinctive in the differentiation of patients according to the duration of the latent phase (receiver operating characteristic or ROC: 0.509; 95% confidence interval or CI: 0.361-0.657; p = 0.904). There was no significant correlation between the lactate level in the vaginal fluid and the transition from the latent phase to the active phase of labour in pregnancies complicated by PPROM.