Premature rupture of membranes before 34 weeks managed expectantly: maternal and perinatal outcomes in singletons

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

Background

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

Methods

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

Results

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

Conclusions

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

Funding

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

Host-microbiome interactions in distinct subsets of preterm labor and birth

Preterm birth, the leading cause of perinatal morbidity, often follows premature labor, a syndrome whose prevention remains a challenge. To better understand the relationship between premature labor and host-microbiome interactions, we conducted a mechanistic investigation using three preterm birth models. We report that intra-amniotic delivery of LPS triggers inflammatory responses in the amniotic cavity and cervico-vaginal microenvironment, causing vaginal microbiome changes and signs of active labor. Intra-amniotic IL-1α delivery causes a moderate inflammatory response in the amniotic cavity but increasing inflammation in the cervico-vaginal space, leading to vaginal microbiome disruption and signs of active labor. Conversely, progesterone action blockade by RU-486 triggers local immune responses accompanying signs of active labor without altering the vaginal microbiome. Preterm labor facilitates ascension of cervico-vaginal bacteria into the amniotic cavity, regardless of stimulus. This study provides compelling mechanistic insights into the dynamic host-microbiome interactions within the cervico-vaginal microenvironment that accompany premature labor and birth.

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.

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.

Determinants of Premature Rupture of Membranes Among Pregnant Women Admitted to Public Hospitals in Southern Ethiopia, 2020: A Hospital-Based Case-Control Study

BACKGROUND

A gush of amniotic fluid any time before the onset of labor is known as premature rupture of the membranes (PROM). Its consequences vary from maternal and neonatal mortality and morbidity to country-wide economic loss. At the national level in general, and in the study area in particular, little is known about PROM and its determinants. Hence, this study aimed at identifying determinants of PROM among pregnant women admitted to public hospitals in Southern Ethiopia, 2020.

METHODS AND MATERIALS

A hospital-based unmatched case-control study was conducted on 279 pregnant women (93 cases and 186 controls) admitted to public hospitals from October 1 to 30, 2020. Pregnant women admitted to maternity wards of selected hospitals with a painless gush of fluid spilling out from the vaginal canal were considered as cases. Interviewer-administered questionnaires and data abstraction tools were used to collect data. The data were coded and entered into Epi-Data version 3.1 and exported to SPSS version 23 for analysis. The determinants of PROM were identified by applying a multivariable logistic regression analysis at a p-value <0.05.

RESULTS

Term PROM accounted for the majority, 55 (59.2%) of cases. Previous history of abortion (AOR: 4.14, 95% CI: 2.21-9.07), lack of ANC (AOR: 3.51; 95% CI: 1.33-8.27), previous history of PROM (AOR: 4.91; 95% CI: 2.23-9.82), caesarean delivery (AOR: 3.02, 95% CI: 1.24-6,40), using of a maternal waiting room (MWR) (AOR: 0.33, 95% CI: 0.15-0.74), and mid-upper arm Circumference (MAUC) <23cm (AOR: 3.69, 95% CI: 1.58-8.64) were identified as significant determinants of PROM.

CONCLUSION

Health-care providers should work on providing adequate ANC by tracing mothers who have not received it and advising pregnant women to use MWR in the final weeks of their pregnancy. Furthermore, maternal and child health care units must place a strong focus on screening and managing the nutritional status of pregnant women. Furthermore, women with a history of abortion, caesarean section, and PROM need due attention from health care providers to mitigate the occurrence of PROM.

Transabdominal amniocentesis in expectant management of preterm premature rupture of membranes: A single center prospective study

AIMS

The aim of this study was to evaluate the role of IL-6 point-of-care test in amniotic fluid obtained from serial amniocentesis in expectantly managed women with PPROM between 24 and 34 weeks of gestation.

METHODS

We conducted a prospective observational cohort study which included 62 pregnant women with PPROM in gestational weeks between 22+0 and 34+0. Women aged >18 years were eligible if they presented with PPROM and a singleton pregnancy. Only women who delivered at >24.0 weeks were included in the study. In all women, the maternal blood sampling and a transabdominal amniocentesis were performed at the time of admission prior to the administration of corticosteroids, antibiotics, or tocolytics, to rule out signs of chorioamnionitis. Maternal temperature, maternal serum C-reactive protein (CRP) and white blood cell (WBC) counts were assayed every subsequent day until delivery. Amniotic fluid was used for the clinical assessment (IL-6 point-of-care test, identification of microorganisms in the amniotic fluid. After one week of expectant management of PPROM, second amniocentesis with amniotic fluid sampling was performed in patients who did not deliver. For all newborns, medical records regarding neonatal morbidity and mortality were reviewed.

RESULTS

In total, 62 women aged 19 to 41 years were recruited in the study. The mean gestational age at the time of PPROM was 31+0, the mean gestational age at labor was 32+1, and the median time from PPROM to childbirth was 112 h. IL-6 point-of-care test values above 1,000 pg/mL (positive Il-6 AMC) were found in 12 women (19.4%) with median interval from PPROM to childbirth 56 h (min-max: 6.4-288). IL-6 point-of-care test values below 1,000 pg/mL (negative Il-6 AMC) were found in 51 women (81.0%). The neonatal mortality rate was 1.9% and was associated with prematurity.

CONCLUSION

The major clinical finding of our study is that serial transabdominal amniocentesis with Il-6 point-of-care test helps to identify a high inflammatory status in amniotic fluid in women with PPROM. Subsequent expectant management of women with PPROM does not lead to worsening of short-term neonatal outcomes.

Cervical Length as a Predictor of Latency to Labour in Twin Pregnancies Complicated by Preterm Pre-Labour Rupture of Membranes: A Retrospective Study

OBJECTIVE

Preterm pre-labour rupture of membranes (PPROM), one of the leading causes of preterm delivery, represents a serious economic and psychosocial health care burden. The unpredictability of the interval between PPROM and labour, also known as the latency period, can be unsettling for patients and clinicians alike. In singleton pregnancies, the literature supports the use of ultrasound-determined cervical length to estimate the latency period.

METHODS

With this retrospective cohort study, we sought to determine whether a shorter cervical length (≤25 vs. >25 mm) is associated with a shorter latency period in twin pregnancies complicated by PPROM. At McMaster University Medical Centre, a tertiary care centre, we used the Better Outcomes Registry Network (BoRN) database to identify patient records that met our criteria for inclusion over a 5-year period.

RESULTS

Forty-three records were included in our analysis. On average, shorter cervical length was statistically significantly associated with a 6-day shorter latency period (P = 0.035). Confounders were controlled for using ANCOVA statistical analysis. A moderate, positive correlation between cervical length and latency period was also identified (r = 0.4).

CONCLUSION

Understanding that a shorter cervical length is associated with a shorter latency period can assist clinicians in optimizing maternal counselling and patient care, including triaging transfers to tertiary care centres.

The effects of latency period in PPROM cases managed expectantly

Objective: Preterm premature rupture of membranes (PPROM), associated with prematurity, is an important obstetric complication that may cause neonatal mortality and morbidity. The optimal delivery time is controversial in cases with the expectant approach. The fetal effects of long-term exposure to PPROM are unknown. This study aimed to evaluate the maternal and fetal outcomes of expectantly-managed PPROM cases with different latency periods at 24^0/7-34^6/7weeks of gestation.Material and method: The study group consisted of 206 patients at 24^0/7-34^6/7weeks of gestation who met the inclusion criteria. Patients were divided into three groups according to their weeks of PPROM diagnosis as 24^0/7-28^6/7, 29^0/7-31^6/7, and 32^0/7-34^6/7. The period from membrane rupture to delivery was defined as the latency period and divided into three subgroups as 3-7 days, 8-13 days and ≥14 days. In addition to the demographic characteristics of the patients, maternal and obstetric complications, primary and secondary neonatal outcomes were compared between the groups. Primary neonatal outcomes were determined in terms of pathological Apgar scores (<5 at minute 1, <7 at minute 5), requiring resuscitation, admission to Neonatal Intensive Care Unit (NICU) and NICU length of stay. Secondary neonatal outcomes were determined in terms of respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, patent ductus arteriosus, periventricular leukomalacia, and neonatal sepsis. In addition, for the prediction of morbidity and mortality, newborns were evaluated by SNAPPE II (Score for Neonatal Acute Physiology with Perinatal extension-II) consisting of the combination of biochemical and physiological parameters, using the parameters including mean blood pressure (mm/Hg), corporal temperature (°C), PO₂/FiO₂ ratio, lowest serum pH, multiple seizures, urine output (ml/kg/hr), Apgar score, birth weight, and small for gestational age. The higher the score of SNAPPE II, the higher the morbidity and mortality risk of neonates. For the statistical analysis, the Kruskal Wallis and one-way ANOVA tests were utilized for the numerical data. Categorical data were compared using the chi-square test. The receiver operating characteristic (ROC) test was used to determine the threshold value of the data affecting neonatal morbidity.Results: The mean PPROM week was found to be 29.7 ± 3.0 weeks and the mean delivery week was 31.8 ± 2.5 weeks. The mean latency period for all the patients was 15.1 ± 13.8 days. Clinic chorioamnionitis was observed in 17% of the cases. The lowest chorioamnionitis rate (8.6%) was in the 3-7-day latency period group. Total complications were significantly lower in the 29^0/7-31^6/7week PPROM group in which the latency period was ≥14 days, compared to those in 3-7 days and 8-13 days (p = .001). Total complications were lower in the < 32 weeks PPROM groups in which the latency period was ≥14 days compared to those obtained in 3-7 days and 8-13 days. There was no significant difference between the latency period and total complications after 32 weeks (p = .422). The best discriminative cutoff value of SNAPPE-II for neonatal morbidity was 11.0 (sensitivity 82%, specificity 80%). In the present study, the optimal latency period for the best neonatal outcomes was found to be 34.5 days (sensitivity 70% and specificity 84%) between weeks 24^0/7-28^6/7, and 11.0 days between weeks 29^0/7-31^6/7 (sensitivity 68% and specificity 85%).Conclusions: Our findings indicated that a long latency period did not increase neonatal morbidity and there was no increase in neonatal complications after 32 weeks of the gestational period compared to those obtained before 32 weeks.

Azithromycin vs erythromycin for the management of preterm premature rupture of membranes

BACKGROUND

Preterm premature rupture of membranes complicates 2-3% of pregnancies. Many institutions have advocated for the use of azithromycin instead of erythromycin. This is secondary to national shortages of erythromycin, ease of administration, better side effect profile, and decreased cost of azithromycin as compared with erythromycin.

OBJECTIVE

The objective of the study was to evaluate whether there are differences in the latency from preterm premature rupture of membranes to delivery in patients treated with different dosing regimens of azithromycin vs erythromycin.

STUDY DESIGN

This is a multicenter, retrospective cohort of women with singleton pregnancies with confirmed rupture of membranes between 23⁰ and 33⁶ weeks from January 2010 to June 2015. Patients were excluded if there was a contraindication to expectant management of preterm premature rupture of membranes. Patients received 1 of 4 antibiotic regimens: (1) azithromycin 1000 mg per os once (azithromycin 1 day group); (2) azithromycin 500 mg per os once, followed by azithromycin 250 mg per os daily for 4 days (azithromycin 5 day group); (3) azithromycin 500 mg intravenously for 2 days, followed by azithromycin 500 mg per os daily for 5 days (azithromycin 7 day group); or (4) erythromycin intravenously for 2 days followed by erythromycin per os for 5 days (erythromycin group). The choice of macrolide was based on institutional policy and/or availability of antibiotics at the time of admission. In addition, all patients received ampicillin intravenously for 2 days followed by amoxicillin per os for 5 days. Primary outcome was latency from diagnosis of rupture of membranes to delivery. Secondary outcomes included clinical and histopathological chorioamnionitis and neonatal outcomes.

RESULTS

Four hundred fifty-three patients who met inclusion criteria were identified. Seventy-eight patients received azithromycin for 1 day, 191 patients received azithromycin for 5 days, 52 patients received azithromycin for 7 days, and 132 patients received erythromycin. Women who received the 5 day regimen were younger and less likely to be non-African American, have hypertension, have sexually transmitted infection, or experienced substance abuse. There was no statistical difference in median latency time of azithromycin 1 day (4.9 days, 95% confidence interval, 3.3-6.4), azithromycin 5 days (5.0, 95% confidence interval, 3.9-6.1), or azithromycin 7 days (4.9 days, 95% confidence interval, 2.8-7.0) when compared with erythromycin (5.1 days, 95% confidence interval, 3.9-6.4) after adjusting for demographic variables (P = .99). Clinical chorioamnionitis was not different between groups in the adjusted model. Respiratory distress syndrome was increased in the azithromycin 5 day group vs azithromycin 1 day vs erythromycin (44% vs. 29% and 29%, P = .005, respectively).

CONCLUSION

There was no difference in latency to delivery, incidence of chorioamnionitis, or neonatal outcomes when comparing different dosing regimens of the azithromycin with erythromycin, with the exception of respiratory distress syndrome being more common in the 5 day azithromycin group. Azithromycin could be considered as an alternative to erythromycin in the expectant management of preterm premature rupture of membranes if erythromycin is unavailable or contraindicated. There appears to be no additional benefit to an extended course of azithromycin beyond the single-day dosing, but final recommendations on dosing strategies should rely on clinical trials.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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.

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

OBJECTIVE

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

RESULTS

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

[Management of preterm premature rupture of membranes (except for antibiotherapy): CNGOF preterm premature rupture of membranes guidelines]

OBJECTIVE

To review the different parts of therapeutic management of viable preterm premature rupture of membranes (PPROM), except the antibiotherapy and birth modalities.

METHODS

The Medline, Cochrane Library, and Google Scholar databases over a period from 1980 to September 2018 have been consulted.

RESULTS

When the diagnostic of viable PPROM is reached, the woman should be hospitalized and signs of intrauterine infection (IUI) should be sought (Professional consensus). If cervical assessment appears necessary, speculum, digital examination or cervical ultrasound may be performed (Professional consensus). It is recommended to limit cervical evaluation regardless of the method used (Professional consensus). Initial ultrasound is recommended to determine the fetal presentation, locate the placenta, estimate the fetal weight and the residual amniotic fluid volume (Professional consensus). Performing vaginal and urinary bacteriological sampling at admission is recommended before any antibiotic (Professional consensus). In the case of positive vaginal culture, an antibiogram is necessary since it can guide antibiotherapy in the case of IUI and early onset neonatal bacterial sepsis (Professional consensus). In absence of demonstrated neonatal benefit, there is insufficient evidence to recommend or to not recommend initial tocolysis in PPROM (Grade C). If tocolysis was administered, it is recommended not to prolong it for more than 48hours (Grade C). Antenatal corticosteroid administration is recommended before 34 weeks of gestation (WG) (Grade A) and magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 WG (Grade A). Vitamin supplementation (vitamins C and E) is not recommended (Professional consensus), and it is recommended not to impose strict bed rest in case of PPROM (Professional consensus). In case of clinical signs of IUI with cerclage, it is recommended to remove the cerclage immediately (Professional consensus). The home care management of clinically stable PPROM after 48hours of hospital observation can be considered (Professional consensus). During the monitoring of a PPROM, it is recommended to identify elements relating to the diagnosis of IUI (Professional consensus).

CONCLUSION

The level of evidence and scientific data in the literature concerning the management (except antibiotics) of PPROM are low. Initial management of viable PPROM requires hospitalization. The main objectives of the management are the detection and medical care of maternal and fetal complications.

[Epidemiology, risk factors and child prognosis: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVES

To synthetize the available evidence regarding the incidence and risk factors of preterm premature rupture of membranes (PPROM). To describe the evolution of pregnancy, neonatal outcomes and the prognosis of infants born in a context of PPROM, according to the existence of an associated intrauterine infection and to the latency duration.

METHOD

Consultation of the Medline database, from 1980 to February 2018.

RESULTS

PPROM before 37 and before 34 weeks' gestation occur in 2-3% and <1% of pregnancies, respectively (LE2). Although many risk factors are identified, few are modifiable, and the vast majority of patients have no risk factors (LE2). Consequently, individual prediction of the risk of PPROM and primary prevention measures have not been shown to be effective and are not recommended in clinical practice (Grade B). Most women give birth within the week following PPROM (LE2). The main complications of PPROM are prematurity, intrauterine infection and obstetric and maternal complications (LE2). Latency duration and the frequency of complications decrease with increasing gestational age at PPROM (LE2). Neonatal prognosis is largely conditioned by gestational age at birth, with no apparent over-risk of poor outcomes linked to PPROM compared to other causes of preterm birth (LE2). In contrast, intrauterine infection is associated with an increased risk of in utero fetal death (LE3), necrotizing enterocolitis (LE1) and early-onset sepsis (LE2). The association of intrauterine infection with neurological morbidity remains controversial. Prolongation of latency, from gestational age at PPROM, is beneficial for the child (LE2).

CONCLUSION

PPROM is a major cause of prematurity and short- and long-term mortality and morbidity. Antenatal care is an important issue for obstetric and pediatric teams, aiming to reduce complications and adverse consequences for both mother and child.

Preterm premature rupture of membranes: Which criteria contraindicate home care management?

INTRODUCTION

Home care management offers a suitable alternative to hospitalization for management of preterm premature rupture of membranes (PPROM). Eligibility criteria have not been clearly established. Our aim was to determine predictive factors of complication during home care management of PPROM in order to define optimal eligibility criteria.

MATERIAL AND METHODS

Retrospective cohort study of all women with singleton pregnancies with PPROM managed as outpatients between 2009 and 2015. Complications were defined as the occurrence of one of these events: fetal death, placental abruption, umbilical cord prolapse, delivery outside maternity hospital, neonatal death.

RESULTS

In all, 187 women with PPROMs were managed as outpatients, of whom 12 had a complication (6.4%). In the "complication" group, gestational age at diagnosis (P = 0.006) and at delivery (P < 0.001) were lower, with no difference in latency between these two events. Three criteria significantly increased the risk for a severe complication: PPROM occurring before 26 weeks (P = 0.008), non-cephalic fetal presentation (P = 0.02) and oligoamnios (P = 0.02). When unfavorable criteria were associated with PPROM, the risk was increased (1 criterion, odds ratio [OR] 1.6; 2 criteria, OR 6.9 and 3 criteria, OR 32.8).

CONCLUSIONS

Combination of these three criteria is an indication for conventional hospitalization to limit maternal and fetal morbidity. When two criteria are combined, home care should be discussed for each case. If only one unfavorable criteria is present, outpatient management is suitable. To validate these results, a prospective randomized study should be conducted.

Neonatal outcome in preterm deliveries before 34-week gestation - the influence of the mechanism of labor onset

Purpose: To evaluate neonatal outcomes in preterm infants with less than 34 weeks after spontaneous labor, preterm premature rupture of membranes (PPROM) or iatrogenic delivery and to clarify whether the mechanism of labor onset is a risk factor for adverse short-term neonatal outcome. Methods: We performed a retrospective case-control study, which included 266 preterm newborns with less than 34-week gestation, between 2011 and 2015. Neonatal outcomes were compared according to the mechanism of labor onset. Our primary outcomes were neonatal death, sequelae on hospital discharge and a composite of these two variables (combined neonatal outcome). Results: Compared to spontaneous preterm labor, iatrogenic preterm newborns were at increased risk of respiratory distress syndrome (RDS) [Odds Ratio (OR) 3.05 (95%CI 1.31; 7.12)], and need of exogenous surfactant administration [OR 3.87 (95%CI 1.60; 9.35)]. PPROM was associated with higher risk of neonatal sepsis [OR 12.96 (95%CI 1.18; 142.67)]. There were no differences regarding the combined outcome for iatrogenic [OR 0.94 (95%CI 0.33; 2.71)] or PPROM [OR 1.11 (95%CI 0.35; 3.49)] groups. Conclusions: In our study, the different mechanisms of labor onset are associated with different neonatal outcomes. Iatrogenic preterm birth was associated with an increased risk of RDS and a higher need of exogenous surfactant administration than spontaneous group. The rate of neonatal sepsis was significantly higher in PPROM group along with a higher prevalence of histological chorioamnionitis.

Platelet-to-lymphocyte ratio: A new inflammatory marker for the diagnosis of preterm premature rupture of membranes

Objective:

Preterm premature rupture of membranes (PPROM) is closely related with maternal and fetal complications. Therefore, early diagnosis is extremely important to provide maternal and fetal well-being. Many inflammatory markers have been evaluated for their ability to diagnose membrane rupture at early stages. We aimed to investigate the relationship between the platelet-to-lymphocyte ratio (PLR) and preterm premature membrane rupture.

Material and Methods:

In this study, 121 pregnant women with PPROM and 96 age-matched pregnant women with spontaneous preterm labor who were admitted to our hospital between January 2014 and December 2015 were enrolled. Demographic data, complete blood cell count results, and neonatal outcomes were recorded.

Results:

The neutrophil and platelet counts were higher in the PPROM group (9948.4±3393.2 vs. 7466.1±1698.5/mm³ and 244.5±60 vs. 210.6±64.8/mm³, respectively, p<0.001). The PLR and neutrophil-to-lymphocyte ratios (NLR) were both significantly higher in the PPROM group (p<0.001). Correlation analysis revealed that the PLR was positively correlated with the NLR (r=0.10, p=0.031). The ability of the PLR to diagnose preterm premature rupture of membranes was evaluated using an ROC curve. The sensitivity and specificity of the PLR was 57.8% and 73.7%, respectively, at a threshold >117.14 (p<0.001).

Conclusion:

The PLR might be a cost effective, easy to use, and practical marker for the early diagnosis of PPROM, which can help to determine the appropriate waiting time for delivery and provide maternal and fetal well-being.

Evaluating the effects of copper supplement during pregnancy on premature rupture of membranes and pregnancy outcome

OBJECTIVE

To evaluate the effects of copper (Cu) supplementation during pregnancy on the rupture of membranes and pregnancy outcomes.

METHODS

Study was conducted as a triple-blind randomized clinical trial. In one group, Cu in a dose of 1000 mg per day, and in the other group, placebo was prescribed orally from 16th week of pregnancy.

RESULTS

The women of the two groups did not have significant difference according to age, gestational age at recruitment, BMI, and socioeconomic conditions. There was no statistically significant difference between case and control group regarding the incidence of PPROM, PROM, preterm labor, vaginal bleeding during pregnancy, preeclampsia, and the incidence of placenta abruption. There was a 75% and 90% decrease in depressive symptoms in 2nd trimester and 3rd trimester in supplemented group, respectively. Also, there was a 45% and 80% decrease in anxiety symptoms in 2nd trimester and 3rd trimester in the supplemented group, respectively The rate of infection during pregnancy was significantly higher in control group (p = 0.046). There was no difference between the two groups according to neonatal outcomes.

CONCLUSIONS

Cu supplementation during pregnancy could not influence positively on ROM; however, it could improve some mood status of the women.

Maternal and fetal outcomes in term premature rupture of membrane

BACKGROUND

Premature rupture of membrane (PROM) is linked to significant maternal prenatal mortalities and morbidity. In Ethiopia, where maternal mortality is still high, the maternal and fetal outcomes in PROM is very important to decrease maternal and child mortality and for better management and prevention of complications. Thus, this study aimed to detect the maternal and fetal outcomes and associated factors in term PROM at Mizan-Aman General Hospital, south-west Ethiopia.

METHODS

A retrospective cross sectional study was conducted using data available at Mizan-Aman General Hospital during a period of 3 years (January 2011 to December 2013). We examined records of 4 525 women who gave birth in the hospital; out of these women, 185 were diagnosed with term PROM and all of them were included in the study. The data of these women were collected using a checklist based on registration books. The data were analyzed using SPSS version 20.0 statistical package. The association between independent and dependent variables was assessed by bivariate and multiple logistic regression analyses. 95%CI and P value less than 0.05 were considered statistically significant.

RESULTS

Of the 4 525 women who gave birth in the hospital, 202 were complicated by term PROM. About 22.2% of the women showed unfavorable maternal outcomes. The most common cause of maternal morbidity and mortality was puerperal sepsis. About 33.5% of neonates experienced unfavorable outcomes. The duration of PROM >12 hours (AOR=5.6, 95%CI 1.3-24.1) latency >24 hours (AOR=2.8, 95%CI 1.7-11.8), residing in rural areas (AOR=4.2, 95%CI 3.96-29.4) and birth weight less than 2 500 g were associated with unfavorable outcomes.

CONCLUSION

Women residing in rural areas, long latency, and neonates with birth weight less 2 500 g may have unfavorable outcomes. Therefore, optimum obstetric and medical care is essential for the reduction of the devastating complications related to disorders.

Transvaginal cervical length and amniotic fluid index: can it predict delivery latency following preterm premature rupture of membranes?

OBJECTIVE

We sought to determine whether transvaginal cervical length (TVCL), amniotic fluid index (AFI), or a combination of both can predict delivery latency within 7 days in women presenting with preterm premature rupture of membranes (PPROM).

STUDY DESIGN

This was a prospective observational study of TVCL measurements in 106 singleton pregnancies with PPROM between 23-33 weeks. Delivery latency was defined as the period (in days) from the initial TVCL after PPROM to delivery of the infant, with our primary outcome being delivery within 7 days of TVCL. The independent predictability of significant characteristics for delivery within 7 days was determined using multiple logistic regression. Sensitivity, specificity, and predictive values were used to examine whether the presence of a short TVCL, AFI, or a combination of both affected the risk of delivery within 7 days.

RESULTS

Delivery within 7 days occurred in 51/106 (48%) of pregnancies. Median duration (interquartile range) from PPROM to delivery and TVCL to delivery was 8 days (4.0-16.0) and 8 days (3.0-15.0), respectively. Using multiple regression TVCL as a continuous variable (odds ratio, 0.65; 95% confidence interval, 0.44-0.97; P < .05), AFI ≤5 cm (odds ratio, 4.69; 95% confidence interval, 1.58-13.93; P < .01) were determined to be independent predictors of delivery within 7 days. In all, 42 women (40%) had a TVCL ≤2 cm, while 62 (59%) had AFI ≤5 cm. A total of 26 women (25%) had a combination of both TVCL ≤2 cm and AFI ≤5 cm, while 28 women (27%) had neither characteristic. The predictive value of delivery within 7 days for a TVCL ≤2 cm was 62%, and for an AFI ≤5 cm was 58%. Having a combination of low TVCL and low AFI did not increase the predictive value of delivery within 7 days (58%). In contrast, only 3 of 27 women (11%) with neither characteristic delivered within 7 days. The predictive value of delivery >7 days for TVCL >2 cm alone was 61%. This predictive value changed when analyzed in conjunction with an AFI ≤5 cm and >5 cm at 42% and 89%, respectively.

CONCLUSION

A shorter TVCL and an AFI ≤5 cm independently predict delivery within 7 days in women presenting with PPROM. The combination of an AFI >5 cm and TVCL >2 cm greatly improved the potential to remain undelivered at 7 days following cervical length assessment. These findings may be helpful for counseling and optimizing maternal and neonatal care in women with PPROM.