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Li L, Huang X, Yan J, Zhang J, Yang D, Pan M. Predictive value of serum inflammatory markers for histological chorioamnionitis among women with preterm premature rupture of membranes after undergoing cervical cerclage. Clinics (Sao Paulo) 2023; 78:100292. [PMID: 37879248 PMCID: PMC10618699 DOI: 10.1016/j.clinsp.2023.100292] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023] Open
Abstract
PURPOSE To determine the predictive value of maternal White Blood Cells (WBC), neutrophils, and C-Reactive Protein (CRP) for diagnosing Histological Chorioamnionitis (HCA) among women with Preterm Premature Rupture of Membranes (PPROM) who underwent cervical cerclage. METHODS A retrospective cross-sectional study was conducted among women with singleton pregnancy and PPROM, who underwent cervical cerclage during 2018-2020. RESULTS A total of 55 eligible women were included in the final analysis, including 36 (61.02%) cases with HCA and 19 (38.98%) without HCA. Women with HCA had higher WBC count (12.31 ± 2.80) × 109/L and neutrophil count (9.67 ± 2.90)×109/L than those without HCA (10.35 ± 2.53) × 109/L and 7.82 ± 2.82 × 109/L, respectively) (both p < 0.05). The cut-off value of WBC count at 10.15×109/L was found to be the most effective in identifying HCA, with an Area Under Curve (AUC) of 0.707 (95% CI: 0.56-0.86; p = 0.012), sensitivity of 86.11%, specificity of 57.90%, Positive Predictive Value (PPV) of 79.49%, Negative Predictive Value (NPV) of 68.75%, and Youden index of 0.44. The combination of WBC + neutrophil had a slightly higher (AUC = 0.711, 95% CI: 0.57-0.86; p = 0.011), specificity (68.42%), and PPV (81.25%), but lower sensitivity (72.22%), than the WBC count alone. A cut-off value of neutrophil at 7.46 × 109/L was effective in identifying HCA, with an AUC of 0.689 (95% CI: 0.53-0.84; p = 0.022). DISCUSSION Combination use of WBC+neutrophil was found to be the most accurate predictor of HCA among women with PPROM after surgery of cervical cerclage.
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Affiliation(s)
- Li Li
- Department of Obstetrics, Department of Healthcare, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Xinxin Huang
- Department of Obstetrics, Department of Healthcare, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jianying Yan
- Department of Obstetrics, Department of Healthcare, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jun Zhang
- Department of Obstetrics, Department of Healthcare, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Danlin Yang
- Department of Obstetrics, Department of Healthcare, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Mian Pan
- Department of Obstetrics, Department of Healthcare, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian Province, China.
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Hsiao CH, Chen CH, Chang YF, Tsauer JC, Chou WS. Retrospective analysis of stillbirth and induced termination of pregnancies: Factors affecting determination. Taiwan J Obstet Gynecol 2022; 61:626-629. [PMID: 35779911 DOI: 10.1016/j.tjog.2022.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The aim of this study was to identify the factors and frequencies of induced termination of pregnancies. MATERIALS AND METHODS This is a retrospective study of 488 terminations of pregnancies (TOPs) between January 2011 and December 2021 to demonstrate the factors affecting the decision to terminate the pregnancy. All cases had been hospitalized to manage the induction of labor. Methods included serial multiple laminaria dilation of the cervix and administration of a cervical misoprostol suppository. After induction of labor, the subject may experience amniotomy, instrumental evacuation of the uterus, and even hysterotomy. Pre-procedure counseling included an agreement to share medical records (paper-based and electronic). We verified the indications for all patients seeking TOPs. All cases were performed according to known diagnostic classifications and divided into seven groups for analysis. RESULTS The patient ages ranged from 12 to 46 years. The median maternal age was 34 years [interquartile range (IQR) 30, 37]; 52.2% had at least one prior delivery. The pre-procedure diagnosis was divided into seven groups including the following: chromosomal and genetic abnormalities (146/488, 29.9%), no intrauterine heartbeats (126/488, 25.8%), structural anomalies (84/488, 17.2%), elective termination (56/488, 11.5%), preterm premature rupture of membranes (PPROM) (42/488, 8.6%), cervical incompetence (32/488, 6.6%), and other conditions (2/488, 0.4%). After excluding elective terminations, the eleven-year rate of fetal death and stillbirth to births did not show significant changes from 2011 to 2021. CONCLUSIONS Knowing the factors underlying the decision to induce intrauterine fetal death (IUFD) including reasons for objecting to pregnancy are important for obstetricians-they can offer better planning and medical counseling. It is important to educate all women about family planning to prevent large numbers of unwanted and unsafe pregnancy terminations.
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Affiliation(s)
- Ching Hua Hsiao
- Department of Obstetrics and Gynecology, Taipei City Hospital, Women and Children Campus, Taiwan; Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taiwan.
| | - Ching Hsuan Chen
- Department of Obstetrics and Gynecology, Taipei City Hospital, Women and Children Campus, Taiwan
| | - Yi Fen Chang
- Department of Obstetrics and Gynecology, Taipei City Hospital, Women and Children Campus, Taiwan
| | - Ju Chin Tsauer
- Department of Obstetrics and Gynecology, Taipei City Hospital, Women and Children Campus, Taiwan
| | - Wei Shin Chou
- Department of Obstetrics and Gynecology, Taipei City Hospital, Women and Children Campus, Taiwan
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Turhan U, Tatar B. The association between increased maternal PARK7 (DJ-1) levels and the occurrence of preterm premature rupture of membranes - A randomized prospective study. Turk J Obstet Gynecol 2021; 18:279-284. [PMID: 34955006 PMCID: PMC8711678 DOI: 10.4274/tjod.galenos.2021.25588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: Parkinson’s disease protein 7 (PARK7/DJ-1) is an important antioxidant multiprotein against inflammation and oxidative stress. We therefore planned this study to demonstrate the association between maternal PARK7 levels and the occurrence of preterm premature rupture of membranes (PPROM). Materials and Methods: We enrolled 80 pregnant women; 50 PPROM patients and 30 healthy controls, into this cross- sectional study between the 24th and 36th gestational weeks. Furthermore, we measured serum PARK 7 levels using enzyme-Linked immunosorbent assay method. Results: Plasma PARK7 levels were higher in PPROM patients compared to those in the healthy controls (p<0.001). With a cutoff value of 2.57 pg/mL; PARK 7 had a 92% sensitivity, 86% specificity, 88% positive predictive value and 83% negative predictive value (p<0.01) for PPROM. PARK7 had positive correlation with blood leukocyte levels (p<0.001), C-reactive protein levels (p<0.001), and negatively correlated with birth weight and birth week. Conclusion: PARK 7 is overexpressed in PPROM patients. Due to its anti-inflammatory and antioxidant properties, PARK7 may be a novel marker in better understanding the pathophysiology and prediction of the prognosis PPROM. Further large-scale studies are needed.
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Affiliation(s)
- Uğur Turhan
- University of Health Sciences Turkey, Samsun Training and Research Hospital, Clinic of Obstetrics and Gynecology, Division of Perinatology, Samsun, Turkey
| | - Burak Tatar
- University of Health Sciences Turkey, Samsun Training and Research Hospital, Clinic of Obstetrics and Gynecology, Division of Gynecological Oncology, Samsun, Turkey
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Abstract
BACKGROUND The aim of the present study was to compare the outcomes of pregnancies complicated by preterm premature rupture of membranes (PPROM) in China. METHODS The present study was a single-center retrospective study of women admitted to Beijing Obstetrics and Gynecology Hospital in 2012, 2014, and 2017. Deliveries at <24 and >37 weeks, fatal deformities, stillbirths, and multiple pregnancies were excluded. Pregnancies were divided into 24-27+6, 28-33+6, and 34-36+6 weeks according to weeks of gestation in each year. In total, 1,178 pregnancies complicated by PPROM were analyzed in terms of incidence rate, risk factors, delivery mode, and neonatal outcomes. RESULTS The rate of PPROM was 3.11% in 2012, 2.35% in 2014, and 2.4% in 2017; the difference was significant (P<0.001). Age [odds ratio (OR): 1.046, P<0.001], intrauterine infection (OR: 2.087, P=0.007), and vaginitis (OR: 1.812, P=0.039) were risk factors for PPROM. In all 3 years, patients with PPROM tended to choose vaginal delivery rather than cesarean section (CS) delivery (68.9% in 2012, P<0.001; 76.5% in 2014, P<0.001; 69.3% in 2017, P<0.001), and the rate of vaginal deliveries in 2014 was higher than that in 2012 and 2017 (P=0.027). Indications for PPROM at 34-36+6 weeks varied significantly among the 3 years (P<0.001). No significant difference was found in body weight, body length, and Apgar score at 1, 5, and 10 min; however, there was a significant difference in Apgar score after 1 min at 28-33+6 weeks (P=0.012). CONCLUSIONS The incidence rate of PPROM at our single center varied between 2012, 2014, and 2017. Risk factors for pregnancies complicated by PPROM include age, intrauterine infection, and vaginitis. The rate of CS delivery varied, and breech/transverse presentation was the major indication for patients with PPROM at 34-36+6 weeks.
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Affiliation(s)
- Haili Jiang
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Chang Lu
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Weiyuan Zhang
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
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Abstract
Preterm premature rupture of membranes (PPROM) is almost uniformly associated with preterm birth and thus sequelae of prematurity explain many of the complications associated with this condition. However, the unique inflammatory environment and oligohydramnios associated with PPROM may impart unique neonatal and childhood morbidity compared with other preterm birth pathways.
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Affiliation(s)
- Lillian B Boettcher
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Suite 2B200, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Erin A S Clark
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Suite 2B200, 30 North 1900 East, Salt Lake City, UT 84132, USA.
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Abstract
Periviable deliveries (less than 26 weeks) are a small percentage of deliveries but account for a disproportionately high number of long-term morbidities. Few studies describe interventions and outcomes for periviable preterm premature rupture of membranes (PPROM). The available reports may include only those neonates who received resuscitation, making interpretation and application difficult. Counseling should consider the impact of oligohydramnios on fetal lung development. This article discusses standard and experimental interventions that may offer neonatal benefit. Antenatal corticosteroids, antibiotics, and magnesium sulfate may improve outcomes but data to support an improvement in outcome are limited. Studies specifically evaluating these interventions are needed.
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Affiliation(s)
- Kelly S Gibson
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Case Western Reserve University, The MetroHealth System, Suite G240, 2500 MetroHealth Drive, Cleveland, Ohio 44109, USA.
| | - Kerri Brackney
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Case Western Reserve University, The MetroHealth System, Suite G240, 2500 MetroHealth Drive, Cleveland, Ohio 44109, USA
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Erenberg M, Yagel Y, Press F, Weintraub AY. Chorioamnionitis caused by Serratia marcescens in a healthy pregnant woman with preterm premature rupture of membranes: A rare case report and review of the literature. Eur J Obstet Gynecol Reprod Biol. 2017;211:227-230. [PMID: 28283205 DOI: 10.1016/j.ejogrb.2017.02.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 02/13/2017] [Accepted: 02/23/2017] [Indexed: 12/15/2022]
Abstract
The incidence of chorioamnionitis varies widely. The highest incidence is reported in preterm deliveries. Among preterm deliveries, chorioamnionitis usually occurs after preterm premature rupture of membranes (PPROM). To date, only five cases of chorioamnionitis due to Serratia marcescens were reported. Here we present a case of a pregnant woman with chorioamnionitis due to Serratia marcescens who delivered a premature neonate at 28 weeks and four days of gestation. We also conducted a review of the literature in order to identify and characterize the clinical presentation and outcomes of this rare infection. A 36 year old female (gravida 9, para 6) was admitted with cervical effacement of 16mm and intact membranes at gestational age of 25 weeks and five days. One week following her admission PPROM was noticed. Treatment with the standard antibiotic regimen for PPROM was initiated. Thirteen days after the diagnosis of PPROM (28 weeks and four days) she developed chills, abdominal pain, sub febrile fever, tachycardia, leukocytosis and fetal tachycardia, and a clinical diagnosis of chorioamnionitis was made. An urgent CS was performed. In the first post-operative day the patient developed surgical sight infection. Cultures obtained from the purulent discharge of the wound, as well as cultures from the placenta and uterine cavity that were obtained during surgery grew Serratia marcescens. The patient was treated with Meropenem for six days, with a good clinical response. We present a rare case of nosocomialy acquired Serratia marcescens chorioamnionitis in a patient with PPROM. This case emphasizes the need for good infection control measures. Our favorable outcome together with the scares reports in the literature, add insight into this type of rare infection.
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Kurek Eken M, Tüten A, Özkaya E, Karatekin G, Karateke A. Major determinants of survival and length of stay in the neonatal intensive care unit of newborns from women with premature preterm rupture of membranes. J Matern Fetal Neonatal Med 2016; 30:1972-1975. [PMID: 27624140 DOI: 10.1080/14767058.2016.1235696] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Meryem Kurek Eken
- a Department of Obstetric and Gynecology , Adnan Menderes University , Aydın , Turkey
| | - Abdülhamit Tüten
- b Department of Neonatology , Zeynep Kamil Maternity and Children Hospital , İstanbul , Turkey , and
| | - Enis Özkaya
- c Department of Obstetric and Gynecology , Zeynep Kamil Maternity and Children Hospital , Istanbul , Turkey
| | - Güner Karatekin
- b Department of Neonatology , Zeynep Kamil Maternity and Children Hospital , İstanbul , Turkey , and
| | - Ateş Karateke
- c Department of Obstetric and Gynecology , Zeynep Kamil Maternity and Children Hospital , Istanbul , Turkey
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Zhou Q, Zhang W, Xu H, Liang H, Ruan Y, Zhou S, Li X. Risk factors for preterm premature rupture of membranes in Chinese women from urban cities. Int J Gynaecol Obstet 2014; 127:254-9. [PMID: 25200254 DOI: 10.1016/j.ijgo.2014.06.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 06/18/2014] [Accepted: 08/04/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the prevalence of preterm premature rupture of membranes (PPROM) in urban areas in China and examine the associated risk factors. METHODS A population-based, prospective study was undertaken in 14 cities in China between January 1, 2011, and January 31, 2012. Women were recruited at their first prenatal-care visit, when maternal characteristics were recorded. Risk factors were analyzed by one-way analysis of variance. RESULTS Of 112 439 women included in analyses, 3077 (2.7%) had PPROM. Univariate analysis showed an increased risk of PPROM before 28weeks of pregnancy in migrant women (odds ratio [OR] 2.25; 95% confidence interval [CI] 1.53-3.30; P<0.001), in those with a history of recurrent induced abortions (OR 2.75; 95% CI 1.66-4.56; P<0.001), and in those with a history of preterm birth (OR 3.90; 95% CI 0.77-19.61; P<0.001). The associations were maintained in multivariate analysis (P<0.001). CONCLUSION Migration as a result of urbanization, high rates of induced abortion, and preterm birth are potential risk factors for PPROM in Chinese women.
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Affiliation(s)
- Qiongjie Zhou
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Weiyuan Zhang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Huan Xu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Huan Liang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Yan Ruan
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Shufeng Zhou
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Xiaotian Li
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; The Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China; Institute of Biomedical Sciences, Fudan University, Shanghai, China.
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Eleje GU, Adinma JI, Ghasi S, Ikechebelu JI, Igwegbe AO, Okonkwo JE, Okafor CI, Ezeama CO, Ezebialu IU, Ogbuagu CN. Antibiotic susceptibility pattern of genital tract bacteria in pregnant women with preterm premature rupture of membranes in a resource-limited setting. Int J Gynaecol Obstet 2014; 127:10-4. [PMID: 24994495 DOI: 10.1016/j.ijgo.2014.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/17/2014] [Accepted: 06/09/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify microbes prevalent in the genital tract of pregnant women with preterm premature rupture of membranes (PPROM) and to assess the susceptibility of the microbial isolates to a range of antibiotics to determine appropriate antibiotics for treating cases of PPROM in resource-limited settings. METHODS A prospective cross-sectional study was undertaken involving women with (n=105) and without (n=105) a confirmed diagnosis of PPROM admitted to Nnamdi Azikiwe University Teaching Hospital, southeast Nigeria, between January 1, 2011, and April 30, 2013. Endocervical swabs were collected from all participants and examined microbiologically. Antibiotic sensitivity testing was performed using Kirby-Bauer disk diffusion. RESULTS Streptococcus spp., Staphylococcus aureus, and Escherichia coli were significantly more prevalent among women with PPROM than among those without PPROM (P<0.01). Among the antibiotics considered safe to use during pregnancy, the bacteria were most sensitive to ampicillin-sulbactam, cefixime, cefuroxime, and erythromycin. CONCLUSION For the first 48hours, women with PPROM should receive an intravenous dose combining ampicillin-sulbactam, cefixime, cefuroxime, or erythromycin with metronidazole followed by oral administration of the chosen antibiotic combination to complete a 7-day course.
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Affiliation(s)
- George U Eleje
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.
| | - Joseph I Adinma
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Samuel Ghasi
- Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Joseph I Ikechebelu
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Anthony O Igwegbe
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - John E Okonkwo
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Charles I Okafor
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Chukwuemeka O Ezeama
- Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Ifeanyichukwu U Ezebialu
- Department of Obstetrics and Gynecology, Anambra State University Teaching Hospital, Awka, Nigeria
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