Evaluation of fetal cardiac output in preterm premature rupture of membranes

AIM

We aimed to investigate fetal cardiac output (CO) in pregnancies with preterm premature rupture of membranes (PPROM) and its relationship with umbilical cord pH.

METHODS

This was a prospective study in total 90 pregnancies at 24-37 weeks gestation including 42 pregnancies with PPROM and 48 that healthy controls. Fetal cardiac function including combined, left and right CO z-scores were compared. The neonates in the PPROM group were separated with umbilical cord pH above and below 7.25, and cardiac output was compared between groups.

RESULTS

In PPROM group, CCO z-score, left cardiac output (LCO) z-score, and right cardiac output (RCO) were significantly lower compared to healthy pregnancies (p = .036, p = .001, p = .032, respectively), while RCO z-score showed no significant differences between the two groups. The aortic annulus and pulmonary artery annulus z-scores were measured smaller in the PPROM group (p = .000 and p = .001, respectively). In PPROM group, the fetal LCO z-score was significantly lower in neonates with an umbilical cord pH of 7.25 or less (p = .048).

CONCLUSION

This study provides evidence that fetal CCO is lower in PPROM compared with healthy pregnancies. Reduced LCO z-scores may be useful for predicting adverse neonatal outcomes in pregnancies with PPROM.

Comparison of Neonatal Morbidity and Mortality Following Spontaneous and Medically Indicated Preterm Births: A Retrospective Population-Based Study Using Data from the Slovenian National Perinatal Information System 2013-2018

BACKGROUND This retrospective population-based study analyzed data from the Slovenian National Perinatal Information System (NPIS) between 2013 and 2018 to compare neonatal morbidity and mortality following spontaneous and medically indicated preterm births. MATERIAL AND METHODS Retrospective population-based cohort. Entries to the NPIS database were searched by gestational age (GA) <37 weeks in Slovenia between 2013 and 2018. Of 9200 (6252 following spontaneous birth, 2948 following medically indicated) neonates included, 1358 were born at extremely to very preterm GA (998 following spontaneous birth, 360 following medically indicated). Logistic regression analysis was used to examine the association between neonatal mortality and composite severe neonatal morbidity and preterm birth type (spontaneous vs medically indicated) controlling for potential confounding variables. Analysis was first performed for all preterm births (GA 22 0/7 to 36 6/7) and later only for extremely to very preterm births (GA 22 0/7 to 31 6/7). RESULTS Neonatal mortality was significantly lower following spontaneous preterm birth at extremely to very preterm GA (odds ratio [OR] 0.34; 95% confidence interval [CI] [0.14, 0.81]), while there was no association in all preterm births group (OR 0.56; 95% CI [0.26, 1.20]). No significant correlation between preterm birth type and neonatal morbidity was found (OR 0.76; 95% CI [0.54, 1.09] for all preterm births and OR 0.71; 95% CI [0.47, 1.07] for extremely to very preterm births). CONCLUSIONS In this population study from Slovenia between 2013 and 2018, medically indicated preterm births at <32 weeks of GA were associated with significantly increased neonatal mortality but not neonatal morbidity.

Toward a new taxonomy of obstetrical disease: improved performance of maternal blood biomarkers for the great obstetrical syndromes when classified according to placental pathology

BACKGROUND

The major challenge for obstetrics is the prediction and prevention of the great obstetrical syndromes. We propose that defining obstetrical diseases by the combination of clinical presentation and disease mechanisms as inferred by placental pathology will aid in the discovery of biomarkers and add specificity to those already known.

OBJECTIVE

To describe the longitudinal profile of placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), and the PlGF/sFlt-1 ratio throughout gestation, and to determine whether the association between abnormal biomarker profiles and obstetrical syndromes is strengthened by information derived from placental examination, eg, the presence or absence of placental lesions of maternal vascular malperfusion.

STUDY DESIGN

This retrospective case cohort study was based on a parent cohort of 4006 pregnant women enrolled prospectively. The case cohort of 1499 pregnant women included 1000 randomly selected patients from the parent cohort and all additional patients with obstetrical syndromes from the parent cohort. Pregnant women were classified into six groups: 1) term delivery without pregnancy complications (n=540; control); 2) preterm labor and delivery (n=203); 3) preterm premature rupture of the membranes (n=112); 4) preeclampsia (n=230); 5) small-for-gestational-age neonate (n=334); and 6) other pregnancy complications (n=182). Maternal plasma concentrations of PlGF and sFlt-1 were determined by enzyme-linked immunosorbent assays in 7560 longitudinal samples. Placental pathologists, masked to clinical outcomes, diagnosed the presence or absence of placental lesions of maternal vascular malperfusion. Comparisons between mean biomarker concentrations in cases and controls were performed by utilizing longitudinal generalized additive models. Comparisons were made between controls and each obstetrical syndrome with and without subclassifying cases according to the presence or absence of placental lesions of maternal vascular malperfusion.

RESULTS

1) When obstetrical syndromes are classified based on the presence or absence of placental lesions of maternal vascular malperfusion, significant differences in the mean plasma concentrations of PlGF, sFlt-1, and the PlGF/sFlt-1 ratio between cases and controls emerge earlier in gestation; 2) the strength of association between an abnormal PlGF/sFlt-1 ratio and the occurrence of obstetrical syndromes increases when placental lesions of maternal vascular malperfusion are present (adjusted odds ratio [aOR], 13.6 vs 6.7 for preeclampsia; aOR, 8.1 vs 4.4 for small-for-gestational-age neonates; aOR, 5.5 vs 2.1 for preterm premature rupture of the membranes; and aOR, 3.3 vs 2.1 for preterm labor (all P<0.05); and 3) the PlGF/sFlt-1 ratio at 28 to 32 weeks of gestation is abnormal in patients who subsequently delivered due to preterm labor with intact membranes and in those with preterm premature rupture of the membranes if both groups have placental lesions of maternal vascular malperfusion. Such association is not significant in patients with these obstetrical syndromes who do not have placental lesions.

CONCLUSION

Classification of obstetrical syndromes according to the presence or absence of placental lesions of maternal vascular malperfusion allows biomarkers to be informative earlier in gestation and enhances the strength of association between biomarkers and clinical outcomes. We propose that a new taxonomy of obstetrical disorders informed by placental pathology will facilitate the discovery and implementation of biomarkers as well as the prediction and prevention of such disorders.

The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data

BACKGROUND

Two randomized controlled trials compared the neonatal and infant outcomes after fetoscopic endoluminal tracheal occlusion with expectant prenatal management in fetuses with severe and moderate isolated congenital diaphragmatic hernia, respectively. Fetoscopic endoluminal tracheal occlusion was carried out at 27⁺⁰ to 29⁺⁶ weeks' gestation (referred to as "early") for severe and at 30⁺⁰ to 31⁺⁶ weeks ("late") for moderate hypoplasia. The reported absolute increase in the survival to discharge was 13% (95% confidence interval, -1 to 28; P=.059) and 25% (95% confidence interval, 6-46; P=.0091) for moderate and severe hypoplasia.

OBJECTIVE

Data from the 2 trials were pooled to study the heterogeneity of the treatment effect by observed over expected lung-to-head ratio and explore the effect of gestational age at balloon insertion.

STUDY DESIGN

Individual participant data from the 2 trials were reanalyzed. Women were assessed between 2008 and 2020 at 14 experienced fetoscopic endoluminal tracheal occlusion centers and were randomized in a 1:1 ratio to either expectant management or fetoscopic endoluminal tracheal occlusion. All received standardized postnatal management. The combined data involved 287 patients (196 with moderate hypoplasia and 91 with severe hypoplasia). The primary endpoint was survival to discharge from the neonatal intensive care unit. The secondary endpoints were survival to 6 months of age, survival to 6 months without oxygen supplementation, and gestational age at live birth. Penalized regression was used with the following covariates: intervention (fetoscopic endoluminal tracheal occlusion vs expectant), early balloon insertion (yes vs no), observed over expected lung-to-head ratio, liver herniation (yes vs no), and trial (severe vs moderate). The interaction between intervention and the observed over expected lung-to-head ratio was evaluated to study treatment effect heterogeneity.

RESULTS

For survival to discharge, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion was 1.78 (95% confidence interval, 1.05-3.01; P=.031). The additional effect of early balloon insertion was highly uncertain (adjusted odds ratio, 1.53; 95% confidence interval, 0.60-3.91; P=.370). When combining these 2 effects, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion with early balloon insertion was 2.73 (95% confidence interval, 1.15-6.49). The results for survival to 6 months and survival to 6 months without oxygen dependence were comparable. The gestational age at delivery was on average 1.7 weeks earlier (95% confidence interval, 1.1-2.3) following fetoscopic endoluminal tracheal occlusion with late insertion and 3.2 weeks earlier (95% confidence interval, 2.3-4.1) following fetoscopic endoluminal tracheal occlusion with early insertion compared with expectant management. There was no evidence that the effect of fetoscopic endoluminal tracheal occlusion depended on the observed over expected lung-to-head ratio for any of the endpoints.

CONCLUSION

This analysis suggests that fetoscopic endoluminal tracheal occlusion increases survival for both moderate and severe lung hypoplasia. The difference between the results for the Tracheal Occlusion To Accelerate Lung growth trials, when considered apart, may be because of the difference in the time point of balloon insertion. However, the effect of the time point of balloon insertion could not be robustly assessed because of a small sample size and the confounding effect of disease severity. Fetoscopic endoluminal tracheal occlusion with early balloon insertion in particular strongly increases the risk for preterm delivery.

Results of expectant management in singleton and twin pregnancies complicated by preterm premature rupture of membranes

OBJECTIVES

This study aimed to examine whether expectant management in twin pregnancies with preterm premature rupture of membranes (pPROM) is as safe as in singleton pregnancies.

MATERIAL AND METHODS

It was a retrospective cohort study comparing pregnancy course and outcome in singleton (n = 299) and twin pregnancies (n = 49) complicated by preterm premature rupture of membranes. Analysed factors included maternal diseases, gestational age at premature rupture of membranes (PROM), management during hospitalization, latency periods between PROM and delivery, gestational age at delivery, neonatal management and outcome.

RESULTS

The difference in the proportion of patients with latency up to 72 hours, latency between 72 hours and seven days, and latency exceeding seven days were insignificant. The percentage of patients who received intravenous tocolysis and antenatal corticosteroids were similar; however, patients in twin pregnancies more often received incomplete steroids dose (p = 0.01). The occurrence of the positive non-stress test result and signs of intrauterine infection were similar between the groups. No statistically significant differences in the prevalence of neonatal complications except transient tachypnoea of the newborn were identified (24% in the singleton vs 13% in the twin group, p = 0.03).

CONCLUSIONS

Expectant management of pPROM in singleton and twin pregnancies results in similar perinatal and neonatal outcome. Consequently, in case of no evident contraindications, expectant management of twin pregnancies seems to be equally as safe as in singleton pregnancies. Patients in twin pregnancies may be at higher risk of delivery before administration of full antenatal corticosteroids dose, therefore require immediate management initiation and transfer to a tertiary referral centre.

How should fetal surgery for congenital diaphragmatic hernia be implemented in the post-TOTAL trial era: a discussion. Prenat Diagn 2022;42:301-309. [PMID: 35032132 DOI: 10.1002/pd.6091]

Following prenatal diagnosis of congenital diaphragmatic hernia, severity can be predicted based on the presence of associated abnormalities, and in isolated cases, on lung size and position of the liver. Severe hypoplasia is defined by a contralateral lung size < 25% on ultrasound; moderate hypoplasia is when that lung measures between 25 and 45% of the normal. In fetuses with predicted poor postnatal outcome a procedure that reverses pulmonary hypoplasia may be considered. In uncontrolled studies, fetoscopic endoluminal tracheal occlusion (FETO) improved neonatal outcome. Recently, two randomized controlled trials compared the neonatal and infant outcomes in fetuses with isolated CDH (www.totaltrial.eu). In severe cases, FETO was carried out at 27⁺⁰ -29⁺⁶ weeks' gestation (referred to as "early") and in moderate at 30⁺⁰ -31⁺⁶ weeks ("late"). Survival to discharge from the neonatal intensive care unit increased by 25% (95%-CI:+6 - +46; P=.0091) and 13% (-1 - +28; P=.059), in fetuses with severe and moderate cases, respectively. Following FETO gestational age at delivery was on average 3.2 (2.3-4.1) weeks earlier following early and 1.7 (1.1 - 2.3) following late FETO. Here the strengths and weaknesses of the TOTAL trials and their translation to the clinic are debated. Discussants are the lead for the trial (JD) and a colleague (AF) not involved. The discussant notes that the observed survival, both in treated and expectantly managed fetuses, was overall less than what is reported by some high volume centers, particularly in North America. Additional criticisms are the potential effects of prematurity on the long term, the inclusion of low-volume centers, and the potential of FETO for severe iatrogenic complications. Therefore results may not be generalizable. The discussants concluded that although FETO may have its value it remains a procedure with a high risk for prematurity and it can be lethal when the balloon cannot be removed prior to delivery. This article is protected by copyright. All rights reserved.

Interventional resealing of preterm premature rupture of the membranes: a systematic review and meta-analysis

OBJECTIVE

To compare the effectiveness and outcomes of interventional resealing of membranes, "amniopatch" for spontaneous vs. iatrogenic preterm premature rupture of the membranes (sPPROM and iPPROM).

METHODS

We performed a systematic review of literature involving an electronic search of the following databases: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Scopus. An indirect meta-analysis was then performed to compare the obstetric, maternal, fetal, and neonatal outcomes of amniopatch between the sPPROM and iPPROM groups.

RESULTS

The mean gestational age (GA) at the time rupture was 17.8 ± 1.8 and 25.2 ± 3.8 weeks for iPPROM and sPPROM, respectively, p = .005. Mean GA at the time of amniopatch procedure was 19.2 ± 2.07 weeks for iPPROM and 23 ± 3.1 weeks of gestation for sPPROM, p = .023. The rates of fluid re-accumulation (sPPROM 26% and iPPROM 53%, p = .09) were comparable between the sPPROM and iPPROM groups. Neonatal outcomes except for the rate of IUFD were also comparable between the groups. The incidence of IUFD was significantly higher in the iPPROM group (ES: 24%; 95% CI: 8.00-44.0%; p < .001), compared to sPPROM (ES: 0%; 95% CI: 0.00-4.00%). Obstetric and maternal outcomes were comparable between the two groups.

CONCLUSIONS

Amniopatch appears to be a feasible and safe procedure for PPROM treatment. Further research is warranted to investigate the effectiveness of this procedure and establish a standardized criterion for the appropriate selection of patients that could benefit from this intervention.

Risk Profiling of the Solomon Technique versus Selective Technique of Fetoscopic Laser Surgery for Twin-Twin Transfusion Syndrome

We evaluated the outcomes and adverse events after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) using the Solomon technique in comparison to the selective technique. A retrospective analysis of a single-center consecutive cohort of FLS-treated TTTS using the selective (January 2010 to July 2014) and Solomon (August 2014 to December 2017) techniques was performed. Among 395 cases, 227 underwent selective coagulation and 168 underwent the Solomon technique. The incidence rates of recurrent TTTS (Solomon vs. selective: 0% vs. .9%, p = .510) and twin anemia-polycythemia sequence (.6% vs. .4%, p = .670) were very low in both groups. The incidence rates of placental abruption (Solomon vs. selective: 10.7% vs. 3.5%, p = .007) and preterm premature rupture of the membranes (pPROM) with subsequent delivery before 32 weeks (20.2% vs. 7.1%, p < .001) were higher in the Solomon group. The median birth recipient weight was significantly smaller in the Solomon group (1790 g vs. 1933 g, p = .049). The rate of survival of at least one twin was significantly higher in the Solomon group (98.2% vs. 93.8%, p = .046). The Solomon technique and total laser energy were significant risk factors for pPROM (odds ratio: 2.64, 1.07, 95% CI [1.32, 5.28], [1.01, 1.13], p = .006, p = .014, respectively). These findings suggest that the Solomon technique led to superior survival outcomes but increased risks of placental abruption, pPROM and fetal growth impairment. Total laser energy was associated with the occurrence of pPROM. Close attention to adverse events is required for perinatal management after FLS to treat TTTS using the Solomon technique.

A specific bacterial DNA signature in the vagina of Australian women in midpregnancy predicts high risk of spontaneous preterm birth (the Predict1000 study)

BACKGROUND

Intrauterine infection accounts for a quarter of the cases of spontaneous preterm birth; however, at present, it is not possible to efficiently identify pregnant women at risk to deliver preventative treatments.

OBJECTIVE

This study aimed to establish a vaginal microbial DNA test for Australian women in midpregnancy that will identify those at increased risk of spontaneous preterm birth.

STUDY DESIGN

A total of 1000 women with singleton pregnancies were recruited in Perth, Australia. Midvaginal swabs were collected between 12 and 23 weeks' gestation. DNA was extracted for the detection of 23 risk-related microbial DNA targets by quantitative polymerase chain reaction. Obstetrical history, pregnancy outcome, and demographics were recorded.

RESULTS

After excluding 64 women owing to losses to follow-up and insufficient sample for microbial analyses, the final cohort consisted of 936 women of predominantly white race (74.3%). The overall preterm birth rate was 12.6% (118 births); the spontaneous preterm birth rate at <37 weeks' gestation was 6.2% (2.9% at ≤34 weeks' gestation), whereas the preterm premature rupture of the membranes rate was 4.2%. No single individual microbial target predicted increased spontaneous preterm birth risk. Conversely, women who subsequently delivered at term had higher amounts of Lactobacillus crispatus, Lactobacillus gasseri, or Lactobacillus jensenii DNA in their vaginal swabs (13.8% spontaneous preterm birth vs 31.2% term; P=.005). In the remaining women, a specific microbial DNA signature was identified that was strongly predictive of spontaneous preterm birth risk, consisting of DNA from Gardnerella vaginalis (clade 4), Lactobacillus iners, and Ureaplasma parvum (serovars 3 and 6). Risk prediction was improved if Fusobacterium nucleatum detection was included in the test algorithm. The final algorithm, which we called the Gardnerella Lactobacillus Ureaplasma (GLU) test, was able to detect women at risk of spontaneous preterm birth at <37 and ≤34 weeks' gestation, with sensitivities of 37.9% and 44.4%, respectively, and likelihood ratios (plus or minus) of 2.22 per 0.75 and 2.52 per 0.67, respectively. Preterm premature rupture of the membranes was more than twice as common in GLU-positive women. Adjusting for maternal demographics, ethnicity, and clinical history did not improve prediction. Only a history of spontaneous preterm birth was more effective at predicting spontaneous preterm birth than a GLU-positive result (odds ratio, 3.6).

CONCLUSION

We have identified a vaginal bacterial DNA signature that identifies women with a singleton pregnancy who are at increased risk of spontaneous preterm birth and may benefit from targeted antimicrobial therapy.

Comparison of maternal characteristics, pregnancy course, and neonatal outcome in preterm births with and without prelabor rupture of membranes

OBJECTIVES

The aim of this study was to evaluate pregnancy outcome of patients with prelabor rupture of membranes receiving expectant management and giving birth prematurely in comparison to preterm births of patients with intact membranes.

MATERIAL AND METHODS

It was a retrospective cohort study comparing maternal and neonatal outcome in two groups of preterm births. The first group included 299 consecutive singleton preterm births complicated by prelabor rupture of membranes. The second group consisted of 349 consecutive singleton preterm births without prelabor rupture of membranes.

RESULTS

Patients without pPROM underwent Caesarean sections more often than women from the pPROM group (65.3% vs 45.2%; p < 0.001). No statistically significant differences regarding the gestational age during delivery were identified. Lower birth weight was detected in the group with no history of pPROM (p < 0.001). No differences regarding early-onset sepsis were identified and higher percentage of late-onset infections was observed in infants with no history of pPROM (8.9% vs 4.7%; p = 0.04). Pulmonary hypertension was more common in the infants from the pPROM group (4% vs 1.4%; p = 0.049). Neonatal respiratory distress syndrome and respiratory failure were more prevalent in cases of no pPROM history - 20% vs 12.7% (p = 0.02) and 40% vs 25.8% (p < 0.001), respectively.

CONCLUSIONS

Development of multiple complications in preterm neonates may be more associated with the management, gestational age at birth, and birth weight than with the occurrence of preterm prelabor rupture of membranes.

Successful treatment of severe intra-amniotic inflammation and cervical insufficiency with continuous transabdominal amnioinfusion and cerclage: A case report

Severe intra-amniotic inflammation, even with a negative bacterial culture, can lead to premature labor. We report a 43-year-old multiparous woman with severe intra-amniotic inflammation and cervical insufficiency at 23 weeks and 5 days of gestation. Continuous transabdominal amnioinfusion was started 2 days after the diagnosis. The amniotic fluid interleukin-6 level normalized after 2 days of treatment. She underwent Shirodkar cervical cerclage on day 7. Despite termination of amnioinfusion and catheter removal on day 16, the pregnancy was maintained without any subsequent treatment. At 33 weeks and 5 days of gestation, an intrauterine Ureaplasma parvum infection and the onset of contractions led to repeat cesarean delivery. The birth weight was 2292 g, and the Apgar scores were 8/8. Both mother and infant had good outcomes. Continuous transabdominal amnioinfusion may have eliminated factors causing intra-amniotic inflammation, thereby prolonging the pregnancy and improving the infant's prognosis.

A cut-off value for systemic immune-inflammation index in the prediction of adverse neonatal outcomes in preterm premature rupture of the membranes

AIM

To determine a cut-off value for systemic immune-inflammation index (SII)(neutrophil × platelet /lymphocyte) in the prediction of adverse neonatal outcomes in preterm premature rupture of the membranes (PPROM).

METHODS

This retrospective cohort study was conducted among singleton pregnancies with PPROM. Cases were divided into two main groups: Group 1) PPROM diagnosed at 24th-28th weeks of gestation and Group 2) PPROM diagnosed at >28th-34th weeks of gestation. Thereafter, main study groups were divided into two subgroups: Subgroup A: pregnancies with favorable neonatal outcomes and Subgroup B: pregnancies with composite adverse neonatal outcomes. Subgroups were compared in terms of demographic features, clinical characteristics, laboratory test results and SII values. Furthermore, cut-off values of SII for the prediction of composite adverse neonatal outcomes were determined for two main groups. A Mann-Whitney U test was conducted to compare the median values and the chi-square test was used to compare categorical variables among the groups. Receiver operating characteristic (ROC) curves were used to assess the performance of SII value in predicting composite adverse neonatal outcomes.

RESULTS

Significant differences were observed for median platelet and SII values between the subgroups (P < 0.001 for both in group 1 and P = 0.002 and P = 0.005, respectively, in group 2). Cut-off values of 1695.14 10⁹ /L (83.3% sensitivity, 85.7% specificity) and 1430.90 × 10⁹ /L (71.4% sensitivity, 75.7% specificity) for composite adverse neonatal outcomes were determined, respectively in group 1 and 2 according to the ROC curve analysis.

CONCLUSION

SII may be used as an additional indicator for the prediction of adverse neonatal outcomes in PPROM.

The relationship of the subtypes of preterm birth with retinopathy of prematurity

BACKGROUND

Retinopathy of prematurity is an adverse outcome of preterm birth and is a leading cause of childhood blindness. The relationship between the subtypes of preterm birth with retinopathy of prematurity is understudied.

OBJECTIVE

To investigate whether there is a difference in the incidence of type 1 or type 2 retinopathy of prematurity in infants with preterm birth resulting from spontaneous preterm labor, a medical indication of preterm birth, or preterm premature rupture of the membranes.

STUDY DESIGN

A retrospective cohort study was conducted of 827 infants screened for retinopathy of prematurity who were delivered at a single tertiary care center in Colorado. All infants fulfilled the American Academy of Pediatrics 2013 screening criteria for retinopathy of prematurity defined as "infants with a birth weight of ≤1500 g or gestational age of 30 weeks or less (as defined by the attending neonatologist) and selected infants with a birth weight between 1500 and 2000 g or gestational age of >30 weeks with an unstable clinical course, including those requiring cardiorespiratory support and who are believed by their attending pediatrician or neonatologist to be at high risk for retinopathy of prematurity." Two independent reviewers masked to retinopathy of prematurity outcomes determined whether preterm birth resulted from spontaneous preterm labor, medical indication of preterm birth, or preterm premature rupture of the membranes. Discrepancies were resolved by a third reviewer. Data were analyzed with univariate and multivariable logistic regression.

RESULTS

In our cohort, the frequency of preterm birth resulting from spontaneous preterm labor, medical indication of preterm birth, or preterm premature rupture of the membranes was 34%, 40%, and 26%, respectively. The mean gestational age (weeks, days) ± SD (range) in the cohort and across the preterm birth subtypes was as follows: entire cohort, 28 weeks, 6 days ± 2 weeks, 3 days (23 weeks, 3 days - 36 weeks, 4 days); spontaneous preterm labor, 28 weeks 1 day ± 2 weeks, 3 days (23 weeks, 3 days - 33 weeks, 4 days); medical indication of preterm birth, 29 weeks, 1 day ± 2 weeks, 2 days (24-36 weeks, 4 days); preterm premature rupture of the membranes, 28 weeks, 4 days ± 2 weeks, 1 day (24-33 weeks, 1 day). Among infants with type 1, type 2, or no retinopathy of prematurity, the incidence of type 1 or type 2 retinopathy of prematurity in births from spontaneous preterm labor, medical indication of preterm birth, and preterm premature rupture of the membranes was 37 of 218 (17%), 27 of 272 (10%), and 10 of 164 (6%), respectively. Adjusted for gestational age, birth weight, and multiparity and compared with the preterm premature rupture of the membranes group, the odds ratios of spontaneous preterm labor and medical indication of preterm birth for type 1 or type 2 retinopathy of prematurity were 6.1 (95% confidence interval, 1.8 to 20, P = .003) and 5.5 (95% confidence interval, 1.4 to 21, P = .01), respectively. Among neonates born after preterm premature rupture of the membranes, the probability of developing type 1 or type 2 retinopathy of prematurity was greatest in infants with rupture of membrane duration of up to 24 hours. After 24 hours, the probability of developing type 1 or type 2 retinopathy of prematurity declined. The odds of developing type 1 or type 2 retinopathy of prematurity was 9.0 (95% confidence interval 2.3 to 34, P = .002) in infants who had preterm premature rupture of the membranes ≤ 24 hours compared with infants who had preterm premature rupture of the membranes > 24 hours.

CONCLUSION

Type 1 or type 2 retinopathy of prematurity are adverse ocular outcomes linked with not only lower gestational age and birth weight at delivery but also with events in the intrauterine environment that trigger a preterm birth. The reduced incidence of type 1 or type 2 retinopathy of prematurity in the preterm premature rupture of the membranes group compared with other causes of preterm birth may be related to the perinatal therapies associated with preterm premature rupture of the membranes (such as corticosteroids, antibiotics, maternal-fetal surveillance), which may have an inhibitory effect on the development of retinopathy of prematurity. We suggest that the physiologic events that predispose infants to type 1 or type 2 retinopathy of prematurity begin before delivery.

Histologic Chorioamnionitis and Bronchopulmonary Dysplasia in Preterm Infants: The Epidemiologic Study on Low Gestational Ages 2 Cohort

OBJECTIVE

To investigate the association between histologic chorioamnionitis (HCA) and bronchopulmonary dysplasia (BPD) in very preterm infants, both in a general population and for those born after spontaneous preterm labor and after preterm premature rupture of membranes (pPROM).

STUDY DESIGN

This study included 2513 live born singletons delivered at 24-31 weeks of gestation from a national prospective population-based cohort of preterm births; 1731 placenta reports were available. HCA was defined as neutrophil infiltrates in the amnion, chorion of the membranes, or chorionic plate, associated or not with funisitis. The main outcome measure was moderate or severe BPD. Analyses involved logistic regressions and multiple imputation for missing data.

RESULTS

The incidence of HCA was 28.4% overall: 38% in cases of preterm labor, 64% in cases of pPROM, and less than 5% in cases of vascular disorders. Overall, the risk of BPD after adjustment for gestational age, sex, and antenatal steroids was reduced for infants with HCA (HCA alone: aOR 0.6 [95% CI 0.4-0.9]; associated with funisitis: aOR 0.5 [95% CI 0.3-0.8]). This finding was explained by the high rate of BPD and low rate of chorioamnionitis among children with fetal growth restriction. HCA was not associated with BPD in the preterm labor (13.4% vs 8.5%; aOR 0.9; 95% CI 0.5-1.8) or in the pPROM group (12.9% vs 12.1%; aOR 0.6; 95% CI 0.3-1.3).

CONCLUSION

In homogeneous groups of infants born after preterm labor or pPROM, HCA is not associated with BPD.

Measurement of Interleukin 8 in Cervicovaginal Fluid in Women With Preterm Premature Rupture of Membranes: A Comparison of Amniotic Fluid Samples

Cervicovaginal fluid (CVF) samples may be a feasible alternative to amniotic fluid (AF) sampling in women with preterm premature rupture of the membranes (PPROMs), because PPROM causes AF to spill into the CVF. We aimed to assess the correlation and limits of agreement of interleukin 8 (IL-8) levels between CVF and AF in women with PPROM and to compare the clinical value of CVF IL-8 to AF IL-8 for the prediction of microbial invasion of amniotic cavity (MIAC). A retrospective cohort observational study was conducted on 85 women with singleton pregnancies (24-34 weeks) presenting with PPROM. The CVF samples were obtained simultaneously with AF samples retrieved by transabdominal amniocentesis. The levels of IL-8 in paired CVF and AF samples were measured with enzyme-linked immunosorbent assay in the same plate in duplicate using the same dilutions. The prevalence of a positive AF culture was 40% (34 of 85). The CVF IL-8 levels were significantly and positively correlated with AF IL-8 levels ( r = 0.778). However, the level of agreement between CVF and AF IL-8 levels yielded a Cohen κ statistic of 0.276. Paired Student t test revealed that the difference between CVF and AF IL-8 levels was statistically significant. The area under the curve for AF IL-8 was significantly higher than that for CVF IL-8 ( P = .013). In women with PPROM, IL-8 levels in CVF were significantly correlated with, but were significantly different from, those in AF samples. The CVF IL-8 has moderate predictive capability for the risk of MIAC, but this is inferior to AF IL-8.

Can platelet count and mean platelet volume during the first trimester of pregnancy predict preterm premature rupture of membranes?

AIM

The aim of our study was to evaluate the values of platelet count and mean platelet volume (MPV) obtained from maternal serum during the first trimester to predict subsequent preterm premature rupture of membranes (PPROM).

MATERIAL AND METHODS

The records of 318 women with PPROM and 384 healthy controls in a single center between 2009 and 2013 were retrospectively evaluated. Platelet count and MPV values between 7 and 14 weeks of gestation were compared. Receiver-operator curve analysis was performed to identify the optimal platelet count and MPV cut-off levels predicting PPROM.

RESULTS

Compared with controls, women with PPROM had significantly increased levels of platelet count and significantly decreased levels of MPV in the first trimester (P < 0.001). The area under the receiver-operator curve was 0.642 for MPV and 0.579 for platelet count. The cut-off values of MPV ≤ 8.6 fL and platelet count ≥216 × 10(3) /μL predicted PPROM with a sensitivity of 58% and 65% and specificity of 62% and 44%, respectively.

CONCLUSION

MPV can be used as a more efficient predictor for an early diagnosis of PPROM than platelet count. However, further research combining other markers is needed to increase the efficiency of prediction.

Expression of 8-oxoguanine glycosylase in human fetal membranes

PROBLEM

The most common DNA lesion generated by oxidative stress (OS) is 7, 8-dihydro-8-oxoguanine (8-oxoG) whose excision repair is performed by 8-oxoguanine glycosylase (OGG1). We investigated OGG1 expression changes in fetal membranes from spontaneous preterm birth (PTB) and preterm premature rupture of the membranes (pPROM) and its changes in vitro in normal fetal membranes exposed to OS inducer water-soluble cigarette smoke extract (CSE).

METHOD OF STUDY

DNA damage was determined in amnion cells treated with CSE by comet and FLARE assays. OGG1 mRNA expression and localization in fetal membranes from clinical specimens and in normal term membranes exposed to CSE were examined by QRT-PCR and by immunohistochemistry.

RESULTS

DNA strand and base damage was seen in amnion cells exposed to CSE. OGG1 expression was 2.5-fold higher in PTB samples compared with pPROM (P = 0.045). No significant difference was seen between term and pPROM or PTB and term. CSE treatment showed a nonsignificant decrease in OGG1. OGG1 was localized to both amnion and chorion with less intense staining in pPROM and CSE-treated membranes.

CONCLUSION

Increased OS-induced DNA damage predominated by 8-oxoG is likely to persist in fetal cells due to reduced availability of base excision repair enzyme OGG1. This can likely lead to fetal cell senescence associated with some adverse pregnancy outcome.