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Bergeson K, Prasad S. PURLs: Deliver or wait with late preterm membrane rupture? THE JOURNAL OF FAMILY PRACTICE 2016; 65:820-822. [PMID: 28087870 PMCID: PMC5117834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
While ACOG recommends delivery for all women with ruptured membranes after 34 weeks' gestation, a new study finds expectant management may be the way to go.
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Abstract
BACKGROUND Preterm prelabour rupture of the membranes (PPROM) complicates approximately 2% of pregnancies and can be either spontaneous or iatrogenic in nature. Complications of PPROM include prematurity, chorioamnionitis, neonatal sepsis, limb position defects, respiratory distress syndrome, pulmonary hypoplasia chronic lung disease, periventricular leukomalacia and intraventricular haemorrhage.A number of different sealing techniques have been employed which aim to restore a physical barrier against infection and encourage the re-accumulation of amniotic fluid. Routine use of sealants is currently not recommended due to a lack of sufficient evidence to support the safety and effectiveness of such interventions. OBJECTIVES To assess the effects of sealing techniques following PPROM against each other, or versus standard care (including no sealant), on maternal and neonatal outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing different techniques for sealing preterm prelabour ruptured membranes. Cluster-randomised trials and trials using a cross-over design were not eligible for inclusion in this review. We planned to include abstracts when sufficient information was provided. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS We included two studies (involving 141 women - with data from 124 women). We considered both studies as being at high risk of bias. Meta-analysis was not possible because the included studies examined different interventions (both in comparison with standard care) and reported on few, but different, outcomes. One study compared cervical adapter (mechanical sealing), and the other study examined an immunological membrane sealant. Neither of the included studies reported on this review's primary outcome of interest - perinatal mortality. Similarly, data were not reported for the majority of this review's secondary infant and maternal outcomes. Cervical adapter (mechanical sealing) versus standard care (one study, data from 35 participants)No data were reported for this review's primary outcome - perinatal mortality. Data were reported for few of this review's infant or maternal secondary outcomes.There was no clear difference between the mechanical sealing group and the standard care control in relation to the incidence of neonatal sepsis (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.28 to 5.09 (very low-quality evidence)) or chorioamnionitis (RR 1.19, 95% CI 0.28 to 5.09 (very low-quality evidence)). Oral immunological membrane sealant versus standard care (one study, data from 94 participants)No data were available for perinatal mortality (this review's primary outcome) or for the majority of this review's infant and maternal secondary outcomes. Compared to standard care, the immunological membrane sealant was associated with a reduction in preterm birth less than 37 weeks (RR 0.48, 95% CI 0.34 to 0.68 (very low-quality evidence)) and a reduction in neonatal death (RR 0.38, 95% CI 0.19 to 0.75 (very low-quality evidence)). However, there was no clear difference between groups in terms of neonatal sepsis (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)) or respiratory distress syndrome (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)). AUTHORS' CONCLUSIONS There is insufficient evidence to evaluate sealing procedures for PPROM. There were no data relating to this review's primary outcome (perinatal mortality) and the majority of our infant and maternal secondary outcomes were not reported in the two included studies.There was limited evidence to suggest that an immunological membrane sealant was associated with a reduction in preterm birth at less than 37 weeks and neonatal death, but these results should be interpreted with caution as this is based on one small study, with a high risk of bias, and the intervention has not been tested in other studies.Although midtrimester PPROM is not a rare occurrence, there are only a small amount of published data addressing the benefits and risks of sealing procedures. Most of these studies are retrospective and cohort based and could therefore not be included in our data-analysis.This review highlights the paucity of prospective randomised trials in this area. Current evidence provides limited information both on effectiveness and safety for the interventions described. Given the paucity of high-quality data, we recommend that future research efforts focus on the conduct of randomised trials assessing the effect of promising interventions that have been only evaluated to date in cohort studies (e.g. amniopatch). Future trials should address outcomes including perinatal mortality, preterm birth, neonatal death, respiratory distress syndrome, neonatal sepsis and developmental delay. They should also evaluate maternal outcomes including sepsis, mode of delivery, length of hospital stay and emotional well-being.
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Ruptured Membranes: When the Bag of Water Breaks. J Midwifery Womens Health 2016; 61:545-6. [PMID: 27305653 DOI: 10.1111/jmwh.12509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 05/24/2016] [Indexed: 11/29/2022]
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Morris JM, Roberts CL, Algert CS, Thornton JG. Expectant management in pregnancies with ruptured membranes - Authors' reply. Lancet 2016; 387:1996-7. [PMID: 27203768 DOI: 10.1016/s0140-6736(16)30367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Milosevic I, Hartley P, Dale A, Drysdale H, Goldacre B. Expectant management in pregnancies with ruptured membranes. Lancet 2016; 387:1996. [PMID: 27203769 DOI: 10.1016/s0140-6736(16)30462-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lorain P, Laas E, Girard G. [Premature rupture of membranes between 34 et 36+6weeks: How to manage?]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2016; 44:248-249. [PMID: 27053040 DOI: 10.1016/j.gyobfe.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 06/05/2023]
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Sahibzadi Hingoro SA, Rizwan N, Qazi RA. Maternal outcome of early intervention in women with prom at term (37 weeks or more). J PAK MED ASSOC 2016; 66:334-336. [PMID: 26968288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Pre-labour rupture of membranes (PROM) is associated with complications as increase in the rate of induction of labour, foetal distress, foetal and maternal infection, and caesarean section. The objective of this case series was to determine the maternal outcome of early intervention with prostaglandin E2 in women with PROM at term in a Tertiary Care Hospital. The study period was six months from 2nd July 2014 to 1st January 2015. A total of 183 women with spontaneous PROM were selected. Detailed history was taken and clinical examination was performed. Prostaglandins 3mg tablet was kept in the posterior fornix of the vagina, which was repeated 6 hours later. The average age of the patients was 27.68±1.19 years. Chorioamniotis was observed in 2.19% (4/183) women and caesarean section in 8.2% (15/183) cases. It was concluded that Vaginal PGE2 tablet was very effective for labour induction in patients with PROM at term.
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Morris JM, Roberts CL, Bowen JR, Patterson JA, Bond DM, Algert CS, Thornton JG, Crowther CA. Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial. Lancet 2016; 387:444-52. [PMID: 26564381 DOI: 10.1016/s0140-6736(15)00724-2] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. METHODS The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. FINDINGS Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). INTERPRETATION In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. FUNDING Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.
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Dumitrescu B, Axelsson O, Strand R. [Bed rest when the water breaks early--in accordance with the evidence or old habit?]. LAKARTIDNINGEN 2015; 112:DHZM. [PMID: 26241811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Bed rest is often prescribed as part of the treatment plan for women with preterm premature rupture of membranes in the hope of avoid-ing premature birth. The purpose of this study was to determine the routine care of these patients in Swedish hospitals.A survey was sent to all hospitals in Sweden with an obstetrics department (n=45). Out of these, 31 answered our survey (69 %). The women were separated into three groups depending on gestation length (22+0-26+6, 27+0-32+6 and 33+0-36+6).Most hospitals chose to admit the women and to recommend total or partial bed rest. The earlier in the pregnancy the rupture occurred, the more likely the patient was to be confined to total bed rest.The study shows that this topic is controversial. Most hospitals use bed rest even though there is no evidence to support that it is of benefit for the patient. More studies in this area are required in order to find an optimal treatment for this patient group.
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McKenzie F, Tucker Edmonds B. Offering induction of labor for 22-week premature rupture of membranes: a survey of obstetricians. J Perinatol 2015; 35:553-7. [PMID: 25927269 PMCID: PMC4754108 DOI: 10.1038/jp.2015.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/16/2015] [Accepted: 03/13/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To describe obstetricians' induction counseling practices for 22-week preterm premature rupture of membranes (PPROM) and identify provider characteristics associated with offering induction. METHODS Surveyed 295 obstetricians on their likelihood (0-10) of offering induction for periviable PPROM across 10 vignettes. Twenty-two-week vignettes were analyzed, stratified by parental resuscitation preference. Bivariate analyses identified physician characteristics associated with reported likelihood ratings. RESULTS Obstetricians (N=205) were not likely to offer induction. Median ratings by preference were as follows: resuscitation 1.0, uncertain 1.0 and comfort care 3.0. Only 41% of obstetricians were likely to offer induction to patients desiring comfort care. In addition, several provider-level factors, including practice region, parenting status and years in practice, were significantly associated with offering induction. CONCLUSIONS Obstetricians do not readily offer induction when counseling patients with 22-week ruptured membranes, even when patients prefer palliation. This may place women at risk for infectious complications without accruing a neonatal benefit from prolonged latency.
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Wong LF, Holmgren CM, Silver RM, Varner MW, Manuck TA. Outcomes of expectantly managed pregnancies with multiple gestations and preterm premature rupture of membranes prior to 26 weeks. Am J Obstet Gynecol 2015; 212:215.e1-9. [PMID: 25218125 PMCID: PMC4312545 DOI: 10.1016/j.ajog.2014.09.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/22/2014] [Accepted: 09/03/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the study was to determine the obstetric and neonatal outcomes of expectantly managed multifetal pregnancies complicated by early preterm premature rupture of membranes (PPROM) prior to 26 weeks. STUDY DESIGN This was a retrospective cohort of all multifetal pregnancies complicated by documented PPROM occurring before 26 0/7 weeks and managed expectantly by a single maternal-fetal medicine practice between July 4, 2002, and Sept. 1, 2013. Neonatal and maternal outcomes were assessed and comparisons made between the fetus with ruptured membranes and the first fetus to deliver with intact membranes. RESULTS Twenty-three pregnancies (46 fetuses) were analyzed with a median gestational age at PPROM of 22.9 weeks; 74% experienced PPROM at less than 24 weeks' gestation. A median latency of 11 days was achieved with expectant management. Of the 46 neonates, 20 (43%) survived to hospital discharge. Of these, 12 (60%) experienced severe neonatal morbidity defined as defined as grade III or IV intraventricular hemorrhage, bronchopulmonary dysplasia, pulmonary hypoplasia, necrotizing enterocolitis requiring surgical intervention, and/or grade 3 or 4 retinopathy of prematurity. Eight neonates survived to hospital discharge without severe neonatal morbidity. The multiple with ruptured membranes was more likely to experience intrauterine demise but otherwise had similar outcomes as the multiple with intact membranes. Maternal morbidity was considerable, with 7 of 23 pregnancies (30%) complicated by clinical chorioamnionitis, 12 of 23 (52%) delivering by cesarean, of which 3 of 12 (25%) were classical cesarean deliveries. CONCLUSION Overall, neonatal survival to hospital discharge was 43%, but only 17% survived without significant neonatal morbidity. These data provide a basis for counseling and management of women with multifetal gestation complicated by very early PPROM.
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MESH Headings
- Abnormalities, Multiple
- Adult
- Bronchopulmonary Dysplasia
- Cerebral Hemorrhage
- Cesarean Section
- Chorioamnionitis
- Disease Management
- Enterocolitis, Necrotizing
- Female
- Fetal Membranes, Premature Rupture/therapy
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases
- Lung/abnormalities
- Lung Diseases
- Pregnancy
- Pregnancy Outcome
- Pregnancy Trimester, Second
- Pregnancy, Quadruplet
- Pregnancy, Twin
- Retinopathy of Prematurity
- Retrospective Studies
- Watchful Waiting
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Ulkumen BA, Pala HG, Baytur YB, Koyuncu FM. Outcomes and management strategies in pregnancies with early onset oligohydramnios. CLIN EXP OBSTET GYN 2015; 42:355-357. [PMID: 26152010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the outcomes and management options in pregnancies with early onset oligohydramnios. MATERIALS AND METHODS The file datas of all pregnancies diagnosed as oligohydramnios or anhydramnios before 27 gestational weeks between January 2006 and September 2013 were evaluated retrospectively. The underlying pathology and associated anomalies, karyotype analysis, the outcome of the pregnancy (either termination or labour), and gestational week at the time of diagnosis were analyzed. RESULTS A total of 54 pregnancies were evaluated; mean gestational week at the time of the diagnosis was 19.8 ± 4.6. Mean maternal age was 27.28 ± 6.03. Thirty-seven pregnancies were anhydramniotic, 13 fetuses had associated anomalies, five of them had multicyctic dysplastic kidney, five had bilateral renal agenesis, one had hypoplastic right heart syndrome, one had clubfoot, and one had ventricular septal defect and cleft palate. Karyotyping was normal regarding the fetuses with structural anomalies. Nineteen patients had premature preterm rupture of membranes and 39 patients had termination of pregnancy. CONCLUSION The prognosis of early onset oligohydramnios is poor. Main determinant is gestational week at the time of the diagnosis.
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[Diagnosis and treatment of premature rupture of membrane]. ZHONGHUA FU CHAN KE ZA ZHI 2015; 50:3-8. [PMID: 25877416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Torricelli M, Vannuccini S, Moncini I, Cannoni A, Voltolini C, Conti N, Di Tommaso M, Severi FM, Petraglia F. Anterior placental location influences onset and progress of labor and postpartum outcome. Placenta 2014; 36:463-6. [PMID: 25573094 DOI: 10.1016/j.placenta.2014.12.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of the study is to evaluate whether placental location at term is associated with delivery outcome. METHODS A prospective study including 2354 patients with singleton pregnancy at term admitted for vaginal delivery was conducted. Placental position was determined before delivery by ultrasonographic examination performed transabdominally with women in the supine position. Maternal characteristics and delivery outcome such as premature rupture of membranes, induction of labor, mode and gestational age at delivery, indication for cesarean section, duration of the third stage, postpartum hemorrhage (PPH) and manual removal of placenta were correlated with anterior, posterior or fundal placental locations. RESULTS Among women enrolled: i) 1164 had an anterior placenta, ii) 1087 a posterior placenta, iii) 103 a fundal placenta. Women with anterior placenta showed: i) a higher incidence of induction of labor (p = 0.0001), especially for postdate pregnancies and prolonged prelabor rupture of membranes (p < 0.0001), ii) a higher rate of cesarean section rate for failure to progress in labor (p = 0.02), iii) a prolonged third stage (p = 0.01), iv) a higher incidence of manual removal of placenta (p = 0.003) and a higher rate of PPH in vaginal deliveries (p = 0.02). DISCUSSION The present study showed the influence of anterior placental location on the course of labor, with a later onset of labor, a higher rate of induction and cesarean section and postpartum complications. The reason for this influence on labor and delivery complications remains to be elucidated.
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MESH Headings
- Adult
- Cesarean Section/adverse effects
- Female
- Fetal Membranes, Premature Rupture/epidemiology
- Fetal Membranes, Premature Rupture/etiology
- Fetal Membranes, Premature Rupture/therapy
- Gestational Age
- Hospitals, University
- Humans
- Incidence
- Italy/epidemiology
- Labor, Induced/adverse effects
- Obstetric Labor Complications/epidemiology
- Obstetric Labor Complications/etiology
- Obstetric Labor Complications/therapy
- Placenta/diagnostic imaging
- Postpartum Hemorrhage/epidemiology
- Postpartum Hemorrhage/etiology
- Postpartum Hemorrhage/therapy
- Pregnancy
- Pregnancy Outcome
- Pregnancy, Angular/diagnostic imaging
- Pregnancy, Angular/physiopathology
- Pregnancy, Angular/therapy
- Pregnancy, Prolonged/epidemiology
- Pregnancy, Prolonged/etiology
- Pregnancy, Prolonged/therapy
- Prospective Studies
- Ultrasonography, Prenatal
- Young Adult
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Galyean A, Garite TJ, Maurel K, Abril D, Adair CD, Browne P, Combs CA, How H, Iriye BK, Kominiarek M, Lu G, Luthy D, Miller H, Nageotte M, Ozcan T, Porto M, Ramirez M, Sawai S, Sorokin Y. Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial. Am J Obstet Gynecol 2014; 211:399.e1-7. [PMID: 24726507 DOI: 10.1016/j.ajog.2014.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 03/18/2014] [Accepted: 04/07/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The decision of whether to retain or remove a previously placed cervical cerclage in women who subsequently rupture fetal membranes in a premature gestation is controversial and all studies to date are retrospective. We performed a multicenter randomized controlled trial of removal vs retention of cerclage in these patients to determine whether leaving the cerclage in place prolonged gestation and/or increased the risk of maternal or fetal infection. STUDY DESIGN A prospective randomized multicenter trial of 27 hospitals was performed. Patients included were those with cerclage placement at ≤23 weeks 6 days in singleton or twin pregnancies, with subsequent spontaneous rupture of membranes between 22 weeks 0 days and 32 weeks 6 days. Patients were randomized to retention or removal of cerclage. Patients were then expectantly managed and delivered only for evidence of labor, chorioamnionitis, fetal distress, or other medical or obstetrical indications. Management after 34 weeks was at the clinician's discretion. RESULTS The initial sample size calculation determined that a total of 142 patients should be included but after a second interim analysis, futility calculations determined that the conditional power for showing statistical significance after randomizing 142 patients for the primary outcome of prolonging pregnancy was 22.8%. Thus the study was terminated after a total of 56 subjects were randomized with complete data available for analysis, 32 to removal and 24 to retention of cerclage. There was no statistical significance in primary outcome of prolonging pregnancy by 1 week comparing the 2 groups (removal 18/32, 56.3%; retention 11/24, 45.8%) P = .59; or chorioamnionitis (removal 8/32, 25.0%; retention 10/24, 41.7%) P = .25, respectively. There was no statistical difference in composite neonatal outcomes (removal 16/33, 50%; retention 17/30, 56%), fetal/neonatal death (removal 4/33, 12%; retention 5/30, 16%); or gestational age at delivery (removal mean 200 days; retention mean 198 days). CONCLUSION Statistically significant differences were not seen in prolongation of latency, infection, or composite neonatal outcomes. However, there was a numerical trend in the direction of less infectious morbidity, with immediate removal of cerclage. These findings may not have met statistical significance if the original sample size of 142 was obtained, however they provide valuable data suggesting that there may be no advantage to retaining a cerclage after preterm premature rupture of membranes and a possibility of increased infection with cerclage retention.
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Sirak B, Mesfin E. MATERNAL AND PERINATAL OUTCOME OF PREGNANCIES WITH PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM) AT TIKUR ANBESSA SPECIALIZED TEACHING HOSPITAL, ADDIS ABABA, ETHIOPIA. ETHIOPIAN MEDICAL JOURNAL 2014; 52:165-172. [PMID: 26410989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Preterm premature rupture of membranes is a common complication of pregnancy associated with significant maternal, fetal and neonatal risks. An understanding of its magnitude and consequences is critical in providing appropriate intervention to prevent poor pregnancy outcomes. OBJECTIVE To describe maternal and perinatal outcomes of preterm premature rupture of membranes at Tikur Anbessa Hospital, Addis Ababa, Ethiopia. METHODOLOGY A Retrospective cross-sectional descriptive study done at Tikur Anbessa Hospital from June, 2010 G.C. to June, 2013 G.C. RESULTS The prevalence ofpreterm premature rupture of membranes in this study was 1.4%. Intra-amniotic infection, seen in 31.5% (35/111), was the commonest maternal complication. The mean latency period from rupture of membranes to delivery was 6.6 days. Twenty-six (23.2%) neonates were delivered by cesarean section. There were a total of 12 perinatal deaths, 4 (3.6%) stillbirths (2 antepartum and 2 itrapartum) and 8 (7.1%) early neonatal deaths, making the gross perinatal mortality rate to be 107 per 1000 live births. Prematurity was the commonest cause of neonatal death. CONCLUSION AND RECOMMENDATIONS Although the prevalence of preterm premature rupture of membranes in this study appears lower than many prior reports, the level of maternal and perinatal morbidity is high compared to many prior reports from similar setups. Especially the proportion of mothers presenting with established chorioamnionitis is high. Therefore, it is important that women be well informed regarding maternal, fetal and neonatal complications ofpremature rupture of membranes so that proper and timely management is provided.
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Fujiwara A, Fukushima K, Inoue H, Takashima T, Nakahara H, Satoh S, Ochiai M, Hara T, Shimokawa M, Kato K. Perinatal management of preterm premature ruptured membranes affects neonatal prognosis. J Perinat Med 2014; 42:499-505. [PMID: 24413214 DOI: 10.1515/jpm-2013-0192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 12/13/2013] [Indexed: 11/15/2022]
Abstract
AIM To determine the factors affecting neonatal prognosis in preterm premature rupture of membranes (PPROM). METHOD We conducted a case-control study involving 92 women between the years 2000 and 2010 diagnosed with PPROM between 25 and 31 weeks' gestation, who received antenatal steroids, and delivered between 26 and 31 weeks' gestation; a retrospective cohort study was conducted based on the results. We used data from four tertiary centers and compared the frequencies of neonatal neurologic deficits and neonatal deaths. RESULTS There was a difference between the two groups; specifically, the ND group (n=18) consisted of patients whose infants had neurologic deficits and/or neonatal deaths and the neurologically normal (NN) group (n=74) included NN neonates amongst the patients who had expectant management (94% vs. 73%, respectively). Multivariable analysis revealed that expectant management was independently associated with an increased risk for neonatal neurologic deficits and neonatal deaths (odds ratio, 16.14). All neonates with poor prognosis in the expectant-management group delivered within 14 days after PPROM. CONCLUSIONS Expectant management within 14 days after PPROM is associated with poor neonatal outcomes. Decisions regarding an expectant strategy should be made carefully. An immediate, planned delivery after steroid administration should be considered to improve neonatal prognosis in patients who have PPROM after 26 weeks' gestation.
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Roberts D, Vause S, Martin W, Green P, Walkinshaw S, Bricker L, Beardsmore C, Shaw N, McKay A, Skotny G, Williamson P, Alfirevic Z. Amnioinfusion in very early preterm prelabor rupture of membranes (AMIPROM): pregnancy, neonatal and maternal outcomes in a randomized controlled pilot study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:490-499. [PMID: 24265189 DOI: 10.1002/uog.13258] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/03/2013] [Accepted: 11/07/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To assess short- and long-term outcomes of pregnant women with very early rupture of membranes randomized to serial amnioinfusion or expectant management, and to collect data to inform a larger, more definitive clinical trial. METHODS This was a prospective non-blinded randomized controlled trial with randomization stratified for pregnancies in which the membranes ruptured between 16 + 0 and 19 + 6 weeks' gestation and 20 + 0 and 23 + 6 weeks' gestation to minimize the risk of random imbalance in gestational age distribution between randomized groups. Intention-to-treat analysis was used. The study was conducted in four UK hospital-based fetal medicine units (Liverpool Women's NHS Trust, St Mary's Hospital Manchester, Birmingham Women's NHS Foundation Trust and Wirral University Hospitals Trust). The participants were women with confirmed preterm prelabor rupture of membranes at 16 + 0 to 24 + 0 weeks' gestation. Women with multiple pregnancy, fetal abnormality or obstetric indication for immediate delivery were excluded. Participants were randomly allocated to either serial weekly transabdominal amnioinfusions if the deepest pool of amniotic fluid was < 2 cm or expectant management until 37 weeks' gestation. Short-term maternal, pregnancy and neonatal and long-term outcomes for the child were studied. Long-term respiratory morbidity was assessed using validated respiratory questionnaires at 6, 12 and 18 months of age and infant lung function test at around 12 months of age. Neurodevelopment was assessed using the Bayley Scales of Infant Development, second edition (BSID-II) at corrected age of 2 years. RESULTS Fifty-eight women were randomized to the study. Two babies were excluded from the analysis because of termination of pregnancy for lethal anomaly, leaving 56 participants (28 assigned to serial amnioinfusion and 28 to expectant management) recruited between 2002 and 2009. There was no significant difference in perinatal mortality (19/28 vs 19/28; relative risk (RR) 1.0 (95% CI, 0.70-1.43)) and maternal or neonatal morbidity. The overall chance of surviving without long-term respiratory or neurodevelopmental disability was 4/56 (7.1%); 4/28 (14.3%) in the amnioinfusion group and 0/28 in the expectant group (RR 9.0 (95% CI, 0.51-159.70)). CONCLUSIONS This pilot study found no major differences in maternal, perinatal or pregnancy outcomes. The study was not designed to show a difference between the groups and the number of survivors was too small to draw any conclusions about long-term outcomes. It does, however, signal that a larger definitive study to evaluate amnioinfusion for improvement in healthy survival is needed. The pilot suggests that, with appropriate funding, such a study is feasible.
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Makrydimas G. Re: Amnioinfusion in very early preterm prelabor rupture of membranes (AMIPROM): pregnancy, neonatal and maternal outcomes in a randomized controlled pilot study. D. Roberts, S. Vause, W. Martin, P. Green, S. Walkinshaw, L. Bricker, C. Beardsmore, N. Shaw, A. McKay, G. Skotny, P. Williamson and Z. Alfirevic. Ultrasound Obstet Gynecol 2014; 43: 490-499. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:488. [PMID: 24789305 DOI: 10.1002/uog.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Abou El Senoun G, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation. Cochrane Database Syst Rev 2014; 2014:CD008053. [PMID: 24729384 PMCID: PMC11008104 DOI: 10.1002/14651858.cd008053.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established. OBJECTIVES To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and the reference lists of all the identified articles. SELECTION CRITERIA Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction. MAIN RESULTS We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05). There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is moderate heterogeneity for this outcome (I² = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs. AUTHORS' CONCLUSIONS The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.
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Hofmeyr GJ, Eke AC, Lawrie TA. Amnioinfusion for third trimester preterm premature rupture of membranes. Cochrane Database Syst Rev 2014; 2014:CD000942. [PMID: 24683009 PMCID: PMC7061243 DOI: 10.1002/14651858.cd000942.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Preterm premature rupture of membranes (PPROM) is a leading cause of perinatal morbidity and mortality. Amnioinfusion aims to restore amniotic fluid volume by infusing a solution into the uterine cavity. OBJECTIVES The objective of this review was to assess the effects of amnioinfusion for PPROM on perinatal and maternal morbidity and mortality. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 December 2013). SELECTION CRITERIA Randomised trials of amnioinfusion compared with no amnioinfusion in women with PPROM. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy. MAIN RESULTS We included five trials, of moderate quality, but we only analysed data from four studies (with a total of 241 participants). One trial did not contribute any data to the review.Transcervical amnioinfusion improved fetal umbilical artery pH at delivery (mean difference 0.11; 95% confidence interval (CI) 0.08 to 0.14; one trial, 61 participants) and reduced persistent variable decelerations during labour (risk ratio (RR) 0.52; 95% CI 0.30 to 0.91; one trial, 86 participants).Transabdominal amnioinfusion was associated with a reduction in neonatal death (RR 0.30; 95% CI 0.14 to 0.66; two trials, 94 participants), neonatal sepsis (RR 0.26; 95% CI 0.11 to 0.61; one trial, 60 participants), pulmonary hypoplasia (RR 0.22; 95% CI 0.06 to 0.88; one trial, 34 participants) and puerperal sepsis (RR 0.20; 95% CI 0.05 to 0.84; one trial, 60 participants). Women in the amnioinfusion group were also less likely to deliver within seven days of membrane rupture (RR 0.18; 95% CI 0.05 to 0.70; one trial, 34 participants). These results should be treated with circumspection as the positive findings were mainly due to one trial with unclear allocation concealment. AUTHORS' CONCLUSIONS These results are encouraging but are limited by the sparse data and unclear methodological robustness, therefore further evidence is required before amnioinfusion for PPROM can be recommended for routine clinical practice.
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Kamper CH, Hvidman L, Helmig RB. [Implementation of new guidelines for management of prelabour rupture of membranes did not have the desired effect]. Ugeskr Laeger 2014; 176:250-253. [PMID: 24629755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Many resources are used in developing guidelines for the treatment and handling of different diseases and clinical situations. It is important to evaluate the effect of these guidelines; are they being followed and do they have the desired impact on patient care? This report describes a quality control evaluation of whether the implementation of a new PROM (prelabour rupture of membranes) management guideline at Department Y at the Aarhus University Hospital had the wanted effect on the length of labour, use of prophylactic antibiotics, frequency of neonatal admission and neonatal infection.
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Engels AC, Van Calster B, Richter J, DeKoninck P, Lewi L, De Catte L, Devlieger R, Deprest JA. Collagen plug sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:54-59. [PMID: 23801588 DOI: 10.1002/uog.12547] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To investigate the efficacy of collagen plugs at reducing the risk of preterm premature rupture of membranes (PPROM) after fetoscopic surgery for congenital diaphragmatic hernia (CDH). METHODS This was a single-center cohort study on all consecutive cases undergoing fetoscopic endoluminal tracheal occlusion (FETO) for severe or moderate CDH, between April 2002 and May 2011 (n = 141). Cases either received a collagen plug for sealing the fetal membrane defect after FETO or did not, depending on the operating surgeon. The principal outcome measure was the time from fetal surgery to PPROM, further referred to as 'latency'. A multivariable Cox regression model was used to investigate the association between collagen plug and latency while adjusting for risk factors for PPROM. RESULTS Of the 141 cases, 54 (38%) received a collagen plug and 87 (62%) did not. Sixty cases experienced PPROM, 26 among cases with and 34 among cases without a plug (48 vs 39%). The hazard ratio of plug use was 1.29 (95% CI, 0.76-2.19), which does not exclude a potentially increased risk for PPROM when a collagen plug is used. For cases with a plug, 24% had PPROM before balloon removal and 24% had PPROM after elective balloon removal. For cases without a plug, these rates were 30 and 9%, respectively. Perinatal outcomes were similar in both groups. CONCLUSIONS No evidence was found that collagen plugs reduce the risk of PPROM after FETO for CDH.
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