Antibiotics for preterm rupture of membranes

Assessing the applicability of obstetrical randomized controlled trials in real-world practices

This article examines the applicability of obstetrical randomized controlled trials (RCTs) in the real-world and proposes a classification of the value of these trials based on their potential for achieving sustainable practices. In the context of this discussion, real-world results pertain to the potential impact of the RCT on sustainable interventions and practices, and its implications for healthcare practice or policy, in the country (or countries) that was conducted. While RCTs are generally regarded as the gold standard of medical evidence, their effectiveness in producing meaningful real-world results depends, among various other factors, on the clarity and specificity of the trial definitions used for diagnosis (characteristics of the study group or enrollment criteria) and treatment (intervention). The definitions used for diagnosis and treatment, especially in pragmatic trials, can influence the likelihood for real-world implementation. By analyzing notable obstetrical RCTs, the authors find that trials with well-defined diagnoses and treatments that can be implemented without specialized expertise are more likely to generate results that are relevant to general practice, indicating higher value. In contrast, RCTs with ambiguous or undefined diagnoses and treatments often lead to variations in practice and produce unreliable real-world outcomes and practices suggesting lower value. Recognizing this variability can offer valuable guidance for the design and evaluation of RCTs in obstetrics.

Extreme prematurity: Factors associated with perinatal management and morbi-mortality in western Normandy, France

BACKGROUND

Extreme prematurity (birth before 26 weeks of gestation), presents complex challenges and can lead to various complications. Survival rates of extremely preterm infants are lower in France than in other countries. The choice between active and palliative care is decisive in managing these births.

OBJECTIVE

To conduct an observational study focused on factors associated with perinatal management, mortality, and morbidity outcomes among extremely preterm births in a regional perinatal network.

METHODS

We undertook a retrospective, multicenter study within the western Normandy perinatal network, encompassing live births between 230/6 and 256/6 weeks from 2015 to 2019. Data were extracted from the perinatal network database and medical records.

RESULTS

One hundred and seven infants born from 94 women were included. In the antenatal period, 79 were exposed to corticosteroids, 66 to magnesium sulfate, and 67 to antibiotics. Active care at birth was provided to 84 neonates of whom 42 survived. In total, 65 infants died. Among the 42 surviving neonates, 9 experienced no severe morbidity, 29 displayed one and 4 exhibited two criteria of severe morbidity. Active care was associated with gestational age. Neonatal survival was correlated with antenatal exposure to antibiotics and magnesium sulfate as well as with postnatal corticosteroids. We found no significant association between mortality and gestational age at birth.

CONCLUSION

Prognostic factors must be weighed to discuss active antenatal care which is crucial for survival of extremely preterm neonates. Cooperation between obstetricians and neonatal caregivers is a cornerstone on a regional perinatal network scale.

Predictive value of serum inflammatory markers for histological chorioamnionitis among women with preterm premature rupture of membranes after undergoing cervical cerclage

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.

The eNAMPT/TLR4 inflammatory cascade drives the severity of intra-amniotic inflammation in pregnancy and predicts infant outcomes

Introduction: Intra-amniotic inflammation (IAI) or chorioamnionitis is a common complication of pregnancy producing significant maternal morbidity/mortality, premature birth and neonatal risk of chronic lung diseases such as bronchopulmonary dysplasia (BPD). We examined eNAMPT (extracellular nicotinamide phosphoribosyltransferase), a critical inflammatory DAMP and TLR4 ligand, as a potential therapeutic target to reduce IAI severity and improve adverse fetal/neonatal outcomes. Methods: Blood/tissue samples were examined in: 1) women with histologically-proven chorioamnionitis, 2) very low birth weight (VLBW) neonates, and 3) a preclinical murine pregnancy model of IAI. Groups of pregnant IAI-exposed mice and pups were treated with an eNAMPT-neutralizing mAb. Results: Human placentas from women with histologically-proven chorioamnionitis exhibited dramatic NAMPT expression compared to placentas without chorioamnionitis. Increased NAMPT expression in whole blood from VLBW neonates (day 5) significantly predicted BPD development. Compared to untreated LPS-challenged murine dams (gestational day 15), pups born to eNAMPT mAb-treated dams (gestational days 15/16) exhibited a > 3-fold improved survival, reduced neonate lung eNAMPT/cytokine levels, and reduced development and severity of BPD and pulmonary hypertension (PH) following postnatal exposure to 100% hyperoxia days 1-14. Genome-wide gene expression studies of maternal uterine and neonatal cardiac tissues corroborated eNAMPT mAb-induced reductions in inflammatory pathway genes. Discussion: The eNAMPT/TLR4 inflammatory pathway is a highly druggable contributor to IAI pathobiology during pregnancy with the eNAMPT-neutralizing mAb a novel therapeutic strategy to decrease premature delivery and improve short- and long-term neonatal outcomes. eNAMPT blood expression is a potential biomarker for early prediction of chronic lung disease among premature neonates.

Daily monitoring of vaginal interleukin 6 as a predictor of intraamniotic inflammation after preterm premature rupture of membranes - a new method of sampling studied in a prospective multicenter trial

OBJECTIVES

(A) To introduce a new technique for vaginal fluid sampling (biocompatible synthetic fiber sponge) and (B) evaluate the collected vaginal fluid interleukine-6 (IL-6_vag)-concentration as a new diagnostic tool for daily monitoring of intrauterine inflammation after preterm premature rupture of membranes (PPROM). Secondary objectives were to compare the potential to predict an intrauterine inflammation with established inflammation parameters (e.g., maternal white blood cell count).

METHODS

This prospective clinical case-control diagnostic accuracy multicenter study was performed with women after PPROM (gestational age 24.0/7 - 34.0/7 weeks). Sampling of vaginal fluid was performed once daily. IL-6_vag was determined by electrochemiluminescence-immunoassay-kit. Neonatal outcome and placental histology results were used to retrospectively allocate the cohort into two subgroups: 1) inflammation and 2) no inflammation (controls).

RESULTS

A total of 37 cases were included in the final analysis. (A): Measurement of IL-6 was successful in 86% of 172 vaginal fluid samples. (B): Median concentration of IL-6_vag in the last vaginal fluid sample before delivery was significantly higher within the inflammation group (17,085 pg/mL) compared to the controls (1,888 pg/mL; p=0.01). By Youden's index an optimal cut-off for prediction an intrauterine inflammation was: 6,417 pg/mL. Two days before delivery, in contrast to all other parameters IL-6_vag remained the only parameter with a sufficient AUC of 0.877, p<0.001, 95%CI [0.670-1.000].

CONCLUSIONS

This study established a new technique for vaginal fluid sampling, which permits assessment of IL-6_vag concentration noninvasively in clinical daily routine monitoring.

Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is an inflammatory disease affecting premature infants. Intestinal microbial composition may play a key role in determining which infants are predisposed to NEC and when infants are at highest risk of developing NEC. It is unclear how to optimize antibiotic therapy in preterm infants to prevent NEC and how to optimize antibiotic regimens to treat neonates with NEC. This article discusses risk factors for NEC, how dysbiosis in preterm infants plays a role in the pathogenesis of NEC, and how probiotic and antibiotic therapy may be used to prevent and/or treat NEC and its sequelae.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Maternal serum procalcitonin levels in prediction of chorioamnionitis in women with preterm premature rupture of membranes

INTRODUCTION

Chorioamnionitis is one of the most important maternal complications in the expectant management of patients with preterm premature rupture of membranes (PPROM). Procalcitonin (proCT), the precursor of the hormone calcitonin, is used to differentiate bacterial infections from non-bacterial ones. The objective of the study was to determine the efficacy of maternal serum procalcitonin levels in the early prediction of chorioamnionitis in women with PPROM.

MATERIAL AND METHODS

The study was conducted in 76 pregnant women hospitalized due to PPROM at the maternal-fetal medicine unit of a tertiary center in Istanbul. Patients were followed up with white blood cell (WBC), C-reactive protein (CRP) and proCT levels every 2 days. The values of investigated parameters were recorded at the diagnosis of PPROM and at the time of delivery. The maximum values during the follow-up period were also recorded.

RESULTS

Out of the 76 patients with PPROM, 15 (19.73%) developed clinical chorioamnionitis. No significant difference could be detected in the gravidity, parity, duration of hospitalization and gestational week at diagnosis between those patients who developed clinical chorioamnionitis and those who did not. The WBC at the time of hospital admittance and before delivery, and CRP levels before delivery were statistically higher in the chorioamnionitis group (p < 0.05). No difference in the proCT levels could be detected either at the time of hospital admittance or before delivery between the two groups.

CONCLUSIONS

Maternal proCT was not found to be predictive of chorioamnionitis. However, since there are reports in the literature that contradict these results, further studies are warranted to determine the true efficacy of proCT in the prediction of clinical chorioamnionitis.

Platelet indices as a predictive marker in neonatal sepsis and respiratory distress in preterm prelabor rupture of membranes

Preterm Prelabor rupture of membranes (PPROM) accompanies 2-3% of all pregnancies and 1/3rd of all preterm deliveries leading to intraamniotic infection, postpartum infections, sepsis along with perinatal morbidity and mortality worldwide. Early diagnosis and treatment can prevent the complications of PPROM and improve mother and child health. The platelet indices (platelet count, Mean platelet volume, Plateletcrit and Immature platelet fraction) could be a useful predictive parameters in PPROM, as platelets are acute phase reactants and there parameters may vary with inflammation and increased platelet consumption/production. In the present study, Mean Platelet volume (MPV) levels showed significant increase in cases as compared to controls (10.47 ± 1.92 fl Vs 8.84 ± 1.30 fl; P < 0.004). Plateletcrit (PCT) levels were also significantly increased in cases with respect to controls (0.22 ± 0.10% Vs 0.18 ± 0.05%; P = 0.004). Immature platelet fraction (IPF) is significantly increased in cases than in control subjects (8.73 ± 6.67% Vs 4.43 ± 1.75%; P < 0.001). Also, Mean Platelet volume (MPV) levels were found to be significantly higher in subjects whose neonate had developed sepsis(11.39 ± 1.69 fl Vs 8.91 ± 1.31 fl; P < 0.001) and respiratory distress (10.62 ± 2.09 fl Vs 9.26 ± 1.56 fl; P = 0.003). Similarly, PCT was significantly higher in groups with positive neonatal sepsis (0.32 ± 0.74% Vs 0.19 ± 0.65%; P = 0.010) and with respiratory distress (0.24 ± 0.78% Vs 0.18 ± 0.59%; P < 0.001). Levels of IPF were also increased in positive neonatal sepsis group (10.11 ± 6.27% Vs 5.06 ± 4.07%; P < 0.001) and respiratory distress group (9.11 ± 6.38% Vs 5.54 ± 4.43%; P = 0.009). The findings suggest that maternal platelet parameters (MPV, PCT and IPF) can be utilized as evidence of early predictors of development of neonatal sepsis and respiratory distress and may be considered as a predictive markers for adverse neonatal outcome.

Categorising interventions to levels of inpatient care for small and sick newborns: Findings from a global survey

Background

In 2017, 2.5 million newborns died, mainly from prematurity, infections, and intrapartum events. Preventing these deaths requires health systems to provide routine and emergency care at birth, and quality inpatient care for small and sick newborns. Defined levels of emergency obstetric care (EmOC) and standardised measurement of “signal functions” has improved tracking of maternal care in low- and middle-income countries (LMICs). Levels of newborn care, particularly for small and sick newborns, and associated signal functions are still not consistently defined or tracked.

Methods

Between November 2016-November 2017, we conducted an online survey of professionals working in maternal and newborn health. We asked respondents to categorise 18 clinical care interventions that could act as potential signal functions for small and sick newborns to 3 levels of care they thought were appropriate for health systems in LMICs to provide: “routine care at birth”, “special care” and “intensive care”. We calculated the percentage of respondents that classified each intervention at each level of care and stratified responses to look at variation by respondent characteristics.

Results

Six interventions were classified to specific levels by more than 50% of respondents as “routine care at birth,” three interventions as “special care” and one as “intensive care”. Eight interventions were borderline between these care levels. Responses were more consistent for interventions with relevant WHO clinical care guidelines while more variation in respondents’ classification was observed in complex interventions that lack standards or guidelines. Respondents with experience in lower-income settings were more likely to assign a higher level of care for more complex interventions.

Conclusions

Results were consistent with known challenges of scaling up inpatient care in lower-income settings and underline the importance of comprehensive guidelines and standards for inpatient care. Further work is needed to develop a shortlist of newborn signal functions aligned with emergency obstetric care levels to track universal health coverage for mothers and their newborns.

The Effect of Non-penicillin Antibiotic Regimens on Neonatal Outcomes in Preterm Premature Rupture of Membranes

Objective  A 7-day course of a penicillin (PCN) and macrolide is standard of care (SAR) in preterm premature rupture of membranes (PPROM). Data regarding alternative antibiotic regimens are limited. We sought to assess the impact of non-PCN regimens on neonatal outcomes. Study Design  Secondary analysis of randomized controlled trial of antenatal magnesium sulfate. Singleton, nonanomalous pregnancies complicated by PPROM at > 24 weeks of gestation receiving the SAR were compared with women receiving a non- β -lactam regimen and a macrolide (NPCR). Primary outcome was a neonatal composite. Secondary outcomes included pregnancy latency, endometritis, and chorioamnionitis. Results  A total of 949 women met inclusion criteria; 821(56%) received the SAR and 128(8.8%) received NPCR. Adjusted models did not demonstrate worse outcomes (AOR [adjusted odds ratio] = 0.50; 95% CI [confidence interval]: 0.22-1.11). Neonates receiving SAR were less likely to have bronchopulmonary dysplasia (BPD; p  = 0.03) but more likely to have severe necrotizing enterocolitis (sNEC; p  = 0.04). Risk for chorioamnionitis and median latency did not differ between groups but women receiving the SAR were less likely to get endometritis (AOR = 0.35; 95% CI: 0.14-0.91). Conclusions  In this cohort, receiving NPCR in the setting of PPROM did not impact the overall risk of adverse neonatal outcomes or latency, but did increase the risk of endometritis. Alterations in individual neonatal morbidities suggest follow-up studies are needed.

An extremely rare case of hand prolapse with preterm premature rupture in the membrane of one twin

The latency in preterm premature rupture of membranes (PPROM) can last for weeks. We describe an extremely rare case of hand prolapse with PPROM that was exposed for 23 days before delivery. The patient had spontaneous PPROM of twin A at 21.4 weeks of gestation with shoulder presentation. The right arm of the fetus eventually protruded out the vagina and the hand was exposed for extended period of time of 23 days until delivery. Daily dressing by applying collagen to dry skin and silicone to keep moisture was done to the protruding hand to prevent dehydration and desquamation of the skin. Prophylactic antibiotics were used and the patient underwent emergent cesarean section due to uncontrolled preterm labor at 25.2 weeks. To the best of our knowledge, this is the first case of hand prolapse of one twin with extended period of latency before delivery.

Genital tract GBS and rate of histologic chorioamnionitis in patients with preterm premature rupture of membrane

INTRODUCTION

Histologic chorioamnionitis (HC) is a common finding in the placenta from patients with preterm premature rupture of membranes (PPROM). The purpose of this study is to determine if HC differs based on the Group B streptococcus (GBS) status in patients managed expectantly with PPROM <34 weeks gestation.

METHODS

A retrospective study was performed of patients admitted with PPROM between 23 0/7 and 33 6/7 weeks from 2003 to 2014 at one institution. Patients were excluded if in labor, evidence of clinical chorioamnionitis, nonreassuring fetal status, multifetal gestation, HIV positive, or if GBS specimens or placental histology were not available. Placental pathology results were compared using Fisher's exact test.

RESULTS

One hundred eighty-one patients met inclusion criteria and 55 (30.3%) were GBS positive. The prevalence of HC did not differ between the GBS positive and GBS negative groups (69 versus 64.2%, respectively; p = .62). Clinical chorioamnionitis, endomyometritis, wound infection, maternal and neonatal sepsis did not differ between the two groups.

CONCLUSIONS

Vaginal-rectal colonization with GBS on admission does not appear to affect the rate of HC nor neonatal outcome in patients managed conservatively with PPROM <34 weeks gestation.

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

Objective:

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

Material and Methods:

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

Results:

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

Conclusion:

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

Pathogenesis of NEC: Role of the innate and adaptive immune response

Necrotizing enterocolitis (NEC) is a devastating disease in premature infants with high case fatality and significant morbidity among survivors. Immaturity of intestinal host defenses predisposes the premature infant gut to injury. An abnormal bacterial colonization pattern with a deficiency of commensal bacteria may lead to a further breakdown of these host defense mechanisms, predisposing the infant to NEC. Here, we review the role of the innate and adaptive immune system in the pathophysiology of NEC.

Evaluation of perinatal outcomes in pregnant women with preterm premature rupture of membranes

OBJECTIVE

To determine the association between amniotic fluid index (AFI) and perinatal outcomes in preterm premature rupture of membranes (PPROM).

METHOD

A retrospective cohort study was conducted between 2008 and 2012. 86 pregnant women were included, with a diagnosis of PPROM and gestational age from 24 to 35 weeks. Women who presented hypertensive disorders, diabetes, fetuses with birth defects and infection at admission were excluded. To determine the association between AFI and perinatal outcomes, chi-square and Fisher's exact test were used if necessary, as well as risk ratio (RR) and 95% confidence intervals (95CI). Correlation between AFI and perinatal outcomes was determined by using simple linear regression, and AFI progression during pregnancy was analyzed by Z-test.

RESULTS

When comparing newborns presenting ultrasound with AFI<5cm and AFI>5cm, there was a higher frequency of perinatal mortality when the AFI was lower than 5 cm. However, when the oligohydramnios was diagnosed as severe (AFI<3cm), there was a higher frequency of Apgar scores less than seven at 1 minute, neonatal sepsis and early neonatal mortality compared to those presenting AFI>3cm. There was a positive correlation between AFI and gestational age at delivery, birth weight and Apgar scores at minutes 1 and 5. There was also a decrease in amniotic fluid volume with increased gestational age.

CONCLUSION

The presence of severe oligohydramnios after PPROM contributed to a higher frequency of perinatal complications and death.

'First 1000 days' health interventions in low- and middle-income countries: alignment of South African policies with high-quality evidence

BACKGROUND

In South Africa (SA), despite adoption of international strategies and approaches, maternal, neonatal and child (MNC) morbidity and mortality rates have not sufficiently declined.

OBJECTIVES

To conduct an umbrella review (UR) that identifies interventions in low- and middle-income countries, with a high-quality evidence base, that improve MNC morbidity and mortality outcomes within the first 1000 days of life; and to assess the incorporation of the evidence into local strategies, guidelines and documents.

METHODS

We included publications about women and children in the first 1000 days of life; healthcare professionals and community members. Comparators were those who did not receive the intervention. Interventions were pharmacological and non-pharmacological. Outcomes were MNC morbidity and mortality. Authors conducted English language electronic and manual searches (2000-2013). The quality of systematic reviews and meta-analyses (SRs/MAs) were reviewed. Interventions were ranked according to level of evidence; and then aligned with SA strategies, policies and guidelines. A tool to extract data was developed and used by two authors who independently extracted data. Summary measures from MAs or summaries of SRs were reviewed and the specificities of the various interventions listed. A search of all local high-level documents was done and these were assessed to determine the specificities of the recommendations and their alignment to the evidence.

RESULTS

In total, 19 interventions presented in 32 SRs were identified. Overall, SA's policymakers have sufficiently included high-quality evidence-based interventions into local policies. However, optimal period of birth spacing (two to five years) is not explicitly promoted nor was ante- and postnatal depression adequately incorporated. Antenatal care visits should be increased from four to about eight according to the evidence.

CONCLUSION

Incorporation of existing evidence into policies can be strengthened in SA. The UR methods are useful to inform policymaking and identify research gaps. RESPONSIBLE EDITOR Nawi Ng, Umeå University, Sweden.

N-acetylcysteine attenuates lipopolysaccharide-induced impairment in lamination of Ctip2-and Tbr1- expressing cortical neurons in the developing rat fetal brain

Oxidative stress and inflammatory insults are the major instigating events of bacterial intrauterine infection that lead to fetal brain injury. The purpose of this study is to investigate the remedial effects of N-acetyl-cysteine (NAC) for inflammation-caused deficits in brain development. We found that lipopolysaccharide (LPS) induced reactive oxygen species (ROS) production by RAW264.7 cells. Macrophage-conditioned medium caused noticeable cortical cell damage, specifically in cortical neurons. LPS at 25 μg/kg caused more than 75% fetal loss in rats. An increase in fetal cortical thickness was noted in the LPS-treated group. In the enlarged fetal cortex, laminar positioning of the early born cortical cells expressing Tbr1 and Ctip2 was disrupted, with a scattered distribution. The effect was similar, but minor, in later born Satb2-expressing cortical cells. NAC protected against LPS-induced neuron toxicity in vitro and counteracted pregnancy loss and alterations in thickness and lamination of the neocortex in vivo. Fetal loss and abnormal fetal brain development were due to LPS-induced ROS production. NAC is an effective protective agent against LPS-induced damage. This finding highlights the key therapeutic impact of NAC in LPS-caused abnormal neuronal laminar distribution during brain development.

Impact of Prematurity and Perinatal Antibiotics on the Developing Intestinal Microbiota: A Functional Inference Study

BACKGROUND

The microbial colonization of the neonatal gut provides a critical stimulus for normal maturation and development. This process of early microbiota establishment, known to be affected by several factors, constitutes an important determinant for later health.

METHODS

We studied the establishment of the microbiota in preterm and full-term infants and the impact of perinatal antibiotics upon this process in premature babies. To this end, 16S rRNA gene sequence-based microbiota assessment was performed at phylum level and functional inference analyses were conducted. Moreover, the levels of the main intestinal microbial metabolites, the short-chain fatty acids (SCFA) acetate, propionate and butyrate, were measured by Gas-Chromatography Flame ionization/Mass spectrometry detection.

RESULTS

Prematurity affects microbiota composition at phylum level, leading to increases of Proteobacteria and reduction of other intestinal microorganisms. Perinatal antibiotic use further affected the microbiota of the preterm infant. These changes involved a concomitant alteration in the levels of intestinal SCFA. Moreover, functional inference analyses allowed for identifying metabolic pathways potentially affected by prematurity and perinatal antibiotics use.

CONCLUSION

A deficiency or delay in the establishment of normal microbiota function seems to be present in preterm infants. Perinatal antibiotic use, such as intrapartum prophylaxis, affected the early life microbiota establishment in preterm newborns, which may have consequences for later health.

An Algorithm for Predicting Neonatal Mortality in Threatened Very Preterm Birth

OBJECTIVE

To develop a prediction model for neonatal mortality using information readily available in the antenatal period.

METHODS

A multiple logistic regression model of a complete population-based geographically defined cohort of very preterm infants of 23+0 to 30+6 weeks' gestation was used to identify antenatal factors which were predictive of mortality in this population. Infants lt; 23 weeks and those with major anomalies were excluded.

RESULTS

Between 1996 and 2012, 1240 live born infants lt; 31 weeks' gestation were born to women residing in Nova Scotia. Decreasing gestational age strongly predicted an increased mortality rate. Other factors significantly contributing to increased mortality included classification as small for gestational age, oligohydramnios, maternal psychiatric disorders, antenatal antibiotic therapy, and monochorionic twins. Reduced neonatal mortality was associated with antenatal use of antihypertensive agents and use of corticosteroids of any duration of therapy given at least 24 hours before delivery. An algorithm was developed to estimate the risk of mortality without the need for a calculator.

CONCLUSION

Prediction of the probability of neonatal mortality is influenced by maternal and fetal factors. An algorithm to estimate the risk of mortality facilitates counselling and informs shared decision making regarding obstetric management.

A proposed bio-panel to predict risk for spontaneous preterm birth among African American women

Preterm birth (PTB), or birth prior to 37 weeks gestation, impacts 11.5% of U.S. deliveries. PTB results in significant morbidity and mortality among affected children and imposes a large societal financial burden. Racial disparities in PTB are alarming. African American women are at more than 1.5 times the risk for PTB than white women. Unfortunately, the medical community's ability to predict who is at risk for PTB is extremely limited. History of a prior PTB remains the strongest predictor during a singleton gestation. Cervical length and fetal fibronectin measurement are helpful tools. However, usefulness is limited, particularly among the 95% of U.S. women currently pregnant and lacking a history of PTB. Therefore, preventive therapies do not reach a great number of women who may benefit from them. This manuscript, in response to the pressing need for predictors of PTB risk and elimination of racial disparities in PTB, presents a proposed bio-panel for use in predicting risk for spontaneous PTB among African American women. This bio-panel, measured each trimester, includes stimulated production of interleukin (IL)-1β, tumor necrosis factor (TNF)-α, IL-1 receptor antagonist (Ra), soluble(s) TNF receptor(R) 1, and sTNFR2, and cortisol responsiveness. We hypothesize that greater IL-1β and TNF-α production, decreased IL-1Ra, sTNFR1, and sTNFR2 production, and decreased cortisol responsiveness at each time point as well as a more expedient alignment with this unfavorable profile over time will be associated with PTB. The choice to focus on inflammatory parameters is supported by data highlighting a crucial role for inflammation in labor. Specific inflammatory mediators have been chosen due to their potential importance in preterm labor among African American women. The bio-panel also focuses on inflammatory regulation (i.e., cytokine production upon ex vivo stimulation), which is hypothesized to provide insight into potential in vivo leukocyte responses and potential for initiation of a preterm inflammatory cascade. Production of receptor antagonists is also considered, as pro-inflammatory mediator effects can be greatly influenced by their balance with respective antagonists. Finally, leukocyte responsiveness to cortisol is included as a measure of cortisol's ability to convey anti-inflammatory signals. The development of a bio-panel predictive of risk for spontaneous PTB among African American women would represent a significant advancement. Available preventive therapies, namely progesterone supplementation, could be delivered to women deemed at risk. Further, the identification of biological predictors of PTB may uncover novel targets for preventive therapies.

Vision Amniotic Leak Detector (ALD) to Eliminate Amniotic Fluid Leakage as a Cause of Vaginal Wetness in Pregnancy: A NICE Medical Technology Guidance

In prelabour rupture of membranes (PROM) or preterm PROM the amniotic membranes rupture prior to labour. Where this is not overt a speculum examination is undertaken to confirm diagnosis. The Vision Amniotic Leak Detector (ALD) is a panty liner that can diagnose amniotic fluid as a cause of vaginal wetness. It was evaluated by the UK National Institute for Health and Care Excellence (NICE) as part of the Medical Technologies Evaluation Programme. The sponsor (CommonSense Ltd) identified five studies, of which three were deemed within scope by the External Assessment Centre (EAC). Two of these three used an inappropriate comparator. The EAC recalculated the diagnostic accuracy of Vision ALD using speculum examination as the comparator: sensitivity of 97% (95% CI 93-99%), negative predictive value of 96% (95% CI 92-98%). A negative result would therefore allow patients to be discharged with confidence. In the sponsor's cost-consequence model only patients with a positive Vision ALD result would have a speculum examination, producing a cost saving of around £10 per patient. The EAC felt that some costs were unjustified and the model did not include infection outcomes or use in a community setting. The EAC revised the sponsor's model and found the results were most sensitive to clinician costs. Vision ALD was associated with savings of around £15-£25 per patient when administration in lower-cost community healthcare avoided a referral to a higher-cost secondary-care centre. NICE published guidance MTG15 in July 2013 recommending that the case for adopting Vision ALD was supported by the evidence.

Drugs to block cytokine signaling for the prevention and treatment of inflammation-induced preterm birth

Preterm birth (PTB) at less than 37 weeks of gestation is the leading cause of neonatal morbidity and mortality. Intrauterine infection (IUI) due to microbial invasion of the amniotic cavity is the leading cause of early PTB (<32 weeks). Commensal genital tract Ureaplasma and Mycoplasma species, as well as Gram-positive and Gram-negative bacteria, have been associated with IUI-induced PTB. Bacterial activation of Toll-like receptors and other pattern recognition receptors initiates a cascade of inflammatory signaling via the NF-κB and p38 mitogen-activated protein kinase (MAPK) signaling pathways, prematurely activating parturition. Antenatal antibiotic treatment has had limited success in preventing PTB or fetal inflammation. Administration of anti-inflammatory drugs with antibiotics could be a viable therapeutic option to prevent PTB and fetal complications in women at risk of IUI and inflammation. In this mini-review, we will discuss the potential for anti-inflammatory drugs in obstetric care, focusing on the class of drugs termed “cytokine suppressive anti-inflammatory drugs” or CSAIDs. These inhibitors work by specifically targeting the NF-κB and p38 MAPK inflammatory signaling pathways. Several CSAIDs are discussed, together with clinical and toxicological considerations associated with the administration of anti-inflammatory agents in pregnancy.

Inflammatory predictors of neurologic disability after preterm premature rupture of membranes

OBJECTIVE

The maternal-fetal inflammatory response contributes to both preterm premature rupture of membranes (PPROM) and adverse neurological outcomes. Additionally, cytokines associated with fetal placental inflammation can be detrimental to brain development regardless of inciting infection. We investigated whether differential patterns of cytokine markers in maternal and fetal plasma samples reflect subtypes of placental inflammation and neurological outcomes at 6 months in infants born to mothers with PPROM.

STUDY DESIGN

Within a prospective cohort study of 25 women with PPROM, plasma cytokines (interleukin [IL]-1β, IL-6, IL-8, and tumor necrosis factor-α) were measured by enzyme-linked immunosorbent assay from maternal blood samples at rupture and delivery, and from fetal umbilical cord blood samples. Patterns of cytokine expression were correlated with specific placenta pathologies. Infants underwent cranial ultrasound after birth and standardized neurological examinations at 6 months' corrected gestational age. Predictors of inflammation and adverse neurological outcome were assessed by logistic regression, adjusting for gestational age at birth.

RESULTS

Inflammation of the fetal side of the placenta was associated with elevated maternal IL-6 and IL-8 at delivery and fetal IL-1β, IL-6, IL-8, and tumor necrosis factor-α. Worse neurological outcome at 6 months was associated with inflammation of the fetal side of the placenta and shorter duration from rupture of membrane to delivery, independent of gestational age at birth or cranial ultrasound results.

CONCLUSION

Our findings support the connection between fetal inflammation with adverse neurological outcome with PPROM, regardless of cranial ultrasound results. Further longitudinal studies are needed to adequately examine these patterns, and will aid in risk assessment and intervention strategies.

Fetal assessment methods for improving neonatal and maternal outcomes in preterm prelabour rupture of membranes

BACKGROUND

Fetal assessment following preterm prelabour rupture of membranes (PPROM) may result in earlier delivery due to earlier detection of fetal compromise. However, early delivery may not always be in the fetal or maternal interest, and the effectiveness of different fetal assessment methods in improving neonatal and maternal outcomes is uncertain.

OBJECTIVES

To study the effectiveness of fetal assessment methods for improving neonatal and maternal outcomes in PPROM. Examples of fetal assessment methods that would be eligible for inclusion in this review include fetal cardiotocography, fetal movement counting and Doppler ultrasound.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials comparing any fetal assessment methods, or comparing one fetal assessment method to no assessment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion into the review. The same two review authors independently assessed trial quality and independently extracted data. Data were checked for accuracy.

MAIN RESULTS

We included three studies involving 275 women (data reported for 271) with PPROM at up to 34 weeks' gestation. All three studies were conducted in the United States. Each study investigated different methods of fetal assessment. One study compared weekly endovaginal ultrasound scans with no assessment (n = 93), one compared amniocentesis with no assessment (n = 47), and one compared daily nonstress testing with daily modified biophysical profiling (n = 135). We were unable to perform a meta-analysis, but were able to report data from individual studies.There was no convincing evidence of increased risk of neonatal death in the group receiving endovaginal ultrasound scans compared with the group receiving no assessment (risk ratio (RR) 7.30, 95% confidence interval (CI) 0.39 to 137.54; one study, 92 women), or in the group receiving amniocentesis compared with the group receiving no amniocentesis (RR 1.00, 95% CI 0.07 to 15.00; one study, 44 women). For both these interventions, we inferred that there were no fetal deaths in the intervention or control groups. The study comparing daily nonstress testing with daily modified biophysical profiling did not report fetal or neonatal death. Primary outcomes of maternal death and serious maternal morbidity were not reported in any study. Overall, there were few statistically significant differences in outcomes between the comparisons.The overall quality of evidence is poor, because participant blinding was not possible for any study.

AUTHORS' CONCLUSIONS

There is insufficient evidence on the benefits and harms of fetal assessment methods for improving neonatal and maternal outcomes in women with PPROM to draw firm conclusions. The overall quality of evidence that does exist is poor.Further high-quality randomised controlled trials are required to guide clinical practice.

Essential pre-pregnancy and pregnancy interventions for improved maternal, newborn and child health

The statistics related to pregnancy and its outcomes are staggering: annually, an estimated 250000-280000 women die during childbirth. Unfortunately, a large number of women receive little or no care during or before pregnancy. At a period of critical vulnerability, interventions can be effectively delivered to improve the health of women and their newborns and also to make their pregnancy safe. This paper reviews the interventions that are most effective during preconception and pregnancy period and synergistically improve maternal and neonatal outcomes. Among pre-pregnancy interventions, family planning and advocating pregnancies at appropriate intervals; prevention and management of sexually transmitted infections including HIV; and peri-conceptual folic-acid supplementation have shown significant impact on reducing maternal and neonatal morbidity and mortality. During pregnancy, interventions including antenatal care visit model; iron and folic acid supplementation; tetanus Immunisation; prevention and management of malaria; prevention and management of HIV and PMTCT; calcium for hypertension; anti-Platelet agents (low dose aspirin) for prevention of Pre-eclampsia; anti-hypertensives for treating severe hypertension; management of pregnancy-induced hypertension/eclampsia; external cephalic version for breech presentation at term (>36 weeks); management of preterm, premature rupture of membranes; management of unintended pregnancy; and home visits for women and children across the continuum of care have shown maximum impact on reducing the burden of maternal and newborn morbidity and mortality. All of the interventions summarized in this paper have the potential to improve maternal mortality rates and also contribute to better health care practices during preconception and periconception period.

Essential interventions: implementation strategies and proposed packages of care

In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.

Dichotomisation of a continuous outcome and effect on meta-analyses: illustration of the distributional approach using the outcome birthweight

BACKGROUND

Power and precision are greater in meta-analyses than individual study analyses. However, dichotomisation of continuous outcomes in certain studies poses a problem as estimates from primary studies can only be pooled if they have a common outcome. Meta-analyses may include pooled summaries of either or both the continuous and dichotomous forms, and potentially have a different combination of studies for each depending on whether the outcome was dichotomised in the primary studies or not. This dual-outcome issue can lead to loss of power and/or selection bias. In this study we aimed to illustrate how dichotomisation of a continuous outcome in primary studies may result in biased estimates of pooled risk and odds ratios in meta-analysis using secondary analyses of published meta-analyses with the outcome, birthweight, which is commonly analysed both as continuous, and dichotomous (low birthweight: birthweight < 2,500 g).

METHODS

Meta-analyses published in January 2010 - December 2011 were obtained using searches in PubMed, Embase, Web of Science, and Cochrane Database of Systematic Reviews with the outcome birthweight. We used a distributional method to estimate the pooled odds/risk ratio of low birthweight and its standard error as a function of the data reported in the primary studies of the included meta-analyses where accessible.

RESULTS

Seventy-six meta-analyses were identified. Thirty-seven percent (28/76) of the meta-analyses reported only the dichotomous form of the outcome while 26% (20/76) reported only the continuous form. In one meta-analysis (1/76), birthweight was analysed as continuous for one intervention and as binary for another and 36% (27/76) presented both dichotomous and continuous birthweight summaries. In meta-analyses with a continuous outcome, primary studies data were accessible in 39/48 and secondary analyses using the distributional approach provided consistent inferences for both the continuous and distributional estimates in 38/39.

CONCLUSION

The distributional method applied in primary studies allows both a continuous and dichotomous outcome to be estimated providing consistent inferences. The use of this method in primary studies may restrict selective outcome bias in meta-analyses.

Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation

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.

Prophylactic antibiotics for inhibiting preterm labour with intact membranes

BACKGROUND

The aetiology of preterm birth is complex and there is evidence that subclinical genital tract infection influences preterm labour in some women but the role of prophylactic antibiotic treatment in the management of preterm labour is controversial. Since rupture of the membranes is an important factor in the progression of preterm labour, it is important to see if the routine administration of antibiotics confers any benefit or causes harm, prior to membrane rupture.

OBJECTIVES

To assess the effects of prophylactic antibiotics administered to women in preterm labour with intact membranes, on maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013).

SELECTION CRITERIA

Randomised trials that compared antibiotic treatment with placebo or no treatment for women in preterm labour (between 20 and 36 weeks' gestation) with intact membranes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, and undertook quality assessment and data extraction. We contacted study authors for additional information. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for data measured on a continuous scale with their respective 95% confidence intervals (CI). The number needed to treat to benefit (NNTB) and the number needed to treat to harm (NNTH) was calculated where appropriate.

MAIN RESULTS

In this update (2013), with the addition of three trials (305 women), the large ORACLE II 2001 trial continues to dominate the results of this review. This review now includes a total of 14 studies randomising 7837 women. No significant difference was shown in perinatal or infant mortality for infants of women allocated to any prophylactic antibiotics compared with no antibiotics. However, an increase in neonatal deaths was shown for infants of women receiving any prophylactic antibiotics when compared with placebo (RR 1.57, 95% CI 1.03 to 2.40; NNTH 149, 95% CI 2500 to 61). No reduction in preterm birth or other clinically important short-term outcomes for the infant were shown.Long-term child outcomes to seven years of age were available for infants in the UK enrolled in the ORACLE II trial. Comparing any antibiotics with placebo, a marginally non-statistically significant increase was shown in any functional impairment (RR 1.10, 95% CI 0.99 to 1.23) and cerebral palsy (CP) (RR 1.82, 95% CI 0.99 to 3.34). In subgroup analysis, CP was statistically significantly increased for infants of women allocated to macrolide and beta-lactam antibiotics combined compared with placebo (RR 2.83, 95% CI 1.02 to 7.88; NNTH 35, 95% CI 333 to 9).Further, exposure to any macrolide antibiotics (including erythromycin alone or erythromycin plus co-amoxiclav) versus no macrolide antibiotics (including placebo and co-amoxiclav alone) was shown to increase neonatal death (RR 1.52, 95% CI 1.05 to 2.19; NNTH 139, 95% CI 1429 to 61), any functional impairment (RR 1.11, 95% CI 1.01 to 1.20; NNTH 24, 95% CI 263 to 13) and CP (RR 1.90, 95% CI 1.20 to 3.01; NNTH 64, 95% CI 286 to 29). Exposure to any beta-lactam (beta-lactam alone or in combination with macrolide antibiotics) versus no beta-lactam antibiotics resulted in more neonatal deaths (RR 1.51, 95% CI 1.06 to 2.15; NNTH 143, 95% CI 1250 to 63) and CP (RR 1.67, 95% CI 1.06 to 2.61; NNTH 79, 95% CI 909 to 33), however no difference was shown in functional impairment.Maternal infection was reduced with the use of any prophylactic antibiotics compared with placebo (RR 0.74, 95% CI 0.63 to 0.86; NNTB 34, 95% CI 24 to 63) and any beta-lactam compared with no beta-lactam antibiotics (RR 0.80, 95% CI 0.69 to 0.92; NNTB 47, 95% CI 31 to 119). However, caution should be exercised with this finding due to the possibility of bias shown by funnel plot asymmetry. Any beta-lactam compared with no beta-lactam antibiotics was associated with an increase in maternal adverse drug reaction (RR 1.61, 95% CI 1.02 to 2.54; NNTH 17, 95% CI 526 to 7).

AUTHORS' CONCLUSIONS

This review did not demonstrate any benefit in important neonatal outcomes with the use of prophylactic antibiotics for women in preterm labour with intact membranes, although maternal infection may be reduced. Of concern, is the finding of short- and longer-term harm for children of mothers exposed to antibiotics. The evidence supports not giving antibiotics routinely to women in preterm labour with intact membranes in the absence of overt signs of infection.Further research is required to develop sensitive markers of subclinical infection for women in preterm labour with intact membranes, as this is a group that might benefit from future novel interventions, including new modalities of antibiotic therapy. The results of this review demonstrate the need for future trials in the area of preterm birth to include assessment of long-term neurodevelopmental outcome.

Antibiotics for preterm rupture of membranes

BACKGROUND

Premature birth carries substantial neonatal morbidity and mortality. Subclinical infection is associated with preterm rupture of membranes (PROM). Prophylactic maternal antibiotic therapy might lessen infectious morbidity and delay labour, but could suppress labour without treating underlying infection.

OBJECTIVES

To evaluate the immediate and long-term effects of administering antibiotics to women with PROM before 37 weeks, on maternal infectious morbidity, neonatal morbidity and mortality, and longer-term childhood development.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013).

SELECTION CRITERIA

Randomised controlled trials comparing antibiotic administration with placebo that reported clinically relevant outcomes were included as were trials of different antibiotics. Trials in which no placebo was used were included for the outcome of perinatal death alone.

DATA COLLECTION AND ANALYSIS

We extracted data from each report without blinding of either the results or the treatments that women received. We sought unpublished data from a number of authors.

MAIN RESULTS

We included 22 trials, involving 6872 women and babies.The use of antibiotics following PROM is associated with statistically significant reductions in chorioamnionitis (average risk ratio (RR) 0.66, 95% confidence interval (CI) 0.46 to 0.96, and a reduction in the numbers of babies born within 48 hours (average RR 0.71, 95% CI 0.58 to 0.87) and seven days of randomisation (average RR 0.79, 95% CI 0.71 to 0.89). The following markers of neonatal morbidity were reduced: neonatal infection (RR 0.67, 95% CI 0.52 to 0.85), use of surfactant (RR 0.83, 95% CI 0.72 to 0.96), oxygen therapy (RR 0.88, 95% CI 0.81 to 0.96), and abnormal cerebral ultrasound scan prior to discharge from hospital (RR 0.81, 95% CI 0.68 to 0.98). Co-amoxiclav was associated with an increased risk of neonatal necrotising enterocolitis (RR 4.72, 95% CI 1.57 to 14.23).One study evaluated the children's health at seven years of age (ORACLE Children Study) and found antibiotics seemed to have little effect on the health of children.

AUTHORS' CONCLUSIONS

Routine prescription of antibiotics for women with preterm rupture of the membranes is associated with prolongation of pregnancy and improvements in a number of short-term neonatal morbidities, but no significant reduction in perinatal mortality. Despite lack of evidence of longer-term benefit in childhood, the advantages on short-term morbidities are such that we would recommend antibiotics are routinely prescribed. The antibiotic of choice is not clear but co-amoxiclav should be avoided in women due to increased risk of neonatal necrotising enterocolitis.

Antibiotic Therapy for Premature Rupture of Membranes and Preterm Labor and Effect on Fetal Outcome

In Germany almost 10 % of children are born before the end of 37th week of gestation. In at least one quarter of these cases, ascending infection of the vagina plays a causative role, particularly during the early weeks of gestation. If, in addition to the decidua, the amniotic membrane, amniotic fluid and the umbilical cord are also affected, infection not only triggers uterine contractions and premature rupture of membranes but also initiates a systemic inflammatory reaction on the part of the fetus, which can increase neonatal morbidity. Numerous studies and meta-analyses have found that antibiotic therapy prolongs pregnancy and reduces neonatal morbidity. No general benefit of antibiotic treatment was found for premature uterine contractions. But it is conceivable that a subgroup of pregnant women would benefit from antibiotic treatment. It is important to identify this subgroup of women and offer them targeted treatment. This overview summarizes the current body of evidence on antibiotic treatment for impending preterm birth and the effect on neonatal outcomes.

Bacterial aetiological agents of intra-amniotic infections and preterm birth in pregnant women

Infection-related preterm birth is a leading cause of infant mortality and morbidity; knowledge of bacterial populations invading the amniotic cavity and the routes of invasion is required to make progress in the prevention of preterm birth. Significant advances have been made in understanding bacterial communities in the vagina, but much less studied are intra-uterine bacterial populations during pregnancy. A systematic review of data published on the intra-uterine microbiome was performed; molecular information and summaries of species found in healthy individuals and in women with diagnosed infections served to construct a database and to analyse results to date. Thirteen studies fulfilled the review's inclusion criteria. The data of various investigations were collated, organized, and re-analyzed to achieve a more comprehensive understanding of microbial populations in the intra-amniotic space. The most common intra-amniotic bacterial taxa were species that can colonies the vagina in health and disease; there were others associated with the habitats of the mouth, gastrointestinal tract, and respiratory tract. The results suggest a central role for the ascending route of infections during pregnancy, and point to a possible secondary contribution via haematogenous invasion of the intra-amniotic space. The complete census of the intra-uterine microbiome awaits completion.

The epidemiology of life-threatening complications associated with reproductive process in public hospitals in Argentina

OBJECTIVE

To analyse life-threatening obstetric complications that occurred in public hospitals in Argentina.

DESIGN

Multicentre collaborative cross-sectional study.

SETTING

Twenty-five hospitals included in the Perinatal Network of Buenos Aires Metropolitan Area.

POPULATION

Women giving birth in participating hospitals during a 1-year period.

METHODS

All cases of severe maternal morbidity (SMM) and maternal mortality (MM) during pregnancy (including miscarriage and induced abortion), labour and puerperium were included. Data were collected prospectively.

MAIN OUTCOME MEASURES

Identification criteria, main causes and incidence of SMM; case-fatality rates, morbidity-mortality index and effective intervention's use rate.

RESULTS

A total of 552 women with life-threatening conditions were identified: 518 with SMM, 34 with MM. Identification criteria for SMM were case-management (48.9%), organ dysfunction (15.2%) and mixed criteria (35.9%). Incidence of SMM was 0.8% (95% confidence interval [95% CI] 0.73-0.87%) and hospital maternal death ratio was 52.3 per 100 000 live births (95% CI 35.5-69.1). Main causes of MM were abortion complications and puerperal sepsis; main causes of SMM were postpartum haemorrhage and hypertension. Overall case-fatality rate was 6.2% (95% CI 4.4-8.6): the highest due to sepsis (14.8%) and abortion complications (13.3%). Morbidity-mortality index was 15:1 (95% CI 7.5-30.8). Use rate of known effective interventions to prevent or treat main causes of MM and SMM was 52.3% (95% CI 46.9-57.7).

CONCLUSIONS

This study describes the importance of life-threatening obstetric complications that took place in public hospitals with comprehensive obstetric care and the low utilisation of known effective interventions that may decrease rates of SMM and MM. It also provides arguments that justify the need to develop a surveillance system for SMM.

Risk of early-onset neonatal infection with maternal infection or colonization: a global systematic review and meta-analysis

BACKGROUND

Neonatal infections cause a significant proportion of deaths in the first week of life, yet little is known about risk factors and pathways of transmission for early-onset neonatal sepsis globally. We aimed to estimate the risk of neonatal infection (excluding sexually transmitted diseases [STDs] or congenital infections) in the first seven days of life among newborns of mothers with bacterial infection or colonization during the intrapartum period.

METHODS AND FINDINGS

We searched PubMed, Embase, Scopus, Web of Science, Cochrane Library, and the World Health Organization Regional Databases for studies of maternal infection, vertical transmission, and neonatal infection published from January 1, 1960 to March 30, 2013. Studies were included that reported effect measures on the risk of neonatal infection among newborns exposed to maternal infection. Random effects meta-analyses were used to pool data and calculate the odds ratio estimates of risk of infection. Eighty-three studies met the inclusion criteria. Seven studies (8.4%) were from high neonatal mortality settings. Considerable heterogeneity existed between studies given the various definitions of laboratory-confirmed and clinical signs of infection, as well as for colonization and risk factors. The odds ratio for neonatal lab-confirmed infection among newborns of mothers with lab-confirmed infection was 6.6 (95% CI 3.9-11.2). Newborns of mothers with colonization had a 9.4 (95% CI 3.1-28.5) times higher odds of lab-confirmed infection than newborns of non-colonized mothers. Newborns of mothers with risk factors for infection (defined as prelabour rupture of membranes [PROM], preterm <37 weeks PROM, and prolonged ROM) had a 2.3 (95% CI 1.0-5.4) times higher odds of infection than newborns of mothers without risk factors.

CONCLUSIONS

Neonatal infection in the first week of life is associated with maternal infection and colonization. High-quality studies, particularly from settings with high neonatal mortality, are needed to determine whether targeting treatment of maternal infections or colonization, and/or prophylactic antibiotic treatment of newborns of high risk mothers, may prevent a significant proportion of early-onset neonatal sepsis. Please see later in the article for the Editors' Summary.

Development of quality of care indicators from systematic reviews: the case of hospital delivery

BACKGROUND

The objective of this research is to generate quality of care indicators from systematic reviews to assess the appropriateness of obstetric care in hospitals.

METHODS

A search for systematic reviews about hospital obstetric interventions, conducted in The Cochrane Library, clinical evidence and practice guidelines, identified 303 reviews. We selected 48 high-quality evidence reviews, which resulted in strong clinical recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The 255 remaining reviews were excluded, mainly due to a lack of strong evidence provided by the studies reviewed.

RESULTS

A total of 18 indicators were formulated from these clinical recommendations, on antepartum care (8), care during delivery and postpartum (9), and incomplete miscarriage (1). Authors of the systematic reviews and specialists in obstetrics were consulted to refine the formulation of indicators.

CONCLUSIONS

High-quality systematic reviews, whose conclusions clearly claim in favour or against an intervention, can be a source for generating quality indicators of delivery care. To make indicators coherent, the nuances of clinical practice should be considered. Any attempt made to evaluate the extent to which delivery care in hospitals is based on scientific evidence should take the generated indicators into account.

The prevention, diagnosis and treatment of premature labor

BACKGROUND

The percentage of preterm births in Germany is high at 9%, but stable. 77% of cases of perinatal death are in prematurely born infants. Intensive research efforts are being directed toward the development of new means of primary and secondary prevention, diagnostic assessment, and pharmacotherapy of premature labor.

METHODS

We review pertinent publications that were retrieved by a selective search of the literature from 1966 to 2012, including current meta-analyses from the Cochrane database and the guidelines of German and foreign obstetric societies.

RESULTS

Preterm labor is a multifactorial problem. The current treatment options are symptomatic, rather than causally directed. Preventive treatment with progesterone can lower the rate of preterm birth in high-risk groups by more than 30%. Transporting the pregnant women to an appropriately qualified perinatal care center and induction of fetal lung maturation lowers perinatal mortality. A variety of tocolytic drugs with different mechanisms of action (betamimetics, oxytocin antagonists, calcium-channel blockers, NO donors, and inhibitors of prostaglandin synthesis) can be used for individualized tocolytic treatment. Premature rupture of the membranes is an indication for antibiotics.

CONCLUSION

The goal of all attempts to prevent and treat preterm labor is to improve preterm infants' chances of surviving with as few complications as possible. The methods discussed here can be used to prolong pregnancies at risk for preterm labor and so to reduce perinatal morbidity and mortality.

Pregnancy disorders appear to modify the risk for retinopathy of prematurity associated with neonatal hyperoxemia and bacteremia

OBJECTIVE

To explore (1) whether extremely low gestational age newborns exposed to inflammation-associated pregnancy disorders differ in retinopathy of prematurity (ROP) risk from infants exposed to placenta dysfunction-associated disorders, and (2) whether ROP risk associated with postnatal hyperoxemia and bacteremia differs among infants exposed to these disorders.

METHODS

Pregnancy disorders resulting in preterm birth include inflammation-associated: preterm labor, prelabor premature rupture of membranes (pPROM), cervical insufficiency, and abruption and placenta dysfunction-associated: preeclampsia and fetal indication. The risk of severe ROP associated with pregnancy disorders was evaluated by multivariable analyses in strata defined by potential effect modifiers, postnatal hyperoxemia and bacteremia.

RESULTS

Compared to preterm labor, infants delivered after pPROM were at reduced risk of plus disease (Odds ratio = 0.4, 95% confidence interval: 0.2-0.8) and prethreshold/threshold ROP (0.5, 0.3-0.8). Infants delivered after abruption had reduced risk of zone I ROP (0.2, 0.1-0.8) and prethreshold/threshold ROP (0.3, 0.1-0.7). In stratified analyses, infants born after placenta dysfunction had higher risks of severe ROP associated with subsequent postnatal hyperoxemia and bacteremia than infants born after inflammation-associated pregnancy disorders.

CONCLUSION

Infants exposed to placenta dysfunction have an increased risk of severe ROP following postnatal hyperoxemia and bacteremia compared to infants exposed to inflammation-associated pregnancy disorders.

A blueprint for the prevention of preterm birth: vaginal progesterone in women with a short cervix

Preterm birth is the leading cause of perinatal morbidity and mortality worldwide, and is the most important challenge to modern obstetrics. A major obstacle has been that preterm birth is treated (implicitly or explicitly) as a single condition. Two thirds of preterm births occur after the spontaneous onset of labor, and the remaining one third after "indicated" preterm birth; however, the causes of spontaneous preterm labor and "indicated" preterm birth are different. Spontaneous preterm birth is a syndrome caused by multiple etiologies, one of which is a decline in progesterone action, which induces cervical ripening. A sonographic short cervix (identified in the midtrimester) is a powerful predictor of spontaneous preterm delivery. Randomized clinical trials and individual patient meta-analyses have shown that vaginal progesterone reduces the rate of preterm delivery at <33 weeks of gestation by 44%, along with the rate of admission to the neonatal intensive care unit, respiratory distress syndrome, requirement for mechanical ventilation, and composite neonatal morbidity/mortality score. There is no evidence that 17-α-hydroxyprogesterone caproate can reduce the rate of preterm delivery in women with a short cervix, and therefore, the compound of choice is natural progesterone (not the synthetic progestin). Routine assessment of the risk of preterm birth with cervical ultrasound coupled with vaginal progesterone for women with a short cervix is cost-effective, and the implementation of such a policy is urgently needed. Vaginal progesterone is as effective as cervical cerclage in reducing the rate of preterm delivery in women with a singleton gestation, history of preterm birth, and a short cervix (<25 mm).

[Maternal antibiotic use and Gram negative bacteria infection in neonates]

Prevention strategies by maternal antibiotic use have provided undeniable benefits for neonates regarding early neonatal group B streptococcal infections. But at a time where the evolution of resistance of Gram negative bacteria is of particular concern, it is our duty to reassess prevention strategies with a careful evaluation of their potential impact on Gram negative bacteria in the newborn. We conducted a literature review to define the state of the art of antenatal antibiotic prophylaxis and its bacteriological consequences on the newborn. Prevention strategies of early-onset neonatal group B streptococcal disease with selective intrapartum chemoprophylaxis should not be challenged, even at the cost of a small increase of the incidence of late-onset infections with resistant Gram negative bacteria. However, other indications seem more controversial and the type of antibiotics used is not always based on methodologically well-conducted studies. In these indications the prevention strategies should consider not only the immediate expected benefits, but also the long-term ecological impact by using whenever possible narrow-spectrum antibiotics.