Physiopathologie des conséquences respiratoires néonatales de la rupture prématurée des membranes : application à la prise en charge néonatale

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Major determinants of survival and length of stay in the neonatal intensive care unit of newborns from women with premature preterm rupture of membranes

OBJECTIVE

To assess the predictors of outcome in terms of length of stay in the neonatal intensive care unit (NICU) and survival of neonates from women with preterm premature rupture of membranes (PPROM).

METHODS

A population-based retrospective study including 331 singleton pregnant women with PPROM at 24-34 gestational weeks between January 2013 and December 2015 was conducted. Gestational age at delivery, birth weight, route of delivery, newborn gender, maternal age, oligohydramnios, premature retinopathy (ROP), necrotising enterocolitis (NEC), sepsis, fetal growth retardation (FGR), intracranial hemorrhagia (ICH), bronchopulmonary dysplasia (BPD), respiratory distress syndrome (RDS), primary pulmonary hypertension (PPH), congenital cardiac disease (CCD), patent ductus arteriosus (PDA), use of cortisol (betamethasone) and maternal complications including gestational diabetes, preeclampsia and chorioamnionitis were used to predict neonatal outcomes in terms of length of stay in the NICU and survival.

RESULTS

In linear regression analyses, birth weight, ROP, CCD, BPD, PDA, NEC and preeclampsia were significant confounders for length of stay in the NICU. Among them, birth weight was the most powerful confounder for prolongation of the NICU stay (t: -6.43; p < 0.001). In multivariate logistic regression analyses, birth weight, PDA, ROP and PPH were significantly correlated with neonatal survival. PPH was the most powerful confounder in neonatal survival (β: 7.22; p = 0.005).

CONCLUSION

Prematurity-related complications are the most important problems for which precautions should be taken. Therefore, premature deliveries should be avoided to prevent infection and to prolong the latent period in cases of PPROM in order to decrease prematurity-related outcomes.

Outcome at Two Years of Very Preterm Infants Born after Rupture of Membranes before Viability

Purpose

To compare the respiratory and neurological outcomes at two years of age of preterm children born before 33 weeks of gestation (WG) after early preterm premature rupture of membranes (EPPROM) between 14 and 24 WG with preterm children without EPPROM.

Design and Patients

This single-center case-control retrospective study was conducted at Rouen University Hospital between 1^st January 2000 and 31^st December 2010. All the cases with EPPROM born from 26WG to 32WG were included. Each newborn was matched by sex, gestational age (GA) and year of birth to two very preterm children, born without EPPROM. At two years of corrected age, motor and cognitive abilities were assessed by routine score based on the Amiel-Tison and Denver developmental scales.

Results

Ninety-four cases with EPPROM before 24WG have been included. The 31 children born from 26WG to 32WG were matched with 62 controls. The EPPROM group had poorer clinical evaluation at one year for motor (p = 0.003) and cognitive developmental scores (p = 0.016). Neuromotor rehabilitation was performed more often (p = 0.013). However, there was no difference at 2 years of age. Children born after EPPROM were hospitalized more often for bronchiolitis (p<0.001) during their first 2 years, which correlates with increased incidence of pneumothorax (p = 0.017), pulmonary hypoplasia (p = 0.004) and bronchopulmonary dysplasia (p = 0.005) during neonatal period.

Conclusion

At two years, despite an increase in severe bronchiolitis and the need for more neuromotor rehabilitation during the first month of the life after discharge, there was no difference in neurological outcomes in the very preterm children of the EPPROM group compared to those born at a similar GA without EPPROM.

Neonatal respiratory distress in a reference neonatal unit in Cameroon: an analysis of prevalence, predictors, etiologies and outcomes

Introduction

Neonatal respiratory distress (NRD) is a main cause of neonatal morbidity and mortality in developing countries. Early detection of its risk factors and early treatment of its etiologies are major challenges. However, few studies in developing countries have provided data needed to tackle it. We aimed to determine the prevalence, predictors, etiologies and outcome of NRD in a tertiary health care centre of Cameroon.

Methods

We analyzed the hospital files of all newborns admitted to the Neonatal unit of Douala General Hospital from 1^st January 2011 to 28^th February 2013. NRD was diagnosed based on the presence of one or more of the following signs: an abnormal respiratory rate, expiratory grunting, nasal flaring, chest wall recessions and thoraco-abdominal asynchrony with or without cyanosis, in their files. Socio-demographic and clinical variables of newborns and their mothers were analyzed using logistic regression analysis.

Results

The prevalence of NRD was 47.5% out of the 703 newborns studied. Acute fetal distress, elective caesarean delivery, APGAR score < 7 at the 1^st minute, prematurity, male gender and macrosomia were independent predictors of NRD. The main etiologies were neonatal infections (31%) and transient tachypnea of the newborn (25%). Its neonatal mortality rate was 24.5%, mainly associated with neonatal sepsis and hyaline membrane disease.

Conclusion

NRD is a frequent emergency and causes high morbidity and mortality. Most of its risk factors and etiologies are preventable. Adequate follow-up of pregnancy and labor for timely intervention may improve the neonatal outcomes.

Noninvasive prediction of intra-amniotic infection and/or inflammation in preterm premature rupture of membranes

OBJECTIVE

To develop a model based on noninvasive parameters to predict the probability of intra-amniotic infection and/or inflammation (IAI) in women with preterm premature rupture of membranes (PPROMs).

METHODS

Maternal blood was collected for determination of the C-reactive protein (CRP) level and white blood cell (WBC) count immediately after amniocentesis in 171 consecutive women with PPROMs. Intra-amniotic infection and/or inflammation was defined as a positive amniotic fluid (AF) culture and/or an elevated AF interleukin 6 level (≥2.6 ng/mL).

RESULTS

A risk score based on a model including maternal blood CRP, WBC, parity, and gestational age was calculated for each patient. The model was shown to have an adequate goodness of fit (P = .516), and the area under the receiver-operating characteristic curve was 0.848, indicating very good discrimination.

CONCLUSION

The noninvasive model based on maternal blood CRP, WBC, parity, and gestational age is highly predictive of IAI in women with PPROMs.

Combination therapy for life-threatening pulmonary hypertension in a premature infant: first report on bosentan use

Premature infants with preterm premature rupture of membranes (PPROM) are at high risk of severe respiratory failure because of lung hypodysplasia associated with persistent pulmonary hypertension of the newborn (PPHN). We describe the clinical course of a 28-week gestation infant with PPROM from the 20th week and prolonged oligohydramnios before delivery, who developed refractory hypoxia treated with oral bosentan as adjunct therapy to inhaled nitric oxide (iNO) and oral sildenafil. Conclusion Our experience suggests that bosentan can be used in the premature infant with PPHN after PPROM. To the best of our knowledge, this is the first report of bosentan treatment in a premature infant.