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

Society for Maternal-Fetal Medicine Consult Series #71: Management of previable and periviable preterm prelabor rupture of membranes

Previable and periviable preterm prelabor rupture of membranes are challenging obstetrical complications to manage given the substantial risk of maternal morbidity and mortality, with no guarantee of fetal benefit. The following are the Society for Maternal-Fetal Medicine recommendations for the management of previable and periviable preterm prelabor rupture of membranes before the period when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient: (1) we recommend that pregnant patients with previable and periviable preterm prelabor rupture of membranes receive individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management to guide an informed decision; all patients with previable and periviable preterm prelabor rupture of membranes should be offered abortion care, and expectant management can also be offered in the absence of contraindications (GRADE 1C); (2) we recommend antibiotics for pregnant individuals who choose expectant management after preterm prelabor rupture of membranes at ≥24 0/7 weeks of gestation (GRADE 1B); (3) antibiotics can be considered after preterm prelabor rupture of membranes at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C); (4) administration of antenatal corticosteroids and magnesium sulfate is not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (GRADE 1B); (5) serial amnioinfusions and amniopatch are considered investigational and should be used only in a clinical trial setting; they are not recommended for routine care of previable and periviable preterm prelabor rupture of membranes (GRADE 1B); (6) cerclage management after previable or periviable preterm prelabor rupture of membranes is similar to cerclage management after preterm prelabor rupture of membranes at later gestational ages; it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making (GRADE 2C); and (7) in subsequent pregnancies after a history of previable or periviable preterm prelabor rupture of membranes, we recommend following guidelines for management of pregnant persons with a previous spontaneous preterm birth (GRADE 1C).

Evaluation and Management of Premature Rupture of Membranes: A Review Article

Premature rupture of membranes (PROM), now also referred to as "pre-labour rupture of membranes," is the rupture of gestational membranes after 37 weeks but before the process of labour begins. When membrane rupture occurs before 37 weeks of gestation, it is referred to as preterm PROM (PPROM). Prematurity is held accountable for the majority of newborn morbidity and mortality. PROM causes around one-third of all preterm deliveries and complicates 3% of pregnancies. Significant morbidity and mortality rates have been associated with PROM. Preterm (PROM) pregnancies are more difficult to manage. Pre-labour rupture of membranes is characterised by its short latency, higher intrauterine infection risk, and greater umbilical cord compression probability. Women with preterm PROM are more likely to develop chorioamnionitis and placental abruption. Various diagnostic modalities include sterile speculum examination, the nitrazine test, the ferning test, and the latest advances, which are the Amnisure test and the Actim test. Despite all these tests, there is still a need for newer, non-invasive, rapid, and accurate tests. Admission to a hospital, amniocentesis to rule out infection, and, if necessary, prenatal corticosteroids and broad-spectrum antibiotics are all alternatives for treatment. As a result, the clinician managing a pregnant woman whose pregnancy has been affected by PROM plays a crucial role in the management and must be well aware of probable complications and control measures to reduce risks and increase the likelihood of the required outcome. PROM's proclivity for recurrence in later pregnancies provides a chance for prevention. Furthermore, prenatal and neonatal care developments will continue to enhance the outcomes of women and their children. The purpose of this article is to summarise the concepts related to the evaluation and management of PROM.

Antimicrobial and Toxic Effects of Boswellia serrata Roxb. and Mentha piperita Linn. Essential Oils on Vaginal Inhabitants

Commercial essential oils (EOs) of incense, Boswellia serrata Roxb, and mint, Mentha piperita L., were investigated against vaginal bacterial and Candida albicans isolates for antimicrobial potential and safety use. The antimicrobial activity of EOs was investigated through a double-dilution micro-plate assay. A brine shrimp assay was used for the determination of toxicity, while the determination of the chemical composition of EOs was carried out using GS-MS. Obtained minimal inhibitory (MIC) and minimal bactericidal concentration (MBC) point to the activity of mint essential oil (EO) against the multi-resistant P. aeruginosa isolate (MIC/MBC at 6.25 µL/mL), while MIC and MBC values for other isolates were reached at higher concentrations (25-50 µL/mL). According to the toxicity assay, the incense EO reached the LC50 value at 3.07 µL/mL, while mint EO showed higher toxicity at lower concentrations (0.5 µL/mL) and the LC50 could not be determined. The highest antimicrobial potential was obtained for incense against P. aeruginosa. Although the toxicity assay showed high toxicity of mint EO to the eggs of aquatic crustaceans Artemia salina, further testing of EO toxicity is proposed, for example on healthy cell-lines. According to the GC/MS spectrometry, the most represented components of mint EO were the oxygenated hydrocarbons L-menthone (20.86%) and menthol (31.86%), and they could be proposed for further antimicrobial and toxicity investigation.

Metagenomics Approaches to Investigate the Neonatal Gut Microbiome

Early infancy is critical for the development of an infant's gut flora. Many factors can influence microbiota development during the pre- and postnatal periods, including maternal factors, antibiotic exposure, mode of delivery, dietary patterns, and feeding type. Therefore, investigating the connection between these variables and host and microbiome interactions in neonatal development would be of great interest. As the "unculturable" era of microbiome research gives way to an intrinsically multidisciplinary field, microbiome research has reaped the advantages of technological advancements in next-generation sequencing, particularly 16S rRNA gene amplicon and shotgun sequencing, which have considerably expanded our knowledge about gut microbiota development during early life. Using omics approaches to explore the neonatal microbiome may help to better understand the link between the microbiome and newborn diseases. Herein, we summarized the metagenomics methods and tools used to advance knowledge on the neonatal microbiome origin and evolution and how the microbiome shapes early and late individuals' lives for health and disease. The way to overcome limitations in neonatal microbiome studies will be discussed.

Antibiotic Timing in Previable Prelabor Rupture of Membranes Less Than 24 Weeks of Gestation

OBJECTIVE

This study aimed to compare neonatal and maternal outcomes between immediate and delayed prophylactic antibiotic administration after previable prelabor premature rupture of membranes (PROM) less than 24 weeks of gestation.

STUDY DESIGN

Retrospective cohort study of singleton pregnancies with PROM between 16^0/7 and 23^6/7 weeks of gestational age conducted at a single tertiary care referral center between June 2011 and December 2015. Patients with multiple gestations, fetal anomalies, those who elected augmentation, or with a contradiction to expectant management, such as suspected intra-amniotic infection or stillbirth, were excluded from the study. We compared pregnancy characteristics, maternal complications, and neonatal outcomes between women who received a course of antibiotics within 24 hours of PROM and women who received antibiotics after 24 hours of PROM. The primary outcome was neonatal survival to hospital discharge. Secondary outcomes included gestational age at delivery, time from PROM to delivery, neonatal birth weight, days in the neonatal intensive care unit (NICU), composite adverse neonatal outcomes, and maternal morbidity.

RESULTS

Ninety-four women met inclusion criteria, 57 (61%) received antibiotics within 24 hours of PROM and 37 (39%) received antibiotics 24 hours after PROM. Baseline maternal characteristics were similar in both groups. The mean gestational age at PROM was similar between groups at 20.8 ± 2.3 weeks in the immediate antibiotics group and 20.6 ± 2.1 weeks in the delayed antibiotics group (p = 0.48). Compared with delayed antibiotic administration, immediate antibiotic administration was not associated with a significant difference in latency time from PROM to delivery, rate of stillbirth, days in an ICU, or adverse neonatal outcomes. Maternal outcomes also did not differ significantly between groups. Neonatal birth weight was lower in the immediate antibiotics group (p = 0.012).

CONCLUSION

Our data suggest that there is no maternal or neonatal benefit to immediate administration of latency antibiotics compared with delayed administration.

KEY POINTS

· Adverse neonatal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Maternal outcomes did not differ based on timing of latency antibiotics for previable PROM.. · Neonatal birth weight was lower in infants that received immediate antibiotics after previable PROM..

An 18-year retrospective study on the epidemiology of early-onset neonatal sepsis - emergence of uncommon pathogens

BACKGROUND

Nationwide group B Streptococcus agalactiae (GBS) antepartum screening was instituted in Taiwan in 2012. The impact of the policy on early-onset sepsis (EOS) has not been evaluated. This study aimed to examine the impact of the policy on the incidence of neonatal EOS.

METHODS

This was a retrospective study conducted at MacKay Children's Hospital. Patients with culture-proven neonatal EOS were enrolled and divided by birth year in relation to the implementation of GBS prevention policy: Epoch 1, 2001-2004 pre-GBS screening; Epoch 2, 2005-2011 elective GBS screening; and Epoch 3, 2012-2018 universal GBS screening. The pathogens and antimicrobial resistance patterns were reviewed and analyzed. The incidence was modeled using Poisson regression.

RESULTS

A total of 128 neonates met the enrollment criteria. The observed incidence of EOS was 1.52‰. The incidence rates of EOS, GBS, and Escherichia coli (E. coli) sepsis were similar in Epoch 1 and Epoch 3. E. coli and non-Enterococcal group D Streptococcus (GDS) infection increased significantly in term infants, whereas the EOS-related mortality rate declined in preterm infants. Approximately 72% of the isolated E. coli were ampicillin-resistant, and the antimicrobial sensitivity remained unaltered during the studied period.

CONCLUSIONS

The overall EOS incidence has not changed from 2001 to 2018. However, changes in the causative pathogens were observed in both term and preterm infants. Clinicians should be aware of this evolving epidemiology to provide prompt appropriate perinatal management.

[Management of Infection in Threatened Preterm Birth - A Survey of German Perinatal Centers]

INTRODUCTION

In spite of insufficient evidence, we assume a high willingness to diagnose and treat vaginal infections in threatened preterm births in Germany.

METHODS

Online survey on the management of infection in threatened preterm birth in all 212 German perinatal centers.

RESULTS

The response rate was 31.6% (n=67). 78.8% disclaim an empirical antibiotic treatment in threatened preterm birth below 34 weeks of gestation. Half of the remaining 14 centers always start an antibiotic treatment in cases with signs or symptoms of threatened preterm birth. 94% perform vaginal swabs for culture. 37.3% use a microscopic assessment by vaginal Nugent score or Amsel score. An abnormal vaginal microbiota is mostly treated (bacterial vaginosis 79.1%, n=53, Candida spp. 77.6%, n=52, Ureaplasma spp. 49.3%, n=33). After treatment, 70.1% agree with repeating the culture diagnosis. There is common consensus for antibiotic treatment in cases with preterm premature rupture of membranes. 72.6% favor a monotherapy with a β-lactam antibiotic. Statements on duration of therapy were inconsistent, whereby 58% of centers treat for more than 7 days.

CONCLUSION

In German perinatal centers, we observed a great willingness to diagnose and treat infections in threatened preterm birth. However, the management of infection is heterogeneous and partly contradicts the present guidelines.

Diseases and conditions that impact maternal and fetal health and the potential for nanomedicine therapies

Maternal mortality rates in the United States have steadily increased since 1987 to the current rate of over 16 deaths per 100,000 live births. Whereas most of these deaths are related to an underlying condition, such as cardiovascular disease, many pregnant women die from diseases that emerge as a consequence of pregnancy. Both pre-existing and emergent diseases and conditions are difficult to treat in pregnant women because of the potential harmful effects of the treatment on the developing fetus. Often the health of the woman and the health of the baby are at odds and must be weighed against each other when medical treatment is needed, frequently leading to iatrogenic preterm birth. However, the use of engineered nanomedicines has the potential to fill the treatment gap for pregnant women. This review describes several conditions that may afflict pregnant women and fetuses and introduces how engineered nanomedicines may be used to treat these illnesses. Although the field of maternal-fetal nanomedicine is in its infancy, with additional research and development, engineered nanotherapeutics may greatly improve outcomes for pregnant women and their offspring in the future.

Preterm Birth, Inflammation and Infection: New Alternative Strategies for their Prevention

BACKGROUND

Worldwide, the progress in reducing neonatal mortality has been very slow. The rate of preterm birth has increased over the last 20 years in low-income and middle-income countries. Its association with increased mortality and morbidity is based on experimental studies and neonatal outcomes from countries with socioeconomic differences, which have considered implementing alternative healthcare strategies to prevent and reduce preterm births.

METHODS

Currently, there is no widely effective strategy to prevent preterm birth. Pharmacological therapies are directed at inhibiting myometrial contractions to prolong parturition. Some drugs, medicinal plants and microorganisms possess myorelaxant, anti-inflammatory and immunomodulatory properties that have proved useful in preventing preterm birth associated with inflammation and infection.

RESULTS

This review focuses on the existing literature regarding the use of different drugs, medicinal plants, and microorganisms that show promising benefits for the prevention of preterm birth associated with inflammation and infection. New alternative strategies involving the use of PDE-4 inhibitors, medicinal plants and probiotics could have a great impact on improving prenatal and neonatal outcomes and give babies the best start in life, ensuring lifelong health benefits.

CONCLUSION

Despite promising results from well-documented cases, only a small number of these alternative strategies have been studied in clinical trials. The development of new drugs and the use of medicinal plants and probiotics for the treatment and/or prevention of preterm birth is an area of growing interest due to their potential therapeutic benefits in the field of gynecology and obstetrics.

Cytokine profiles of umbilical cord blood mononuclear cells upon in vitro stimulation with lipopolysaccharides of different vaginal gram-negative bacteria

Inflammatory immune responses induced by lipopolysaccharides (LPS) of gram-negative bacteria play an important role in the pathogenesis of preterm labor and delivery, and in neonatal disorders. To better characterize LPS-induced inflammatory response, we determined the cytokine profile of umbilical cord blood mononuclear cells (UBMC) stimulated with LPS of seven vaginal gram-negative bacteria commonly found in pregnant women with preterm labor and preterm rupture of membrane. UBMC from ten newborns of healthy volunteer mothers were stimulated with purified LPS of Escherichia coli, Enterobacter aerogenes, Klebsiella pneumoniae, Proteus mirabilis, Acinetobacter calcoaceticus, Citrobacter freundii, and Pseudomonas aeruginosa. UBMC supernatants were tested for the presence of secreted pro-inflammatory cytokines (IL-6, IL-1β, TNF), anti-inflammatory cytokine (IL-10), TH₁-type cytokines (IL-12, IFN-γ), and chemokines (IL-8, MIP-1α, MIP-1β, MCP-1) by Luminex technology. The ten cytokines were differentially induced by the LPS variants. LPS of E. coli and E. aerogenes showed the strongest stimulatory activity and P. aeruginosa the lowest. Interestingly, the ability of UBMC to respond to LPS varied greatly among donors, suggesting a strong individual heterogeneity in LPS-triggered inflammatory response.

Group B streptococcus prevalence, serotype distribution and colonization dynamics in Western Australian pregnant women

PURPOSE

Streptococcus agalactiae, or group B streptococcus (GBS), is a leading neonatal pathogen that causes sepsis, meningitis and pneumonia. Globally, strategies have been implemented to address vertical transmission, and in Western Australia (WA), culture-based screening at 35-37 weeks' gestation is part of routine care and guides antibiotic administration. Previous Australian studies have focused on other regions or included low sample-size representatives; we aimed to describe antenatal GBS colonization in WA.

METHODOLOGY

A cohort of 814 pregnant women attending antenatal clinics (2015-2017) self-collected vaginal and rectal swabs at ≤22 weeks (n=814) and ≥33 weeks' (n=567) gestation. These were assessed for GBS presence using culture and PCR, and serotyping was conducted using molecular methods. Lifestyle questionnaires and medical data were collected.

RESULTS

We observed an overall GBS colonization rate of 24%, with 10.6  % of positive participants transiently colonized. Ethnicity (Aboriginal, Torres Strait Islander and African), maternal age ≥25 years, vitamin use, frequent sexual intercourse (≥5 times/week) and use of sex toys were associated with GBS colonization. The dominant serotypes identified were Ia (27.9%), III (20.9%), II (16.3%), V (15.8%), Ib (8.4%), VI (5.1%), IV (2.8%), NT (1.9), VIII (0.5%) and IX (0.5%) at visit one, with V (18.9%) preceding serotype II (18.2%) at visit two. Serotype VII was not detected.

CONCLUSION

This is the first cohort study to assess GBS colonization in Western Australian pregnant women and will be highly beneficial for guiding clinical practice and future therapeutic options, in particular, the selection of suitable vaccine candidates.

Vaginal dysbiosis increases risk of preterm fetal membrane rupture, neonatal sepsis and is exacerbated by erythromycin

BACKGROUND

Preterm prelabour rupture of the fetal membranes (PPROM) precedes 30% of preterm births and is a risk factor for early onset neonatal sepsis. As PPROM is strongly associated with ascending vaginal infection, prophylactic antibiotics are widely used. The evolution of vaginal microbiota compositions associated with PPROM and the impact of antibiotics on bacterial compositions are unknown.

METHODS

We prospectively assessed vaginal microbiota prior to and following PPROM using MiSeq-based sequencing of 16S rRNA gene amplicons and examined the impact of erythromycin prophylaxis on bacterial load and community structures.

RESULTS

In contrast to pregnancies delivering at term, vaginal dysbiosis characterised by Lactobacillus spp. depletion was present prior to the rupture of fetal membranes in approximately a third of cases (0% vs. 27%, P = 0.026) and persisted following membrane rupture (31%, P = 0.005). Vaginal dysbiosis was exacerbated by erythromycin treatment (47%, P = 0.00009) particularly in women initially colonised by Lactobacillus spp. Lactobacillus depletion and increased relative abundance of Sneathia spp. were associated with subsequent funisitis and early onset neonatal sepsis.

CONCLUSIONS

Our data show that vaginal microbiota composition is a risk factor for subsequent PPROM and is associated with adverse short-term maternal and neonatal outcomes. This highlights vaginal microbiota as a potentially modifiable antenatal risk factor for PPROM and suggests that routine use of erythromycin for PPROM be re-examined.

Applications for Bacteriophage Therapy during Pregnancy and the Perinatal Period

Pregnant women and their unborn children are a population that is particularly vulnerable to bacterial infection. Physiological changes that occur during pregnancy affect the way women respond to such infections and the options that clinicians have for treatment. Antibiotics are still considered the best option for active infections and a suitable prophylaxis for prevention of potential infections, such as vaginal/rectal Streptococcus agalactiae colonization prior to birth. The effect of such antibiotic use on the developing fetus, however, is still largely unknown. Recent research has suggested that the fetal gut microbiota plays a critical role in fetal immunologic programming. Hence, even minor alterations in this microbiota may have potentially significant downstream effects. An ideal antibacterial therapeutic for administration during pregnancy would be one that is highly specific for its target, leaving the surrounding microbiota intact. This review first provides a basic overview of the challenges a clinician faces when administering therapeutics to a pregnant patient and then goes on to explore common bacterial infections in pregnancy, use of antibiotics for treatment/prevention of such infections and the consequences of such treatment for the mother and infant. With this background established, the review then explores the potential for use of bacteriophage (phage) therapy as an alternative to antibiotics during the antenatal period. Many previous reviews have highlighted the revitalization of and potential for phage therapy for treatment of a range of bacterial infections, particularly in the context of the increasing threat of widespread antibiotic resistance. However, information on the potential for the use of phage therapeutics in pregnancy is lacking. This review aims to provide a thorough overview of studies of this nature and discuss the feasibility of bacteriophage use during pregnancy to treat and/or prevent bacterial infections.

The role of Escherichia coli in reproductive health: state of the art

Escherichia coli is a well-known commensal of the normal intestinal microbiome that can also colonize the vaginal microbiome, usually without symptoms. However, E. coli can also be a highly virulent and frequently deadly pathogen. In this review, I will discuss the role E. coli has in reproductive health and disease.

Antibiotic prophylaxis for premature rupture of membranes and perinatal outcome

AIM

To evaluate the perinatal outcomes of newborns after premature rupture of membranes (PROM) at the term according to the timing of initial antibiotic administration.

MATERIAL AND METHODS

This is a retrospective, cohort study investigating perinatal outcomes of newborns in pregnant women with PROM at the term who were treated with ampicillin within or after 6 h from the PROM. Statistical analysis was performed using Student's t-test for continuous variables test and chi-square or for categorical data.

RESULTS

The study involved 144 pregnant women with PROM and their newborns, a lower number received antibiotics after birth were in the group who received antibiotics within 6 h of PROM (26.4% versus 73.6%), the mediane values of C-reactive protein were lower (3.0 ± 2.9 mg/l versus 6.1 ± 7.3 mg/l; p < 0.001), their newborns remained shorter in hospital after birth (4.13 versus 4.94; p =0.023) and time between PROM and delivery was shorter (p < 0.001). In group who received prophylactic antibiotics after 6 h of the PROM had significantly higher frequency of infection in newborns (45.3% versus 15.4%), and higher number of chorioamnionitis (9.72% versus 3,47%) compared to group who received antibiotics within 6h.

CONCLUSION

Timely usage of antibiotic prophylaxis and shorter time between PROM and delivery improve perinatal outcomes.

Obstetrical disease spectrum in China: an epidemiological study of 111,767 cases in 2011

BACKGROUND

No national research on maternal and fetal complications and outcomes has been carried out in the mainland of China in recent years. This study was to provide a scientific basis for better control of obstetrical and neonatal diseases and better allocation of medical resources by analyzing the epidemiological characteristics of obstetrical diseases in the mainland of China.

METHODS

Hospitalized obstetrical cases from 19 tertiary and 20 secondary hospitals in 14 provinces (nationally representative) during the period January 1, 2011 to December 31, 2011 were randomly selected. The general condition, pregnancy complications, and perinatal outcomes of the patients were studied.

RESULTS

The top five medical and surgical complications of pregnant women in the mainland of China were anemia (6.34%), uterine fibroids (2.69%), thyroid disease (1.11%), thrombocytopenia (0.59%), and heart disease (0.59%). The incidences of premature rupture of membranes (PROM), preterm birth, prolonged pregnancy, hypertensive disorders complicating pregnancy (HDCP), multiple pregnancy, intrahepatic cholestasis of pregnancy (ICP), placenta previa, placental abruption, postpartum hemorrhage, and amniotic fluid embolism were 15.27%, 7.04%, 6.71%, 5.35%, 1.57%, 1.22%, 1.14%, 0.54%, 3.26% and 0.06%, respectively. The incidences of anemia and prolonged pregnancy were significantly lower in tertiary than secondary hospitals (P < 0.001), whereas the incidence of uterine fibroids, thyroid diseases, thrombocytopenia, heart disease, PROM, preterm birth, HDCP, multiple pregnancy, ICP, placenta previa, and placental abruption were significantly higher in tertiary than secondary hospitals (P < 0.001). The cesarean section (CS) rate was 54.77%. The newborn sex ratio was 119:100, and 1.03% of the neonates were malformed. The percentages of low birth weight and fetal macrosomia in full-term babies were 2.10% and 7.09%, respectively.

CONCLUSIONS

The incidence of some obstetrical diseases is still high in the mainland of China. The CS rate is much higher than World Health Organization recommendations, in which CS delivery by maternal request (CDMR) accounted for a large proportion. The government should propose solutions to reduce CS rate, especially the rate of CDMR. Most obstetrical complications have higher incidence in tertiary hospitals compared with secondary hospitals. It is important to manage the health of pregnant women systematically, especially those with high-risk factors.