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Schmidt EM, Powell JM, Garg B, Caughey AB. Association between Gestational Age and Perinatal Outcomes in Women with Late Preterm Premature Rupture of Membranes. Am J Perinatol 2024. [PMID: 38754462 DOI: 10.1055/a-2328-6192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
OBJECTIVE The American College of Obstetricians and Gynecologists (ACOG) suggests expectant management until 34 weeks for patients with preterm premature rupture of membranes (PPROM). New data suggest extending to 37 weeks might enhance neonatal outcomes, reducing prematurity-linked issues. This study aims to assess adverse neonatal outcomes across gestational ages in women with PPROM. STUDY DESIGN A retrospective cohort study was performed using linked vital statistics and the International Classification of Diseases, Ninth Revision data. Gestational age at delivery ranged from 32 to 36 weeks. Outcomes include neonatal intensive care unit (NICU) admission >24 hours, neonatal sepsis, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. Multivariate regression analyses and chi-square tests were employed for statistical comparisons. RESULTS In this cohort of 28,891 deliveries, there was a statistically significant decline in all studied adverse neonatal outcomes with increasing gestational age, without an increase in neonatal sepsis. At 32 weeks, 93% of newborns were in the NICU >24 hours compared with 81% at 34 weeks and 22% at 36 weeks (p < 0.001). At 32 weeks, 20% had neonatal sepsis compared with 11% at 34 weeks and 3% at 36 weeks (p < 0.001). At 32 weeks, 67% had respiratory distress syndrome compared with 44% at 34 weeks and 12% at 36 weeks (p < 0.001). CONCLUSION In the setting of PPROM, later gestational age at delivery is associated with decreased rates of adverse neonatal outcomes without an increase in neonatal sepsis. KEY POINTS · The ACOG recommends expectant management until 34 weeks for patients with PPROM.. · However, expectant management to 37 weeks might improve neonatal outcomes.. · Later gestational age at delivery was associated with decreased rates of adverse neonatal outcomes.. · Later gestational age at delivery was not associated with an increase in neonatal sepsis.. · The management of PPROM is complex and should be individualized..
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Affiliation(s)
- Eleanor M Schmidt
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Jacqueline M Powell
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, Wisconsin
| | - Bharti Garg
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
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Akhter T, Hesselman S, Lindström L, Axelsson O, Poromaa IS. Maternal and Perinatal Outcomes in Singleton Nulliparous Spontaneous Preterm Birth with and without Preterm Premature Rupture of Membranes-A National Population-Based Cohort Study. Am J Perinatol 2024; 41:e958-e967. [PMID: 36347503 DOI: 10.1055/a-1973-7482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Preterm birth (PTB, birth before 37 gestational weeks) is the leading cause of neonatal death and a major challenge for obstetric and neonatal care. About two-thirds of PTBs are spontaneous PTB (sPTB), of which approximately 30% start with preterm premature rupture of membranes (PPROM). The aim of the study was to investigate risk factors and maternal and perinatal outcomes in sPTB with and without PPROM. STUDY DESIGN This is a national population-based cohort study including all singleton pregnancies in nulliparous women with spontaneous onset of labor and vaginal births (n = 266,968) registered in the Swedish Medical Birth Register 2005 to 2014. sPTB with PPROM (sPTB-PPROM) and sPTB without PPROM were compared regarding risk factors and maternal and perinatal outcomes. Logistic regression was used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Adjustments were made for maternal age, body mass index, country of birth, smoking, chronic hypertension, pregestational and gestational diabetes, and gestational length. RESULTS sPTB-PPROM (n = 5,037), compared with sPTB without PPROM (n = 8,426), was more common in women with previous spontaneous abortions, prepregnancy urinary tract infections, chronic hypertension, and gestational diabetes and had a higher risk of postpartum endometritis (aOR: 2.78, 95% CI: 1.55-5.00). Infants born to women with sPTB-PPROM had a lower risk of birth asphyxia (aOR: 0.60, 95% CI: 0.43-0.83), respiratory distress syndrome (aOR: 0.86, 95% CI: 0.70-1.00), retinopathy of prematurity (aOR: 0.93, 95% CI: 0.92-0.94), necrotizing enterocolitis (aOR: 0.95, 95% CI: 0.94-0.96), and higher risk of hypoglycemia (aOR: 1.14, 95% CI: 1.01-1.28), and hyperbilirubinemia (aOR: 1.28, 95% CI: 1.19-1.38) compared with infants born to sPTB without PPROM. CONCLUSION Our findings of risk factors and distinct differences in adverse outcomes after sPTB-PPROM compared with sPTB without PPROM are of vital importance and might serve as a basis when elaborating programs for the prevention and management of PPROM. KEY POINTS · This is a large cohort study of spontaneous preterm birth (sPTB).. · Singleton nulliparous sPTB with/without preterm premature rupture of membrane (PPROM) were studied.. · Distinct differences in adverse perinatal outcomes in sPTB with and without PPROM were observed..
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Affiliation(s)
- Tansim Akhter
- Department of Women's and Children's Health, Section of Obstetrics and Gynecology, Uppsala University, Uppsala, Sweden
| | - Susanne Hesselman
- Department of Women's and Children's Health, Section of Obstetrics and Gynecology, Uppsala University, Uppsala, Sweden
- Department of Clinical Research, Falun; Uppsala University, Uppsala, Sweden
| | - Linda Lindström
- Department of Women's and Children's Health, Section of Obstetrics and Gynecology, Uppsala University, Uppsala, Sweden
| | - Ove Axelsson
- Department of Women's and Children's Health, Section of Obstetrics and Gynecology, Uppsala University, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden and Centre for Clinical Research, Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Inger Sundström Poromaa
- Department of Women's and Children's Health, Section of Obstetrics and Gynecology, Uppsala University, Uppsala, Sweden
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Ruggieri S, Guido M, Taccaliti C, Latorre G, Gallini F, Forziati V, Caringella D, Giocolano A, Fantasia I. Conservative management of preterm premature rupture of membranes < 30 weeks of gestational age: Effectiveness of clinical guidelines implementation strategies. Eur J Obstet Gynecol Reprod Biol X 2023; 19:100209. [PMID: 37426941 PMCID: PMC10329107 DOI: 10.1016/j.eurox.2023.100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023] Open
Abstract
Objective To compare obstetrical and neonatal outcomes in patients with p-PROM (preterm premature rupture of membranes) at less than 30 weeks of gestational age before and after the application of protocols developed on the basis of international guidelines and to identify local barriers and strategies for their implementation. Study design Single and twin pregnancies with p-PROM < 30 weeks of gestation without signs of infection were retrospectively collected. The population was divided in two groups. Group A contained patients treated before the introduction of the protocol, hospitalized from the day of the p-PROM to delivery and treated according to clinicians' practice. Group B included patients managed according to a standardized protocol, treated with home care management under strict surveillance, after 48 h of hospitalization. Results 19 women with 21 newborns in group A and 22 women with 26 newborns in group B were enrolled. Maternal characteristics and p-PROM gestational age were comparable. In group A we observed minor latency time from diagnosis to delivery (1.6 vs 6.5 weeks, p < 0.001) with lower gestational age at delivery (25.8 ± 2 vs 30.7 ± 4.2 weeks, p = 0.00) and lower newborn weight (859 ± 268 vs 1511 ± 917 g, p = 0.002). Concerning neonatal outcomes, in group A there were lower Apgar score at 1 min (4.0 ± 2.1vs 6.3 ± 2, p = 004), longer hospitalization (42 ± 38 vs 68 ± 38 days, p = 0.05) and, even if non statistically significant, major rate of neonatal mortality (11,5% vs 19%, p = 1.00) and of neonatal complications (need of neonatal intensive care unit, sepsis, bronchopulmonary dysplasia, retinopathy of prematurity, mechanical ventilation). Postnatal follow-up showed comparable outcomes at 24 months of correct age. Conclusions Educational and interdisciplinary meetings, along with group performance audit and standardization of procedures are successful strategies to implement guidelines application. Applying this strategy, we developed a protocol according to international guidelines for the treatment of early onset p-PROM based on a standardized conservative management at home, achieving better results compared to hospital management in terms of latency, gestational age at delivery, neonatal weight and neonatal hospitalization.
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Affiliation(s)
- Stefania Ruggieri
- Department of Obstetrics and Gynecology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
- Obstetrics & Gynaecology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome 00168, Italy
| | - Maurizio Guido
- Obstetrics & Gynaecology Unit, San Salvatore Hospital, L'Aquila 67100, Italy
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila 67100, Italy
| | - Chiara Taccaliti
- Department of Obstetrics and Gynecology, Civitanova Marche Hospital, Civitanova Marche 62012, Italy
| | - Giuseppe Latorre
- Neonatology Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Francesca Gallini
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome 00168, Italy
| | - Vincenzo Forziati
- Neonatology Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Domenico Caringella
- Department of Obstetrics and Gynecology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Alessandra Giocolano
- Department of Obstetrics and Gynecology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Ilaria Fantasia
- Obstetrics & Gynaecology Unit, San Salvatore Hospital, L'Aquila 67100, Italy
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Point F, Ghesquiere L, Drumez E, Petit C, Subtil D, Houfflin-Debarge V, Garabedian C. Risk factors associated with shortened latency before delivery in outpatients managed for preterm prelabor rupture of membranes. Acta Obstet Gynecol Scand 2021; 101:119-126. [PMID: 34747005 DOI: 10.1111/aogs.14287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Preterm prelabor rupture of membranes (PPROM) occurs in 3% of pregnancies and is the main cause (~30%) of premature delivery. Home care seems to be a safe alternative for the management of patients with PPROM, who have a longer latency than those with PPROM managed with conventional hospitalization. We aimed to identify the risk factors associated with a shortened latency before delivery in women with PPROM managed as outpatients. MATERIAL AND METHODS The design was a retrospective cohort study and the setting was a Monocentric Tertiary centre (Lille University Hospital, France) from 2009 to 2018. All consecutive patients in home care after PPROM at 24-36 weeks were included. For the main outcome measure we calculated the latency ratio for each patient as the ratio of the real latency period to the expected latency period, expressed as a percentage. The risk factors influencing this latency ratio were evaluated. RESULTS A total of 234 patients were managed at home after PPROM. Mean latency was 35.5 ± 20.7 days, corresponding to an 80% latency ratio. In 196 (83.8%) patients the length of home care was more than 7 days. A lower latency ratio was significantly associated with oligohydramnios (p < 0.001), gestational age at PPROM (p = 0.006), leukocyte count at PPROM more than 12 × 109 /L (p = 0.025), and C-reactive protein concentration more than 5 mg/L at 7 days after PPROM (p = 0.046). Cervical length was not associated with a lower latency ratio. CONCLUSIONS Women with PPROM managed with home care are stable. The main risk factor associated with a reduced latency is oligohydramnios. Outpatients with oligohydramnios should be informed of the probability of a shortened latency period.
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Affiliation(s)
- Florian Point
- Department of Obstetrics, Lille University Hospital, Lille, France
| | | | - Elodie Drumez
- Department of Biostatistics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
| | - Céline Petit
- Department of Obstetrics, Lille University Hospital, Lille, France
| | - Damien Subtil
- Department of Obstetrics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
| | - Véronique Houfflin-Debarge
- Department of Obstetrics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
| | - Charles Garabedian
- Department of Obstetrics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
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Delorme P, Lorthe E, Sibiude J, Kayem G. Preterm and term prelabour rupture of membranes: A review of timing and methods of labour induction. Best Pract Res Clin Obstet Gynaecol 2021; 77:27-41. [PMID: 34538740 DOI: 10.1016/j.bpobgyn.2021.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 01/07/2023]
Abstract
Prelabour rupture of membranes (PROM) exposes both foetuses and mothers to the risk of infection. Induction of labour has been proposed to reduce this risk, but its neonatal and maternal risks and benefits must be balanced against those of expectant management (EM). Recent randomized studies of preterm PROM show that EM until 37 weeks of gestation is associated with lower overall neonatal morbidity. In term PROM, active management is associated with a shorter birth interval but not with lower rates of neonatal infection. Similar maternal and neonatal outcomes are reported regardless of whether induction uses oxytocin, PGE2, or oral misoprostol.
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Affiliation(s)
- Pierre Delorme
- Sorbonne Université, AP-HP, Department of Gynaecology and Obstetrics, Trousseau Hospital, Paris, France; INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), FHU PREMA, Paris Descartes University, Paris, France
| | - Elsa Lorthe
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), FHU PREMA, Paris Descartes University, Paris, France; Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Jeanne Sibiude
- Université de Paris, IAME, INSERM, F-75018, Paris, France; AP-HP, Hôpital Louis Mourier, Service de Gynécologie-Obstétrique, F-92700, Colombes, France
| | - Gilles Kayem
- Sorbonne Université, AP-HP, Department of Gynaecology and Obstetrics, Trousseau Hospital, Paris, France; INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), FHU PREMA, Paris Descartes University, Paris, France.
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Fulova V, Hostinska E, Studnickova M, Huml K, Zapletalova J, Halek J, Pilka R. Transabdominal amniocentesis in expectant management of preterm premature rupture of membranes: A single center prospective study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:305-315. [PMID: 33087938 DOI: 10.5507/bp.2020.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/15/2020] [Indexed: 11/23/2022] Open
Abstract
AIMS The aim of this study was to evaluate the role of IL-6 point-of-care test in amniotic fluid obtained from serial amniocentesis in expectantly managed women with PPROM between 24 and 34 weeks of gestation. METHODS We conducted a prospective observational cohort study which included 62 pregnant women with PPROM in gestational weeks between 22+0 and 34+0. Women aged >18 years were eligible if they presented with PPROM and a singleton pregnancy. Only women who delivered at >24.0 weeks were included in the study. In all women, the maternal blood sampling and a transabdominal amniocentesis were performed at the time of admission prior to the administration of corticosteroids, antibiotics, or tocolytics, to rule out signs of chorioamnionitis. Maternal temperature, maternal serum C-reactive protein (CRP) and white blood cell (WBC) counts were assayed every subsequent day until delivery. Amniotic fluid was used for the clinical assessment (IL-6 point-of-care test, identification of microorganisms in the amniotic fluid. After one week of expectant management of PPROM, second amniocentesis with amniotic fluid sampling was performed in patients who did not deliver. For all newborns, medical records regarding neonatal morbidity and mortality were reviewed. RESULTS In total, 62 women aged 19 to 41 years were recruited in the study. The mean gestational age at the time of PPROM was 31+0, the mean gestational age at labor was 32+1, and the median time from PPROM to childbirth was 112 h. IL-6 point-of-care test values above 1,000 pg/mL (positive Il-6 AMC) were found in 12 women (19.4%) with median interval from PPROM to childbirth 56 h (min-max: 6.4-288). IL-6 point-of-care test values below 1,000 pg/mL (negative Il-6 AMC) were found in 51 women (81.0%). The neonatal mortality rate was 1.9% and was associated with prematurity. CONCLUSION The major clinical finding of our study is that serial transabdominal amniocentesis with Il-6 point-of-care test helps to identify a high inflammatory status in amniotic fluid in women with PPROM. Subsequent expectant management of women with PPROM does not lead to worsening of short-term neonatal outcomes.
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Affiliation(s)
- Veronika Fulova
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic
| | - Eliska Hostinska
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic
| | - Martina Studnickova
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic
| | - Karel Huml
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic
| | - Jana Zapletalova
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Jan Halek
- Department of Neonatology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic
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Can maternal characteristics on admission for preterm prelabor rupture of membranes predict pregnancy latency? Am J Obstet Gynecol MFM 2020; 2:100194. [PMID: 33345914 DOI: 10.1016/j.ajogmf.2020.100194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/13/2020] [Accepted: 07/21/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Latency duration after preterm prelabor rupture of membranes has been an area of investigation for many years. Previously described factors associated with latency include gestational age at the time of rupture, cervical dilation of >1 cm, vaginal bleeding at the time of presentation, and oligohydramnios. However, little is known about the impact of composite maternal factors and presenting symptoms on the duration or prediction of the latency period. OBJECTIVE This study aimed to determine whether maternal factors and subjective presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes. STUDY DESIGN This is a retrospective observational study of singleton pregnancies complicated by preterm prelabor rupture of membranes for over 3 years at a single institution utilizing a uniform management protocol. Maternal demographics, obstetrical data, maternal subjective symptoms and physical examination findings on admission, amniotic fluid volume assessment, presence of contractions, and maternal perception of feeling unwell were collected and analyzed. Clinical characteristics were summarized with mean and standard deviation for continuous measures and frequency and percentages for categorical variables. For skewed variables, medians with 25th and 75th percentiles were reported. Cumulative latency duration (ie, survival time) was estimated with a Kaplan-Meier model. Multivariable Cox proportional hazards regression model with backward variable selection was used to determine the effects of maternal factors on latency duration. RESULTS Of the 212 patients available for analysis, there was a considerable variability in the latency duration with values ranging between 0 and 119 days. Factors related to latency duration included maternal age, parity, gestational age at rupture, cervical dilation, amniotic fluid volume, and contractions. Advancing maternal age (P=.012), increased gestational age at rupture (P<.0001), cervical dilation of ≥3 (vs 0; P<.0001), anhydramnios or oligohydramnios (vs normal amniotic fluid; P<.0001), cramping (P=.012), and painful contractions (P=.015) were associated with a shorter latency duration. Utilizing these statistically significant factors, we constructed a nomogram to predict latency for 1-day, 1-week, and overall median latency duration. CONCLUSION Maternal factors and presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes. We created a nomogram for clinical use that provides a visual display of the probability of pregnancy latency. This tool may be useful for counseling and providing additional information on expectations for providers and patients with pregnancies complicated by preterm prelabor rupture of membranes.
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