Using vaginal Group B Streptococcuscolonisation in women with preterm premature rupture of membranes to guide the decision for immediate delivery: a secondary analysis of the PPROMEXIL trials

Analysis of cases of premature rupture of membranes and preterm births to identify effective management measures to prevent them

OBJECTIVE

Aim: Based on retrospective analysis recognize the key factors of development of premature childbirth and elaborate highly specific criteria for individual prognosis to improve perinatal outcomes.

PATIENTS AND METHODS

Materials and Methods: A retrospective analysis of the birth histories of 250 women and their newborns with spontaneous preterm births at 22-36 weeks was conducted using archival data from the department for pregnant women with obstetric pathology of the State Institution "Institute of Pediatrics, Obstetrics and Gynecology named by academician OM Lukianova of the National Academy of Medical Sciences of Ukraine".

RESULTS

Results: Important risk factors for premature rupture of membranes (PROM) in preterm pregnancy include the presence of sexually transmitted diseases (χ2=31.188, p=0.001), bacterial vaginosis (χ2=30.913, p=0.0001), a history of abortion and/or preterm birth (χ2=16.62, p=0.0002), SARS during pregnancy (χ2=16.444, p=0.0002), chronic adnexitis in anamnesis (χ2=11.522, p=0.0031), inflammatory cervical disease (χ2=11.437, p=0.0032), anaemia (χ2=10.815, p=0.0044), isthmic-cervical insufficiency (ІСІ) (χ2=10.345, p=0.0057), chronic pyelonephritis with exacerbation (χ2=9.16, p=0.01), smoking during pregnancy (χ2=10.815, p=0.0044).

CONCLUSION

Conclusions: The results of a retrospective analysis of 250 cases of preterm birth at 22 to 36 weeks allowed us to identify ways to effectively use existing diagnostic measures to determine readiness for pregnancy and the possibility of prolonging pregnancy to the viability of the newborn. Ways to improve the prevention of preterm birth and the design of further research were identified.

Prevention of Early-Onset Neonatal Group B Streptococcal Disease: A Comprehensive Review of Major Guidelines

Importance

Group B Streptococcus (GBS) colonization during pregnancy is associated with significant neonatal morbidity and mortality and represents a major public health concern, often associated with poor screening and management.

Objective

The aim of this study was to review and compare the most recently published influential guidelines on the screening and management of this clinical entity during antenatal and intrapartum periods.

Evidence Acquisition

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, and the Society of Obstetricians and Gynecologists of Canada on the prevention of early-onset neonatal group B streptococcal disease was carried out.

Results

There is a consensus among the reviewed guidelines regarding the optimal screening specimen type, indications for intrapartum antibiotic administration such as bacteriuria during pregnancy, clinical signs of chorioamnionitis or maternal pyrexia, and history of GBS-related neonatal disease. There is also agreement on several conditions where no intervention is recommended, that is, antepartum treatment of GBS and GBS-positive women with planned cesarean delivery and intact membranes. Controversy exists regarding the optimal screening time, with the Royal College of Obstetricians and Gynecologists stating against routine screening and on management strategies related to preterm labor and preterm prelabor rupture of membranes.

Conclusions

The development of consistent international practice protocols for the timely screening of GBS and effective management of this clinical entity both during pregnancy and the intrapartum period seems of paramount importance to safely guide clinical practice and subsequently improve neonatal outcomes.

Colonisation of Group B Streptococcus and its effects on pregnancy outcomes in pregnant women in Guangzhou, China: a retrospective study

OBJECTIVES

This study was to investigate the colonisation rate of Group B Streptococcus (GBS) during pregnancy, and to evaluate the influence of GBS colonisation on pregnancy outcomes.

DESIGN

A retrospective cohort study.

SETTING

Data of 47 380 pregnant women from 2016 to 2022 were collected from the Maternal and Child Health Hospital of Huadu District, Guangzhou City, China.

PARTICIPANTS

A total of 15 040 pregnant women were eligible for this study, of which 32 340 were excluded due to non-native pregnant women, in vitro fertilization infants, malformed fetuses, habitual abortion, abortions due to poor reproductive or obstetrical history, artificial insemination, umbilical cord torsion, and other diseases during pregnancy.

PRIMARY OUTCOME MEASURES

The incidence rates of GBS colonisation and premature delivery, fetal distress, premature rupture of membranes (PROM), low birth weight (LBW), abortion and stillbirth.

RESULTS

Of the 15 040 pregnant women included in this study, 1445 developed GBS colonisation, with a prevalence of 9.61% (95% CI, 9.15 to 10.09). Advanced maternal age (≥35 years) predisposed women to GBS colonisation, and the occurrence of GBS colonisation varied among different ethnic groups. Our data revealed that fetal distress, PROM and LBW were more common in pregnant women colonised with GBS than in pregnant women not colonised with GBS. The incidence for premature delivery, fetal distress, PROM and LBW in infants of pregnant women colonised with GBS was 41.0% (OR=1.410, 95% CI, 1.134 to 1.753), 282.5% (OR=3.825, 95% CI, 3.185 to 4.593), 14.9% (OR=1.149, 95% CI, 1.005 to 1.313), and 29.7% (OR=1.297, 95% CI, 1.010 to 1.664), respectively.

CONCLUSIONS

GBS colonisation was relatively low in pregnant women in Guangzhou. Women of advanced maternal age were more prone to GBS colonisation, and pregnant women colonised with GBS were more predisposed to fetal distress, PROM and LBW.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, September 2022) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and on the Management of Preterm Premature Rupture of Membranes

Aim The revision of this guideline was coordinated by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (OEGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of the guideline is to improve the prediction, prevention and management of preterm birth based on evidence from the current literature, the experience of members of the guidelines commission, and the viewpoint of self-help organizations. Methods The members of the contributing professional societies and organizations developed recommendations and statements based on international literature. The recommendations and statements were presented and adopted using a formal process (structured consensus conferences with neutral moderation, written Delphi vote). Recommendations Part 2 of this short version of the guideline presents statements and recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Group B Streptococcus and Pregnancy: Critical Concepts and Management Nuances

Importance

Group B Streptococcus (GBS) is a common pathogen with an effective treatment. However, it remains a significant cause of neonatal sepsis, morbidity, and mortality. The screening and management of this infection are some of the first concepts learned during medical training in obstetrics. However, effective screening and evidence-based management of GBS are nuanced with many critical caveats.

Objective

The objectives of this review are to discuss the essential aspects of GBS screening and management and to highlight recent changes to recommendations and guidelines.

Evidence Acquisition

Original research articles, review articles, and guidelines on GBS were reviewed.

Results

The following recommendations are based on review of the evidence and professional society guidelines. Screening for GBS should occur between 36 weeks and the end of the 37th week. The culture swab should go 2 cm into the vagina and 1 cm into the anus. Patients can perform their own swabs as well. Penicillin allergy testing has been shown to be safe in pregnancy. Patients with GBS in the urine should be treated at term with antibiotic prophylaxis, independent of the colony count of the culture. Patients who are GBS-positive with preterm and prelabor rupture of membranes after 34 weeks are not candidates for expectant management, as this population has higher rates of neonatal infectious complications. Patients with a history of GBS colonization in prior pregnancy who are GBS-unknown in this current pregnancy and present with labor should receive intrapartum prophylaxis. Work on the GBS vaccine continues.

Conclusions

Although all of the efforts and focus on neonatal early-onset GBS infection have led to lower rates of disease, GBS still remains a major cause of neonatal morbidity and mortality requiring continued vigilance from obstetric providers.

Directive clinique no 430 : Diagnostic et prise en charge de la rupture prématurée des membranes avant terme

OBJECTIF

Fournir des directives claires et concises pour le diagnostic et la prise en charge de la rupture prématurée des membranes avant terme (RPMAT).

POPULATION CIBLE

Toute patiente manifestant une rupture prématurée des membranes avant 37 semaines d'aménorrhée. BéNéFICES, RISQUES ET COûTS: La présente directive clinique vise à fournir les premières recommandations générales canadiennes sur la prise en charge de la rupture des membranes avant terme. Elle repose sur un examen complet et à jour des données probantes sur le diagnostic de la rupture et sur la prise en charge, le bon moment et les modes d'accouchement. DONNéES PROBANTES: Des recherches ont été effectuées dans PubMed-Medline et Cochrane en 2021 en utilisant les termes suivants : preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, PAMG-1, IGFBP-1 test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des directives cliniques et des études observationnelles. D'autres publications pertinentes ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins de santé prénatale ou périnatale. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guideline No. 430: Diagnosis and management of preterm prelabour rupture of membranes

OBJECTIVE

To provide clear and concise guidelines for the diagnosis and management of preterm prelabour rupture of membranes (PPROM) TARGET POPULATION: All patients with PPROM <37 weeks gestation BENEFITS, HARMS, AND COSTS: This guideline aims to provide the first Canadian general guideline on the management of preterm membrane rupture. It includes a comprehensive and up-to-date review of the evidence on the diagnosis, management, timing and method of delivery.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane in 2021: preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, placental alpha microglobulin-1 (PAMG-1) test, insulin-like growth factor-binding protein-1 (IGFBP-1) test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/ antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/Neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Articles included were randomized controlled trials, meta-analyses, systematic reviews, guidelines, and observational studies. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All prenatal and perinatal health care providers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Immediate birth for women between 34 and 37 weeks of gestation with prolonged preterm prelabour rupture of membranes and detection of vaginal or urine group B streptococcus: an economic evaluation

Objective

What are the costs, benefits and harms of immediate birth compared with expectant management in women with prolonged preterm prelabour rupture of membranes (PPROM) at 34⁺⁰–36⁺⁶ weeks of gestation and detection of vaginal or urine group B streptococcus (GBS)?

Design

Mathematical decision model comprising three independent decision trees.

Setting

UK National Health Service (NHS) and personal social services perspective.

Population

Women testing positive for GBS with PPROM at 34⁺⁰–36⁺⁶ weeks of gestation.

Methods

The model estimates lifetime costs and quality‐adjusted life years (QALYs) using evidence from randomised trials, UK NHS data sources and further observational studies. Simulated events include neonatal infections, morbidity associated with preterm birth and consequences of caesarean birth. Deterministic and probabilistic sensitivity analyses (PSAs) were performed.

Main outcome measures

QALYs, costs and incremental cost‐effectiveness ratio (ICER).

Results

In this population, immediate birth dominates expectant management: it is more effective (average lifetime QALYs, 24.705 versus 24.371) and it is cheaper (average lifetime costs, £14,372 versus £19,311). In one‐way sensitivity analysis, results are robust to all but the odds ratio estimating the relative effect on incidence of infections. Threshold analysis shows that the odds of infection only need to be >1.5% with expectant management for the benefit of avoiding infections to outweigh the disadvantages of immediate birth. In PSA, immediate birth is the preferred option in >80% of simulations.

Conclusions

Neonatal GBS infections are expensive to treat and may result in substantial adverse health consequences. Therefore, immediate birth, which is associated with a reduced risk of neonatal infection compared with expectant management, is expected to generate better health outcomes and decreased lifetime costs.

Tweetable abstract

For women with preterm prelabour rupture of membranes and group B streptococcus in vaginal or urine samples, immediate birth is associated with improved health in their babies and reduced costs, compared with expectant management.

For women with preterm prelabour rupture of membranes and group B streptococcus in vaginal or urine samples, immediate birth is associated with improved health in their babies and reduced costs, compared with expectant management.

Risk Factors for Periventricular Leukomalacia in Preterm Infants: A Systematic Review, Meta-analysis, and GRADE-Based Assessment of Certainty of Evidence

BACKGROUND

We analyzed the certainty of evidence (CoE) for risk factors of periventricular leukomalacia (PVL) in preterm neonates, a common morbidity of prematurity.

METHODS

Medline, CENTRAL, Embase, and CINAHL were searched. Cohort and case-control studies and randomised randomized controlled trials were included. Data extraction was performed in duplicate. A random random-effects meta-analysis was utilizedused. CoE was evaluated as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

One hundred eighty-six studies evaluating 95 risk factors for PVL were included. Of the 2,509,507 neonates assessed, 16,569 were diagnosed with PVL. Intraventricular hemorrhage [adjusted odds ratio: 3.22 (2.52-4.12)] had moderate CoE for its association with PVL. Other factors such as hypocarbia, chorioamnionitis, PPROM >48 hour, multifetal pregnancy reduction, antenatal indomethacin, lack of antenatal steroids, perinatal asphyxia, ventilation, shock/hypotension, patent ductus arteriosus requiring surgical ligation, late-onset circulatory collapse, sepsis, necrotizing enterocolitis, and neonatal surgery showed significant association with PVL after adjustment for confounders (CoE: very low to low). Amongst the risk factors associated with mother placental fetal (MPF) triad, there was paucity of literature related to genetic predisposition and defective placentation. Sensitivity analysis revealed that the strength of association between invasive ventilation and PVL decreased over time (P < 0.01), suggesting progress in ventilation strategies. Limited studies had evaluated diffuse PVL.

CONCLUSION

Despite decades of research, our findings indicate that the CoE is low to very low for most of the commonly attributed risk factors of PVL. Future studies should evaluate genetic predisposition and defective placentation in the MPF triad contributing to PVL. Studies evaluating exclusively diffuse PVL are warranted.

Preterm and term prelabour rupture of membranes: A review of timing and methods of labour induction

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.

Updates in prevention policies of early-onset group B streptococcal infection in newborns

Invasive disease owing to group B Streptococcus (GBS) is a major cause of illness and death among newborns. Maternal GBS colonization of gastrointestinal tract and/or vagina is the primary risk factor for neonatal GBS early-onset disease (EOD). In Europe and America, there are marked declines in neonatal GBS-EOD through widespread implementation of guidelines for maternal GBS screening and subsequent intrapartum antibiotic prophylaxis (IAP). The key measures necessary for prevention of GBS-EOD include correct specimen collection and processing, nucleic acid amplification testing (NAAT) for GBS identification, regimens for mothers with premature rupture of membranes (PROM), preterm labor or penicillin allergy, and coordination between obstetrics and pediatrics. Antibiotic prophylaxis has some disadvantages, so researchers should develop other preventive measures. Maternal vaccines to prevent perinatal GBS infection are currently under development. However, as large, population-based sampling studies are rarely conducted, the colonization rate and the disease burden of GBS in perinatal period are poorly understood in developing countries. The harm of GBS to newborns has been recognized in recent years in mainland China, but authorized prevention measures are still lacking. In order to enhance the understanding of GBS-EOD prevention, the most recent guidelines updates by the American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (AAP) in 2019-2020 are summarized in this article.

Ascertaining the Prevalence of Group B Streptococcal Infection in Patients with Preterm Premature Rupture of Membranes: A Cross-Sectional Analysis from Pakistan

Introduction Literature has shown varying results regarding the presence of group B Streptococcal (GBS) infection in pregnant females with preterm premature rupture of membranes (PPROM). The infection can be detrimental to maternal and neonatal well-being. There is a lack of studies that showed the extent of this problem in the local population of Pakistan. Our study aims to determine the frequency of GBS infection in females with PPROM. Methods This cross-sectional study was conducted at the Department of Obstetrics & Gynecology, Lahore General Hospital, Pakistan for six months. Informed consent was obtained from each patient. Demographic data were also recorded. Then the amniotic fluid sample was taken during a vaginal examination and was sent to the laboratory of the hospital for assessment of the presence or absence of GBS. Reports were assessed for GBS infection. Baseline demographics including age, body mass index (BMI), parity, and gestational age were presented as mean and standard deviation. Categorical data like parity and GBS infection were presented as frequency and percentage. Results The mean age of women was 30.04 ± 6.75 years. The mean gestational age of patients was 34.51 ± 1.75 weeks. Among 150 women, GBS infection was diagnosed in 24 (16%) patients. The occurrence of GBS infection was significantly associated with the age and parity status of women (p < 0.05). However, it was not significantly associated with gestational age and BMI of women (p > 0.05). Conclusion Our study showed a low prevalence of GBS infection in females presenting with PPROM. Nonetheless, the presence of infection can lead to detrimental outcomes including neonatal and maternal sepsis. The rate and risk factors of maternal and neonatal GBS colonization may vary in different communities. These rates, as well as the incidence of neonatal disease, need to be thoroughly evaluated to develop appropriate strategies for prevention.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Prevention of Group B Streptococcal Early-Onset Disease in Newborns: ACOG Committee Opinion, Number 782

Group B streptococcus (GBS) is the leading cause of newborn infection. The primary risk factor for neonatal GBS early-onset disease (EOD) is maternal colonization of the genitourinary and gastrointestinal tracts. Approximately 50% of women who are colonized with GBS will transmit the bacteria to their newborns. Vertical transmission usually occurs during labor or after rupture of membranes. In the absence of intrapartum antibiotic prophylaxis, 1-2% of those newborns will develop GBS EOD. Other risk factors include gestational age of less than 37 weeks, very low birth weight, prolonged rupture of membranes, intraamniotic infection, young maternal age, and maternal black race. The key obstetric measures necessary for effective prevention of GBS EOD continue to include universal prenatal screening by vaginal-rectal culture, correct specimen collection and processing, appropriate implementation of intrapartum antibiotic prophylaxis, and coordination with pediatric care providers. The American College of Obstetricians and Gynecologists now recommends performing universal GBS screening between 36 0/7 and 37 6/7 weeks of gestation. All women whose vaginal-rectal cultures at 36 0/7-37 6/7 weeks of gestation are positive for GBS should receive appropriate intrapartum antibiotic prophylaxis unless a prelabor cesarean birth is performed in the setting of intact membranes. Although a shorter duration of recommended intrapartum antibiotics is less effective than 4 or more hours of prophylaxis, 2 hours of antibiotic exposure has been shown to reduce GBS vaginal colony counts and decrease the frequency of a clinical neonatal sepsis diagnosis. Obstetric interventions, when necessary, should not be delayed solely to provide 4 hours of antibiotic administration before birth. This Committee Opinion, including , , and , updates and replaces the obstetric components of the CDC 2010 guidelines, "Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines From CDC, 2010."

Impact of the new guidelines on the management of premature rupture of membranes for the prevention of late preterm birth: an 11-year retrospective study

Objectives To evaluate the number of late preterm (LPT) births (between 34 0/7 and 36 6/7 weeks) that could have been prevented if expectant management of preterm premature rupture of membranes (PPROM) had been applied according to new recommendations. Methods A retrospective cohort study included all births at one Swiss center between January 1, 2002 and December 31, 2012. Births were categorized using an adapted evidence-based classification. Two scenarios were considered: best scenario (maximum averted cases) and a conservative scenario (minimum averted cases). Results Among 2017 LPT births (5.0% of all deliveries; n=40,609), 1122 (60.6%) women had PPROM. Spontaneous labor occurred in 473 (42.2%) cases and 649 (57.8%) had induction of labor or an elective cesarean section. In the latter group, 44 (6.8%) had evidence-based indications for LPT delivery and 605 (83.2%) had non-evidence-based indications. Depending on the scenario, the rate of avoided LPT cases would have varied between 4.2% (95% confidence interval [CI]: 3.4-5.2) if the conservative scenario was applied, and 30% (95% CI: 28.0-32.0) for the best scenario. Conclusion Adoption of new guidelines for the management of PPROM will prevent a considerable number of LPT births and help decrease the adverse effects and potential disability associated with late preterm infants.

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.

[Modalities of birth in case of uncomplicated preterm premature rupture of membranes: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVE

To identify the ideal gestational age at delivery for preterm premature rupture of membranes and modalities of birth.

METHOD

To identify studies, research was conducted using Pub-Med, Embase and Cochrane databases.

RESULTS

Prolonged latency duration after pPROM does not worsen neonatal prognosis (NP3). Therefore, it is recommended not to deliver before 34 weeks of gestation for patient with uncomplicated preterm rupture of membranes (pPROM) (Grade C). After 34 weeks of gestation, expectant management for pPROM is not associated with neonatal sepsis (NP1) but is associated to intra-uterine infection (NP2). Early delivery is associated with higher risk of respiratory distress syndrome (NP2), higher risk of cesarean section (NP2) and longer duration of NICU hospitalization (NP2). Before 37 weeks of gestation, expectant management is recommended for uncomplicated pPROM (Grade A), even if vaginal group B streptococcus is positive, as long as antibiotics are used at the time of membranes rupture (Professional consensus). Elective cesarean section is reserved for usual obstetrical indications. Oxytocin and prostaglandins are reasonable options for inducing labor (Professional consensus). Data are too scarce to establish recommendation regarding intra-cervical balloons in case of pPROM (Professional consensus).

CONCLUSION

Expectant management is recommended for uncomplicated pPROM before 37 weeks of gestation.

A novel one-step real-time multiplex PCR assay to detect Streptococcus agalactiae presence and serotypes Ia, Ib, and III

Streptococcus agalactiae is the leading cause of early-onset neonatal sepsis. Culture-based screening methods lack the sensitivity of molecular assays and do not indicate serotype; a potentially important virulence marker. We aimed to develop a multiplex PCR to detect S. agalactiae while simultaneously identifying serotypes Ia, Ib, and III; commonly associated with infant disease. Primers were designed to target S. agalactiae serotype-specific cps genes and the dltS gene. The assay was validated with 512 vaginal specimens from pregnant women. 112 (21.9%) were dltS positive, with 14.3%, 0.9%, and 6.3% of these identified as cps Ia, Ib, and III, respectively. Our assay is a specific and sensitive method to simultaneously detect S. agalactiae and serotypes Ia, Ib, and III in a single step. It is of high significance for clinical diagnostic applications and also provides epidemiological data on serotype, information that may be important for vaccine development and other targeted non-antibiotic therapies.

Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome

BACKGROUND

Current management of preterm prelabour rupture of the membranes (PPROM) involves either initiating birth soon after PPROM or, alternatively, adopting a 'wait and see' approach (expectant management). It is unclear which strategy is most beneficial for mothers and their babies. This is an update of a Cochrane review published in 2010 (Buchanan 2010).

OBJECTIVES

To assess the effect of planned early birth versus expectant management for women with preterm prelabour rupture of the membranes between 24 and 37 weeks' gestation for fetal, infant and maternal well being.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (30 September 2016), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials comparing planned early birth with expectant management for women with PPROM prior to 37 weeks' gestation. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated trials for inclusion into the review and for methodological quality. Two review authors independently extracted data. We checked data for accuracy. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 12 trials in the review (3617 women and 3628 babies). For primary outcomes, we identified no clear differences between early birth and expectant management in neonatal sepsis (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.66 to 1.30, 12 trials, 3628 babies, evidence graded moderate), or proven neonatal infection with positive blood culture (RR 1.24, 95% CI 0.70 to 2.21, seven trials, 2925 babies). However, early birth increased the incidence of respiratory distress syndrome (RDS) (RR 1.26, 95% CI 1.05 to 1.53, 12 trials, 3622 babies, evidence graded high). Early birth was also associated with an increased rate of caesarean section (RR 1.26, 95% CI 1.11 to 1.44, 12 trials, 3620 women, evidence graded high).Assessment of secondary perinatal outcomes showed no clear differences in overall perinatal mortality (RR 1.76, 95% CI 0.89 to 3.50, 11 trials, 3319 babies), or intrauterine deaths (RR 0.45, 95% CI 0.13 to 1.57, 11 trials, 3321 babies) when comparing early birth with expectant management. However, early birth was associated with a higher rate of neonatal death (RR 2.55, 95% CI 1.17 to 5.56, 11 trials, 3316 babies) and need for ventilation (RR 1.27, 95% CI 1.02 to 1.58, seven trials, 2895 babies, evidence graded high). Babies of women randomised to early birth were delivered at a gestational age lower than those randomised to expectant management (mean difference (MD) -0.48 weeks, 95% CI -0.57 to -0.39, eight trials, 3139 babies). Admission to neonatal intensive care was more likely for those babies randomised to early birth (RR 1.16, 95% CI 1.08 to 1.24, four trials, 2691 babies, evidence graded moderate).In assessing secondary maternal outcomes, we found that early birth was associated with a decreased rate of chorioamnionitis (RR 0.50, 95% CI 0.26 to 0.95, eight trials, 1358 women, evidence graded moderate), and an increased rate of endometritis (RR 1.61, 95% CI 1.00 to 2.59, seven trials, 2980 women). As expected due to the intervention, women randomised to early birth had a higher chance of having an induction of labour (RR 2.18, 95% CI 2.01 to 2.36, four trials, 2691 women). Women randomised to early birth had a decreased total length of hospitalisation (MD -1.75 days, 95% CI -2.45 to -1.05, six trials, 2848 women, evidence graded moderate).Subgroup analyses indicated improved maternal and infant outcomes in expectant management in pregnancies greater than 34 weeks' gestation, specifically relating to RDS and maternal infections. The use of prophylactic antibiotics were shown to be effective in reducing maternal infections in women randomised to expectant management.Overall, we assessed all 12 studies as being at low or unclear risk of bias. Some studies lacked an adequate description of methods and the risk of bias could only be assessed as unclear. In five of the studies there were one and/or two domains where the risk of bias was judged as high. GRADE profiling showed the quality of evidence across all critical outcomes to be moderate to high.

AUTHORS' CONCLUSIONS

With the addition of five randomised controlled trials (2927 women) to this updated review, we found no clinically important difference in the incidence of neonatal sepsis between women who birth immediately and those managed expectantly in PPROM prior to 37 weeks' gestation. Early planned birth was associated with an increase in the incidence of neonatal RDS, need for ventilation, neonatal mortality, endometritis, admission to neonatal intensive care, and the likelihood of birth by caesarean section, but a decreased incidence of chorioamnionitis. Women randomised to early birth also had an increased risk of labour induction, but a decreased length of hospital stay. Babies of women randomised to early birth were more likely to be born at a lower gestational age.In women with PPROM before 37 weeks' gestation with no contraindications to continuing the pregnancy, a policy of expectant management with careful monitoring was associated with better outcomes for the mother and baby.The direction of future research should be aimed at determining which groups of women with PPROM would not benefit from expectant management. This could be determined by analysing subgroups according to gestational age at presentation, corticosteroid usage, and abnormal vaginal microbiological colonisation. Research should also evaluate long-term neurodevelopmental outcomes of infants.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial

BACKGROUND

Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity.

METHODS

The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060.

FINDINGS

Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7).

INTERPRETATION

In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term.

FUNDING

Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Streptococcus agalactiae in pregnancies complicated by preterm prelabor rupture of membranes

OBJECTIVE

The main aim of this study was to evaluate the presence of Streptococcus agalactiae (S. agalactiae) in the vagina and the amniotic fluid in pregnancies complicated by preterm prelabor rupture of membranes (PPROM). The next aim was to evaluate the incidence of S. agalactiae early onset sepsis in newborns from PPROM pregnancies, with respect to the presence of S. agalactiae in the vagina and the amniotic fluid.

METHODS

Singleton gestations with PPROM between 24 + 0 and 36 + 6 were included. A vaginal swab was obtained, and amniocentesis was performed at admission. The presence of S. agalactiae in the vagina and in the amniotic fluid was assessed by culture and by real-time polymerase chain reaction, respectively.

RESULTS

In total, 336 women were included. The presence of S. agalactiae in the vaginal and amniotic fluid was found in 9% (31/336) and 1% (3/336) of women. One woman had S. agalactiae in the amniotic fluid but was negative for the presence of S. agalactiae in the vaginal fluid. Early onset neonatal sepsis developed in one newborn from pregnancies complicated by the presence of S. agalactiae in the amniotic fluid.

CONCLUSION

The presence of S. agalactiae in the vagina and amniotic fluid complicated approximately each 10th and each 100th PPROM pregnancy. Cultivation-negative findings of S. agalactiae in the vagina did not exclude the positivity of the amniotic fluid for S. agalactiae and the development of early onset sepsis in newborns.