A systematic review of pregnancy outcome following preterm premature rupture of membranes at a previable gestational age

Pregnancy outcomes following maternal macrolide use: A systematic review and meta-analysis

To determine whether gestational use of all or specific macrolides (azithromycin, clarithromycin, roxithromycin or erythromycin) lead to an increase in rates of overall major congenital malformations, organ-specific malformations, and other adverse pregnancy outcomes in infants. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials and Reprotox® databases were searched. Dichotomous outcomes or calculated log odds ratios and standard errors from observational studies are combined using the random-effects method in Review Manager 5.3. No significant increased risks for major congenital malformation (OR 1.06 [95% CI 0.99, 1.13]) and congenital heart defect (OR 1.05 [95% CI 0.92, 1.19]) following all macrolides use during the first trimester were detected. Prenatal azithromycin use was associated with a significantly increased risk of major congenital malformations in the analysis of cohort studies (OR 1.21 [95% CI 1.08-1.36]). This significance was also present in the sensitivity analysis. There were no statistically significant associations between the risk of organ specific malformations and all or specific macrolide exposures except for the decreased risk in hypospadias following erythromycin use in the meta-analysis of case-control studies (OR 0.38 [95% CI 0.18, 0.81]. Also, a significant 1.5-fold increased risk for spontaneous abortion following macrolide use was detected. A slight yet significantly increased rate of major congenital malformation with azithromycin exposure during pregnancy may be associated with maternal confounders. Nevertheless, level II ultrasound can be suggested following maternal azithromycin use during the first trimester. Future studies should take into account the inclusion of a disease-matched control group and accurate classification of the malformations.

Maternal and neonatal outcomes of expectantly managed pregnancies with previable preterm premature rupture of membranes

PURPOSE

This study aimed to describe the maternal and fetal outcomes associated with expectant management following previable preterm premature rupture of membranes (PPROM) before 24 weeks of gestation. We also analyzed the risk estimates of potential confounders to clarify whether these variables are contributed to the risk of postnatal mortality among these neonates.

METHODS

This retrospective cohort study included all pregnant patients who experienced previable PPROM before 24 weeks of gestation at a tertiary maternal-fetal medicine center. We used the neonatal data from birth until discharge.

RESULTS

A total of 128 women were enrolled. The survival to discharge rate was 60.9%. The median latency period (80 vs. 20 days, respectively, p < 0.001) was significantly longer, the median gestational week at delivery (34 vs. 25 weeks, respectively, p < 0.001) and median birth weight (2100 vs. 710 g, p < 0.001) was significantly higher in the survivor group than the non-survivor group. Surviving neonates had significantly lower frequencies of anhydramnios at any time during the latency period than the non-survivor neonates (38.4% vs. 86.0%, respectively, p < 0.001).

CONCLUSION

This study demonstrated an opposite correlation between the duration of latency period and gestational age at PPROM with earlier membrane rupture in pregnancies having a longer latency period, which additionally clarifies the higher gestational age at delivery. The antepartum factors that increased the possibility of postnatal mortality within our study included the gestational week at delivery, duration of the latency period, anhydramnios at any time during the latency period, and birth weight.

Maternal morbidity after preterm premature rupture of membranes at <24 weeks' gestation

BACKGROUND

After preterm premature rupture of membranes at <24 weeks' gestation, pregnant women may choose continuation (expectant management) or termination of pregnancy, via either dilation and evacuation or labor induction. Neonatal outcomes after expectant management are well described. In contrast, limited research addresses maternal outcomes associated with expectant management compared to termination of pregnancy.

OBJECTIVE

This study aimed to compare maternal morbidity after preterm premature rupture of membranes at <24 weeks' gestation in women who choose either expectant management or termination of pregnancy.

STUDY DESIGN

This retrospective cohort study included women with preterm premature rupture of membranes between 14 0/7 and 23 6/7 weeks' gestation with singleton or twin pregnancies at 3 institutions from 2011 to 2018. We excluded pregnancies complicated by fetal anomalies, rupture of membranes immediately after obstetrical procedures (chorionic villus sampling, amniocentesis, cerclage placement, fetal reduction), spontaneous delivery <24 hours after membrane rupture, and contraindications to expectant management. Our primary outcome was the difference in composite maternal morbidity between women choosing expectant management and women choosing termination of pregnancy. We defined composite maternal morbidity as at least 1 of the following: chorioamnionitis, endometritis, sepsis, unplanned operative procedure after delivery (dilation and curettage, laparoscopy, or laparotomy), injury requiring repair, unplanned hysterectomy, unplanned hysterotomy (excluding cesarean delivery), uterine rupture, hemorrhage of >1000 mL, transfusion, admission to the maternal intensive care unit, acute renal insufficiency, venous thromboembolism, pulmonary embolism, and readmission to the hospital within 6 weeks. We compared the demographic and antenatal characteristics of women choosing expectant management with that of women choosing termination of pregnancy and used logistic regression to quantify the association between initial management decision and composite maternal morbidity.

RESULTS

We identified 350 women with pregnancies complicated by preterm premature rupture of membranes at <24 weeks' gestation, and 208 women were eligible for the study. Of the 208 women, 108 (51.9%) chose expectant management as initial management, and 100 (48.1%) chose termination of pregnancy as initial management. Among women selecting termination of pregnancy, 67.0% underwent labor induction, and 33.0% underwent dilation and evacuation. Compared to women who chose termination of pregnancy, women who chose expectant management had 4.1 times the odds of developing chorioamnionitis (38.0% vs 13.0%; 95% confidence interval, 2.03-8.26) and 2.44 times the odds of postpartum hemorrhage (23.1% vs 11.0%; 95% confidence interval, 1.13-5.26). Admissions to the intensive care unit and unplanned hysterectomy only occurred after expectant management (2.8% vs 0.0% and 0.9% vs 0.0%). Of women who chose expectant management, 36.2% delivered via cesarean delivery with 56.4% non-low transverse uterine incisions. Composite maternal morbidity rates were 60.2% in the expectant management group and 33.0% in the termination of pregnancy group. After adjusting for gestational age at rupture, site, race and ethnicity, gestational age at entry to prenatal care, preterm premature rupture of membranes in a previous pregnancy, twin pregnancy, smoking, cerclage, and cervical examination at the time of presentation, expectant management was associated with 3.47 times the odds of composite maternal morbidity (95% confidence interval, 1.52-7.93), corresponding to an adjusted relative risk of 1.91 (95% confidence interval, 1.35-2.73). Among women who chose expectant management, 15.7% avoided morbidity and had a neonate who survived to discharge.

CONCLUSION

Expectant management for preterm premature rupture of membranes at <24 weeks' gestation was associated with a significantly increased risk of maternal morbidity when compared to termination of pregnancy.

Maternal, perinatal and childhood outcomes of the PPROMEXIL-III cohort: Pregnancies complicated by previable prelabor rupture of membranes

OBJECTIVE

Perinatal mortality after previable prelabor rupture of membranes (previable PROM) might be underestimated as most studies exclude patients with poor prognosis, or solely include patients in tertiary-care centers. We aimed to report perinatal, neonatal and long-term outcomes in a consecutive series of women with pregnancies complicated by previable PROM.

STUDY DESIGN

We conducted a prospective cohort study including women with singleton pregnancies and previable PROM ≤ 23⁺⁶ weeks gestational age (GA) from one tertiary hospital and eight affiliated secondary hospitals in the region of Amsterdam, the Netherlands (June 2012 until January 2016, PPROMEXIL-III cohort). Exclusion criteria were signs of active labor before onset of PROM or fetal structural anomalies visible at ultrasound. We assessed perinatal mortality. Furthermore, outcomes were maternal, perinatal, neonatal and long-term child characteristics.

RESULTS

We included 98 pregnancies with previable PROM. Twelve women (12.2%) opted for termination of pregnancy, resulting in 86 pregnancies included in further analyses. Median GA at PROM was 20⁺² weeks (interquartile range (IQR) 17⁺⁶-22⁺⁰). Median GA at delivery was 22⁺⁶ weeks (IQR 20⁺¹-26⁺⁴). Delivery within 1 week occurred in 38.4% of women and 60.4% delivered before 24 weeks GA (viability). Perinatal mortality occurred in 73.3% of pregnancies. 23/33 (69.7%) live-born neonates survived to discharge, representing 26.7% of total. None of the children died after discharge. Developmental data at two and/or five years of age was available for 13/23 children (i.e. all children born before 32 weeks of gestation), with 69.2% of children reporting a normal neurodevelopment. However, more than half of children reported respiratory problems.

CONCLUSION

In women with previable PROM perinatal mortality was 73.3%, with a normal neurodevelopment in 69.2% of surviving children with follow-up data. Due to broad inclusion criteria, this cohort represents a population more generalizable to daily practice as compared to previous studies.

Predicting previable preterm premature rupture of membranes (pPPROM) before 24 weeks: maternal and fetal/neonatal risk factors for survival

We sought to compare maternal and neonatal risk factors in cases with previable premature rupture of membranes (pPPROM, between 14-24 weeks) for optimal counselling. Therefore, 192 pregnancies of 485 cases which met selection criteria and agreed to follow-up were retrospectively analysed. Mean gestational age at pPPROM was 20.45 weeks. Live births occurred in 171 cases, but 67 (39.2%) of them died in the neonatal period (neonatal death group) and 104 cases (60.8%) constituted surviving neonate group. Of the surviving neonates, 37 (33.7%) experienced at least one complication. Most seen maternal complications were chorioamnionitis (24.48%) and placental abruption (8.33%). Although amniotic fluid volume, length of pPPROM period, completing antibiotherapy and CRP values were significant, amniotic fluid volume and length of pPPROM showed also significance for multivariate regression analysis for maternal risk factors. Risk factors for birth were gestational age at pPPROM, gestational age at birth, new-born weight at birth, 1^st and 5^th minute Apgar scores, umbilical cord pH value and need for neonatal resuscitation. Furthermore, development of respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage and retinopathy of premature were additional risk factors for neonate. Of them, gestational age at birth, new-born weight at birth, respiratory distress syndrome and retinopathy of prematurity were also significant in multivariate regression analysis.Impact StatementWhat is already known on this subject? Management of previable premature rupture of membranes is controversial and there is no definite consensus on the approach. The factor that best predicts neonatal survival is the gestational age at birth (Deutsch et al. 2010).What do the results of this study add? Appropriate counselling for pPPROM cases is important especially during antenatal period (maternal factors) and postpartum period (neonatal factors). Maternal infection risk is increased with an increased latency period of PPROM. As the gestational age at birth increases, the survival rate increases and neonatal complication rates decrease. Other important determinants of neonatal survival and well-being are the presence of oligo-anhydramnios and latency period of previable PPROM to delivery.What are the implications of these findings for clinical practice and/or further research? Counselling the patient with previable PPROM about pregnancy complications and paediatric outcome is challenging because of the small size, different gestational age ranges, and retrospective nature of the multiple studies on this subject. The most important feature of our study was the relatively high number of patients compared to other series. Thus, we can counsel pregnant women with PPROM prior to 24 weeks of gestation about the maternal antenatal factors and neonatal postnatal factors with related outcomes and help make an informed decision regarding termination or conservative follow-up. Nevertheless, there is a need for larger multicentric prospective studies to validate our data and to establish the prognosis of previable PPROM for both mother and foetus.

Factors Associated with Previable Delivery following Second Trimester Rupture of Membranes

OBJECTIVE

To identify factors associated with previable delivery in second trimester preterm rupture of membranes (PROM).

STUDY DESIGN

We conducted a single-center retrospective cohort study of women with pregnancies complicated by second trimester PROM (14.0-21.9 weeks' gestation) from 2000 to 2015 who elected expectant pregnancy management and achieved at least 24 hours latency. Maternal characteristics and clinical factors were compared among pregnancies that reached viability (≥ 23.0 weeks) and pregnancies delivered before viability (< 23.0 weeks) using appropriate statistical methods.

RESULTS

Of 73 pregnancies complicated by second trimester PROM, 49 (67%) delivered before viability. Maternal race, history of preterm birth, and tobacco use were similar between women who delivered < 23 weeks versus ≥ 23 weeks. Gestational age at PROM, cervical dilation > 1cm, Group B streptococcus carrier status, bacterial vaginosis, and chlamydial infection during pregnancy were similar between groups. Median time to delivery was significantly shorter in women who delivered < 23 weeks compared with those who reached ≥ 23 weeks (6 vs. 46 days, p < 0.01).

CONCLUSION

Previable delivery occurred in the majority of women with second trimester PROM. No maternal or clinical factors were associated with delivery prior to viability. Counseling women with second trimester PROM should include the inability to determine which pregnancies will reach viability.

[Antenatal management in case of preterm premature rupture of membranes before fetal viability: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVES

To evaluate the maternal, perinatal and long-term prognosis in the event of previable premature rupture of the membranes (PROM) and to specify the interventions likely to reduce the risks and improve the prognosis.

METHODS

The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

Previable PROM is a rare event whose frequency varies from 0.3 to 1% according to estimates (NP4). When occurring as a complication of amniocentesis, the prognosis is generally better than when spontaneous (NP3). Between 23 and 39% of women will deliver in the week following PROM and nearly 40% of women will not have given birth 2 weeks after (NP3). The frequency of medical termination of pregnancy varies greatly according to the studies (NP4), as does that of fetal death (NP4). Hospital survival and survival rates without major morbidity as a proportion of conservatively treated patients range from 17-55% and 26-63%, respectively (NP4). Neonatal prognosis is largely dominated by prematurity and its complications (NP3). The frequency of maternal sepsis varies from 0.8 to 4.8% in the most recent studies (NP4). Only one case of maternal death is reported, although 3 cases were identified in France between 2007 and 2012 (NP3). Information is a major component of the care to be provided to women and their partners (Professional consensus). An initial period of hospitalization may be proposed after previable PROM (Professional consensus). Thereafter, there is no argument to recommend hospital management rather than extra-hospital management when there is no argument in favour of intrauterine infection (Professional consensus). An evaluation of the amount of amniotic fluid by ultrasound may be proposed at the initial consultation and after a period of 7 to 14 days if pregnancy continues (Professional consensus). Prophylactic antibiotic treatment is recommended as soon as PROM is diagnosed (Professional consensus). The gestational age at which corticosteroid therapy may be proposed will depend on the thresholds selected for neonatal resuscitation care. In particular, it will take into account parental positioning (Professional consensus). From the time of the decision to perform neonatal resuscitation until the gestational age of 32 weeks, it is recommended to administer MgSO₄ to the woman whose delivery is imminent (Grade A). Tocolysis is not recommended in this context (Professional consensus). In certain situations, meeting strictly the conditions mentioned by the CSP article L. 2213-1, a maternal request for medical interruption of pregnancy may be discussed.

CONCLUSION

The levels of evidence of scientific work on the management of previable PROM are low, therefore, most of the recommendations proposed here are based on professional agreement by "reasonable" extension of recommendations valid for later gestational ages.

Preterm premature rupture of membranes at 22-25 weeks' gestation: perinatal and 2-year outcomes within a national population-based study (EPIPAGE-2)

BACKGROUND

Most clinical guidelines state that with early preterm premature rupture of membranes, obstetric and pediatric teams must share a realistic and individualized appraisal of neonatal outcomes with parents and consider their wishes for all decisions. However, we currently lack reliable and relevant data, according to gestational age at rupture of membranes, to adequately counsel parents during pregnancy and to reflect on our policies of care at these extreme gestational ages.

OBJECTIVE

We sought to describe both perinatal and 2-year outcomes of preterm infants born after preterm premature rupture of membranes at 22-25 weeks' gestation.

STUDY DESIGN

EPIPAGE-2 is a French national prospective population-based cohort of preterm infants born in 546 maternity units in 2011. Inclusion criteria in this analysis were women diagnosed with preterm premature rupture of membranes at 22-25 weeks' gestation and singleton or twin gestations with fetus(es) alive at rupture of membranes. Latency duration, antenatal management, and outcomes (survival at discharge, survival at discharge without severe morbidity, and survival at 2 years' corrected age without cerebral palsy) were described and compared by gestational age at preterm premature rupture of membranes.

RESULTS

Among the 1435 women with a diagnosis of preterm premature rupture of membranes, 379 were at 22-25 weeks' gestation, with 427 fetuses (331 singletons and 96 twins). Median gestational age at preterm premature rupture of membranes and at birth were 24 (interquartile range 23-25) and 25 (24-27) weeks, respectively. For each gestational age at preterm premature rupture of membranes, nearly half of the fetuses were born within the week after the rupture of membranes. Among the 427 fetuses, 51.7% were survivors at discharge (14.1%, 39.5%, 66.8%, and 75.8% with preterm premature rupture of membranes at 22, 23, 24, and 25 weeks, respectively), 38.8% were survivors at discharge without severe morbidity, and 46.4% were survivors at 2 years without cerebral palsy, with wide variations by gestational age at preterm premature rupture of membranes. Survival at 2 years without cerebral palsy was low with preterm premature rupture of membranes at 22 and 23 weeks but reached approximately 60% and 70% with preterm premature rupture of membranes at 24 and 25 weeks.

CONCLUSION

Preterm premature rupture of membranes at 22-25 weeks is associated with high incidence of mortality and morbidity, with wide variations by gestational age at preterm premature rupture of membranes. However, a nonnegligible proportion of children survive without severe morbidity both at discharge and at 2 years' corrected age.

Maternal and neonatal outcomes following expectant management of preterm prelabor rupture of membranes before viability

Purpose: To provide center-based outcome data on obstetric and neonatal complications arising from expectantly managed pregnancies affected by preterm prelabor rupture of membranes (PPROM) before viability.Materials and methods: We collected data on 130 consecutive pregnancies complicated by spontaneous rupture of membranes before 24 week's gestation, occurring over a 7-year period. These were women who delivered >24 h after membrane rupture, and had no signs of chorioamnionitis or advanced labor at admission. Women with amniocentesis-induced PPROM (n = 7) were analyzed separately. The descriptive statistics of obstetrics and neonatal outcomes were reported.Results: The overall neonatal survival to discharge rate was 33.8%. Stratification of patients into early (12 to 19⁺⁶ weeks' gestation) and late pre-viable PPROM (20 to 23⁺⁶ weeks' gestation) revealed a 3.6-fold increase in survival rate in the latter group (12.2% versus 43.8%, p < .001). Pre-viable PPROM following amniocentesis predicted a 100% survival outcome, however anhydramnios impacted negatively. The most common neonatal morbidities of those admitted to intensive care unit were respiratory distress syndrome (78.7%) and bronchopulmonary dysplasia (84.4%). The most common maternal morbidities affecting pre-viable PPROM were clinical chorioamnionitis (47.7%), histological chorioamnionitis (81.8%), retained products of conception (39.3%) and preterm labor (45.4%).Conclusions: Later gestational ages at PPROM were associated with better survival rates, however neonatal morbidity remained high. Women experiencing pre-viable PPROM following amniocentesis can be reassured, while those with anhydramnios at any time during the latency period should be adequately counseled regarding poorer outcomes.

Outcomes of hypoxic respiratory failure at birth associated with previable rupture of membranes

OBJECTIVE

To characterize clinical outcomes of infants born after previable rupture of membranes (pROM, < 23 weeks gestation and latency period ≥ 2 weeks) in relation to refractory hypoxic respiratory failure (rHRF).

STUDY DESIGN

pROM neonates categorized as rHRF (FiO₂ > 0.6 for ≥ 2 h) and treated (high frequency ventilation + inhaled nitric oxide) were compared with no rHRF group. Primary outcome was survival until discharge. Factors associated with rHRF and mortality were identified.

RESULT

Overall, mortality and disability rates were 28% and 22%, respectively. Treated rHRF group (n = 32) had longer period of ROM, mortality was (31% vs. 14%; p = 0.20), with similar survival-without-disability (54% vs. 47%; p = 0.67). Higher gestational age at birth [1.57 (1.03,2.39)] and cesarean delivery [12.6 (1.22,125)] were associated with increased survival.

CONCLUSION

Birth after pROM is associated with high rates of adverse outcomes, independent of latency period. Following treatment, rHRF infants may have similar long-term outcomes as those without rHRF.

Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability

AIM

To assess the contemporary maternal and neonatal outcomes following expectant management of preterm premature rupture of membranes (PPROM) prior to 24 weeks' gestation and to identify prognostic indicators of this morbid presentation.

METHODS

We performed a systematic review in the Pubmed and EMBASE databases to identify the primary (perinatal mortality, severe neonatal morbidity and serious maternal morbidity) and secondary (neonatal survival and morbidity) outcomes following expectant management of previable PPROM.

RESULTS

Mean latency between PPROM and delivery ranged between 20 and 43 days. Women with PPROM <24 weeks had an overall live birth rate of 63.6% and a survival-to-discharge rate of 44.9%. The common neonatal morbidities were respiratory distress syndrome, bronchopulmonary dysplasia and sepsis. The majority of neonatal deaths within 24 h post birth were associated with pulmonary hypoplasia, severe intraventricular haemorrhage and neonatal sepsis. The common maternal outcomes were chorioamnionitis and caesarean sections. The major predictors of neonatal survival were later gestational age at PPROM, adequate residual amniotic fluid levels, C-reactive protein <1 mg/dL within 24 h of admission and PPROM after invasive procedures.

CONCLUSION

Pregnancy latency and neonatal survival following previable PPROM has improved in recent years, although neonatal morbidity remains unchanged despite recent advances in obstetric and neonatal care. There is heterogeneity in management practices across centres worldwide.

Air pollution and preterm premature rupture of membranes: a spatiotemporal analysis

Preterm premature rupture of membranes (PROM) is the leading identifiable predisposing factor for preterm birth. Although maternal exposure to air pollution can potentially have an impact on preterm PROM, there is no available evidence on such an impact. In this study, based on 5,555 singleton births occurring in Barcelona, Spain (2002-2005), we investigated the associations of maternal exposure to nitrogen dioxide, nitrogen oxides, and particulate matter with aerodynamic diameters of ≤2.5 µm (PM2.5), 2.5 µm-10 µm, and ≤10 µm and PM2.5 light absorption with preterm PROM and gestational age at the rupture of membranes (ROM). We utilized temporally adjusted land-use regression models to predict pollutant levels at each subject's home address during each week of her pregnancy. We conducted matched (according to the length of exposure) case-control analyses to estimate the preterm PROM risk associated with 1 interquartile-range increase in exposure levels during the entire pregnancy and during the last 3 months prior to ROM. We found an increase in preterm PROM risk of up to 50% (95% confidence interval: 4, 116) and a 1.3-day (95% confidence interval: -1.9, -0.6) reduction in gestational age at ROM associated with PM2.5 absorbance, nitrogen dioxide exposure, and nitrogen oxide exposure during the entire pregnancy and the last 3 months prior to ROM.

Predictive factors for neonatal survival in women with periviable preterm rupture of the membranes

OBJECTIVE

To identify clinical, hematological or instrumental factors available at the time of the diagnosis that may predict neonatal survival in periviable preterm premature rupture of the membranes (PROM).

METHODS

We report on a cohort (n = 85) of women with periviable PROM (14-23.6 weeks' gestation) occurring over a 10-year period in a single institution. The main outcome chosen was the survival rate beyond the neonatal period. Variables considered were those available at 24 h after admission.

RESULTS

The overall survival rate was 49%. In the multivariate analysis, significant contributions for the prediction of neonatal survival were provided by four variables: genetic amniocentesis-related cause of PROM (p < 0.001), gestational age at PROM (p = 0.019), CRP > 1 mg/dl within 24 h after admission (p = 0.042) and oligohydramnios (largest vertical pocket ≤2 cm) (p = 0.041). The corresponding adjusted odds ratio (OR)s were 73.9 (95% CI: 7.9-694.7), 1.5 (95% CI: 1.1-2.0) per week, 0.26 (95% CI: 0.07-0.95) and 0.20 (95% CI: 0.04-0.93), respectively.

CONCLUSIONS

Genetic amniocentesis-related cause of PROM, gestational age at PROM, C-reactive protein >1 mg/dl and oligohydramnios are significantly associated with survival in women with periviable PROM. The evaluation of these few and easily available variables may help physicians and patients in the decision-making process of this demanding condition.

Amniopatch procedure after previable iatrogenic rupture of the membranes: a two-center review

OBJECTIVE

This study aimed to analyze success rates and pregnancy outcomes of amniopatch procedures for previable iatrogenic preterm prelabour rupture of the membranes (PPROM) with associated oligohydramnios.

METHODS

Retrospective analysis of amniopatch procedures performed at the University Hospitals Leuven, Belgium, and the Mount Sinai Hospital Toronto, Canada. Cases were analyzed overall and in two sub-groups: PPROM after a needle-based procedure (NP group, n = 13) or after fetoscopic intervention (FI group, n = 11). Complete technical success was defined as cessation of leakage and normalization of amniotic fluid volume, partial success as cessation of leakage, or re-establishment of volume. Further outcomes were pregnancy duration and outcome, fetal/neonatal morbidity and mortality, and maternal morbidity.

RESULTS

Gestational age at amniopatch was comparable in both groups (NP: 20.1, FI: 21.0 weeks). Amniopatch was completely and partially successful in 29% (NP: 31%; FI: 27%) and 29% (NP: 15%; FI: 45%), respectively. Mean gestational age at delivery was 27.5 weeks (NP: 25.5; FI: 29.4 weeks). Overall neonatal survival was 17/31 (55%) (NP: 4/13 (31%), FI: 13/18 (72%); p = .02). Chorioamnionitis occurred in three cases, two associated with maternal sepsis. Severe neonatal morbidity occurred in two survivors.

CONCLUSION

Amniopatch for iPPROM was successful in 58%, with an overall live birth rate of 68% and survival to discharge of 55%.

Premature rupture of membranes before 28 weeks managed expectantly: maternal and perinatal outcomes in a developing country

This study aimed to assess outcomes of expectant management for early preterm premature rupture of membranes (PPROM). This retrospective cohort involved 66 women with PPROM <28 weeks managed in a single hospital (1999-2006). Main outcomes were chorioamnionitis, severe maternal morbidity (maternal sepsis, haemorrhage/blood transfusion, hysterectomy or admission to intensive care unit), maternal mortality, low birth weight, preterm birth, neonatal infection and perinatal mortality. Mean gestational ages at PPROM and delivery were 21.7 ± 4.2 and 28.4 ± 5.9 weeks, respectively. Chorioamnionitis was diagnosed in 47%; no cases of severe maternal morbidity or mortality occurred. Stillbirth rate was 25.7% and >80% of infants were delivered before 34 weeks. Neonatal infection was diagnosed in 42.9% of the 49 live-births. Overall survival rate was 57.6%. Expectant management of PPROM <28 weeks resulted in high rates of chorioamnionitis and preterm deliveries but in over half of the cases, a live infant was discharged home.

Early functional echocardiogram and inhaled nitric oxide: usefulness in managing neonates born following extreme preterm premature rupture of membranes (PPROM)

AIM

Poor neonatal outcome of preterm premature rupture of membranes (PPROM) < 24 weeks' gestational age (GA) is probably a result of abnormalities in both airway and vascular developments, ventilation perfusion mismatch, and possibly persistent pulmonary hypertension of the newborn (PPHN). Perinatal mortality of 50-90% has been reported in the past, with recent literature reporting significant improvement in neonatal survival. We report our 8-year experience in this group of infants using early diagnostic functional echocardiography (fECHO), high-frequency ventilation (HFV) and inhaled nitric oxide (iNO).

METHODS

The obstetric and neonatal databases were searched to identify babies with PPROM (< 20 weeks' gestation) or rupture earlier than 25 weeks for more than 14 days.

RESULTS

Twenty-six infants were identified, of whom 20 were admitted to the neonatal intensive care unit (NICU; mean GA 27.8 weeks, mean birth weight (BW) 1207 g). Early echocardiographic data were available in 12/15 infants requiring mechanical ventilation of whom 10 had evidence of PPHN. All infants who received iNO therapy survived to discharge and only two infants died. Survival to discharge was 69% for the whole cohort of infants and 90% for infants admitted to the NICU. In contrast, for the cohort from pre-iNO and -HFV era, the overall survival to discharge was 62% and 66% for the infants admitted to the NICU.

CONCLUSION

Premature infants with PPROM and presumed severe hypoxemic respiratory failure because of hypoplastic lungs often have significant PPHN and may show improvement in oxygenation after treatment with HFV and iNO. Early fECHO results in earlier identification and treatment of infants with PPHN in this high-risk group.

Rupture of membranes before the age of viability and birth after the age of viability: comparison of outcomes in a matched cohort study

OBJECTIVE

To compare composite adverse outcome rate of infants <32 weeks gestational age (GA) who were born after preterm premature rupture of membranes (PPROM) at previable gestation to those born without PPROM.

STUDY DESIGN

Retrospective review of prospective collected data for infants discharged between 2004 and 2007 was conducted. Cases were infants with >7 days of PPROM that occurred before 24 weeks. Matched cohort consisted of infants born without PPROM (matched for GA, sex and admission date). Composite adverse outcome was assessed considering death or any of the following three severe morbidities (severe neurological injury, severe retinopathy of prematurity or chronic lung disease).

RESULT

The 29 cases had higher mean severity of illness score compared with 74 matched infants. Mean duration of ROM was 45 vs 2 days and mean GA at the ROM was 21 vs 27 weeks, respectively. Logistic regression confirmed significantly higher risk of composite adverse outcome rates for cases (69 vs 47%; P=0.02, adjusted odds ratio 4.0, 95% CI 1.2, 13.6).

CONCLUSION

The survival rate for infants born at <32 weeks following PPROM at previable age has improved significantly; however, these infants had a higher rate of adverse composite neonatal outcome.

Early preterm breech delivery: is a policy of planned vaginal delivery associated with increased risk of neonatal death?

OBJECTIVE

The purpose of this study was to compare neonatal death rates in preterm singleton breech deliveries from 26 weeks to 29 weeks 6 days of gestation in centers with either a policy of planned vaginal delivery (PVD) or planned cesarean delivery (PCD).

STUDY DESIGN

Women with preterm singleton breech deliveries were identified from the databases of 3 perinatal centers and classified as PVD or PCD according to the center's management policy.

RESULTS

The study included 84 women in the PVD group and 85 women in the PCD group. Incidence of neonatal death was similar in both (10.7% vs 7.1%; P = .40). Head entrapment (adjusted odds ratio, 7.2; 95% CI, 1.7-29.8), preterm premature rupture of membranes at <24 weeks of gestation (adjusted odds ratio, 13.3; 95% CI, 2.8-63.0), and gestational age between 26 weeks and 27 weeks 6 days of gestation (adjusted odds ratio, 4.7; 95% CI, 1.2-18.5) were associated independently with neonatal death.

CONCLUSION

Risk of neonatal death was not associated with any particular policy of mode of delivery.

Successful patching of iatrogenic rupture of the fetal membranes

Rupture of the fetal membranes is a common, but potentially serious complication of invasive fetal procedures. Quintero described a technique to seal the fetal membrane defect by means of a bloodpatch, usually called 'amniopatch' in this application. The successful use in two consecutive patients with ruptured membranes after a fetoscopic intervention at respectively 17 and 22 weeks' gestational age is described, together with a literature review of published experience.

Outcomes after expectant management of extremely preterm premature rupture of the membranes

OBJECTIVE

This study was undertaken to assess contemporary outcomes in pregnancies managed expectantly after extremely preterm premature (< or =24 weeks) premature rupture of the membranes (EPPROM).

STUDY DESIGN

We queried antepartum and ultrasound databases for patients with EPPROM. Data on pregnancy outcome and short-term neonatal outcomes were collected.

RESULTS

Forty-six patients with EPPROM were studied. Patients were hospitalized at 24 weeks' gestation and given antibiotics and antenatal steroids. Median gestational age at PPROM was 22.0 weeks (range 16.9-24 weeks); 43 (93%) elected expectant management, 2 of whom later had an intrauterine fetal death. Median latency period to delivery was 13 days (range 0-96 days), with mean gestational age at delivery of 25.8+/-3.4 weeks. Overall survival was 47% (27 of 57 infants), after a median hospital stay of 71 days (range 17-209 days). Ten (37%) of the survivors have serious sequelae.

CONCLUSION

Although significant pregnancy prolongation after previable PPROM occurs in many cases, neonatal outcomes remain poor.

Recent evidence associated with the condition of preterm prelabour rupture of the membranes

PURPOSE OF REVIEW

The published literature on preterm prelabour rupture of the membranes is voluminous yet despite advances in obstetric and neonatal care, the problem remains a major cause of perinatal mortality and morbidity. The purpose of this review is to present recent evidence pertaining to the role of inflammatory mediators such as cytokines and the tissue damage and long-term handicap they cause, the molecular biology and physiology of membrane structure, the role of host susceptibility and the genetics of preterm birth and therapeutic options for the management of preterm prelabour rupture, including antibiotics, amnioinfusion and special situations.

RECENT FINDINGS

Neonatal morbidity from preterm prelabour rupture of the membranes is mainly related to oligohydramnios and pulmonary hypoplasia. Occupational factors have a significant effect on the occurrence and outcome following rupture. Matrix metalloproteinases control growth and remodelling of the pregnant uterus, placenta and membranes and are linked to a genetic predisposition to preterm birth through gene expression and variation. Transvaginal ultrasound scan, oncofetal fibronectin and the presence of abnormal genital tract flora (bacterial vaginosis) in pregnancy may help in the prediction of preterm birth.

SUMMARY

Preterm prelabour membrane rupture remains a management problem, particularly at very early gestations, yet obstetric and neonatal care can make a difference to outcome. While at early gestations the prognosis is poor, it is not hopeless. Careful selection of the recent literature on the subject might interest and inform those faced regularly with the problem, prevent therapeutic nihilism, promote confidence in our ability to make a difference and realise that we are not alone when faced with the therapeutic dilemma that is this condition.