Epidemiological correlates of preterm premature rupture of membranes

Active versus expectant management for premature rupture of membranes at term: A randomized, controlled study

OBJECTIVE

To compare the effects on feto-maternal outcomes of expectant versus active management for premature rupture of membranes (PROM) at term.

METHODS

This was a prospective randomized (1:1) controlled study involving 86 pregnant-women who received either expectant management (n = 43) or active management with misoprostol (n = 43) for PROM at term. Primary outcome was route of delivery. Secondary outcomes were: PROM to presentation interval; latency period; PROM to delivery interval; recruitment to delivery interval; labour and delivery complications.

RESULTS

Baseline-characteristics were similar between groups. There was no significant difference between active and expectant groups in mean PROM to presentation/admission, or PROM to delivery. However, mean latency period (11.1 ± 7.3 hours vs 8.8 ± 5.5 hours) and mean recruitment to delivery intervals after PROM (14.7 ± 5.2 hours vs 11.8 ± 5.0 hours) were significantly shorter for the active group compared with the expectant group. Although the rate of caesarean section was less in expectant management group (21%) compared with the active management group (30%), the difference was not statistically significant. There were no significant differences between groups in delivery or perinatal complications.

CONCLUSION

Active and expectant management for PROM at term gave comparable outcomes in terms of methods of delivery and complications. However, active management significantly shortened the latency period and induction to delivery intervals compared with expectant management.Trial-Registration: Pan-African-trial-registry-(PACTR)-approval-number PACTR202206797734088.

Management of Preterm Premature Rupture of Membranes in the Late Preterm Period

Importance

For patients who present with prelabor rupture of membrane (PROM) in the late preterm period (34 to 36 6/7 weeks), management remains unclear due to lack of consensus. However, recent guidelines have suggested that shared decision-making may be used and expectant management can be considered up to 37 0/7 weeks.

Objective

In this article, we review the contemporary studies comparing the risks and benefits of immediate delivery versus expectant management for patients with late preterm prelabor rupture of membranes (PPROM).

Evidence Acquisition

Original research articles, review articles, and guidelines on management of late PPROM.

Results

Three randomized clinical trials and 2 meta-analyses comparing expectant management and immediate delivery outcomes in late PPROM showed no significant difference in neonatal sepsis rates between groups. Expectant management increased the likelihood that pregnancies reached term while decreasing the rate of cesarean delivery. However, data suggest an increased risk of antepartum hemorrhage among patients in the expectant management groups, as well as higher rates of histologic chorioamnionitis.

Conclusions and Relevance

We recommend that clinicians offer expectant management as an alternative to immediate delivery in the setting of late PPROM through a shared decision-making process that clearly outlines the risks and benefits.

Maternal Smoking during Pregnancy and the Risk for Childhood Infectious Diseases in the Offspring: A Population-Based Cohort Study

OBJECTIVE

Infectious diseases account for up to 43% of childhood hospitalizations. Given the magnitude of infection-related hospitalizations, we aimed to evaluate the effect of maternal smoking during pregnancy on the risk for long-term childhood infectious morbidity.

STUDY DESIGN

This is a population-based cohort analysis comparing the long-term risk for infectious diseases, in children born to mothers who smoked during pregnancy versus those who did not. Infectious diseases were predefined based on International Classification of Diseases, Ninth Revision codes. Deliveries occurred between the years 1991 and 2014.

RESULTS

A total of 246,854 newborns met the inclusion criteria; 2,986 (1.2%) were born to mothers who smoked during pregnancy. Offspring of smokers had significantly higher risk for several infectious diseases during childhood (upper respiratory tract, otitis, viral infections, and bronchitis) as well as increased risk for total infection-related hospitalizations (odds ratio = 1.5, 95% confidence interval [CI]: 1.3-1.7; p = 0.001). Cumulative incidence of infection-related hospitalizations was significantly higher in offspring of smokers (log-rank test, p = 0.001). Controlling for maternal age, diabetes, hypertensive disorders, and gestational age at index delivery, smoking remained an independent risk factor for infectious diseases during childhood (adjusted hazard ratio = 1.5, 95% CI: 1.3-1.6; p = 0.001).

CONCLUSION

Intrauterine exposure to maternal smoking may create an environment leading to an increased future risk for long-term pediatric infectious morbidity of the offspring.

Tobacco and Nicotine Cessation During Pregnancy: ACOG Committee Opinion, Number 807

Pregnant women should be advised of the significant perinatal risks associated with tobacco use, including orofacial clefts, fetal growth restriction, placenta previa, abruptio placentae, preterm prelabor rupture of membranes, low birth weight, increased perinatal mortality, ectopic pregnancy, and decreased maternal thyroid function. Children born to women who smoke during pregnancy are at an increased risk of respiratory infections, asthma, infantile colic, bone fractures, and childhood obesity. Pregnancy influences many women to stop smoking, and approximately 54% of women who smoke before pregnancy quit smoking directly before or during pregnancy. Smoking cessation at any point in gestation benefits the pregnant woman and her fetus. The greatest benefit is observed with cessation before 15 weeks of gestation. Although cigarettes are the most commonly used tobacco product in pregnancy, alternative forms of tobacco use, such as e-cigarettes or vaping products, hookahs, and cigars, are increasingly common. Clinicians should advise cessation of tobacco products used in any form and provide motivational feedback. Although counseling and pregnancy-specific materials are effective cessation aids for many pregnant women, some women continue to use tobacco products. Clinicians should individualize care by offering psychosocial, behavioral, and pharmacotherapy interventions. Available cessation-aid services and resources, including digital resources, should be discussed and documented regularly at prenatal and postpartum follow-up visits.

Serum Decorin, Biglycan, and Extracellular Matrix Component Expression in Preterm Birth

Preterm birth is a leading cause of infant morbidity and mortality. Decorin and biglycan are proteoglycans that play key roles in maintaining the connective tissue matrix and tensile strength of human fetal membranes and have been previously linked to PPROM. Extracellular matrix proteins, such as matrix metalloproteinase 2 (MMP-2), matrix metalloproteinase 9 (MMP-9), TIMP metallopeptidase inhibitor 1 (TIMP-1), TIMP metallopeptidase inhibitor 2 (TIMP-2), and collagen VI (COL-6), have also been linked to PPROM and may have utility in a serum-based screening model for this condition. To define the natural course of serum decorin and biglycan expression throughout the duration of healthy pregnancy, to explore patterns of serum decorin and biglycan expression in serum of asymptomatic women who go on to develop spontaneous preterm labor, and to investigate the potential role for matrix metalloproteinases, their inhibitors, and collagen VI in a serum-based screening model to predict PPROM. Serum decorin level decreases less than 1% per week, and serum biglycan decreases by 2.9% per week over the duration of healthy pregnancy. Serum decorin and biglycan concentrations do not differ in spontaneous preterm labor cases compared with those in controls. Mean concentrations of MMP-2, MMP-9, TIMP-1, TIMP-2, and COL-6 do not differ in PPROM cases compared with those in controls. We have demonstrated that serum decorin and biglycan concentrations remain stable throughout the duration of normal pregnancy and are not early indicators of preterm labor, while common MMPs, TIMPs, and collagen VI are not early indicators of PPROM.

Risk Factors and Outcomes of Preterm Premature Rupture of Membranes in a Cohort of 6968 Pregnant Women Prospectively Recruited

We revisited risk factors and outcomes related to the preterm premature rupture of membranes (PPROM). A total of 7866 pregnant women were recruited during 5 years at their first prenatal visit to the perinatal clinic of the institution. We compared three groups (women without prematurity, women with spontaneous preterm labor with intact membranes (sPL with IM), women with PPROM) regarding 60 criteria about characteristics, lifestyle, medical, gynecological, obstetrical history of mothers, medication during pregnancy, events at delivery, and complications in neonates. Logistic regression analyses adjusting for potential confounding factors were used. Of the 6968 women selected, 189 (2.8%) presented a PPROM, and 225 (3.2%) an sPL with IM. The specific risk factors for PPROM were body mass index (BMI) <18.5 kg/m² (adjusted odds ratio, aOR: 2.00 (1.09-3.67)), history of PPROM (aOR: 2.75 (1.19-6.36)), nulliparity (aOR: 2.52 (1.77-3.60)), gestational diabetes (aOR: 1.87 (1.16-2.99)), and low level of education (aOR: 2.39 (1.20-4.78)). The complications associated with PPROM were abruption placentae, cesarean, APGAR 5' <4, birth weight <2500 g, stillbirth, neonatal jaundice, and hospitalization of mother and neonates. All these complications were also associated with sPL with IM. Our study confirms some of the risk factors of PPROM and highlights a new one: gestational diabetes. Outcomes of PPROM are related to prematurity.

ACOG Committee Opinion No. 762: Prepregnancy Counseling

The goal of prepregnancy care is to reduce the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, and provide education about healthy pregnancy. All those planning to initiate a pregnancy should be counseled, including heterosexual, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals. Counseling can begin with the following question: "Would you like to become pregnant in the next year?" Prepregnancy counseling is appropriate whether the reproductive-aged patient is currently using contraception or planning pregnancy. Because health status and risk factors can change over time, prepregnancy counseling should occur several times during a woman's reproductive lifespan, increasing her opportunity for education and potentially maximizing her reproductive and pregnancy outcomes. Many chronic medical conditions such as diabetes, hypertension, psychiatric illness, and thyroid disease have implications for pregnancy outcomes and should be optimally managed before pregnancy. Counseling patients about optimal intervals between pregnancies may be helpful to reduce future complications. Assessment of the need for sexually transmitted infection screening should be performed at the time of prepregnancy counseling. Women who present for prepregnancy counseling should be offered screening for the same genetic conditions as recommended for pregnant women. All patients should be routinely asked about their use of alcohol, nicotine products, and drugs, including prescription opioids and other medications used for nonmedical reasons. Screening for intimate partner violence should occur during prepregnancy counseling. Female prepregnancy folic acid supplementation should be encouraged to reduce the risk of neural tube defects.

Prepregnancy counseling: Committee Opinion No. 762

The goal of prepregnancy care is to reduce the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, and provide education about healthy pregnancy. All those planning to initiate a pregnancy should be counseled, including heterosexual, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals. Counseling can begin with the following question: "Would you like to become pregnant in the next year?" Prepregnancy counseling is appropriate whether the reproductive-aged patient is currently using contraception or planning pregnancy. Because health status and risk factors can change over time, prepregnancy counseling should occur several times during a woman's reproductive lifespan, increasing her opportunity for education and potentially maximizing her reproductive and pregnancy outcomes. Many chronic medical conditions such as diabetes, hypertension, psychiatric illness, and thyroid disease have implications for pregnancy outcomes and should be optimally managed before pregnancy. Counseling patients about optimal intervals between pregnancies may be helpful to reduce future complications. Assessment of the need for sexually transmitted infection screening should be performed at the time of prepregnancy counseling. Women who present for prepregnancy counseling should be offered screening for the same genetic conditions as recommended for pregnant women. All patients should be routinely asked about their use of alcohol, nicotine products, and drugs, including prescription opioids and other medications used for nonmedical reasons. Screening for intimate partner violence should occur during prepregnancy counseling. Female prepregnancy folic acid supplementation should be encouraged to reduce the risk of neural tube defects.

Smoking during pregnancy as a possible risk factor for pediatric neoplasms in the offspring: A population-based cohort study

OBJECTIVE

The aim of this study was to evaluate the association between maternal smoking during pregnancy and future risk of childhood neoplasm risk.

STUDY DESIGN

A population based cohort analysis comparing the risk for long-term childhood neoplasms in children born (1991-2014) to mothers that smoked during pregnancy vs. those that did not. Childhood neoplasms were pre-defined based on ICD-9 codes, as recorded in the hospital medical files. Children with congenital malformations and multiple gestations were excluded from the analysis. Kaplan-Meier survival curves were constructed to compare cumulative oncological morbidity over time. Cox proportional hazards model was used to control for confounders.

RESULTS

241,273 infants met the inclusion criteria; out of those 2841 were born to mothers that smoked during pregnancy. Offspring to smoking mothers had higher incidence of benign (OR 1.6, 95%CI 1.02-2.58; p value = .038) but not malignant tumors. Total cumulative neoplasm incidence was significantly higher in smoking women (Log Rank = 0.001) but no significant difference in the incidence of malignant tumors was noted (Log Rank = 0.834). In a Cox regression model controlling for maternal confounders; a history of maternal smoking during pregnancy remained independently associated only with increased risk for benign tumors (adjusted HR 2.5, 95%CI 1.57-3.83, p = .001).

CONCLUSION

Maternal smoking during pregnancy is associated with increased long-term risk for benign but not malignant tumors. This is important when counseling mothers regarding potential future risks and recommended lifestyle modifications. Despite this large population study with long follow-up, childhood malignancies are rare, and clarifying the possible association may require further studies.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Risk factors of premature rupture of membranes in public hospitals at Mekele city, Tigray, a case control study

BACKGROUND

The incidence of premature rupture of membranes ranges from about 5% to 10% of all deliveries. A woman with premature rupture of membranes is at risk of intra-amniotic infection, postpartum infection, endometritis, and death. A neonate born from premature rupture of membranes mother is at high risk of respiratory distress syndrome, sepsis, intraventricular hemorrhage and death. Little is known regarding the risk factors in Ethiopia. Therefore, this study was conducted to identify risk factors of premature rupture of membranes among pregnant women admitted to public hospitals in Mekelle city, Tigray, Ethiopia.

METHODS

Hospital based unmatched case control study design was implemented on 240 samples (160 controls and 80 cases) from pregnant mothers admitted to public hospitals in Mekelle city from February - April/2016. Data was collected by interviewer administered Structured questionnaire and checklist. Binary logistic regression model was used to see the association between dependent and independent variables and multivariable logistic regression was used to identify the independent predictors of premature rupture of membranes.

RESULTS

A total of 160 controls and 80 cases were enrolled in the study. Multivariable logistic regression showed that history of abortion [AOR 3.06 (CI: 1.39, 6.71)], history of PROM [AOR 4.45 (CI: 1.87, 10.6)], history of caesarean section [AOR 3.15(CI: 1.05, 9.46)] and abnormal vaginal discharge in the index pregnancy [AOR 3.31(CI: 1.67, 6.56)] were positively associated with premature rupture of membranes.

CONCLUSIONS

Past obstetric history and risks in the index pregnancy have an association with premature rupture of membranes. The finding of the study suggests early identification and treatment of genitourinary infection.

Committee Opinion No. 721: Smoking Cessation During Pregnancy

Smoking is the one of the most important modifiable causes of poor pregnancy outcomes in the United States, and is associated with maternal, fetal, and infant morbidity and mortality. The physical and psychologic addiction to cigarettes is powerful; however, the compassionate intervention of the obstetrician-gynecologist can be the critical element in prenatal smoking cessation. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral has been proved to increase quit rates. A short counseling session with pregnancy-specific educational materials and a referral to the smokers' quit line is an effective smoking cessation strategy. The 5A's is an office-based intervention developed to be used under the guidance of trained practitioners to help pregnant women quit smoking. Knowledge of the use of the 5A's, health care support systems, and pharmacotherapy add to the techniques providers can use to support perinatal smoking cessation. The use of alternative forms of nicotine, such as e-cigarettes and vaping, have increased substantially in recent years, but there are little data regarding the health effects of these agents, either in the general population or in pregnant women specifically.

Patient Awareness of Untoward Effects of Smoking on Fetal and Maternal Well-being During Pregnancy: A Pilot Study

INTRODUCTION

To identify knowledge gaps regarding adverse effects of smoking during pregnancy that could be targeted through antenatal education.

METHODS

This was a cross-sectional survey of patients who presented for initial prenatal care from April 6, 2011, through May 25, 2011. Inclusion criteria included fluency in English and completion of at least 75% of the questionnaire. Survey included demographic information and 4 sections that assessed (1) general knowledge about the effects of smoking, (2) cancer risks associated with smoking, (3) maternal and fetal complications resulting from smoking, and (4) long-term effects of smoking on offspring. Participants were grouped as nonsmokers, former smokers, and current smokers. Data from each group were compared using analysis of variance with Tukey-Kramer post-hoc tests.

RESULTS

There were 82 participants (54 nonsmokers, 17 former smokers, and 11 smokers). Self-perceived knowledge about the adverse effects of smoking was significantly less in smokers than in nonsmokers (P < 0.05). There was no statistical difference between the knowledge base of smokers when compared with nonsmokers and former smokers. Smokers seemed to be less aware of the long-term respiratory morbidity associated with maternal smoking in their offspring. There was an overall deficit in knowledge among all 3 groups of cancer risks associated with smoking other than lung cancer.

CONCLUSIONS

Obstetrician-gynecologists should employ more aggressive approaches in the education of pregnant parturients about the known deleterious maternal and fetal effects of smoking, especially those risks related to cancers other than lung and long-term respiratory morbidity in their children.

The relationship between maternal depression and smoking cessation during pregnancy--a cross-sectional study of pregnant women from 15 European countries

Epidemiologic studies have reported an association between depression and continuing smoking during pregnancy. However, differences in study design and methodology challenge study comparability. The purpose of this study was to examine the relationship between maternal depression and continuing smoking among pregnant European women while adjusting for maternal characteristics. This multinational, web-based study evaluated pregnant women in 15 European countries recruited from October 2011 to February 2012. Data on depression status, smoking habits, maternal socio-demographic characteristics, and life-style factors were collected via an anonymous online questionnaire. Associations were estimated with logistic regression. Of 4,295 women included, 1,481 (34.5 %) reported smoking before pregnancy, and 391 (26.4 %) continued smoking during pregnancy whereof 127 (32.5 %) were depressed. The association between depression and continuing smoking during pregnancy were uniform across the European countries (OR 2.02, 95 % CI 1.50-2.71), with about twice the prevalence of continuing smoking among the depressed. There was a strong relationship between continuing smoking in pregnancy and low education level (OR 4.46, 95 % CI 2.72-7.32), which coincided with risky pregnancy behavior such as failure to attend pregnancy/birth preparation courses (OR 1.80, 95 % CI 1.19-2.72) and follow recommended use of folic acid (OR 1.81, 95 % CI 1.23-2.65). Women who perceived the risk for the fetus of continued smoking during pregnancy as higher were the least likely to continue smoking during pregnancy (OR 0.72, 95 % CI 0.68-0.77). This underlines the clustering of risk in some pregnant women, and the results should guide antenatal care of depressed women struggling to quit smoking during pregnancy.

Characteristics of women who continue smoking during pregnancy: a cross-sectional study of pregnant women and new mothers in 15 European countries

BACKGROUND

Some women continue smoking during pregnancy despite the extensive information available on the dangers smoking poses to their fetus. This study aimed to examine the prevalence and determinants of smoking before and during pregnancy and the extent of smoking during pregnancy from a European perspective in relation to maternal sociodemographic characteristics, health literacy, morbidity, and pregnancy-related factors.

METHODS

This multinational, web-based study evaluated pregnant women and new mothers in 15 European countries recruited from October 2011 to February 2012. Data were collected via an anonymous online questionnaire.

RESULTS

Of 8344 women included, 2944 (35.3%) reported smoking before pregnancy, and 771 (26.2%) continued smoking during pregnancy, 88 (11.4%) of whom smoked more than 10 cigarettes per day. There was a wide variation among the 15 European countries in smoking rates before and during pregnancy, ranging from 25.0% (Sweden) to 50.0% (Croatia) before and 4.2% (Iceland) to 18.9% (Croatia) during pregnancy. Women who lived in Eastern Europe, without a spouse/partner, with a low education level and unplanned pregnancy, who did not take folic acid, and consumed alcohol during pregnancy were the most likely to smoke before pregnancy. Women who lived in Eastern or Western Europe, without a spouse/partner, with a low education level and health literacy, being a housewife, having previous children and unplanned pregnancy, and who did not take folic acid were the most likely to continue smoking during pregnancy. Women who smoked more than 10 cigarettes per day during pregnancy were the most likely to be living in Eastern Europe and to have a low education level.

CONCLUSION

Women with fewer resources living in Western or Eastern Europe are more likely not only to smoke before pregnancy but also to continue smoking during pregnancy. These high-risk women are characterized as living alone, having high school or less as highest education level, having low health literacy, being a housewife, having previous children, having unplanned pregnancy, and no use of folic acid. Our findings indicated that focus on smoking cessation is important in antenatal care in Europe as many women smoke before pregnancy, and still continue to do so in pregnancy.

Evidence in support of a role for anti-angiogenic factors in preterm prelabor rupture of membranes

OBJECTIVE

Vaginal bleeding, placental abruption, and defective placentation are frequently observed in patients with preterm prelabor rupture of membranes (PROM). Recently, a role of vascular endothelial growth factor (VEGF) and its receptor, VEGF receptor (VEGFR)- 1 has been implicated in the mechanisms of membrane rupture. The purpose of this study was to determine whether the soluble form of VEGFR-1 and -2 concentrations in amniotic fluid (AF) change with preterm PROM, intra-amniotic infection/inflammation (IAI), or parturition.

STUDY DESIGN

This cross-sectional study included 544 patients in the following groups: (1) midtrimester (MT) (n = 48); (2) preterm labor (PTL) leading to term delivery (n = 143); (3) PTL resulting in preterm delivery with (n = 72) and without IAI (n = 100); (4) preterm PROM with (n = 46) and without IAI (n = 42); (5) term in labor (n = 48); and (6) term not in labor (n = 45). The concentrations of sVEGFR-1 and sVEGFR-2 were determined by ELISA. Non-parametric statistics and logistic regression analysis were applied.

RESULTS

(1) Preterm PROM (with and without IAI) had a lower median AF concentration of sVEGFR-1 than patients with PTL who delivered at term (p < 0.001 for each comparison); (2) A decrease in AFsVEGFR-1 concentrations per each quartile was associated with PROM after adjusting for confounders (OR 1.8; 95%CI 1.4-2.3); (3) IAI, regardless of the membrane status, was not associated with a change in the median AF concentrations of sVEGFR-1 and sVEGFR-2 (p > 0.05 for each comparison); and (4) Spontaneous term and PTL did not change the median sVEGFR-1 and sVEGFR-2 concentrations (p > 0.05 for each comparison).

CONCLUSION

(1) This is the first evidence that preterm PROM is associated with a lower AF concentration of sVEGFR-1 than patients with PTL intact membranes. These findings cannot be attributed to gestational age, labor, or IAI; and (2) AF concentrations of sVEGFR-2 did not change with preterm PROM, IAI, or labor at term and preterm.

The bacteriology of pre-labour rupture of membranes in a Nigerian teaching hospital

A prospective case control study that was conducted at the University of Ilorin Teaching Hospital, Ilorin, Nigeria, between 1st January and 31st December 2002. The purpose of this study was to determine the association and the pattern of bacteria/microorganisms in the aetiology of pre-labour premature rupture of membrane (PROM) in this centre. A total of 108 cases of PROM and 98 control cases that presented between 37 completed weeks' and 40 weeks' gestation were analysed. Pathogens were isolated in 48 patients, giving a recovery rate of 44.4%. The common pathogens include Gardnerella vaginalis (29.1%), Candida (23.0%) and Staphylococcus aureus (18.7%). Others were Streps. Pyogenes (16.6%), coagulase negative staphylococcus (CONS) (6.3%) and Klebsiella (6.3%). Only Candida and S. aureus were isolated in the controls. Ofloxacin and azithromycin were 100% active against all the isolated pathogens, while ampicillin was the least active. G. vaginalis was the most sensitive among the isolates while CONS and Klebsiella were the least sensitive. It is evident in this study that some pathogens were associated with PROM and that G. vaginalis was the most common organism and azithromycin was the only antibiotic with 100% sensitivity. We suggest that metronidazole should be added to azithromycin to cover for anaerobes in cases of PROM, where facilities for screening for anaerobes are not available.

Pre-term premature rupture of fetal membranes: the dilemma of management in a developing nation

This study aims at evaluating the outcome of pregnancies complicated by pre-term premature rupture of membrane (PPROM) in a developing country and to highlight the problems of managing such cases and ways of improving future management. This was a retrospective review of 344 patients with PPROM at a University of Nigeria Teaching Hospital Enugu, Nigeria over a 10-year period (January 1994-December 2003). The prevalence of PPROM in this study was 25 per 1,000 births and patients of low parity (para 0-2) accounted for the highest number (56.4%). Previous abortion was significantly more among these women of low parity and may be a factor in the aetiology of PPROM. The gestational age range 28-30 weeks recorded the highest incidence (29.7%) of PPROM. The most common associated aetiological factor was cervical incompetence (11.6%), while chorioamnionitis, a major complication in the patients showed a statistically significant reduction with early antibiotic administration (p<0.05). About 72% (n=248) of the patients arrived at the hospital within 24 h of membrane rupture. Perinatal mortality was high (520 per 1,000 births) due to prematurity and perinatal infections. Better fetal outcomes were recorded among patients with PPROM at gestational age above 30 weeks, fetal weight above 2 kg, normal delivery, absence of maternal infection and latent period of not more than 5 days (p<0.05). The parity of the women did not significantly affect fetal outcome (p>0.05). Two (0.6%) maternal deaths were recorded. Prompt patient referral, early institution of antibiotics and improvement of neonatal facilities in tertiary health institutions in developing countries is advocated as a way of improving fetal survival in PPROM.

Smoking during pregnancy and preterm birth according to obstetric history: French national perinatal surveys

The relation between smoking and preterm delivery is not totally known. Our aim was to determine whether smoking during pregnancy was associated with preterm birth among women at different risk according to their obstetric history. The study was based on data from the 1998 French national perinatal survey. Of the 13073 singleton live births, 4.7% were preterm; 15% of the pregnant women were moderate (one to nine cigarettes per day) and 10% heavy smokers (at least 10 cigarettes per day). Smoking heavily was related to preterm birth (crude odds ratio [OR] = 1.35, 95% confidence interval [95% CI]: [1.04, 1.74]). Multivariable logistic regression showed a relation between smoking and preterm birth among multiparae without previous adverse pregnancy outcomes; the associated adjusted ORs (AORs) were 1.25 [95% CI 0.83, 1.87] among moderate smokers and 1.46 [95% CI 0.98, 2.20] among heavy smokers. The corresponding AORs were 0.69 [95% CI 0.46, 1.05]) and 0.96 [95% CI 0.59, 1.56] for primiparae and 1.11 [95% CI 0.63, 1.93] and 0.50 [95% CI 0.25, 0.98] for multiparae with previous adverse pregnancy outcomes. Our study showed a relation between heavy smoking during pregnancy and preterm birth mostly for women with low obstetric risk.

Pharmacological treatment for pregnant women who smoke cigarettes

Smoking has been associated with several concerns in pregnancy including miscarriage, preterm delivery and stillbirth. Unfortunately, approximately 12% of the pregnant population continue to smoke cigarettes, suggesting a need for additional therapy beyond behavioural change. This paper reviews the literature on the use of nicotine replacement therapy and bupropion (Zyban^®) in the pregnant human population, the pharmacokinetics of nicotine in the pregnant woman, and current guidelines for smoking cessation for pregnant patients. There are currently four studies that have investigated the use of nicotine patch, three for nicotine gum, and registry and preliminary reports for bupropion. These studies did not show any adverse pregnancy outcomes with the use of pharmacological aid for smoking cessation. All the nicotine replacement therapy studies, with the exception of one randomized-controlled nicotine patch trial had small sample sizes and looked at short-term use of drug in the third trimester. Two studies have examined the pharmacokinetics of nicotine in the pregnant woman. The results from these studies reveal greater nicotine metabolism in pregnant individuals who continue to smoke during pregnancy. Current guidelines from several organizations uniformly recommend that Nicotine Replacement Therapy should be considered if non-pharmacological therapies have been unsuccessful. Bupropion is recommended in pregnancy if the benefits outweigh the risks. There is a need for further studies on the safety and effectiveness of Nicotine Replacement therapy and bupropion in pregnancy. However, considering the current research and guidelines, pharmacological cessation aids should be considered if non-pharmacological therapies have not been effective.

Ultrasonographic evaluation of cervical length in pregnancies complicated by preterm premature rupture of membranes

OBJECTIVE

To evaluate the usefulness of transvaginal ultrasonography in the determination of the risk of preterm delivery and chorioamnionitis in pregnancies affected by preterm premature rupture of membranes preterm premature rupture of membranes.

DESIGN

One hundred and one singleton pregnancies with preterm premature rupture of membranes were included in this prospective study over a 3-year period. Patients underwent cervical length measurement by transvaginal ultrasonography at admission and thereafter, in the absence of chorioamnionitis, were managed expectantly.

RESULTS

The median time interval between admission and delivery (latency period) was 48 h. A cervical length of less than 20 mm was associated with a significant risk of early delivery (mean latency period was 59.44 +/- 159.93 h vs. 240.94 +/- 364.67; P < 0.05). There was no relation between cervical length and occurrence of chorioamnionitis or neonatal sepsis.

CONCLUSIONS

These data suggest that the use of transvaginal ultrasonography for cervical length measurement during preterm premature rupture of membranes may predict an early delivery but cannot anticipate the risk of chorioamnionitis or neonatal sepsis.

Prevalence and risk factors for prelabor rupture of the membranes (PROM) at or near-term in an urban Swedish population

AIMS

To determine the prevalence, recurrence rate and to identify risk factors for prelabor rupture of the membranes (PROM) after 34 completed weeks in an urban Swedish population.

METHODS

In a retrospective cohort study a sample of 2880 women aged 25-41 years, resident in the city of Göteborg, was randomly selected from the population register. According to information from the national Medical Birth Register (MBR), 1507 of these 2880 women had given birth 2736 times. 2270 of these deliveries had occurred in hospitals in the city of Göteborg and case records for 2242 of these deliveries were found. The case records were systematically analyzed for the occurrence of PROM and potential risk factors for PROM. 2208 of these deliveries occurred after 34 weeks of gestation. The further analyses were based on these 2208 deliveries.

RESULTS

The prevalence of PROM after 34 week of gestation in this urban Swedish population was 12.9% and about 20% of the women in the population had experienced PROM at least once. In the multiple stepwise regression analysis, risk factors for PROM were primiparity, premature contractions, PROM in a previous pregnancy and bleeding in the first trimester.

CONCLUSIONS

PROM is a common complication at or near term. The risk factors for PROM found in this representative study are difficult to influence and thus provide no guidance about how pregnancies should be managed to reduce the occurrence of PROM in the future.

Effects of smoking during pregnancy. Five meta-analyses

BACKGROUND

The purpose of this study was to estimate, using meta-analysis, pooled odds ratios for the effects of smoking on five pregnancy complications: placenta previa, abruptio placenta, ectopic pregnancy, preterm premature rupture of the membrane (PPROM), and pre-eclampsia.

METHODS

Published articles were identified through computer search and literature review. Five criteria were applied to those studies initially identified to determine those eligible for the meta-analysis. A random effects model was applied to derive pooled odds ratios for the eligible studies for each pregnancy complication. Meta-analyses were repeated on subsets of the studies to confirm the overall results.

RESULTS

Smoking was found to be strongly associated with an elevated risk or placenta previa, abruptio placenta, ectopic pregnancy, and PPROM, and a decreased risk of pre-eclampsia. All pooled odds ratios were statistically significant. The pooled ratios ranged from 1.58 for placenta previa to 1.77 for ectopic pregnancy. The pooled odds ratio for pre-eclampsia was 0.51 and all subset analyses confirmed this seemingly protective effect.

CONCLUSIONS

Smoking during pregnancy is a significant and preventable factor affecting ectopic pregnancy, placental abruption, placenta previa, and PPROM. The findings of smoking's apparently protective effect on pre-eclampsia should be balanced with these harmful effects. In addition, the biological linkage between smoking and pre-eclampsia is not yet well understood. Pregnant women should be advised to stop smoking in order to reduce the overall risk of pregnancy complications as well as any risk of adverse impact on the unborn child.

The pathobiology of premature rupture of membranes

Premature rupture of membranes arises from what are likely multifaceted and multistep pathogenic pathways. Pathophysiological processes may involve both endogenous and exogenous fetal and maternal factors. This article reviews and analyzes information regarding, first, the form and function of fetal membranes; second, how membranes physically fail (rupture) at term and preterm gestations; and third, evaluates if we can reduce risks of rupture using physiological understanding and evidence-based clinical studies.

Midtrimester premature rupture of the membranes

Midtrimester premature rupture of the membranes is an uncommon adverse complication of pregnancy with an occurrence of approximately 0.65%. Significant perinatal and maternal morbidity includes pulmonary hypoplasia, restriction deformities, and sequelae of prematurity as well as maternal chorioamnionitis and endometritis. Moreover, 31% of survivors are affected by long-term complications such as chronic lung disease, neurological and developmental abnormalities. Fetal survival is evident with increasing latency and good residual amniotic fluid (largest vertical pocket > or = 2 cm). In this article, we review the relevant literature regarding prognosis, counseling, and management of the patient with membrane rupture in the midtrimester.