Assessment of risk factors for survival of neonates born after second-trimester PPROM

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.

Chorioamnionitis and Risk for Maternal and Neonatal Sepsis: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate the risk of maternal and neonatal sepsis associated with chorioamnionitis.

DATA SOURCES

PubMed, BIOSIS, and ClinicalTrials.gov databases were systematically searched for full-text articles in English from inception until May 11, 2020.

METHODS OF STUDY SELECTION

We screened 1,251 studies. Randomized controlled trials, case-control, or cohort studies quantifying a relationship between chorioamnionitis and sepsis in mothers (postpartum) or neonates born at greater than 22 weeks of gestation were eligible. Studies were grouped for meta-analyses according to exposures of histologic or clinical chorioamnionitis and outcomes of maternal or neonatal sepsis.

TABULATION, INTEGRATION, AND RESULTS

One hundred three studies were included, and 55 met criteria for meta-analysis (39 studies of preterm neonates, 10 studies of general populations of preterm and term neonates, and six studies of late preterm and term neonates). Study details and quantitative data were abstracted. Random-effects models were used to generate pooled odds ratios (ORs); most studies only reported unadjusted results. Histologic chorioamnionitis was associated with confirmed and any early-onset neonatal sepsis (unadjusted pooled ORs 4.42 [95% CI 2.68-7.29] and 5.88 [95% CI 3.68-9.41], respectively). Clinical chorioamnionitis was also associated with confirmed and any early-onset neonatal sepsis (unadjusted pooled ORs 6.82 [95% CI 4.93-9.45] and 3.90 [95% CI 2.74-5.55], respectively). Additionally, histologic and clinical chorioamnionitis were each associated with higher odds of late-onset sepsis in preterm neonates. Confirmed sepsis incidence was 7% (early-onset) and 22% (late-onset) for histologic and 6% (early-onset) and 26% (late-onset) for clinical chorioamnionitis-exposed neonates. Three studies evaluated chorioamnionitis and maternal sepsis and were inconclusive.

CONCLUSION

Both histologic and clinical chorioamnionitis were associated with early- and late-onset sepsis in neonates. Overall, our findings support current guidelines for preventative neonatal care. There was insufficient evidence to determine the association between chorioamnionitis and maternal sepsis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020156812.

Pyrethroid pesticide exposure during early pregnancy and birth outcomes in southwest China: a birth cohort study

Despite the developmental toxicity reported in animals, few epidemiologic studies have investigated the potential effects of prenatal exposure to pyrethroid pesticides (PYRs) on fetal growth. A birth cohort study was conducted to examine the association between prenatal exposure to PYRs and birth outcomes, and a nested case-control study was conducted in this cohort to evaluate the effects of PYR on congenital defects. The assessment of PYR exposure was based on self-reported household pesticide use and urinary PYR metabolite levels. We found that pregnant women in this region were ubiquitously exposed to low-level PYRs, although few reported household pesticide use. Women who often ate bananas or cantaloupes had a higher level of urinary 3-(2,2-dibromovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid (DBCA), and the number of fruit types consumed by pregnant women was positively related to the concentrations of 3-phenoxybenzoic acid (3PBA) and total PYR metabolites (P < 0.05). Increased urinary 4-fluoro-3-phenoxybenzoic acid (4F3PBA), DBCA, and total PYR metabolites were associated with increased birth weight, length, and gestational age, and with decreased risk of small for gestational age (SGA) and/or premature birth. However, maternal household pesticides use was related to congenital anomalies. Thus, although prenatal exposure to low-dose PYRs promoted the fetal growth, the beneficial effects of fruit intake may outweigh the adverse effects of pesticide exposure. This study provided us an insight into the biological mechanisms for the effect of prenatal PYR exposure on fetal development, and suggested that further investigations in a larger study population with low-dose PYR exposure is needed.

Association of Histological and Clinical Chorioamnionitis With Neonatal Sepsis Among Preterm Infants: A Systematic Review, Meta-Analysis, and Meta-Regression

Chorioamnionitis (CA) is considered a key risk factor for very preterm birth and for developing early onset sepsis (EOS) in preterm infants, but recent data suggest that CA might be protective against late onset sepsis (LOS). We performed a systematic review and meta-analysis of studies exploring the association between CA and sepsis. A comprehensive literature search was performed in PubMed/MEDLINE and EMBASE, from their inception to December 1, 2018. A random-effects model was used to calculate odds ratios (OR) and 95% confidence intervals (CI). Sources of heterogeneity were analyzed by subgroup and meta-regression analyses. The following categories of sepsis were analyzed: EOS, LOS, unspecified onset sepsis (UOS), culture-proven, and clinical sepsis. CA was subdivided into clinical and histological chorioamnionitis. Funisitis was also analyzed. We found 3,768 potentially relevant studies, of which 107 met the inclusion criteria (387,321 infants; 44,414 cases of CA). Meta-analysis showed an association between any CA and any EOS (OR 4.29, CI 3.63-5.06), any LOS (OR 1.29, CI 1.11-1.54), and any UOS (OR 1.59, CI 1.11-1.54). Subgroup analysis showed that CA was associated with culture-proven EOS (OR 4.69, CI 3.91-5.56), clinical EOS (OR 3.58, CI 1.90-6.76), and culture-proven LOS (OR 1.31, CI 1.12-1.53), but not with clinical LOS (OR 1.52, CI 0.78-2.96). The presence of funisitis did not increase the risk of either EOS or LOS when compared with CA without funisitis. CA-exposed infants had lower gestational age (-1.11 weeks, CI -1.37 to -0.84) than the infants not exposed to CA. Meta-regression analysis showed that the lower gestational age of the CA group correlated with the association between CA and LOS but not with the association between CA and EOS. In conclusion, our data suggest that the positive association between chorioamnionitis and LOS may be modulated by the effect of chorioamnionitis on gestational age.

Funisitis is associated with adverse neonatal outcome in low-risk unselected deliveries at or near term

This study aimed to determine the incidence and clinical outcomes for varying patterns of placental histological inflammation (consistent with fetal or maternal inflammatory response) in an unselected population of >1000 women with a singleton pregnancy resulting in live birth delivering at or near term. One thousand one hundred nineteen cases were studied in a blind, prospective, unselected study with placentas categorized into five histological subgroups reflecting underlying maternal or fetal inflammatory response. Clinical outcomes studied included interventional delivery, an Apgar score <7 at 1 min, neonatal acidosis (pH < 7.2) and admission to neonatal special care. One hundred eighty-eight placentas (17 %) showed histological evidence of acute inflammation: 64 with funisitis (with or without other inflammation; 6 %); 16 with extensive acute inflammation across the chorionic plate, free membranes and subchorionic fibrin (1 %); 28 with acute inflammation restricted to the chorionic plate (2 %); 12 with acute inflammation restricted to the free membranes (1 %) and 68 with acute inflammation restricted to the subchorionic fibrin (6 %). Features of extensive acute inflammation were significantly associated with increased rate of interventional delivery (assisted vaginal delivery or emergency caesarean section; P < 0.01). The presence of funisitis was significantly associated with interventional delivery and other adverse outcomes including an Apgar score <7 at 1 min, clinical evidence of sepsis and admission to the neonatal intensive care unit (P < 0.05 for all). The data represent a quantitative rather than purely qualitative analysis of the contribution of histological lesions related to inflammation on short-term adverse neonatal outcomes and interventional delivery. Funisitis and extensive inflammation are associated with adverse clinical outcomes, but the precise mechanism underlying these remains to be elucidated.