Expectant management versus selective fetal reduction in dichorionic-diamniotic twins following mid-trimester, preterm premature rupture of membranes in 1 twin: Review of literature and meta-analysis.

This study aimed to examine whether expectant management in twin pregnancies with preterm premature rupture of membranes (pPROM) is as safe as in singleton pregnancies. It was a retrospective cohort study comparing pregnancy course and outcome in singleton (n = 299) and twin pregnancies (n = 49) complicated by preterm premature rupture of membranes. Analysed factors included maternal diseases, gestational age at premature rupture of membranes (PROM), management during hospitalization, latency periods between PROM and delivery, gestational age at delivery, neonatal management and outcome. The difference in the proportion of patients with latency up to 72 hours, latency between 72 hours and seven days, and latency exceeding seven days were insignificant. The percentage of patients who received intravenous tocolysis and antenatal corticosteroids were similar; however, patients in twin pregnancies more often received incomplete steroids dose (p = 0.01). The occurrence of the positive non-stress test result and signs of intrauterine infection were similar between the groups. No statistically significant differences in the prevalence of neonatal complications except transient tachypnoea of the newborn were identified (24% in the singleton vs 13% in the twin group, p = 0.03). Expectant management of pPROM in singleton and twin pregnancies results in similar perinatal and neonatal outcome. Consequently, in case of no evident contraindications, expectant management of twin pregnancies seems to be equally as safe as in singleton pregnancies. Patients in twin pregnancies may be at higher risk of delivery before administration of full antenatal corticosteroids dose, therefore require immediate management initiation and transfer to a tertiary referral centre.

Pregnancy and birth outcomes of multiple gestations with PPROM occurred within 24 h after fetal reduction: A case series

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

The management of preterm premature rupture of the membranes near the limit of fetal viability

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.

Radiofrequency ablation (RFA) is the preferred approach for selective reduction in complex monochorionic (MC) multiple pregnancies owing to the ease of operation and minimal invasiveness. To optimize the RFA technique and reduce the risk of adverse pregnancy outcome resulting from the heat-sink effect of RFA therapy, we used an innovative RFA method, in which an electrode needle was expanded incrementally and stepwise. This study aimed to assess the efficacy and safety profile of this novel multistep incremental expansion RFA method for selective fetal reduction in MC twin and triplet pregnancies. This was a single-center retrospective cohort study of all MC multiple pregnancies undergoing RFA between March 2016 and October 2022 at our center. The multistep RFA technique involved the use of an expandable needle, which was gradually expanded during the RFA procedure until cessation of umbilical cord blood flow was achieved. The needle used for the single-step RFA method was fully extended from the start of treatment. In total, 132 MC multiple pregnancies underwent selective reduction using RFA, including 50 cases undergoing multistep RFA and 82 cases undergoing single-step RFA. The overall survival rates were not significantly different between the multistep and single-step RFA groups (81.1% vs 72.3%; P = 0.234). Similarly, the rates of preterm prelabor rupture of the membranes within 2 weeks after RFA, procedure-related complications, spontaneous preterm delivery and pathological findings on cranial ultrasound, as well as gestational age at delivery and birth weight, did not differ between the two groups. However, there was a trend towards a prolonged procedure-to-delivery interval following multistep RFA compared with single-step RFA (median, 109 vs 99 days; P = 0.377). Moreover, the fetal loss rate within 2 weeks after RFA in the multistep RFA group was significantly lower than that in the single-step RFA group (10.0% vs 24.4%; P = 0.041). The median ablation time was shorter (5.3 vs 7.8 min; P < 0.001) and the median ablation energy was lower (10.2 vs 18.0 kJ; P < 0.001) in multistep compared with single-step RFA. There were no significant differences in neonatal outcomes following multistep vs single-step RFA. Overall survival rates were similar between the two RFA methods. However, the multistep RFA technique was associated with a lower risk of fetal loss within 2 weeks after RFA. The multistep RFA technique required significantly less ablation energy and a shorter ablation time compared with single-step RFA in selective fetal reduction of MC twin and triplet pregnancies. Additionally, there was a trend towards a prolonged procedure-to-delivery interval with the multistep RFA technique. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Background Preterm premature rupture of membranes (PPROM) is a condition where the amniotic sac ruptures before the onset of labor, occurring in about 3% of pregnancies. It is a leading cause of perinatal morbidity and mortality, resulting in neonatal morbidities such as respiratory distress syndrome, necrotising enterocolitis, and sepsis. Depending on the gestational age, complications such as chorioamnionitis, premature placental abruption, umbilical cord prolapse, and postpartum infections can occur. The clinical course following PPROM depends on the latency period, which is inversely correlated with gestational age and influenced by several factors, including the presence of antepartum hemorrhage and cervical opening. Objective To examine the efficacy and safety of planned outpatient management versus hospital admission for women with preterm prelabor rupture of the membranes (PPROM) in terms of fetal, neonatal, and mother outcomes. Patients and Methods patients were divided into two groups (O) was planned for outpatient care and Group (H) was hospitalized after randomization. The primary outcome was comparing between two groups regarding the latency period and other maternal and neonatal outcomes were recorded. Results Regarding the results of our study, we found that there is no statistically significant difference between the study groups regarding age and parity. No statistically significant difference between the study groups regarding gestational age at enrollment and delivery as well as well as the latency period between them being slightly longer in the outpatient group. As regards the neonatal outcome, the rate of complications was insignificant among both groups, Intra-amniotic infection being slightly higher among hospitalized group, antenatal fetal distress &amp; post-natal fetal respiratory distress syndrome as well. Conclusion PPROM is a serious condition that can result in neonatal morbidities and maternal complications. Expectant management is usually implemented, with hospitalization being the conventional policy recommended until delivery. However, outpatient care may offer a safe and low-cost alternative with a relatively longer latency period. Further studies are needed to confirm the safety of outpatient care in PPROM patients and to address the concerns about potential obstetric emergencies.

Mid-trimester preterm premature rupture of membranes (PPROM), defined as rupture of fetal membranes prior to 28 weeks of gestation, complicates approximately 0.4%-0.7% of all pregnancies. This condition is associated with a very high neonatal mortality rate as well as an increased risk of long- and short-term severe neonatal morbidity. The causes of the mid-trimester PPROM are multifactorial. Altered membrane morphology including marked swelling and disruption of the collagen network which is seen with PPROM can be triggered by bacterial products or/and pro-inflammatory cytokines. Activation of matrix metalloproteinases (MMP) have been implicated in the mechanism of PPROM. The propagation of bacteria is an important contributing factor not only in PPROM, but also in adverse neonatal and maternal outcomes after PPROM. Inflammatory mediators likely play a causative role in both disruption of fetal membrane integrity and activation of uterine contraction. The "classic PPROM" with oligo/an-hydramnion is associated with a short latency period and worse neonatal outcome compared to similar gestational aged neonates delivered without antecedent PPROM. The "high PPROM" syndrome is defined as a defect of the chorio-amniotic membranes, which is not located over the internal cervical os. It may be associated with either a normal or reduced amount of amniotic fluid. It may explain why sensitive biochemical tests such as the Amniosure (PAMG-1) or IGFBP-1/alpha fetoprotein test can have a positive result without other signs of overt ROM such as fluid leakage with Valsalva. The membrane defect following fetoscopy also fulfils the criteria for "high PPROM" syndrome. In some cases, the rupture of only one membrane - either the chorionic or amniotic membrane, resulting in "pre-PPROM" could precede "classic PPROM" or "high PPROM". The diagnosis of PPROM is classically established by identification of nitrazine positive, fern positive watery leakage from the cervical canal observed during in specula investigation. Other more recent diagnostic tests include the vaginal swab assay for placental alpha macroglobulin-1 test or AFP and IGFBP1. In some rare cases amniocentesis and infusion of indigo carmine has been used to confirm the diagnosis of PPROM. The management of the PPROM requires balancing the potential neonatal benefits from prolongation of the pregnancy with the risk of intra-amniotic infection and its consequences for the mother and infant. Close monitoring for signs of chorioamnionitis (e.g. body temperature, CTG, CRP, leucocytes, IL-6, procalcitonine, amniotic fluid examinations) is necessary to minimize the risk of neonatal and maternal complications. In addition to delayed delivery, broad spectrum antibiotics of penicillin or cephalosporin group and/or macrolide and corticosteroids have been show to improve neonatal outcome [reducing risk of chorioamnionitis (average risk ratio (RR)=0.66), neonatal infections (RR=0.67) and abnormal ultrasound scan of neonatal brain (RR=0.67)]. The positive effect of continuous amnioinfusion through the subcutaneously implanted perinatal port system with amniotic fluid like hypo-osmotic solution in "classic PPROM" less than 28/0 weeks' gestation shows promise but must be proved in future prospective randomized studies. Systemic antibiotics administration in "pre-PPROM" without infection and hospitalization are also of questionable benefit and needs to be further evaluated in well-designed randomized prospective studies to evaluate if it is associated with any neonatal benefit as well as the relationship to possible adverse effect of antibiotics on to fetal development and neurological outcome.

Our aim was to assess neonatal and maternal complications of the expectant management of pregnancies with preterm premature rupture of membranes (P-PROM) prior to 24 weeks of gestation and to delineate a patient consult strategy. We included all consecutive cases of early midtrimester P-PROM (16-24 weeks gestation). Information coded in our perinatal database was analyzed. Descriptive statistics, Student's t-test and Mann-Whitney test, and a logistic regression model were built accordingly. A total of 28 women presented with P-PROM at 16-24 weeks (mean 22.7+/-1.0 weeks). Two patients declined conservative management and one was lost to follow-up (10.7%). In all, 25 (89.2%) were followed until the onset of labor or development of chorioamnionitis. Overall, 8/25 (32%) Of the neonates survived. Pulmonary hypoplasia accounted for three deaths (3/25, 12%). Of 10 pregnancies with P-PROM before 22 weeks gestation, two (20%) neonates survived. The amount of amniotic fluid and gestational age at the time of diagnosis were crucial independent factors determining overall survival. Pulmonary hypoplasia (12%) and skeletal deformities (0%) were infrequent. The 21-day mean maternal antenatal hospital stay was further complicated by a high cesarean rate delivery (33.7%) and by postpartum infectious morbidity (32%). In cases of early midtrimester P-PROM (<24 weeks) expectantly managed, neonatal survival is positively associated with the amount of amniotic fluid present and with the gestational age at the time of diagnosis. The mothers are at increased risk of prolonged antenatal hospitalization, cesarean delivery, preterm birth, and postpartum infection. In very early midtrimester P-PROM (<22 weeks), the maternal complication rate outweighs the poor neonatal outcome and expectant management should be reconsidered.

Intentional delivery versus expectant management of women with preterm premature rupture of the membranes: A meta-analysis of randomized, controlled trials

Introduction: The aim of this study was to investigate the factors associated with selective fetal reduction (SFR) procedures that result in adverse pregnancy outcomes. Methods: The study cohort comprises all multiple pregnancies that underwent SFR during the period of six years. The SFR procedure has been performed for two main indications: first, in cases of fetal anomaly; and secondly, electively to reduce the number of fetuses in triplet and higher-order pregnancies. Preterm birth or preterm premature rupture of the membranes prior to 34 weeks of gestation, placental abruption, pregnancy loss before 24 weeks of gestation, and intrauterine fetal death defined as adverse pregnancy outcomes. Procedural factors associated with adverse pregnancy outcomes were evaluated. Results: A total of 39 SFR procedures were performed on 33 multiple pregnancies, with 31 resulting in live birth. A higher rate of adverse pregnancy outcomes was observed in pregnancies that underwent elective SFR, more than one procedure , were having triplets or higher-order pregnancies prior to the procedure, or were having twin or higher-order pregnancies post-procedure. Elective SFR procedures and multiple procedures have been demonstrated to be associated with an 8-fold and a 13.3-fold increased risk of adverse pregnancy outcomes. The risk ratio of triplet or higher-order pregnancies prior to the procedure and twin or higher-order pregnancies post-procedure was found to be 6.5 and 5.8, respectively, for adverse pregnancy outcomes. Conclusions: Instead of considering SFR as the first option in the management of higher order pregnancies, it is recommended that assisted reproductive technologies be used in a way that does not lead to high-order pregnancies. In cases where the prevention of a higher order pregnancy has not been possible, SFR should be considered in terms of its risks and benefits as a method of reducing adverse pregnancy outcomes.

A prospective, randomized, placebo-controlled trial of penicillin in preterm premature rupture of membranes

OBJECTIVE: Preterm premature rupture of membranes (PPROM) has unfavorable consequences for the neonate and the mother if it occurs before 24 weeks of gestation. We aim to present our series to elucidate the course of previable PPROM and to detect maternal and neonatal outcomes. STUDY DESIGN: A single-centered retrospective cohort study that involves singleton patients diagnosed with spontaneous PPROM before 24 weeks. Data were retrieved from medical records, and maternal and neonatal outcomes were noted. RESULTS: Seventy-eight women were diagnosed with PPROM before 24 weeks, 42 patients (54%) opted for termination of pregnancy, and seven patients (9%) had spontaneous abortion. Twentynine patients (37%) gave live birth after a median latency of 47 days. Neonatal complications were respiratory distress syndrome (n=19; 65%), early sepsis (n=10; 34%), late sepsis (n=5; 17%), bronchopulmonary dysplasia (n=5;17%), retinopathy of prematurity (n=3; 10%), pneumothorax (n=5; 17%), intracranial hemorrhage (n=2; 6%), necrotizing enterocolitis (n=1; 3%) and meningitis (n=1; 3%). In the liveborn group, the neonatal survival rate was 62%. Of the survivors, twelve babies (66%) were discharged without composite neonatal morbidity. Maternal complications in the expectant management group included clinical chorioamnionitis (n=12, 33%) and placental abruption (n=2, 5%). CONCLUSION: In previable PPROM, overall half of the babies survive after expectant management. While a prolonged latency period and subsequent delivery at advanced gestational ages improve neonatal outcomes, such a conservative approach poses a substantial risk for chorioamnionitis.

PurposeThe aim of this study was to evaluate the average latency to delivery, obstetric outcomes and neonatal survival in pregnancies complicated by preterm premature rupture of membranes (PPROM) before 32 weeks.MethodsA retrospective study was conducted on pregnant women admitted for PPROM before 32 weeks. Patients were categorized into three groups based on gestational age (GA) at PPROM (< 24, 24 to 28, 28 to 32 weeks). Latency to delivery, obstetric outcomes and neonatal survival were analyzed.Results 86 women who had PPROM before 32 weeks were identified. The mean GA at PPROM was 26.1 weeks and the median latency to delivery was 16 days (IQR 4, 27). The median latency to delivery was 22 days for previable PPROM, 11 days for PPROM between 24 and 28 weeks, and 16 days for PPROM between 28 and 32 weeks (p = 0.29). All cases of placental abruption (7/86, 8%) and cord prolapse (6/86, 7%) occurred in women with PPROM before 28 weeks. In 44% of PPROM, placental histology demonstrated chorionamnionitis. Neonatal survival at discharge was significantly lower in previable PPROM (< 24 weeks) compared to PPROM at 24–26 weeks (58% vs 92%, p = 0.04), and it reached 100% in cases of PPROM after 28 weeks.ConclusionIn PPROM occurring before 32 weeks the median latency to delivery ranged between 11 and 22 days. Neonatal survival improves with higher GA at PPROM, and it increases by more than 33% when PPROM occurs after 24 weeks of gestation. These data may be valuable for patient counselling.

To determine the temporal persistence of the residual cell-free DNA (cfDNA) of the deceased cotwin in maternal circulation after selective fetal reduction and evaluate its long persistence in noninvasive prenatal testing (NIPT). Dichorionic diamniotic twins (N=5) undergoing selective fetal reduction because of a trisomy were recruited. After informed consent, maternal blood was collected immediately before reduction and periodically after reduction until birth. The plasma cfDNA of each sample was sequenced and analyzed for fetal aneuploidy and fetal fractions. In all pregnancies, the fetal fraction of the cfDNA of the deceased fetus increased to peak at 7-9weeks after fetal reduction, and subsequently decreased gradually to almost undetectable during the late third trimester. The NIPT T-scores persistently reflected the detection of fetal trisomy up to 16 (median 9.5) weeks after fetal reduction. Residual cfDNA from the deceased cotwin after selective reduction at 14-17 gestational weeks led to the persistent generation of false-positive NIPT results for up to 16weeks postdemise. Thus, providing NIPT for pregnancies with a cotwin demise in early second trimester is prone to misleading results and not recommended.