Systematic review of national and international clinical practice guidelines for management of preterm prelabour rupture of membranes.

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

Booster course of antenatal corticosteroids after preterm prelabor rupture of membranes: a double-blind randomized trial

After completing this article, readers should be able to: 1. Describe the rationale for the use of antenatal corticosteroids for human fetal maturation. 2. Delineate recommendations of the 1994 National Institutes of Health Consensus Conference on Antenatal Corticosteroids. 3. Review areas of controversy in the clinical use of antenatal corticosteroids. 4. Describe the potential risks of multiple courses of antenatal corticosteroids. 5. Delineate current recommendations for clinical use of antenatal corticosteroids to promote fetal maturation. Glucocorticoid administration initially was appreciated as a method for accelerating development of the intestine more than 40 years ago. Since that time, developmental effects of these agents have been defined in at least 16 tissues of mammals. More than 30 years ago, while studying the mechanism of initiation of labor in sheep, Liggins made the observation that infusion of corticosteroids into fetal lambs was associated with improved survival and decreased lung disease in animals delivered preterm. Subsequently, numerous studies in cell culture, animal models, and human fetal tissue have delineated the multiple effects of glucocorticoids on the developing lung. These include increases in both the total tissue and alveolar surfactant pools; a decrease in vascular permeability, with less protein leak into the alveolar spaces; enhanced clearance of lung water; maturation of parenchymal structure; increase in lung compliance and maximal lung volume; enhanced response to surfactant treatment; and improvement in respiratory function, outcome, and survival. (See accompanying article on scientific rationale for use of antenatal glucocorticoids.) In 1972, the first randomized clinical trial of administration of antenatal corticosteroids (ANCS) in humans demonstrated decreased mortality and a decreased incidence of respiratory distress syndrome (RDS) in preterm infants born at less than 34 weeks’ gestation, who were treated with betamethasone for at least 24 hours before delivery. Over the ensuing 20 years, multiple clinical investigations continued to document the effectiveness of ANCS on …

Neonatal outcomes by delivery indication after administration of antenatal late preterm corticosteroids

Use of Antenatal Corticosteroids in Preterm Prelabor Rupture of Membranes

Preterm Labour and Birth: A Survey of Clinical Practice Regarding Use of Tocolytics, Antenatal Corticosteroids, and Progesterone

Background While antenatal corticosteroids are routinely used to decrease adverse neonatal outcomes following preterm delivery, corticosteroids are also associated with worse outcomes in patients with viral respiratory infections. Currently in the setting of the COVID-19 pandemic, it is unclear whether antenatal corticosteroids for infant benefit outweigh the potential harm to a pregnant woman with a COVID-19 infection. Objective To determine at which gestational ages administering antenatal corticosteroids is the optimal management strategy for hospitalized women with preterm prelabor rupture of membranes (PPROM) who have a COVID-19 infection. Methods We designed a decision-analytic model to assess the maternal and infant outcomes associated with antenatal corticosteroid administration for risk of preterm delivery following rupture of membranes in the setting of a COVID-19 infection. We used a theoretical cohort of 10,000 women at each gestational age between 24 and 32 weeks who were hospitalized with PPROM and found to be COVID-19 positive. Maternal outcomes included intensive care unit admission and death related to COVID-19 infection. The infant outcomes of interest included respiratory distress syndrome, intraventricular hemorrhage, neurodevelopmental delay, and death, and were assessed along with maternal and infant quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were used to evaluate model assumptions. Results In our theoretical cohort of 10,000 women with COVID-19 infection and preterm prelabor rupture of membrane between 24 and 32 weeks, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths at each gestational age. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths at each gestational age. Antenatal corticosteroid administration also resulted in fewer cases of respiratory distress syndrome, intraventricular hemorrhage, and infant death. Overall, we found that between 24 and 30 weeks of gestation, administering antenatal corticosteroids was the optimal management strategy as it resulted in higher combined QALYs than no corticosteroid use. For 31 and 32 weeks of gestation, antenatal corticosteroid administration resulted in lower combined QALYs. On sensitivity analyses, we found that with increasing gestational age, the probability which antenatal corticosteroids was the optimal management strategy decreased. Conclusion Administration of antenatal corticosteroids was an effective management strategy compared to no corticosteroid administration at gestational ages less than 31 weeks. These results provide data for clinicians to utilize when counseling pregnant patients hospitalized with PPROM and have a COVID-19 infection.

Preterm prelabour rupture of membranes (PPROM) is a common obstetric complication with significant maternal and foetal consequences. There is a lack of contemporary evidence regarding the optimal management of PPROM, including the best antibiotic regimen and management at previable gestations. To understand the contemporary management of PPROM among clinicians in Australia and Aotearoa New Zealand. An anonymous web-based survey was designed and distributed, consisting of 31 questions about individual clinicians' routine management of PPROM across a range of different gestations. The survey was completed by 235 clinicians from across Australia and Aotearoa New Zealand. The majority (225/232, 97%) routinely prescribed prophylactic antibiotics after PPROM, with 90 different antibiotic regimens documented. The most commonly prescribed prophylactic antibiotics were erythromycin (198/225, 88%) and penicillins (103/225, 46%). There was variation in practice regarding the timing of birth after PPROM, with 62% (147/235) routinely delaying birth until after 37 weeks of gestation, and 61% (143/235) expediting birth after 34 weeks of gestation if Group B Streptococcus was cultured antenatally. For previable PPROM (< 22 weeks of gestation), 74% (171/232) of women were routinely admitted to hospital at the time of diagnosis and 77% (173/225) were routinely offered antibiotics. There was significant variation in the earliest gestational ages at which antenatal corticosteroids and resuscitation are offered. We observed wide variation in clinical practice of management of PPROM. With a lack of national consensus regarding optimal management of this common pregnancy complication, contemporary clinical trials to define best practices are required.

ED FROM Crowther CA, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease. Cochrane Database Syst Rev 2007;(3):CD003935. Correspondence to:...

Previous reports have shown that suboptimal antenatal corticosteroids administration occurs in most cases. However, as multifetal gestations were either excluded or constituted a small proportion of the participants in these studies, little is known about the patterns of use of antenatal corticosteroids in twin pregnancies. We reviewed the records of women who received antenatal corticosteroids and delivered between 240/7 and 346/7 weeks of gestation during 2015-2017 at 2 university hospitals. Optimal antenatal corticosteroids timing was defined as delivery ≥24hours ≤7days from the previous antenatal corticosteroids course. Of 424 pregnancies, 307 (72.4%) were singleton and 117 were (27.6%) twin. For twin compared with singleton pregnancies, gestational age at initial antenatal corticosteroids administration was lower (P=0.02), the proportion of deliveries within the optimal window of the initial antenatal corticosteroids course was lower (19.7% vs 33.2%, P=0.001), and the proportion of women eligible for a rescue antenatal corticosteroids course was higher (58.1% vs 32.9%, P<0.0001). However, despite similar rates of rescue antenatal corticosteroids administration (P=0.64), the overall rate of delivery within any optimal window (either initial or rescue course) was lower in twin than singleton pregnancies (26.5% vs 42.3%, P=0.004), and the antenatal corticosteroids-to-delivery interval was longer (median 6.9 vs 4.2days, P=0.0009). In multivariate analysis, optimal antenatal corticosteroids administration was negatively associated with twin pregnancy (P=0.04) and preterm labor (P=0.05), and positively associated with the presence of gestational hypertensive disorders (P=0.03). Twin pregnancy is an independent risk factor for suboptimal antenatal corticosteroids administration. Directed efforts should be made to improve the utilization of antenatal corticosteroids in this vulnerable group of women.

Preterm prelabour rupture of membranes is a common clinical event. It is associated with infection in approximately 50% of cases. Clinical practice guidelines have been developed at the Royal Women's Hospital, Melbourne, Australia for investigation and management of this condition. To perform an audit of management of women presenting with this diagnosis and assess how inpatient management compares with the Hospital's current clinical practice guideline and how the clinical practice guideline compares with the evidence in the literature. Retrospective audit over a 3-month period collecting data on maternal age, gestation, microbiological results, other investigations, pharmacological treatment and outcome. All the 56 women admitted for this reason received at least one dose of antibiotic, most commonly erythromycin. More than two thirds of patients had the antibiotic changed at least once during their admission. Ten patients were prescribed intravenous antibiotics without a clear indication. Sixty-four percent received steroids for lung maturation of the neonate and 30% received tocolysis with nifedipine. Almost two thirds of patients delivered within 7 days and there were four neonatal deaths. In general management of women with premature rupture of membranes is in keeping with the current clinical practice guideline at the Royal Women's Hospital although antibiotic prescribing and management of Group B streptococcus colonisation could be improved. In addition, routine measurement of C reactive protein should cease. The current clinical practice guideline should be modified to reflect the current evidence in the literature.

Outcomes of extremely preterm infants exposed to prolonged prelabor rupture of membranes before 24 weeks of gestation.

Expectant management of preterm prelabour rupture of membranes — the significance of oligohydramnios at presentation

Preterm prelabor rupture of membranes: the use of amniocentesis to detect intraamniotic infection reduces maternal and neonatal duration of antibiotic exposure.

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