Treatment by autologous amniopatch of premature rupture of membranes following mid‐trimester amniocentesis

Abstract

We report a case in which amniopatch was used to treat previable premature rupture of membranes (PROM). Iatrogenic PROM often seals spontaneously, but can lead to chorioamnionitis, miscarriage, stillbirth or pulmonary hypoplasia. Various therapies have been attempted, with mixed results. PROM occurred in a 39-year-old woman 6 h after an uneventful genetic amniocentesis at 15 + 2 weeks' gestation, with a single fundal, non-transplacental insertion of a 20-G needle. Ultrasound examination showed oligohydramnios with amnion–chorion separation (Figure 1a). There were no contractions, nor clinical or biological signs of infection. After 2 days of inpatient bed rest, no amniotic fluid pocket was measurable (Figure 1b). After 2 weeks, leakage persisted with severe oligohydramnios. The karyotype was found to be normal. After counseling regarding the available options, including expectant management and termination of pregnancy, the patient opted for amniopatch treatment, but declined to receive donor blood products. Ultrasound images showing oligohydramnios and amnion–chorion separation immediately following premature rupture of membranes (PROM) at 15 + 2 weeks' gestation (a) and severe oligohydramnios 2 days following PROM (b). Autologous platelets and plasma were prepared by plasmapheresis, after appropriate screening, and plasma was transformed into cryoprecipitate. Cryoprecipitate is no longer registered on the official list of human blood derivatives, but the regional blood agency allowed for its compassionate use. Before use, it was thawed for 7 min. Final fibrinogen and factor VIIIc concentrations were 5 g/L and 2.36 IU/mL, respectively. The procedure was performed at 18 + 2 weeks' gestation, 3 weeks after PROM. Under local anesthesia, a 22-G needle was placed in the virtual intra-amniotic space distal to the placenta and near a fetal leg. After amnioinfusion of 10 mL of normal saline to check for correct needle placement, 30 mL of platelet concentrate was injected, immediately followed by 20 mL of cryoprecipitate. Much of the fluid injected into the amniotic cavity flowed into the extra-amniotic space. The fetal heart rate remained normal throughout. Spiramycin and progesterone were given for 1 week. Four days later, fetal movements and amniotic fluid volume were normal, and the amnion–chorion separation had disappeared (Figure 2). The pregnancy evolved normally, and a healthy male weighing 3500 g was delivered at 38 weeks. The placenta and membranes appeared normal on macroscopic examination. Ultrasound image showing normal amniotic fluid 4 days after amniopatch treatment. The amniopatch treatment successfully achieved membrane sealing in this case of iatrogenic PROM, which otherwise had a clearly unfavorable prognosis. Since Quintero et al. described the procedure in 19961, 35 cases have been published following iatrogenic PROM; 21 of these were in singleton pregnancies1-9, nine following an amniocentesis, five following chorionic villus sampling and seven following fetoscopy. The outcome was favorable in almost half of these cases (10/21). Experimental evidence indicates that injecting platelets and cryoprecipitate anywhere into the amniotic cavity can seal the defect caused by needle insertion10. In spontaneous PROM, such therapy is less likely to be effective because the defect is large and near the internal cervical os10, and amniotic infection is common. Although amniopatch is a promising technique in cases of previable iatrogenic PROM with persistent severe oligohydramnios, its risks are a concern as cases of fetal bradycardia have been reported10, possibly due to activation of vasoactive substances released by platelets. It must be stressed that most cases of amniotic leakage after amniocentesis do not require invasive management as they resolve spontaneously within a few days11. L. Mandelbrot* , L. Bourguignat , I. Sahraoui Mellouhi* , L. Gavard* , F. Morin§, P. Bierling§, * Service de Gynécologie– Obstétrique, Assistance Publique-Hopitaux de Paris (AP-HP), Hôpital Louis Mourier, Colombes, France, Service d'Hématologie, Assistance Publique-Hopitaux de Paris (AP-HP), Hôpital Louis Mourier, Colombes, France, Université Diderot-Paris 7, France, § Etablissement Français du Sang, Paris, France