Management Of Preterm Prelabour Rupture Research Articles

Ambulation for latency during expectant management of preterm prelabor rupture of membranes: a randomized controlled trial (AMBLE)

BackgroundIndividuals hospitalized with preterm prelabor rupture of the membranes (PPROM) are often advised to limit their activity or adhere to bedrest. Some evidence suggests that greater activity is associated with longer latency and improved outcomes, but no high-quality evidence from a randomized-controlled trial exists. ObjectiveTo evaluate whether encouragement to ambulate at least 2,000 steps daily impacts latency among individuals with PPROM compared with usual care. Study DesignMultisite unblinded, two-arm randomized trial of individuals at 23 0/7 to 35 0/7 weeks gestation undergoing inpatient expectant management of PPROM with planned delivery at least 7 days away. Each participant wore a Fitbit InspireTM that tracked steps. The intervention arm was encouraged (verbal and Fitbit-based reminders) to reach a goal of 2,000 steps per day. The usual care arm was allowed ad lib activity with no step goal or reminders. The primary outcome was latency (days) from randomization to delivery. Secondary analyses included composite neonatal and maternal clinical outcomes and maternal mental health survey results. Statistical analyses were intent-to-treat under a Bayesian framework using neutral priors (a priori assumed 50:50 likelihood of longer latency in either arm). 100 participants were required to have 80% power to demonstrate a 4-day difference in latency with 75% certainty (Bayesian probability). ResultsAmong 163 eligible individuals, 100 (61%) were randomized, and after loss to follow-up, 95 were analyzed. Gestational age at randomization was 29 3/7 weeks (interquartile range [IQR] 26 2/7, 31 5/7) in the intervention arm and 27 4/7 weeks (IQR 25 4/7, 29 6/7) in the usual care arm. Median step counts were 1,690/day in the intervention arm (IQR 1,031-2,641) and 1,338/day in the usual care arm (IQR 784-1,913). Median days of latency were 9 days in the intervention arm (IQR 4-17) and 6 days in the usual care arm (IQR 2-14). The primary analysis indicated a 65% posterior probability that the intervention increased latency versus usual care (posterior relative risk [RR] 1.09; 95% credible interval [CrI], 0.70-1.71). The RR for composite neonatal adverse outcome was 0.55 (95% CrI 0.32-0.82) with 99% posterior probability of intervention benefit and for composite maternal adverse outcome was 0.94 (95% CrI 0.72-1.20), with 70% posterior probability of intervention benefit. There was a 94% posterior probability of the intervention arm having a greater decrease in maternal stress score from baseline to before delivery compared with the usual care arm (mean arm difference 3.24 points [95% CrI -7.23-0.79]). Adjustment for gestational age at randomization had minimal impact on secondary outcome results. ConclusionsIndividuals with PPROM randomized to encouragement to ambulate had a longer latency to delivery and improved neonatal and mental health outcomes with similar maternal clinical outcomes compared to usual care.

Outpatient management of preterm prelabor rupture of membranes before 34 weeks: Maternal and neonatal outcomes.

To evaluate the maternal, fetal, and neonatal outcomes of pregnant women complicated with preterm prelabor rupture of membranes (PPROM) eligible for outpatient care. This study included a retrospective cohort of patients with singleton pregnancies with PPROM between 23+0 to 34+0 weeks who remained pregnant after the first 72 h. Outpatient management was considered in women with clinical, ultrasound and analytical stability, and easy access to hospital. Maternal, fetal, and neonatal results were compared between women managed as inpatients versus those managed as outpatients. Women eligible for the outpatient management had a better prognostic profile (no anhydramnios, longer cervical length, less intraamniotic infection, and clinical, ultrasound, and analytical stability) and presented a lower gestational age at admission and longer latency to delivery, resulting in a similar gestational age at delivery as the inpatient group. Postpartum curettage, uterine atony, respiratory distress syndrome, and bronchopulmonary dysplasia were less frequent in the outpatient group. Composite maternal-fetal morbidity and mortality outcomes were similar in both groups, while composite neonatal morbidity and mortality outcomes were significantly lower in the outpatient group. Outpatient management may be an option for women presenting stable PPROM before 34 weeks when adequate selection criteria are fulfilled. Differences in perinatal outcomes in the outpatient group compared with the inpatient group are probably attributable to baseline characteristics. Further prospective randomized studies are needed to confirm the benefits of outpatient management in PPROM.

Different azithromycin protocols for management of preterm prelabour rupture of membranes: a randomized clinical trial

BackgroundPreterm prelabor rupture of membranes is associated with polymicrobial infection; hence broad-spectrum antibiotics are recommended. Nowadays, Azithromycin is used instead of Erythromycin due to erythromycin shortages, its ease of administration, decreased cost, and better side effect profile. This study aimed to evaluate the efficacy of different azithromycin protocols for the conservative management of preterm prelabor rupture of membranes.MethodsIt was a single-blinded randomized clinical trial including pregnant women at 24–36+6 weeks with viable singleton pregnancies and confirmed preterm prelabor rupture of membranes from January 01, 2020, to June 01, 2021. The participants were randomized into two groups: Group I was made of women who received Azithromycin 1000 mg PO once, and Group II of women who received Azithromycin 500 mg PO once, followed by Azithromycin 250 mg PO daily for four days. The primary study outcome was the length of the latency period from the diagnosis of preterm prelabor rupture of membranes to delivery (days).ResultsThe latency period in group I was significantly higher than that in Group II (5.80 ± 5.44 days vs. 2.88 ± 2.37; respectively, p = 0.0001). The mean gestational age at the time of delivery was significantly higher in Group I (p = 0.0001). However, postpartum endometritis and respiratory distress syndrome (RDS) rates were significantly higher in Group II (p = 0.003 and p = 0.0001, respectively).ConclusionThe higher dose of Azithromycin was associated with better maternal and neonatal outcomes.Trial registrationClinical trial identification number: Clinical trial.gov: NCT04202380 (17/ 12/ 2019).Date of registration: 1/1 /2020.Date of initial participant enrollment30 /1/2020.URL of the registration site: https://www.clinicaltrials.gov/ct2/show/NCT04202380

Use of Azithromycin in Pregnancy: More Doubts than Certainties.

Macrolides such as azithromycin are commonly prescribed antibiotics during pregnancy. The good oral bioavailability and transplacental transfer of azithromycin make this drug suitable for the treatment of sexually transmitted diseases, toxoplasmosis, and malaria. Moreover, azithromycin is useful both in the management of preterm pre-labor rupture of membranes and in the adjunctive prophylaxis for cesarean delivery. The aim of this comprehensive narrative review is to critically analyze and summarize the available literature on the main aspects of azithromycin use in pregnant women, with a special focus on adverse offspring outcomes associated with prenatal exposure to the drug. References for this review were identified through searches of MEDLINE, PubMed, and EMBASE. Fetal and neonatal outcomes following prenatal azithromycin exposure have been investigated in several studies, yielding conflicting results. Increased risks of spontaneous miscarriage, major congenital malformations, cardiovascular malformations, digestive system malformations, preterm birth, and low birth weight have been reported in some studies but not in others. Currently, there is no conclusive evidence to support that azithromycin use by pregnant women causes adverse outcomes in their offspring. Therefore, this agent should only be used during pregnancy when clinically indicated, if the benefits of treatment are expected to outweigh the potential risks.

Feasibility of pharmacologic venous thromboembolism prophylaxis for women with preterm prelabor rupture of membranes

To determine the proportion of women admitted for expectant management of preterm prelabor rupture of membranes (PPROM) who deliver within 12 hours of typical dosing of pharmacologic venous thromboembolism (VTE) prophylaxis

Tocolysis in the management of preterm prelabor rupture of membranes at 22\u201333\u2009weeks of gestation: study protocol for a multicenter, double-blind, randomized controlled trial comparing nifedipine with placebo (TOCOPROM)

BackgroundPreterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation complicates 1% of pregnancies and accounts for one-third of preterm births. International guidelines recommend expectant management, along with antenatal steroids before 34 weeks and antibiotics. Up-to-date evidence about the risks and benefits of administering tocolysis after PPROM, however, is lacking. In theory, reducing uterine contractility could delay delivery and reduce the risks of prematurity and its adverse short- and long-term consequences, but it might also prolong fetal exposure to inflammation, infection, and acute obstetric complications, potentially associated with neonatal death or long-term sequelae. The primary objective of this study is to assess whether short-term (48 h) tocolysis reduces perinatal mortality/morbidity in PPROM at 22 to 33 completed weeks of gestation.MethodsA randomized, double-blind, placebo-controlled, superiority trial will be performed in 29 French maternity units. Women with PPROM between 220/7 and 336/7 weeks of gestation, a singleton pregnancy, and no condition contraindicating expectant management will be randomized to receive a 48-hour oral treatment by either nifedipine or placebo (1:1 ratio). The primary outcome will be the occurrence of perinatal mortality/morbidity, a composite outcome including fetal death, neonatal death, or severe neonatal morbidity before discharge. If we assume an alpha-risk of 0.05 and beta-risk of 0.20 (i.e., a statistical power of 80%), 702 women (351 per arm) are required to show a reduction of the primary endpoint from 35% (placebo group) to 25% (nifedipine group). We plan to increase the required number of subjects by 20%, to replace any patients who leave the study early. The total number of subjects required is thus 850. Data will be analyzed by the intention-to-treat principle.DiscussionThis trial will inform practices and policies worldwide. Optimized prenatal management to improve the prognosis of infants born preterm could benefit about 50,000 women in the European Union and 40,000 in the United States each year.Trial registrationClinicalTrials.gov identifier: NCT03976063 (registration date June 5, 2019).

218 Expectant management of preterm prelabor rupture of membranes at 34 weeks: a cost effective analysis

To examine the outcomes and cost effectiveness of expectant management versus immediate delivery of women who experience preterm prelabor rupture of membranes (PPROM) at 34 weeks or greater. A decision-analytic model was built using TreeAge software to compare outcomes in women with PPROM at 34 weeks undergoing expectant management until maximum 37 weeks versus immediate delivery. The number of women with PPROM per year was estimated at 37,455 (1% of all births). Outcomes included stillbirth, neonatal sepsis, neonatal death, neonatal neurodevelopmental delay, maternal sepsis, maternal death, cost, and quality-adjusted life years (QALYs). Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALYs. In our theoretical cohort of 37,455 women, expectant management resulted in 3,884 more quality-adjusted life years and a cost savings of $1.2 billion per year, making it a dominant strategy. Expectant management yielded 60 fewer neonatal deaths and 172 fewer cases of neonatal neurodevelopmental delay. However, it resulted in 204 more cases of neonatal sepsis and 60 more cases of maternal sepsis. Univariate sensitivity analysis demonstrated that expectant management yielded more QALYs until the risk of neonatal sepsis reached 23% (baseline estimate: 1.7%). Univariate sensitivity analysis also demonstrated that expectant management yielded improved QALYS until the risk of maternal sepsis exceeded 35% (baseline estimate: 0.6%). Expectant management was also cost effective until the weekly cost of antepartum admission reached $30,372 (baseline estimate: $12,348). In our theoretical cohort, expectant management of PPROM at 34 weeks yielded better outcomes on balance at a lower cost than immediate delivery. This analysis is important and timely in light of recent trials suggesting improved neonatal outcomes with expectant management. However, individual risks must be considered in making this clinical decision as expectant management may increase risk of adverse outcomes once risk of infection increases.

Maternal and perinatal outcomes in midtrimester rupture of membranes

Objective The aim of this study was to assess neonatal and maternal adverse outcomes following expectant management of preterm prelabor rupture of membranes (PPROM) between 18 and 26 weeks and to identify maternal morbidity and prognostic factors for neonatal outcomes. Methods Data were collected from all pregnant women who presented PPROM between 18+0 and 26+0 weeks admitted into two tertiary centers in Brazil from 2005 to 2016. The neonatal adverse outcomes (mortality or the development of a severe morbidity) and maternal adverse outcomes were analyzed and compared among four groups (180/7 to 200/7 weeks, 20+1 to 220/7 weeks, 22+1 to 240/7 weeks and 24+1 to 260/7 weeks). A multiple logistic regression was performed for each predictor of neonatal adverse outcomes, and the area under the receiver operating characteristics curves for birth weight and gestational age at birth were calculated. Results Of the 101 women with PPROM during the study period, 97 fulfilled the eligible criteria. Among these patients, 30 (30.9%) had a miscarriage or stillbirth. Overall there were 67/97 (69.1%) livebirths, 45/97 newborns survived to discharge (46.3%), and 53/97 (54.6%) experienced severe neonatal adverse outcome. The median latency period was seven days, with 36 (37.1%) patients ending the pregnancy in 2–14 days. Among 29 patients with PPROM at 24+1 to 260/7 weeks, only 13 (44.8%) delivered between 2 and 14 days. Multivariate analysis has demonstrated that the independent predictor for adverse neonatal outcome was birthweight. The maternal morbidity was high; however, the expectant management did not increase the rate of severe maternal morbidity. Conclusions PPROM between 18+0 and 26+0 weeks has high morbidity and mortality, and the only significant independent predictor of severe adverse neonatal outcomes is birthweight. Maternal morbidity is high, however, the expectant management is not increased by expectant management.

Successful Deliveries of Twins from Two Pregnant Women Following Preterm Prelabor Rupture of Membranes in the Early Second-Trimester Pregnancy

Abstract The management of preterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation is intractable, due to pulmonary immaturity, many complications, poor pregnancy outcomes. In particular, the pre-viable PPROM (<23 weeks of gestation) is much more difficult to be treated. The clinical recommendation is to terminate the pregnancy as soon as possible. The pregnancy outcomes of PPROM in the early second-trimester of two twin pregnant women in our hospital were reported to explore the treatment protocols. The pregnancies of the two women developed PROM at 12 and 16 weeks of gestation, respectively. After expectant treatment, they were delivered successfully at 34+6 and 34+4 weeks of gestation, respectively. The assessment of growth and development of infants was normal during the following six months after birth. Therefore, if PPROM occurs in the early second-trimester of pregnancy, the management of PPROM should be individualized, it's a long process which should include comprehensive communication between patients and families regarding alternative treatment options (including expectant management) and risks and benefits of the procedure. In the absence of spontaneous labor or occurrence of complications that would prompt delivery (intra-amniotic infection, abruptio placenta, cord prolapse), and fetal status is normal, the patients should proceed with expectant treatment, induction of labor is commonly performed in pregnancies with PPROM ≥34 weeks of gestation.

Preterm Prelabor Rupture of Membranes: Outcomes with Expectant Management until 34 versus 35 Weeks

To evaluate outcomes with expectant management of preterm prelabor rupture of membranes (PROM) until 35 weeks versus immediate delivery at ≥34 weeks. This was a multicenter retrospective cohort study of singletons with preterm PROM at >20 weeks from 2011 through 2017. Groups were defined as expectant management until 35 weeks versus immediate delivery at ≥34 weeks. Primary outcome was composite neonatal morbidity: need for respiratory support, culture positive neonatal sepsis, or antibiotic administration for >72 hours. Univariate and general estimating equation models were used with p < 0.05 considered significant. A total of 280 mother-infant dyads were included. There was no difference in composite neonatal outcome in pregnancies managed with expectant management compared with immediate delivery (43.4 vs. 37.5%; p = 0.32). Those with expectant management had shorter length of neonatal intensive care unit (NICU) admission but higher rates of neonatal antibiotics for > 72 hours, endometritis, and histological chorioamnionitis. There were no cases of fetal demise, neonatal death, or maternal sepsis, and only three cases of neonatal sepsis. There is no difference in composite neonatal morbidity in pregnancies with preterm PROM managed with expectant management until 35 weeks as compared with immediate delivery at 34 weeks. Expectant management is associated with a decreased length of NICU admission but increased short-term infectious morbidity.

Maternal and neonatal outcomes following expectant management of preterm prelabor rupture of membranes before viability

Purpose: To provide center-based outcome data on obstetric and neonatal complications arising from expectantly managed pregnancies affected by preterm prelabor rupture of membranes (PPROM) before viability.Materials and methods: We collected data on 130 consecutive pregnancies complicated by spontaneous rupture of membranes before 24 week’s gestation, occurring over a 7-year period. These were women who delivered >24 h after membrane rupture, and had no signs of chorioamnionitis or advanced labor at admission. Women with amniocentesis-induced PPROM (n = 7) were analyzed separately. The descriptive statistics of obstetrics and neonatal outcomes were reported.Results: The overall neonatal survival to discharge rate was 33.8%. Stratification of patients into early (12 to 19+6 weeks’ gestation) and late pre-viable PPROM (20 to 23+6 weeks’ gestation) revealed a 3.6-fold increase in survival rate in the latter group (12.2% versus 43.8%, p < .001). Pre-viable PPROM following amniocentesis predicted a 100% survival outcome, however anhydramnios impacted negatively. The most common neonatal morbidities of those admitted to intensive care unit were respiratory distress syndrome (78.7%) and bronchopulmonary dysplasia (84.4%). The most common maternal morbidities affecting pre-viable PPROM were clinical chorioamnionitis (47.7%), histological chorioamnionitis (81.8%), retained products of conception (39.3%) and preterm labor (45.4%).Conclusions: Later gestational ages at PPROM were associated with better survival rates, however neonatal morbidity remained high. Women experiencing pre-viable PPROM following amniocentesis can be reassured, while those with anhydramnios at any time during the latency period should be adequately counseled regarding poorer outcomes.

Immediate Delivery Compared With Expectant Management After Preterm Prelabor Rupture of the Membranes Close to Term (PPROMT Trial): A Randomized Controlled Trial

(Lancet. 2016;387:444–452) Rupture of the membranes before the onset of labor is a common problem, occurring in 20% of all births and 40% of preterm births. The management of preterm prelabor rupture of membranes close to term varies among different countries. The professional obstetric societies in the United States and United Kingdom do recommend immediate delivery from 34 weeks gestation onward. However, these recommendations are based on scant scientific evidence. The goal of this current study (named the PPROMT trial) was to establish whether immediate birth or expectant management resulted in better outcomes in the setting of ruptured membranes close to term in singleton pregnancies.

Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability

To assess the contemporary maternal and neonatal outcomes following expectant management of preterm premature rupture of membranes (PPROM) prior to 24 weeks' gestation and to identify prognostic indicators of this morbid presentation. We performed a systematic review in the Pubmed and EMBASE databases to identify the primary (perinatal mortality, severe neonatal morbidity and serious maternal morbidity) and secondary (neonatal survival and morbidity) outcomes following expectant management of previable PPROM. Mean latency between PPROM and delivery ranged between 20 and 43 days. Women with PPROM <24 weeks had an overall live birth rate of 63.6% and a survival-to-discharge rate of 44.9%. The common neonatal morbidities were respiratory distress syndrome, bronchopulmonary dysplasia and sepsis. The majority of neonatal deaths within 24 h post birth were associated with pulmonary hypoplasia, severe intraventricular haemorrhage and neonatal sepsis. The common maternal outcomes were chorioamnionitis and caesarean sections. The major predictors of neonatal survival were later gestational age at PPROM, adequate residual amniotic fluid levels, C-reactive protein <1 mg/dL within 24 h of admission and PPROM after invasive procedures. Pregnancy latency and neonatal survival following previable PPROM has improved in recent years, although neonatal morbidity remains unchanged despite recent advances in obstetric and neonatal care. There is heterogeneity in management practices across centres worldwide.

Comparison of conservative &amp; aggressive management of PPROM at 34-36 weeks gestation in terms of development of neonatal sepsis &amp; RDS

Objective : To compare the conservative and aggressive management of Preterm prelabor rupture of membranes (PPROM) at 34-36 weeks gestation in terms of development of neonatal sepsis and respiratory distress syndrome (RDS). Method : 194 pregnant women with PPROM at gestational age 34-36 weeks admitted in labour ward were included in the study conducted from 2009-2010 in department of Obstetrics & Gynaecology, SMS Medical College, India. Random allocation to conservative & aggressive management group was done by offering Chit Box Method assigning 97 cases in each group. In conservative management cases were hospitalised & provided bed rest, Daily fetal monitoring, Maternal vitals monitoring, Oral tab erythromycin 500 mg T.D.S for 7 days, Daily WBC count and c-reactive protein estimation. Expectant management was abandoned if there was clinical evidence of labour, infection or fetal distress. In aggressive management induction of labour was done by Tab Misoprostol 25 mg orally, at 4-6 hour intervals, for a maximum of 5 doses. Caesarean delivery was performed for standard obstetrical indication and for failed induction. After delivery neonatal care was provided by neonatologist. Results : Out of 97 cases in aggressive management group 4 (4.12%) newborn babies suffered from neonatal sepsis and out of 97 newborn babies in conservative management group 14 (14.43%) babies had neonatal sepsis. Out of 97 cases in aggressive management group 15 (15.46%) newborn suffered from RDS and out of 97 cases in conservative management group 12 (12.34%) newborn suffered from RDS. Conclusion : Rate of neonatal sepsis was higher in conservative management group than aggressive management group. Thus there was significant association observed for neonatal sepsis in between aggressive management and conservative management group. The rate of RDS was lower in conservative management group as compared to aggressive management group. But there is no significant association were observed between RDS in both conservative and aggressive management group.

Comparison of duration of maternal hospital stay in conservative &amp; aggressive management of Preterm prelabor rupture of membranes(PPROM) in Indian women at 34-36 weeks gestation.

Aim:To compare the conservative and aggressive management of Preterm prelabor rupture of membranes (PPROM) in Indian women at 34-36 weeks gestation in terms of duration of their hospital stay. Materials & Method:194 pregnant women with PPROM at gestational age 34-36 weeks admitted in labour ward were included in the study conducted from 2009 -2010 in department of Obstetrics & Gynaecology, SMS Medical College, India. Random allocation to conservative & aggressive management group was done by offering Chit Box Method assigning 97 cases in each group. In conservative management cases were hospitalized& provided bed rest, Daily fetal monitoring, maternal vitals monitoring, Oral tab erythromycin 500 mg t.d.s for 7 days, Daily WBC count and C reactive protein estimation. Expectant management was abandoned if there was clinical evidence of labour, infection or fetal distress. In aggressive management induction of labour was done by Tab Misoprostol 25 g orally, at 4-6 hour intervals, for a maximum of 5 doses. Caesarean delivery was performed for standard obstetrical indication and for failed induction. After delivery neonatal care was provided by neonatologist Results:Out of total 97 cases, in aggressive management, majority 73 (75.26%) cases had duration  5 days, 19 (19.59%) up to 6-10 days and 5 (5.15%) cases up to 11+ days. Similarly out of total 97 cases in conservative management, majority 46 (47.42%) cases had duration  5 days, 33 (34.02%) up to 6-10 days and 18 (18.56%) cases up to 11+ days. The mean duration of hospital stay of mother in aggressive management were 4.10  3.10 days and in conservative management it is 7.21  3.36 days. Conclusion:Majority of cases in both aggressive and conservative management group had duration of hospital stay of  5 days. But the total duration of hospital stay of mother were much higher in conservative management group in present study. Thus mean duration of hospital stay of mother were much higher in conservative management group as compared to aggressive management. Keywords-PPROM, conservative, aggressive, hospital stay.

Latency after preterm prelabor rupture of the membranes: increased risk for periventricular leukomalacia.

Objective. To identify the risk factors for cystic periventricular leukomalacia (cPVL) and their implications for deciding between immediate delivery and conservative management of preterm prelabor rupture of the membranes (pPROM). Methods. The following risk factors were compared between cPVL infants and 6440 controls: chorioamnionitis, sex, gestational age (GA), birth weight, pPROM, and pPROM-delivery interval. Factor impact on cPVL risk and clinical decision-making was determined by multivariate logistic regression. Results. Overall cPVL prevalence (n = 32) was 0.99/1000 births. All cPVL infants but one were born <34 weeks of gestation and were <2500 g; 56% had histological chorioamnionitis versus 1.1% of controls (OR 35.9; 95%-CI 12.6–102.7). Because chorioamnionitis is a postnatal diagnosis, logistic regression was performed with prenatally available factors: pPROM-delivery interval >48 hours (OR 9.0; 95%-CI 4.1–20.0), male gender (OR 3.2; 95%-CI 1.4–7.3). GA was not a risk factor if birth weight was included. Risk decreased with increasing fetal weight despite a prolonged pPROM-delivery interval. Conclusion. pPROM-delivery interval is the single most important prenatally available risk factor for the development of cPVL. Immediate delivery favors babies with chorioamnionitis but disfavors those with non infectious pPROM. In the absence of clinical chorioamnionitis fetal weight gain may offset the inflammatory risk of cPVL caused by a prolonged pPROM-delivery interval.

Changes in neonatal morbidity after rcog guideline 44 for preterm prelabour rupture of membranes

IntroductionThe RCOG published Guideline 44 in November 2006 for the management of preterm prelabour rupture of membranes, recommending delivery at 34 weeks. Concern was raised that this may have had...

Management of preterm prelabour rupture of membranes: an audit. How do the results compare with clinical practice guidelines?

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.

Recent evidence associated with the condition of preterm prelabour rupture of the membranes.

The published literature on preterm prelabour rupture of the membranes is voluminous yet despite advances in obstetric and neonatal care, the problem remains a major cause of perinatal mortality and morbidity. The purpose of this review is to present recent evidence pertaining to the role of inflammatory mediators such as cytokines and the tissue damage and long-term handicap they cause, the molecular biology and physiology of membrane structure, the role of host susceptibility and the genetics of preterm birth and therapeutic options for the management of preterm prelabour rupture, including antibiotics, amnioinfusion and special situations. Neonatal morbidity from preterm prelabour rupture of the membranes is mainly related to oligohydramnios and pulmonary hypoplasia. Occupational factors have a significant effect on the occurrence and outcome following rupture. Matrix metalloproteinases control growth and remodelling of the pregnant uterus, placenta and membranes and are linked to a genetic predisposition to preterm birth through gene expression and variation. Transvaginal ultrasound scan, oncofetal fibronectin and the presence of abnormal genital tract flora (bacterial vaginosis) in pregnancy may help in the prediction of preterm birth. Preterm prelabour membrane rupture remains a management problem, particularly at very early gestations, yet obstetric and neonatal care can make a difference to outcome. While at early gestations the prognosis is poor, it is not hopeless. Careful selection of the recent literature on the subject might interest and inform those faced regularly with the problem, prevent therapeutic nihilism, promote confidence in our ability to make a difference and realise that we are not alone when faced with the therapeutic dilemma that is this condition.

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

In a retrospective study, the relationship between oligohydramnios (largest amniotic fluid pocket less than 2 × 2 cm) at the time of presentation and the outcome of expectant management of patients with preterm (< 35 weeks) prelabour rupture of membranes (PROM) was examined in 62 patients admitted with a confirmed diagnosis and in the absence of complications or established labour. There were no differences in the maternal age, incidence of multiparity, or additional complications between patients without (Group 1, n = 24) and with (Group 2, n = 38) oligohydramnios. However in Group 2, 44.7% of the patients developed PROM before 28 weeks and 63.2% were delivered within 48 h of assessment, in contrast to 20.8% ( P < 0.05) and 12.5% ( P < 0.001), respectively, in Group 1. Group 2 patients had a higher incidence of histological chorioamnionitis (55.3% vs. 29.3%, P < 0.05) and funisitis (44.7% vs. 16.7%, P < 0.02), an earlier mean gestation at delivery (29.1 ± 2.8 weeks vs. 31.5 ± 2.0 weeks, P < 0.001) and lower birth weight (1373 ± 467 g vs. 1856 ± 496 g, P < 0.001). Our results indicate that oligohydramnios at presentation of preterm PROM is an unfavourable prognostic sign in the expectant management of these pregnancies.