Prelabour Rupture Of The Membranes Research Articles

Prelabour rupture of the membranes at term: antibiotic overuse in Italy.

The proper management of women with premature rupture of membrane (PROM) and not spontaneously entering in labour remains controversial. The aim of this study was to identify the current management for women with PROM at term according to the Group B Streptococcus (GBS) status across different Italian hospitals. Anonymous online survey evaluating: the current practice of women with PROM in terms of management (expectant management vs. induction of labour) and antibiotic prophylaxis according to GBS status. In case of negative GBS status, the 82.4% of respondents wait until 24 hours before labour induction. Antibiotics are administered for prophylaxis in 35.3%, 27.5% and 2% at 18, 12 and 24 hours respectively. The remaining 35.3% of respondents are divided between those using antibiotics only with signs of infections or according to different risk factors (i.e. meconium-stained amniotic fluid or suspected infection). Neonates born from a mother with negative GBS status almost never (90.2%) receive prophylactic antibiotics. In case of positive GBS status, induction is started as soon as possible by 49.1% of respondents; the remnants choose to wait 6 (15.7%), 12 (17.6%), 18 (3.9%) and 24 (13.7%) hours. Antibiotics are administered as soon as possible by 78.4% of clinicians. In the neonates, 51% of neonatologist administer antibiotics upon clinical indications (suspected sepsis); 15.7% use antibiotics routinely or with a short interval between maternal antibiotics and delivery (17.6%). The management after PROM is highly heterogeneous with an inappropriate extension of antibiotic prophylaxis in cases with negative GBS status.

Comprehensive assessment of risk factors as a method for predicting prelabour rupture of membranes

BACKGROUND: Prelabour rupture of the membranes (PROM) is a common obstetric pathology, the incidence of which reaches 20%. There is evidence that PROM is the main risk factor not only for abnormal labor, but also for postpartum hypotonic bleeding. Meanwhile, the etiology and pathogenesis of this complication have not been finally determined until now.
 AIM: The aim of this study was to create a model that allows for predicting PROM, based on a comprehensive assessment of risk factors.
 MATERIALS AND METHODS: Based on the data collected in the Regional Clinical Hospital Perinatal Center, Chita, Russia in 2018-2021, the prospective analysis of 213 cases of labor was carried out. The total sample was divided into two study groups: group 1 included 142 cases of labor with timely rupture of membranes; group 2 included 71 cases of labor, complicated by PROM. The groups were comparable in terms of nationality, age, material and social living conditions of women, frequency of genital pathology, gestational age and gender distribution of newborns. On the eve of labor (1-2 days), all patients underwent a general clinical examination and clarification of the anamnesis. Ultrasound examination was carried out both the day before and during labor in order to clarify fetal position. Statistical processing of the results was carried out using the IBM SPSS Statistics Version 25.0 program.
 RESULTS: Risk factors for PROM are: the presence of posterior view of the occipital presentation (RR = 2.67 (95 % CI 1.13-6.31), p = 0.02) and varicose veins (RR = 3.2 (95 % CI 1.09-9.43), p = 0.04), distantia cristarum more than 28.5 cm (RR = 1.99 (95 % CI 1.12-3.54), p = 0.02), distantia trochanterica more than 30.5 cm (RR = 2.15 (95 % CI 1.09-4.23), p = 0.03), and conjugata externa more than 20.5 cm (RR = 1.84 (95 % CI 1.01-3.37), p = 0.046). Oligohydroamnion is a protective factor in relation to PROM (RR = 0.31 (95 % CI 0.11-0.85), p = 0.02). This predictive model, which takes into account such factors as the type of fetal head presentation, the presence of oligohydramnios and varicose veins, and the size of distantia cristarum, allows for predicting PROM with much effect.
 CONCLUSIONS: The comprehensive assessment of risk factors, despite its simplicity and availability, allows for predicting the timeliness of rupture of the membranes with an accuracy of 71.0%. Application of the developed model makes it possible to identify a risk group subject to preventive preinduction, which in the future will help to reduce the frequency of abnormal labor and associated complications.

Obstetric implications of maternal chronic hepatitis B virus infection

Antenatal screening for hepatitis B surface antigen seropositivity is widely adopted to identify pregnant women with chronic hepatitis B virus (HBV) infection in order to target their newborn infants for combined passive-active neonatal immunization to prevent the maternal-to-child transmission of HBV. It is less certain whether the presence of chronic HBV infection in these largely asymptomatic women could impact their pregnancy outcome. There is now gathering information in the literature, though sometimes conflicting, on the obstetric implications of chronic HBV infection. The conflicting data is most probably related to confounding factors such as the immunological phase of chronic HBV infection, viral genotype and activity, presence of hepatic inflammation and other co-existing liver disorders such as non-alcoholic fatty liver disease, and coinfection with other virus such as hepatitis C virus and micro-organisms, which are usually not examined, but which could have made significant influence on the occurrence of many of the pregnancy complications and adverse fetal and neonatal outcome. For pregnancy complications, the evidence suggests association with increased gestational diabetes mellitus, preterm birth, intrahepatic cholestasis of pregnancy, caesarean delivery, and postpartum haemorrhage, probably increased placental abruption and prelabour rupture of the membranes, and no effect or a reduction in the hypertensive disorders of pregnancy, especially preeclampsia. For perinatal outcome, there may be increased miscarriage and fetal malformations, and increase in both low birthweight and large-for-gestational age/macrosomic infants, as well as increased intrauterine fetal demise/stillbirth and fetal distress. However, most studies have not elaborated on the mechanisms or explanations of many of the adverse outcomes. Taken together, maternal chronic HBV infection increases the risk of adverse obstetric outcome overall, but further prospective studies are warranted to elucidate the reasons and mechanisms of, and with a view to mitigate, these adverse obstetric outcomes.

Indications of Labor Induction at Delivery Room of Maternity Teaching Hospital in Erbil City

Background and objectives: Induction of labour means stimulation of contractions before the birth starts spontaneously, with or without ruptured membranes. The most common indications include oligohydramnios, pre-labour rupture of the membranes, high blood pressure during pregnancy, severe fetal growth restriction, post-term pregnancy, and var-ious maternal medical conditions such as chronic hypertension and diabetes. The aim of the study was to find out the different indications of labour and associated obstetrical factors in a local tertiary hospital. Methods: A cross-sectional study was conducted among 120 parturient women who attended a delivery room in the Maternity Teaching Hospital in Erbil City from the period of 2nd June to 2nd October 2020. After reviewing the literature, a questionnaire was pre-pared to obtain socio-demographic data, data related to reproductive characteristic and data related to the indications for labour induction. The data were analyzed using descrip-tive and inferential statistical approaches. Results: The study included 120 patients with the highest percentage of the patients (49.1%) were 16 to 23 years old and more than half of the sample (51.6%) had a post-term pregnancy, gestational hypertension and pre-eclampsia (15%). There were highly significant statistical differences between parity, gestational age and indication of labour induction, and significant differences between gravidity and antenatal care visits and indi-cations for labour induction. Conclusions: The majority of the sample had a post-term pregnancy of 40 and 42 weeks as an indication for induction of labour followed by gestational hypertension and pre-eclampsia, oligohydramnios and pre-labour rupture of membrane. There was a statistical-ly significant difference between the antenatal care visit and parity with the induction of labour.

The correlation between prelabour rupture of the membranes and neonatal infectious diseases, and the evaluation of guideline implementation in China: a multi-centre prospective cohort study

BackgroundThe aim of this study was to describe the epidemiology of prelabour rupture of membranes (PROM) in China and to assess the association between clinical practice following the guidelines and early neonatal infections. MethodsWe conducted a prospective cohort study of 15926 deliveries in ShenZhen Baoan Women's and Children's Hospital, Xibei Women's and Children's Hospital and Chengdu Women's and Children's Hospital between August 1, 2017, to March 31, 2018. Clinical data were collected for each participant. The epidemiology of PROM was described. The association between PROM with early neonatal infectious outcomes and the influence of the implementation of the guideline on early neonatal infectious outcomes were assessed. FindingsThe incidence of PROM was 18•7%. PROM was showed to be a risk factor for neonatal infectious diseases (adjusted OR 1•92, 95%CI 1•49~2•49, p<0•0001), early-onset pneumonia (EOP) (adjusted OR 1•81, 95%CI 1•29~2•53, p=0•0006) and early-onset sepsis(EOS) (adjusted OR 14•56, 95%CI 1•90~111•67, p=0•01) for term neonates. For term neonates born from mother with PROM, induction of labor according to the guideline was a protective factor for neonatal diseases(adjusted OR 0•50, 95%CI 0•25~1•00, p=0•00498) and EOP(adjusted OR 0•32, 95%CI 0•11~0•91, p=0•03). For preterm neonates born from mother with PROM, using antibiotics according to the guideline showed to be protective for neonatal infectious diseases (adjusted OR 0•14, 95%CI 0•09~0•23, p<0•0001) and EOP (adjusted OR 0•08, 95%CI 0•04~0•14, p<0•0001). InterpretationOur study showed the risk of PROM for infectious diseases (including EOP and EOS) and the benefit of the usage of antibiotics according to the guideline for infectious diseases and EOP for preterm neonates. FundingNational Natural Science Foundation of China, Capital Medical Development Research Fund of Beijing.

Child outcomes after amnioinfusion compared with no intervention in women with second-trimester rupture of membranes: a long-term follow-up study of the PROMEXIL-III trial.

ObjectiveTo assess the effect of transabdominal amnioinfusion or no intervention on long‐term outcomes in children born after second‐trimester prelabour rupture of the membranes (PROM between 16+0/7–24+0/7 weeks) and oligohydramnios.PopulationFollow up of infants of women who participated in the randomised controlled trial: PPROMEXIL‐III (NTR3492).MethodsSurviving infants were invited for neurodevelopmental assessment up to 5 years of corrected age using a Bayley Scales of Infant and Toddler Development or a Wechsler Preschool and Primary Scale of Intelligence. Parents were asked to complete several questionnaires.Main outcome measuresNeurodevelopmental outcomes were measured. Mild delay was defined as −1 standard deviation (SD), severe delay as −2 SD. Healthy long‐term survival was defined as survival without neurodevelopmental delay or respiratory problems.ResultsIn the amnioinfusion group, 18/28 children (64%) died versus 21/28 (75%) in the no intervention group (relative risk 0.86; 95% confidence interval [CI] 0.60–1.22). Follow‐up data were obtained from 14/17 (82%) children (10 amnioinfusion, 4 no intervention). In both groups, 2/28 (7.1%) had a mild neurodevelopmental delay. No severe delay was seen. Healthy long‐term survival occurred in 5/28 children (17.9%) after amnioinfusion versus 2/28 (7.1%) after no intervention (odds ratio 2.50; 95% CI 0.53–11.83). When analysing data for all assessed survivors, 10/14 (71.4%) survived without mild neurodevelopmental delay and 7/14 (50%) were classified healthy long‐term survivor.ConclusionsIn this small sample of women suffering second‐trimester PROM and oligohydramnios, amnioinfusion did not improve long‐term outcomes. Overall, 71% of survivors had no neurodevelopmental delay.Tweetable abstractHealthy long‐term survival was comparable for children born after second‐trimester PROM and treatment with amnioinfusion or no intervention.

C-reactive protein and white blood cell count as predictors of maternal and neonatal infections in prelabour rupture of membranes between 34 and 41 weeks of gestation

Prelabour rupture of the membranes (PLROM) is defined as rupture of membranes before the onset of labour. It is one of the most common clinical events, where pregnancy can turn into a high-risk situation for mother and foetus. As prevention of PLROM is difficult, one has to concentrate on management to reduce its complications. Accurate prediction of infection remains a main challenge in cases of PLROM. We conducted a prospective study of all women admitted for PLROM at or after 34–41 weeks of gestation to investigate the predictive value of C-reactive protein (CRP) and white blood cell (WBC) count for early-onset neonatal infection (EONI) and maternal chorioamnionitis. The analysis was done by comparing areas under ROC curves and sensitivity. Lowest best cut off of maternal serum CRP level >4.9 mg/l and lowest cut off of WBC count 12,450/cumm have good predictive values for maternal chorioamnionitis and EONI.Impact statementWhat is already known on this subject? The ability to detect chorioamnionitis and predict neonatal infection at an early stage would be helpful in its treatment and would make it possible to prolong the pregnancy.What do the results of this study add? Maternal serum CRP level and WBC count obtained at admission are predictors of chorioamnionitis and EONI although WBC count alone is not a good indicator of them. A lowest best cut off of serum CRP level >4.9 mg/l and lowest cut off of WBC count 12,450/cumm have good predictive values for maternal chorioamnionitis and EON.What are the implications of these findings for clinical practice and/or further research? We propose that maternal serum CRP level and WBC count should be used as screening test for EONI and chorioamnionitis rather than a diagnostic test.

PREMATURE RUPTURE OF MEMBRANES

Background: Pre-labour rupture of the membranes is one of the most commonclinical presentations in an obstetric setting. Early diagnosis is a major challenge faced byevery obstetrician and key to effective management and prevention of complications. As aresult of PROM, amniotic fluid that provides protection to the developing fetus is lost, exposingit to the outside environment. β-hCG is a hormone secreted by syncytiotrophoblasts found inamniotic fluid that can be studied for the evaluation of PROM. Objectives: To find the DiagnosticAccuracy of β human chorionic gonadotrophin test in vaginal washings taking amniotic fluidpooling as gold standard of diagnosing PROM. Study Design: Cross-sectional study. Setting:Unit II, Department of Obstetrics &amp; Gynecology, Lahore General Hospital, Lahore. Period: Threemonths from January 2017 to March 2017. Material and methods: Females of age 18-40 yearswith gestational age &gt;36weeks (calculated by LMP) complaining of PV leaking were includedin the study. Samples for β-hCG measurements were taken after informed consent. A β-hCGkit (Acu-check) was used for detection of β-hCG in vaginal fluid washings of pregnant women.Results: Diagnostic accuracy of β-hCG test was 91.66%. Sensitivity and specificity of β-hCGtest was 86.66% and 96.66%. Positive predictive and negative predictive value was 96.29% and87.87% respectively. Conclusion: Results of this study showed that for diagnosis of patientshaving PROM, beta human chorionic gonadotrophin (β-hCG) is a reliable, easy and quick test.

DIAGNOSTIC ACCURACY OF β-hCG TEST IN VAGINAL WASHINGS TAKING AMNIOTIC FLUID POOLING AS GOLD STANDARD OF DIAGNOSING PRON

Background: Pre-labour rupture of the membranes is one of the most commonclinical presentations in an obstetric setting. Early diagnosis is a major challenge faced byevery obstetrician and key to effective management and prevention of complications. As aresult of PROM, amniotic fluid that provides protection to the developing fetus is lost, exposingit to the outside environment. β-hCG is a hormone secreted by syncytiotrophoblasts found inamniotic fluid that can be studied for the evaluation of PROM. Objectives: To find the DiagnosticAccuracy of β human chorionic gonadotrophin test in vaginal washings taking amniotic fluidpooling as gold standard of diagnosing PROM. Study Design: Cross-sectional study. Setting:Unit II, Department of Obstetrics &amp; Gynecology, Lahore General Hospital, Lahore. Period: Threemonths from January 2017 to March 2017. Material and methods: Females of age 18-40 yearswith gestational age &gt;36weeks (calculated by LMP) complaining of PV leaking were includedin the study. Samples for β-hCG measurements were taken after informed consent. A β-hCGkit (Acu-check) was used for detection of β-hCG in vaginal fluid washings of pregnant women.Results: Diagnostic accuracy of β-hCG test was 91.66%. Sensitivity and specificity of β-hCGtest was 86.66% and 96.66%. Positive predictive and negative predictive value was 96.29% and87.87% respectively. Conclusion: Results of this study showed that for diagnosis of patientshaving PROM, beta human chorionic gonadotrophin (β-hCG) is a reliable, easy and quick test.

Antibiotic Regimen and Induction of Labour Protocol Used in Spontaneous Rupture of Membrane-A Clinical Audit Conducted at a Rural Tertiary Care Hospital In Andhra Pradesh

Background: Prelabour rupture of the membranes (PROM) at term or pre-term increases the risk of infection for the woman and her baby. The routine use of antibiotics for women with PROM or PPROM may reduce this risk. However, due to increasing problems with bacterial resistance and it is important to ensure judicious use of antibiotics. Many studies have reported a wide matrix of variation in the management protocol of spontaneous rupture of membrane before the onset of labour at term or pre-term. Hence, we undertook an audit to assess the need for antibiotic prophylaxis and induction of labour in women with PROM or PPROM. Objective: In the paucity of a uniform protocol in the institution, this study aimed to fix a common antibiotic regimen and induction of labour protocol in all cases of PROM and PPROM. Methods: A retrospective and prospective clinical audit was conducted in the department of OBG, PESIMR, Kuppam, for the accrual period of October 2014–October 2015. A retrospective audit for a period of 6 months of the different management protocols of PROM & PPROM cases was carried out to know the prevailing practices of all recruited patients in our hospital across all the three units. Data was collected in a systematic manner using a formatted proforma from the medical records. Following introduction of a uniform protocol, a prospective study was conducted for 6 months. Results: It was noted that in the prospective study the need for antibiotics was reduced to 84.61% as compared to 93.84% in the retrospective group. 69.23% of women required induction in the retrospective group, whereas only 25.64% required induction in the prospective group. The difference was statistically significant. There was not much difference in the caesarean section rates, maternal & neonatal morbidity prior to and following introduction of a uniform protocol (46.15% in the retrospective group to 48.71% in the prospective group). Conclusions: This study helped us introduce a uniform protocol in the department. It reduced the need for induction and antibiotic usage. There was a reduction in the need of induction if expectant management was allowed. There was no reduction in the caesarean section rate. We need more robust studies to come to a conclusion.

Predicting preeclampsia from a history of preterm birth.

ObjectiveTo assess whether women with a history of preterm birth, independent on the presence of prelabour rupture of the membranes (PROM) and growth deviation of the newborn, are more likely to develop preeclampsia with preterm or preterm birth in a subsequent pregnancy.MethodsWe conducted a population-based cohort study, based on Medical Birth Registry of Norway between 1967 and 2012, including 742,980 women with singleton pregnancies who were followed up from their 1st to 2nd pregnancy. In the analyses we included 712,511 women after excluding 30,469 women with preeclampsia in the first pregnancy.ResultsAfter preterm birth without preeclampsia in the first pregnancy, the risk of preterm preeclampsia in the second pregnancy was 4–7 fold higher than after term birth (odds ratios 3.5; 95% confidence interval (CI) 3.0–4.0 to 6.5; 95% CI 5.1–8.2). The risk of term preeclampsia in the pregnancy following a preterm birth was 2–3 times higher than after term birth (odds ratios 1.6; 95% CI 1.5–1.8 to 2.6; 95% CI 2.0–3.4). After spontaneous non-PROM preterm birth and preterm PROM, the risk of preterm preeclampsia was 3.3–3.6 fold higher than after spontaneous term birth. Corresponding risks of term preeclampsia was 1.6–1.8 fold higher. No significant time trends were found in the effect of spontaneous preterm birth in the first pregnancy on preterm or term preeclampsia in the second pregnancy.ConclusionsThe results suggest that preterm birth, regardless of the presence of PROM, and preeclampsia share pathophysiologic mechanisms. These mechanisms may cause preterm birth in one pregnancy and preeclampsia in a subsequent pregnancy in the same woman. The association was particularly evident with preterm preeclampsia.

Expression of TREM-1 in maternal leukocytes in preterm, prelabour rupture of the membranes

Studies have shown that triggering receptor expressed on myeloid cells-1 (TREM-1) is the mediator and activator of neutrophils and monocytes after stimulation with lipopolysaccharide (LPS), heat-inactivated Gram (−) bacteria, Gram (+) bacteria or fungi. Different studies have measured the expression of TREM-1 in patients with bacterial infections and critical states. The purpose of this study was to evaluate the expression of TREM-1 in circulating maternal leukocytes in premature rupture of the membranes (PRM). Two groups of patients were included in this case control study: pregnant women with PRM and healthy controls. All patients were free of any infection, including cervix and urinary tract. Although all patients expressed TREM-1 to some extent, there was no statistically significant difference in the expression of different cellularities in both groups; except for the mononuclear leukocytes (p < 0.05). In this study, TREM-1 was not altered in PRM.

Sealing procedures for preterm prelabour rupture of membranes

Preterm prelabour rupture of the membranes (PPROM) complicates approximately 2% of pregnancies and can be either spontaneous or iatrogenic in nature. Complications of PPROM include prematurity, chorioamnionitis, neonatal sepsis, limb position defects, respiratory distress syndrome, pulmonary hypoplasia chronic lung disease, periventricular leukomalacia and intraventricular haemorrhage.A number of different sealing techniques have been employed which aim to restore a physical barrier against infection and encourage the re-accumulation of amniotic fluid. Routine use of sealants is currently not recommended due to a lack of sufficient evidence to support the safety and effectiveness of such interventions. To assess the effects of sealing techniques following PPROM against each other, or versus standard care (including no sealant), on maternal and neonatal outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016) and reference lists of retrieved studies. Randomised and quasi-randomised controlled trials comparing different techniques for sealing preterm prelabour ruptured membranes. Cluster-randomised trials and trials using a cross-over design were not eligible for inclusion in this review. We planned to include abstracts when sufficient information was provided. Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. We included two studies (involving 141 women - with data from 124 women). We considered both studies as being at high risk of bias. Meta-analysis was not possible because the included studies examined different interventions (both in comparison with standard care) and reported on few, but different, outcomes. One study compared cervical adapter (mechanical sealing), and the other study examined an immunological membrane sealant. Neither of the included studies reported on this review's primary outcome of interest - perinatal mortality. Similarly, data were not reported for the majority of this review's secondary infant and maternal outcomes. Cervical adapter (mechanical sealing) versus standard care (one study, data from 35 participants)No data were reported for this review's primary outcome - perinatal mortality. Data were reported for few of this review's infant or maternal secondary outcomes.There was no clear difference between the mechanical sealing group and the standard care control in relation to the incidence of neonatal sepsis (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.28 to 5.09 (very low-quality evidence)) or chorioamnionitis (RR 1.19, 95% CI 0.28 to 5.09 (very low-quality evidence)). Oral immunological membrane sealant versus standard care (one study, data from 94 participants)No data were available for perinatal mortality (this review's primary outcome) or for the majority of this review's infant and maternal secondary outcomes. Compared to standard care, the immunological membrane sealant was associated with a reduction in preterm birth less than 37 weeks (RR 0.48, 95% CI 0.34 to 0.68 (very low-quality evidence)) and a reduction in neonatal death (RR 0.38, 95% CI 0.19 to 0.75 (very low-quality evidence)). However, there was no clear difference between groups in terms of neonatal sepsis (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)) or respiratory distress syndrome (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)). There is insufficient evidence to evaluate sealing procedures for PPROM. There were no data relating to this review's primary outcome (perinatal mortality) and the majority of our infant and maternal secondary outcomes were not reported in the two included studies.There was limited evidence to suggest that an immunological membrane sealant was associated with a reduction in preterm birth at less than 37 weeks and neonatal death, but these results should be interpreted with caution as this is based on one small study, with a high risk of bias, and the intervention has not been tested in other studies.Although midtrimester PPROM is not a rare occurrence, there are only a small amount of published data addressing the benefits and risks of sealing procedures. Most of these studies are retrospective and cohort based and could therefore not be included in our data-analysis.This review highlights the paucity of prospective randomised trials in this area. Current evidence provides limited information both on effectiveness and safety for the interventions described. Given the paucity of high-quality data, we recommend that future research efforts focus on the conduct of randomised trials assessing the effect of promising interventions that have been only evaluated to date in cohort studies (e.g. amniopatch). Future trials should address outcomes including perinatal mortality, preterm birth, neonatal death, respiratory distress syndrome, neonatal sepsis and developmental delay. They should also evaluate maternal outcomes including sepsis, mode of delivery, length of hospital stay and emotional well-being.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial

Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Antibiotics for prelabour rupture of membranes at or near term.

Prelabour rupture of the membranes (PROM) at or near term (defined in this review as 36 weeks' gestation or beyond) increases the risk of infection for the woman and her baby. The routine use of antibiotics for women at the time of term PROM may reduce this risk. However, due to increasing problems with bacterial resistance and the risk of maternal anaphylaxis with antibiotic use, it is important to assess the evidence addressing risks and benefits in order to ensure judicious use of antibiotics. This review was undertaken to assess the balance of risks and benefits to the mother and infant of antibiotic prophylaxis for PROM at or near term. To assess the effects of antibiotics administered prophylactically to women with PROM at 36 weeks' gestation or beyond, on maternal, fetal and neonatal outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014). All randomised trials that compared outcomes for women and infants when antibiotics were administered prophylactically for prelabour rupture of the membranes at or near term, with outcomes for controls (placebo or no antibiotic). Two review authors independently extracted the data and assessed risk of bias in the included studies. Additional data were received from the investigators of included studies. This update includes an additional two studies involving 1801 women, giving a total of four included studies of 2639 women. Whereas the previous version of this review showed a statistically significant reduction in endometritis with the use of antibiotics, no such effect was shown in this update (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.05 to 2.31). No differences were shown on the primary outcome measures of probable early-onset neonatal sepsis (average RR 0.69, 95%; CI 0.21 to 2.33); definite early-onset neonatal sepsis (average RR 0.57, 95% CI 0.08 to 4.26); maternal infectious morbidity (chorioamnionitis and/or endometritis) (average RR 0.48, 95% CI 0.20 to 1.15); stillbirth (RR 3.00, 95% CI 0.61 to 14.82); and perinatal mortality (RR 1.98, 95% CI 0.60 to 6.55), though the number of cases in the control group for these outcomes was low. There were no cases of neonatal mortality or serious maternal outcome in the studies assessed. Caesarean section was increased with the use of antibiotics (RR 1.33, 95% CI 1.09 to 1.61) as was duration of maternal stay in hospital (mean difference (MD) 0.06 days, 95% CI 0.01 to 0.11), largely owing to one study of 1640 women where repeat caesarean section, increased baseline hypertension and pre-eclampsia were evident in the antibiotic group, despite random allocation and allocation concealment.Subgroup analyses by timing of induction (early induction versus late induction) showed no difference in either probable or definite early-onset neonatal sepsis in the early induction group (RR 1.47, 95% CI 0.80 to 2.70 and RR 1.29, 95% CI 0.48 to 3.44, respectively) or the late induction group (RR 0.14, 95% CI 0.02 to 1.13 and RR 0.16, 95% CI 0.02 to 1.34, respectively), although there were trends toward reduced probable and definite early-onset neonatal sepsis in the late induction group. A test for subgroup differences confirmed a differential effect of the intervention on probable early-onset neonatal sepsis between the subgroups (Chi² = 4.50, df = 1 (P = 0.03), I² = 77.8%). No difference in maternal infectious morbidity (chorioamnionitis and/or endometritis) was found in either subgroup, though again there was a trend towards reduced maternal infectious morbidly in the late induction group (average RR 0.34, 95% CI 0.08 to 1.47). No differences were shown in stillbirth or perinatal mortality. The quality of the evidence for the primary outcomes using GRADE was judged to be low to very low. This updated review demonstrates no convincing evidence of benefit for mothers or neonates from the routine use of antibiotics for PROM at or near term. We are unable to adequately assess the risk of short- and long-term harms from the use of antibiotics due to the unavailability of data. Given the unmeasured potential adverse effects of antibiotic use, the potential for the development of resistant organisms, and the low risk of maternal infection in the control group, the routine use of antibiotics for PROM at or near term in the absence of confirmed maternal infection should be avoided.

British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review).

British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review).

Induction of labour at a regional hospital in KwaZulu-Natal, South Africa

Background. Clinicians working in maternity units must recognise the risks associated with induction of labour (IOL. They need to analyse the indications for IOL, methods used and outcomes on a regular basis to reduce complications. Objective. To determine the indications for IOL and outcomes of current methods at a regional hospital in rural KwaZulu-Natal, South Africa. Methods. Clinical data for all patients who had IOL over an 8-month period were collected and analysed. Results. There were 6 649 deliveries, and of these patients 532 had IOL (induction rate 8.0%); 502 patient files had complete information for analysis. The main indications for IOL were hypertensive disorders (43.6%, n =219), post-dates pregnancy (25.9%, n =130) and pre-labour rupture of the membranes (14.7%, n =74). Other indications accounted for 15.7% of cases ( n =79). The most common methods of IOL were oral misoprostol (63.5%, n =319) and vaginal misoprostol (30.3%, n =152). Vaginal deliveries were achieved in 59.8% of patients ( n =300), and 40.2% (202) had caesarean sections (CSs); 69.7% of patients ( n =350) delivered within 24 hours (this includes CSs and vaginal deliveries). Normal vaginal births within 24 hours accounted for 44.4% of total deliveries ( n =223), and CSs within 24 hours for 24.3% ( n =122). There were 34 babies (6.8%) admitted to the neonatal intensive care unit. Prematurity accounted for 10 of these admissions (2.0% of all babies), hypoxic ischaemic encephalopathy for 9 (1.8%), and congenital pneumonia for 7 (1.4%). There was 1 early neonatal death. Conclusion. Current methods of IOL at the rural study site are associated with outcomes similar to those in a report from an urban regional hospital in South Africa.

Rate of spontaneous onset of labour before planned repeat caesarean section at term.

BackgroundGuidelines recommend that, in the absence of compelling medical indications (low risk) elective caesarean section should occur after 38 completed weeks gestation. However, implementation of these guidelines will mean some women go into labour before the planned date resulting in an intrapartum caesarean section. The aim of this study was to determine the rate at which low-risk women planned for repeat caesarean section go into spontaneous labour before 39 weeks.MethodsWe conducted a population-based cohort study of women who were planned to have an elective repeat caesarean section (ERCS) at 39-41 weeks gestation in New South Wales Australia, 2007-2010. Labour, delivery and health outcome information was obtained from linked birth and hospital records for the entire population. Women with no pre-existing medical or pregnancy complications were categorized as ‘low risk’. The rate of spontaneous labour before 39 weeks was determined and variation in the rate for subgroups of women was examined using univariate and multivariate analysis.ResultsOf 32,934 women who had ERCS as the reported indication for caesarean section, 17,314 (52.6%) were categorised as ‘low-risk’. Of these women, 1,473 (8.5% or 1 in 12) had spontaneous labour or prelabour rupture of the membranes before 39 weeks resulting in an intrapartum caesarean section. However the risk of labour <39 weeks varied depending on previous delivery history: 25% (1 in 4) for those with spontaneous preterm labour in a prior pregnancy; 15% (1 in 7) for women with a prior planned preterm birth (by labour induction or prelabour caesarean) and 6% (1 in 17) among those who had only previously had a planned caesarean section at term. Smoking in pregnancy was also associated with spontaneous labour. Women with spontaneous labour prior to a planned CS in the index pregnancy were at increased risk of out-of-hours delivery, and maternal and neonatal morbidity.ConclusionsThese findings allow clinicians to more accurately determine the likelihood that a planned caesarean section may become an intrapartum caesarean section, and to advise their patients accordingly.

Can maternal serum C-reactive protein levels predict successful labour induction with intravenous oxytocin in term pregnancies complicated with premature rupture of the membranes? A cross-sectional study.

High sensitive C-reactive protein (hs-CRP) is a serum marker for acute inflammation and/or infection. The diagnostic value of serum levels of this protein has been investigated among patients with preterm delivery, premature rupture of the membranes (PROM) and preeclampsia. In this study, the predictive value of hs-CRP for successful labour induction in patients with PROM has been evaluated. Eighty-six term pregnant patients who experienced pre-labour amniotic membrane rupture from 37-41 weeks of gestation were selected for the study. Maternal serum hs-CRP levels were determined upon admission to the delivery unit and low dose intravenous oxytocin infusion was started to induce labour. The mode of delivery and time interval from labour induction to delivery were the primary endpoints of the study. Twenty-five (29%) out of 86 patients had delivered by caesarean section, while the remaining 61 (71%) had delivered vaginally. The receiver operator characteristic (ROC) curve for testing the significance of higher hs-CRP values and lower probability of vaginal delivery revealed that higher hs-CRP values were found to be insignificant for predicting the need for caesarean section. No statistically significant correlation between high serum hs-CRP levels and the probability of caesarean delivery has been established (Spearman rho:-.126; p=0.24). The mean maternal serum hs-CRP levels during PROM were found to be similar between vaginal and abdominal deliveries. Hs-CRP, as an inflammatory marker, was found to be neither specific nor sensitive for the prediction of successful labour induction in term pregnancies with pre-labour rupture of the membranes.

Amniopatch for iatrogenic rupture of the fetal membranes

With the increased use of invasive fetal procedures, the number of women facing post-procedure membrane rupture is increasing. Here we review the use of platelets and fresh frozen plasma for sealing iatrogenic fetal membrane defects by describing the mechanisms of action of the amniopatch procedure as well as published experience. In cases of iatrogenic preterm pre-labour rupture of the membranes, amniopatch effectively seals the fetal membranes in over two-thirds of cases. There is a risk of 16% of in utero fetal death, which may occur at varying intervals from the procedure and often for unknown reasons. Amniopatch has also been used as a treatment of chorionic membrane separation. In summary, current experience suggests that in cases of early onset but persistent amniotic fluid leakage following an invasive fetal procedure, amniopatch is an option.