Previable Premature Rupture Of Membranes Research Articles

Respiratory outcomes of neonates born after previable premature rupture of membranes and treated with gentle ventilation.

We aim to describe neonatal respiratory outcomes following previable preterm premature rupture of membranes(PPROM) when gentle ventilation is utilized. We also report maternal morbidity and mortality. This is a retrospective single-center cohort study of infants delivered between 2016 and 2020 that included infants born at ≥23 weeks without major congenital anomaly after a pregnancy complicated with PPROM before 23 weeks gestation. Statistical analysis utilized unpaired Student's t-test or Mann-Whitney U-test when appropriate. 35 infants from 33 pregnancies were included. 91.4% of infants survived until discharge and 12.1% developed Bronchopulmonary Dysplasia (BPD). Those who developed BPD had significantly lower amniotic fluid levels prior to delivery (p < 0.05). There was no significant maternal morbidity or mortality in this cohort. This cohort had high survival and low rates of respiratory morbidities. This suggests the use of gentle ventilation might be the optimal strategy for patients born after previable PPROM.

Perinatal Outcome of Previable Premature Rupture of Membranes Before 24 Weeks of Gestation: A Single-Centered Retrospective Cohort Ctudy

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

Neonatal Survival and Morbidity Following Expectant Management of Previable Premature Rupture of Membranes at a Single Center

Neonatal Survival and Morbidity Following Expectant Management of Previable Premature Rupture of Membranes at a Single Center

Maternal Mortality in Women With Previable Premature Rupture of Membranes: An Analysis From the French Confidential Enquiry into Maternal Deaths

(Acta Obstet Gynecol Scand. 2022;101:1395–1402) Previable premature rupture of membranes (PvPROM) is a rare complication of pregnancy (&lt;1% frequency) but can lead to severe maternal adverse outcomes including sepsis and death. Conservative management without fetal extraction is common, but the documented risk of maternal sepsis remains elevated and variable even with prophylactic antibiotic treatment. The data on maternal mortality is lacking, and underreporting is a concern. The aim of this study was to characterize the lethality of PvPROM to inform decision-making as to whether to prolong a ruptured pregnancy or recommend termination.

Previable Premature Rupture of Membranes in Dichorionic Diamniotic Twin Gestation, Loss of Leading Twin, Emergency Cervical Cerclage and Ceaserean Delivery at Term

Introduction: Multiple pregnancies have a higher risk of premature delivery and a weakened cervix has been associated with it. In most cases, emergency cerclage has proved to be beneficial as the birth of the first twin is usually followed by the unavoidable delivery of the second twin and most fetus dies shortly after delivery. Studies have noted that delayed delivery of the second fetus in a twin pregnancy is an effective management choice and the use of cervical cerclage after the first delivery is associated with a longer inter-delivery interval. We present a case of previable premature rupture of membrane of a dichorionic diamniotic twin gestation leading to the loss of the leading twin and subsequently having emergency cervical cerclage for the second twin and caesarean delivery at term. Case Presentation: She was a case of a 29 years old, G6P1+4 with 1 living child at a gestational age of 17 weeks plus 5 days who initially was diagnosed with dichorionic diamniotic twin gestation following an early ultrasound but presented with a history of bleeding and passage of liquor per vaginam. Ultrasound done on admission showed cervical funneling and a stable state of the second twin. She subsequently had emergency cervical cerclage after stabilization on account of previable premature rupture of membrane of a dichorionic diamniotic twin gestation with the loss of the leading twin. A repeat ultrasound done prior to discharge showed closed cervical os and a good state of the fetus. She then had elective caesarean delivery at term with a good feto-maternal outcome. Conclusion: Emergency cervical cerclage should be part of the options of management after stabilization in cases of previable premature rupture of membrane in a dichorionic or multichoronic gestation so as to save the viable once.

Outcomes of immediate subsequent pregnancy following previable preterm premature rupture of membranes

The risk of recurrent preterm birth (PTB) or premature rupture of membranes (PPROM) in subsequent pregnancy after spontaneous PTB or PPROM is well-described. Less is known about outcomes in subsequent pregnancy after previable PPROM (pPPROM). This study describes outcomes in a single health system over 10 years.

Maternal and neonatal outcomes following previable PROM or cervical insufficiency < 22 weeks in texas

Current Texas law prohibits immediate delivery in previable pregnancy complications, unless there is a medical emergency and threat to maternal health, which has in turn caused changes to the standard of care. We report maternal and neonatal outcomes of patients who presented < 22 wks with previable premature rupture of membranes (PPROM) or cervical insufficiency.

Maternal mortality in women with pre-viable premature rupture of membranes: An analysis from the French confidential enquiry into maternal deaths.

Pre-viable premature rupture of membranes (pre-viable PROM) is a rare event occurring in less than 1% of pregnancies. Nevertheless, it can be responsible for severe maternal complications, the risk of which needs to be balanced with the possibility to prolong the pregnancy up to viable gestational age. Maternal sepsis was reported in 1%-5% of women who received conservative management and prophylactic antibiotics, but information on maternal mortality is lacking. Our objective was to identify maternal deaths in women who had pre-viable PROM, describe the characteristics of the women, explore preventability factors within the care they received, and estimate the lethality of pre-viable PROM. We identified all maternal deaths associated with pre-viable PROM from the 2001-2015 French National Confidential Enquiry into Maternal Deaths (NCMM). Data on women's characteristics and the care they received were extracted from the ENCMM database. The lethality was determined after estimating the total number of pregnant women with pre-viable PROM from the national hospital discharge database. Between 2001 and 2015, we identified seven maternal deaths associated with pre-viable PROM, representing 0.6% of all maternal deaths over this period (ie, maternal mortality ratio 0.06/100 000 live births). Six maternal deaths were attributed to sepsis after genital infection by Gram-negative bacilli and one to postpartum hemorrhage due to placenta accreta. Four of these seven cases were considered preventable. The main preventability factors were delayed diagnosis, delayed fetal extraction, and inappropriate antibiotic treatment. The estimated lethality was 4.5/10 000 women with pre-viable PROM. Maternal death associated with pre-viable PROM is rare but possible. Most of these deaths seem preventable, with areas for improvement related to earlier diagnosis and better treatment of uterine infections, which can evolve rapidly.

Is amniopatch an effective treatment for spontaneous previable premature rupture of membranes? Analysis of perinatal outcome.

To characterize the perinatal outcomes of pregnancies complicated by spontaneous previable premature rupture of membranes with a therapeutic intervention in the form of amniopatch (AP) at the 2nd Department of Obstetrics and Gynecology (2008‒2019). The retrospective analysis of perinatal markers and early neonatal morbidity of pregnancies treated with amniopatch. Discussion comparison with the published papers of cases of spontaneous previable rupture of membranes managed expectantly. Out of the total number of pregnancies, 53 met the exclusion criteria, of which 35 were terminated by delivering a live newborn, 3 newborns died during the hospitalization. The following incidence of early complications has been reported in live births: 1) Bronchopulmonary dysplasia (10/35-28.57 %), 2) Newborn respiratory distress syndrome (25/35-71.42 %), 3) Neonatal sepsis (15/35-42.85 %), 4) Intraventricular hemorrhage (14/35-40 %), 5) Periventricular leukomalacia (3/35-8.57 %), 6). Necrotizing enterocolitis (2/35-5.71 %), 7) Retinopathy of prematurity (7/35-20 %) and 8) Foetal compression syndrome (16/35-45.71 %). In a discussion comparison with available publications of expectantly managed pregnancies, we observed a statistically significantly lower incidence of respiratory distress syndrome, retinopathy, and chorioamnionitis in our cohort along with a higher incidence of foetal compression defects. Amniopatch can be a therapeutic method for reducing the neonatal mortality associated with RDS, maternal infectious morbidity, and an alternative in patients, who require an active approach to such a compromised pregnancy (Tab. 12, Fig. 1, Ref. 50).

Subsequent pregnancy following previable premature rupture of membranes: does elective cervical cerclage prevent preterm birth?

The aim of this study was to determine the obstetric and perinatal outcome in subsequent pregnancies after early previable premature rupture of membranes (PPROM) in pregnant women treated with and without elective cervical cerclage.

Predicting previable preterm premature rupture of membranes (pPPROM) before 24 weeks: maternal and fetal/neonatal risk factors for survival

We sought to compare maternal and neonatal risk factors in cases with previable premature rupture of membranes (pPPROM, between 14-24 weeks) for optimal counselling. Therefore, 192 pregnancies of 485 cases which met selection criteria and agreed to follow-up were retrospectively analysed. Mean gestational age at pPPROM was 20.45 weeks. Live births occurred in 171 cases, but 67 (39.2%) of them died in the neonatal period (neonatal death group) and 104 cases (60.8%) constituted surviving neonate group. Of the surviving neonates, 37 (33.7%) experienced at least one complication. Most seen maternal complications were chorioamnionitis (24.48%) and placental abruption (8.33%). Although amniotic fluid volume, length of pPPROM period, completing antibiotherapy and CRP values were significant, amniotic fluid volume and length of pPPROM showed also significance for multivariate regression analysis for maternal risk factors. Risk factors for birth were gestational age at pPPROM, gestational age at birth, new-born weight at birth, 1st and 5th minute Apgar scores, umbilical cord pH value and need for neonatal resuscitation. Furthermore, development of respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage and retinopathy of premature were additional risk factors for neonate. Of them, gestational age at birth, new-born weight at birth, respiratory distress syndrome and retinopathy of prematurity were also significant in multivariate regression analysis. Impact Statement What is already known on this subject? Management of previable premature rupture of membranes is controversial and there is no definite consensus on the approach. The factor that best predicts neonatal survival is the gestational age at birth (Deutsch et al. 2010). What do the results of this study add? Appropriate counselling for pPPROM cases is important especially during antenatal period (maternal factors) and postpartum period (neonatal factors). Maternal infection risk is increased with an increased latency period of PPROM. As the gestational age at birth increases, the survival rate increases and neonatal complication rates decrease. Other important determinants of neonatal survival and well-being are the presence of oligo-anhydramnios and latency period of previable PPROM to delivery. What are the implications of these findings for clinical practice and/or further research? Counselling the patient with previable PPROM about pregnancy complications and paediatric outcome is challenging because of the small size, different gestational age ranges, and retrospective nature of the multiple studies on this subject. The most important feature of our study was the relatively high number of patients compared to other series. Thus, we can counsel pregnant women with PPROM prior to 24 weeks of gestation about the maternal antenatal factors and neonatal postnatal factors with related outcomes and help make an informed decision regarding termination or conservative follow-up. Nevertheless, there is a need for larger multicentric prospective studies to validate our data and to establish the prognosis of previable PPROM for both mother and foetus.

Antepartum uterine rupture in a woman with previous iatrogenic uterine perforation

A 32-year-old pregnant woman, gravida 2, para 0, presented at 34 weeks of gestation with lower right quadrant abdominal pain, radiating to the lumbar region. She had a history of...

Intracervical elastomeric sealant in an ex vivo model

Background Premature rupture of membranes occurring in previable midtrimester patients is associated with perinatal mortality, and optimal therapeutic methods are yet to be established. Objective This study’s objective was to investigate whether an elastomeric sealant, which has been used as a hemostatic agent for arterial anastomosis, could plug the uterine endocervical canal to prevent leakage of intrauterine fluid in an ex vivo model. Methods The elastomeric sealant or fibrin glue was applied to the cervix of uteri removed for benign gynecological disease (n = 4). Normal saline was administered into the ex vivo uterine cavity through a catheter using a pressure infusion bag. Intrauterine pressure was measured using a digital pressure gauge, and the pressure at which normal saline started leaking out of the uterine cervix was compared between both the sealants. Results No fluid leakage was observed with the elastomeric sealant until the pressure exceeded 20 kPa (150 mmHg), while the leakage onset pressure with fibrin sealant was 6.6 ± 1.8 kPa (50 ± 14 mmHg). The threshold leak pressure where the onset of liquid flow was initiated was significantly different between both the sealants (p < .0001). Conclusions Intracervical elastomeric sealant exhibited powerful fluid leakage prevention in an ex vivo model. The sealant would have potential to prevent the leakage of amniotic fluid in pregnancies with previable premature rupture of membranes.

P19.01: Previable premature rupture of membranes in dichorionic twin pregnancies: selective reduction or expectant management? A retrospective case series

P19.01: Previable premature rupture of membranes in dichorionic twin pregnancies: selective reduction or expectant management? A retrospective case series

A systematic review of amniopatch

The objective of this review is to evaluate the safety and effectiveness of the amniopatch procedure for the treatment ofpreterm premature rupture of the membranes. The searches were conducted via electronic databases including Ovid-MEDLINE, Ovid-Embase, the Cochrane Library, and eight Korean databases. In the study design, in addition to randomized controlled trials, case report studies in which patients underwent the amniopatch procedure were included. Two reviewers independently selected data in standardized form and assessed the methodological quality. Quality evaluation was performed by the SIGN (Scottish Intercollegiate Guideline Network) method. A total of 11 studies (2 cohort studies, 1 case series, and 8 case reports) were included. There were no serious maternal or fetal complications. It was reported that there were lower rates of maternal chorioamnionitis after the amniopatch relative to conservative treatment (control). The mean gestational age at delivery was 27.7 weeks (a total of 70 cases in 10 studies; spontaneous group, 27.6 weeks; iatrogenic group, 27.8 weeks). The amniopatch was successful in 46.6% of cases (33/71 cases in 11 studies). The overall neonatal survival rate was 55.3% (52/94 cases in 11 studies). Neonatal morbidity was 23.4% (11/47 cases in 7 studies). Although this systematic review, did not find clear evidence of the safety and effectiveness, the amniopatch procedure is a viable treatment option to prolong a pregnancy with previable premature rupture of membranes.

Second trimester dilation and evacuation: a risk factor for preterm birth?

To evaluate whether second trimester pregnancy termination with dilation and evacuation (D&E) vs induction of labor (IOL) affects subsequent risk of preterm birth. Our cohort was a retrospective cohort of women undergoing second trimester pregnancy termination for fetal anomalies, fetal death or previable premature rupture of membranes. We analyzed the rates of spontaneous delivery <37 weeks in the first pregnancy following the termination. We also compared preterm birth rates in our cohort with national averages and analyzed by the total number of prior procedures. There were 173 women in our cohort. Women who had undergone a D&E (n=130) were less likely to have a subsequent preterm birth (6.9 vs 30.2%; P<0.01). This held true for a low risk subset without obstetric risk factors. There was no statistical difference in preterm birth rates for women who had undergone a D&E as compared with national averages, nor between the rates of preterm birth for women with 0, 1, 2 or 3 or more prior first or second trimester procedures. We did not find that D&E was a risk factor for preterm delivery when compared with women with a prior IOL or national rates.

366: Impact of maternal preference in counseling after pre-viable premature rupture of membranes

Counseling women with preterm premature rupture of membranes (PPROM) during the pre-viable period is challenging due to the uncertainty of the outcome & personal preferences of the expectant mother. There is a dearth of literature incorporating maternal preferences as to continue or end a pregnancy in the setting of pre-viable PPROM. Our goal was to provide an estimation of outcomes that can be expected from pre-viable PPROM & estimate the level of desirability required to make expectant management favorable.

P16.21: Fetal weight and neonatal outcomes in pre‐viable rupture of membranes

The aim of this study was to identify the adverse neonatal outcomes, with an emphasis on mortality, morbidity (considered here as pulmonary hypoplasia, ROP, PVL and PIH) and morbimortality, and to analyze fetal weight as a predictors of adverse neonatal outcomes in pre-viable premature rupture of membranes. Data were collected between January, 2005 and December, 2011 from all of the pregnant women who presented premature rupture of membranes (PROM) between 18 and 26 complete weeks and who were admitted to one of three Brazilian institutes. The adverse outcomes included mortality or the development of a severe morbidity during the lengh of stay in the neonatal intensive care unit (NICU). The descriptive statistics of the population were reported. A multiple logistic regression was performed for fetal weight of neonatal adverse outcomes. The area under the receiver operating characteristics curves for the fetal weight was calculated. Adverse outcomes during the NICU stay occurred in 82.1% (n = 23) of the cases and included 33 (54%) deaths, 19 (67.8%) cases of retinopathy of prematurity (ROP), 13 (46.4%) cases of pulmonary hypoplasia (BPD), 8 (28.5%) cases of periventricular-intraventricular hemorrhage (PIH) and 3 (10.7%) cases of periventricular leukomalacia (PVL). Only 17.8% (n = 5) of the neonates survived without morbidity. The area under the curve for the fetal weight was 0,90 (95% IC: 0.81-0.98) for the prediction of mortality. Fetal weight was identified as an important predictor of neonatal outcome, leading us to conclude that when we choose conservative management for a pre-viable PROM pregnancy, all of the efforts should be focused on prolonging the latency period (for example, through the use of antibiotic prophylaxis) and increasing the birthweight. However, it should be noted that the fetal weight only influences the neonatal mortality and not the morbidity, which remains a concern for these neonates.

Conflicts in Care for Obstetric Complications in Catholic Hospitals

Background: A recent national survey revealed that over half of obstetrician-gynecologists working in Catholic hospitals have conflicts with religious policies, but the survey did not elucidate the nature of the conflicts. Our qualitative study examines the nature of physician conflicts with religious policies governing obstetrician-gynecologist (ob-gyn) care. Results related to restrictions on the management of obstetric complications are reported here. Methods: In-depth interviews lasting about one hour were conducted with obstetrician-gynecologists throughout the United States. Questions focused on physicians’ general satisfaction with their hospital work settings and specific experiences with religious doctrine-based ob-gyn policies in the various hospitals where they have worked. Results: Conflicts reported here include cases in which Catholic hospital religious policy (Ethical and Religious Directives for Catholic Health Care Services) impacted physicians’ abilities to offer treatment to women experiencing certain obstetric emergencies, such as pregnancy-related health problems, molar pregnancy, miscarriage, or previable premature rupture of membranes (PPROM), because hospital authorities perceived treatment as equivalent to a prohibited abortion. Physicians were contractually obligated to follow doctrine-based policies while practicing in these Catholic hospitals. Conclusions: For some physicians, their hospital's prohibition on abortion initially seemed congruent with their own principles, but when applied to cases in which patients were already losing a desired pregnancy and/or the patient's health was at risk, some physicians found the institutional restrictions on care to be unacceptable.

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

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