Treatment options for bacterial vaginosis in patients at high risk of preterm labor and premature rupture of membranes

AIM: To estimate the efficacy of different therapeutic modalities on proven cases of bacterial vaginosis (BV) in patients at high risk of preterm labor and premature rupture of membranes. METHODS: This was a longitudinal prospective comparative study set in the antenatal outpatient clinic of the department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt. Four hundred and sixty-eight patients with a clinical picture of threatened preterm labor or at high risk of premature rupture of membranes in the third trimester were screened for BV. Positive BV was diagnosed in 156 patients. They were randomly classified into four equal groups according to the line of medical treatment. The treatments were: (i) oral metronidazole, (ii) clindamycin vaginal cream, (iii) oral clindamycin, or (iv) metronidazole vaginal suppositories. The effects of medical treatment on Amsel's criteria as well as maternal and fetal outcomes were measured. RESULTS: Based on Amsel's criteria, 156 patients (33.3%) were diagnosed with BV. There was a significant disappearance of vaginal discharge, with decreased percentages of pH > 4.5, positive amine test, and clue cells after treatment of BV in the four groups without any statistically significant difference between them. There were variable effects of the different treatments on increasing birthweight values, admission to neonatal intensive care units, and prolongation of the gestational age. Some maternal adverse effects have been recorded. There were significant improvements of the outcomes for oral metronidazole and clindamycin compared with outcomes for intravaginal metronidazole and clindamycin. CONCLUSIONS: Metronidazole and clindamycin achieve nearly equivalent cure rates when administered orally or vaginally in patients at high risk of preterm labor and premature rupture of membranes. Oral metronidazole is considered the drug of choice in treating BV due its high cure rate, better outcomes, and low cost.     

Comparison of changes in etiologic microorganisms causing early-onset neonatal sepsis between preterm labor and preterm premature rupture of membranes

Objective: To investigate changes in the etiologic microorganisms causing early-onset neonatal sepsis (EONS) in preterm labor (PTL) or preterm premature rupture of membranes (pPROM) cases over the past 16 years and to analyze the associated factors.

Methods: We included consecutive singleton pregnancies delivered before 34 weeks due to PTL or pPROM. The etiologic microorganisms causing EONS in PTL and pPROM cases were compared between period 1 (1996–2004) and period 2 (2005–2012).

Results: There was no difference in the incidence of Gram-positive bacteria causing EONS between period 1 and 2, either in PTL (2.0% versus 2.1%, p?=?1.0) or in pPROM (1.5% versus 1.6%, p?=?1.0). However, the incidence of EONS caused by Gram-negative bacteria was significantly increased in pPROM (0.6% versus 2.7%, p?=?0.040) during period 2, compared to period 1; but not in PTL (0.3% versus 1.2%, p?=?0.211). Multivariable analysis revealed that a prolonged ROM-to-delivery interval (>7?d) was significantly associated with EONS caused by Gram-negative bacteria in pPROM (odds ratio: 6.6, 95% confidence interval: 1.4–31.8, p?=?0.018).

Conclusions: The etiologic microorganisms causing EONS have changed over the past 16 years in pPROM cases but not in PTL cases.     

Prolactin and calcitropic hormones in preterm premature rupture of membranes.

OBJECTIVES: To investigate the role of prolactin and calcitropic hormones in preterm premature rupture of membranes (PPROM) with intrauterine infection. METHODS: Amniotic fluid was retrieved by transabdominal amniocentesis from 40 patients with PPROM and 36 normal pregnant women of matched gestational age. Microbial state of amniotic cavity included culture for aerobic and anaerobic bacteria, mycoplasmas and ureaplasma. Maternal serum and fetal serum prolactin, parathyroid hormone mid-molecule PTH-M, 1,25-dihydroxyvitamin D3 and calcitonin were determined by the corresponding radioimmunoassay Maternal serum and fetal serum electrolytes were determined by ion-selective electrodes. Chlorides were assayed colorimetrically and osmolality was determined by osmometry. RESULTS: Microbiological evaluation of amniotic fluid PPROM revealed aerobic, anaerobic or mixed aerobic anaerobic infections PPROM was associated with significant elevation of both fetal serum and amniotic fluid prolactin concentrations, increased amniotic fluid osmolality, sodium, chlorides and calcium. Amniotic fluid potassium level was significantly decreased, compared with controls. Maternal serum and fetal serum PTH-M, 1,25-dehydroxyvitamin D3 were significantly higher in patients with PPROM than in controls. CONCLUSIONS: Increased amniotic fluid prolactin leads to impairment of structural integrity of fetal membranes through electrolytes disturbances. Moreover, increased amniotic fluid calcium induced by increased fetal calcitropic hormones evokes myometrial contraction through prostaglandin E2 release. Both mechanisms may combine to trigger the onset of PPROM associated with intrauterine infection.     

Outcomes of preterm premature rupture of membranes in twin pregnancies

Objective. To describe outcomes in twin pregnancies with preterm premature rupture of membranes (PPROM).

Methods. Dichorionic twin pregnancies complicated by PPROM at <34 weeks of gestation for the period 2003 to 2006 were identified. Outcomes were obtained through chart review. The relationship between gestational age at premature rupture of membranes (PROM), latency from PROM to delivery, and infection were examined.

Results. In 49 twin pregnancies, the median gestational age at PROM was 31 weeks with a median latency between PROM and delivery of 0 days (interquartile range 0–6). Latency intervals of ≥2 and ≥7 days were achieved by 40.8% and 22.4%, respectively. PPROM at <30 weeks was associated with significantly higher rates of latency of ≥ 2 days (70.6% vs. 25.0%) and ≥7 days (47.1% vs. 9.4%). There was a significant relationship between latency and clinical and histologic signs of infection.

Conclusions. After 30 weeks, most twin pregnancies with PPROM delivered within 2 days. Infection appears to be a consequence rather than a cause of PPROM in most cases.     

Procalcitonin for prediction of chorioamnionitis in preterm premature rupture of membranes*

Objective: To assess serum procalcitonin (PCT), a marker of monocyte activity, in predicting chorioamnionitis in preterm premature rupture of membranes (PPROM).

Methods: Prospective cohort study in singleton gestation patients with PPROM between 2 2?+?0 to 3 3?+?6 weeks gestation. Two blood samples were taken – admission and delivery or diagnosis of clinical chorioamnionitis. Maternal serum PCT?>?0.1?ng/mL was considered positive. Patients were divided into four groups: clinical evidence of chorioamnionitis confirmed by placental pathology (group C?+?P); pathological evidence of chorioamnionitis without clinical signs (group P); clinical signs only (group C); and patients without clinical or pathological findings (group N). Groups were compared to gestational age matched controls.

Results: Forty eight patients recruited, with 28 eligible for analysis: 10 in C?+?P group, 10 P group, 3 C group, and 5?N group. None of the control or PPROM patients had positive PCT on admission. At delivery, 3 of 10 group C?+?P and 4 of 10 group P had positive PCT. Maternal serum PCT sensitivity was 50% and specificity 55.6% for diagnosis of pathological chorioamnionitis.

Conclusions: Maternal serum PCT is not detectable in PPROM patients at admission or in uncomplicated pregnant controls and is a poor predictor for clinical or pathological chorioamnionitis.     

Short interpregnancy interval increases the risk of preterm premature rupture of membranes and early delivery

Objectives: Preterm premature rupture of membranes (PPROM) is a major contributor to overall preterm birth (PTB) rates. A short interpregnancy interval (IPI) is a well-known risk factor for PTB. It is unknown if a short IPI specifically affects the risk of developing PPROM in a subsequent pregnancy. We sought to determine the association between IPI and the risk of PPROM in a subsequent pregnancy.

Methods: A retrospective cohort study using the Missouri birth certificate database of singleton births from 2003 to 2013 was conducted. A short IPI (delivery of the prior pregnancy to conception of the index pregnancy) was defined as ≤6 months. IPI >6 months was categorized into two groups: IPI 7–23 months and IPI ≥24 months. PPROM was defined as premature rupture of membranes between 16⁰ and 36⁶ weeks. Multivariable logistic regression was conducted to determine the association between IPI and PPROM while controlling for maternal age, race, body mass index (BMI), education level, use of social services (Medicaid insurance, food stamps, or participation in the WIC [Women, Infants, and Children] program), tobacco use, and history of PTB. Secondary outcome included the gestational age at delivery, categorized into five subgroups (≤24⁰, 24¹?28⁰, 28¹?32⁰, 32¹?34⁰, and 34¹?36⁶ weeks).

Results: 474,957 subjects with singleton gestations had data available to calculate the IPI. Of these, 1.4% (n?=?6797) experienced PPROM. IPI ≤6 months was significantly associated with an increased risk of developing PPROM compared with patients with IPI ≥24 months (odds ratio (OR) 1.80, 95% CI 1.70–1.90, p?1 and 32⁰ weeks compared to the other two IPI groups (27.0 versus 15.0 and 16.4%, p?2, BMI ≥30?kg/m², use of social services, tobacco use, and a prior PTB.

Conclusion: Our data demonstrate that an IPI of ≤6 months is significantly associated with an increased risk of developing PPROM in the subsequent pregnancy. Of greater clinical relevance is that these women were more likely to deliver between 28¹ and 32⁰ weeks as compared with women with a longer IPI. Novel to this study is the establishment of a specific link between a short IPI and PPROM with subsequent early delivery. Several maternal demographic factors known to be associated with PTB risk were also found to be associated with an increased risk of PPROM. Further studies are necessary to elucidate plausible biologic mechanisms ultimately leading to the development and implementation of preventive and therapeutic strategies for this high-risk cohort.     

松弛素与早产胎膜早破的相关性研究

目的探讨松弛素(relaxin,RLN)与早产胎膜早破(preterm prematu rerupture of membranes,PPROM)的相关性。方法 ELISA法分别检测25例PPROM、32例足月胎膜早破(TPROM)及31例正常足月分娩孕妇分娩前血清RLN2水平;免疫组化SP法检测以上三组孕产妇胎盘和胎膜组织中松弛素受体LGR7蛋白的表达。结果①三组血清RLN2水平比较,PPROM组(372.26±143.13)pg/ml显著高于TPROM组(292.73±96.01)pg/ml及对照组(241.71±91.57)pg/ml(P<0.05);②三组孕妇的胎盘、胎膜组织中均有LGR7蛋白的表达,PPROM组胎盘、胎膜组织中松弛素受体LGR7蛋白强阳性表达率(96.00%)高于另两组,TPROM组(75.00%)高于正常组(58.06%);③胎盘、胎膜组织中松弛素受体LGR7蛋白表达水平与血清RLN2水平呈正相关关系(rs=0.453,P=0.0001)。结论孕晚期血清RLN2水平及胎盘、胎膜组织中松弛素受体LGR7蛋白表达水平的增高可能与PPROM的发病有关。     

Difficulties in establishing routine amniocentesis for preterm labor evaluation

After a recent practice change implementing amniocentesis into the evaluation of preterm labor (PTL) or preterm premature rupture of membranes (PPROM), actual performance of the procedure was tracked. Fifty-nine patients were admitted with these diagnoses. Twenty-three patients (39%) were offered amniocentesis and 36 patients (61%) were not offered amniocentesis as part of the clinical protocol. Seven (30%) patients of those offered an amniocentesis underwent the procedure. The predominant reasons for not performing an amniocentesis were patient refusal and provider discomfort. In conclusion, implementation of amniocentesis to evaluate for subclinical infection/inflammation in the setting of PTL or PPROM proved difficult, as only 7 of 59 (11.9%) patients admitted with these diagnoses actually received an amniocentesis.     

Maternal blood endotoxin activity in pregnancies complicated by preterm premature rupture of membranes

Objective: To compare maternal blood endotoxin activity (EA) in women with preterm premature rupture of membranes (PPROM) with gestational age (GA) matched controls; to evaluate serial EA till birth in PPROM and its correlation with latency to delivery.

Methods: We followed singleton preterm pregnancies from admission with PPROM until birth. Uncomplicated, GA-matched pregnancies served as controls. Demographics, birth and neonatal outcomes were collected. EA (EAA?) was assessed serially in PPROM and at study entry in controls. EA was compared using Mann Whitney and Wilcoxon tests, p value <.05 was considered significant.

Results: We recruited 20 cases of PPROM and 20 controls. Demographics were similar between groups. Mean GA of PPROM was 29.0?±?2.2 weeks and median latency was 7.5 (IQR 14.1) weeks. Median EA at admission following PPROM was significantly elevated over controls (0.43 (0.18) versus 0.36 (0.2); p?p?=?.2) following PPROM. However, on comparing cases with latency to delivery ≤7 days (n?=?10) versus >7 days (n?=?10), there was a significant drop in EA in the latter group (0.44 (0.2) versus 0.34 (0.2); p?相似文献   

Spontaneous preterm labor and premature rupture of membranes at late preterm gestations: to deliver or not to deliver

Nationwide the American College of Obstetricians and Gynecologists noted in 1995 that the survival rate for newborns at 34 weeks is within 1% of those born at or beyond 37 weeks. Newborn major morbidity is slightly but significantly increased from 34(0) to 36(6) compared with 37 or greater weeks. These data form the basis for and reflect the perinatal outcomes associated with the standardized obstetric practices of effecting delivery for women with amnion rupture and also of not attempting tocolysis for preterm labor at or beyond 34(0) weeks gestation. Pragmatically, a prospective randomized management trial of women at late preterm gestation (34(0) to 36(6)) and with spontaneous preterm labor or amnion rupture would require multi-institutional support to achieve a required study population.     

Factors affecting the duration of the latency period in preterm premature rupture of membranes

Objective.?To investigate the natural course of preterm premature rupture of membranes (PPROM) at <34 + 0 weeks and to identify factors that affect the duration of the latency period.

Design.?A retrospective cohort study of all women diagnosed with PPROM prior to 34 + 0 weeks during 1998–2006. Latency period was defined as the time between onset of PPROM to either spontaneous delivery, labor induction at 34 + 0 weeks, or indicated delivery prior to 34 + 0 weeks because of suspected chorioamnionitis or nonreassuring fetal heart rate.

Results.?The overall rate of PPROM was 1.4% (905/66,775), of which 46% (417/905) occurred at <34 + 0 weeks. Overall, the latency period exceeded 48 h in about 73.4% of cases (306/471). Women with short latency periods (<48 h) were characterised by higher degree of cervical dilatation and higher gestational age at admission and were more likely to be nulliparous. The duration of the latency period ranged between 0 and 59 days and was inversely related to gestational age at admission (r = ?0.63, P < 0.001). Using Cox proportional hazards model, gestational age at admission (HR = 1.29, 95% CI = 1.22–1.37), oligohydroamnios (HR = 1.49, 95% CI = 1.18–1.87), cervical dilatation >1 cm (HR = 0.65, 95% CI = 0.52–0.83), fetal growth restriction (HR = 2.94, 95% CI = 1.24–6.94) and nulliparity (HR = 1.28, 95% CI = 1.12–1.63) were significantly associated with shorter duration of the latency period.

Conclusion.?In this study, we have identified several predictive factors for the duration of the latency period in cases of PPROM. This information may assist clinicians in risk stratification and in providing consultation for women presenting with PPROM prior to 34 weeks of gestation.     

Amniopatch treatment for preterm premature rupture of membranes before 23 weeks' gestation and factors associated with its success

Objective

The purpose of this study is to investigate the factors associated with successful amniopatch treatment in patients with iatrogenic preterm premature rupture of membranes (iPPROM) or spontaneous PPROM (sPPROM) before 23 weeks' gestation.