Amniotic fluid soluble Toll-like receptor 4 in pregnancies complicated by preterm prelabor rupture of the membranes

Objective: To determine amniotic fluid soluble Toll-like receptor 4 (sTLR4) levels in women with preterm prelabor rupture of the membranes according to the presence of microbial invasion of the amniotic cavity and histological chorioamnionitis and its relation to neonatal outcome. Methods: One hundred two women with singleton pregnancies with a gestational age between 24?+?0 and 36?+?6 weeks were included in a prospective cohort study. Amniocenteses were performed, and the concentrations of sTLR4 in the amniotic fluid were determined using sandwich enzyme-linked immunosorbent assay technique. Results: Women with the presence of microbial invasion of the amniotic cavity had higher sTLR4 levels [median 54.2?ng/mL, interquartile range (IQR) 10.15–289.9] than those without this condition (median 18.1?ng/mL, IQR 8.1–29.9; p?=?0.001). Women with the presence of histological chorioamnionitis had a higher sTLR4 level (median 28.0?ng/mL, IQR 11.15–178.1) compared with women without histological chorioamnionitis (median 13.0?ng/mL, IQR 7.8–28.7; p?=?0.003). A mixed linear model was used to adjust for confounders. The difference was found only between women with and without microbial invasion of the amniotic cavity in this model. Conclusions: Microbial invasion of the amniotic cavity was associated with higher amniotic fluid sTLR4 levels independent of confounders.     

A systematic review of intentional delivery in women with preterm prelabor rupture of membranes

Objective.?To evaluate the effect of intentional delivery versus expectant management in women with preterm prelabor rupture of membranes (PPROM).

Methods.?We searched electronic databases and trials registries, contacted experts, and checked reference lists of relevant studies. Studies were included if they were randomized controlled trials comparing intentional delivery versus expectant management after PPROM, the gestational age of participants was between 30 and 36 weeks, and the study reported one of several pre-determined outcomes.

Results.?Four studies were included in the meta-analysis. No difference was found between intentional delivery and expectant management in neonatal intensive care unit (NICU) length of stay (LOS) (weighted mean difference (WMD) ?0.81 day, 95% confidence interval (CI) ?1.66, 0.04), respiratory distress syndrome (risk difference (RD) ?0.01, 95% CI ?0.07, 0.06), and confirmed neonatal sepsis (RD ?0.01, 95% CI ?0.05, 0.04). One study found a significantly lower incidence of suspected neonatal sepsis among the intentional delivery group (RD ?0.31, 95% CI ?0.50, ?0.12; number needed to treat (NNT) 3, 95% CI 2, 8). Maternal LOS was significantly shorter for the intentional delivery group (WMD ?1.39 day, 95% CI ?2.03, ?0.75). There was a significant difference in the incidence of clinical chorioamnionitis favoring intentional delivery (RD ?0.16, 95% CI ?0.23, ?0.10; NNT 6, 95% CI 5, 11). There was no significant difference in the incidence of other maternal outcomes, including cesarean section (RD 0.05, 95% CI ?0.01, 0.11).

Conclusions.?Intentional delivery may be favorable to expectant management for some maternal outcomes (chorioamnionitis and LOS). There is insufficient evidence to suggest that either strategy is beneficial or harmful for the baby. Large multicenter trials with primary neonatal outcomes are required to assess whether intentional delivery is associated with less neonatal morbidity.     

Residual amniotic fluid volume predicts the sealing of preterm prelabor rupture of fetal membranes in the pre- and periviable period

ObjectivePreterm prelabor rupture of fetal membranes (pPROM) is a leading cause of preterm birth. When pPROM occurs around the pre- and periviable period, the perinatal outcome is unfavorable. However, there have been a few cases in which the leakage of amniotic fluid ceases and the ruptured fetal membranes are spontaneously sealed.Materials and methodsThe prognosis of 38 cases of pPROM at less than 27 weeks of gestation in Kyoto University Hospital were studied. The clinical factors related to the sealing of fetal membranes were investigated.ResultsSpontaneous sealing was confirmed in five patients (13%), and sealing occurred within 14 days of pPROM. Women in the no sealing group delivered at 26.3 ± 0.5 weeks of gestation, whereas women in the sealing group delivered at term at 38.8 ± 0.4 weeks (p < 0.0001). The maximum vertical pocket (MVP) of amniotic fluid at the time of pPROM diagnosis was 2.2 ± 0.3 cm in the no sealing group and 3.8 ± 0.5 cm in the sealing group (p = 0.043). All cases of sealing occurred when the MVP at diagnosis was more than 2 cm, and there were no cases of sealing if the MVP at diagnosis was less than 2 cm. In addition, the value of C-reactive protein at ROM was less than 0.4 mg/dL in all cases in the sealing group.ConclusionThe residual volume of sterile amniotic fluid at the onset of pPROM may predict the possibility of fetal membrane sealing.     

Inflammatory cytokine mRNA detection by real time PCR in chorioamniotic membranes from pregnant women with preterm premature rupture of membranes

Objective

To quantify the expression of interleukin (IL)-1β, IL-6, IL-8 and tumor necrosis factor alpha (TNF-α) in chorioamniotic membranes of PPROM pregnant women with chorioamnionits.

Study design

The study included 25 PPROM women in labor, 15 PPROM without labor, and 25 pregnant women in preterm labor (PTL). Chorioamniotic membranes were collected for histopathological analyses and cytokine mRNA expression quantification by real time PCR. Comparisons were performed using the Mann–Whitney, Kruskal–Wallis, Fisher's exact test or z test with significance set at p < 0.05. The software employed was the SigmaStat version 3.1.

Results

During the study PPROM incidence was 4.6% and chorioamnionits was present in 75% of the samples. IL-1β, IL-6, and IL-8 mRNA expression did not statistically differ among study groups. TNF-α mRNA expression was statistically higher in PTL. No difference in the mRNA concentration of the cytokines studied in the presence of chorioamnionitis was observed.

Conclusion

Chorioamniotic membranes are sources of IL-1β, IL-6, IL-8, and TNF-α and their mRNA concentrations in PPROM are not related to the presence of chorioamnionitis.     

Factors associated with latency period in preterm prelabor rupture of membranes

Objective: To determine the factors associated with prolonged latency periods in preterm prelabor rupture of membrane (PPROM).

Methods: This retrospective study analyzed data from singleton pregnant women with gestational age between 28 and 34 weeks suffering from PROM. Multivariate regression analysis was used to evaluate the association between the factors and latency period?≥?2 and?≥?7 days.

Results: A total of 231 cases of PPROM were included. Prolong latency period?≥2 and 7 days were achieved in 141 (61%) and 54 (23.4%) cases. Higher gestational age at PPROM and cervical dilatation?>2?cm were associated with a shorter latency period <2 days. Multiparity and presence of uterine contraction at admission were associated with a shorter latency period <7 days. Prophylactic antibiotics [odds ratio (ORs) 6.69, 95% confidence interval (CI) 3.0–14.89], and tocolysis (ORs 2.74, 95%CI 1.25–6.02) were factors associated with latency period?≥?2 days. Only prophylactic antibiotics (ORs 7.7, 95%CI 2.54–23.34) was a factor associated with latency period?≥7 days.

Conclusions: Prophylactic antibiotics and tocolysis are two major factors associated with latency period?≥2 days in PPROM, where prophylactic antibiotics is the main factor associated with latency period?≥7 days in PPROM.     

Microbial invasion and histological chorioamnionitis upregulate neutrophil-gelatinase associated lipocalin in preterm prelabor rupture of membranes

Our recent exploratory proteomic study suggested increased levels of neutrophil-gelatinase associated lipocalin (P80188, NGAL_HUMAN) due to microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis (HCA) in women with preterm prelabor rupture of the membranes. In this study, we verified the proteomics findings by assessing the amniotic fluid NGAL by ELISA in the original exploratory cohort. The NGAL level was significantly higher in women positive for both MIAC and HCA compared to women with both conditions ruled out (median 75.1?ng/ml versus 27.9?ng/ml; p?<?0.0001). For independent validation and to assess NGALs potential to stratify women positive for both MIAC and HCA from women in whom at least one of these conditions was absent, we subsequently designed a retrospective replication cohort. Significantly higher NGAL levels were found in women positive for both MIAC and HCA (median 65.9?ng/ml versus 34.2?ng/ml; p?=?0.0061). Significantly higher levels of NGAL were confirmed only in strata below 32 weeks of gestation. Based on the observed likelihood ratio, the best predictive cutoff level (47.1?ng/ml) was evaluated in both cohorts. Data from the verification cohort implied that NGAL is a valuable clinical marker for revealing MIAC leading to HCA; however, this potential was not replicated in the replication cohort.     

The maternal thiol/disulfide homeostasis does not change in pregnancies complicated by preterm prelabor rupture of membranes

Purpose: To evaluate the maternal thiol/disulfide homeostasis in pregnant women complicated by preterm prelabor rupture of membranes (PPROM) and to compare the results with healthy pregnancies.

Materials and methods: This cohort study consisted of thirty-nine pregnancies complicated by PPROM and 44 gestational age-matched healthy pregnancies in the third trimester of gestation. Maternal serum samples were obtained at the day of diagnosis, and thiol/disulfide profiles were measured by using an automated assay method. The patients were followed till delivery, and perinatal outcomes were noted.

Results: The maternal native thiol (319.9?±?30.5?μmol/L versus 305.1?±?49.2?μmol/L, p: .100), total thiol (379.2?±?38.8?μmol/L versus 363.6?±?56.4?μmol/L, p: .142) and disulfide (29.7?±?11.7?μmol/L versus 29.3?±?10.1?μmol/L, p: .864) levels were similar between the groups. Maternal disulfide/native thiol, disulfide/total thiol and native thiol/total thiol ratios were similar between the groups (p: .610, p: .565 and .562, respectively). The maternal serum thiol/disulfide profiles were not significantly correlated with maternal serum C-reactive protein, white blood cell count values and ongoing pregnancy outcomes (p?>?.05).

Conclusions: The current study demonstrated that there was not any disturbance in maternal thiol/disulfide homeostasis in pregnancies complicated by PPROM at the time of initial diagnosis. Follow-up studies with larger sample size are needed to confirm our results.     

Histological chorioamnionitis in preterm prelabor rupture of the membranes is associated with increased expression of galectin-3 by amniotic epithelium

Purpose: Gal-3, which can regulate immune responses upon infection and inflammation, was not studied so far in intrauterine infection leading to preterm prelabor rupture of the membranes (PPROM), although gal-1 was reported to be implicated in the process. Gal-3 mRNA and protein expression in amnion and its changes during histological chorioamnionitis were studied here.

Materials and methods: Fetal membranes were obtained from women with PPROM with (n?=15) and without histological chorioamnionitis (n?=15) during second and third trimester. Immunohistochemical reactivity was evaluated semiquantitatively and analyzed using t-test. Galectin profile of amniotic epithelia was determined by polymerase chain reaction (PCR) and change assessed in gal-3 in PPROM with (n?=5) or without histological chorioamnionitis (n?=5) by real-time PCR.

Results: Human amniotic epithelium was found to express gal-1, gal-3, gal-7 and gal-8 mRNA. Gal-3 mRNA and protein is increased in fetal membranes and in the amniotic epithelium in patients with chorionamnionitis.

Conclusion: Histological chorioamnionitis is associated with increased gal-3 expression and strong immunoreactivity of the amnion. Gal-3 may participate in the regulation of the inflammatory responses to chorioamniotic infection and/or direct interaction with pathogens.     

Neonatal outcomes in subgroups of women with preterm prelabor rupture of membranes before 34 weeks

Objective: To evaluate the influence of microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis (HCA) on short-term neonatal outcome in women with preterm prelabor rupture of membranes before 34 weeks of gestation.

Methods: A prospective observational cohort study including 122 pregnant women with PPROM between 24+0 and 34+0. MIAC was defined as a positive PCR result for Ureaplasma species, Mycoplasma hominis and Chlamydia trachomatis and/or positive PCR result for the 16S rRNA gene in the amniotic fluid. HCA was defined according to the Salafia classification. Maternal and short-term neonatal outcomes were evaluated according to the presence or absence of MIAC and/or HCA.

Results: The presence of both MIAC and HCA was observed in 36% (45/122) of women, HCA alone in 34% (41/122) and MIAC in 5% (6/122). A significantly higher incidence of early onset sepsis was observed in newborns born from women with both MIAC and HCA [33% (15/45)] compared with women with HCA alone [12% (5/41)] or MIAC alone [0% (0/6)] or women without MIAC or HCA detected [0% (0/30); p?=?0.001].

Conclusions: The presence of both MIAC and HCA increases the risk of early onset sepsis in pregnancies complicated by preterm prelabor rupture of membranes before 34 weeks of gestation.     

Midwifery management of prelabor rupture of membranes at term

Spontaneous rupture of membranes before the onset of labor at term is commonly referred to as PROM (either premature or preterm rupture of membranes) and occurs in about 8% of term pregnancies. PROM is associated with an increased risk of infection. Many controversies exist regarding the optimal management of PROM, including the choice of induction or expectant management, use of digital vaginal exams, and routine administration of antibiotics. This article reviews the literature on PROM and illustrates some of the management issues encountered by presenting approaches used in three midwifery services.     

Outcome of pregnancies with preterm prelabor rupture of membranes before 27 weeks’ gestation: a retrospective cohort study

Objective

Preterm prelabor rupture of membranes (PPROM) before 27 weeks’ gestation is associated with severe perinatal complications, but quantitative estimates are lacking. The aim of this study was to report and predict outcomes of pregnancies complicated by early PPROM and to study antepartum risk factors that might predict perinatal death in future patients.

Study design

We performed a retrospective cohort study of women with PPROM between 13⁺⁰ weeks and 27⁺⁰ weeks’ gestation between 1994 and 2009 in three perinatal centers.

Main outcome measures

Perinatal mortality, composite neonatal morbidity and premature delivery. A model to predict these outcomes was developed from antepartum variables.

Results

We identified 314 women with PPROM before 27 weeks, including 28 multiple pregnancies. Six pregnancies (2%) were terminated before 24 weeks’ gestation, and three were lost to follow up, leaving 305 pregnancies for analysis. Overall, there were 166 perinatal deaths (49%). The perinatal mortality rate decreased with increasing gestational age at PPROM (from 70% in the group PPROM 13–20 weeks to 27% in the group PPROM 24–27 weeks). Of the 170 surviving neonates, 70 suffered from serious morbidity (41%). Early gestational age at PPROM, long interval between PPROM and birth and positive vaginal culture (any bacteria) were associated with perinatal mortality.

Conclusion

Perinatal mortality in PPROM before 27 weeks occurred in half of the cases and among those who survive approximately 40% suffered serious morbidity. Antenatal parameters can be helpful to predict perinatal mortality.     

Vitamins C and E in the latency period in women with preterm premature rupture of membranes.

OBJECTIVE: To determine whether supplementation with vitamins C and E after preterm premature rupture of membranes (PPROM) is associated with an increased latency period. METHODS: In this double-blind, randomized, controlled trial, 60 women with singleton pregnancies of 26 to 34 weeks' duration and PPROM were randomly assigned to vitamin C (500 mg/day) and vitamin E (400 IU/day) or placebo until delivery. All women received 2 doses of betamethasone in the first 24 h after admission as well as broad-spectrum antibiotic prophylaxis. RESULTS: Important demographic, as well as clinical characteristics such as number of cases of chorioamnionitis, early neonatal sepsis, and respiratory distress syndrome, were similar in the 2 groups. A statically significant difference in the mean+/-S.D. number of days of latency was found between the groups (10.5+/-5.2 days vs. 3.5+/-4.0 days (P = 0.03). CONCLUSION: Vitamins C and E supplementation of after PPROM is associated with a longer latency before delivery.     

Use of C-reactive protein as a predictor of chorioamnionitis in preterm prelabour rupture of membranes: a systematic review

Background  Studies examining the use of C-reactive protein (CRP) as a predictor of chorioamnionitis in preterm prelabour rupture of membranes (PPROM) report highly conflicting results. Despite this, CRP is commonly used for the early diagnosis of chorioamnionitis.
Objective  To determine the diagnostic accuracy of CRP in the detection of chorioamnionitis in women with PPROM.
Design  Systematic review.
Search strategy  Studies were identified from MEDLINE (1966–2006), EMBASE (1974–2006), PubMed and the Cochrane Library (2005) and from reference lists from primary studies and reviews.
Selection criteria  Only studies of good methodological quality that evaluated the diagnostic performance of CRP in chorioamnionitis in women with PPROM were selected.
Data collection and analysis  Positive and negative likelihood ratios (LR) and diagnostic odds ratios (DOR) were calculated. An attempt was made at pooling data for meta-analysis, but this was considered inappropriate due to the significant unexplained heterogeneity between studies.
Main results  There were eight primary studies comprising 610 cases which met the inclusion criteria. There was wide variation in the positive and negative LR and DOR between the studies, with significant lack of precision demonstrated by wide confidence intervals. Three of the studies concluded that CRP was a useful diagnostic tool for chorioamnionitis (DOR ranging from 4.2 to 191.6), although one of them suggested a higher CRP threshold. The other five studies concluded the opposite (DOR ranging from 1.4 to 17.7).
Author's conclusions  There is no clear evidence to support the use of CRP for the early diagnosis of chorioamnionitis. Further research is required to address the contradictory findings of diagnostic accuracy.     

Amniotic fluid soluble Toll-like receptor 2 in pregnancies complicated by preterm prelabor rupture of membranes

Objective: To determine amniotic fluid soluble Toll-like receptor 2 (sTLR2) levels in PPROM according to the presence of microbial invasion of the amniotic cavity (MIAC), histological chorioamnionitis (HCA), and both these conditions. To test the cutoff level of 222.7?ng/mL, as proposed in our previous study, in order to distinguish women with both MIAC and HCA. Methods: 169 women with a gestational age between 24+0 and 36+6 weeks were included in a prospective cohort study. Amniocenteses were performed, and sTLR2 in the amniotic fluid were determined using ELISA. Results: Women with MIAC had higher sTLR2 levels (median 113.2?ng/mL) than those without MIAC (median 47.1 ng/mL; p < 0.0001). Women with HCA did not have a higher sTLR2 level (median 52.6?ng/mL) compared with women without HCA (median 47.1?ng/mL; p = 0.23). Women with both MIAC and HCA had higher sTLR2 levels (median: 311.3?ng/mL) than other women (17.5?ng/mL; p < 0.0001). The cutoff level 222.7?ng/mL had a sensitivity of 63%, a specificity of 98%, and a likelihood ratio of 40.3 for the prediction of both MIAC and HCA. Conclusions: Amniotic fluid sTLR2 is a promising predictor of both MIAC and HCA with high specificity in PPROM.     

Antibiotic administration to patients with preterm premature rupture of membranes does not eradicate intra-amniotic infection

Objective. Antibiotic administration has become part of the standard of care for patients with preterm premature rupture of membranes (PROM). Yet, the natural history of intrauterine infection/inflammation during antibiotic therapy remains largely unknown. This study was conducted to determine if antibiotic administration to the mother eradicates intra-amniotic infection and/or reduces the frequency of intra-amniotic inflammation, a risk factor for impending preterm labor/delivery and adverse neonatal outcome.

Methods. A subset of patients with preterm PROM admitted to our institution underwent amniocenteses before and after antibiotic administration in order to guide clinical management. Amniotic fluid analysis consisted of a Gram stain, culture for aerobic and anaerobic bacteria as well as genital mycoplasmas, and amniotic fluid white blood cell (WBC) count. Microbial invasion of the amniotic cavity (MIAC) was defined as a positive amniotic fluid culture. Intra-amniotic inflammation was defined as an amniotic fluid WBC count ≥100/mm³. Patients were given antibiotics and steroids after the 24^th week of gestation. Antibiotic treatment consisted of ampicillin and erythromycin for 7 days for patients without evidence of intra-amniotic inflammation or MIAC, and ceftriaxone, clindamycin and erythromycin for 10–14 days for those with intra-amniotic inflammation or MIAC.

Results. Forty-six patients with preterm PROM whose first amniocentesis was performed between 18 and 32 weeks (median 27.4 weeks) were included in the study. The overall prevalence of intra-amniotic inflammation in the first amniocentesis was 39% (18/46). Seven had a positive amniotic fluid culture for microorganisms. At the time of the second amniocentesis, six of the seven patients with a positive amniotic fluid culture had microorganisms. Of 18 patients with intra-amniotic inflammation at admission, only three showed no evidence of inflammation after antibiotic treatment. Among patients with no evidence of intra-amniotic inflammation at admission, 32% (9/28) developed inflammation despite therapy. Five of these nine patients had positive amniotic fluid cultures.

Conclusions. (1) Antibiotic administration (ceftriaxone, clindamycin, and erythromycin) rarely eradicates intra-amniotic infection in patients with preterm PROM; (2) intra-amniotic inflammation developed in one-third of patients who did not have inflammation at admission, despite antibiotic administration; (3) a sub-group of patients with documented inflammation of the amniotic cavity demonstrated a decrease in the intensity of the inflammatory process after antibiotic administration.     

Use of beta subunit of human chorionic gonadotropin assay as a diagnostic tool for prelabor rupture of membranes

Purpose: The study aimed at assessment of the accuracy of the β-hCG test in vaginal washing fluid for diagnosis of prelabor rupture of membranes (PROM).

Patients and methods: Two groups of pregnant women from 17 to 38 weeks of gestation were recruited. The first group (PROM group) included 50 pregnant women with unequivocal PROM. The other group included 50 pregnant women with intact membranes. A sterile speculum examination was performed. If less than 5?cc was collected or no fluid found, 10?cc sterile saline was sprinkled on the vaginal wall and 5?cc were recollected in a sterile syringe. Two drops of collected fluid were used for qualitative testing of β-hCG. The remaining fluid was used for quantitative assessment of β-hCG.

Results: The quantitative β-hCG test results were significantly higher in PROM group (median and range: 138.5 (23–475) versus 13 (1–55); the difference in medians and 95% CI: 105 (91–166); p value: <.001). The qualitative β-hCG test was positive in 42/50 (84%) of the PROM group, while it was negative in 50/50 (100%) of the intact membranes group. Areas under receiver operating characteristics (AUC) for both the quantitative and qualitative β-hCG tests were high (0.97, 95% CI: 0.91–0.99, p value: <.001 and .92, 95% CI: 0.84–0.96, p value: <.001, respectively). The suggested cut-off of β-hCG for the quantitative test was 32 mIU/ml. The sensitivity of quantitative and qualitative tests are: 94, 95% CI: 83.5–98.7% and 84, 95% CI: 70.9–92.8%, respectively. The specificity of quantitative and qualitative tests are: 94, 95% CI: 83.5–98.7% and 100, 95% CI: 92.9–100%, respectively.

Conclusion: β-hCG test (either quantitative or qualitative) in vaginal washing fluid can be used in the diagnosis of PROM in both preterm and term cases.