The association between histological chorioamnionitis,funisitis and neonatal outcome in women with preterm prelabor rupture of membranes

Abstract

Objective: To determine the impact of histological chorioamnionitis (HCA) and funisitis on neonatal outcome in preterm prelabor rupture of membranes (PPROM) pregnancies.

Methods: Women with PPROM between 24?+?0 to 36?+?6 weeks of gestation, admitted to the Department of Obstetrics and Gynecology at the University Hospital Hradec Kralove in the Czech Republic, between July 2008 and October 2010, were enrolled in the study (n?=?231).

Results: The incidence of early-onset sepsis (EOS) differed significantly in neonates born to women with and without HCA, after adjustment for gestational age (11% versus 1%, p?=?0.011). The incidence of EOS in neonates was also significantly different, after adjustment for gestational age, in cases with and without funisitis (18% versus 4%, p?=?0.002). The same was also found for retinopathy of prematurity (ROP) cases with and without funisitis (23% versus 4%, p?=?0.014), after adjustment for gestational age.

Conclusions: HCA and funisitis increase the risk of adverse perinatal outcome in PPROM pregnancies.     

The bacteriology of pre-labour rupture of membranes in a Nigerian teaching hospital.

A prospective case control study that was conducted at the University of Ilorin Teaching Hospital, Ilorin, Nigeria, between 1st January and 31st December 2002. The purpose of this study was to determine the association and the pattern of bacteria/microorganisms in the aetiology of pre-labour premature rupture of membrane (PROM) in this centre. A total of 108 cases of PROM and 98 control cases that presented between 37 completed weeks' and 40 weeks' gestation were analysed. Pathogens were isolated in 48 patients, giving a recovery rate of 44.4%. The common pathogens include Gardnerella vaginalis (29.1%), Candida (23.0%) and Staphylococcus aureus (18.7%). Others were Streps. Pyogenes (16.6%), coagulase negative staphylococcus (CONS) (6.3%) and Klebsiella (6.3%). Only Candida and S. aureus were isolated in the controls. Ofloxacin and azithromycin were 100% active against all the isolated pathogens, while ampicillin was the least active. G. vaginalis was the most sensitive among the isolates while CONS and Klebsiella were the least sensitive. It is evident in this study that some pathogens were associated with PROM and that G. vaginalis was the most common organism and azithromycin was the only antibiotic with 100% sensitivity. We suggest that metronidazole should be added to azithromycin to cover for anaerobes in cases of PROM, where facilities for screening for anaerobes are not available.     

胎膜早破患者发生组织学绒毛膜羊膜炎的影响因素及新生儿结局

目的:探讨胎膜早破(PROM)患者发生组织学绒毛膜羊膜炎(HCA)的影响因素及新生儿结局。方法:回顾分析2011年9月至2013年7月在郑州大学第三附属医院住院分娩的180例PROM孕妇的临床资料,根据产后胎盘组织病理检查结果分为HCA组(72例)和对照组(108例),比较两组孕妇的年龄、破膜孕周、终止妊娠方式、有无人工流产史、体重指数(BMI)、潜伏期、分娩前C反应蛋白(CRP)值、血红蛋白(Hb)含量、血清白蛋白值、新生儿体重、新生儿Apgar 1min评分、新生儿CRP值、新生儿肺炎、新生儿败血症、新生儿死亡率。结果:(1)180例患者中HCA发生率为66.7%(72/180)。(2)HCA组的潜伏期、分娩前CRP值均显著高于对照组(P0.05);HCA组的剖宫产率[58.1%(42/72)]显著高于对照组[(21.7%(23/108)](P0.05),血红蛋白平均值[(98.19±14.49)g/L]显著低于对照组[(107.21±13.8)g/L](P0.05),平均血清白蛋白值[(32.35±2.8)g/L]低于对照组[(33.13±3.0)g/L],但无显著差异(P0.05)。(3)多因素Logistic回归分析发现,破膜孕周32周、潜伏期48h、既往有人工流产史、BMI≥26kg/m2、60g/L≤Hgb≤90g/L是HCA发生的危险因素。(4)HCA组和对照组的新生儿出生体重分别为(2815.38±741.99)g和(2863.16±651.46)g,两组比较无显著差异(P0.05)。HCA组新生儿出生后1min Apgar评分7分发生率(1.3%)、新生儿肺炎发生率(61.7%)及围产儿死亡率(0.02%)均显著高于对照组(0.04%、32.1%、0)(P0.05)。结论:孕周32周、潜伏期时间48h、既往有人工流产史、BMI≥26kg/m2、中度贫血与HCA发生有关。HCA可导致新生儿肺炎发病率和新生儿死亡率升高。     

Prolonged rupture of the fetal membranes and neonatal outcome

In order to establish the incidence of neonatal infection following prolonged (greater than 24 hours) rupture of the fetal membranes (PROM) and assess outcome of two year retrospective study was undertaken. The names of all babies born following PROM were obtained from the computerised obstetric record and the bacteriological results and outcome reviewed. Of 208 babies born following PROM only three had blood cultures containing pathogens--all of whom were of less than 1500 g birthweight and all of whom died. This represents a fivefold increased frequency of infection for premature babies but no increased risk for full term babies. The overall incidence of infection was much lower than in previous series and this may be due to performing amniocentesis as soon as possible following rupture and inducing labour where there was evidence of incipient chorioamnionitis. Meningitis was not associated with prolonged rupture of the membranes. The mortality for these babies was higher than those of babies without PROM in the 28-31 week gestation group. This was strongly associated with early onset of membrane rupture and none of the babies born following membrane rupture prior to 20 weeks gestation survived. Non-infective pulmonary disease was the main cause of increased mortality.     

Previable rupture of membranes: effect of amniotic fluid on pregnancy outcome

OBJECTIVE: To evaluate pregnancy outcome and the role of the amount of amniotic fluid (AF) in the prognosis of extremely preterm (<24 weeks) premature rupture of membranes (EPPROM). STUDY DESIGN: Women with EPPROM and on-going pregnancy after 1 week of expectant management were included. Exclusion criteria: fetal anomalies, termination of pregnancy and spontaneous recovery of AF within the first week. The effect of the large vertical pocket (LVP) on pregnancy outcome was assessed by a Cox regression model which included three covariates: LVP measurements from rupture to 24 weeks, gestational age at rupture of membranes and sealing procedure. RESULTS: Thirty-seven women were included in the study. The overall survival rate after the neonatal period was 40.5% (15/37) which increased to 62.5% (15/24) in neonates born alive after 24 weeks of gestation. Mean and S.D. of gestational age at rupture of membranes were 19.0 (+/-3.8) weeks. From rupture to 24 weeks, the pooled mean and standard deviation of LVP were 20.5 (+/-15.4)mm. Multivariate analysis showed that the likelihood for neonate survival increased by 2.7 (95% CI 1.45-4.65) for each 5mm of LVP during the follow-up from rupture to 24 weeks. After controlling for AF amount, neither the gestational age at rupture nor the sealing procedure showed any significant effect on pregnancy outcome. CONCLUSION: Although the prognosis of EPPROM is poor overall, survival improves as the amount of AF before 24 weeks increases.     

Pre-term premature rupture of fetal membranes: the dilemma of management in a developing nation.

This study aims at evaluating the outcome of pregnancies complicated by pre-term premature rupture of membrane (PPROM) in a developing country and to highlight the problems of managing such cases and ways of improving future management. This was a retrospective review of 344 patients with PPROM at a University of Nigeria Teaching Hospital Enugu, Nigeria over a 10-year period (January 1994-December 2003). The prevalence of PPROM in this study was 25 per 1,000 births and patients of low parity (para 0-2) accounted for the highest number (56.4%). Previous abortion was significantly more among these women of low parity and may be a factor in the aetiology of PPROM. The gestational age range 28-30 weeks recorded the highest incidence (29.7%) of PPROM. The most common associated aetiological factor was cervical incompetence (11.6%), while chorioamnionitis, a major complication in the patients showed a statistically significant reduction with early antibiotic administration (p<0.05). About 72% (n=248) of the patients arrived at the hospital within 24 h of membrane rupture. Perinatal mortality was high (520 per 1,000 births) due to prematurity and perinatal infections. Better fetal outcomes were recorded among patients with PPROM at gestational age above 30 weeks, fetal weight above 2 kg, normal delivery, absence of maternal infection and latent period of not more than 5 days (p<0.05). The parity of the women did not significantly affect fetal outcome (p>0.05). Two (0.6%) maternal deaths were recorded. Prompt patient referral, early institution of antibiotics and improvement of neonatal facilities in tertiary health institutions in developing countries is advocated as a way of improving fetal survival in PPROM.     

Cocaine use and preterm premature rupture of membranes: improvement in neonatal outcome

OBJECTIVE: Our aim was to determine whether cocaine use increases neonatal morbidity in patients with preterm premature rupture of membranes. STUDY DESIGN: We reviewed records of pregnancies that were complicated with preterm premature rupture of membranes between 24 weeks to 34 weeks of gestation. Clinical characteristics and neonatal outcomes of patients who had positive results for cocaine in the urine were compared with patients with negative test results. RESULTS: During the study period, 16.1% (85/528 patients) had a positive result in a urine screen for cocaine use. Patients who used cocaine were older and of higher gravidity and parity. When major neonatal morbidities were compared, there was improvement in morbidities that were linked to neonatal infection in patients with positive test results for cocaine, including pneumonia (3.5% vs 11.7%; P =.012) and sepsis (5.9% vs 14.7%; P =.016). Jointly, neonatal outcomes were significantly worse in the negative cocaine group (chi(2) = 5.143; P =.023). CONCLUSION: The association of preterm premature rupture of membranes with major neonatal morbidity was unexpectedly and significantly weaker in pregnancies complicated by cocaine use.     

Chorioamnionitis risk and neonatal outcome in preterm premature rupture of membranes

Objective The objective of this study was to compare the neonatal outcome in patients with preterm premature rupture of membranes with and without clinical chorioamnionitis.Study design This is a retrospective study that included 254 pregnant women with preterm rupture of membranes. The study group was divided according to the presence or absence of clinical chorioamnionitis defined as the presence of two or more of the following criteria: maternal temperature >38°C on two or more occasions 1 h apart, maternal tachycardia (120 beats/min), uterine tenderness, foul smelling amniotic fluid, maternal leukocytosis 20,000 mm^–3 with bands and positive C reactive protein. Also the study population was divided according to the use of tocolysis. Exclusion criteria included multiple pregnancy, fetal congenital anomalies, diabetes mellitus and severe preeclampsia. Amniotic fluid was collected from the cervix or from the transabdominal amniocentesis. Antibiotics and tocolysis were used according to the hospital protocols. Parametric and nonparametric statistics were used for comparisons.Results There were no significant differences in birth weight, Apgar scores at 1 and 5 min, rates of respiratory distress syndrome, intraventricular hemorrhage and necrotizing enterocolitis between patients with and without clinical chorioamnionitis or between women who received tocolysis and the ones that did not receive tocolysis. In cases of clinical chorioamnionitis and when tocolysis was used the neonates stayed longer in the neonatal intensive care unit (NICU).Conclusion Patients with preterm premature rupture of membranes and clinical chorioamnionitis have similar neonatal outcomes than the ones without clinical chorioamnionitis.     

Gastroschisis: the effect of labor and ruptured membranes on neonatal outcome

OBJECTIVES: The purpose of this study was to examine the relationship between labor and ruptured membranes on the neonatal outcome of infants with gastroschisis. STUDY DESIGN: We reviewed the outcomes of 60 neonates who were prenatally diagnosed with gastroschisis and who were delivered at the University of North Carolina Hospitals between June 1989 and April 1999. RESULTS: The mean gestational age at delivery was 36 weeks. Four infants (7%) died in the neonatal period, and 19 infants (32%) had a major morbidity. No significant differences appeared in any of the neonatal outcomes when they were stratified by the presence or absence of labor and presence or absence of ruptured membranes. After being controlled for confounding variables, the risk of neonatal death or major neonatal morbidity because of exposure to either labor or ruptured membranes was no different than the risks caused by no labor or intact membranes, respectively. CONCLUSION: Labor and ruptured membranes do not appear to be associated with increased neonatal morbidity or mortality rates in neonates with gastroschisis.     

Preterm premature rupture of membranes and neonatal outcome prior to 34 weeks of gestation.

OBJECTIVES: To investigate the impact of preterm premature rupture of membranes on neonatal outcome. METHODS: A retrospective study was conducted among singleton pregnancies with or without intact amniochorional membranes. The impact of maternal age, gestational age at birth, 1- and 5-min Apgar scores, birthweight, presence of meconium, use of tocolytics, corticosteroids and antibiotics, mode of delivery, umbilical artery pH, histologic presence of chorioamnionitis, and state of the membranes were analyzed in relation to neonatal outcome. Neonatal outcomes were categorized into: none, presence of respiratory distress syndrome, early neonatal sepsis, neonatal death, and days at neonatal intensive care unit. RESULTS: A total of 180 preterm deliveries with ruptured (n=80) and intact membranes (n=100) constituted the study group (group 1) and the control group (group 2), respectively. Compared with group 2, there were more cases in group 1 of maternal antibiotic use (P<0.001), short-term tocolysis (P=0.03), and histologic chorioamnionitis (P<0.001). Multiple logistic regression analysis showed that gestational age at delivery (P=0.009), 1-min Apgar score (P=0.013), and umbilical artery pH (P=0.05) were the independent factors affecting neonatal outcome. CONCLUSIONS: Neonatal outcome was mainly affected by prematurity rather than by preterm premature rupture of membranes.     

24 hour rhythm in the timing of pre-labour spontaneous rupture of membranes at term

OBJECTIVE: To study the timing of pre-labour spontaneous rupture of membranes (SROM) in term pregnancies. DESIGN: Prospective cohort. SETTING: A maternity hospital in the United Kingdom. SAMPLE: Women who were more than 37 weeks gestation with confirmed spontaneous rupture of membranes and not in labour after 4 h. METHODS: Women who were admitted into labour ward with a diagnosis of spontaneous rupture of membranes after 37 weeks of gestation were included. The women's demographic details were recorded and inquiries about whether they had sexual intercourse in the preceding 12 h. The final outcome of their pregnancy was recorded and analysed. MAIN OUTCOME MEASURES: (1) The exact time of spontaneous rupture of membranes, (2) the time of onset of spontaneous labour, (3) delivery details. RESULTS: One hundred and ninety-six women were studied. A 24 h rhythm in the timing of spontaneous rupture of membranes was found with 33.2% occurring between 00:00 and 04:00 h. When contractions representing the onset of labour occurred there was no diurnal rhythm to the timing of onset of contractions. CONCLUSIONS: There is a 24 h rhythm in the timing of spontaneous rupture of membranes in term gestations. The physiological reasons for this rhythm are not understood at the present time.     

Increased apoptosis of human fetal membranes in rupture of the membranes and chorioamnionitis

Apoptosis is thought to participate pathophysiologically in the rupture of human fetal membranes (ROM). The aim of this study was to assess apoptosis of the amnion and the chorion in relation to ROM and chorioamnionitis (CAM). The amnion and chorion at the position of the cervical os and fundus of the uterus were obtained from 44 patients. Apoptotic DNA fragmentation was densitometrically determined, and the relative ratio was used for the quantitative evaluation. Among patients without CAM, the relative ratios of apoptosis in the amnion from patients with ROM were higher than those in patients without ROM (P< 0.05). Among patients without ROM, the apoptotic levels in the amnion from patients with CAM were higher than those in patients without CAM (P< 0.05). These were the cases with the amnion at the position of cervical os and fundus, but not with the chorion. The highest ratio of apoptosis was seen in the amnion from patients with CAM and ROM. Among patients with ROM and no CAM, the apoptotic levels at the cervical os in the amnion (P=0.059) and chorion (P< 0.05) was higher than those at the fundus. The increased apoptosis of human fetal membranes was related to ROM and CAM. Apoptosis plays a role in the pathophysiology of ROM.