Cervical cerclage and preterm PROM

Preterm premature rupture of membranes (PPROM) occurs in 38% of women with cerclage in place. Controversy exists on what to do with the cerclage in this clinical scenario. The objective was to review the literature addressing retention versus removal of cerclage after PPROM and present management recommendations. Retention of cerclage for more than 24 hours after PPROM was found to prolong pregnancy for more than 48 hours, but also to increase maternal chorioamnionitis and neonatal mortality from sepsis, making immediate cerclage removal as the usually preferred therapeutic approach. Steroids for fetal maturity before cerclage removal can be considered between 24 and 33 6/7 weeks gestation.     

Herpes simplex and HIV infections and preterm PROM

Maternal human immunodeficiency virus (HIV) and genital herpes simplex virus (HSV) infection in pregnancy have potential for vertical transmission that may result in death or morbidity. The risk increases with preterm delivery and prolonged ruptured membranes. When managing preterm premature rupture of membranes, the risk of transmission must be weighed against the risk of prematurity. Before 32 to 34 weeks, expectant management is preferred for patients with well controlled HIV or recurrent active genital HSV infection. For patients with advanced HIV disease or primary genital HSV infection, the risk of vertical transmission is higher and many clinical factors need to be considered.     

Impact of oral probiotics on neurodevelopmental outcomes in preterm infants

Objective: The aim of the study was to evaluate the neurodevelopment outcomes of very low birth weight (VLBW) preterm infants supplemented with oral probiotics for the prevention of necrotizing enterocolitis (NEC).

Methods: A prospective follow-up study was performed in a cohort of VLBW preterm infants enrolled in a single center randomized controlled clinical trial to evaluate the efficacy of oral probiotics for the prevention of NEC. Cognitive and neuromotor developments were assessed by using the Bayley scales of infant development II. Sensory and neurological performance was evaluated by standard techniques. The primary outcome was neurodevelopmental impairment at 18–24 months’ corrected age.

Results: A total of 400 infants completed the trial protocol. Of the 370 infants eligible for follow-up, 249 infants (124 in the probiotics group and 125 in the control group) were evaluated. There was no significant difference in any of the neurodevelopmental and sensory outcomes between the two groups.

Conclusion: Oral probiotic given to VLBW infants to reduce the incidense and severity of NEC started with the first feed did not affect neuromotor, neurosensory and cognitive outcomes at 18–24 months’ corrected age.     

Antibiotics in the management of PROM and preterm labor

A significant fraction of preterm birth results from subclinical intrauterine infection. It is presumed that ascending bacterial colonization of the decidua results and either uterine contractions or membrane weakening that results in the clinical presentation of preterm labor or PROM. Those with overt infection require delivery. However, it is plausible that adjunctive antibiotic treatment during therapy for preterm labor and PROM remote from term could result in pregnancy prolongation and reductions in gestational age-dependent and infectious newborn morbidities. Data support adjunctive antibiotic treatment during conservative management of PROM remote from term. Such treatment should include broad-spectrum agents, typically intravenous therapy initially, and continue for up to 7 days if undelivered. Such treatment should be reserved for women presenting remote from term where significant improvement in neonatal outcomes can be anticipated with conservative management. Alternatively, current evidence suggests that antibiotic treatment in the setting of preterm labor with intact membranes does not consistently prolong pregnancy or improve newborn outcomes. Given this, and the concerning findings from the ORACLE II trial of antibiotics for preterm labor, this treatment should not be offered in the setting of preterm labor with intact membranes. Although one could speculate that women with preterm labor and with either a short cervical length for a positive fetal fibronectin screen might benefit from antibiotic therapy, no well-designed, randomized, controlled trials addressing this issue have been completed. Therefore, antibiotic therapy for women in preterm labor should be reserved for usual clinical indications, including suspected bacterial infections, GBS prophylaxis, and chorioamnionitis.     

Predictors of long-term neurodevelopmental outcomes of children born extremely preterm

Children born extremely preterm (<28 weeks’ gestation) are at high risk of a range of adverse neurodevelopmental outcomes in later childhood compared with their peers born at term, including cognitive, motor, and behavioral difficulties. These difficulties can be associated with poorer academic achievement and health outcomes at school age. In this review, we discuss several predictors in the newborn period of early childhood neurodevelopmental outcomes including perinatal risk factors, neuroimaging findings and neurobehavioral assessments, along with social and environmental influences for children born extremely preterm. Given the complexity of predicting long-term outcomes in children born extremely preterm, we recommend multi-disciplinary teams in clinical practice to assist in determining an individual child's risk for adverse long-term outcomes and need for referral to targeted intervention, based upon their risk.     

Impact of chorioamnionitis on short- and long-term outcomes in very low birth weight preterm infants: the Neonatal Research Network Japan

Objective: To evaluate the short- and long-term outcomes among very low birth weight (VLBW) preterm infants after histologic chorioamnionitis (HCA).

Methods: We performed a retrospective analysis of 5849 single infants (birth weight <1500?g) born at a gestational age between 22?+?0 and 33?+?6 weeks. Clinical data were obtained from the Neonatal Research Network Japan between 2003 and 2007. Multivariable logistic regression analyses were performed to assess the effect of HCA on short- and long-term outcome.

Results: According to logistic regression analysis, HCA was associated with lower incidence of respiratory distress syndrome (odds ratio [OR]?=?0.54; p?<?0.001), increased chronic lung disease (OR?=?1.68; p?<?0.001) and sepsis (OR?=?1.71; p?<?0.001) and as a short-term outcomes. There was no significant association with intraventricular hemorrhage (OR?=?1.11; p?=?0.33), periventricular leukomalacia (OR?=?1.07; p?=?.070) and death before discharge (OR?=?0.97; p?=?0.084). HCA was associated with increased home oxygen therapy (OR?=?3.09; p?<?0.001), but not with cerebral palsy (CP; OR?=?0.91; p?=?0.63), develop quotient?<?70 (OR?=?1.27; p?=?0.17), visual impairment (OR?=?1.08; p?=?0.77), severe hearing impairment (OR?=?1.28; p?=?0.62) and death (OR?=?0.98; p?=?0.91) before three years of age.

Conclusions: In this retrospective population-based study in Japan, HCA was not a risk factor for death, neurodevelopmental impairment and CP in VLBW three-year-old preterm infants.     

Amnioinfusion in preterm PROM: effects on amnion and cord histology.

OBJECTIVE: To investigate the effects of transabdominal amnioinfusion (TA) on the histology of amnion (A) and umbilical cord (UC). STUDY DESIGN: From a cohort of 56 singleton pregnancies with premature rupture of membranes (PROM) at 相似文献   

Placental bed disorders in preterm labor, preterm PROM, spontaneous abortion and abruptio placentae

Failure of physiologic transformation of the spiral arteries has been studied using placental bed biopsies in several obstetrical syndromes. Contrary to what was originally believed, this lesion is not restricted to preeclampsia and/or intrauterine growth restriction. A review of published evidence indicates that failure of physiologic transformation can be observed in women with spontaneous second trimester abortions, preterm labor with intact membranes, preterm prelabor rupture of membranes and abruptio placentae. Therefore, disorders of deep placentation are present in a wide range of complications of pregnancy, emphasizing the importance of understanding the physiology and pathology of transformation of the spiral arteries. We propose that changes in the population and function of immunocytes at the maternal-fetal interface can be part of the mechanism of disease of obstetrical disorders, and this requires further investigation.     

Following through: Interventions to improve long-term outcomes of preterm infants

The inequalities in income, wealth, and opportunity so deeply ingrained in our society's history of enslavement, genocide, racism, and discrimination are root causes of health disparities. Follow through is a comprehensive approach that begins before birth and continues into childhood, where health professionals, families, and communities partner to meet the social as well as medical needs of infants and families to achieve health equity. This article discusses potentially better practices for follow through, offering neonatal care providers tangible ways to address social determinants of health, the conditions in which people are born, grow, work, live, and age and the systems that creates these conditions.     

不同类型早产所致围生儿存活及发病情况研究

目的:探讨不同类型早产是否与围生儿的存活及发病情况有关。方法:回顾分析489例活胎妊娠孕妇(孕28~36+6周)及其分娩的550例新生儿(活产儿539个,死产儿11个),按早产类型将其分为自发性早产(SPB)、胎膜早破性早产(PPROM)、医源性早产(IPD)3组。对3组孕妇和新生儿的临床特征,围产儿的存活和发病情况进行了比较分析。结果:(1)IPD单胎围生儿存活率低于SPB和PPROM(P<0.01)。多胎围生儿存活率无统计学差异;(2)围生儿主要并发症的发病率在3组早产中无统计学差异(P>0.05)。(3)非条件Logistic回归多因素分析结果显示:Apgar 5m in评分,孕周,剖宫产与围生儿的存活成正相关。医源性早产,小于胎龄儿与围生儿存活成负相关。Apgar 5m in评分,孕周与围生儿的发病成负相关。结论:IPD与围生儿的存活呈负相关,IPD单胎围生儿存活率低于SPB和PPROM(P<0.01)。     

Identifying the associated factors with onset of preterm PROM compared with term PROM - A retrospective cross-sectional study

ObjectiveTo determine the risk factors associated with the preterm premature rupture of membranes (p-PROM).Materials and methodsThis retrospective cross-sectional study assessed 110 p-PROM cases from among 6642 deliveries at a Japanese perinatal medical center, from June 2016 to September 2018. The control group comprised 220 term PROM (t-PROM) cases. We excluded cases with artificial PROM or rupture of membranes after labor, those with multiple pregnancies, those with p-PROM at 36 weeks and those with t-PROM at 37 weeks. In order to compare p-PROM with t-PROM, univariate and multivariate analysis were performed using several clinical factors at the time of PROM onset.ResultsThe p-PROM group included 110 cases with 14–35 weeks PROM, and the t-PROM group included 220 cases with 38–41 weeks PROM. Eleven factors were identified as significant factors on the univariate analysis. A history of cervical conization (OR 37.5, 95% CI: 2.31–607.1), cervical length <25 mm at 28 weeks (OR 9.31, 95% CI: 1.76–49.3), negative Lactobacillus (OR 4.01, 95% CI: 1.18–13.7), and bleeding during the second trimester (OR 3.35, 95% CI: 1.18–9.53) were identified as significant factors by the multivariate analysis. Based on the risk factors identified during the multivariate analysis, we divided the 330 cases in the following three groups: 0 group (n = 244), 1 group (n = 60), and 2–4 group (n = 26). The ratio of p-PROM:t-PROM was calculated and compared for each group. The ratios were 21% (0 group), 57% (1 group), and 100% (2–4 group), indicating statistically significant differences between the groups (p < 0.001).ConclusionWe found that the following four factors were associated with p-PROM: history of cervical conization, cervical length <25 mm at 28 weeks, negative Lactobacillus, and bleeding during the second trimester. Our results suggest that we can identify patients who are at increased risk for p-PROM, based on these factors. Further research is necessary to determine the optimal treatment approach for these patients to prevent p-PROM.     

Cesarean versus vaginal delivery: long-term infant outcomes and the hygiene hypothesis

Concurrent with the trend of increasing cesarean delivery numbers, there has been an epidemic of both autoimmune diseases and allergic diseases. Several theories have emerged suggesting that environmental influences are contributing to this phenomenon, most notably, the hygiene hypothesis. This article provides background about the human microbiota and its relationship to the developing immune system as well as the relationship of mode of delivery on the colonization of the infant intestine, development of the immune system, and subsequent childhood allergies, asthma, and autoimmune diseases.     

Extreme preterm birth: onset of delivery and its effect on infant survival and morbidity

OBJECTIVE: To investigate whether correlations could be found between the onset of preterm delivery and infant outcome, that is, survival and major morbidity. METHODS: The study was a retrospective, hospital-based cohort study. All women with a live fetus on admission, giving birth at 22(+0) to 27(+6) weeks of gestation between 1998 and 2003 were included. The deliveries were subdivided into those that began with either preterm labor, preterm premature rupture of membranes (PROM), or iatrogenic preterm delivery. These groups were compared for survival and survival without major morbidity (intraventricular hemorrhage grade 3-4, periventricular leukomalacia, retinopathy of prematurity grade 3-4, bronchopulmonary dysplasia, or necrotizing enterocolitis) at discharge. RESULTS: The cause of the preterm birth was preterm labor in 154 of 288 (53%), preterm PROM 83 of 288 (29%), and iatrogenic preterm delivery 51 of 288 (18%). There were 83% liveborn children, and 67% survived until discharge. Survival was lower for preterm PROM (54%) than for preterm labor (75%) and iatrogenic preterm delivery (67%). Multivariable analyses showed that survival was positively associated with gestational age and antenatal steroid treatment. Negative associations concerning survival were found for preterm PROM and being small for gestational age. Survival without major morbidity did not differ significantly between the groups and was positively associated with gestational age and negatively associated with being small for gestational age. CONCLUSION: Infant survival was significantly lower when the onset of preterm delivery was preterm PROM as compared with preterm labor and iatrogenic delivery. For surviving infants there was no significant difference in major morbidity between the groups. LEVEL OF EVIDENCE: III.     

Neuroprotection of the preterm infant

The past 30 years has seen an increase in the survival of extremely preterm infants, however, lifelong neurodisability remains a significant problem for this population. No single intervention can prevent preterm brain injury, given the complex interaction between pathological processes, developmental trajectory, genetic susceptibility and environmental influences. However, a number of interventions, both antenatal and postnatal, have been shown to improve neurodevelopmental outcome. These include the antenatal administration of steroids and magnesium sulphate, delayed cord clamping, prevention and treatment of chorioamnionitis, stabilisation of the cerebral circulation, caffeine and optimising nutrition. Applying this evidence in daily practice offers the best chance of improving outcomes in this vulnerable population.     

Environmental light and the preterm infant

The lighting environment of the preterm baby is quite unlike that experienced at any other time of life. Physical and physiological factors control how much light reaches the retina of the preterm baby. With respect to the former, although many neonatal intensive care units are brightly and continuously lit, there is a trend to employ lower levels of illumination and to introduce cycling regimens. Physiological determinants of the retinal light dose include: eyelid opening and transmission, pupil diameter and the transmission characteristics of the ocular media. Early exposure to light does not significantly hasten or retard normal visual development, and it is not a factor in the development of retinopathy of prematurity. However, ambient neonatal intensive care unit illumination may be implicated in some of the more subtle visual pathway sequelae that cannot be attributed to other major complications of preterm birth including altered visual functions and arrested eye growth.     

Macrosomia--maternal characteristics and infant complications

Using a 1982 to 1983 regional network data bank of 33,545 delivered infants, a study was conducted comparing 574 macrosomic infants weighing greater than 4500 g to a control group of 18,739 infants whose birth weights were 2500 to 3499 g. Macrosomic infants occurred in 1.7% of the deliveries. Women delivering macrosomic infants were significantly older, of higher parity, more obese (greater than 90 kg), and more frequently diabetic and postmature (longer than 42 weeks) than the controls. The women having macrosomic infants had a higher frequency of cesarean deliveries. The macrosomic infants were more often male and had more birth trauma and shoulder dystocia, higher death rates, and lower Apgar scores. Five-minute Apgar scores were lowest in the very macrosomic subgroup (greater than 5000 g). The high-risk group triad included obesity, diabetes, and post-dates and had a macrosomia frequency of 5 to 14%. Macrosomic infants delivered by cesarean section had significantly fewer birth injuries. Because of these serious perinatal problems, women at risk should be screened for macrosomic infants, and if found, they should be delivered electively by cesarean section.     

The viability of the preterm infant

Viability is the capability of the liveborn infant to survive without major handicaps. Although opinions differ in the Netherlands as to the justification of starting treatment in infants of less than 26 weeks gestation, our preliminary results indicate that mortality and major-handicap rate do not differ in infants of less than 26 weeks compared to infants of 26 and 27 weeks. However, we should encourage preventive perinatal medicine in order to reduce the alarming high rate of major handicaps in all extremely preterm infants.