未足月妊娠胎膜早破并发早产分娩方式分析

未足月妊娠胎膜早破常并发早产。此时由于胎儿较小 ,各个器官功能发育尚不成熟 ,且对缺氧的耐受能力较差 ,因此 ,需权衡分娩方式对母婴可能产生的利弊。1　资料与方法1.1　一般资料1998年 1月至 2 0 0 1年 12月在我院住院分娩的孕妇共 36 18例 ,同期发生胎膜早破 392例 (10 83% ) ,而妊娠在2 8～ 36 + 6周之间发生胎膜早破者 119例。未足月妊娠胎膜早破占同期住院分娩总数的 3 2 8% ,占整个胎膜早破的30 35 %。本组病例平均妊娠周数为 33+ 4 周 ,平均年龄2 6 5岁。其中初产妇 10 9例 ,经产妇 10例 ;单胎 10 9例 ,双胎 10例 ;胎死宫内 2例…     

未足月胎膜早破的封闭疗法

1PPROM概况 未足月胎膜早破（preterm premature rupture of the membranes，PPROM）是指妊娠未满37周胎膜在临产前发生破裂。在所有妊娠中PPROM发生率为2％～3％，早产30％～40％由PPROM引发，PPROM孕妇中只有7．7％～9．7％的胎膜破损能够自然闭合，而60％～80％的孕妇在胎膜破裂7d内分娩，其中位潜伏期为6．6d。     

未足月胎膜早破分娩方式的选择及分娩注意事项

未足月胎膜早破（preterm premature rupture of the membranes，PPROM）在所有妊娠中的发生率为1％～3％，约占早产的30％～40％。PPROM的主要危害是早产、脐带脱垂、宫内感染及胎儿窘迫等。因此，根据孕周、破膜时间、胎儿情况等选择适当的分娩方式以及处理好分娩过程的各个环节可以减少各种因素对胎儿及新生儿的损害，降低新生儿发病率和死亡率。     

未足月胎膜早破的宫缩抑制剂治疗

胎膜早破的病因主要有:生殖道感染、羊膜腔内压力增高、羊水过多、胎位异常、宫颈内口松弛及胎膜发育异常等。胎膜早破可导致孕妇感染和胎盘早剥,以及胎儿早产、感染、脐带脱垂等并发症。临床上用宫缩抑制剂治疗未足月胎膜早破(PPROM)以延长孕周提高围产儿存活率,因治疗同时也有发生宫内感染、胎儿宫内窘迫等,宫缩抑制剂的使用还存在有不同看法。     

未足月胎膜早破的处理

<正>未足月胎膜早破(preterm premature rupture of the membranes,PPROM)是指妊娠未满37周胎膜在临产前发生破裂。单胎妊娠PPROM的发生率为2%～4%,双胎妊娠为7%～20%[1]。PPROM导致的早产占早产的1/3,同时可能并发绒毛膜羊膜炎、     

未足月胎膜早破抗生素使用

未足月胎膜早破（PPROM）病因复杂,但感染是首要病因。PPROM与感染互为因果。PPROM应用抗生素可以降低母儿发病率及延长孕周。PPROM确诊后通过评估适宜期待保胎者应第一时间行阴道和肛周的B族溶血性链球菌（GBS）筛查和中段尿培养,同时应用广谱抗生素。抗生素的选择建议氨苄青霉素联合红霉素,开始为静脉滴注,48 h后口服,共用药7 d。对于青霉素过敏者,应单独使用红霉素类抗生素。但GBS（+）,青霉素过敏者应启动其他敏感药物,孕周小于32周者应用抗生素治疗的益处更为明显。孕周≥34周者则建议积极引产。是否应用抗生素根据个体情况决定,GBS（+）者即使之前应用了抗生素治疗,在临产后仍应针对GBS应用青霉素类药物预防母胎感染。严重感染者,注意选用更广谱的抗生素。     

地塞米松、黄体酮对未足月胎膜早破患者CRH及分娩时间影响的研究

目的:研究地塞米松(DEX)、黄体酮(P)对未足月胎膜早破患者外周血促肾上腺皮质激素释放激素(CRH)及分娩时间的影响,探讨用于促胎肺成熟时可能存在的促分娩发动作用及拮抗作用。方法:选取57例妊娠34~36周发生胎膜早破的孕妇,随机分为4组,DEX组14例,肌肉注射地塞米松5mg,1次/12h,连用2天;DEX+P组14例,肌肉注射地塞米松同时给予黄体酮20mg,1次/d,连用2天;P组13例,肌肉注射黄体酮20mg,1次/d,连用2天;对照组16例,未给予地塞米松和黄体酮的胎膜早破孕妇。分别于入院时、入院后24h、48h测定4组孕妇外周血CRH含量及入院至胎儿娩出的时间。用放射免疫法测定CRH含量,同时定期监测研究对象的体温、脉搏、外周血白细胞及C反应蛋白。结果:(1)所有研究对象观察期间体温、脉搏、白细胞和C反应蛋白均在正常范围,各组间无统计学差异(P>0.05);(2)4组孕妇入院时外周血CRH无统计学差异(P>0.05),入院24h及48h DEX组CRH水平高于DEX+P组、P组及对照组,差异有统计学意义(P<0.05,P<0.01);后3组之间无统计学差异(均P>0.05);(3)4组孕妇均经阴分娩。DEX组的分娩时间显著短于DEX+P组(P<0.05)、P组(P<0.01)及对照组(P<0.01);(4)CRH水平与分娩时间呈负相关(r=-0.79,P<0.05);(5)4组研究对象的新生儿评分和体重均无统计学差异(P>0.05)。结论:地塞米松可能通过上调促肾上腺皮质激素释放激素发挥促分娩发动作用,黄体酮可对抗地塞米松的促分娩发动作用。     

未足月胎膜早破治疗的研究进展

未足月胎膜早破的处理方法包括期待疗法与终止妊娠。期待疗法中目前传统的预防感染、抑制宫缩、促胎肺成熟三大联合措施在未足月胎膜早破治疗中占主导地位，但疗效不佳。羊膜腔灌注虽有较好的疗效，但因其属介入性操作，有导致羊膜腔感染的风险，临床应用甚少。新兴起的羊膜腔封闭疗法是用特殊材料经腹或宫颈封闭胎膜破口治疗未足月胎膜早破的根本方法。该法使羊膜腔重新处于封闭状态，降低母婴感染病率，减少由于羊水过少而导致的胎儿畸形与发育迟缓，具有较好的研究潜能。但此方法目前尚不成熟，封闭途径及封闭材料的选择尚无统一定论，安全性和有效性有待进一步研究，期望成为其他疗法的替代疗法。     

未足月胎膜早破的羊膜腔封闭疗法

未足月胎膜早破 (preterm premature rupture of themem branes,PPROM)是指胎膜于妊娠 2 0～ 37周间发生破裂 ,约占妊娠总数的 2 %～ 3% ,在早产的原因中 ,30 %～4 0 %是由 PPROM发展而来。由于 PPROM的围产儿死亡率、新生儿发病率及孕妇感染率较高 ,目前无有效的治疗方法 ,故 PPROM是产科的棘手问题之一。按照有无羊膜腔手术史将 PPROM分为自发性和医源性胎膜早破 (继发于各种羊膜腔手术、操作后 )。由于我国目前产前遗传学诊断和胎儿外科技术尚未广泛开展 ,PPROM多为自发性。 PPROM造成的羊膜腔开放状态和持续羊水渗漏以及…     

未足月胎膜早破病因及预防和处理

未足月胎膜早破(PPROM)是产科综合征疾病之一,可严重影响母儿健康,其病因复杂,存在多种通路协同作用,且可能与感染互为因果,其临床处理策略一直是产科临床工作中的棘手问题。目前,诊疗策略依据发病孕周的特点及预后,权衡监测严重并发症临床征象与早产风险利弊,选择最佳终止妊娠时机,但存在诊疗滞后和处理被动等问题,主动积极的管理策略应将重点放在不同病因的低成本筛查和干预措施上,有助于推进PPROM早防控与精细化管理。     

Amniotic fluid index,single deepest pocket and transvaginal cervical length: Parameter of predictive delivery latency in preterm premature rupture of membranes

Objective

Prediction of delivery latency complicated with preterm premature rupture of membrane (PPROM) is crucial for reducing maternal and neonatal complications. Therefore, we investigated the correlations between latency period and cut-off values of ultrasonographic parameters, ultimately predicting delivery latency.

Pentraxin 3 in amniotic fluid as a marker of intra-amniotic inflammation in women with preterm premature rupture of membranes

Objective

To determine whether amniotic fluid levels of pentraxin 3 (PTX3) are of value in the prenatal diagnosis of acute histological chorioamnionitis in preterm premature rupture of membranes (PPROM).

Methods

Forty pregnant women with PPROM between 24 and 36 weeks of pregnancy without (n = 21) and with (n = 19) histological chorioamnionitis (PPROM group) and 42 women between 16 and 20 weeks of pregnancy (midtrimester group) were included in the study. We compared amniotic fluid PTX3 levels in the PPROM group with versus without histological chorioamnionitis, and between the PPROM and the midtrimester groups using nonparametric tests (Mann-Whitney test), given the non-normal distribution of the analyte.

Results

Patients with histological chorioamnionitis had a significantly higher median amniotic fluid PTX3 concentration than patients without the histological signs of chorioamnionitis (3.69 ng/mL [0.51-106.8] versus 0.8 ng/mL [0.36-121.0]; P = 0.015). Patients in the PPROM group reached a significantly higher median amniotic fluid concentration of PTX3 compared with those in the midtrimester group (1.0 ng/mL [0.36-121.0] versus 0.67 ng/mL [0.4-2.8]; P = 0.007).

Conclusion

Histological chorioamnionitis is associated with a significant increase of amniotic fluid pentraxin 3 levels. Amniotic fluid pentraxin 3 appears to be a marker of intra-amniotic inflammation.     

Transabdominal amnioinfusion in preterm premature rupture of membranes

Objective

To evaluate the effect of transabdominal amnioinfusion on prolongation of pregnancy, and maternal and neonatal outcomes in preterm premature rupture of membranes (pPROM).

Methods

We conducted a prospective randomized controlled study of women with pPROM during singleton live pregnancy—between 26 and 33 + 6 weeks—whose amniotic fluid index (AFI) was less than the 5th percentile. The study group underwent transabdominal amnioinfusion at admission and then weekly if their AFI fell below the 5th percentile again. The control group received expectant management.

Results

The difference in the mean interval from pPROM to delivery between the groups was not statistically significant. Neonatal and maternal outcomes were significantly improved in the study group compared with the control group (fetal distress [10% vs 37%]; early neonatal sepsis [17% vs 63%]; neonatal mortality [17% vs 63%]; spontaneous delivery [83% vs 53%]; and postpartum sepsis [7% vs 33%]).

Conclusion

Transabdominal amnioinfusion reduced fetal distress, early neonatal sepsis, and neonatal mortality. In the study group, more participants delivered spontaneously and there were fewer cases of postpartum sepsis, although the pPROM-delivery interval was not increased.     

Duration of antibiotic therapy after preterm premature rupture of fetal membranes

OBJECTIVE: This study was undertaken to compare the efficacy of 3 days versus 7 days of ampicillin in prolonging gestation for at least 7 days in women with preterm premature rupture of membranes (PPROM). STUDY DESIGN: We performed a randomized clinical trial comparing 3 days of ampicillin with 7 days ampicillin in patients with PPROM. Our primary outcome was the prolongation of pregnancy for at least 7 days. Secondary outcomes included rates of chorioamnionitis, postpartum endometritis, and neonatal morbidity and mortality. RESULTS: Forty-eight patients were randomly selected. There was no statistically significant difference in the ability to achieve a 7-day latency (relative risk 0.83, 95% CI 0.51-1.38). In addition, there was no statistically significant difference in the rates of chorioamnionitis, endometritis, and our composite neonatal morbidity. CONCLUSION: In patients with PPROM, length of antibiotic therapy does not change the rate of a 7-day latency or affect the rate of chorioamnionitis, postpartum endometritis, or neonatal morbidity.     

未足月胎膜早破孕妇剩余羊水量与母儿结局

目的 探讨未足月胎膜早破(PPROM)发生后剩余羊水量与母儿结局的关系.方法 选择2002年1月-2009年2月重庆医科大学附属第一医院产科住院分娩的PPROM孕妇78例,2005年1月-2009年2月重庆市妇幼保健院产科住院分娩的PPROM孕妇67例,共计145例.根据胎膜破裂后羊水指数(AFI)结果将孕妇分为3组:羊水量正常组(80 mm≤AFI＜180 mm)78例;羊水量偏少组(50 mm≤AFI＜80 mm)31例;羊水量过少组(AFI＜50 mm)36例.观察各组AFI、孕妇发热情况、白细胞计数、发生PPROM的孕周、潜伏期时限、分娩方式、围产期感染、胎儿窘迫、新生儿窒息情况及出生体重、新生儿呼吸窘迫综合征(NRDS)、新牛儿呼吸衰竭、新生儿缺血缺氧性脑病(HIE)、缺血缺氧性心肌损害等,并对各组的母儿围产期发病情况进行分析.结果 (1)3组孕妇破膜时间、新生儿出生体重、胎盘早剥、白细胞计数、发热等指标分别比较,差异无统计学意义(P＞0.05).羊水量过少组孕妇潜伏期时间明显短于羊水量偏少组及羊水量正常组,分别比较,差异有统计学意义(P＜0.01).羊水量过少组孕妇剖官产率(69%)明显高于羊水量正常组(39%),两组比较,差异有统计学意义(P＜0.01).(2)羊水量过少组羊膜腔感染13例(36%,13/36),羊水量偏少组8例(26%,8/31),羊水量正常组7例(9%,7/78),3组分别比较,差异均有统计学意义(P＜0.01).(3)羊水量过少组新生儿败血症10例(28%,10/36),羊水量偏少组8例(26%,8/31),羊水量正常组7例(9%,7/78),3组分别比较,差异均有统计学意义(P＜0.05).(4)羊水量过少组的胎儿窘迫(19%)、新生儿窜息(28%)、缺血缺氧性心肌损伤发生率(56%)明显高于羊水量正常组(分别为3%、8%、13%),差异均有统计学意义(P＜0.01);3组的NRDS、呼吸衰竭、新生儿HIE、新生儿黄疸、新生儿低血糖、新生儿脑室出血发生率分别比较,差异均无统计学意义(P＞0.05).(5)以羊膜腔感染为应变量,logistic回归分析显示,PPROM剩余羊水量过少为羊膜腔感染的惟一有效自变量(r=0.863±0.374,P＜0.05);以新生儿病率为应变量,logistic回归分析显示,PPROM剩余羊水量过少是新生儿败血症的惟一有效白变量(γ=0.874±0.462,P＜0.05).结论 PPROM后的剩余羊水量过少与潜伏期缩短,剖官产率升高、羊膜腔感染、胎儿窘迫、新生儿窒息、新生儿败血症、新生儿缺氧缺血性心肌损害的增加有关;PPROM后剩余羊水量的多少可作为期待治疗时有效预测母儿结局的指标.     

The natural history of preterm premature rupture of membranes in twin pregnancies

Objective: To compare the characteristics of preterm premature rupture of membranes (PPROM) between twin and singleton pregnancies.

Methods: This was a retrospective study of all women with twin and singleton pregnancies admitted with PPROM between 24–34 weeks of gestation.

Results: Overall 698 women with PPROM were eligible for the study: 101 (14.5%) twins and 597 (85.5%) singletons. Twins presented with PPROM at a more advanced gestational age compared with singletons (29.1?±?2.7 vs. 28.5?±?2.8 weeks, p?=?0.03). The latency period was shorter in twins compared with singletons, especially for women presenting after 28 weeks of gestation (5.0?±?0.8 vs. 7.0?±?0.4 days, p?=?0.01). Women with twins were more likely to deliver within 48?h (OR:?2.7; 95%CI: 1.7–4.2) and were less likely to deliver within 2–7 days (OR: 0.5; 95%CI: 0.3–0.9) following PPROM. The rate of clinical chorioamnionitis or placental abruption following PPROM was lower in twins compared with singletons (15.8% vs. 26.0%, p?=?0.03).

Conclusions: PPROM in twin pregnancies tends to occur at a more advanced gestational age, is associated with a shorter latency period and is less likely to be complicated by chorioamnionitis or placental abruption compared with singletons. This information may be useful for counseling and management decisions in cases of PPROM in women with twins.     

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.     

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.     

Perinatal outcomes in pregnancies with oligohydramnios after preterm premature rupture of membranes

Objective: Our purpose was to determine whether singleton pregnancies complicated by preterm premature rupture of membranes (PPROM) and oligohydramnios are at an increased risk of having maternal and neonatal morbidity.

Methods: We performed a retrospective analysis of 389 women with PPROM between 24 and 34 weeks of gestation in a single tertiary center during 2008–2014. Patients were divided into two groups on the basis of amniotic fluid index (AFI)?n?=?188) or AFI?≥?5?cm (n?=?201). Perinatal outcomes were compared according to amniotic fluid volume. The Student's t-test and Mann–Whitney U test were used to compare variables with normal and abnormal distribution, respectively. Categorical variables were examined by the chi-square test.

Results: Patients with an AFI?p?p?=?0.029) and emergency cesarean delivery (p?=?0.043) and a lower neonatal Apgar score at first minute (p?=?0.004).

Conclusion: Initial oligohydramnios after PPROM is associated with shorter latency to delivery, higher rate of clinical chorioamnionitis, higher rate of emergency cesarean delivery, and lower 1-min Apgar score.