Na Hyun Lee; Jae Hyun Park; Jin Gon Bae

doi:10.14734/PN.2019.30.4.193

Journal List > Perinatology > v.30(4) > 1144128

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee, Park, and Bae: Perinatal Outcomes Following Prolonged Preterm Premature Rupture of Membranes before Limit of Viability – A Single Center Experience

Original Article

Perinatology 2019;30(4):193-199.

Published online: 20 September 2019

DOI: https://doi.org/10.14734/PN.2019.30.4.193

Perinatal Outcomes Following Prolonged Preterm Premature Rupture of Membranes before Limit of Viability – A Single Center Experience

Na Hyun Lee, MD, Jae Hyun Park, MD, PhD, Jin Gon Bae, MD

¹Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea

²Department of Obstetrics and Gynecology, Keimyung University Dongsan Medical Center, Daegu, Korea

Correspondence to Jae Hyun Park, MD, PhD Department of Pediatrics, Keimyung University Dongsan Medical Center, 1035 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea Tel: +82-53-258-4852 Fax: +82-53-258-4875 E-mail: jhpark.neo@gmail.com

Received 12 May 2019 Revised 20 May 2019 Accepted 11 June 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

To investigate maternal and neonatal outcomes following prolonged preterm premature rupture of membrane (PPROM) before limit of viability in a single center.

Methods

Thirty-two women with PPROM before 25 weeks' gestation without overt intrauterine infection were administered expectant management. We investigated maternal and neonatal outcomes of pregnancies following PPROM occurring before 25 weeks' gestation and with latent period (from membrane rupture to delivery) of 7 days or more.

Results

Median gestational age at membrane rupture was 22.1 weeks. Median latent period was 32 days. Median gestational age at delivery was 26.6 weeks. The incidence of clinical pulmonary hypo plasia and early onset sepsis was 43.5% (10/23) and 21.7% (5/23), respectively. The overall mortality in neonatal intensive care unit (NICU) was 43.5% (10/23). Latent period was negatively correlated with gestational age at membrane rupture (r=-0.501, P=0.015), but not associated with maternal complications. As the length of latent period increased, overall mortality in NICU decreased (relative risk=0.898, P=0.011).

Conclusion

The expectant management in women with PPROM before 25 weeks' gestation did not induce maternal complications and might help to improve the neonatal outcomes rather than the immediate delivery.

Keywords: Fetal membranes, premature rupture, Pregnancy maintenance, Pregnancy complications, Infant mortality

References

1. Mercer BM. Preterm premature rupture of the membranes. Obstet Gynecol. 2003; 101:178–93.

2. Melamed N, Hadar E, Ben-Haroush A, Kaplan B, Yogev Y. Factors affecting the duration of the latency period in preterm premature rupture of membranes. J Matern Fetal Neonatal Med. 2009; 22:1051–6.

3. Kenyon S, Boulvain M, Neilson JP. Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev. 2010; 8:CD001058.

4. Garite TJ, Freeman RK. Chorioamnionitis in the preterm gestation. Obstet Gynecol. 1982; 59:539–45.

5. Beydoun SN, Yasin SY. Premature rupture of the membranes before 28 weeks: conservative management. Am J Obstet Gynecol. 1986; 155:4719.

6. American College of Obstetrics and Gynecology. ACOG practice bulletin. Perinatal care at the threshold of viability. Number 38, September 2002. American College of Obstetrics and Gynecology. Int J Gynaecol Obstet. 2002; 79:181–8.

7. Yeast JD. Preterm premature rupture of the membranes before viability. Clin Perinatol. 2001; 28:849–60.

8. Taylor J, Garite TJ. Premature rupture of membranes before fetal viability. Obstet Gynecol. 1984; 64:615–20.

9. Major CA, Kitzmiller JL. Perinatal survival with expectant management of midtrimester rupture of membranes. Am J Obstet Gynecol. 1990; 163:838–44.

10. Xiao ZH, André P, Lacaze-Masmonteil T, Audibert F, Zupan V, Dehan M. Outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks of gestation. Eur J Obstet Gynecol Reprod Biol. 2000; 90:67–71.

11. Muris C, Girard B, Creveuil C, Durin L, Herlicoviez M, Dreyfus M. Management of premature rupture of membranes before 25 weeks. Eur J Obstet Gynecol Reprod Biol. 2007; 131:163–8.

12. Manuck TA, Eller AG, Esplin MS, Stoddard GJ, Varner MW, Silver RM. Outcomes of expectantly managed preterm premature rupture of membranes occurring before 24 weeks of gestation. Obstet Gynecol. 2009; 114:29–37.

13. Williams O, Hutchings G, Debieve F, Debauche C. Contemporary neonatal outcome following rupture of membranes prior to 25 weeks with prolonged oligohydramnios. Early Hum Dev. 2009; 85:273–7.

14. Brumbaugh JE, Colaizy TT, Nuangchamnong N, O'Brien EA, Fleener DK, Rijhsinghani A, et al. Neonatal survival after prolonged preterm premature rupture of membranes before 24 weeks of gestation. Obstet Gynecol. 2014; 124:992–8.

15. Kibel M, Asztalos E, Barrett J, Dunn MS, Tward C, Pittini A, et al. Outcomes of pregnancies complicated by preterm premature rupture of membranes between 20 and 24 weeks of gestation. Obstet Gynecol. 2016; 128:313–20.

16. Kilbride HW, Thibeault DW. Neonatal complications of preterm premature rupture of membranes. Pathophysiology and management. Clin Perinatol. 2001; 28:761–85.

17. Kilbride HW, Yeast J, Thibeault DW. Defining limits of survival: lethal pulmonary hypoplasia after midtrimester premature rupture of membranes. Am J Obstet Gynecol. 1996; 175:675–81.

18. Everest NJ, Jacobs SE, Davis PG, Begg L, Rogerson S. Outcomes following prolonged preterm premature rupture of the membranes. Arch Dis Child Fetal Neonatal Ed. 2008; 93:F207–11.

19. Rotschild A, Ling EW, Puterman ML, Farquharson D. Neonatal outcome after prolonged preterm rupture of the membranes. Am J Obstet Gynecol. 1990; 162:46–52.

20. Winn HN, Chen M, Amon E, Leet TL, Shumway JB, Mostello D. Neonatal pulmonary hypoplasia and perinatal mortality in patients with midtrimester rupture of amniotic membranes–a critical analysis. Am J Obstet Gynecol. 2000; 182:1638–44.

21. Waters TP, Mercer BM. The management of preterm premature rupture of the membranes near the limit of fetal viability. Am J Obstet Gynecol. 2009; 201:230–40.

22. Lee J, Romero R, Kim SM, Chaemsaithong P, Park CW, Park JS, et al. A new antimicrobial combination prolongs the latency period, reduces acute histologic chorioamnionitis as well as funisitis, and improves neonatal outcomes in preterm PROM. J Matern Fetal Neonatal Med. 2016; 29:707–20.

23. Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin No. 188: prelabor rupture of membranes. Obstet Gynecol. 2018; 131:e1–14.

24. Gibbs RS, Romero R, Hillier SL, Eschenbach DA, Sweet RL. A review of premature birth and subclinical infection. Am J Obstet Gynecol. 1992; 166:1515–28.

25. Redline RW, Faye-Petersen O, Heller D, Qureshi F, Savell V, Vogler C. Amniotic infection syndrome: nosology and reproducibility of placental reaction patterns. Pediatr Dev Pathol. 2003; 6:435–48.

26. Zaichkin JG. Neonatal resuscitation: neonatal resuscitation program 7th edition practice integration. Crit Care Nurs Clin North Am. 2018; 30:53347.

27. Suzuki K. Respiratory characteristics of infants with pulmonary hypoplasia syndrome following preterm rupture of membranes: a preliminary study for establishing clinical diagnostic criteria. Early Hum Dev. 2004; 79:31–40.

28. Hadi HA, Hodson CA, Strickland D. Premature rupture of the membranes between 20 and 25 weeks' gestation: role of amniotic fluid volume in perinatal outcome. Am J Obstet Gynecol. 1994; 170:1139–44.

29. Joshi S, Kotecha S. Lung growth and development. Early Hum Dev. 2007; 83:789–94.

30. McMurtry IF. Introduction: pre-and postnatal lung development, maturation, and plasticity. Am J Physiol Lung Cell Mol Physiol. 2002; 282:L341–4.

31. Singh K, Mercer B. Antibiotics after preterm premature rupture of the membranes. Clin Obstet Gynecol. 2011; 54:344–50.

32. Bromiker R, Ernest N, Meir MB, Kaplan M, Hammerman C, Schimmel MS, et al. Correlation of bacterial type and antibiotic sensitivity with maternal antibiotic exposure in early-onset neonatal sepsis. Neonatology. 2013; 103:48–53.

Fig. 1.

Flowchart of pregnant women and infants with PPROM before 25 weeks of gestation. PPROM, prolonged preterm premature rupture of membrane; GA, gestaional age; NICU, neonatal intensive care unit.

Table 1.

Maternal Characteristics and Outcomes

Variable	Women (n=21)
Maternal age (years)	34 (32–36)
Nulliparity	8 (38.1)
Para	1 (0–2)
Multiple pregnancy	5 (23.8)
Cerclage intervention	7 (33.3)
Amniocentesis before membrane rupture	0
GA at membrane rupture (weeks)	22.1 (21.0–23.1)
Latent period (days)	32 (23–58)
³) ³/mm WBC at admission (10	12.6 (8.7–15.1)
CRP at admission (mg/L)	0.6 (0.1–1.8)
GA at delivery (weeks)	26.6 (25.7–29.9)
Cesarean section	16 (76.2)
Clinical chorioamnionitis	11 (52.4)
Histologic chorioamnionitis	12 (75.0)
Maternal sepsis	3 (14.3)
Retained placenta necessitating curettage	2 (9.5)
Placenta abruptio	0

Values are presented as median (interquartile range) or number (%). Abbreviations: GA, gestational age; WBC, white blood cell; CRP, C-reactive protein.

Table 2.

Neontal Characteristics and Outcomes

Variable	Neonate (n=23)
GA at delivery (weeks)	27.7 (25.7–29.7)
Birth weight (g)	1,050 (780–1,420)
MVP at membrane rupture (mm)	31 (17–53)
5-minutes Apgar score	8 (7–8)
Clinical pulmonary hypoplasia	10 (43.5)
Air leak syndrome	6 (26.1)
Persistent fetal circulation	7 (30.4)
Perinatal death at postnatal 7 days	4 (17.4)
Early onset sepsis	5 (21.7)
Moderate to severe BPD	4 (17.4)
Overall mortality in NICU	10 (43.5)

Values are presented as median (interquartile range) or number (%). Abbreviations: GA, gestational age; MVP, maximum vertical pocket; BPD, bronchopulmonary dysplasia; NICU, neonatal intensive care unit.

Table 3.

Infants Who Died in Neonatal Intensive Care Unit

No.	GA at membrane rupture (weeks)	MVP at membrane rupture (mm)	Latent period (days)	GA at delivery (weeks)	Birth I weight (g)	Intubated at birth	Clinical pulmonary hypoplasia	Air leak syndrome	Persistent fetal circulation	Early onset sepsis	Postnata age at death (days)	al Cause of death
1	19.7	60	32	24.3	620	+	–	–	–	–	7	Respiratory failure
2	21.1	0	25	24.7	650	+	+	–	+	–	0	Respiratory failure
3	21.1	53	25	24.7	710	+	–	–	–	+	9	Infection
4	22.4	41	13	24.3	780	+	–	–	–	–	56	Necrotizing enterocolitis
5	22.6	0	22	25.7	770	+	+	+	–	+	7	Respiratory failure
6	22.7	0	27	26.6	1,050	+	–	–	–	–	12	Respiratory failure
7	22.7	64	12	24.4	660	+	–	–	–	–	10	Intraventricular hemorrhage
8	23.0	40	39	28.6	1,320	+	+	–	–	–	1	Respiratory failure
9	23.7	17	15	25.9	970	+	–	–	–	–	35	Infection
10	24.4	27	23	27.7	1,070	+	+	+	+	–	2	Respiratory failure

Abbreviations: GA, gestational age; MVP, maximum vertical pocket.

Table 4.

Infants Who Survived in Neonatal Intensive Care Unit

No.	GA at membrane rupture (weeks)	MVP at membrane rupture (mm)	Latent period (days)	GA at delivery (weeks)	Birth weight (g)	Intubated at birth	Clinical pulmonary hypoplasia	Air leak syndrome	Persistent fetal circulation	Early onset sepsis	BPD, moderate to severe	Hospitalization (days)
1	19.7	18	83	31.6	1,640	+	+	+	+	+	+	147
2	19.9	60	72	30.4	1,560	–	–	–	–	–	–	43
3	20.9	26	54	28.6	1,070	+	+	–	+	–	–	63
4	20.9	45	54	28.6	1,100	+	+	–	+	–	–	74
5	21.0	40	36	30.0	1,720	+	–	–	–	–	–	43
6	21.1	24	53	28.7	1,320	+	+	+	+	–	–	63
7	21.7	26	56	29.7	1,420	+	+	+	+	+	–	54
8	21.7	47	56	29.7	1,580	–	–	–	–	+	–	46
9	22.0	56	60	30.6	920	+	+	+	–	–	–	157
10	22.1	0	25	25.7	930	+	–	–	–	–	+	84
11	23.1	31	18	25.7	900	+	–	–	–	–	+	115
12	23.7	0	20	26.6	790	+	–	–	–	–	+	108
13	23.9	69	74	34.4	2,580	–	–	–	–	–	–	6

Abbreviations: GA, gestational age; MVP, maximum vertical pocket; BPD, bronchopulmonary dysplasia.

Table 5.

Correlation Coefficient between Perinatal Parameters and Latent Period

Perinatal parameters	Latent	period
Perinatal parameters	r	P-value
GA at membrane rupture (weeks)	–0.501	0.015
MVP at membrane rupture (mm)	0.327	0.128
GA at delivery (weeks)	0.903	<0.001
Birth weight (g)	0.785	<0.001
5-minutes Apgar score	0.135	0.540

Abbreviations: GA, gestaitonal age; MVP, maximum vertical pocket.

Table 6.

Maternal and Neonatal Outcomes Associated with Latent Period from Membrane Rupture to Delivery

Outcomes	Relative risk (95% CI)	P-value
Maternal	0.968 (0.926–1.012)	0.147
Clinical chorioamnionitis	0.968 (0.926–1.012)	0.147
Histologic chorioamnionitis	1.005 (0.965–1.047)	0.795
Maternal sepsis	0.952 (0.870–1.041)	0.281
Retained placenta necessitating curettage	1.056 (0.975–1.145)	0.182
Neonatal
Clinical pulmonary hypoplasia	1.028 (0.987–1.071)	0.189
Air leak syndrome	1.028 (0.983–1.076)	0.223
Persistent fetal circulation	1.031 (0.987–1.077)	0.167
Perinatal death at postnatal 7 days	0.958 (0.896–1.026)	0.221
Early onset sepsis	1.023 (0.977–1.072)	0.335
Overall mortality in NICU	0.898 (0.827–0.976)	0.011

Abbreviations: CI, confidence interval; NICU, neonatal intensive care unit.

TOOLS

Similar articles