Expectant management of PPROM until 36 weeks reduced neonatal morbidity without increasing chorioamnionitis

AbstractAim:To assess the contemporary maternal and neonatal outcomes following expectant management of preterm premature rupture of membranes (PPROM) prior to 24 weeks’ gestation and to identify prognostic indicators of this morbid presentation.Methods:We performed a systematic review in the Pubmed and EMBASE databases to identify the primary (perinatal mortality, severe neonatal morbidity and serious maternal morbidity) and secondary (neonatal survival and morbidity) outcomes following expectant management of previable PPROM.Results:Mean latency between PPROM and delivery ranged between 20 and 43 days. Women with PPROM <24 weeks had an overall live birth rate of 63.6% and a survival-to-discharge rate of 44.9%. The common neonatal morbidities were respiratory distress syndrome, bronchopulmonary dysplasia and sepsis. The majority of neonatal deaths within 24 h post birth were associated with pulmonary hypoplasia, severe intraventricular haemorrhage and neonatal sepsis. The common maternal outcomes were chorioamnionitis and caesarean sections. The major predictors of neonatal survival were later gestational age at PPROM, adequate residual amniotic fluid levels, C-reactive protein <1 mg/dL within 24 h of admission and PPROM after invasive procedures.Conclusion:Pregnancy latency and neonatal survival following previable PPROM has improved in recent years, although neonatal morbidity remains unchanged despite recent advances in obstetric and neonatal care. There is heterogeneity in management practices across centres worldwide.

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727: Neonatal morbidity and mortality associated with induction of labor at 39 weeks versus expectant management

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2019.11.741 ◽

2020 ◽

Vol 222 (1) ◽

pp. S460-S461

Author(s):

Sabrina Burn ◽

Ruofan Yao ◽

Jordan Rossi ◽

Maria Diaz ◽

Stephen Contag

Keyword(s):

Expectant Management ◽

Neonatal Morbidity ◽

Induction Of Labor ◽

Morbidity And Mortality

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A study on the obstetric outcome in preterm pre-labour rupture of membranes

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20205411 ◽

2020 ◽

Vol 10 (1) ◽

pp. 78

Author(s):

Anusree Saraswathy ◽

Ajitha Ravindran ◽

Jayshree V. Vaman ◽

C. Nirmala

Keyword(s):

Neonatal Sepsis ◽

Early Onset ◽

Tertiary Care ◽

Expectant Management ◽

Neonatal Morbidity ◽

Fetal Distress ◽

Postnatal Period ◽

Neonatal Deaths ◽

Management Scheme ◽

Gestational Age At Delivery

Background: The major risks to the baby following preterm pre-labour rupture of membranes (PPROM) are related to the complications of prematurity. Since the goal of management in PPROM is prolongation of pregnancy, the most commonly accepted management scheme for the patient less than 34 weeks is expectant management in the hospital which consists of careful observation for signs of infection, labour or fetal distress in an effort to gain time for fetal growth and maturation.Methods: Patients admitted in Obstetrics and Gynaecology Department SAT Hospital, Medical College Trivandrum, Kerala with PPROM meeting the inclusion and exclusion criteria were recruited for the study. They were followed in the antenatal, intrapartum and postnatal period and the babies were also followed in the postnatal ward. The maternal and neonatal outcome were analysed and studied.Results: Maternal chorioamnionitis developed in 12.1% of cases, abruption 1.7%, puerperal pyrexia 8.8%, early onset neonatal sepsis in 22.9% of cases, congenital pneumonia in 17% cases and neonatal deaths in 6.3% of cases. The mean gestational age at delivery in this study was 33.42 weeks with majority of cases delivering between 32-34 weeks.Conclusions: The study suggests that maternal chorioamnionitis, puerperal pyrexia, congenital pneumonia, early onset neonatal sepsis, neonatal death, and requirement for ICU care occur with increased frequency in cohorts with PPROM. The present study concluded that most common maternal morbidity associated with PPROM was chorioamnionitis, that of neonatal morbidity was prematurity and its complications. A team effort by the obstetrician and neonatologist in a tertiary care setting can ensure healthy and fruitful life for the mother and her baby.

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A comparative study of feto-maternal outcome in expectant management versus active management in pre-labor rupture of membranes at term

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20175836 ◽

2017 ◽

Vol 7 (1) ◽

pp. 146

Author(s):

Savitha T. S. ◽

Pruthvi S. ◽

Sudha C. P. ◽

Vikram S. Nadig

Keyword(s):

Caesarean Section ◽

Maternal Morbidity ◽

Caesarean Section Rate ◽

Mode Of Delivery ◽

Expectant Management ◽

Neonatal Morbidity ◽

Neonatal Infection ◽

Induction Of Labour ◽

Active Management ◽

Induction Group

Background: Premature rupture of the membranes at term is spontaneous rupture of the membranes after 37 weeks of gestation and before the onset of the regular painful uterine contractions, complicates 5-10% of pregnancies, 80% of cases of PROM occur at term. It complicates the pregnancy leading to maternal and fetal complications, immediate risks such as cord prolapse, cord compression and placental abruptions, and later risks such as maternal or neonatal infection and the interventions such as caesarean section and instrumental vaginal delivery. These cases are either managed conservatively or by immediate induction of labour. Objective of present study is to compare the efficacy and safety of induction of labor versus expectant management at term PROM, in terms of maternal and fetal outcome.Methods: A randomized control trial of 100 women coming to KIMSH from 01 /04 /2015 to 01 /05 /2016 with PROM at term with duration of leak ≤6 hours and a Bishop score ≤5 were assigned to group A immediate induction group and group B expectant management group with 50 cases in each group.Results: The mean interval from PROM to delivery was significantly shorter in the induction Group 15.62±4.97 as compared with expectant group 17.58±4.78. Incidence of maternal morbidity and neonatal morbidity was comparable in both the groups. Intrapartum complications and mode of delivery were similar in both groups.Conclusions: Immediate induction of labour in cases of PROM at term using oral misoprostol resulted in shorter induction delivery interval and hospital stay. Maternal morbidity and neonatal morbidity was comparable in both groups. It is concluded that immediate induction is better than expectant management. With active management many patients delivered vaginally within 24 hours without increase in the Caesarean section rate and decreased the need for oxytocin augmentation.

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Induction of labour at 41 weeks or expectant management until 42 weeks: A systematic review and an individual participant data meta-analysis of randomised trials

PLoS Medicine ◽

10.1371/journal.pmed.1003436 ◽

2020 ◽

Vol 17 (12) ◽

pp. e1003436

Author(s):

Mårten Alkmark ◽

Judit K. J. Keulen ◽

Joep C. Kortekaas ◽

Christina Bergh ◽

Jeroen van Dillen ◽

...

Keyword(s):

Perinatal Outcome ◽

Primary Outcome ◽

Meta Analysis ◽

Perinatal Outcomes ◽

Expectant Management ◽

Neonatal Morbidity ◽

Individual Participant Data ◽

Nulliparous Women ◽

Multiparous Women ◽

Individual Participant

Background The risk of perinatal death and severe neonatal morbidity increases gradually after 41 weeks of pregnancy. Several randomised controlled trials (RCTs) have assessed if induction of labour (IOL) in uncomplicated pregnancies at 41 weeks will improve perinatal outcomes. We performed an individual participant data meta-analysis (IPD-MA) on this subject. Methods and findings We searched PubMed, Excerpta Medica dataBASE (Embase), The Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsycINFO on February 21, 2020 for RCTs comparing IOL at 41 weeks with expectant management until 42 weeks in women with uncomplicated pregnancies. Individual participant data (IPD) were sought from eligible RCTs. Primary outcome was a composite of severe adverse perinatal outcomes: mortality and severe neonatal morbidity. Additional outcomes included neonatal admission, mode of delivery, perineal lacerations, and postpartum haemorrhage. Prespecified subgroup analyses were conducted for parity (nulliparous/multiparous), maternal age (<35/≥35 years), and body mass index (BMI) (<30/≥30). Aggregate data meta-analysis (MA) was performed to include data from RCTs for which IPD was not available. From 89 full-text articles, we identified three eligible RCTs (n = 5,161), and two contributed with IPD (n = 4,561). Baseline characteristics were similar between the groups regarding age, parity, BMI, and higher level of education. IOL resulted overall in a decrease of severe adverse perinatal outcome (0.4% [10/2,281] versus 1.0% [23/2,280]; relative risk [RR] 0.43 [95% confidence interval [CI] 0.21 to 0.91], p-value 0.027, risk difference [RD] −57/10,000 [95% CI −106/10,000 to −8/10,000], I2 0%). The number needed to treat (NNT) was 175 (95% CI 94 to 1,267). Perinatal deaths occurred in one (<0.1%) versus eight (0.4%) pregnancies (Peto odds ratio [OR] 0.21 [95% CI 0.06 to 0.78], p-value 0.019, RD −31/10,000, [95% CI −56/10,000 to −5/10,000], I2 0%, NNT 326, [95% CI 177 to 2,014]) and admission to a neonatal care unit ≥4 days occurred in 1.1% (24/2,280) versus 1.9% (46/2,273), (RR 0.52 [95% CI 0.32 to 0.85], p-value 0.009, RD −97/10,000 [95% CI −169/10,000 to −26/10,000], I2 0%, NNT 103 [95% CI 59 to 385]). There was no difference in the rate of cesarean delivery (10.5% versus 10.7%; RR 0.98, [95% CI 0.83 to 1.16], p-value 0.81) nor in other important perinatal, delivery, and maternal outcomes. MA on aggregate data showed similar results. Prespecified subgroup analyses for the primary outcome showed a significant difference in the treatment effect (p = 0.01 for interaction) for parity, but not for maternal age or BMI. The risk of severe adverse perinatal outcome was decreased for nulliparous women in the IOL group (0.3% [4/1,219] versus 1.6% [20/1,264]; RR 0.20 [95% CI 0.07 to 0.60], p-value 0.004, RD −127/10,000, [95% CI −204/10,000 to −50/10,000], I2 0%, NNT 79 [95% CI 49 to 201]) but not for multiparous women (0.6% [6/1,219] versus 0.3% [3/1,264]; RR 1.59 [95% CI 0.15 to 17.30], p-value 0.35, RD 27/10,000, [95% CI −29/10,000 to 84/10,000], I2 55%). A limitation of this IPD-MA was the risk of overestimation of the effect on perinatal mortality due to early stopping of the largest included trial for safety reasons after the advice of the Data and Safety Monitoring Board. Furthermore, only two RCTs were eligible for the IPD-MA; thus, the possibility to assess severe adverse neonatal outcomes with few events was limited. Conclusions In this study, we found that, overall, IOL at 41 weeks improved perinatal outcome compared with expectant management until 42 weeks without increasing the cesarean delivery rate. This benefit is shown only in nulliparous women, whereas for multiparous women, the incidence of mortality and morbidity was too low to demonstrate any effect. The magnitude of risk reduction of perinatal mortality remains uncertain. Women with pregnancies approaching 41 weeks should be informed on the risk differences according to parity so that they are able to make an informed choice for IOL at 41 weeks or expectant management until 42 weeks. Study Registration: PROSPERO CRD42020163174

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EARLY ONSET PREECLAMPSIA: MATERNALAND PERINATAL OUTCOME

10.36106/ijsr/5233163 ◽

2020 ◽

pp. 1-4

Author(s):

Debika Biswas ◽

Shalini Gainder ◽

Debarshi Jana

Keyword(s):

Early Onset ◽

Perinatal Outcome ◽

Expectant Management ◽

Neonatal Morbidity ◽

Fetal Outcome ◽

Clinical Syndrome ◽

Primary Objective ◽

Maternal Complications ◽

Early Presentation ◽

Early Onset Preeclampsia

Preeclampsia is a heterogeneous clinical syndrome which is a leading cause of maternal, fetal, and neonatal morbidity and mortality. The aim of the study evaluate the maternal and fetal outcome in women with diagnosis of early onset preeclampsia. The present study was conducted with the primary objective to study the maternal, fetal and neonatal outcome among women diagnosed with early onset of preeclampsia without severe feature and with severe features. The overall outcome in women where pregnancies were continued after giving Mgso4 therapy were also studied. This was a prospective hospital based study in which 119 pregnant women were enrolled from emergency ward (labour room) who were diagnosed to have early onset preeclampsia at less than 32 weeks of gestation. Women with early onset preeclampsia were given expectant management and the maternal and perinatal outcome in women were reviewed as per severity that is whether PE occurred with or without severe features. The maternal complications did not increase in women who received expectant management in women with PE with severe features, as well as the group which had received prophylactic Mgso4 therapy and in whom subsequently pregnancy continued for few days to weeks. The perinatal outcome was compromised because of early presentation of PE which probably causes the placental insufficiency even in women without severe features. Significant number of days gained during expectant management has an impact on the perinatal outcome which was from few days to weeks in this study.

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The impact of labor induction at 39 weeks gestation compared with expectant management on maternal and neonatal morbidity in low-risk women: A United States of America Cohort Study

10.22541/au.160915266.65778062/v1 ◽

2020 ◽

Author(s):

Sabrina Burn ◽

Ruofan Yao ◽

Maria Diaz ◽

Jordan Rossi ◽

Stephen Contag

Keyword(s):

Cohort Study ◽

Expectant Management ◽

Neonatal Morbidity ◽

Induction Of Labor ◽

P Value ◽

Cesarean Hysterectomy ◽

Management Group ◽

Induction Group ◽

Prolonged Ventilation ◽

Nicu Admission

Objective: To determine maternal and neonatal morbidity associated with induction of labor at 39 weeks compared with expectant management through 42 weeks. Design: Cohort study Setting & Population: Low risk American women who delivered between 39 and 42 weeks in 2015 to 2017. Methods: Data was abstracted from the national vital statistics database. Multivariable log-binomial regression analysis was conducted to estimate the relative risk of morbidity. Main Outcome Measures: Maternal morbidity included Triple I, blood transfusion, ICU admission, uterine rupture, cesarean hysterectomy, and cesarean delivery. Neonatal morbidity included 5 minute Apgar ≤3, prolonged ventilation, seizures, NICU admission, and neonatal death. Results: A total of 1,885,694 women were included for analysis. Women undergoing induction of labor at 39 weeks were less likely to develop Triple I (p-value < 0.001; aRR 0.66; 95% CI [0.64-0.68]) and require a cesarean section (p-value <0.01; aRR 0.69l 95% CI [0.68-0.69]) than the expectant management group. There was a small, but significant increase in cesarean hysterectomy in the induction group (p-value <0.01; aRR 1.32; 95% CI [1.05-1.65]). Neonates of the induction group were less likely to have 5 minute Apgar ≤3 (p-value < 0.01; aRR 0.69; 95% CI [0.64-0.74]), prolonged ventilation (p-value < 0.01; aRR 0.77; 95% CI [0.72-0.82]), NICU admission (p-value < 0.01; aRR 0.80; 95% CI [0.79-0.82]), and/or neonatal seizures (p-value <0.01; aRR 0.80; 95% CI [0.66-0.98]) compared to the expectant management group. Conclusions: Induction of labor at 39 weeks gestation compared with expectant management is not harmful and has maternal and neonatal benefits.

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Outcomes before and after Adopting Guidelines for Expectant Management of Severe Preeclampsia

American Journal of Perinatology ◽

10.1055/s-0040-1714677 ◽

2020 ◽

Author(s):

Aalok R. Sanjanwala ◽

Victoria C. Jauk ◽

Gabriella D. Cozzi ◽

David A. Becker ◽

Lorie M. Harper ◽

...

Keyword(s):

Age Groups ◽

Perinatal Outcomes ◽

Expectant Management ◽

Neonatal Morbidity ◽

Severe Preeclampsia ◽

Trend Test ◽

Chi Square ◽

Before And After ◽

Armitage Trend Test ◽

Student’S T

Objective This study aimed to compare maternal and neonatal outcomes in women with severe preeclampsia before and after implementation of the American College of Obstetricians and Gynecologists (ACOG) taskforce hypertensive guidelines. Study Design Single-center retrospective cohort study of women with severe preeclampsia delivering live nonanomalous singletons 23 to 342/7 weeks from 2013 to 2017. In 2015, the ACOG guidelines for expectant management of severe preeclampsia were implemented at our institution. Based on this, patients were categorized as preguideline (January 2013–December 2015) or postguideline adoption (January 2016–December 2017). Primary outcomes included composite maternal morbidity and composite neonatal morbidity; secondary outcomes included composite components, length of stay, birth weight, and delivery gestational age. Groups were compared with Student's t-test, Chi-square, and Wilcoxon's rank-sum tests; adjusted odds ratios (aOR; 95% confidence intervals [CIs]) were calculated. Yearly composite outcomes were compared using the Cochran–Armitage trend test. We estimated a sample size of 250 per group would provide 80% power at α = 0.05 to detect a 50% reduction in neonatal morbidity from a baseline rate of 21.5%. Results From 2013 to 2017, a total of 543 women with severe preeclampsia were identified: 278 (51%) preguideline and 265 (49%) postguideline. Baseline characteristics were overall similar between groups. There were no significant differences in maternal (aOR = 0.96, 95% CI: 0.6–1.41) or neonatal (aOR = 0.88, 95% CI: 0.61–1.28) composite morbidity between groups. Furthermore, there were no differences in composite maternal or neonatal morbidity over time. Conclusion Perinatal outcomes were similar before and after implementation of severe preeclampsia management guidelines at our institution. Studies to evaluate if benefits are limited to subsets of this population, such as earlier gestational ages, are needed. Key Points

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Preterm Prelabor Rupture of Membranes: Outcomes with Expectant Management until 34 versus 35 Weeks

American Journal of Perinatology ◽

10.1055/s-0038-1675647 ◽

2018 ◽

Vol 36 (07) ◽

pp. 659-668

Author(s):

Tara A. Lynch ◽

Courtney Olson-Chen ◽

Sarah Colihan ◽

Jeffrey Meyers ◽

Conisha Holloman ◽

...

Keyword(s):

Neonatal Sepsis ◽

Neonatal Intensive Care ◽

Expectant Management ◽

Neonatal Morbidity ◽

Estimating Equation ◽

Antibiotic Administration ◽

Fetal Demise ◽

Maternal Sepsis ◽

Nicu Admission ◽

Prelabor Rupture Of Membranes

Objective To evaluate outcomes with expectant management of preterm prelabor rupture of membranes (PROM) until 35 weeks versus immediate delivery at ≥34 weeks. Study Design This was a multicenter retrospective cohort study of singletons with preterm PROM at >20 weeks from 2011 through 2017. Groups were defined as expectant management until 35 weeks versus immediate delivery at ≥34 weeks. Primary outcome was composite neonatal morbidity: need for respiratory support, culture positive neonatal sepsis, or antibiotic administration for >72 hours. Univariate and general estimating equation models were used with p < 0.05 considered significant. Results A total of 280 mother–infant dyads were included. There was no difference in composite neonatal outcome in pregnancies managed with expectant management compared with immediate delivery (43.4 vs. 37.5%; p = 0.32). Those with expectant management had shorter length of neonatal intensive care unit (NICU) admission but higher rates of neonatal antibiotics for > 72 hours, endometritis, and histological chorioamnionitis. There were no cases of fetal demise, neonatal death, or maternal sepsis, and only three cases of neonatal sepsis. Conclusion There is no difference in composite neonatal morbidity in pregnancies with preterm PROM managed with expectant management until 35 weeks as compared with immediate delivery at 34 weeks. Expectant management is associated with a decreased length of NICU admission but increased short-term infectious morbidity.

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An Analysis of Factors Affecting the Duration of Latency Period and Its Impact on Neonatal Outcome in Patients with PPROM

International Journal of Infertility & Fetal Medicine ◽

10.5005/jp-journals-10016-1048 ◽

2012 ◽

Vol 3 (3) ◽

pp. 87-91 ◽

Cited By ~ 1

Author(s):

Manju Puri ◽

Neha Gami ◽

Seema Singhal

Keyword(s):

Gestational Age ◽

Neonatal Outcome ◽

Latency Period ◽

Expectant Management ◽

Neonatal Morbidity ◽

Inverse Association ◽

Prognostic Information ◽

Factors Affecting ◽

Time Of Presentation ◽

Singleton Pregnancies

ABSTRACT Introduction Preterm premature rupture of membranes (PPROM) complicates approximately 3% of all births, but accounts for 30% of neonatal morbidity and mortality among premature gestations. Prediction of latency period for women with PPROM is imprecise and therefore consulting women with PPROM about their predicted latency period is a difficult task. The studies are limited, thus more information is required to support clinical decisions and to provide prognostic information in cases of expectant management following PPROM. Materials and methods We conducted a prospective observational study of women with singleton pregnancies presenting with rupture of membranes. A total of 120 women presenting with PPROM from 26 to 36 weeks with rupture of membrane were included in this study. Results Advanced maternal age >30 years was found to be associated with prolongation of latency period (p = 0.000). Nulliparity was found to be associated with shortening of latency period (p = 0.012). An inverse association between gestational age at the time of presentation and latency period was established. The average gain in duration of latency period by not doing a digital examination was found to be statistically significant (p = 0.000). Gestational age and duration of latency period were found to be the important predictors of neonatal outcome. Conclusion In the current study, several predictive factors were identified which affect the duration of the latency period in cases of PPROM. This information may assist clinician in risk stratification and in providing consultation regarding the natural course of expectant management for women presenting with PPROM. How to cite this article Singhal S, Puri M, Gami N. An Analysis of Factors Affecting the Duration of Latency Period and Its Impact on Neonatal Outcome in Patients with PPROM. Int J Infertility Fetal Med 2012;3(3):87-91.

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