Premature rupture of the membranes is the leaking of amniotic fluid from around the fetus at any time before labor starts. If labor does not begin within 6 to 12 hours, the risk of infections in the woman and fetus increases. If the pregnancy is less than 32 weeks, women may be given magnesium sulfate to reduce the risk of cerebral palsy. The flow varies from a trickle to a gush. As soon as the membranes have ruptured, a woman should contact her doctor or midwife.
Some taxa, detected by PCR, have been previously reported in the gastrointestinal tract e. Thomson, A. Gynecol Obstet Invest. In a case-control study, the minor C allele was found to be protective against PPROM, consistent with its reduced promoter function [ 58 ]. The separation of the amnion from choriodecidua occurs as an integral part of the FM rupture process [ 49 ].
History of centering pregnancy. Introduction
It is thought to occur in 0. In this case, either watchful waiting at home or an induction of labor done. The longer it takes for labor to start, the greater your chance of getting an infection. Browse the Encyclopedia. You will also receive antibiotics to help prevent infections. This can lead to chorioamnionitis an infection of the fetal membranes and amniotic fluid which can be life-threatening to both the mother and fetus. Fetal membranes likely break because they become weak and fragile. However, this can be a problem when it occurs before 37 weeks preterm. When the fetus is 34 to 37 weeks gestation, the risk of being born prematurely must Fetal google membranes premature rupture weighed against the risk of PROM. If the water breaks before the 37th week of pregnancy, it is called preterm premature rupture of membranes PPROM. Slips and stockings, in cases of preterm PROM, amniotic fluid will stop leaking and the amniotic fluid volume will return to normal.
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- Rupture of membranes ROM is one of the most common complications of pregnancy.
- Prelabor rupture of membranes PROM , previously known as premature rupture of membranes , is breakage of the amniotic sac before the onset of labor.
- It is thought to occur in 0.
- Amniotic fluid is the water that surrounds your baby in the womb.
Help us improve our products. Sign up to take part. A Nature Research Journal. Preterm premature rupture of membranes PPROM is associated with an increased risk of serious maternal, fetal, and neonatal morbidities. Neonatal outcomes were compared between the two groups using logistic regression. A second analysis was performed to compare inpatient care and effective outpatient care discharge from hospital through propensity score matching.
The outcome was a neonatal composite variable including one or more of the neonatal morbidity complications. The perinatal composite outcome was After using the ratio propensity score matching, effective outpatient care was not associated with a significantly higher risk of the perinatal composite outcome OR 0.
Outpatient care is not associated with an increased rate of obstetric or neonatal complications and can be an alternative to hospital care for women with uncomplicated PPROM. PPROM is associated with an increased risk of serious maternal, fetal, and neonatal morbidities, especially the risks of preterm delivery, and infectious complications such as chorioamnionitis, sepsis and neonatal infection 1 , 7 , 8 , 9 , However, this practice is controversial because deliveries at home have been reported Moreover, obstetricians fear not managing fast enough serious complications such as home delivery, cord prolapse and placental abruption in an outpatient policy There is currently no guideline concerning outpatient or inpatient management.
In recent years, some centers have evaluated outpatient care management in PPROM and suggested that it is an acceptable option with comparable maternal and neonatal outcomes 14 , 15 , 16 , However, those retrospective studies had limitations, such as small sample size 18 to 61 patients and comparison of care within the same center, which increases the risk of selection bias.
The Cochrane review on outpatient versus hospital care following PPROM includes two randomized trials with a total of women It concluded that outpatient care is associated with fewer days in hospital and less cost.
As a comparison of different center policies has never been performed, we opted for this study design in order to limit the risk of bias. Our aim was therefore to compare neonatal outcomes for women with PPROM before 34 WG, firstly according to their management policies - inpatient and outpatient care - and secondly between inpatients and effective outpatients discharge from hospital.
This retrospective study was carried out in six French tertiary care referral centers. The study was conducted over a 4-year period between January 1, and December 31, Women were identified through the electronic database of each center.
Data were then collected from obstetric and neonatal hospitalization reports. Exclusion criteria were twin pregnancies, cases with fetal abnormalities conditioning prognosis and women who delivered in another maternity unit. Gestational age was determined using the routine ultrasound examination performed in the first trimester. A patient eligible for outpatient care was discharged from the second day of hospitalization with the following management: daily fetal cardiotocography, a laboratory blood sample twice a week and a weekly clinical and ultrasound exam.
In the ICP group, the same protocol was applied, but the patient was not discharged until delivery. Antibiotic therapy was amoxicillin in five centers and cefotaxime in one center. All patients were managed expectantly until spontaneous labor, signs of chorioamnionitis, fetal heart rate anomalies, or acute complications placental abruption, cord prolapse. If not delivered at 37 WG, induction of labor or cesarean section was performed. Data upon admission were collected: gestational age at PPROM, vaginal bacterial culture, maternal serum levels of inflammatory markers C-reactive protein and white blood cell count 21 , fetal presentation, and amount of amniotic fluid evaluated by the single deepest pocket.
In centers reporting an OCP, inpatient or outpatient care following the initial period in hospital and duration of hospitalization were collected. Other neonatal outcomes included birth weight, gestational age at birth, and Apgar scores. Other obstetric outcomes included gestational age at delivery, latency duration i. Post-partum endometritis was defined by the association of fever with foul lochia or a painful uterus at mobilization. Firstly, outcomes were compared according to the management policy of the center.
Other variables were compared using the chi-square test and the Fisher exact test, where appropriate. Continuous variables are expressed as mean and standard deviation or median and interquartile range and categorical variables as percentages. All tests were two-sided at a significance level of 0. Neonatal morbidity and mortality were compared using a univariate logistic regression.
Secondly, neonatal outcomes were compared between inpatients and effective outpatients using propensity score matching.
In our study, propensity score is the probabilistic measure that reflects the propensity of the patient, based on other characteristics, to have outpatient management. For each group, the propensity to have outpatient management was calculated using multivariate logistic regression with outpatient as the dependent variable and all available patient characteristics as the independent variables.
So, propensity score is used to reduce confounding variables and thus includes variables thought to be related to both outpatient management and outcome. Effective outpatient was the actual discharge from hospital because some patients were candidates for outpatient management but were not discharged from hospital for various reasons.
This statistical strategy was used to minimize the effects of covariables related to differences in the two groups of patients The analysis was based on propensity score matching with a matching algorithm without replacement. The ORs for neonatal morbidity early neonatal infection with sepsis, respiratory distress syndrome, bronchopulmonary dysplasia at discharge, grade 3 or 4 intraventricular hemorrhage, and necrotizing enterocolitis and mortality were analyzed in the matched sample.
The need to obtain informed consent was waived by the ethics committee. An information sheet explained the purpose and the design of the study to the patients.
The original identification of each patient in the database has been encrypted and replaced with surrogate identification. All methods were performed in accordance with the relevant guidelines and regulations. During the study period, 74, patients were delivered in the six maternity units. Twenty-nine patients 4. In the centers with outpatient care, the effective rate of outpatient was The rate of sonographic anhydramnios and median cervical length was similar in the two groups.
Initial duration of hospitalization was significantly higher for ICP: There was no difference in the neonatal composite outcome between the two groups: The chorioamnionitis rate was similar in the two groups: There was no difference concerning intrauterine death, placental abruption, maternal sepsis, or endometritis rates between the two groups.
Propensity scores among the 66 patients in the effective outpatient care group and the in the inpatient group were calculated. They take into account the possible criteria for in- or outpatient management. Gestational age at birth was not considered in the models because it can be a result of management.
Mean propensity score and covariates were balanced across in- and outpatients. Thus, the quality of the matching was acceptable. Each effective outpatient is matched only with control inpatients whose propensity score is within a predefined neighborhood of the propensity score of the outpatient.
Therefore, patients could be matched, with 66 in each group, inpatients and outpatients. After propensity score matching, in the matched sample with a ratio propensity score, the risk of neonatal morbidity assessed using the composite criteria among inpatients was comparable to the risk among effective outpatients OR 0.
In addition, the risk of chorioamnionitis was comparable in the two groups OR 0. Risks of prolapse cord and placental abruption were no longer significantly different between the two groups. Severe acute complications such as placental abruption, cord prolapse or intrauterine death in centers were not more frequent with an outpatient policy. After propensity score matching, the risk of neonatal morbidity and neonatal sepsis was not increased for patients receiving outpatient care.
Three retrospective studies have shown that maternal outcomes chorioamnionitis, mode of delivery and neonatal outcomes hospitalization in intensive care units, respiratory distress syndrome, intraventricular hemorrhage were comparable between outpatients and inpatients, but these studies suffer from selection bias 14 , 27 , 28 , Indeed, most of the women in outpatient care were different from inpatients because of specific eligibility criteria with better prognostic factors.
Furthermore, two studies were conducted in a single center with small sample sizes 14 , The Cochrane review reported data from two randomized trials with a total of patients 55 patients in Carlan et al. These trials compared neonatal and maternal morbidity and perinatal mortality between planned outpatient and inpatient care in patients with PPROM before 37 WG. The risk of neonatal morbidity and mortality was not increased for outpatients.
But the trials did not have sufficient statistical power to detect meaningful differences between inpatient and outpatient groups The risk of acute complications such as placental abruption and cord prolapse was suggested as the main argument for the need for inpatient management Ellestad et al. They concluded that because of the obstetric emergency or the premature birth of a child, being at home could have prevented adequate and sufficiently rapid care in a gestational age-appropriate center This is not in agreement with our results, which show that placental abruption rate was similar in the two groups and that the cord prolapse rate was significantly higher in the ICP.
However, after propensity score matching, these differences were no longer significant. One of the strengths of our study is that it relates to a large sample of patients with PPROM with a non-selected population and a low rate of loss to follow-up 4. The patients lost to follow-up gave birth in another maternity hospital, which could be the one where they were initially managed.
The study design consisted of two complementary analyses. Firstly, we opted for an original study design with comparison of center policies.
The center policy was applied to all patients in the centers even if effective outpatient care concerned only Secondly, we compared effective outpatients with inpatients using propensity score matching. This strategy reduces selection bias due to nonrandom outpatient care assignment in the case of our observational data.
Our study, though, has several limitations. Its multicenter nature allowed for large enrollment but induced differences in management.
Differences in protocol mainly involved the administration of tocolysis for centers with an inpatient policy, as well as the type of antibiotic therapy administered.
Fetal google membranes premature rupture. Why Does PROM Happen?
Electronic address: hugo. If cervical assessment appears necessary, speculum, digital examination or cervical ultrasound may be performed Professional consensus. It is recommended to limit cervical evaluation regardless of the method used Professional consensus. Initial ultrasound is recommended to determine the fetal presentation, locate the placenta, estimate the fetal weight and the residual amniotic fluid volume Professional consensus.
Performing vaginal and urinary bacteriological sampling at admission is recommended before any antibiotic Professional consensus. In the case of positive vaginal culture, an antibiogram is necessary since it can guide antibiotherapy in the case of IUI and early onset neonatal bacterial sepsis Professional consensus. In absence of demonstrated neonatal benefit, there is insufficient evidence to recommend or to not recommend initial tocolysis in PPROM Grade C. If tocolysis was administered, it is recommended not to prolong it for more than 48hours Grade C.
Antenatal corticosteroid administration is recommended before 34 weeks of gestation WG Grade A and magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 WG Grade A. Vitamin supplementation vitamins C and E is not recommended Professional consensus , and it is recommended not to impose strict bed rest in case of PPROM Professional consensus. In case of clinical signs of IUI with cerclage, it is recommended to remove the cerclage immediately Professional consensus.
The home care management of clinically stable PPROM after 48hours of hospital observation can be considered Professional consensus.
The main objectives of the management are the detection and medical care of maternal and fetal complications. All rights reserved.