Survival and 2-year outcome with expectant management of second-trimester rupture of membranes

doi:10.1016/S0029-7844(98)00287-7

Obstetrics & Gynecology

Volume 92, Issue 6, December 1998, Pages 895-901

https://doi.org/10.1016/S0029-7844(98)00287-7 Get rights and content

Abstract

Objective: To evaluate the perinatal and 2-year outcomes in pregnancies complicated by preterm premature rupture of membranes (PROM) during the second trimester.

Methods: Fifty-three consecutive singleton pregnancies with PROM at 14 to 28 weeks of gestation were studied retrospectively. Management goals were to prolong the pregnancies to 32 weeks through expectant management and to avoid fetal compromise through closer monitoring and active intervention, when necessary, after 23 weeks. Outcome of the surviving infants was based on neurologic, audiometric, and ophthalmologic examinations at 2 years of corrected age.

Results: Rupture of membranes occurred at 14–19 weeks (mean 17.4 weeks) in 10 women, at 20–25 weeks (mean 24.0 weeks) in 24, and at 26–28 weeks (mean 27.6 weeks) in 19. The median latency periods to delivery were 72 days, 12 days, and 10 days when rupture of membranes occurred at 14–19 weeks, 20–25 weeks, and 26–28 weeks, respectively. The overall incidence of chorioamnionitis was 28%. There were no fetal deaths and nine neonatal deaths. When rupture of membranes occurred at 14–19 weeks, 20–25 weeks, and 26–28 weeks, the perinatal survival rates were 40%, 92%, and, 100%, respectively. Pulmonary hypoplasia accounted for seven deaths. Of the live-born infants, 81% were alive at 2 years of corrected age. Survival without major impairment was observed in 75%, 80%, and 100% of the survivors when rupture of membranes occurred at 14–19 weeks, 20–25 weeks, and 26–28 weeks, respectively.

Conclusion: Expectant management of second-trimester PROM offers better perinatal and long-term survival than previously thought.

Section snippets

Patients and methods

All women with PROM admitted to Umeå University Hospital, a tertiary care center, between February 1989 and June 1994 were identified. Their obstetric, neonatal, and pediatric records were reviewed. The study population comprised all women in whom PROM occurred between 14 and 28 completed weeks of gestation and who delivered at Umeå University Hospital. Exclusion criteria included amniorrhexis complicated by onset of active labor within 12 hours of rupture of membranes (n = 4), clinical

Results

Table 1 shows obstetric characteristics and outcomes of the 53 mother-infant pairs, divided into three groups according to gestational age at the time of rupture of membranes. All infants delivered between 23 and 32 weeks’ gestation. There was a significant inverse relationship (Figure 1) between length of latency and gestational age at rupture of membranes (r = −.78, P < .001, n = 53).

Fifteen (28%) of 53 women developed chorioamnionitis. The mean ± standard deviation (SD) latency period was

Discussion

Advances in fetal and neonatal care, such as regular use of antenatal steroids, surfactant therapy, more effective ventilation strategies, and improved nutrition, have increased the chances of neonatal survival. Despite existing controversy regarding the management of PROM,1 the approach of expectant management has become realistic. Since the early 1980s, studies have shown successive increase in perinatal survival after preterm PROM. In these studies, perinatal survival with PROM occurring

References (34)

T.J. Garite
Premature rupture of the membranesThe enigma of the obstetrician
Am J Obstet Gynecol
(1985)
S.N. Beydoun et al.
Premature rupture of the membranes before 28 weeksConservative management
Am J Obstet Gynecol
(1986)
M. Moretti et al.
Maternal and perinatal outcome in the premature rupture of membranes in the midtrimester
Am J Obstet Gynecol
(1988)
C.A. Major et al.
Perinatal survival with expectant management of midtrimester rupture of membranes
Am J Obstet Gynecol
(1990)
W.J. Morales et al.
Premature rupture of membranes at <25 weeksA management dilemma
Am J Obstet Gynecol
(1993)
L. Papile et al.
Relationship of cerebral intraventricular hemorrhage and early childhood neurological handicaps
J Pediatr
(1983)
M. Perlman et al.
Secular changes in the outcomes to eighteen to twenty-four months of age of extremely low birth weight infants, with adjustment for changes in risk factors and severity of illness
J Pediatr
(1995)
B.M. Mercer et al.
Antimicrobial therapy in expectant management of preterm premature rupture of membranes
Lancet
(1995)
A.M. Vintzileos et al.
Preterm premature rupture of membranesA risk factor for the development of abruptio placentae
Am J Obstet Gynecol
(1987)
C.A. Major et al.
Preterm premature rupture of membranes and abruptio placentaeIs there an association between these pregnancy complications?
Am J Obstet Gynecol
(1995)

M. Blott et al.

Preterm membrane rupture in pregnancies less than 34 weeks gestation

Early Hum Dev

(1989)

S.F. Bottoms et al.

Obstetric determinants of neonatal survivalInfluence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants

Am J Obstet Gynecol

(1997)

P. Vergani et al.

Risk factors of pulmonary hypoplasia in second trimester premature rupture of membranes

Am J Obstet Gynecol

(1994)

C. Nimrod et al.

The effects of very prolonged membrane rupture of fetal development

Am J Obstet Gynecol

(1984)

D.W. Thibeault et al.

Neonatal pulmonary hypoplasia with premature rupture of fetal membranes and oligohydramnios

J Pediatr

(1985)

E.L. Capeless et al.

Management of preterm premature rupture of membranesLack of national consensus

Am J Obstet Gynecol

(1987)

Multicenter randomized, controlled trial of a preterm birth prevention program

Am J Obstet Gynecol

(1993)

Cited by (82)

Periviable Premature Rupture of Membranes
2020, Obstetrics and Gynecology Clinics of North America
Citation Excerpt :
Of all women who experience periviable PROM, up to 40% develop endometritis.34 Placental abruption complicates a significant proportion of pregnancies with periviable PPROM and is correlated inversely with gestational age at the time of membrane rupture.35 Specifically, a study of PROM between 20 weeks and 24 weeks showed a 17% incidence of placental abruption,24 whereas studies of PROM prior to 20 weeks show a placental abruption rate as high as 50%.
In the case of premature live birth, is very early rupture of the membranes an additional risk factor for morbidity and mortality?
2018, Gynecologie Obstetrique Fertilite et Senologie
Décrire le taux de survie après rupture prématurée des membranes (RPM) avant 25 SA et comparer la morbi-mortalité néonatale parmi les enfants nés vivants avec des enfants nés au même terme sans RPM.
Étude rétrospective, unicentrique, menée à la maternité Port Royal entre 2007 et 2015, comparant les issues néonatales des enfants nés vivants après une RPM survenue avant 25 SA avec un groupe non exposé à la RPM. Chaque enfant né vivant après RPM était apparié avec l’enfant suivant né après travail spontané à membranes intactes sur l’âge gestationnel à la naissance, le sexe et l’administration ou non d’une corticothérapie anténatale. Un critère composite de morbidité néonatale sévère a été défini par la présence d’une ou plusieurs des complications suivantes : rétinopathie stade 3–4, dysplasie bronchopulmonaire, hémorragie intraventriculaire grade 3–4, leucomalacie périventriculaire ou décès.
Sur 77 cas de rupture très prématurée des membranes, 55 enfants sont nés vivants. Parmi les enfants nés vivants, le terme moyen de naissance était de 28 SA et 1 jour. Le taux de morbidité néonatale sévère ne différait pas entre les deux groupes (43,6 % dans le groupe RPM vs. 36,4 %, p = 0,44) et le taux de survie à la sortie de réanimation était également similaire dans les deux groupes (85,5 % vs. 83,6 %, p = 0,98).
Parmi les enfants nés vivants, la RPM avant 25 SA n’est pas associée à une augmentation du risque de morbi-mortalité par rapport à des enfants nés au même terme après travail spontané à membranes intactes.
To describe survival rate after preterm premature rupture of membranes (PPROM) before 25 weeks of gestation and compare neonatal morbidity and mortality among those born alive with a control group of infants born at a similar gestational age without premature rupture of membranes.
We conducted a retrospective single-centre study at Port-Royal maternity, from 2007 to 2015, comparing neonatal outcomes between liveborninfants exposed to PPROM prior to 25 weeks of gestation (WG) and a control group not exposed to premature rupture of the membranes. For each live-born child, the next child born after spontaneous labor without PPROM was matched for gestational age at birth, sex, and whether or not they received antenatal corticosteroid therapy. The primary endpoint was severe neonatal complications assessed by a composite endpoint including neonatal deaths, grade 3–4 HIV, bronchopulmonary dysplasia, leukomalacia and stade 3–4 retinopathies.
Among 77 cases of very premature rupture of the membranes, 55 children were born alive. Among these, the average gestational age at birth was 28 WG and 1 day. The rate of severe neonatal complications did not differ between the two groups (43.6% in the PPROM group vs. 36.4%, P = 0.44) and the survival rate at discharge was also similar in the two groups (85.5% vs. 83.6%, P = 0.98).
In our cohort and among livebirths after 24 WG, PPROM before 25 WG was not associated with an increased risk of morbidity and mortality compared to children born at the same gestational age after a spontaneous labor with intact membranes.
Management and outcomes of pregnancies complicated by preterm premature rupture of membranes before 26 weeks of gestation
2014, Gynecologie Obstetrique et Fertilite
Évaluer le devenir à court terme des grossesses compliquées d’une rupture prématurée des membranes (RPDM) avant 26 semaines d’aménorrhée (SA).
Étude rétrospective incluant 40 patientes prises en charge entre 1998 et 2008.
La moitié des RPDM a eu lieu avant 23 SA. Un pourcentage de 21,4 des enfants ont survécu lorsque la RDPM a eu lieu avant 22 SA versus 54,5 % lorsqu’elle a eu lieu entre 22 et 23 SA + six jours et 80 % après 24 SA (p = 0,006). Les patientes primigestes ont été plus fréquemment confrontées à un décès périnatal (OR = 5,16 ; IC95 %[0,99–36,59]). La réalisation d’un geste invasif avant la RPDM n’a pas modifié le taux de survie. Le tabagisme a induit un raccourcissement de la latence (19,1 ± 13,8 jours vs 40,5 ± 32,3 jours ; p = 0,01). Une chorioamniotite a compliqué toutes les grossesses interrompues avant 26 SA versus 50 % des grossesses après 26 SA (p = 0,02). Soixante-dix pour cent des germes à l’origine d’une chorioamniotite étaient identifiés en anténatal. Les patientes dont la CRP était supérieure à 6 mg/L lors de la RPDM ont eu un taux de mortalité fœtale supérieur (63,6 % vs 27,8 % ; p = 0,02 ; OR = 4,3 ; IC95 %[0,99–22,1]). Il n’a pas été retrouvé de différence significative pour la fréquence de survenue d’une chorioamniotite en fonction de l’âge gestationnel à la rupture, du résultat du prélèvement vaginal à l’admission ou de la quantité de liquide amniotique (LA).
L’âge gestationnel de la RPDM et celui de la naissance restent les facteurs pronostiques majeurs. Les patientes primigestes sont plus exposées au décès périnatal. La CRP apparaît comme un facteur prédictif de décès périnatal.
To evaluate short-term outcomes of pregnancies complicated by preterm premature rupture of membranes (PPROM) before 26 weeks of gestation (wg).
Forty patients were included in a retrospective study from 1998 to 2008.
Fifty percent of PPROM occurred before 23 wg. Survival rate was 21.4% when PPROM occurred before 22 wg versus 54.5% when it occurred between 22 and 23 + 6 wg and reached 80% after 24 wg (P = 0.006). Perinatal mortality affected more frequently primigravida women (OR = 5.16; IC95%[0.99–36.59]). Invasive procedures before PPROM did not affect survival rates. Smoking induced shorter latency (19.1 ± 13.8 vs. 40.3 ± 2.3j; P = 0.01). Chorioamnionitis complicated all pregnancies terminated before 26wg versus 50% of pregnancies terminated after 26 wg (P = 0.02). In case of chorioamnionitis, 70% of the germs were identified prenatally. Patients whose CRP was higher than 6 mg/L at the time of PPROM had a higher fetal mortality rate (63.6% vs. 27.8%; P = 0.02; OR = 4.3; IC95%[0,99–22,1]). No significant difference was found in the occurrence of chorioamnionitis based on gestational age at PPROM, result of the vaginal swab on admission or the amount of amniotic fluid.
The gestational age of PPROM and the one of delivery are the major prognostic factors. Primigravida women are more exposed to perinatal mortality. CRP appears to be a predictive factor of perinatal mortality.
Outcome of pregnancies with preterm prelabor rupture of membranes before 27 weeks' gestation: A retrospective cohort study
2013, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Latency seems related to gestational age at ROM, with early GA at ROM being related to a longer latency. A previous study from Farooqi et al. reports a mean latency period varying from 12 to 72 days [10]. We found a latency period of 25 days.
Preterm prelabor rupture of membranes (PPROM) before 27 weeks’ gestation is associated with severe perinatal complications, but quantitative estimates are lacking. The aim of this study was to report and predict outcomes of pregnancies complicated by early PPROM and to study antepartum risk factors that might predict perinatal death in future patients.
We performed a retrospective cohort study of women with PPROM between 13⁺⁰ weeks and 27⁺⁰ weeks’ gestation between 1994 and 2009 in three perinatal centers.
Perinatal mortality, composite neonatal morbidity and premature delivery. A model to predict these outcomes was developed from antepartum variables.
We identified 314 women with PPROM before 27 weeks, including 28 multiple pregnancies. Six pregnancies (2%) were terminated before 24 weeks’ gestation, and three were lost to follow up, leaving 305 pregnancies for analysis. Overall, there were 166 perinatal deaths (49%). The perinatal mortality rate decreased with increasing gestational age at PPROM (from 70% in the group PPROM 13–20 weeks to 27% in the group PPROM 24–27 weeks). Of the 170 surviving neonates, 70 suffered from serious morbidity (41%). Early gestational age at PPROM, long interval between PPROM and birth and positive vaginal culture (any bacteria) were associated with perinatal mortality.
Perinatal mortality in PPROM before 27 weeks occurred in half of the cases and among those who survive approximately 40% suffered serious morbidity. Antenatal parameters can be helpful to predict perinatal mortality.
Neonatal and two-year outcomes after rupture of membranes before 25 weeks of gestation
2013, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Thus, extremely PPROM appears to be an additional risk factor for neurodevelopmental disorders. Two-year follow-up of infants born after mid-trimester PPROM has been previously reported in two studies flawed by the absence of a matched control group [4,17]. In nine infants born at a mean gestational age of 273/7 weeks and alive at 2 years of corrected age, overall assessment showed one child with severe, one with moderate and one with mild disability.
To assess the impact of extreme preterm premature rupture of membranes (PPROM) <25 weeks of gestation on preterm child outcome.
Retrospective study comparing the neonatal and 2-year outcomes of infants exposed to extremely PPROM <25 weeks with a non-exposed group of neonates in a tertiary care referral centre located in Paris, France, between 2003 and 2007. All women with singleton pregnancy and PPROM between 15^0/7 and 24^6/7 weeks of gestation were recruited. For each infant born alive, the next inborn neonate matched for gestational age and sex was selected as a control among neonates born alive after spontaneous preterm labour with intact membranes. The main outcome measures were neonatal outcome assessed by a combined criterion of adverse neonatal outcomes and the two-year neurodevelopmental outcome assessed by developmental Brunet–Lézine tests and neurological examinations.
In 78 cases of extremely PPROM, 22 live births occurred at a mean gestational age of 26^5/7 weeks. The percentage of neonates with adverse neonatal outcomes was significantly higher among PPROM than non-exposed cases (68.2 versus 27.3%). At 2 years of age, children from the PPROM group were more likely to have delayed acquisitions (64.3 versus 15.8%) and behavioural disorders (57.1 versus 15.8%). Mean Brunet–Lézine language score was significantly lower among those infants (78.9 versus 96.8).
PPROM <25 weeks is associated with increased neonatal mortality and morbidity and with increased risks of delayed acquisitions, behavioural disorders and lower language performance scores at 2 years in comparison with matched preterm neonates born after spontaneous preterm labour with intact membranes.
Use of Atosiban in a Twin Pregnancy With Extremely Preterm Premature Rupture in the Membrane of one Twin: A Case Report and Literature Review
2010, Taiwanese Journal of Obstetrics and Gynecology
Pregnancies with extremely preterm premature rupture of membranes (EPPROM), especially before 20 weeks of gestation, are usually considered to be a termination of pregnancy. By improvement of obstetric and neonatal care, we can prolong the pregnancy across the threshold of survival by aggressive tocolysis.
Using intrauterine insemination, a 32-year-old woman became pregnant with twins (first pregnancy). Threatened abortion occured since 9 weeks of gestation and EPPROM of the upper twin was noted at 18 weeks. Massive vaginal bleeding and vigorous uterine contractions occurred at 22 weeks. Poor control of preterm labor occurred using ritodrine and MgSO₄. Atosiban was applied to calm uterine activities. After discontinuation of atosiban at 30 weeks, the uterine contractions became severe again and an emergency cesarean section was performed to deliver two live, premature babies weighing 1,518 g and 830 g, respectively. Twin A was healthy, weighing 2,030 g at 35 days after birth and subsequently discharged. The smaller twin B was dependent on continuous positive airway pressure and died of pulmonary infection 120 days after birth.
Comparing to other tocolytic agents, Atosiban has few side effects and assisted in prolonging a pregnancy involving twins that experienced EPPROM.

View all citing articles on Scopus

View full text

Original ArticlesSurvival and 2-year outcome with expectant management of second-trimester rupture of membranes

Abstract

Section snippets

Patients and methods

Results

Discussion

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

J Pediatr

J Pediatr

Lancet

Am J Obstet Gynecol

Am J Obstet Gynecol

Early Hum Dev

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

J Pediatr

Management of preterm premature rupture of membranesLack of national consensus

Am J Obstet Gynecol

Multicenter randomized, controlled trial of a preterm birth prevention program

Am J Obstet Gynecol

Original Articles
Survival and 2-year outcome with expectant management of second-trimester rupture of membranes