Conservative management of preterm premature rupture of membranes < 30 weeks of gestational age: Effectiveness of clinical guidelines implementation strategies.

Objective: To compare obstetrical and neonatal outcomes in patients with p-PROM (preterm premature rupture of membranes) at less than 30 weeks of gestational age before and after the application of protocols developed on the basis of international guidelines and to identify local barriers and strategies for their implementation. Study design: Single and twin pregnancies with p-PROM < 30 weeks of gestation without signs of infection were retrospectively collected. The population was divided in two groups. Group A contained patients treated before the introduction of the protocol, hospitalized from the day of the p-PROM to delivery and treated according to clinicians' practice. Group B included patients managed according to a standardized protocol, treated with home care management under strict surveillance, after 48 h of hospitalization. Results: 19 women with 21 newborns in group A and 22 women with 26 newborns in group B were enrolled. Maternal characteristics and p-PROM gestational age were comparable. In group A we observed minor latency time from diagnosis to delivery (1.6 vs 6.5 weeks, p < 0.001) with lower gestational age at delivery (25.8 ± 2 vs 30.7 ± 4.2 weeks, p = 0.00) and lower newborn weight (859 ± 268 vs 1511 ± 917 g, p = 0.002). Concerning neonatal outcomes, in group A there were lower Apgar score at 1 min (4.0 ± 2.1vs 6.3 ± 2, p = 004), longer hospitalization (42 ± 38 vs 68 ± 38 days, p = 0.05) and, even if non statistically significant, major rate of neonatal mortality (11,5% vs 19%, p = 1.00) and of neonatal complications (need of neonatal intensive care unit, sepsis, bronchopulmonary dysplasia, retinopathy of prematurity, mechanical ventilation). Postnatal follow-up showed comparable outcomes at 24 months of correct age. Conclusions: Educational and interdisciplinary meetings, along with group performance audit and standardization of procedures are successful strategies to implement guidelines application. Applying this strategy, we developed a protocol according to international guidelines for the treatment of early onset p-PROM based on a standardized conservative management at home, achieving better results compared to hospital management in terms of latency, gestational age at delivery, neonatal weight and neonatal hospitalization.

Myocardial dysfunction in fetuses exposed to intraamniotic infection: new insights from tissue Doppler and strain imaging.

OBJECTIVE: The purpose of this study was to assess myocardial function of fetuses who were exposed to intraamniotic infection compared with fetuses of uncomplicated pregnancies by the application of tissue Doppler and strain rate (SR) imaging. STUDY DESIGN: We evaluated the right ventricular function of fetuses with preterm premature rupture of membranes and proven intraamniotic infection (n = 12 fetuses) and healthy fetuses (n = 27). Tissue Doppler velocities during early diastolic relaxation (E(m)) and atrial contraction (A(m)) and early diastolic SR were measured as indices of diastolic function, whereas the peak systolic strain and SR were used as parameters of systolic function. RESULTS: Fetuses with intraamniotic infection exhibit impairment in both diastolic and systolic performance, which was characterized by increased diastolic compliance (increased E(m)/A(m) ratio, increased early diastolic SR compared with the control fetuses), decreased systolic contractile function (reduced systolic strain and SR), and longitudinal myocardial dyskinesia. CONCLUSION: New echocardiographic tools suggest that fetal heart is a target organ in the context of intraamniotic infection.

Estrogen receptor (ER) and ER-related receptor expression in normal and atrophic human vagina.

OBJECTIVES: The estrogen level decline in menopausal status is involved in physiological alterations of different human tissues including vaginal mucosa. In this study, we have evaluated the estrogen receptor (ER) and estrogen receptor-related receptor (ERR) expression in tissue samples of posterior vaginal wall obtained from pre- and post-menopausal women. METHODS: The nuclear receptor expression was determined by quantitative real-time PCR (qPCR). RESULTS: The qPCR results showed the presence of the three isoforms of the ERR family (ERRalpha, ERRbeta and ERRgamma) that were coexpressed with ERs in all vaginal tissue samples examined. The ERRalpha and ERRgamma mRNA levels decreased from normal vagina of the pre-menopausal women to atrophic vaginal tissue in post-menopausal women. This trend was also observed for the ERbeta subtype. CONCLUSIONS: The ERRs, such as ERs, are present in human vagina at the mRNA level and the cessation of ovarian estrogen secretion, that is the key event during the post-menopause, may be linked to ERbeta, ERRalpha and ERRgamma mRNA decline in human vaginal mucosa. These findings may provide a biological rationale for the clinical susceptibility of the post-menopausal vagina to local estrogen treatment.