Society for Maternal-Fetal Medicine Consult Series #71: Management of previable and periviable preterm prelabor rupture of membranes.

Previable and periviable preterm prelabor rupture of membranes are challenging obstetric complications to manage, given the substantial risk of maternal morbidity and mortality with no guarantee of fetal benefit. The following are Society for Maternal-Fetal Medicine recommendations for the management of previable and periviable preterm prelabor rupture of membranes prior to the period when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient: (1) we recommend that pregnant patients with previable and periviable preterm prelabor rupture of membranes receive individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management to guide an informed decision. All patients with previable and periviable preterm prelabor rupture of membranes should be offered abortion care. Expectant management can also be offered in the absence of contraindications (GRADE 1C); (2) we recommend antibiotics for pregnant individuals who choose expectant management after preterm prelabor rupture of membranes at ≥ 24 0/7 weeks of gestation (GRADE 1B); (3) antibiotics can be considered after preterm prelabor rupture of membranes at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C); (4) administration of antenatal corticosteroids and magnesium are not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (GRADE 1B); (5) serial amnioinfusions and amniopatch are considered investigational and should be used only in a clinical trial setting; they are not recommended for routine care of previable and periviable preterm prelabor rupture of membranes (GRADE 1B); (6) cerclage management after preterm prelabor rupture of membranes is similar to cerclage management after preterm prelabor rupture of membranes at later gestational ages; it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making (GRADE 2C); (7) in subsequent pregnancies after a history of previable or periviable preterm prelabor rupture of membranes, we recommend following guidelines for management of pregnant persons with a prior spontaneous preterm birth (GRADE 1C).

Selective feticide in dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane before 24 weeks may be a safe therapeutic alternative to ongoing pregnancy.

BACKGROUND: To date, there are no clinical guidelines for dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane (PV-ROM) before 24 weeks of gestation. The typical management options including expectant management and/or pregnant termination, induce the risks of fetal mortality and morbidity. OBJECTIVE: To explore the feasibility selective feticide in DCDA twins complicated with PV-ROM. STUDY DESIGN: A Retrospective cohort study, enrolling 28 DCDA twins suffering from PV-ROM in a tertiary medical center from Jan 01 2012 to Jan 01 2022. The obstetric outcome was compared between selective feticide group and expectant management group. RESULTS: There were 12 cases managed expectantly and 16 underwent selective feticide. More cases suffered from oligohydramnios in expectant management group compared to selective feticide group (P = 0.008). Among 13 cases with ROM of upper sac, the mean gestational age at delivery was (33.9 ± 4.9) weeks in the selective feticide group, which was significantly higher than that in the expectant management (P = 0.038). Five fetuses (83.3%) with selective feticide delivered after 32 weeks, whereas only one (14.3%) case in expectant management group (P = 0.029). However, in the subgroup with ROM of lower sac, no significant difference of the mean gestation age at delivery between groups and none of cases delivered after 32 weeks. CONCLUSION: There was a trend towards an increase in latency interval in DCDA twins with PV-ROM following selective feticide, compared to that with expectant management. Furthermore, selective feticide in cases with PV-ROM of upper sac has a favorable outcome.

Anti-infectious and anti-inflammatory effect of amniopatch in the treatment of spontaneous previable rupture of membranes.

Spontaneous previable rupture of membranes complicates approximately 0.4-0.7% of pregnancies and is associated with severe maternal and neonatal morbidity and mortality. Intra-amniotic inflammation is present in up to 94.4% of cases, most often caused by a bacterial infection. In comparison, the effectiveness of antibiotic therapy in its eradication reaches less than 17%. Inflammatory activity in the amniotic cavity disrupts the physiological development of the fetus with an increase in maternal, fetal, and neonatal inflammatory morbidity through the development of fetal inflammatory response syndrome, maternal chorioamnionitis, and neonatal sepsis. Amniopatch is an invasive therapeutic technique based on intra-amniotic administration of maternal hemoderivates in the form of thromboconcentrate and plasma cryoprecipitate to provide the temporary closure of the fetal membranes defect and secondary restitution of normohydramnios with correction of pressure-volume ratios. The supposed basis of this physical-mechanical action is the aggregation of coagulant components of amniopatch in the area of the defect with the formation of a valve cap. The background for the formulation of the hypothesis on the potential anti-infectious and anti-inflammatory action of non-coagulant components of amniopatch involved: i) clinical-academic and publishing outputs of the authors based on their many years' experience with amniopatch application in the treatment of spontaneous previable rupture of membranes (2008-2019), ii) the documented absence of clinically manifested chorioamnionitis in patients treated this way with a simultaneously reduced incidence of neonatal respiratory distress syndrome compared to expectant management (tocolysis, corticotherapy, antibiotic therapy). The non-coagulant components of plasma cryoprecipitate include mainly naturally occurring isohemagglutinins, albumin, and soluble plasma fibrinogen. Although these components of the amniopatch have not been attributed a significant therapeutic role, the authors assume that due to their opsonizing and aggregative properties, they can significantly participate in optimizing the intrauterine environment through the reduction in bacterial and cytokine charge in the amniotic fluid. The authors think these facts constitute a vital stimulus to future research-academic activity and, at the same time, an idea for reconsidering the therapeutic role of amniopatch as a tool for improving perinatal results of spontaneous previable ruptures of membranes.

Morbimortalidad perinatal en pacientes con rotura prematura ovular ≤24 semanas según cantidad de líquido amniótico al momento del diagnóstico / Perinatal morbidity and mortality in patients with premature ovular rupture ≤24 weeks according to amount of amniotic fluid at diagnosis

Introducción: La rotura prematura ovular (RPO) antes de la viabilidad fetal consiste en una complicación obstétrica de baja incidencia, pero de alta morbimortalidad perinatal asociada. Estudios sugieren que el volumen de líquido amniótico (LA) es un factor importante a considerar. El objetivo de este trabajo es evaluar si en RPO ≤24 semanas, un bolsillo vertical máximo (BVM) <2cm al diagnóstico es un factor de riesgo para aparición de morbimortalidad fetal y neonatal. Métodos: Estudio de cohorte longitudinal retrospectivo de 94 pacientes con RPO ≤24 semanas ingresadas a un hospital terciario para manejo expectante entre los años 2005 y 2014. Embarazo gemelar o malformaciones congénitas fueron criterios de exclusión. Se obtuvieron y compararon 2 grupos según BVM al ingreso (BVM ≥ 2 cm y BVM < a 2 cms) y se comparó la edad gestacional (EG) al momento de la RPO y al parto, la latencia desde la RPO al parto, la presencia de corioamnionitis clínica, el número de óbitos fetales, muerte neonatal precoz (primeros 7 días de vida), tardía (entre los 7 y 28 días) y sobrevida global. Resultados: El 58 por ciento de las pacientes presentó un BVM <2 cm al ingreso, el cual se asoció a menor latencia al parto (p:0,01), menor EG al parto (p:0,02), más óbito fetal (p:0,04), mayor muerte neonatal precoz y tardía (p:0,02 y 0,01 respectivamente) además de menor sobrevida global (p:0,01). Conclusiones: La medición de BVM <2 cm al ingreso en pacientes con RPO ≤24 semanas, es un factor de mal pronóstico y debe ser considerado en el manejo clínico de estas pacientes.(AU)

Introduction: Previable premature rupture of membranes (pPROM) is a low-incidence obstetric complication associated with high perinatal morbidity and mortality. Studies suggest that the volume of amniotic fluid (AL) is an important factor to consider. The aim of this study is to evaluate if in RPO ≤24 weeks, a maximum vertical pocket (MVP) <2 cm to the diagnostic is a risk factor for fetal and neonatal morbidity and mortality. Objectives: Evaluate fetal and neonatal morbidity and mortality according to amniotic fluid (AL) Maximum Vertical Pocket (MVP) ≥ or