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Amnioinfusion in preterm PROM: Effects on placental histology
S56 SMFM Abstracts 159 IMPACT OF QUANTITATIVE FETAL FIBRONECTIN (FFN) CHANGE ON EFFICACY OF ANTIBIOTIC VS. PLACEBO TREATMENT OF ASYMPTOMATIC FFN POSITIVE WOMEN TO PREVENT SUBSEQUENT PRETERM BIRTH (PB) MONIQUE LIN (F)1, 1for the NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: To evaluate whether change in quantitative FFN concentration following antibiotic or placebo treatment of asymptomatic FFN positive women is related to subsequent PB !37 wks. STUDY DESIGN: Secondary analysis of a multicenter double blinded, placebo-controlled study of antibiotic therapy for asymptomatic women with a positive cervicovaginal FFN (R50 ng/mL) between 21-25 wks. Women were randomized to either metronidazole 250 mg tid C erythromycin 250 mg qid for 10 days or identical placebos. Quantitative FFN was assessed at baseline and 2 weeks after treatment. Pre- to post-treatment FFN changes (DFFN) were categorized as: 1) no change or increasing, 2) decreasing with persistent positive FFN at follow-up, and 3) decreasing with follow-up negative FFN. Primary study outcome was PB !37 wks. RESULTS: Of the 715 women enrolled, 591 had quantitative FFN values pre- and post-treatment and outcomes available. Race, gestational age, randomization to follow-up interval, pre-treatment FFN concentration, and BV status were similar between groups. A similar proportion of women were FFN positive at follow-up in the antibiotic group (22.5%) compared with placebo group (16.6%, p=0.07). Irrespective of treatment, rate of PB !37 wks was significantly associated with DFFN with the highest rate noted in women with no change or increased FFN (TABLE). Within each DFFN category, incidence of PB!37 wks between the two treatment groups was not significantly different (TABLE). PB!37 wks DFFN category DFFN
Antibiotics
Placebo
P
Decreasing FFN and follow-up FFN ÿ Decreasing FFN and follow-up FFN C Same or increasing FFN Test of Trend
8.5% 25.7% 36.7% p!0.0001
10.3% 30.0% 36.7% p!0.0001
0.49 0.73 1.00
161 AMNIOINFUSION IN PRETERM PROM: EFFECTS ON PLACENTAL HISTOLOGY ANNA LOCATELLI1, MARIANNA ANDREANI1, CAROLYN SALAFIA2, ALESSANDRO GHIDINI1, MARIA VERDERIO1, LUISA PATANE’1, PATRIZIA VERGANI1, 1University of Milan-Bicocca, Obstetrics and Gynecology, Monza, Italy, 2EarlyPath, Larchmont, New York OBJECTIVE: Use of amnioinfusion in preterm premature rupture of membranes (PROM) with severe oligohydramnios is associated with longer latency and lower rates of pulmonary hypoplasia. The aim of our study was to investigate the effects of the procedure on histologic placental characteristics. STUDY DESIGN: All consecutive singleton pregnancies with preterm PROM at %24.6 weeks lasting O4 days between 1/1999 and 12/2004 were included. Serial transabdominal amnioinfusions with normal saline solution were performed in consenting women in the presence of persistent oligohydramnios. Histopatologic placental examination focused on amnion epithelial integrity, number of polymorphonucleated cells (PMNc), cellularity and necrosis of connective tissue; grade of inflammation and necrosis in choriodecidual plate. We evaluated correlations between histopatological features and clinical characteristics with Spearman´s test. A P!0.05 was considered significant. RESULTS: From a cohort of 56 cases, placental histology was available in 43 (77%). Amnioinfusion was performed in 22 cases (51%), with a median of 3 procedures (range 1-7). Median gestational age (GA) at PROM was 18.2 weeks (range 13.0-24.5) and at delivery 26.1 weeks (17.2-33.5), with a latency period of 45 days (4-158). Amnioinfusion did not correlate with any of the histopatologic features analyzed, whereas it was directly correlated with latency period (R=0.372, P=0.011). Latency period correlated directly with median amniotic fluid pocket during latency (R=0.543, P!0.001) and indirectly with choriodecidual lesions (inflammation R=-0.531, P=0.001; necrosis R=-0.617, P!0.001) and number of PMNc (R=-0.388, P=0.008; R=-0.371, P=0.012). CONCLUSION: Amnioinfusion does not have an adverse effects on amnion integrity. It is positively associated with prolonged latency, which mediates lower rates of histologic chorioamnionitis.
CONCLUSION: Asymptomatic FFN positive women who maintain or increase their FFN from baseline are at increased risk for PB !37 wks when compared with women whose FFN decreases. Antibiotic therapy does not appear to alter DFFN nor the rate of PB !37 wks in women with various categories of FFN change, when compared to placebo.
160 GESTATIONAL AGE AT STEROID ADMINISTRATION AND WHITE MATTER DAMAGE IN VERY PRETERM INFANTS BORN AFTER PREMATURE RUPTURE OF MEMBRANES LAURA TOSO1, ANNA LOCATELLI1, ALESSANDRO GHIDINI1, FRANCESCA ASSI1, MARIANNA ANDREANI1, GIUSEPPE PATERLINI2, MADDALENA INCERTI1, 1 University of Milan-Bicocca, Obstetrics and Gynecology, Monza, Italy, 2 University of Milan-Bicocca, Neonatology, Monza, Italy OBJECTIVE: In women with very preterm premature rupture of membranes (PROM), steroids have a protective effect against the occurrence of white matter damage (WMD). However, the effect of steroids is affected by gestational age at PROM. We investigated whether gestational age at steroid administration and interval between steroids and delivery also affect the occurrence of WMD. STUDY DESIGN: From a cohort of 659 consecutive singletons born at 24.033.6 weeks, we extracted the obstetric and histologic placental variables of those with PROM who underwent at least one full course of steroids (n=130). Gestational age at PROM, at first and last course of steroids, and interval from last course and delivery were compared between those who developed WMD (n=8) and those who did not (n=122) using Fisher´ s exact test and Mann-Whitney U test with P !0.05 considered significant. WMD was defined as intraventricular hemorrhage grade 3 plus, periventricular leukomalacia, or ventriculomegaly without hydrocephaly. RESULTS: Gestational age at PROM (22.5 vs 27.2 weeks, P!0.01) was significantly different between those who developed WMD and those who did not, whereas gestational age at delivery (29.1 vs 30.1 weeks, P=0.2), at first course of steroids (26.6 vs 28.0 weeks, P=0.2), at last course of steroids (27.6 vs 29.0 weeks, P=0.2), and interval from last course and delivery (10.1 vs 9.9 days, P=0.9) were not significantly different. All patients received antibiotic prophylaxis. Rates of clinical and histological chorioamnionitis did not differ between the two groups (2/8 vs 21/122, P=0.63 and 4/8 vs 41/101 placentas available, p=0.71, respectively). CONCLUSION: In very preterm PROM, the beneficial effect of steroids on occurrence of WMD is not related to gestational age at steroid administration or interval between last course of steroids and delivery.
162 PRETERM PREMATURE RUPTURE OF MEMBRANES: OPTIMAL TIMING OF DELIVERY IN A COMMUNITY HOSPITAL JULIO MATEUS1, CHRISTINA DIVENTI1, JERRY COHEN1, RICHARD LATTA1, 1Abington Memorial Hospital, Department of Obstetrics and Gynecology, Abington, Pennsylvania OBJECTIVE: To characterize neonatal and maternal morbidity and mortality rates in pregnancies complicated by preterm premature rupture of membranes (PROM) and determine whether there is an optimal delivery gestational age. STUDY DESIGN: We reviewed maternal and neonatal outcomes of women with PROM from 24 to 36 weeks at our institution from April 2002 to August 2004. Antibiotics were used in all cases and dexamethasone at physician discretion. Outcomes evaluated included neonatal mortality, composite major and minor neonatal morbidity, individual major and minor neonatal morbidity rates, maternal infection morbidity, and maternal and neonatal length of stay. Gestational age–specific maternal and neonatal outcomes were compared with a referent group of pregnancies complicated by preterm PROM that delivered greater than or equal to 36 completed weeks of gestation. RESULTS: During the study interval, 175 women with preterm PROM were identified. Composite major neonatal morbidity was significantly higher among pregnancies delivered at all preterm gestational age categories after preterm PROM as compared with those who delivered at greater than or equal to 36 weeks. There continued to be statistically significant improvement in the composite major and minor neonatal morbidity rates for pregnancies up to 36 weeks of gestation. Respitatory distress syndrome remained the major morbidity at 35 weeks gestation (compared with 36th week p!0.003). Neonatal sepsis was not significant after 32 weeks gestation. Both maternal and infant length of stay were significantly longer for cases of preterm PROM delivered at 34 weeks as compared with those who delivered at 36 weeks. Maternal composite infectious morbidity was not affected by the gestational age at PROM or delivery. CONCLUSION: Our findings suggest that expectant management, in our population, of pregnancies up to 36 weeks is of very small risk with significant reduction in major and minor morbidities.
Antibiotics
Placebo
P
Decreasing FFN and follow-up FFN ÿ Decreasing FFN and follow-up FFN C Same or increasing FFN Test of Trend
8.5% 25.7% 36.7% p!0.0001
10.3% 30.0% 36.7% p!0.0001
0.49 0.73 1.00
161 AMNIOINFUSION IN PRETERM PROM: EFFECTS ON PLACENTAL HISTOLOGY ANNA LOCATELLI1, MARIANNA ANDREANI1, CAROLYN SALAFIA2, ALESSANDRO GHIDINI1, MARIA VERDERIO1, LUISA PATANE’1, PATRIZIA VERGANI1, 1University of Milan-Bicocca, Obstetrics and Gynecology, Monza, Italy, 2EarlyPath, Larchmont, New York OBJECTIVE: Use of amnioinfusion in preterm premature rupture of membranes (PROM) with severe oligohydramnios is associated with longer latency and lower rates of pulmonary hypoplasia. The aim of our study was to investigate the effects of the procedure on histologic placental characteristics. STUDY DESIGN: All consecutive singleton pregnancies with preterm PROM at %24.6 weeks lasting O4 days between 1/1999 and 12/2004 were included. Serial transabdominal amnioinfusions with normal saline solution were performed in consenting women in the presence of persistent oligohydramnios. Histopatologic placental examination focused on amnion epithelial integrity, number of polymorphonucleated cells (PMNc), cellularity and necrosis of connective tissue; grade of inflammation and necrosis in choriodecidual plate. We evaluated correlations between histopatological features and clinical characteristics with Spearman´s test. A P!0.05 was considered significant. RESULTS: From a cohort of 56 cases, placental histology was available in 43 (77%). Amnioinfusion was performed in 22 cases (51%), with a median of 3 procedures (range 1-7). Median gestational age (GA) at PROM was 18.2 weeks (range 13.0-24.5) and at delivery 26.1 weeks (17.2-33.5), with a latency period of 45 days (4-158). Amnioinfusion did not correlate with any of the histopatologic features analyzed, whereas it was directly correlated with latency period (R=0.372, P=0.011). Latency period correlated directly with median amniotic fluid pocket during latency (R=0.543, P!0.001) and indirectly with choriodecidual lesions (inflammation R=-0.531, P=0.001; necrosis R=-0.617, P!0.001) and number of PMNc (R=-0.388, P=0.008; R=-0.371, P=0.012). CONCLUSION: Amnioinfusion does not have an adverse effects on amnion integrity. It is positively associated with prolonged latency, which mediates lower rates of histologic chorioamnionitis.
CONCLUSION: Asymptomatic FFN positive women who maintain or increase their FFN from baseline are at increased risk for PB !37 wks when compared with women whose FFN decreases. Antibiotic therapy does not appear to alter DFFN nor the rate of PB !37 wks in women with various categories of FFN change, when compared to placebo.
160 GESTATIONAL AGE AT STEROID ADMINISTRATION AND WHITE MATTER DAMAGE IN VERY PRETERM INFANTS BORN AFTER PREMATURE RUPTURE OF MEMBRANES LAURA TOSO1, ANNA LOCATELLI1, ALESSANDRO GHIDINI1, FRANCESCA ASSI1, MARIANNA ANDREANI1, GIUSEPPE PATERLINI2, MADDALENA INCERTI1, 1 University of Milan-Bicocca, Obstetrics and Gynecology, Monza, Italy, 2 University of Milan-Bicocca, Neonatology, Monza, Italy OBJECTIVE: In women with very preterm premature rupture of membranes (PROM), steroids have a protective effect against the occurrence of white matter damage (WMD). However, the effect of steroids is affected by gestational age at PROM. We investigated whether gestational age at steroid administration and interval between steroids and delivery also affect the occurrence of WMD. STUDY DESIGN: From a cohort of 659 consecutive singletons born at 24.033.6 weeks, we extracted the obstetric and histologic placental variables of those with PROM who underwent at least one full course of steroids (n=130). Gestational age at PROM, at first and last course of steroids, and interval from last course and delivery were compared between those who developed WMD (n=8) and those who did not (n=122) using Fisher´ s exact test and Mann-Whitney U test with P !0.05 considered significant. WMD was defined as intraventricular hemorrhage grade 3 plus, periventricular leukomalacia, or ventriculomegaly without hydrocephaly. RESULTS: Gestational age at PROM (22.5 vs 27.2 weeks, P!0.01) was significantly different between those who developed WMD and those who did not, whereas gestational age at delivery (29.1 vs 30.1 weeks, P=0.2), at first course of steroids (26.6 vs 28.0 weeks, P=0.2), at last course of steroids (27.6 vs 29.0 weeks, P=0.2), and interval from last course and delivery (10.1 vs 9.9 days, P=0.9) were not significantly different. All patients received antibiotic prophylaxis. Rates of clinical and histological chorioamnionitis did not differ between the two groups (2/8 vs 21/122, P=0.63 and 4/8 vs 41/101 placentas available, p=0.71, respectively). CONCLUSION: In very preterm PROM, the beneficial effect of steroids on occurrence of WMD is not related to gestational age at steroid administration or interval between last course of steroids and delivery.
162 PRETERM PREMATURE RUPTURE OF MEMBRANES: OPTIMAL TIMING OF DELIVERY IN A COMMUNITY HOSPITAL JULIO MATEUS1, CHRISTINA DIVENTI1, JERRY COHEN1, RICHARD LATTA1, 1Abington Memorial Hospital, Department of Obstetrics and Gynecology, Abington, Pennsylvania OBJECTIVE: To characterize neonatal and maternal morbidity and mortality rates in pregnancies complicated by preterm premature rupture of membranes (PROM) and determine whether there is an optimal delivery gestational age. STUDY DESIGN: We reviewed maternal and neonatal outcomes of women with PROM from 24 to 36 weeks at our institution from April 2002 to August 2004. Antibiotics were used in all cases and dexamethasone at physician discretion. Outcomes evaluated included neonatal mortality, composite major and minor neonatal morbidity, individual major and minor neonatal morbidity rates, maternal infection morbidity, and maternal and neonatal length of stay. Gestational age–specific maternal and neonatal outcomes were compared with a referent group of pregnancies complicated by preterm PROM that delivered greater than or equal to 36 completed weeks of gestation. RESULTS: During the study interval, 175 women with preterm PROM were identified. Composite major neonatal morbidity was significantly higher among pregnancies delivered at all preterm gestational age categories after preterm PROM as compared with those who delivered at greater than or equal to 36 weeks. There continued to be statistically significant improvement in the composite major and minor neonatal morbidity rates for pregnancies up to 36 weeks of gestation. Respitatory distress syndrome remained the major morbidity at 35 weeks gestation (compared with 36th week p!0.003). Neonatal sepsis was not significant after 32 weeks gestation. Both maternal and infant length of stay were significantly longer for cases of preterm PROM delivered at 34 weeks as compared with those who delivered at 36 weeks. Maternal composite infectious morbidity was not affected by the gestational age at PROM or delivery. CONCLUSION: Our findings suggest that expectant management, in our population, of pregnancies up to 36 weeks is of very small risk with significant reduction in major and minor morbidities.