Classification of Preterm Birth With Placental Correlates.

Premature birth lacks a widely accepted classification that unites features of the clinical presentation with placental pathology. To further explore associations between the clinical categories of preterm birth and placental histology, 109 infants with gestational age <34 weeks and birth weight <2000 g were selected and, based on electronic records, were classified into preterm birth categories of preterm labor, prelabor premature rupture of membranes, preeclampsia, indicated preterm birth for maternal factors (other than preeclampsia), indicated preterm birth for fetal factors, and the clinical diagnosis of abruption. Corresponding placentas were analyzed for gross and microscopic variables, with findings grouped into categories of amniotic fluid infection, lymphocytic inflammation, maternal vascular malperfusion, and fetal vascular malperfusion. Placental features of maternal vascular malperfusion were pervasive in all preterm birth categories and were commonly associated with amniotic fluid infection and lymphocytic inflammation. Features of maternal vascular malperfusion were significantly associated with preterm birth due to preeclampsia, and amniotic fluid infection was highly associated with prelabor preterm rupture of membranes. Findings of lymphocytic inflammation were significantly increased in cases of abruption. Laminar decidual necrosis was present in all cases of abruption. Placentas from multiple gestations had significantly less histologic findings compared to singletons. Given that 75% of placentas demonstrated at least 1 feature of maternal vascular malperfusion despite different clinical presentations, seemingly different pathologies such as ascending amniotic fluid infection or lymphocytic inflammation may be mechanistically related to processes established early in pregnancy. The concept of "uterine ischemia" may be too simplistic to account for all of the changes attributed to maternal vascular malperfusion in the preterm placenta.

Mid-trimester preterm premature rupture of membranes (PPROM): etiology, diagnosis, classification, international recommendations of treatment options and outcome.

Mid-trimester preterm premature rupture of membranes (PPROM), defined as rupture of fetal membranes prior to 28 weeks of gestation, complicates approximately 0.4%-0.7% of all pregnancies. This condition is associated with a very high neonatal mortality rate as well as an increased risk of long- and short-term severe neonatal morbidity. The causes of the mid-trimester PPROM are multifactorial. Altered membrane morphology including marked swelling and disruption of the collagen network which is seen with PPROM can be triggered by bacterial products or/and pro-inflammatory cytokines. Activation of matrix metalloproteinases (MMP) have been implicated in the mechanism of PPROM. The propagation of bacteria is an important contributing factor not only in PPROM, but also in adverse neonatal and maternal outcomes after PPROM. Inflammatory mediators likely play a causative role in both disruption of fetal membrane integrity and activation of uterine contraction. The "classic PPROM" with oligo/an-hydramnion is associated with a short latency period and worse neonatal outcome compared to similar gestational aged neonates delivered without antecedent PPROM. The "high PPROM" syndrome is defined as a defect of the chorio-amniotic membranes, which is not located over the internal cervical os. It may be associated with either a normal or reduced amount of amniotic fluid. It may explain why sensitive biochemical tests such as the Amniosure (PAMG-1) or IGFBP-1/alpha fetoprotein test can have a positive result without other signs of overt ROM such as fluid leakage with Valsalva. The membrane defect following fetoscopy also fulfils the criteria for "high PPROM" syndrome. In some cases, the rupture of only one membrane - either the chorionic or amniotic membrane, resulting in "pre-PPROM" could precede "classic PPROM" or "high PPROM". The diagnosis of PPROM is classically established by identification of nitrazine positive, fern positive watery leakage from the cervical canal observed during in specula investigation. Other more recent diagnostic tests include the vaginal swab assay for placental alpha macroglobulin-1 test or AFP and IGFBP1. In some rare cases amniocentesis and infusion of indigo carmine has been used to confirm the diagnosis of PPROM. The management of the PPROM requires balancing the potential neonatal benefits from prolongation of the pregnancy with the risk of intra-amniotic infection and its consequences for the mother and infant. Close monitoring for signs of chorioamnionitis (e.g. body temperature, CTG, CRP, leucocytes, IL-6, procalcitonine, amniotic fluid examinations) is necessary to minimize the risk of neonatal and maternal complications. In addition to delayed delivery, broad spectrum antibiotics of penicillin or cephalosporin group and/or macrolide and corticosteroids have been show to improve neonatal outcome [reducing risk of chorioamnionitis (average risk ratio (RR)=0.66), neonatal infections (RR=0.67) and abnormal ultrasound scan of neonatal brain (RR=0.67)]. The positive effect of continuous amnioinfusion through the subcutaneously implanted perinatal port system with amniotic fluid like hypo-osmotic solution in "classic PPROM" less than 28/0 weeks' gestation shows promise but must be proved in future prospective randomized studies. Systemic antibiotics administration in "pre-PPROM" without infection and hospitalization are also of questionable benefit and needs to be further evaluated in well-designed randomized prospective studies to evaluate if it is associated with any neonatal benefit as well as the relationship to possible adverse effect of antibiotics on to fetal development and neurological outcome.

Factores de riesgo y de protección perinatal asociados al manejo conservador de la ruptura prematura de membranas en embarazo pretérminos en el Hospital Bertha Calderón Roque, enero a diciembre del 2007 / Risk factors and protective perinatal associated with the conservative management of the premature rupture of membranes in pregnancy preterm in the Bertha Calderon Hospital Roque, January to December 2007

Objetivos: Determinar la eficacia del manejo conservador para la R:P:M y establecer la diferencia de la morbilidad de los recién nacidos de madres que recibieron tratamiento conservador y las que no lo recibieron. Diseño del estudio: Es un estudio de casos y controles de madres y recién nacidos préterminos con edad gestacional comprendida entre 26 y 34 semanas que se ingresaron para tratamiento conservador de R:P:M. La muestra estuvo constituida por 37 mujeres (casos) con sus recién nacidos y el grupo control por 74 mujeres y sus recién nacidos que no recibieron tratamiento conservador para ruptura prematura de membranas (relación dos controles por cada caso). Se incluyeron a los nacidos por vía vaginal o césarea. La información se obtuvo de los expedientes clínicos de la sala de Alto Riesgo Obstétrico (ARO), labor y partos y Neonatología...

Tema de revisión: ruptura prematura de membranas ovulares / Tema de review: rupture premature of the membranes ovular

Actualmente existe una alta proporción de RPM (2-22 por ciento) y es una de las patologías obstétricas más frecuentes, considerada un problema de salud pública, por ser responsable de la mayoría de partos pretermino (30 por ciento); tiene estrecha relación con la morbi-mortalidad materno-perinatal. Su incidencia es muy variable y depende en gran parte de la situación socioeconómica de la embarazada debido a la menor probabilidad de recibir cuidados médicos prenatales adecuados. Puede presentarse al final del embarazo causada por un debilitamiento natural de las membranas y por la fuerza de las contracciones; también ocurre en etapas tempranas del embarazo y fundamentalmente se asocia a infecciones locales (cervicovaginitis) e infecciones del tracto urinario; mala nutrición y sobredistensión uterina. Otros factores vinculados son los antecedentes de parto pretermino, hemorragia vaginal y tabaquismo. Produce numerosas complicaciones en el binomio materno-fetal como infecciones (corioamnioitis), parto pretermino, compresión del cordón umbilical y prolapso del cordón provocando sufrimiento fetal e incluso muerte fetal. Existen 2 tipos de manejo: activo (culminación del embarazo por cesárea o inducción del trabajo de parto) y expectante (espera del inicio espontáneo del trabajo de parto).

La influencia de un programa psicoprofiláctico de parto en el comportamiento de la mujer gestante frente al embarazo y parto de bajo riesgo en el servico de Ginecologia y obstetricia del hospital Militar Central "Cap. Roberto Orihuela" de la ciudad de La Paz / The influence of a psychoprophylactic program for chilbirth on the behavior of pregnant women in the face the pregnancy and low-risk childbirth in the service of Gynecology and obstetrics of the hospital Military Central Kap Roberto Orihuela de la ciudad de La Paz

Mediante este trabajo de grado de demostró el resultado de apliacción de un programa psicoprofiláctico de parto a mujeres gestantes en el 3er. trimestre en el Servicio de Ginecologia y Obstetricia del Hospital Militrra Central "Cap. Roberto Orihuela" de La Paz, determinando ser un instrumento educar en el embarazo y parto y un medio de influencia para un comportamiento adecuado de la mujer frente al parto natural. Por innvestigación personal, se tiene datos que nunca se dio apoyo a la mujer gestante, mediante programas o algo similar, en este periodo de su vida en el Hospital Militar Central. Para lograr el objetivo se conformó un grupo de 49 mujeres gestantes que se dividió en dos grupos el de control 25 y de estudio 24, se trabajo del mes de octubre 2000 a enero del 2001...

[Frequency of cesarean section in at-term pregnancies with premature rupture of membranes]. / Frecuencia de cesárea en embarazos de término con ruptura prematura de membranas.

The purpose of the present study was to evaluate cesarean section frequency in patients with premature rupture of membranes (PROM) at term, after active management, independent Bishop score. One hundred and four patients was to evaluate, and they was classified in four groups: group 1. nulliparous patients with favorable cervix, group 2. nulliparous patients with unfavorable cervix, group 3. previous delivery patients with unfavorable cervix, group 4. previous delivery patients with favorable cervix. Cesarean section percentage was: 15% in group 1, 24% in group 2, 17% in group 3, and 0% in group 4. Attempt should make to diminish cesarean section frequency, maybe with an expectant management in those patients with PROM at ther and unfavorable cervix.

Frecuencia de cesárea en embarazos de término con ruptura prematura de membranas / Frequency of cesarean section in term pregnancies with premature rupture of membranes

El objetivo de estudio fue valorar la frecuencia de pacientes a las cuales se les efectuó operación cesárea, posterior al manejo activo de la ruptura prematura de membranas (RPM) en embarazos a término, independientemente de la calificación de Bishop. Se evaluaron un total de 140 pacientes, las cuales se clasificaron en cuatro grupos conforme a la paridad y al Bishop; grupo 1. Pacientes nulíparas con cervix favorable, grupo 2. Pacientes nulíparas con cervix desfavorable, grupo 3. Pacientes con parto previo con cervix desfavorable, grupo 4. Pacientes con parto previo y cervix desfavorable. El porcentaje obtenido de cesárea por cada grupo fue de 15 por ciento en el grupo 1, 24 por ciento en el grupo 2, 17 por ciento en el grupo 3, y 0 por ciento en el grupo 4. Como procedimiento para disminuir la frecuencia de cesárea, habría que tomar en cuenta el manejo expectante en aquellas pacientes con RPM en embarazo a término y a cervix desfavorable para inductoconducción

[Etiologic classification of premature labor and its importance for prevention]. / Atiologische Klassifikation der Frühgeburt und ihre Bedeutung für die Prävention.

A retrospective analysis of 202 premature deliveries before 37 weeks was performed to identify major pathologies related to preterm delivery. The most frequent pathologies were premature rupture of membranes (32.4%), premature labour without recognisable aetiology (19.1%), hypertensive diseases in pregnancy (15.6%), multiple pregnancies (14.4%), malformations (9.8%) and bleeding in the 3rd trimester (6.4%). The majority of premature deliveries are related to 4 major pathogenetic disturbances: infection, problems of placentation, pathology of the foetus, pathology of the uterus. Each of these pathologies can lead to premature delivery via premature labour, premature rupture of membranes or termination of pregnancy for foetal or maternal pathology. In one third of premature labour, in another preterm premature rupture of membranes with labour after a variable latent period led to delivery, and in the remaining third, delivery was performed by a primary caesarean section or induction of labour for foetal or maternal pathology. Less than 25% cases were considered as failures of tocolytic treatment. Tocolytics, steroids or antibiotics, may help to improve the survival-rate in particular with very low birth-weight infants at less than 30 weeks gestation. A decrease in the overall rate of prematurity can be achieved only by a general improvement of the socio-economic working and living conditions of the female population, in particular of pregnant women.

Uso de los corticoides en embarazo pretermino con ruptura prematura de membranas / Use of corticoids in preterm pregnancy with premature rupture of membranes

Durante el periodo del 1 de agosto de 1983 al 31 de julio de 1985 se estudiaron 40 pacientes las cuales ingresaron al Hospital Materno Infantil de Bogota, por presentar embarazo pretermino, ruptura prematura de membranas, sin signos de infeccion y sin trabajo de parto en el momento de su ingreso. Durante su permanencia se les comprobo la ruptura de membranas, se les practico amniocentesis y cuando se obtuvo liquido amniotico se practico test de Clements y cultivo para germenes comunes y anaerobicos, frotis de cervix y cultivo, monitoria sin stress para detectar bienestar fetal, ecografia para confirmar la edad gestacional y la disminucion de liquido amniotico. Ademas control de la curva termica cada 6 horas y cuadro hematocrito diario. Se dividieron de forma aleatoria en 2 grupos; Grupo A. Se aplico Betametasona 2 dosis de 12 mgrs, I.M. cada 12 horas y se desembarazaron 48 horas despues de la primera dosis. La via a seguir en el parto estuvo de acuerdo a condiciones obstetricas. Brupo B. Se dejaron en observacion durante 8 horas y luego se desembarazaron de acuerdo a condiciones obstetricas. Se presento una morbilidad de 60% que se distribuyo por igual en ambos grupos y sus causas fueron: sindrome de dificultad respiratoria 47.5%, sepsis 5% e hipoxia neonatal 7.5%. Se presento unicamente 1 caso de corioamnionitis y no hubo morbilidad puerperal.