Published by : PROFESSIONAL MEDICAL PUBLICATIONS
ISSN 1681-715X
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ORIGINAL ARTICLE
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Volume 21
October December 2005 Number 4
Neonatal Outcome and Prenatal
Antibiotic
Treatment in Premature Rupture of Membranes
Kifah Al-Qa’Qa’1 & Fatin Al-Awaysheh2
Abstract:
Aim: To compare the neonatal out come of infants born to mothers with history of PROM who received or did not receive antibiotics before labor.
Methods: This study was carried out at Queen Alia military hospital between January 2003 to June 2004, to compare neonatal outcome of babies born to mothers with history of Premature Rupture Of Membranes (PROM) who received or didn’t receive antibiotics before labor. 255 newborns were included in this study. All of them were admitted to neonatal intensive care with septic work up done and intravenous antibiotic started for atleast 3-4 days. These neonates were divided into two groups depending on maternal history of antibiotic intake before labor.
Results: The total number of neonates included in the study was 225.The maternal age 25 + 10 years. 140 cases (62%) were premature with gestational age ranging between 28-36 weeks, and 85 (38%) were full term. Neonatal death occurred in 20 cases (14%) due to severe prematurity and its complications. Duration of PROM 18-72 hours in 167 cases (74%), 72 hours -1 week in 43 cases (19%) and >1week in 10 cases (7%).History of antibiotic intake before labor was positive in 110 cases (49%),{ 60 (54.5%) of them had premature labor}, and negative in 115 cases (51%) ,{80 ( 69.6%) of them had premature labor }.The risk of neonatal infection in our study was 4.4% in babies with maternal history of antibiotic intake compared with 11% in those whose mothers didn’t.
Conclusion: Antibiotic treatment of women with history of PROM improves neonatal outcome by increasing pregnancy latency and in association with early detection of sepsis and its aggressive management leads to significant improvement in neonatal outcome.
Key words: PROM (Premature Rupture of Membranes), neonatal sepsis, prenatal antibiotics.
Pak J Med Sci October-December 2005 Vol. 21 No. 4 441-444
1. Dr. Kifah Al-Qa’Qa’ MD
2. Dr. Fatin Al-Awaysheh MD
1-2: Pediatric & Neonatology
Department,
Queen Alia Military Hospital,
Royal Medical Services,
Amman, JORDAN
Correspondence:
Dr. Kifah Al-Qa’Qa’
E-Mail: kifah88@yahoo.com
Received for publication:
February 18, 2005
Revision received: MAY 25, 2005
Revision accepted: MAY 26, 2005
Introduction
Premature rupture of membranes (PROM) is defined as rupture of membranes before onset of labor. When this occurs before 37 weeks of gestation it’s called preterm PROM. Membrane rupture may occur for a variety of reasons. At term, weakening of the membranes may result from physiologic changes combined with shearing forces created by uterine contractions.1,2 Intrauterine, especially at earlier gestational ages.3 Factors associated with an increase in PROM include lower socioeconomic status, sexually transmissible infections, prior preterm delivery (especially due to PROM), vaginal bleeding, cervical colonization and cigarette smoking during pregnancy.1,4-6 In many cases, however, PROM may occur in the absence of recognized risk factors.
The most significant maternal risk of term PROM is intrauterine infection the risks of which increases with the duration of membrane rupture.5, 8-10 Fetal risks associated with PROM include umbilical cord compression and ascending infection. For patients with preterm PROM the most likely outcome is preterm delivery within one week with its associated morbidity and mortality risks such as respiratory distress, necrotizing entrocolitis, intraventricular hemorrhage and sepsis.11 Many antibiotics were started to reduce maternal chorioamnionitis and neonatal complications, the most widely used ones were ampicillin, erythromycin and cephalosporin’s.12 Our study was carried out to see the effect of prenatal antibiotic use in mothers with history of PROM on their newborns and to compare them with the newborns of mothers with the same problem who did not receive treatment.
Patients and Methods
This study was carried out at Queen Alia military hospital between January 2003 to June 2004, 255 newborns were included in this study, each was born to a mother with PROM for at least 18 hours and the following information were recorded age, parity, smoking, history of chronic illness, drug intake, preterm labor, neonatal death, duration of, amniotic fluid leak, gestational age, mode of delivery and history of antibiotic use before labor.
Each neonate was admitted to neonatal intensive care with septic work up done including CBC, ESR, blood film, CRP (on admission and third day of life), blood culture and CXR.
All of them received intravenous antibiotic (ampicillin and amikacin) for 3-4 days then continued oral augmentin drops till blood culture result. Except for those who showed clinical or laboratory evidence of sepsis I.V. antibiotics were continued accordingly.
The age of mothers: included was between 16-36 years. The gestational age included was between 28-42 weeks. For the sake of studying and comparing laboratory results and complications of prematurity, we divided them into two groups on the basis of positive or negative history of taking antibiotics pre-natally.
Results
The total number of neonates included in the study was 225.The maternal age was 25 + 10 years. History of chronic illness including hypertension and diabetes were recorded in 20 mothers (9%).None of the mothers included was having history of drug intake except in those mentioned above as treatment for D.M. and or hypertension. 140 cases (62%) were premature with gestational age ranging between 28-36 weeks, and 85 (38%) were full term.
Neonatal death occurred in 20 cases (14%) due to severe prematurity and its complications. Duration of PROM was 18-72 hours in 167case (74%), 72 hours -1 week in 43 cases (19%) and >1week 10 cases (7%).Mode of delivery vaginally 145 cases (64%), instrumental 35 cases (16%), cesarean section 45 cases (20%).Maternal risks including fever, abdominal pain and vaginal discharge occurred in 113 (50%) of the mothers.
History of antibiotic intake before labor was positive in 110 cases (49%), of them 60 (54.5%) had premature labor, and negative in 115 cases (51%), of whom 80 (69.6%) had premature labor. Table-I. The laboratory results of septic workup are summarized in Table-II.
Non of the full term babies included in our study died in both groups but 20 (8.9%) babies of the preterm ones died due to sever prematurity and it’s consequent complications. although there was marked difference in the incidence of complications of prematurity among those whose mothers received anti biotic treatment and those whose mothers didn’t. Table-III.
Discussion
The incidence of neonatal infection for infants born to women with PROM range from 1-2.6%13 in our study it was about 4.4% in patients with positive maternal history of antibiotic intake compared with 11% in those with negative maternal history of antibiotic intake. Preterm premature rupture of fetal membranes defined as rupture before 37 weeks. Occur in 2-4% of pregnancies, is associated with intrauterine infection and increased risk of neonatal sepsis.14 There are several studies in which women presenting with preterm PROM without labor were randomized to receive an antibiotic or placebo. Over all, these studies have shown that antibiotics prolonged the latency period until delivery, reduced maternal choriomnionitis and reduced neonatal complications, including respiratory distress syndrome, IVH, pneumonia and sepsis15,16 as in our study newborns whose mothers received antibiotic before have good outcome.
Neonatal sepsis was defined by positive blood cultures associated with 2 positive CRP readings (CRP>6). 10(4.4%) of our patients fulfilled these criteria in those whose mothers received antibiotics compared with 25 (11%) in those whose mothers did not receive. In many studies it was found that the risk of neonatal infection was increased among mothers colonized with group B streptococci, other risk factor for neonatal infection include premature rupture of membranes >18 hours, maternal fever during labor and prematurity.17 As in our study all patient of PROM >18 hours were admitted to rule out sepsis.
Antibiotic have become an important part of the recent advances in the treatment of PROM. Many studies have demonstrated that antibiotic therapy prolong pregnancy latency time and decreases maternal and neonatal morbidity 3-5, 7-9, 12-16. Diagnosis of early onset neonatal sepsis and close observation for early sign of sepsis and more aggressive evaluation and early treatment has decreased the incidence of early onset sepsis associated with PROM.17,18 All our cases observed clinically and CRP done twice to elicit early sign of sepsis. The most common fetal morbidly associated with PROM is respiratory distress syndrome and is related primarily to gestational age at delivery. It may be advantageous to prolong pregnancy in order to reduce the risk of gestational age dependent morbidity.19 Adjective treatment to expectant management have included prophylactic and therapeutic tocloysis , maternal corticosteroid administration and maternal antibiotic treatment.
Although corticosteroid administration results in significant reduction in incidence of both RDS and grade III and II intra ventricular hemorrhage in premature, but some studies showed that administration of multiple courses of antenatal betamethasone to these patients with preterm PROM is associated with an increased risk of early onset neonatal sepsis.20,21
References
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2. Lavery JP, Miller CE, Knight RD. The effect of labor on the reologic reponse of chorioamniotic membranes. Obstet Gynecol.1982;60:87-92.
3. McGregor JA, French JI. Eviedence based prevention of preterm birth and rupture of membranes: infection and inflammation. J Soc Obstet Gynaeco Can 1997;19:835-52.
4. Harger JH, Hsing AW, Tuomala RE, Gibbs RS, Mead PB, Eschenbach DA, etal. Risk factors for preterm premature rupture of fetal membranes: a multicenter case- Control study. Am J Obstet Gynecol. 1990;163:130-37.
5. Novak- Atolic Z, Pajntar M, Verdenik I, Rupture of the membranes and post partum infection. Eur J Obstet Gynecol Reprod. 1997;71:141-46.
6. Taylor J, Garite TG. Premature rupture of the membrane before fetal viability, Obstet Gynecol 1984;64:615-20.
7. Hannah ME, Ohlsso A , Farine D, Hewson SA, Hodentt ED., Myhr TL, et al. Induction of Labor compared with expectant management for prelabor rupture of the membrane at term . N Eng J Med 1996;334:1005-10.
8. Wagner MV, Chin VP. Peter CJ, Drexler B, Newman LA. A Comparison of early and delayed induction of Labor with spontaneous rupture of membrane at term. Obstet Gynecol 1989;74:93-7.
9. Guise JM, Duff P, Christian JS. Management of term patients with premature rupture of membranes and unfavorable cervix. Am J perinatal. 1992;9:60-65.
10. Johnson JWC, Egerman RS, Moorhead J. Cases with ruptured membranes that "reseal" Am J Obstet Gynecol. 1990;163:1024-32.
11. Beydown SN. Yasin SY. Premature rupture of the membranes before 28 weeks: conservative management. Am J Obstet Gynecol. 1986;155:470-71.
12. Robert L, Goldenberg, Jennifer Flatow Culane. Infection as a cause of preterm birth Clin Perinatol. 2003;30:677-700.
13. Seaward PG. International multicenetr term PROM study; evaluation of predictors of neonatal infection in infants born to paitents with PROM at term.Am J Obstet Gynecol.1998;179:635-9.
14. Ehrenberg HM. Antibiotics and the management of preterm premature rupture of the fatal membranes. Clin perinatol;28:807-18.
15. Nicaise C. Neonatal consequences of preterm premature rupture of membrane (PROM) at 24-34 WG: 118 Singleton pregnancies. J Gynecol Obstet Biol Rpord (Paris). 2002;31:747-54.
16. Killride HW. Neonatal Complications of preterm premature rupture of membranes. Pathophysiology and management. Clin perinatol 2001;28:761-85.
17. David F Lewis. Antibiotic therapy in preterm rupture of membranes. Are seven days necessary? A preliminary randomized clinical trial. Am J obstet Gynecol. 2003 ;188 (6) 1413-6
18. Mercer BM. Preterm Labor and preterm rupture of membranes diagnosis and management. Infect Dis Clin North Am; 1997;11:177-201.
19. Sedogheh Borna. Perinatal out come in preterm premature rupture of membranes with amniotic fluid index <5(5(AF)<5). BMC Pregnancy and child birth. 2004;4:15-20.
20. Mercer BM. Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes. A randomized controlled trial. National Institute of child health and human devlopment maternal fetal medicine units Network. JAMA. 1997;278: 989-95.
21. Vermillion St. Neonatal sepsis after betame thasone administration to patients with premature rupture of membranes.Am J Obstet Gynecol, 1999;181:320-7.
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