BioScience Trends. 2015; 9(1):35-41.

Original Article

35
DOI: 10.5582/bst.2014.01058

Perinatal outcomes of pregnancies complicated by preterm

premature rupture of the membranes before 34 weeks of gestation
in a tertiary center in China: A retrospective review
Haiyan Yu, Xiaodong Wang, Haocheng Gao, Yong You, Aiyun Xing*
Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Chengdu,
Sichuan, China.

Summary

Preterm premature rupture of the membranes (PPROM) remains the leading cause of
preterm deliveries and neonatal mortality and morbidity. The current cohort study sought
to retrospectively examine perinatal outcomes in cases of PPROM < 34 weeks' gestation that
were managed conservatively from 2010 to 2012 and to identify risk factors for short-term
neonatal outcomes. Subjects were 510 pregnancies consisting of 114 twin and 396 singleton
pregnancies. Clinical chorioamnionitis occurred in 17.8% of the pregnancies. Neonatal
mortality was 7.4%, the rate of major neonatal conditions was 40%, and the rate of NICU
admission was 72.9%. The latency period exceeded 48 h in 62.5% of the pregnancies and
7 days in 24.3% of the pregnancies. Twin pregnancies had a shorter latency period than
singleton pregnancies (median of 2 days versus 4 days, p < 0.001). Pregnancies complicated
with early vaginal bleeding had a higher neonatal mortality (13.95% vs. 6.36%, p = 0.013)
and morbidity (51.16% vs. 38.32%, p = 0.024), fewer weeks of gestation at PPROM (p = 0.029).
Multivariate logistic regression analysis revealed that weeks of gestation at PPROM (OR:
0.953, 95% CI: 0.939-0.966, p < 0.001) and a latency period (OR: 0.948, 95%CI: 0.926-0.970,
p < 0.001) were associated with neonatal mortality or morbidity. A twin pregnancy (OR: 0.319,
95% CI: 0.17-0.6, p < 0.001) and weeks of gestation at PPROM (OR: 0.737, 95% CI: 0.660.822, p < 0.001) were associated with the latency period. Gestational age at PPROM, a twin
pregnancy, and the latency period are associated with neonatal mortality and morbidity.
Keywords: Preterm premature rupture of the membranes, neonatal morbidity, neonatal mortality,
latency period

1. Introduction
Preterm birth occurs in approximately 12% of
pregnancies (1). Preterm premature rupture of the
membranes (PPROM), a subtype of preterm labor, is
defined as spontaneous membrane rupture without onset
of labor before 37 weeks of gestation. PPROM occurs in
approximately 3% of pregnancies and results in one-third
of preterm births. It remains the leading cause of preterm
deliveries and neonatal mortality and morbidity (2,3).
Conditions due to prematurity include respiratory
distress syndrome (RDS), intraventricular hemorrhage
*Address correspondence to:
Dr. Xing Aiyun, Department of Obstetrics and Gynecology,
West China Second University Hospital, Sichuan University,
Chengdu 610041, China.
E-mail: aiyun-x@126.com

(IVH), periventricular leukomalacia (PVL), necrotising

enterocolitis (NEC), a prolonged stay in the neonatal
intensive care unit (NICU), neonatal sepsis, required
use of positive pressure ventilation (PPV), cardiac
abnormalities, hyperbilirubinemia and hemolytic
anemia, as well as cerebral palsy, and other long-term
outcomes (4). Therefore, appropriate management of
PPROM is crucial to improving neonatal and maternal
outcomes. Obstetrical strategies to treat PPROM remain
controversial and there is no consensus regarding active
or conservative management of PPROM within 30
and 34 weeks' gestation. Conservative management to
prolong a pregnancy is a classical approach to treating
PPROM before 34 weeks' gestation in association
with antibiotic therapy and corticosteroids. Delivery is
recommended when PPROM occurs at or beyond 34
weeks' gestation (5-7).

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BioScience Trends. 2015; 9(1):35-41.

This Hospital, a tertiary care hospital in southwest

China, conservatively manages PPROM < 34 weeks'
gestation. This Hospital manages the majority of
complicated pregnancies in this area. The aim of the
present study was to evaluate neonatal and maternal
outcomes in women with conservatively managed
PPROM < 34 weeks' gestation and to identify risk
factors for short-term neonatal outcomes.
2. Methods
This was a retrospective cohort study. Approval was
obtained from the Institutional Review Board. Medical
charts of women with spontaneous PPROM < 34
weeks' gestation who were admitted to Obstetrics at
West China Second University Hospital from 2010 to
2012 were reviewed.
2.1. Subjects
Cases of triplets or higher order pregnancies, congenital
malformations incompatible with life, a twin pregnancy
with a delayed-interval delivery, fetal death before
PPROM, and maternal and/or fetal indications for
immediate delivery after admission were excluded.
2.2. PPROM diagnosis
Diagnosis of PPROM was based on the patient's history
of watery discharge and leakage of amniotic fluid from
the cervical os during a sterile speculum examination.
Gestational age was determined based on the patient's
last period or by ultrasound performed during the first
trimester or early second trimester.
2.3. Management of PPROM
Couples were counseled by obstetricians about the
adverse outcomes of an intentional delivery and
conservative management and they selected conservative
management when the patient was not in labor at
admission. Dexamethasone was given for maturation
of the fetal lungs, and the complete course was 4 doses
of 5 mg i.m. within a 48-h interval. A broad-spectrum
antibiotic (ampicillin, ceftezole, or clarithromycin) was
administered from admission until delivery or for up
to 7 days to prevent infection. Magnesium sulfate, a
calcium channel blocker (nifedipine), or a betamimetic
agent (ritodrine) was used as a tocolytic agent depending
on the patient's status.
The status of the mother and fetus was closely
monitored until delivery. Patients were checked by
obstetricians daily. Maternal vital signs were monitored
every 6 hours, and serum C-reactive protein (CRP)
levels and the white blood cell count were checked
weekly. Ultrasound scans were performed once a week
to evaluate the status of the fetus. CTGs were performed

daily to assess the status of the fetus. The treatment

was promptly adjusted when necessary depending on
the status of the mother and fetus. None of the pregnant
women in this study underwent amniocentesis to assess
infection or fetal lung maturity.
Clinical chorioamnionitis was performed if the patient
presented with three or more of the following criteria:
maternal body temperature 38C, maternal tachycardia
( 110 beats/min), persistent fetal tachycardia ( 160
beats/min) or bradycardia (< 120 beats/min), presence
of uterine tenderness, elevated CRP, malodorous vaginal
discharge, and leukocytosis ( 15,000 cells/mm3) in
maternal blood.
When clinical chorioamnionitis was diagnosed during
prolongation of a pregnancy, or there were maternal and/
or fetal indications for delivery, or gestation reached 34
weeks, the pregnancy was managed with active induction
of labor or a Cesarean delivery depending on the patient's
obstetric history and the fetus' status.
2.4. Data collection
Maternal parameters including maternal age, parity,
spontaneous or in vitro fertilization, singleton or twin
pregnancy, and gestational age at PPROM were reviewed.
Furthermore, parameters including weeks of gestation
at delivery, mode of delivery, clinical chorioamnionitis,
and obstetric complications were investigated. Recent
studies of early vaginal bleeding in singleton and twin
pregnancies have cited an increased risk of PPROM,
preterm birth, preeclampsia, and placental abruption (8,9).
Therefore, early vaginal bleeding during the pregnancy
was reviewed during this study. Such bleeding was
defined as the presence of blood in the vagina in the
first or second trimester. Fetal parameters including fetal
distress, birth weight, neonatal death, admission to the
NICU, and major neonatal conditions (including patent
ductus arteriosus (PDA), RDS, IVH, PVL, NEC, and
sepsis) were also studied.
2.5. Statistical analyses
Maternal, fetal, and neonatal parameters were analyzed
using a Chi-squared test, Fisher's exact test, a two-tailed
student's t-test, and Mann-Whitney U test. Multivariate
logistic regression was used to correlate the latency
period, neonatal mortality, and neonatal morbidity
with the parameters collected from medical charts. A p
value < 0.05 was considered statistically significantly.
Analysis was performed with the statistical software
SPSS version 17.0.
3. Results
3.1. Maternal characteristics
Subjects were 510 patients who were diagnosed with

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BioScience Trends. 2015; 9(1):35-41.

Table 1. Maternal characteristics of cases of PPROM < 34
weeks of gestation
Characteristics
Maternal age (mean S.D.)
Maternal age 35years, n (%)
Weeks of gestation at admission (mean S.D.)
Nulliparous, n (%)
Conception
Natural, n (%)
IVF, n (%)
Pregnancy
Singleton, n (%)
Twin, n (%)
Previous cesarean section, n (%)
History of preterm delivery, n (%)
Early vaginal bleeding, n (%)

PPROM, n = 510
28.4 5.6
72 (14.1%)
31.6 1.9
361 (70.8%)
473 (92.8%)
37 (7.3%)
396 (77.7%)
114 (22.4%)
58 (11.4%)
6 (1.2%)
69 (13.5%)

PPROM < 34 weeks' gestation from 2010 to 2012. Of

the 510 pregnancies, 396 were singleton pregnancies
and 114 were twin pregnancies. The mean maternal
age was 28.4 years (range: 17-45 years). The mean
weeks of gestation at PPROM was 31.6 weeks (range:
20+2 -33+6 weeks). Of the 510 patients, 11.4% (58/510)
had a previous Cesarean section, 1.2% (6/510) had
one or more preterm births, and 13.5% (69/510) had a
history of vaginal bleeding in early stages of the current
pregnancy. The maternal characteristics of all patients
in the study are shown in Table 1. There were no
maternal deaths or severe morbidity noted in the current
study.
3.2. Clinical outcomes
The mean weeks of gestation at delivery were 32.5 weeks
(range 27 +2 -34 +3 weeks). Obstetrical complications
such as hypertensive disorders of pregnancy, diabetes,
intrahepatic cholestasis of pregnancy, umbilical
prolapse, and placenta abruption were recorded based on
medical charts and are shown in Table 2. The Cesarean
section was performed in 37.1% of pregnancies with
a medical complication such as breech presentation,
fetal distress, or failure of labor to progress. During
prolongation of a pregnancy, 284 patients (55.7%) went
into labor spontaneously and delivered before 34 weeks.
Indications for active induction of labor or a Cesarean
delivery were as follows: 91 patients (17.8%) presented
with clinical chorioamnionitis, 29 (5.7%) had maternal or
fetal complications during prolongation of the pregnancy,
and 106 (20.8%) had a pregnancy that lasted 34 weeks.
Fetal and neonatal data were reviewed. The mean
neonatal birth weight was 1815.1 462.6 g and 162
neonates (26.1%) were delivered with a birth weight <
1,500g (VLBW). Death of one twin occurred in three
twin pregnancies that were conservatively managed.
The neonatal mortality rate was 7.4% (46 cases) and
the rate of major neonatal conditions was 40% (249
cases). Furthermore, the rate of NICU admission was
72.9%. Major neonatal conditions noted in the current

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Table 2. Clinical outcomes in cases of PPROM

Characteristics
Weeks of gestation at delivery (mean S.D.)
Cesarean delivery, n (%)
Obstetrical complications
Diabetesa, n (%)
Intrahepatic cholestasis of pregnancy, n (%)
Hypertensive disorders of pregnancyb, n (%)
Clinical chorioamnionitis, n (%)
Fetal distress, n (%)
Placenta abruption, n (%)
Umbilical prolapse, n (%)
Fetal death, n (%)
Indications for termination
Clinical chorioamnionitis, n (%)
Maternal or fetal complications
Pregnancy lasted 34 weeks
Neonatal outcomes
Birth weight (mean S.D.)
VLBW, n (%)
NICU admission, n (%)
Neonatal death, n (%)
Major neonatal condition
Intraventricular hemorrhage, n (%)
Respiratory distress syndrome, n (%)
Patent ductus arteriosus, n (%)
Periventricular leukomalacia, n (%)
Sepsis, n (%)
Necrotizing enterocolitis, n (%)

PPROM, n = 510
32.5 1.7
189 (37.1%)
109 (21.4%)
48 (9.4%)
22 (4.3%)
91 (17.8%)
17 (3.3%)
11 (2.2%)
16 (3.1%)
3 (0.6%)
91 (17.8%)
29 (5.7%)
106 (20.8%)
1815.1 462.6
162 (26.1%)
453 (72.9%)
46 (7.4%)
197 (31.7%)
72 (11.6%)
10 (1.6%)
7 (1.1%)
7 (1.1%)
3 (0.5%)

a
Diabetes: includes type 1 diabetes, type 2 diabetes, gestational
diabetes; b Hypertensive disorders of pregnancy: includes chronic
hypertension, gestational hypertension, and preeclampsia.

study were IVH in 197 pregnancies (31.7%), RDS in 72

(11.6%), PDA in 10 (1.6%), PVL in 7 (1.1%), sepsis in 7
(1.1%), and NEC in 3 (0.5%). Data on these conditions
are shown in Table 2.
3.3. Neonatal mortality, major neonatal conditions, and
NICU admission by gestational age at PPROM
The gestational age at PPROM was divided into four
periods to indicate perinatal outcomes by different
weeks of gestation: < 28 weeks, 28-29+6 weeks, 30-31+6
weeks, and 32-33+6 weeks. The groups were analyzed
in terms of the neonatal mortality, the rate of NICU
admission, major neonatal conditions, and the latency
period.
As gestational age at PPROM increased, the risk of
an adverse neonatal outcome declined. The neonatal
mortality rate was 7.4% (46 cases) in cases of PPROM,
50% in pregnancies < 28 weeks, 16.1% in pregnancies
of 28-29 +6 weeks, 5.7% in pregnancies of 30-31 +6
weeks, and 2.2% in pregnancies of 32-33 +6 weeks.
The differences among the groups were statistically
significantly (Table 3). As gestational age at PPROM
increased, the rate of neonatal mortality significantly
decreased.
The rate of major neonatal conditions was 40%
(249 cases) in cases of PPROM, 57.1% in pregnancies
< 28 weeks, 63.44% in pregnancies of 28-29+6 weeks,

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BioScience Trends. 2015; 9(1):35-41.

Table 3. Neonatal mortality, major neonatal conditions, and NICU admission by gestational age at PPROM
Gestational age at PPROM

major neonatal condition, n (%)

< 28 w (n = 28)
28-29+6 w (n = 93)
30-31+6 w (n = 177)
32-33+6 w (n = 323)
Total (n = 621)

neonatal mortality, n (%)

NICU admission, n (%)

14 (50)a
15 (16.1)a
10 (5.7)a
7 (2.2)a
46 (7.4)

16 (57.1)
59 (63.4)
71 (40.1)c
103 (31.9)c
249 (40)

26 (92.9)b
84 (90.3)b
149 (84.2)b
194 (60.1)
453 (72.9)

Comparisons made by chi-square or Fisher's exact test, p < 0.05 is signicant. a compared to each other, b compared to 32+0-33+6 w, c compared
to 28-29+6 w. Major neonatal condition: 28-29+6 w vs. 30-31+6 w, p < 0.001; 28-29+6 w vs. 32-33+6 w, p < 0.001; < 28 w vs. 32-33+6 w, p = 0.007.
Neonatal mortality: < 28 w vs. 28-29+6 w, p < 0.001; < 28 w vs. 30-31+6 w, p < 0.001; < 28 w vs. 32-33+6 w, p < 0.001; 28-29+6 w vs. 30-31+6 w,
p = 0.005; 28-29+6 w vs. 32-33+6 w, p < 0.001; 30-31+6 w vs. 32-33+6 w, p = 0.04. NICU admission: 32-33+6 w vs. < 28 w, p = 0.001; 32-33+6 w vs.
28-29+6 w, p < 0.001; 32-33+6 w vs. 30-31+6 w, p < 0.001.

Table 4. Perinatal outcomes in cases of PPROM with early vaginal bleeding

Characteristics

Present (n = 69)

Absent (n = 441)

Weeks of gestation at PPROM (mean S.D.)

Weeks of gestation at delivery (mean S.D.)
Neonatal birth weight (mean S.D.)
VLBW, %
Neonatal mortality, %
Neonatal morbidity, %

31.1 2.2
32.1 2.0
1766.2 440.9
27.9
13.95
51.16

31.7 1.8
32.6 1.7
1822.9 465.9
25.4
6.36
38.32

p
0.029
0.059
0.292
0.625
0.013
0.024

Comparisons done using a Student's t-test, chi-square test, or Fisher's exact test, p < 0.05 is signicant.

40.11% in pregnancies of 30-31+6 weeks, and 31.9%

in pregnancies of 32-33+6 weeks. The rate of major
neonatal conditions decreased as the gestational age at
PPROM increased (Table 3).
The rate of NICU admission was 60.1% in
pregnancies of 32-33+6 weeks. This rate was significantly
lower than that in pregnancies < 28 weeks, pregnancies
of 28-29+6 weeks, and pregnancies of 30-31+6 weeks
(Table 3).
3.4. Perinatal outcomes in cases of early vaginal
bleeding
Perinatal outcomes were investigated in cases of
early vaginal bleeding and cases where it was absent
(Table 4). Cases of early vaginal bleeding involved a
significantly higher rate of neonatal mortality (13.95%
vs. 6.36%, p = 0.013) and morbidity (51.16% vs.
38.32%, p = 0.024). Cases of early vaginal bleeding
were associated with significantly fewer weeks of
gestation at PPROM (31.1 2.2 weeks vs.31.7 1.8
weeks, p = 0.029).

and neonatal mortality and morbidity.

3.6. Latency period
The latency period was defined as the time from
membrane rupture to delivery. In this study, the median
latency period was 4 days (range 0-56 days). The
latency period was divided into three periods: 48 h, 3-7
days, and > 7 days. The latency period exceeded 48 h in
62.5% of pregnancies and 7 days in 24.3%. Moreover,
twin pregnancies were associated with a shorter latency
period than singleton pregnancies (median latency
period of 2 days versus 4 days, p < 0.001, MannWhitney U test).
There was a strong inverse correlation between
gestational age at PPROM and the latency period.
PPROM at < 28 weeks was associated with a
significantly higher rates of latency 7 days than other
groups (66.7% vs. 30.8%, 66.7% vs. 28.2%, 66.7% vs.
17.1%). PPROM at 32-33+6 weeks was associated with
a significantly higher rates of latency 48 h than other
groups (43.9% vs. 14.3%, 43.9% vs. 29.5%, 43.9% vs.
33.1%).

3.5. Clinical chorioamnionitis

3.7. Analysis of composite factors for the latency period
The latency period and clinical chorioamnionitis were
significant related. The latency period in cases of clinical
chorioamnionitis was longer than that in cases where
clinical chorioamnionitis was absent (median 5 days vs. 3
days, p = 0.001). Cases of clinical chorioamnionitis were
associated with fewer weeks of gestation at PPROM than
were cases where clinical chorioamnionitis was absent
(31.2 2.1 vs. 31.7 1.9, p = 0.014). There was no
significant correlation between clinical chorioamnionitis

Multivariate logistic regression was used to examine

the correlation between the latency period and potential
risk factors such as maternal age, method of conception,
parity, singleton or twin pregnancy, history of early
vaginal bleeding, weeks of gestation at PPROM, and
clinical chorioamnionitis. Results indicated that a twin
pregnancy (OR: 0.319, 95% CI: 0.17-0.6, p < 0.001)
and weeks of gestation at PPROM were associated with

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BioScience Trends. 2015; 9(1):35-41.

the latency interval (OR: 0.737, 95% CI: 0.66-0.822, p
< 0.001).
3.8. Analysis of composite factors for neonatal mortality
or morbidity
Multivariate logistic regression was used to examine
the correlation between neonatal mortality or morbidity
and potential risk factors such as maternal age, method
of conception, parity, singleton or twin pregnancy,
history of early vaginal bleeding, weeks of gestation
at PPROM, clinical chorioamnionitis, and the latency
period. Results indicated that weeks of gestation at
PPROM (OR: 0.953, 95% CI: 0.939-0.966, p < 0.001)
and the latency period (OR: 0.948, 95% CI: 0.926-0.970,
p < 0.001) were associated with neonatal mortality or
morbidity.
4. Discussion
One-third of preterm births are the result of PPROM.
PPROM remains the leading cause of preterm
deliveries and adverse neonatal outcomes. The etiology
of PPROM remains elusive.
Obstetrical strategies to treat PPROM remain
controversial. Intentional delivery should not be an
option for women with PPROM between 28 and 34
weeks of gestation in the absence of other indications
for early delivery since it increases the incidence of
neonatal deaths and the rate of Cesarean sections
(10). Expectant management is a classical approach
to managing PPROM before 34 weeks' gestation,
including admission to the hospital, administration of
corticosteroids, and amniocentesis to exclude intraamniotic infection and/or broad-spectrum antibiotics
prophylaxis (11). Corticosteroids for fetal maturation
have been proven to improve neonatal outcomes in
preterm births and reduce perinatal mortality, RDS,
and IVH (12). According to the guidelines of the
SOGC, following PPROM at 32 weeks' gestation,
antibiotics should be administered to women not in
labor to prolong pregnancy and decrease maternal
and neonatal morbidity; for PPROM at > 32 weeks'
gestation, antibiotics should be administered to prolong
a pregnancy if fetal lung maturity is not evident and/
or delivery is not planned (13). Although there is
no consensus regarding tocolysis, it may be used in
women presenting with uterine contractions or can
be used prophylactically to capitalize on the benefit
of corticosteroids. Delivery is recommended when
PROM occurs at or beyond 34 weeks' gestation (14).
In the current study, management depended on Chinese
guidelines for preterm labor and PPROM, which also
recommend the conservative management of PPROM
before 34 weeks' gestation in combination with
antibiotic therapy and corticosteroids. Indications for
active induction of labor or a Cesarean delivery during

39

prolongation of a pregnancy were as follows: 17.8% of

patients presented with clinical chorioamnionitis, 5.7%
had maternal or fetal complications during prolongation
of a pregnancy, and 20.8% had a pregnancy lasting 34
weeks.
During prolongation of a pregnancy, maternal and
fetal infections can occur. This is especially true for
chorioamnionitis, which is identified by means of
clinical signs, histologic evidence, and the culture of
microorganisms; chorioamnionitis is the most obvious
infection associated with early labor and delivery (15).
The current patients were treated with antibiotics.
There were no maternal deaths or severe neonatal
conditions noted in this study. In this study, clinical
chorioamnionitis was noted in 17.8% of patients. This
figure disagrees with those reported elsewhere due
to differences in inclusion criteria. Ehsanipoor et al.
studied cases of PPROM between 24 and 316/7 weeks'
gestation and noted clinical chorioamnionitis in 9.8%
of twins and 23.2% of singletons; chorioamnionitis
in the placenta was noted in 35.9% of twins and
67.7% in singletons (16). Goya et al. reported that
clinical chorioamnionitis occurred in 23.1% of cases
of expectantly managed PPROM < 34 weeks, and
they diagnosed subclinical chorioamnionitis with
amniocentesis in 4.6% of cases (17). In a retrospective
study of women with singleton and twin pregnancies
and PPROM between 24+0 and 36+6 weeks of gestation,
7.5% were found to have clinical chorioamnionitis
(18). A disadvantage of the current study is that it did
not include histopathological chorioamnionitis due to
incomplete data on placental pathology, so the perinatal
outcomes in cases of PPROM with histopathological
chorioamnionitis could not be determined and the
diagnosis of clinical chorioamnionitis could not be
confirmed with histopathological results.
PPROM is responsible for 30% of the neonatal
morbidity and mortality in premature births. In the
current study, the fetal death rate was 0.6% and the
neonatal mortality rate was 7.41%. These figures agree
with those found in the literature (17). As expected,
the risk of adverse neonatal outcomes declined with a
higher gestational age at PPROM; this finding agrees
with the results of a study by Pasquier et al. (19). In
the current study, the neonatal mortality rate was 50%
at < 28 weeks of gestation, 16.13% at 28-29+6 weeks,
5.65% at 30-31+6 weeks, and 2.17% at 32 weeks.
Another study reported that the neonatal mortality
rate was 53.6% at 28 weeks of gestation, 8.4% at
28-32 weeks, and 3.4% at 33 weeks (4). The rate
of major neonatal conditions in the current study was
40%. These conditions consisted of IVH in 31.7% of
cases, RDS in 11.6%, PDA in 1.6%, PVL in 1.1%,
sepsis in 1.1%, and NEC in 0.5%. These figures agree
with those reported by Gezer et al., who noted RDS in
30.7% of cases, IVH in 11.4%, sepsis in 13.6%, NEC
in 0.4%, PDA in 4.4%, and leukomalacia in 0.4% (4).

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BioScience Trends. 2015; 9(1):35-41.

In the present study, the rate of NICU admission was

72.9%, which is the same as in other studies. Walker et
al. reported that PPROM for > 28 days was associated
with an increased risk of death and morbidity (20).
The current results indicated that weeks of gestation at
PPROM (OR: 0.953, 95% CI: 0.939-0.966, p < 0.001)
and the latency period (OR: 0.948, 95% CI: 0.926-0.970,
p < 0.001) were significantly associated with neonatal
mortality or morbidity. Thus, the contention by Walker
et al. is correct. In light of maternal and fetal findings, a
conservative approach can prove beneficial in cases of
PPROM at < 34 weeks.
Vaginal bleeding in either the first or second
trimester increased the risk of preterm delivery,
PPROM, histological chorioamnionitis, and abruption.
Ascending infection has been implicated as a possible
etiology for PPROM. Data on early vaginal bleeding in
cases of PPROM were analyzed to determine if early
vaginal bleeding in cases of PPROM is associated
with neonatal mortality and morbidity. Perinatal
outcomes were compared in cases of early vaginal
bleeding and cases where it was absent. Cases of early
vaginal bleeding involved significantly fewer weeks of
gestation at PPROM (31.07 2.23 weeks vs. 31.69
1.84 weeks, p = 0.029). Cases of early vaginal bleeding
also involved a higher neonatal mortality and morbidity.
Thus, early vaginal bleeding is a risk factor for fewer
weeks of gestation at PPROM and adverse neonatal
outcomes.
Some factors are known to affect the latency period,
including gestational age, oligohydramnios, number of
fetuses, and complications of pregnancy such as intraamniotic infection, placental abruption, and active
labor (21). In the current study, 37.5% of women with
PPROM delivered within 48 h and 24.3% had a latency
period of 7 days. Gopalani et al. reported 38.8% of
patients with PPROM at 24 to 31.9 weeks delivered
within 48 h, but 32% had a latency period of 7 days
(22). The current study found that a younger gestational
age at PPROM was associated with a longer latency
period and that twin pregnancies were associated with
a shorter latency period than singleton pregnancies
(median latency period of 2 days versus 4 days, p <
0.001). Multivariate logistic regression analysis was
performed after adjusting for confounding factors to
determine risk factors for the latency period. Gestational
age at PPROM (p < 0.001) and a twin pregnancy (p <
0.001) were found to be inversely correlated with the
latency period. This finding agrees with the results of
other studies (18,23,24).
The rate of Cesarean sections in this study was
37.06%. Other studies have reported a rate from 10% to
53% (25,26). The indications for a Cesarean section in
the current cases were fetal distress, repeated Cesarean
sections, abruptio placenta, failure of labor to progress,
and breech presentation.
A limitation of this study was its retrospective

nature. In addition, this study did not include

histopathological chorioamnionitis due to incomplete
data on placental pathology. Perinatal outcomes in cases
of PPROM with histopathological chorioamnionitis
were unable to be determined. Further prospective
studies will focus on the associations revealed by this
analysis.
In conclusion, the current results revealed that weeks
of gestation at PPROM and the latency period were
significantly associated with neonatal mortality or
morbidity. A twin pregnancy and weeks of gestation
at PPROM were significantly correlated with the
latency period. Although early vaginal bleeding was
not significantly associated with neonatal mortality or
morbidity according to multivariate logistic regression,
it may also be a risk factor for perinatal outcomes in
cases of PPROM due to fewer weeks of gestation at
PPROM and a higher neonatal mortality and morbidity.
Acknowledgements
This work was supported by the Scientific Research
Foundation for Chinese Scholars Returning from
Abroad, State Ministry of Education (2012940-1513) and the Science Foundation of Sichuan Province
(2011SZ0195).
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(Received May 9, 2014; Revised December 21, 2014;
Accepted February 17, 2015)

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