在<24周妊娠早产胎膜早破后,孕妇可以选择继续(期待管理)或终止妊娠,通过扩张和疏散或引产。预期管理后的新生儿结局得到了很好的描述。相比之下,与终止妊娠相比,有限的研究涉及与期待管理相关的产妇结局.
本研究旨在比较选择期待治疗或终止妊娠的妇女在妊娠<24周早产胎膜早破后的产妇发病率。
这项回顾性队列研究包括2011年至2018年3个机构的140/7至236/7周早产胎膜早破妇女,其中单胎或双胎妊娠。我们排除了合并胎儿畸形的妊娠,产科手术后立即胎膜破裂(绒毛膜绒毛取样,羊膜穿刺术,环扎放置,胎儿减少),膜破裂后<24小时自发分娩,和预期管理的禁忌症。我们的主要结果是选择待产管理的妇女与选择终止妊娠的妇女之间复合孕产妇发病率的差异。我们将复合母体发病率定义为以下至少1种:绒毛膜羊膜炎,子宫内膜炎,脓毒症,分娩后的计划外手术程序(扩张和刮宫,腹腔镜检查,或剖腹手术),受伤需要修复,计划外子宫切除术,非计划子宫切开术(不包括剖宫产),子宫破裂,出血>1000毫升,输血,入住产妇重症监护病房,急性肾功能不全,静脉血栓栓塞,肺栓塞,并在6周内再次入院。我们比较了选择期待管理的妇女与选择终止妊娠的妇女的人口统计学和产前特征,并使用逻辑回归来量化初始管理决策与复合孕产妇发病率之间的关系。
我们确定了350名在妊娠<24周时因早产胎膜早破而怀孕的妇女,和208名妇女有资格参加这项研究.在208名女性中,108人(51.9%)选择预期管理作为初始管理,100人(48.1%)选择终止妊娠作为初始管理.在选择终止妊娠的妇女中,67.0%进行了引产,33.0%接受了扩张和疏散。与选择终止妊娠的女性相比,选择期待管理的女性发生绒毛膜羊膜炎的几率是其4.1倍(38.0%vs13.0%;95%置信区间,2.03-8.26)和2.44倍的产后出血几率(23.1%vs11.0%;95%置信区间,1.13-5.26)。重症监护病房和计划外子宫切除术仅在预期管理后发生(2.8%vs0.0%和0.9%vs0.0%)。在选择期待管理的女性中,36.2%通过剖宫产分娩,56.4%非下子宫横切口。孕妇复合发病率在期待管理组为60.2%,在终止妊娠组为33.0%。在调整破裂时的胎龄后,site,种族和民族,进入产前护理时的胎龄,在先前的妊娠中胎膜早破,双胎妊娠,吸烟,环扎术,在就诊时进行宫颈检查,期待管理与复合产妇发病率的3.47倍相关(95%置信区间,1.52-7.93),对应于1.91的调整后相对风险(95%置信区间,1.35-2.73)。在选择期待管理的女性中,15.7%的人避免了发病,并有一名新生儿存活出院。
与终止妊娠相比,妊娠<24周时未足月胎膜早破的预期治疗与孕产妇发病风险显著增加相关。
After preterm premature rupture of membranes at <24 weeks\' gestation, pregnant women may choose continuation (expectant management) or termination of pregnancy, via either dilation and evacuation or labor induction. Neonatal outcomes after expectant management are well described. In contrast, limited research addresses maternal outcomes associated with expectant management compared to termination of pregnancy.
This study aimed to compare maternal morbidity after preterm premature rupture of membranes at <24 weeks\' gestation in women who choose either expectant management or termination of pregnancy.
This retrospective cohort study included women with preterm premature rupture of membranes between 14 0/7 and 23 6/7 weeks\' gestation with singleton or twin pregnancies at 3 institutions from 2011 to 2018. We excluded pregnancies complicated by fetal anomalies, rupture of membranes immediately after obstetrical procedures (chorionic villus sampling, amniocentesis, cerclage placement, fetal reduction), spontaneous delivery <24 hours after membrane rupture, and contraindications to expectant management. Our primary outcome was the difference in composite maternal morbidity between women choosing expectant management and women choosing termination of pregnancy. We defined composite maternal morbidity as at least 1 of the following: chorioamnionitis, endometritis, sepsis, unplanned operative procedure after delivery (dilation and curettage, laparoscopy, or laparotomy), injury requiring repair, unplanned hysterectomy, unplanned hysterotomy (excluding cesarean delivery), uterine rupture, hemorrhage of >1000 mL, transfusion, admission to the maternal intensive care unit, acute renal insufficiency, venous thromboembolism, pulmonary embolism, and readmission to the hospital within 6 weeks. We compared the demographic and antenatal characteristics of women choosing expectant management with that of women choosing termination of pregnancy and used logistic regression to quantify the association between initial management decision and composite maternal morbidity.
We identified 350 women with pregnancies complicated by preterm premature rupture of membranes at <24 weeks\' gestation, and 208 women were eligible for the study. Of the 208 women, 108 (51.9%) chose expectant management as initial management, and 100 (48.1%) chose termination of pregnancy as initial management. Among women selecting termination of pregnancy, 67.0% underwent labor induction, and 33.0% underwent dilation and evacuation. Compared to women who chose termination of pregnancy, women who chose expectant management had 4.1 times the odds of developing chorioamnionitis (38.0% vs 13.0%; 95% confidence interval, 2.03-8.26) and 2.44 times the odds of postpartum hemorrhage (23.1% vs 11.0%; 95% confidence interval, 1.13-5.26). Admissions to the intensive care unit and unplanned hysterectomy only occurred after expectant management (2.8% vs 0.0% and 0.9% vs 0.0%). Of women who chose expectant management, 36.2% delivered via cesarean delivery with 56.4% non-low transverse uterine incisions. Composite maternal morbidity rates were 60.2% in the expectant management group and 33.0% in the termination of pregnancy group. After adjusting for gestational age at rupture, site, race and ethnicity, gestational age at entry to prenatal care, preterm premature rupture of membranes in a previous pregnancy, twin pregnancy, smoking, cerclage, and cervical examination at the time of presentation, expectant management was associated with 3.47 times the odds of composite maternal morbidity (95% confidence interval, 1.52-7.93), corresponding to an adjusted relative risk of 1.91 (95% confidence interval, 1.35-2.73). Among women who chose expectant management, 15.7% avoided morbidity and had a neonate who survived to discharge.
Expectant management for preterm premature rupture of membranes at <24 weeks\' gestation was associated with a significantly increased risk of maternal morbidity when compared to termination of pregnancy.