Penyakit infant

All live born infants had at least one of the major neonatal
morbidities analyzed in our study (Table 4). Fifty percent or
more of all liveborn infants suffered from respiratory
distress syndrome or chronic lung disease. More than onethird
had intraventricular hemorrhage. The median duration
of nursery stay for all liveborn fetuses was 106 days (range
1555).
Table 4 shows all complications in the infants surviving
the perinatal period. Among these, eight suffered from
respiratory distress syndrome, nine from chronic lung
disease, six from intraventricular hemorrhage, five had
retinopathy of prematurity, five suffered from sepsis, eight
had to undergo surgery for a patent ductus arteriosus and one
infant had necrotizing enterocolitis. The nursery stay for
infants in 2223 weeks group is represented in Kaplan
Meyer curve (Fig. 1). The estimated median nursery stay for
infants who survived the perinatal period was 143 days. The
nursery stay range was 78555 days. Out of 13 infants who
survived the perinatal period, 1 infant expired in the nursery
after 151 days of birth.

Table 4 presents maternal outcomes

after periviable PROM.
Overall, the
most common maternal morbidity reported
after periviable PROM is chorioamnionitis,
with approximately 37% of
women developing this complication. In
addition, 11% will also develop endometritis.
Of note, maternal sepsis and maternal
death appear to be rare, with sepsis
complicating 1 of every 100 pregnancies
with periviable PROM, and only 1 investigation
reporting a single maternal
death (1/

Maternal morbidity
Most of the studies did not present the maternal morbidity
data according to gestational age of rupture of
membranes. Only two studies showed the morbidities
of mothers following PPROM at less than 23 weeks'
gestation. Morales and TalleyZ7 found the incidence
of chorioamnionitis to be 6.6% and 30% in cases of
PROM in 20 weeks and 20-23 weeks of gestation
respectively. Beydon and YasinZ4 found 50% of
patients developed chorioamnionitis in pregnancies
with PPROM prior to c. 23 weeks of gestation.

Perinatal morbidity and mortality

Fetal death after PROM at or near the
limit of viability is common at 31.6%
(Table 5). Although survival has been reported
with membrane rupture as early
as 11 weeks gestational age,22 a significant
difference in survival can be found
with PROM _22 weeks compared with
PROM occurring _22 weeks (Table 6).
It is important to reiterate that currently
available data likely overstate the survival
through exclusion of those not
amenable to continued conservative
treatment and those electing pregnancy
terminations for persistent fluid leakage,
oligohydramnios, or abnormal ultrasound
findings.
A summary of neonatal morbidities
after conservative management of periviable
PROM are presented in Table 7.
Respiratory complications are frequent
with 66% developing respiratory distress
syndrome. Additional morbidities such
as bronchopulmonary dysplasia and
sepsis are also frequently present. Longterm
outcomes including intact survival
(survival without minor or major impairments)
have been reported; however,
most investigations have limited
long-term follow-up and it is not possible
to differentiate whether the reported
outcomes are optimistic (underreporting
of deaths) or pessimistic (disproportionate
follow-up of those with
morbidity).
To estimate the potential risks and
benefits of latency for periviable PROM,
Everest et al6 evaluated outcomes among
neonatal survivors with prolonged (_2
weeks in duration) periviable PROM in
2008. Of 98 women with PROM occurring
_24 weeks, 40 (41%) delivered a
liveborn infant after a latency of at least
14 days. Ten additionalwomendelivered
a stillbirth after prolonged latency with
PROM _24 weeks. Among the 40 liveborn
infants, the reported mortality was
30% (n _ 12). Overall, 10 newborns
were diagnosed with pulmonary hypoplasia,
but only 1 of the neonatal deaths
had an autopsy performed.
Few data are available regarding the
prognosis of PROM after midtrimester
genetic amniocentesis. Many of the retrospective
trials either do not comment
on this, or these patients are excluded
from the analysis. Morales and Talley21
reported that 8 of 138 total women with
PROM_25 weeks had an amniocentesis
preceding rupture of membranes. Of
these 8 women, 7 eventually resealed
their membranes and had a term delivery.
Gold et al16 reported on 603 cases of
genetic amniocentesis, with 7 (1.2%)
having subsequent rupture of membranes.
In all 7 cases there was cessation
of leakage of fluid with reaccumulation
of a normal amount of amniotic fluid.

In some studies individual outcome data were presented

(n = 4).12,a9s.a In others it was possible to
abstract the data for the specified gestational age
groups tie < 20,2043 weeks) to obtain aggregate data
(n = 4 ).11,24.27,31 Two studiesBsm gave information for
less than 22 weeks but did not allow the data to be
divided into further different gestational age groups.
Shumway et a131 provided data that allowed analysis of
patients with PPROM prior to 20 weeks but categorised
patients in such a way that those with PPROM

between 20-23 weeks could not be identified. The article

by Bengtson et alZ also presented only the information
regarding perinatal survival below 20 weeks of
gestation and no other information could be extracted
from it.
The study by Major and Kitzmillep found perinatal
survival rate to be 50% and 64% among those with
PROM in 19-21 weeks and 21-23 weeks. There was no
neonatal death in this group. Au. were still births. Rib
et alw found no perinatal survival in the group 19-21.9 weeks and 2 0 O 0 survival in the group 22-22.9
weeks. The article by Rib et al% did not present any data regarding still birth and neonatal death in the group

with PPROM prior to 23 weeks.

Table 3 illustrates the survival data in two divided

gestational age groups according to the time of rupture
of membranes. The average live birth rate for all
cases with PPROM less than 23 weeks was 67Oj0 (95O!0
CI: 60-73). The range of perinatal survival when
PPROM occurred in < 20 weeks of gestation was
0-33/o. Among 20-23 weeks of gestation the perinatal
survival ranged from 840%.
In total there were 46 infants who survived the
neonatal period out of 228 pregnancies with PPROM
less than 23 weeks in 11 studies, an average of 21Oh
(95"o CI: 16-27).

Perinatal morbidity
Perinatal morbidity amongst survivors was presented
in different ways from study to study. Only two studies
presented neonatal morbidity data among the surviving
neonates.
Farooqi et all2 found that among the survivors of
PPROM at 14-19 weeks the neonates suffered 75O0 from
respiratory distress syndrome and 25f~ from bronchopulmonary
dysplasia, pneumothorax. sepsis and
pulmonary hypoplas ia .
Pulmonary hypoplasia was the cause of death in ail
seven cases in the group with amniorrhexis before 20
weeks. Pulmonary hypoplasia was associated with the
period of gestation at which the membranes ruptured
and not related to the latency period. Only one neonate
died with PROM at 20 weeks due to sepsis.12 The study
found four out of 10 (40O.0) alive after two years. One of
them was suffering from spastic diplegia and the three
remaining survived without major impairment.
The study by Morales and Talleyn showed the
neonatal morbidity among the live born infants. In the
PROM group at 20-23 weeks of gestation, 67'0 of the
neonates had respiratory distress syndrome, Sooha d
bronchopulmonary dysplasia and 40b had intraventricular
haemorrhage, 27y0 had ret inopathy of prematurity
and 7% had sepsis. Only one neonate in the
group of PROM rc 20 weeks survived the neonatal
period without any morbidity.