ARTICLE INFO

Article Type

Original Research

Authors

Alijani ‎   L. (1)
Mosadegh ‎   H. (1)
Saremi   A.T. (*)
Mashhadikhan   M. (2)






(*) ‎“Sarem Fertility & Infertility Research Center (SAFIR)” and “Sarem Cell Research Center (SCRC)” ‎, Sarem Women’s Hospital, Tehran, Iran
(1) ‎“Sarem Fertility & Infertility Research Center (SAFIR)” and “Sarem Cell Research Center (SCRC)” ‎, Sarem Women’s Hospital, Tehran, Iran
(2) Sarem Cell Research Center (SCRC)‎, Sarem Women’s Hospital, Tehran, Iran

Correspondence

Article History

Received:  September  23, 2016
Accepted:  January 12, 2017
ePublished:  February 15, 2018

BRIEF TEXT


An early rupture of the embryo's sac before the onset of labor pain and before uterine contractions that ‎cause changes in the cervix is called PROM [1].‎

In terms of the time of occurrence, the breakage of the embryo sac is divided into two parts: a rupture ‎of the embryo sac before 37 weeks of pregnancy or Preterm PROM, which occurs in 3-4.5% of ‎pregnancies and rupture after 37 weeks of gestation or PROM[1-3]. ... [4]. Early rupture of the embryo ‎sac can cause preterm delivery and infection with environmental infections, which is one of the main ‎causes of fetal death, fetal injury, infant choking and infant pneumonia [3].‎ A rare complication in PROM is severe maternal bacterial infection (0.8%), which can lead to maternal ‎death (0.14%). Also, in 2-13% of pregnancies with PROM, inflammation of the uterus (endometritis) ‎may occur and in 9-12% of the cases placenta abruption may occur, which may occur before or after ‎the embryo sac rupture [5].‎ Bleeding in pregnancy, twin pregnancy, genital tract infection, urinary tract infections, cigarette ‎smoking, maternal weight, mechanical damage, sexual intercourse, low economic and social status, ‎inappropriate nutrition, amniocentesis, fetal defects, cervical dilatation, history of PROM, etc. are ‎involved in occurrence of PROM [6-8]. Perhaps the strongest factor is the creation of a PROM, is ‎previous progenitor history, or a previous PROM, and it has been shown that the likelihood of ‎recurrence of PROM is higher in those with a history of early delivery before the early preterm. Also, ‎short-term cervical dilatation in vaginal ultrasonography may indicate an increased probability of ‎developing PROM in women who have not given birth or delivered a birth [5]. The final mechanism ‎that is expressed for the early rupture of the embryo sac is a weakness in the amniotic chorionic ‎membrane (partial or complete, topical or general), which may be due to a decrease in the thickness of ‎the membrane in the rupture position, which can reduce the Type 3 collagen or a loss of elasticity, and ‎its possible contributing factor is the secretion of proteolytic enzymes from cervicovaginal flora or ‎infectious amniotic fluid [7].‎

Considering that PROM has a very important role in complications and problems of childbirth, and the ‎prevalence of these factors has been reported in different populations, it is therefore necessary to study ‎the possible causes associated with it. The aim of this study was to investigate the maternal factors ‎affecting premature rupture of the embryo sac after 37 weeks of pregnancy.‎

This is a case-control study.‎

This study was conducted on pregnant women referred to Sarem Specialized Hospital in 2011-2013.

A total of 242 pregnant women were randomly assigned into two groups of case (PROM) and control. ‎‎121 of them had PROM (premature rupture of the embryo sac after 37 weeks of pregnancy) at least one ‎hour before delivery and 121 remaining pregnant women had healthy embryo sac that matched for age ‎of mother with case group, and examined as control group. Only, single pregnancy was included in this ‎study and the neonates with cases diagnosed with abnormal fetus were excluded the study. ‎

In this study, the effects of factors such as vaginal culture, history of abortion, number of pregnancies, ‎history of cervical surgery and cervical length were investigated. Cervical length was measured from ‎screening data at 11-13 weeks of gestation and from 18 to 20 weeks of gestation. Data were analyzed by SPSS software using Chi-square and Fisher exact tests for qualitative data (age, ‎vaginal culture, history of cervical surgery and cervical length) and Mann-Whitney U test for abnormal ‎quantitative data (abortion number and the number of pregnancies).‎

The highest frequency of mothers was in the case group (PROM) and control group in the age group of ‎‎26-30 years and there was no significant difference in age between the two groups (Table 1).‎The frequency of positive and negative results of vaginal culture tests was not significantly different ‎between the two groups. There was a significant relationship between the number of abortions with ‎PROM (p = 0.001; Table 2), while there was no significant relationship between the number of ‎pregnancies and the occurrence of PROM (p = 0.65). The length of the cervix was significantly different ‎between the two groups (p = 0.0001), while the history of cerclage was not significantly different ‎between the two groups of PROM and control (Table 2).‎Several studies have investigated the role of various maternal and even fetal factors in premature ‎rupture of the embryo sac [9-12]. However, due to the various factors involved in its development, this ‎problem still needs to be further investigated in different populations. Based on the findings of Ahirwar ‎et al., most PROMs (about 70%) occur after 37 weeks of pregnancies [4]. Accordingly, in this study, ‎cases of rupture of embryo sac after 37 weeks were investigated.‎ Lee et al. emphasized the effects of a history of abortion or previous PROM and the reoccurrence of this ‎disorder [13]. In the present study, there was a significant relationship between abortion history and ‎premature rupture of the embryo sac, and a significant number of mothers (20%) who had PROM had a ‎history of abortion of at least one or two fetuses. Also, according to the findings of this study, the ‎number of pregnancies did not have a significant effect on the occurrence of PROM and was consistent ‎with the results of Bayat et al., Which was performed on 720 patients referring to the 22 Bahman ‎hospitals of Mashhad [14].‎ In the present study, more than 53% of mothers who had PROM had a cervical length of less than 35 ‎mm. Earlier, SchleuBner had identified shortness of cervical length as an effective factor in the ‎occurrence of rupture [15]. The results of this study showed that individuals with cervical length less ‎than 35 mm are significantly more at risk of premature rupture of the embryo sac. In a review study, Aarts et al. [16] as well as in the study of Berghella et al. [17], on 250 patients, it has ‎been shown that performing cerclage surgery can effectively prevent the occurrence of PROM. But the ‎history of the cerclage does not show any association. In the present study, the history of cerclage ‎surgical treatment in people with PROM did not show any significant difference with the control group.‎



Many studies have emphasized the existence of an effective link between vaginal infectious agents and ‎premature rupture of the embryo sac and, for numerous reasons, it has proven to have a significant ‎effect on the occurrence of PROM [18, 19]. Although the results of the present study did not confirm ‎these results, due to the lack of vaginal culture testing in all mothers and considering that this ‎difference in results may be due to the infection control program during pregnancy or the use of ‎antibiotics, more detailed studies should be conducted. According to the recommendations of the use ‎of antibiotics in this regard [20], as well as the results that indicate that the use of these antibiotics is ‎associated with the occurrence of PROM [21], these points should be more carefully considered by ‎researchers and specialists. Although most of our findings confirmed previous findings regarding the ‎factors affecting the early rupture of embryo sac, this still requires more precise and extensive studies.‎ ‎



Factors such as cervical length less than 35 mm and the number of abortions (both of which are related ‎in some way) are the maternal factors affecting early premature rupture of the sac after 37 weeks of ‎gestation.‎









TABLES and CHARTS

Show attach file


CITIATION LINKS

[1]Iloanusi NE. Evaluation of pregnant women admitted with prelabour rupture of membranes (PROM). University of Witwatersrand Human Research Ethics Committee; 2013.
[2]Nili F, Shams Ansari A. Neonatal complications of premature rupture of membrane. Acta Med Iran. 2003;41(3):175-9. [Persian]
[3]Li N, Fu Q, Cai W. Cause analysis and clinical management experience of the premature rupture of membrane. 2013;3:222-6.
[4]Ahirwar G, Rajput N, Verma YS. Study of patient with premature rupture of membranes. J Evol Med Dent Sci. 2015;4(31):S288-93.
[5]Resnik R, Creasy RK, Iams J, Lockwood Ch, Moore Th. Creasy and resnik's maternal-fetal medicine: Principles and practice. 7th edition. New South Wales: Saunders; 2004.
[6]Gahwagi MM, Busarira MO, Atia M. Premature rupture of membranes characteristics, determinants, and outcomes of in Benghazi, Libya. Open J Obstet Gynecol. 2015;5(9):494-504.
[7]Choudhary M, Rathore SB, Chowdhary J, Garg S. Pre and post conception risk factors in PROM. Int J Res Med Sci. 2015;3(10):2594-8.
[8]Boskabadi H, Maamouri G, Mafinejad S. Neonatal complications related with prolonged rupture of membranes. Maced J Med Sci. 2011;4(1):93-8.
[9]Yildiz H, Abali S, Keskin S. Investigation of risk factors according to gestational age in cases with premature rupture of membrane. pak j Med Sci. 2012;28(1):124-9.
[10]El Messidi A, Cameron A. Diagnosis of premature rupture of membranes: Inspiration from the past and insights for the future. J Obstet Gynaecol Can. 2010;32(6):561-9.
[11]Di Renzo GC, Roura LC, Facchinetti F, Antsaklis A, Breborowicz G, Gratacos E, et al. Guidelines for the management of spontaneous preterm labor: Identification of spontaneous preterm labor, diagnosis of preterm premature rupture of membranes, and preventive tools for preterm birth. J Matern Fetal Neonatal Med. 2011;24(5):659-67.
[12]Cobo T, Palacio M, Martínez Terrón M, Navarro Sastre A, Bosch J, Filella X, et al. Clinical and inflammatory markers in amniotic fluid as predictors of adverse outcomes in preterm premature rupture of membranes. Am J Obstet Gynecol. 2011;205(2):126.e1-8.
[13]Lee T, Carpenter MW, Heber WW, Silver HM. Preterm premature rupture of membranes: Risks of recurrent complications in the next pregnancy among a population-based sample of gravid women. Am J Obstet Gynecol. 2003;188(1):209-13.
[14]Bayat MM, Tabrizian F, Dolatabady E, Khalesian B. Analysis of some maternal risk factors in preterm delivery. J Mediv Sci. 2009;3(19):141-6. [Persian]
[15]Schleubner E. The prevention, diagnosis and treatment of premature labor. Deut Arztebl Int. 2013;110(13):227-35.
[16]Aarts JM, Brons JT, Bruinse HW. Emergency cerclage: A review. Obstet Gynecol Surv. 1995;50(6):459-69.
[17]Berghella V, Rafael TJ, Szychowski JM, Rust OA, Owen J. Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: A meta-analysis. Obstet Gynecol. 2011;117(3):663-71.
[18]Minkoff H, Grunebaum AN, Schwarz RH, Feldman J, Cummings M, Crombleholme W, et al. Risk factors for prematurity and premature rupture of membranes: A prospective study of the vaginal flora in pregnancy. Am J Obstet Gynecol. 1984;150(8):965-72.
[19]Mercer BM, Arheart KL. Antimicrobial therapy in expectant management of preterm premature rupture of the membranes. Lancet. 1995;346(8985):1271-9.
[20]Kenyon S, Boulvain M, Neilson JP. Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev. 203;2:CD001058.
[21]Steinfeld JD, Lenkoski C, Lerer T, Wax JR, Ingardia CJ. Neonatal morbidity at 34-37 weeks: The role of ruptured membranes. Obstet Gynecol. 1999;94(1):120-3.