A study of perinatal outcome in preterm premature rupture of membranes

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“A STUDY OF PERINATAL OUTCOME IN PRETERM PREMATURE RUPTURE OF

The Tamil Nadu Dr. M.G.R Medical University

In partial fulfilment of the requirement for the award of the Degree of

M.S. OBSTETRICS AND GYNAECOLOGY

THE TAMIL NADU Dr. M.G.R MEDICAL UNIVERSITY INSTITUTE OF OBSTETRICS AND GYNAECOLOGY, GOVERNMENT HOSPITAL FOR WOMEN & CHILDREN,

MADRAS MEDICAL COLLEGE.

A STUDY OF PERINATAL OUTCOME IN PRETERM PREMATURE RUPTURE OF

MEMBRANES”

Dissertation submitted to

The Tamil Nadu Dr. M.G.R Medical University

M.S. OBSTETRICS AND GYNAECOLOGY BRANCH II

APRIL-2018

A STUDY OF PERINATAL OUTCOME IN PRETERM PREMATURE RUPTURE OF

The Tamil Nadu Dr. M.G.R Medical University

M.S. OBSTETRICS AND GYNAECOLOGY

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BONAFIDE CERTIFICATE

This is to certify that this dissertation entitled “A STUDY OF PERINATAL OUTCOME IN PRETERM PREMATURE RUPTURE OF MEMBRANES” is the bonafide original work done by Dr.S.YOGALAKSHMI, post graduate in the Department of Obstetrics and Gynaecology, under the guidance of Dr.ARASI SRIVATHSAN, MD, OG., Professor, Institute of Social Obstetrics and Gynaecology, Kasturba Gandhi Hospital, Madras Medical College, Chennai, towards partial fulfilment of the requirement of the Tamil Nadu Dr. M.G.R Medical University for the award of M.S Degree in Obstetrics and Gynaecology, March 2018. The period of post graduate study is from June 2015 to June 2018.

Prof.Dr.ArasiSrivathsan MD, OG Prof Dr.T.K.ShanthyGunasinghMD, DGO

Professor, Director and Superindent,

ISO-KGH IOG

Prof R. NARAYANABABU MD, DCH Dean.

Madras Medical College.

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DECLARATION

I solemnly declare that this dissertation “A STUDY OF PERINATAL OUTCOME IN PRETERM PREMATURE RUPTURE OF MEMBRANES” was prepared by me under the guidance and supervision of Dr.Arasi Srivathsan, MD, OG., Professor, Institute of Social Obstetrics and Gynaecology, Kasturba Gandhi Hospital, Madras Medical College, Triplicane, Chennai.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R.

Medical University, Chennai in partial fulfilment of the University regulations for the award of the degree of M.S. (Obstetrics and Gynaecology).

Place: Chennai

Date: Dr.S.YOGALAKSHMI

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ACKNOWLEDGEMENTS

I gratefully acknowledge and sincerely thank Dr.R.Narayana Babu, MD, DCH., Dean, Madras Medical College, for allowing me to use thefacilities and clinical materials available in the hospital.

I extend my sincere thanks and gratitude to Dr.T.K.Shanthy Gunasingh, MD, DGO., Director and Superintendent, IOG, for granting me permission to utilize the facilities of the institute for my study.

I am extremely grateful to our beloved Professor, Dr.Arasi Srivathsan, MD, OG., Professor of Obstetrics &Gynaecology, ISO-KGH, for her valuable guidance, motivation and encouragement given during the study.

I humbly thank all the Professors and Assistant Professors of IOG, Egmore and Government Kasturba Gandhi Hospital, Triplicane for all their help during the course of the study.

My sincere thanks to my statistician Mr.Padmanabhan who patiently helped me in analysing the results of this study.

My special thanks to my family and friends for their physical help and moral support without which nothing would have been possible.

I am immensely grateful to all the patients who took part in the study.

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CONTENTS

SL.NO TITLE PAGE NO.

1 INTRODUCTION 1

2 AIM AND OBJECTIVES 3

3 MATERIALS AND METHODS 4

4 REVIEW OF LITERATURE 7

5 OBSERVATION AND RESULTS 24

6 DISCUSSION 81

7 CONCLUSION 83

8 BIBLIOGRAPHY 84

9 INFORMED CONSENT FORM 88

10 PROFORMA 90

MASTER CHART

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ABBREVIATION

ROM - Rupture of membranes

PPROM - Preterm premature Rupture of membranes MMPs - matrix metallo proteinase

fFN - Fetal fibronectin

HMD - Hyaline membrane disease RDS - Respiratory Distress syndrome

ACOG - American college of obstetrics and gynaecology NICE - National institute of clinical Excellence

H/O - History of

MOD - Mode of delivery

LSCS - Lower segment cesarean section

B - booked

UB - unbooked

AFI - amniotic fluid index

NICU - neonatal intensive care unit

BMI - body mass index

NEC - necrotizing Enterocolitis

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INTRODUCTION

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INTRODUCTION

Preterm premature rupture rupture of membranes is defined as rupture of fetal membrane before onset of labour at less than 37 completed weeks of gestation and after 28 weeks of gestation.

Incidence ranges from 3-10% of all deliveries. Preterm premature rupture of membrane is one of the important causes of preterm birth can result in high perinatal morbidity and mortality.

Preterm premature rupture of membranes complicates 3% of pregnancies and leads to one third of preterm birth. Preterm delivery affects one in 10 birth in USA and even greater birth in developing continues and causes 40-75% neonatal death.

There are numerous risk factors for preterm premature rupture of membrane such as maternal, socioeconomic class, infection at early gestational age and associated co-morbid condition. Both mother and fetus are at greater risk of infection after preterm premature rupture of membrane.

The fetal and neonatal morbidity and mortality risks are significantly affected by severity of oligohydrominos, duration of latency and gestation at preterm premature rupture of membrane .

Complication of preterm premature rupture of membrane for the fetus and newborn consist of prematurity, fetal distress, altered

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pulmonary development leading to pulmonary hypoplasia, pulmonary hypertension, necrotizing enterocolitis and neurological disorder.

The treatment relies on accurate diagnosis and gestational age is dependent. The diagnosis of preterm premature rupture of membrane is made by a combination of clinical suspicious, patient history and some simple test.

Any evidence of infection , fetal distress and cord accidents is an indication for delivery. A gestational age approach to therapy is important and should be adjusted to each hospitals neonatal care unit. Antenatal antibiotics and steroids have clear benefits and should be offered to all women without complication.

The management of patients with preterm premature rupture of membrane has changed markedly in the past several years. The basis for this is a combination of better understanding of newborn physiology, improved neonatal care and the widespread use of fetal monitoring.

An important recent advance is the recognition that an active observation of program is associated with less morbidity and mortality.

Moreover advances in perinatal and antenatal care will continue to improve the outcomes of these of these women and their children.

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AIMS AND

OBJECTIVES

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AIM & OBJECTIVES

AIM:

To study perinatal outcome in preterm premature rupture of membrane.

OBJECTIVE:

1. To study risk factors associated with preterm premature rupture of membrane.

2. To study perinatal morbidity and mortality associated with preterm premature rupture of membrane.

3. To study the outcome of labour in preterm premature rupture of membrane.

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MATERIALS

ANDMETHODS

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MATERIALS AND METHODS

This study was conducted in ISO-KGH from may 2016-may 2017 under Madras Medical College. Institutional Ethical committee clearance was obtained from Madras Medical College.

SAMPLE SIZE:

200 patients STUDY DESIGN:

Prospective observational study DURATION OF STUDY:

One year

STUDY CENTRE:

Department of obstetrics and gynaecology in ISO KGH, Chennai.

INCLUSION CRITERIA:

All pregnant women with a singleton pregnancy between 28-37 weeks of gestation admitted in labour room were shifted after considering inclusion and exclusion criteria.

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EXCLUSION CRITERIA:

1. Multiple pregnancy 2. Fetal growth restriction 3. Uterine anomalies 4. Foetal anomalies

5. Hypertensive disorder complicating pregnancy 6. Gestational diabetes

7. Antepartum haemarrhage ( Placenta praevia, Abruption ) 8. Class 2-4 cardiac disease

9. Tumour complicating pregnancy ( Fibroid, Ovarian tumour )

10. Medical disorder complicating pregnancy ( Chronic hypertension, Chronic renal disease and SLE

STUDY METHOD:

This was prospective observational study which was carried out those pregnant women admitted with preterm premature rupture of membranes between 28-36 weeks of gestation. The gestational age was calculated from LMP, if there is discrepancy of more than seven days

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between LMP and early weeks USG and consecutive two coincide then USG EDD should be taken.

For above mentioned patients we will do baseline investigation like Hb, pcv, Blood grouping and Typing and High vaginal swab. Per speculum examination should be done to confirm the diagnosis of preterm premature rupture of membranes. Digital examination only be done only when the patient is in the active labour.

The above mentioned patients are closely monitored throughout labour. Immediately after delivery paediatrician was called over and look sign of infection and Respiratory distress syndrome.

All the information was attached in pretested questionare. In study all patients are observed until discharge from hospital. The study was conducted after getting consent from patient. Close monitoring of all patients of preterm premature rupture of membrane during labour and baby immediately after delivery and upto discharge.

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REVIEW OF

LITERATURE

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REVIEW OF LITERATURE

ROM:

Rupture of membrane or amniorrhexis is a term said during pregnancy to describe a rupture of the amniotic sac. Normally it occurs spontaneously at full term either during or at the beginning of lobour.

PPROM:

Preterm premature rupture of membrane defined as rupture of membrane before 37 completed weeks of gestation.

TYPES OF PPROM

Early preterm: 28-32 weeks Moderate preterm: 32-34 weeks Late preterm: 34-36 weeks INCIDENCE:

Incidence of PPROM ranges from 3.0-10.0% of all deliveries.

PPROM complicates approximately 3% of pregnancies and leads to one third of preterm birth.

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STRUCTURE OF FETAL MEMBRANES:

These are the membrane that develop outside the embryo but in close association with it and they carry out certain specific functions.

Fetal membrane consist of amnion, chorion, allantois and yolk sac. The amnion was innermost membrane of fetus and forms amniotic cavity that contains amniotic fluid. The chorion was between amnion and decidua.

AMNION:

The amnion is the membrane that closely covers the embryo.

Pregnancy is the period of time during which a child matures with in the womb of the mother. The period is important for the development of the fetus. During this time the fetus must be protected from internal environment of the mothers body and this is achieved in many ways. One of the primary form of protection is the amniotic sac which is the protective sac and fluid that surrounds the fetus and prevents damage.

The membrane that forms this sac is known as amnion. The amniotic fluid provides a shock absorbing effect to the embryo against womb infections etc. The watery fluid around the embryo helps in maintaining constant temperature and pressure and protects the embryo in case the mother has a fall. The amniotic fluid is derived from the mothers blood and contains foetal cells. This is made use of in the prenatal sex test for the fetus- known as amniocentesis. In amniocentesis the amniotic fluid is

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drawn out with a syringe and the cells are tested for the presence of sex chromosomes.

CHORION:

Chorion is a membrane that develops at the beginning of a pregnancy between the developing fetus and the mother and continuous to grow through out the pregnancy. It is formed by two layers the embryonic mesoderm and double layers of trophoblasts. Chorion protects the embryo and forms placenta for metabolic exchange between mother and fetus.

YOLK SAC:

This is the formed below the embryo. In human beings this contains a fluid but no yolk. It is vestigial organ. Its wall is made of trophoblast and endoderm. The yolk sac functions as the region of the formation of blood cells upto about 6^th week of development when liver of fetus takes up this function.

ALLANTOIS:

This is a small bag like structure that develops from the gut of the embryo and near the yolk sac. This membrane develops around the third

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enclosed in umbilical cord. Allantois helps in the formation of umbilical arteries and veins. The allantois also forms blood cells.

ETIOPATHOGENESIS:

WEAKENED FETAL MEMBRANE:

Fetal membrane likely break because they become fragile and weak. This weakening is a normal process that typically happens at term as the body prepares for labor and delivery. But, this can be a problem when it occurs preterm (preterm). The natural weakening of fetal membrane is thought to be due to one or combination of the following. In preterm premature rupture rupture of membranes, these process are activated too early;

CELL DEATH;

When cells undergoes programmed cell death, they release chemical markers that are detected in high concentration in cases of preterm premature rupture of membrane

Poor assembly of collagen:

Collagen is a molecule that gives fetal membrane their strength. In cases of preterm premature rupture of membranes proteins that bind and cross link collagen to increase its tensile strength are altered.

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BREAKDOWN OF COLLAGEN:

Collagen is broken down by enzymes called matrix metalloproteinases (MMPs), which are found at higher level in PPROM amniotic fluid, this MMPs will break down the strength- bearing collagen, so prostaglandin production will be synthesized in high amount to prompt the uterine contraction and cervical ripening. MMPs are inhibited by tissue inhibitors of MMPs which are found lower levels in PPROM amniotic fluid.

INFECTION:

Infection and inflammation likely explains why membrane break earlier than they are supposed to. In studies bacteria have been found in the amniotic fluid one third of cases of PPROM. Often, testing of amniotic fluid is normal, but a subclinical infection (too small to detect) or infection of maternal tissues next to the amniotic fluid, may still be contributing. In response to infection, the body creates inflammation by making chemicals (ex: cytokines) that weaken the fetal membrane and put them at risk for rupture. PPROM is also risk factor in the development of neonatal infection.

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GENETICS:

Many genes play role in inflammation and collagen production, therefore inherited genes may play a role in predisposing a person to PPROM.

RISK FACTORS:

The cause of PPROM is not clearly understood, but the following are risk factors that have been shown to increase the chance of it happening. In many cases however no risk factors is identified.

1.Infectins: urinary tract infection, sexually transmitted diseases, lower genital infections ( ex: Bacterial vaginosis)

2. Cigarette smoking during pregnancy 3. Illicit drug use during pregnancy

4. Having had PPROM in previous pregnancies 5. Hydrominos: too much amniotic fluid

6. Multiple gestation: being pregnant with two or more fetuses at one time

7. Having had episodes of bleeding anytime during pregnancy

8. Invasive procedure like amniocentesis and chorionic villous sampling

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9. Nutritional deficits

10. Cervical insufficiency: having short or prematurely dilated cervix during pregnancy

11. Low socio economic status 12. Being overweight

DIAGNOSIS OF PPROM:

To know for sure if a women has experienced PPROM a health care clinician must prove that the fluid leaking from the vagina is amniotic fluid, and the lobor has not yet started. To do this, a health care clinician will take a medical history, do a gynecological exam using a sterile speculum and ultrasound.

HISTORY:

A person with PPROM typically recalls a sudden gush of fluid loss from the vagina, or steady loss of small amount of fluid.

SPECLUM EXAMINATION:

A health care clinician will insert a sterile speculum into the vagina in order to see inside and perform the following evaluation. Digital

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measure the cervix, are avoided until the women is in active labor to reduce the risk of infection.

POOLING TEST;

Pooling is when a collection of amniotic fluid can be seen in the back of vagina (vaginal fornix). Sometimes leakage of fluid from the cervical opening can be seen when the person coughs or does a valsalva maneuver.

NITRAZINE TEST:

A sterile cotton swab is used to collect fluid from the vagina and place it on nitrazine paper (phenaphthazne). Amniotic fluid is mildly basic (ph 7.1-7.3) compared to normal vaginal secretion which are acidic ( ph 4.5-6 ). Basic flid, like amniotic fluid, will turn the nitrazine paper from orange to dark blue.

FERN TEST:

A sterile cotton swab is used to collect fluid from vagina and place it on a microscope slide. After drying, amniotic fluid will form a crystallization pattern called arborization which resembles leaves of a fern plant when viewed under a microscope.

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FETAL FIBRONECTIN :( fFN )

It is the protein produced in pregnancy that determine the risk of preterm delivery. The fFN test measures the amount of fetal fibronectin in vaginal secretion and is performed like a pap smear test. A negative test is a predictor that delivery will not occur in the next two weeks, but a positive test does not necessarily indicate that preterm delivery is imminent,

IMMUNOLOGICAL TEST:

Immune- chromatological tests ( Amnisure, Actim PPROM test, Biosynex Amnioquick ). These are commercially available test kits that detect chemicals present in amniotic fluid; placental alpha microglobulin- 1 (AmniSure ) and insulin like growth factor binding protein-1 ( Actim PPROM test ). These are helpful if negative to rule out PPROM, but are not that helpful if positive because the false positive rate is 19-30%.

DYE TEST

In this test a needle is used to inject indigo carmine dye (blue) into the amniotic fluid that remains in the uterus through the abdominal wall.

In the case of PPROM, blue dye can be seen on a stained tampon or pad after about 15-30 minutes. This method can be used to definitively make

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infection. But, can be helpful if the diagnosis is still unclear after the above evaluations have been done.

ULTRASOUND:

Ultrasound can measure the amount of amniotic fluid still in the uterus surrounding the fetus. If the fluid levels are low, PPROM is more likely. This is helpfl in cases when diagnosis is not certain, but is not, by itself, definitive.

OTHER TESTS:

1. Detection of fetal cells in amniotic fluid

2. Detection of vernix and lanugo hair in amniotic fluid

FALSE POSITIVES:

Like amniotic fluid, blood, semen, vaginal secretion, antiseptics, basic urine and cervical mucus also have a basic ph and also turn nitrazine paper blue, Cervical mucus can also make a pattern similar to ferning on a microscope slide, but it is usually patchy and less branching.

DIFFERENTIALDIAGNOSIS:

Other things to keep in mind that may present similarly to PPROM are the following:

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• Urinary incontinence: Leakage of small amounts of urine is common in the last part of pregnancy

• Normal vaginal secretion of pregnancy

• Increased cervical discharge: this can happen when there is a genital tract infection

• Semen

• Douching

• Vesicovaginal fistula: an abnormal connection between the bladder and the vagina

• Loss of the mucus plug

COMPLICATION OF PPROM

COMPLICATIONS INCIDENCE (%) 1. Cord compression 32 to 76

2. Chorioamnionitis 13 to 60 3. Abruptio placentae 4 to 12 4. Antepartum fetal death 1 to 2 5. Respiratory distress syndrome 35

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MATERNAL

1. Choriomnionitis (acute and subclinical)

This was most common complication occurring in PPROM .Clinical chorioamnionitis is Diagnosed solely based on clinical signs since access to uncontaminated amniotic fluid or placenta for culture is invasive and usually avoided. Typically, the presence of fever with in addition two other signs like uterine tenderness, maternal or fetal tachycardia and foul or purulent amniotic fluid. Chorioamnionitis is an indication for termination of pregnancy not cesarean section the latter was indicated in obstetric indication only.

2. Postpartum endometritis

This was another maternal complication of PPROM. Endometritis was usually associated with chrioamnionitis. The duration of antibiotic therapy after preterm premature rupture of membrane does not affect the neonatal morbidity and maternal morbidity.

FETAL

1. Prematurity

2. Hyaline membrane disease 3. Infection

4. Neurological damage 5. Pulmonary hypoplasia

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6. Cerebral palsy

7. Musculoskeletal deformity

THE ROLE OF CORTICOSTEROIDS:

Corticosteroids decrease perinatal morbidity and mortality after PPROM. A recent meta-analysis found that corticosteroids after PPROM, versus no administration, reduced the risk of respiratory distress syndrome (20 versus 35.4%) intraventricular hemorrhage (7.5 versus 15.9%) and necrotizing enterocolitis (0.8 versus 4.6%) without an increase in the risk of maternal and fetal infection. The most widely used and recommended regimens include intramuscular betamethasone 12mg every 24 hours for two days, or intramuscular dexamethasone 6mg every 12 hours for two days. The National institutes of Health recommends administration of corticosteroids nefore 30-32 weeks gestation, assuming fetal viability and no evidence of intra-amniotic infection. Use of corticosteroids between 32-34 weeks is controversial. Adminstration of corticosteroids after 34 weeks gestation is not recommended unless there is evidence of fetal lung immaturity by amniocentesis. Multiple courses are not recommended because studies have shown that two or more courses can result in cerebral palsy.

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ROLE OF ANTIBIOTICS IN PPROM:

Giving antibiotics to patients with PPROM can reduce neonatal infection and the latent period. A meta- analysis showed that a patient receiving antibiotics after PPROM, compared those not receiving antibiotics experienced reduced postpartum endometritis, chorioamnionitis, neonatal sepsis, neonatal pneumonia and intraventricular hemorrhage. Another meta-analysis found a decrease in neonatal intraventricular hemorrhage and sepsis. The regimen studied by the National institute of Child Health and Human Development trial uses an intravenous combination of 2 gms of ampicilin and 250 mg of erythromycin every 6 hours for 48 hours, followed by 250 mg of amoxicillin and 333 mg of erythromycin every 8 hours for 5 days.

TOCOLYTIC THERAPY:

Limited data are available to help determine whether tocolytic therapy is indicated after PPROM. As described above, corticosteroids and antibiotics are beneficial when administered to patients with PPROM, but no studies of these therapies combined with tocolysis are available.

Tocolytic therapy is not improve neonatal outcome. Long term tocolytic therapy in patients with PPROM is not recommended; consideration of this should await further research. ACOG guideline, there is no clear evidence that tocolytic drug improve outcome and therefore it is

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reasonable not to use them. However tocolysis should be considered if the few days gained would be put to good use, such as completing a course of corticosteroids or in utero transfer.

ACOG GUIDELINE:

There is no clear evidence that tocolytic drugs improve outcome and therefore it is reasonable not to use them. However, tocolysis should be considered if the few days gained would be put to good use, such as completing course of corticosteroids or in utero transfer.

MANAGEMENT OF PPROM 1. 28-31 WEEKS

Delivery before 32 weeks gestation may lead to severe neonatal morbidity and mortality. In the absence of intra-amniotic infection pregnancy may be prolonged under antibiotics and corticosteroids until 34 weeks of gestation. Contraindication for conservative management is chorioamnionitis, abruption and non reassuring fetal heart patterns.

Despite these measures many patients will deliver with in two weeks of PPROM. During conservative treatment should watch for maternal temperature, uterine contractions, uterine tenderness and laboratory evidence of infection like leucocytosis or elevated ESR. Evidence

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suggests that prolonged latency lead to increased incidence of intra- amniotic infection.

2. 32-33 WEEKS

PPROM between 32-33 weeks of gestation should be induction of labor after transport of patients to intensive neonatal care should be considered. Prolonging pregnancy after documentation of pulmonary maturity unnecessarily increases the likelihood of maternal infection, umbilical cord compression and neonatal infection. There are few data to guide the care of patients without documented pulmonary maturity.

Physicians must balance the risk of respiratory distress syndrome and other sequelae of premature delivery with the risk of pregnancy prolongation, such as neonatal sepsis and core accidents. Physician should administer a course of corticosteroids and antibiotics to patients without documented lung maturity consider delivery 48 hrs later or perform careful assessment of fetal well being, observe for intra amniotic infection, and deliver at 34 weeks.

3. 34-36 WEEKS

When PPROM occurs between 34-36 weeks gestation, physician should avoid to urge to prolong the pregnancy. Studies shown that labor induction clearly is beneficial at or after 34 weeks of gestation. One study showed that Conservative management between 34-36 weeks of gestational age resulted in an increased risk of chorio amnionitis and a

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lower average umbilical cord ph. PPROM is not a contraindication to vaginal delivery.

PREVENTION:

Both intravaginal progesterone and cervical cerclage are used prophylactically to prevent PPROM in different circumstances, although evidence is lacking on which is more effective and the relative costs and benefits of each. In the UK, NICE has the following recommendations for women who, on a transvaginal ultrasound scan between 16 and 34 weeks, have a cervical length of <25mm. Women who have previously had a preterm birth or pregnancy loss between 16 and 34 weeks, should be offered either intravaginal progesterone or cervical cerclage. Women with no history of a preterm birth or pregnancy loss between 16 and 34 weeks, should be offered intravaginal progesterone. Women who have had PPROM in a previous pregnancy or have a history of cervical trauma, should be offered cervical cerclage. ACOG does not recommend intravaginal progesterone or cervical cerclage and either of which not improve maternal and perinatal outcome.

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OBSERVATION

AND RESULTS

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OBSERVATION AND RESULTS

AGE GROUP Vs PPROMGROUP TABLE 1

PPROMGROUP

(GA in weeks) Total 28-32 33-34 <37

AGE GROUP

UPTO 25

Count 20 16 72 108

% within AGE

GROUP 18.5% 14.8% 66.7% 100.0%

% within

PPROMGROUP 45.5% 30.8% 69.2% 54.0%

% of Total 10.0% 8.0% 36.0% 54.0%

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Count 20 28 24 72

% within AGE

GROUP 27.8% 38.9% 33.3% 100.0%

% within

PPROMGROUP 45.5% 53.8% 23.1% 36.0%

% of Total 10.0% 14.0% 12.0% 36.0%

>30

Count 4 8 8 20

% within AGE

GROUP 20.0% 40.0% 40.0% 100.0%

% within

PPROMGROUP 9.1% 15.4% 7.7% 10.0%

% of Total 2.0% 4.0% 4.0% 10.0%

Total

Count 44 52 104 200

% within AGE

GROUP 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

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Chi-Square Tests

Value df Asymp. Sig.

(2-sided)

Pearson Chi-Square 22.875^a 4 .000

Likelihood Ratio 23.350 4 .000

Linear-by-Linear

Association 8.000 1 .005

N of Valid Cases 200

Patients with Preterm premature rupture of membrane occur in all age group. 54% belong to age group 22<20 years.36% belongs to age group 20-25 years. 10% belong to age group >30 years. But it was more common in age group of < 25 years.

a. 1 cells (11.1%) have expected count less than 5. The minimum expected count is 4.40.

The distribution of age classification among PPROM group is statistically significant. Chi =22.8 P=0.005

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TABLE 2

SOCIOECONOMIC CLASS VS PPROMGROUP PPROMGROUP

(GA in weeks ) Total 28-32 33-34 <37

SOCIO ECONOMIC CLASS

3

Count 8 4 16 28

% within SE CLASS 28.6% 14.3% 57.1% 100.0%

% within PPROMGROUP 18.2% 7.7% 15.4% 14.0%

% of Total 4.0% 2.0% 8.0% 14.0%

4

Count 32 48 84 164

% within SE CLASS 19.5% 29.3% 51.2% 100.0%

% of Total 16.0% 24.0% 42.0% 82.0%

5

Count 4 0 4 8

% within SE CLASS 50.0% 0.0% 50.0% 100.0%

% of Total 2.0% 0.0% 2.0% 4.0%

Total

Count 44 52 104 200

% within SE CLASS 22.0% 26.0% 52.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

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Value Df Asymp. Sig.

(2-sided)

Linear-by-Linear

Association .180 1 .671

Socio economic class distribution among PPROM is statistically significant Chi=8.26 P=0.81

82% of patient of preterm premature rupture of membrane belongs to class 4 socioeconomic class as per modified Kuppusamy classification.

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SOCIO ECONOMIC CLASS

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BMI GROUP vs PPROMGROUP TABLE 3

PPROMGROUP (GA in weeks) 28-32 33-34 <37

BMI GROUP

NORMAL

Count 8 8 16

% within BMI

GROUP 25.0% 25.0% 50.0%

% within

PPROMGROUP 18.2% 15.4% 15.4%

% of Total 4.0% 4.0% 8.0%

OVERWEIGHT

Count 28 36 56

% within BMI

GROUP 23.3% 30.0% 46.7%

% within PPROM GROUP

63.6% 69.2% 53.8%

% of Total 14.0% 18.0% 28.0%

OBESE

Count 8 8 32

% within BMI

GROUP 16.7% 16.7% 66.7%

% within

PPROMGROUP 18.2% 15.4% 30.8%

% of Total 4.0% 4.0% 16.0%

Total

Count 44 52 104

% within BMI

GROUP 22.0% 26.0% 52.0%

% within

PPROMGROUP 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0%

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Value df Asymp. Sig. (2-sided)

Linear-by-Linear

BMI distribution among PPROM is statistically not significant. Chi=5.8 P=0.209

Preterm premature rupture of membrane was more common in obese patients with 53.8%

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GRAVIDA vs PPROMGROUP TABLE 4

PPROMGROUP

(GA in weeks) Total 28-32 33-34 <37

GRAVIDA

1

Count 24 32 52 108

% within GRAVIDA 22.2% 29.6% 48.1% 100.0%

% within

PPROMGROUP 54.5% 61.5% 50.0% 54.0%

% of Total 12.0% 16.0% 26.0% 54.0%

2

Count 12 16 48 76

% within GRAVIDA 15.8% 21.1% 63.2% 100.0%

% within

PPROMGROUP 27.3% 30.8% 46.2% 38.0%

% of Total 6.0% 8.0% 24.0% 38.0%

3

Count 4 4 0 8

% within GRAVIDA 50.0% 50.0% 0.0% 100.0%

% within

PPROMGROUP 9.1% 7.7% 0.0% 4.0%

% of Total 2.0% 2.0% 0.0% 4.0%

4

Count 4 0 0 4

% within GRAVIDA 100.0% 0.0% 0.0% 100.0%

% within

PPROMGROUP 9.1% 0.0% 0.0% 2.0%

% of Total 2.0% 0.0% 0.0% 2.0%

5

Count 0 0 4 4

% within GRAVIDA 0.0% 0.0% 100.0% 100.0%

% within

PPROMGROUP 0.0% 0.0% 3.8% 2.0%

% of Total 0.0% 0.0% 2.0% 2.0%

Total

Count 44 52 104 200

% within GRAVIDA 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(47)

(2-sided)

Linear-by-Linear

Association .180 1 .671

a. 9 cells (60.0%) have expected count less than 5. The minimum expected count is .88.

Gravidae distribution among PPROM is statistically significant.

Chi=31.38 P=0.000

The preterm premature rupture of membrane was more common in primigravidae with 54% incidence.

(48)

(49)

ABORTION VS PPROMGROUP TABLE 5

PPROMGROUP

(GA in weeks) Total 28-32 33-34 <37

ABORTION

0

Count 40 48 84 172

% within ABORTIO 23.3% 27.9% 48.8% 100.0%

% within

PPROMGROUP 90.9% 92.3% 80.8% 86.0%

% of Total 20.0% 24.0% 42.0% 86.0%

1

Count 4 4 16 24

% within ABORTIO 16.7% 16.7% 66.7% 100.0%

% within

PPROMGROUP 9.1% 7.7% 15.4% 12.0%

% of Total 2.0% 2.0% 8.0% 12.0%

2

Count 0 0 4 4

% within ABORTIO 0.0% 0.0% 100.0% 100.0%

% within

PPROMGROUP 0.0% 0.0% 3.8% 2.0%

% of Total 0.0% 0.0% 2.0% 2.0%

Total

Count 44 52 104 200

% within ABORTIO 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(50)

Value df

Asymp. Sig.

(2-sided)

Linear-by-Linear Association 4.747 1 .029 N of Valid Cases 200

Previous abortion distribution among PPROM group is statistically not significant. Chi=6.4 P=0.16

82% of patients with preterm premature rupture of membrane with previous history of abortion.

(51)

ABORTION

(52)

PREVIOUS H/O PPROM VS PPROMGROUP TABLE 6

PPROMGROUP (GA in weeks )

Total 28-32 33-34 <37

PREVIOUS H/O PPROM NO

Count 40 52 104 196

% within PREV H/O 20.4% 26.5% 53.1% 100.0%

% within

PPROMGROUP 90.9% 100.0% 100.0% 98.0%

% of Total 20.0% 26.0% 52.0% 98.0%

YES

Count 4 0 0 4

% within PREV H/O 100.0% 0.0% 0.0% 100.0%

% within

PPROMGROUP 9.1% 0.0% 0.0% 2.0%

% of Total 2.0% 0.0% 0.0% 2.0%

Total

Count 44 52 104 200

% within PREV H/O 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(53)

Value df

Asymp. Sig.

(2-sided)

Linear-by-Linear Association

10.559 1 .001

Previous history distribution among PPROM is statistically not significant. Chi=14.4 P= 0.001

98% of patients with PPROM have no previous history.

(54)

PREVIOUS H/O PPROM

(55)

MODE OF DELIVERY VS PPROMGROUP TABLE 7

Total 28-32 33-34 <37

MODE OF DELIVERY

NORM AL

Count 40 40 48 128

% within MOD 31.3% 31.3% 37.5% 100.0%

90.9% 76.9% 46.2% 64.0%

% of Total 20.0% 20.0% 24.0% 64.0%

LSCS

Count 4 12 56 72

% within MOD 5.6% 16.7% 77.8% 100.0%

9.1% 23.1% 53.8% 36.0%

% of Total 2.0% 6.0% 28.0% 36.0%

Total

Count 44 52 104 200

% within MOD 22.0% 26.0% 52.0% 100.0%

100.0

%

100.0% 100.0% 100.0%

(56)

Value df

Asymp. Sig.

(2-sided)

Linear-by-Linear

Mode of delivery among PPROM distribution is statistically significant, Chi=31.9 P=0.00

64% of patients among present study PPROM delivered vaginally.

(57)

MODE OF DELIVERY

(58)

BOOKED CASE VS PPROMGROUP TABLE 8

PPROMGROUP

(GA in weeks ) Total 28-32 33-34 <37

BOOKED CASE

Count 44 52 104 200

% within B /UB 22.0% 26.0% 52.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

Total

Count 44 52 104 200

% within B /UB 22.0% 26.0% 52.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(59)

BOOKED CASES

a. No statistics are computed because B /UB is a constant.

Booked and Unbooked among PPROM distribution is statistically not significant.

All patients with PPROM in present study is booked case.

(60)

ANEMIA VS PPROMGROUP TABLE 9

Total 28-32 33-34 <37

ANEMIA

NO

Count 32 40 92 164

% within ANEMIA 19.5% 24.4% 56.1% 100.0%

% within

PPROMGROUP 72.7% 76.9% 88.5% 82.0%

% of Total 16.0% 20.0% 46.0% 82.0%

YES

Count 12 12 12 36

% within ANEMIA 33.3% 33.3% 33.3% 100.0%

% within

PPROMGROUP 27.3% 23.1% 11.5% 18.0%

% of Total 6.0% 6.0% 6.0% 18.0%

Total

Count 44 52 104 200

% within ANEMIA 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(61)

(2-sided)

Anaemia distribution among PPROM group is statistically not signicant. Chi=6.4 P=0.04

The above table illustrates that PPROM has no correlation with preexisting anemia in mother (n=164 ) with a incidence of 64% without anemia.

(62)

(63)

INFECTION vs PPROMGROUP TABLE 10

PPROMGROUP

(GA in weeks ) Total 28-32 33-34 <37

INFECTION

NO

Count 36 52 100 188

% within INFECTION 19.1% 27.7% 53.2% 100.0%

% within

PPROMGROUP 81.8% 100.0% 96.2% 94.0%

% of Total 18.0% 26.0% 50.0% 94.0%

YES

Count 8 0 4 12

% within INFECTION 66.7% 0.0% 33.3% 100.0%

% within

PPROMGROUP 18.2% 0.0% 3.8% 6.0%

% of Total 4.0% 0.0% 2.0% 6.0%

Total

Count 44 52 104 200

% within INFECTIO 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(64)

(2-sided)

Infection distribution among PPROM group is statistically not significant.

The above table illustrates that PPROM has no correlation with history of maternal infection ( n= 188) with a incidence of 84% without maternal infection and 6% of patients with anemia have PPROM.

(65)

INFECTION

(66)

LIQUOR VS PPROMGROUP TABLE 11

PPROMGROUP

(GA in weeks ) Total 28-32 33-34 <37

LIQUOR ( AFI)

>8

Count 40 28 68 136

% within LIQUOR 29.4% 20.6% 50.0% 100.0%

% within

PPROMGROUP 90.9% 53.8% 65.4% 68.0%

% of Total 20.0% 14.0% 34.0% 68.0%

5-8

Count 0 12 4 16

% within LIQUOR 0.0% 75.0% 25.0% 100.0%

% within

PPROMGROUP 0.0% 23.1% 3.8% 8.0%

% of Total 0.0% 6.0% 2.0% 8.0%

<5

Count 4 12 32 48

% within LIQUOR 8.3% 25.0% 66.7% 100.0%

% within

PPROMGROUP 9.1% 23.1% 30.8% 24.0%

% of Total 2.0% 6.0% 16.0% 24.0%

Total

Count 44 52 104 200

% within LIQUOR 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(67)

(2-sided)

Linear-by-Linear

The amount of liquor distribution among PPROM group is statistically not significant.

The above table illustrates that that PPROM patients have adequate liquor (n=136) with a incidence of 68% and ( n=48) 48 patients have severe oligohydrominos with a incidence of 24%.

(68)

(69)

APGAR GROUP vs PPROMGROUP TABLE 12

PPROMGROUP (GA in weeks) 28-32 33-34 <37

APGARGROUP

7 & above

Count 40 48 100

% within

APGARGROUP 21.3% 25.5% 53.2%

% within

PPROMGROUP 90.9% 92.3% 96.2%

% of Total 20.0% 24.0% 50.0%

<7

Count 4 4 4

% within

APGARGROUP 33.3% 33.3% 33.3%

% within

PPROMGROUP 9.1% 7.7% 3.8%

% of Total 2.0% 2.0% 2.0%

Total

Count 44 52 104

% within

APGARGROUP 22.0% 26.0% 52.0%

% within

PPROMGROUP 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0%

(70)

APGAR GROUP vs PPROMGROUP

Total

APGARGROUP

7 & above

Count 188

% within APGARGROUP 100.0%

% within PPROMGROUP 94.0%

% of Total 94.0%

<7

Count 12

% of Total 6.0%

Total

Count 200

% of Total 100.0%

(71)

Value df Asymp. Sig. (2-sided) Pearson Chi-Square 1.865^a 2 .394

Linear-by-Linear

Apgar distribution among PPROM group is statistically significant.

Chi=1.8 P=0.3

The above table illustrates that (n=188) newborn have agar of more than seven with a incidence of 94% out of which 100 newborn were belong to late preterm group with a incidence of 50%.

(72)

(73)

NICU vs PPROMGROUP TABLE 13

PPROMGROUP( GA in

weeks ) Total 28-32 33-34 <37

NICU

NO

Count 0 4 32 36

% within NICU 0.0% 11.1% 88.9% 100.0%

% within

PPROMGROUP 0.0% 7.7% 30.8% 18.0%

% of Total 0.0% 2.0% 16.0% 18.0%

YES

Count 44 48 72 164

% within NICU 26.8% 29.3% 43.9% 100.0%

% within

PPROMGROUP 100.0% 92.3% 69.2% 82.0%

% of Total 22.0% 24.0% 36.0% 82.0%

Total

Count 44 52 104 200

% within NICU 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(2-sided)

Linear-by-Linear

(74)

The NICU admission among PPROM group is statistically significant. Chi =24.8 P =0.0

The above table illustrates that (n=164) 82% of newborn was admitted in NICU out of which all early PPROM newborn got admitted in NICU.

(75)

RESPIRATORY DISTRESS VS PPROMGROUP TABLE 14

PPROMGROUP( GA in

weeks ) Total 28-32 33-34 <37

RESPIRATORY ISTRESS

NO

Count 0 8 34 42

% within RD 0.0% 19.0% 81.0% 100.0%

% within

PPROMGROUP 0.0% 15.4% 32.7% 21.0%

% of Total 0.0% 4.0% 17.0% 21.0%

YES

Count 44 44 70 158

% within RD 27.8% 27.8% 44.3% 100.0%

% within

PPROMGROUP 100.0% 84.6% 67.3% 79.0%

% of Total 22.0% 22.0% 35.0% 79.0%

Total

Count 44 52 104 200

% within RD 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(2-sided)

Linear-by-Linear

(76)

RESPIRATORY DISTRESS

The above table illustrates that (n=158) 79% of newborn have got RD out of which all early PPROM newborn have got RD.

(77)

PHOTOTHERAPY vs PPROMGROUP TABLE 15

PPROMGROUP

(GA in weeks ) Total 28-32 33-34 <37

PHOTOTHERAPY NO

Count 8 36 76 120

% within PHOTO 6.7% 30.0% 63.3% 100.0%

% within

PPROMGROUP 18.2% 69.2% 73.1% 60.0%

% of Total 4.0% 18.0% 38.0% 60.0%

YES

Count 36 16 28 80

% within PHOTO 45.0% 20.0% 35.0% 100.0%

% within

PPROMGROUP 81.8% 30.8% 26.9% 40.0%

% of Total 18.0% 8.0% 14.0% 40.0%

Total

Count 44 52 104 200

% within PHOTO 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(2-sided)

Linear-by-Linear

(78)

The above table illustrates that 40% (n=80) of newborn have undergone phototherapy out of which 81.8% (n=36) belongs to early PPROM group.

PHOTOTHERAPY

(79)

FETAL INFECTION vs PPROMGROUP TABLE 16

PPROM GROUP

(GA in weeks ) Total 28-32 33-34 <37

FETAL INFECTION

NO

Count 32 52 100 184

% within FET INFEC 17.4% 28.3% 54.3% 100.0%

% within

PPROMGROUP 72.7% 100.0% 96.2% 92.0%

% of Total 16.0% 26.0% 50.0% 92.0%

YES

Count 12 0 4 16

% within FET INFEC 75.0% 0.0% 25.0% 100.0%

% within

PPROMGROUP 27.3% 0.0% 3.8% 8.0%

% of Total 6.0% 0.0% 2.0% 8.0%

Total

Count 44 52 104 200

% within FET INFEC 22.0% 26.0% 52.0% 100.0%

% within

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

Value df Asymp. Sig.

(2-sided)

Linear-by-Linear

(80)

FETAL INFECTION

The above table illustrates that 8% (n=16) of newborn have clinically obvious infection out of which 6% ( n=12 ) belongs to early PPROM group.

(81)

DEATH vs PPROMGROUP TABLE 17

PPROMGROUP

(GA in weeks ) Total 28-32 33-34 <37

DEATH

NO

Count 32 48 100 180

% within DEATH 17.8% 26.7% 55.6% 100.0%

% within

PPROMGROUP 72.7% 92.3% 96.2% 90.0%

% of Total 16.0% 24.0% 50.0% 90.0%

YES

Count 12 4 4 20

% within DEATH 60.0% 20.0% 20.0% 100.0%

% within

PPROMGROUP 27.3% 7.7% 3.8% 10.0%

% of Total 6.0% 2.0% 2.0% 10.0%

Total

Count 44 52 104 200

% within DEATH 22.0% 26.0% 52.0% 100.0%

% wiSthin

PPROMGROUP 100.0% 100.0% 100.0% 100.0%

% of Total 22.0% 26.0% 52.0% 100.0%

(82)

Value df Asymp. Sig. (2- sided)

Linear-by-Linear

The above table illustrates that 10% (n=16)of newborn have died of complication out of which 6% (n=6%) in the early PPROM group.

(83)

(84)

GA

0 20 40 60 80 100

100-Specificity

Sensitivity

Sensitivity: 45.0 Specificity: 93.3 Criterion : ≤32

ROC curve

Variable GA

Classification variable PHOTO

Sample size 200

Positive group : PHOTO = 1 80 Negative group : PHOTO = 0 120 Disease prevalence (%) unknown

(85)

Area under the ROC curve (AUC) Area under the ROC curve (AUC) 0.690

Standard Error^a 0.0392

95% Confidence interval^b 0.621 to 0.753

z statistic 4.850

Significance level P (Area=0.5) <0.0001

a DeLong et al., 1988

b Binomial exact Youden index

Youden index J 0.3833 Associated criterion ≤32

Sensitivity 45.00

Specificity 93.33

Criterion values and coordinates of the ROC curve [Hide]

Criterion Sensitivity 95% CI Specificity 95% CI +LR -LR

<29 0.00 0.0 - 4.5 100.00 97.0 - 100.0

1.00

≤29 5.00 1.4 - 12.3 96.67 91.7 - 99.1 1.50 0.98

≤30 20.00 11.9 - 30.4 93.33 87.3 - 97.1 3.00 0.86

≤32 45.00 33.8 - 56.5 93.33 87.3 - 97.1 6.75 0.59

≤33 50.00 38.6 - 61.4 86.67 79.3 - 92.2 3.75 0.58

≤34 65.00 53.5 - 75.3 63.33 54.1 - 71.9 1.77 0.55

≤35 75.00 64.1 - 84.0 43.33 34.3 - 52.7 1.32 0.58

(86)

The above ROC curve implies that less than 32 weeks of gestation newborn had phototherapy has sensitivity of 45% and specificity of 93.3%.

GA

0 20 40 60 80 100

100-Specificity S e n s it iv it y

Sensitivity: 73.2

Specificity: 77.8 Criterion : ≤35

ROC curve

Variable GA

Classification variable NICU

Sample size 200

Positive group : NICU = 1 164 Negative group : NICU = 0 36 Disease prevalence (%) unknown

(87)

z statistic 7.604

Sensitivity 73.17

Specificity 77.78

<29 0.00 0.0 - 2.2 100.00 90.3 - 100.0

1.00

≤32 26.83 20.2 - 34.3 100.00 90.3 - 100.0

0.73

≤33 31.71 24.7 - 39.4 88.89 73.9 - 96.9 2.85 0.77

≤34 56.10 48.1 - 63.8 88.89 73.9 - 96.9 5.05 0.49

≤35 73.17 65.7 - 79.8 77.78 60.8 - 89.9 3.29 0.34

≤36 100.00 97.8 - 100.0

0.00 0.0 - 9.7 1.00

(88)

The above ROC curve implies that less than 35 weeks of gestation new born had NICU admission which had 73.2% sensitivity and 77.8%

specificity.

GA

0 20 40 60 80 100

100-Specificity

Sensitivity Sensitivity: 72.8

ROC curve

Variable GA

Classification variable RD

Sample size 200

Positive group : RD = 1 158 Negative group : RD = 0 42 Disease prevalence (%) unknown

(89)

z statistic 6.370

b Binomial exact

Youden index

Sensitivity 72.78

Specificity 69.05

<29 0.00 0.0 - 2.3 100.00 91.6 - 100.0

1.00

≤32 27.85 21.0 - 35.5 100.00 91.6 - 100.0

0.72

≤33 32.28 25.1 - 40.2 88.10 74.4 - 96.0 2.71 0.77

≤34 55.70 47.6 - 63.6 80.95 65.9 - 91.4 2.92 0.55

≤35 72.78 65.1 - 79.6 69.05 52.9 - 82.4 2.35 0.39

≤36 100.00 97.7 - 100.0

0.00 0.0 - 8.4 1.00

(90)

The above ROC curve implies that less than 35 weeks of gestation of newborn had RD and has sensitivity of 72.8% and specificity of 69%.

GA

0 20 40 60 80 100

100-Specificity Sensitivity Sensitivity: 66.7

ROC curve

Variable GA

Classification variable INFECTIO

Sample size 200

Positive group : INFECTIO = 1 12 Negative group : INFECTIO = 0 188 Disease prevalence (%) unknown

(91)

z statistic 3.844

Significance level P (Area=0.5) 0.0001

Sensitivity 66.67

Specificity 89.36

<29 0.00 0.0 - 26.5 100.00 98.1 - 100.0

1.00

≤29 0.00 0.0 - 26.5 95.74 91.8 - 98.1 0.00 1.04

≤30 33.33 9.9 - 65.1 89.36 84.0 - 93.4 3.13 0.75

≤31 66.67 34.9 - 90.1 89.36 84.0 - 93.4 6.27 0.37

≤34 66.67 34.9 - 90.1 53.19 45.8 - 60.5 1.42 0.63

≤35 100.00 73.5 - 100.0

38.30 31.3 - 45.7 1.62 0.00

≤36 100.00 73.5 - 0.00 0.0 - 1.9 1.00

(92)

The above ROC curve implies that less than 35 weeks of gestation of newborn had infection with 66.7% sensitivity and 89.4% specificity.

GA

0 20 40 60 80 100

100-Specificity

S e n s it iv it y

Sensitivity: 60.0 Specificity: 93.3 Criterion : ≤30

ROC curve

Variable GA

Classification variable DEATH

Sample size 200

Positive group : DEATH = 1 20 Negative group : DEATH = 0 180 Disease prevalence (%) unknown

(93)

z statistic 6.203

b Binomial exact

Youden index

Sensitivity 60.00

Specificity 93.33

<29 0.00 0.0 - 16.8 100.00 98.0 - 100.0 1.00

≤29 20.00 5.7 - 43.7 97.78 94.4 - 99.4 9.00 0.82

≤30 60.00 36.1 - 80.9 93.33 88.6 - 96.5 9.00 0.43

≤33 60.00 36.1 - 80.9 75.56 68.6 - 81.6 2.45 0.53

≤34 80.00 56.3 - 94.3 55.56 48.0 - 62.9 1.80 0.36

≤35 100.00 83.2 - 100.0 40.00 32.8 - 47.6 1.67 0.00

≤36 100.00 83.2 - 100.0 0.00 0.0 - 2.0 1.00

(94)

DISCUSSION

(95)

DISCUSSION

PPROM was more common in age group of less than 25 years with a incidence of 54% out of which 36% late PPROM and 10% early PPROM. Ina study by Noor et al in Ayub medical college in 2006 demonstrated that ( 58.8% ) higher incidence among younger age group.

PPROM was more common in low socio economic class with a incidence of 82%. In a study done by Sheela et al demonstrated that 62.8% were belongs to low socio economic class.PPROM was more common in primigravidae with a incidence of 54%. In a study conducted by Ghandhi M et al majority were primigravidae 42.3% and another study by Dkeke et al majority were primigravidae 29.1%.

PPROM was not associated with previous history of PPROM and abortion with a incidence of 2% and 12% respectively. In a syudy by Revathy et al 17% had previous abortion and 10% had previous history of PPROM.

In our study 64% of patients had delivered vaginally and 36% had delivered by LSCS. In a study by Sheela at al 65% had vaginal delivery compared to 16% by LSCS.

Majority of neonatal morbidity noted in our study was Respiratory distress contributing to 79% followed by hyperbilirubinaemia by 40%