Periviable preterm prelabor rupture of membranes: Outcomes of pregnancies following expectant management

Periviable preterm prelabor rupture of membranes: Outcomes of pregnancies following expectant management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Periviable preterm prelabor rupture of membranes: Outcomes of pregnancies following expectant management Melda Kuyucu, Duygu Adiyaman, Bahar Konuralp Atakul, Hakan Golbası, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4120696/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Periviable preterm rupture of membranes (PPROM) is associated with increased risk of perinatal morbidity and mortality. We aimed to assess the outcomes and predictive factors of ekspectant management in pregnancies with periviable preterm prelabor rupture of membranes (PPROM). Methods: This was a retrospective study from January 2015 through December 2019. Women diagnosed with PPROM in the periviable period (20+0 to 25+6 weeks’ gestation) were included. Maternal demographics, clinical characteristics, and neonatal outcomes were reviewed. Clinical data were obtained from the medical records of a single center. Predictive factors for assessed using receiver-operator characteristic (ROC) curves. Results: A total of 142 women with mid-trimester PPROM were evaluated. Among this, 119 (83.8 %) were managed expectantly and included in this study. Forty-five (37.8%) of these pregnancies benefited from expectant management; that is, the newborns survived to discharge from NICU. The remaining 74 pregnancies (62.2%) resulted in pre-viable births, stillbirths, deaths in the delivery room, and neonatal deaths. Pregnancies benefiting from expectant management had a longer latency period, had a greater birth weight, and were born at a more advanced GA compared to women who did not benefit from expectant management. Diagnostic cut-off values were obtained by Receiver-operator characteristic (ROC) curves for this indicators and their combination. ROC curve analysis identified GA at delivery ≤23 weeks, latency period ≤9 days, and birth weight ≤640 grams as predictors of unsuccessful expectant management. Conclusions: Periviable PPROM is associated with poor neonatal outcomes with an overall survival rate of 37.8%. If the mother and fetus stabil during the expectant period, neonatal outcomes can be improved by increasing GA at birth, birth weight and latency period. Preterm premature rupture of membranes periviable chorioamnionitis preterm delivery Figures Figure 1 Figure 2 Figure 3 Introduction The period between 20 + 0 and 25 + 6 weeks gestation, when there is a high probability of neonatal death or significant neonatal morbidity, is the earliest stage of fetal maturity and is called the periviable period ( 1 ). Although the prevalence of preterm prelabor rupture of membranes (PPROM) is less common before 26 or 27 weeks of gestation (0.5%) deliveries occurring during this period are associated with worse neonatal outcomes ( 2 ). Respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), infection, and neurodevelopmental impairment are some of the morbidities experienced by infants surviving extreme prematurity. Neonatal mortality and most neonatal morbidities decrease with increasing gestational age (GA) at delivery ( 3 ). If the condition of the fetus and mother are stable and there is no indication for urgent delivery, such as perinatal infection, abruptio placentae, or umbilical cord compression, it has been observed that neonatal outcomes are not worse if the latency period, the interval between membrane rupture and delivery, is prolonged ( 4 , 5 ). The major complicating factor of periviable PPROM is the appropriateness of expectant management or an option for pregnancy termination (especially before 22 gestational weeks) by parents due to probably poor neonatal outcomes, which causes both socioeconomically and psychologically devastating effects for parents. As a result of the advancement in neonatal intensive care, including the use of antibiotics, antenatal steroids and neuroprotective magnesium sulfate, postnatal surfactant, and optimizing respiratory support, outcomes for infants given birth following PPROM or threshold of viability were better than previously expected ( 1 ). In this study, we aimed to determine the characteristics affecting perinatal and neonatal morbidity and mortality in periviable PPROM cases by evaluating the perinatal, neonatal, and maternal outcomes of periviable PPROM cases. Material and Methods This retrospective cohort study was performed between January 2015 and December 2019 in the Maternal-Fetal Medicine Unit of Health Science University, Izmir Tepecik Research and Training Hospital. The data were obtained from the hospital's digital recording system. This study was conducted following the Helsinki Declaration Ethical Standards and was approved by the local ethics committee with the approval number 2019/15 − 8. Patients Women diagnosed with PPROM during the periviable period (from 20 + 0 to 25 + 6 weeks’ gestation) were evaluated and patients with expectant management were included in the study. Pregnancies known to have fetal structural or chromosomal abnormalities, multiple pregnancies, the presence of labor at the time of diagnosis or giving birth within 24 hours of diagnosis were excluded. Initial approach The diagnosis of PPROM was based on a maternal history of leaking fluid and a sterile speculum examination. When the pooling of amniotic fluid in the posterior fornix was noted, no additional tests were used. If the amniotic fluid was not seen, an assay for placental alpha microglobulin-1 protein in the vaginal fluid was used to confirm the diagnosis ( 6 ). Following the diagnosis of PPROM, all pregnancies were evaluated for the presence of labor, infection and fetal well -being, fetal presentation, and amniotic fluid status on ultrasound examination. Oligohydramnios was defined as an amniotic fluid index (AFI) < 5 cm and/or a deep vertical pocket (DVP) < 2 cm. Anhydramnios was defined as AFI < 3 cm. GA was determined by the date of the last menstrual period and confirmed by a crown-rump length (CRL) at a first-trimester ultrasound. Pregnancy management We discussed the potential risks and benefits of expectant management versus termination of pregnancy with parents for all pregnancies before 22 weeks gestation, and offered the option of pregnancy termination by induction of labor. Patients who preferred expectant management before 22 weeks and all pregnancies over 22 weeks were hospitalized and monitored for maternal and fetal well-being. Patients who refused hospitalization were discharged and scheduled for twice-weekly outpatient visits. We recommended delivery at 34 weeks gestation unless the following occurred: nonreassuring fetal heart rate, placental abruption, clinical chorioamnionitis, cord prolapse, or the presence of spontaneous labor. Inpatients were closely monitored for signs and symptoms of chorioamnionitis and fetal well- being. We performed daily non-stress tests, twice-weekly biophysical profiles and AFI status, daily maternal temperature, presence of uterine tenderness, presence of foul-smelling amniotic fluid, maternal heart rate, and twice-weekly assessment of white blood cell (WBC) count, and C-reactive protein (CRP) levels. All women were treated with prophylactic antibiotics, preferably azithromycin, 1 gram orally, plus ampicillin, 2 grams intravenously 4 times a day for 2 days, and then amoxicillin 500 mg orally 3 times daily for an additional 5 days. This resulted in a 7–10 day course of prophylactic antibiotics. Women who presented between 23 and 34 weeks gestation were given two doses of betamethasone 24 hours apart. Prophylactic tocolysis was only used in selected patients to delay delivery by 48 hours to administer corticosteroids ( 7 ). Only 14 patients received tocolysis, and we did not include these patients in the study. Magnesium sulfate was used for fetal neuroprotection in women with the possibility of an immediate delivery between 24 and 32 weeks gestation, and active resuscitation was performed for all infants born after 22 weeks. Outcomes Maternal demographic characteristics and pregnancy and neonatal outcomes were evaluated. Risk factors for PPROM, such as antepartum hemorrhage, PPROM and history of multiple D&C, smoking, cervical cerclage, and short cervix (cervix length < 25 mm by transvaginal ultrasound), were examined. Maternal demographics included age, gravidity, parity, body mass index, and refugee. Maternal complications included chorioamnionitis, retained placenta, postpartum hemorrhage, sepsis, and death. Pregnancy outcomes included sonographic and laboratory findings, latency period (the days between membrane rupture and delivery), indication for delivery, GA at delivery, and delivery mode. Neonatal outcomes included gender, birth weight, admission to the neonatal intensive care unit (NICU), death, and major morbidities. Major neonatal morbidities included severe BPD, NEC ≥ stage 2, grades III or IV IVH, ROP ≥ stage 3, and PVL. We compared pregnancies that benefited from expectant management, those with neonatal survivors, to those which did not benefit, previable births, deaths in the delivery rooms, stillbirths, and neonatal deaths. Statistical analysis The data were evaluated using SPSS Statistics 24.0 (IBM Corp., Armonk, New York, USA) and IBM AMOS statistical package programs. Descriptive statistics, including unit number (n), percentage (%), mean ± standard deviation, smallest value (min), largest value (max), median, and interquartile range (IQR) ​​were evaluated. Data with a normal distribution of quantitative variables was evaluated by the Shapiro- Wilk normality test and Q-Q graphs. The homogeneity of group variances was evaluated with the Levene Test. Comparisons between two groups with normally distributed data used the independent sample t- test and Mann-Whitney U test. The relationship between categorical variables was evaluated in 2 x 2 and r x c tables by Fisher’s exact test, continuity correction test, and Pearson’s Chi-Square test. A p- value < 0.05 was considered statistically significant. Comparisons of groups with more than two subcategories were evaluated using one-way variance analysis (ANOVA) or the Kruskal-Wallis analysis depending on normality. Receiver-operator characteristic (ROC) curves were drawn for determining factors related to not-benefiting expectant management. Results Between January 2015 and December 2019, 142 pregnancies were diagnosed with periviable PPROM in our clinic. A total of 14 (9.8%) pregnancies were excluded based on multifetal pregnancies, 3 (2.1%) were excluded due to lethal fetal anomalies, 4 (2.8%) were lost to follow-up, and 2 (1.4%) opted for termination before 22 weeks gestation. The remaining 119 (83.8%) women were managed expectantly and included in this study. The mean maternal age was 29.4 ± 6.6 years, and 17.6% were primigravid. The median GA at admission was 23 (IQR 2) weeks. Study flow chart and outcomes of pregnancies are shown in Fig. 1 . Benefit from expectant management Forty-five of these pregnancies benefited from expectant management; that is, the newborns survived to discharge from NICU. The remaining 74 pregnancies resulted in pre-viable births, stillbirths, deaths in the delivery room, and neonatal deaths. A comparison of the characteristics and outcomes of those who benefited from expectation management and those who did not are presented in Table 1. The maternal demographics and risk factors were similar between the two groups. Four women from the not-benefited group had PPROM after an invasive diagnostic procedure (within 15 days after genetic amniocentesis), and four women had pregnancies with assisted reproductive techniques (ART). The rate of pregnancies with outpatient follow- up was higher in the benefited group (26.7% versus 8.1%, p < 0.05). The median latency period was 7 Interquartile Range (IQR 21) days, with a range of 1–80 days, and nearly half of the fetuses (47.1%) were born during the first seven days of latency. Pregnancies benefiting from expectant management had a longer latency period, [16 (IQR 35) versus 4.5 (IQR 14.2) days, p < 0.05] compared with the not-benefiting group. The median AFI was similar between the two groups [30, IQR (22.5) versus 25, IQR (60), p = 0.644]. Oligohydramnios was present at admission in 46.7% of those who benefited from expectant management, but it was present in only 27% of those who did not p = 0.060. Among laboratory findings, only CRP levels at admission were lower in the group benefiting from expectancy management (8.5 (IQR 9.0) vs. 16.0 (IQR 27.0) mg/L; p < 0.001). The infants of pregnancies benefiting from expectant management were born at a more advanced GA, [26 (IQR 4.5) versus 23 (IQR 2.2) weeks, p < 0.05]; and had a higher birth weight, [910 (IQR 570) versus 590 (IQR 226) grams, p < 0.05]. The most majority of fetuses (82.3%) were born extremely preterm, < 28 weeks. Only two infants (1.7%) were delivered at 34 weeks gestation. The mode of delivery was different among groups and the rate of cesarean section was significantly higher in the benefiting group (75.6% versus 50%, p = 0.010). Indications of delivery were similar between the two groups (p = 0.153) and the most common indication of delivery before 34 gestational weeks was the spontaneous onset of labor (57.1%) Maternal complications were similar between the two groups, and no maternal sepsis or death occurred during the expectant management period. The main causes of maternal morbidity were clinical chorioamnionitis (12/119, 10.0%), retained placenta (8/119, 6.7%), postpartum hemorrhage (2/119, 1.7%), and in one case (0.8%) hysterectomy because of placenta accreata spectrum. Outcomes of neonates Of 119 expectantly managed pregnancies, 101 (84.8%) newborns were alive and admitted to the NICU; 45 (44.5% of live births or 37.8% of the overall cohort) of these survived to discharge, and among this, 15 (33.3% of survivors or 12.6% of the overall cohort) had no major morbidities at NICU discharge. However, 30 (66.7% of survivors or 25.2% of the overall cohort) had at least one major morbidity at discharge. Table 2 shows the neonatal demographics and outcomes of neonatal survivors. The median gestational age of delivery was 26 (IQR, 4.5) weeks, and the median birth weight was 910 (IQR, 570) gr in neonatal survivors. The most common neonatal complications were associated with respiratory problems, RDS (84.4%), and severe BPD (60.0%). The other major morbidities included PDA (57.8), ROP stage 3–4 (24.4%), PVL (11.1%), NEC ≥ stage 2–3 (11.1%), and IVH > grade 2 (4.4%). A total of 56 (55.4%) infants died in the postpartum period, primarily (58.9%) in the first seven days following birth (early neonatal death). The primary cause of early neonatal deaths was pulmonary hypoplasia (79%). Receiver operator characteristic (ROC) curve analysis was conducted to estimate the sensitivity and specificity of predicting the presence of non-beneficial expectancy management based on four indicators, including GA at admission, GA at delivery, latency period, and birth weight (Fig. 2 ). GA at admission (weeks) can not predict of not-benefiting expectant management (p = 0.079). GA at delivery, latency period, and birth weight were valuable predictors of adverse outcomes. Specifically, GA at delivery ≤ 23 weeks, latency period ≤ 9 days, and birth weight ≤ 640 grams were associated with an increased risk of not benefiting from expectant management. Table 3 showed the cut-off points and sensitivity analysis for GA at delivery, latency period, birth weight and their combination for not-benefiting ekspectant management. Combined ROC analysis was performed with GA at delivery, latency period and birth weight. The area under the curve was 0.78 (sensitivity 90.38%, specificity 50.00%, p 0.4414 was significantly related to an increased risk of the presence of not-benefiting expectant management in the combined ROC (Fig. 3 ). Discussion In this study, we examined the association between maternal and perinatal characteristics of periviable PPROM cases with perinatal and neonatal outcomes. The controversial problem with periviable PPROM is, on the one hand, the increased rates of neonatal morbidity and mortality due to extremely preterm deliveries, and on the other hand, the high risk of maternal infections and other maternal complications during the expectant management period. Therefore providing proper counseling to families about the benefits and risks of management options is important. Our results revealed that approximately one-third of pregnancies benefited from expectant management, with newborns surviving to discharge from the NICU, and one-third of these infants had no major morbidities during discharge. Notably, the latency period, GA at delivery, and birth weight emerged as crucial factors influencing the success of expectant management. Pregnancies with longer latency periods, higher GA at delivery, and higher birth weight were more likely to benefit from expectant management, highlighting the importance of these parameters in clinical decision-making. In recent years, there have been many studies published about neonatal survival in PPROM cases. In prior studies with a similar population, the overall neonatal survival rate ranged from 45.9–63.2%, and the discharge rate without major morbidity ranged from 17.9–76.7% ( 8 – 11 ). This suggests that our overall survival to discharge rate (37.8%) was relatively lower than previous studies despite our high live birth and NICU admission rate (84.8 %). We povided active resuscitation to infants born after 22 weeks, and noticed even if the infants respond to resuscitation, neonatal mortality rates are very high similar to the study by Anderson et al. ( 12 ). This difference in neonatal mortality may be related to postnatal care in the NICU, and the high incidence of neonatal mortality underscores the need for multidisciplinary neonatal care and emphasizes the challenges in managing extremely preterm infants deliver after PPROM. Another factor may be associated with persistent exposure to oligo-anhydramnios in the second trimester, which can be related to pulmonary hypoplasia and early neonatal deaths although the pregnancy resulted in a live birth. Lee et al.( 13 ) described the significant relationship between persistent oligohydramnios and low survival rates in their study published in 2015. A statistically significant difference was not found between the two groups according to the presence of oligo-anhydramnios, but we evaluated the admission AFI levels and the presence of anhydramnios at any time, not persistent oligo-anhydramnios, and unknown length of oligo-anhydramnios exposure. These results are related to the variability of AFI during the latency period. Considering the antenatal characteristics of the group benefiting from expectant management, higher outpatient rate, lower CRP levels at admission and higher cesarean section rate were not surprising findings. The relationship between maternal CRP levels and neonatal survival has been reported recently ( 14 , 15 ). Since CRP is an inflammatory marker, it may indicate a relationship between chorioamnionitis and a short latency period and poor neonatal outcomes as a consequence of the short latency period. Similar to previous studies showing that outpatient follow-up can be safe in selected patients the benefit of expectant management was higher among women who were managed as outpatients ( 16 – 19 ). Our more active approach to hospitalized women included multiple digital vaginal examinations. This may have accelerated the onset of spontaneous labor and a shortening of latency because stimulation of the cervix can cause prostaglandin release, resulting in the onset of uterine contractions earlier GA at delivery, and poorer neonatal outcomes ( 20 , 21 ). Nosocomial infection may be less common in patients who are followed as outpatients resulting in a longer latency period. Consistent with the literature, within postpartum characteristics, we found that GA at birth, latency period, and birth weight were all higher in infants who survived than those who did not. Through ROC analysis, we established cut-off values for these three indicators and their combinations, thus identifying which pregnant women would not benefit from expectant management. Unlike previous studies, the difference between the two groups according to GA at PPROM could not be determined( 22 – 24 ). The main limitations of our study are its retrospective nature and relatively small sample size including single center data. Additionally, our study included only short-term neonatal outcomes. Our study also had its strengths. In this study, we included all features related to PPROM, as well as maternal and pregnancy characteristics, and examined all parameters that may affect the management of periviable PPROM cases. Conclusion In conclusion, expectant management can offer favorable outcomes in select cases of periviable PPROM, particularly in pregnancies with longer latency periods, higher GA at delivery, and greater birth weight. However, careful patient selection and close monitoring are essential to optimize outcomes and minimize complications. Further research is warranted to refine predictive models and improve risk stratification in this challenging obstetric population. Abbreviations PPROM Preterm Prelabor Rupture of Membranes RDS Respiratory distress syndrome NEC Necrotizing Enterocolitis IVH Intraventricular Hemorrhage PVL Periventricular Leukomalacia BPD Bronchopulmonary Dysplasia ROP Retinopathy of Prematurity GA: Gestational Age AFI Amniotic Fluid Index DVP Deep Vertical Pocket WBC White Blood Cell CRP C-Reactive Protein NICU Neonatal Intensive Care Unit ART Assisted Reproductive Techniques IQR Interquartile Range BMI Body Mass Index Declarations Conflict of interest statement: The authors declare that they have no conflict of interest. Ethics approval and consent to participate This study was conducted following the Helsinki Declaration Ethical Standards and was approved by the Health Science University, Izmir Tepecik Research and Training Hospital local ethics committee with the approval number 2019/15-8. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions MK designed the experiment. MK and OY analyzed and interpreted the data. MK and BKA wrote the manuscript. DA, MO and HG conceived the study and revised the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable References Ecker JL, Kaimal A, Mercer BM, Blackwell SC, DeRegnier RAO, Farrell RM, et al. Obstetric Care consensus No. 6: Periviable Birth. Obstetrics and gynecology [Internet]. 2017 Oct 1 [cited 2022 Sep 17];130(4):e187–99. Available from: https://pubmed.ncbi.nlm.nih.gov/28937572/ Heyden J van der. 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Available from: https://www.degruyter.com/document/doi/10.1515/jpm-2016-0183/html Tables Table 1: Characteristics and Outcomes of Pregnancies Benefiting from expectant management Not- benefiting from expectant management n= 45 n= 74 p value Maternal age ¶ 29.6 + 7 29.1 + 6 0.735 * Maternal age >35, n (%) 9 (20.0) 16 (21.6) 1.000** Gravidity (IQR) 2 (2) 3 (1) 0.881*** Parity (IQR) 1 (2) 1 (2) 0.850*** Primipar, n (%) 29 (64.4) 56 (75.7) 0.269** BMI (kg/m2) ¶ 26 + 4 27 + 4 0.682 * Refugee, n (%) 6 (13.3) 10 (13.5) 1.000** Risk factors of PPROM Antepartum hemorrhage µ , n (%) 10 (22.2) 16 (21.6) 1.000** History of PPROM, n (%) 5 (11.1) 17 (23.0) 0.170** History of multipl D&C, n (%) 8 (17.8) 10 (13.5) 0.715** Smoker, n (%) 6 (13.3) 11(14.9) 1.000** Cervical cerclage, n (%) 2 (4.4) 3 (4.1) 1.000 Cervical length, mm, n:45 29 (14) 32 (20) 0.668*** Short cervix, n= 45 ð n (%) 4 (22.2) 8 (29.6) 0.735***** Type of follow up Inpatient, n 33 (73.3) 68 (91.9) 0.013 ** Outpatient, n 12 (26.7) 6 (8.1) GA at admission (weeks) ¶ 22 + 1.6 22 + 1.3 0.144 * Latency period (days) 16 (35) 4.5 (14.2) 0.000 *** Latency<7 days , n (%) 13 (28.9) 43 (58.1) 0.004 ** Sonographic findings AFI (mm) 30 (22.5) 25 (60) 0.644*** Normal, n (%) 7 (15.6) 22 (29.7) 0.060**** Oligohydramnios, n (%) 21 (46.7) 20 (27.0) Anhydramnios, n (%) 17 (37.8) 32 (43.2) Anhydramnios at any time, n (%) 22 (48.9) 39 (52.7) 0.830** Breech presentation, n (%) 22 (48.9) 34 (45.9) 0.902** Laboratuary findings WBC count at admission (x10 3 /uL) ¶ 13573 + 3100 13900 + 4400 0.666 * WBC> 15000 x10 3 /uL, n (%) 15 (33.3) 27 (36.5) 0.880** CRP levels at admission (mg/L), n:90 8.5 (11) 16 (27) 0.010*** CRP>5 mg/dL, n: 90 (%) 26 (72.2) 40 (83.3) 0.337** GA at delivery (weeks) 26 (4.5) 23 (2.2) 0.000 *** Birth weight (grams) 910 (570) 590 (226) 0.000*** Delivery before 28 gw, n (%) 30 (66.7) 66 (89.2) 0.017**** Type of delivery, n (%) Vaginal delivery 11 (24.4) 37 (50.0) 0.010**** Cesarean section 34 (75.6) 37 (50.0) Fetal gender, n (%) Female 29 (64.4) 34 (45.9) 0.077** Male 16 (35.6) 40 (54.1) Indications of delivery, n (%) Clinical chorioamnionitis 8 (17.8) 4 (5.4) 0.153**** Plasental abruption 6 (13.3) 15 (20.3) Non-reassuring fetal status 5 (11.1) 8 (10.8) Spontane labor 26 (57.8) 42 (56.8) 34. gestational weeks - 2 (2.7) Cord prolapse - 3 (4.1) Maternal morbidity, n (%) 11(24.4) 13 (17.6) 0.502** Benefiting from expectant management: Survival to discharge Not- benefiting from expectant management: Previable births, stillbirths, deaths in delivery room and neonatal deaths. Data are given as median (interquartile range), mean (SD ¶ , standart deviation) or n (%). IQR, Interquartile range; BMI, Body mass index; GA, Gestational age; PPROM, Preterm premature rupture of membranes; D&C, Dilatation and Curetage; AFI, Amniotic Fluid Index; WBC, White Blood Cell; CRP, C-Reactive Protein µ first and/or second trimester vaginal bleeding ð patients whose cervical lenght was <25 mm at admission *Independent sample t test ** Continuity Correction ***Mann- Whitney U ****Pearson chi-square ***** Fisher’s Exact Test Table 2: Neonatal characteristics and outcomes of neonatal survivors n = 45 GA at delivery ¶ (weeks) 26 (4.5) Birth weight (grams) ¶ 910 (570) APGAR 5. minute <7 21 (46.7) Need of NRP 27 (60) Type of NRP PPV 13(29) Intubated 10 (22) Compression 3 (6.7) Drugs 1(2.2) Need of MV 33 (73.3) Days of ıntubated (IQR) 11.0 (24.5) Need of Nasal MV 41 (91.1) Need of HFO 6 (13.3) Neonatal morbidities RDS 38 (84.4) Severe BPD 27 (60) PDA 26 (57.8) Cultur proven sepsis 14 (31.1) ROP stage 3-4 11 (24.4) NEC stage 2-3 5 (11.1) PVL 5 (11.1) Pulmoner hemorrhage 4 (8.9) Konvulsion 4 (8.9) Positional deformity 3 (6.7) IVH grade 3-4 2 (4.4) Duration NICU stay (days) ¶ 73 (5) Survival to discharge with no major morbidity, n (%) 15 (33.3) Survival to discharge with at least one major morbidity, n (%) 30 (66.7) Data are given as median (interquartile range) ¶ or n (%). GA; Gestational age, NRP; Neonatal Resuscitation Program, PPV; Positive Pressure Ventilation, MV; Mechanical Ventilation, HFO; High Frequency Oscillation, RDS; Respiratory Distress Syndrome, BPD; Bronchopulmonary Dysplasia, PDA; Patent Ductus Arteriosus, ROP; Retinopathy of Prematurity, NEC; Necrotizan Enterocolitis, PVL; Periventricular Leucomalacia, IVH; Intraventricular Hemorrhage, NICU; Neonatal Intensive Care Unit Table 3: The sensitivity analysis for GA at delivery (weeks), latency period (days), birth weight (gram) and their combination for not-benefiting ekspectant management Cut-off Sensitivity (95% CI) Specificity (95% CI) PPV (95% CI) NPV (95% CI) AUC+-standard error p GA at delivery ≤23 51,35 (39,4 - 63,1) 93,33 (81,7 - 98,6) 92,7 (80,6 - 97,5) 53,8 (47,7- 59,9) 0.79± 004 <0.001 Latency period ≤9 71,62 59,9- 81,5 66,67 51,0- 80,0 77,9 69,5- 84,5 58,8 48,5- 68,4 0.71± 005 <0.001 Birth weight ≤640 67,57 55,7- 78,0 82,22 67,9- 92,0 86,2 76,6- 92,3 60,7 51,9- 68,8 0,82+-0.04 0,4414 90,38 (79,0- 96,8) 50 (33,4- 66,6) 50 (33,4- 66,6) 79,2(60,9- 90,3) 0,78+-0.05 <0.001 GA; Gestational age, PPV; Positive predictive value, NPV; Negative predictive value, AUC; Area under curve Additional Declarations No competing interests reported. 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The area under the curve (AUC) of combined\u003c/p\u003e\n\u003cp\u003eROC analysis 0.78+-0.05 with p\u0026lt;0.001\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4120696/v1/769f4f81c54c0a526ce70bbf.jpg"},{"id":79411849,"identity":"a384acc6-50b0-4fb7-9330-2022af30e5ff","added_by":"auto","created_at":"2025-03-28 06:17:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1438749,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4120696/v1/c553f65e-afe8-4240-a399-4043beed78bc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Periviable preterm prelabor rupture of membranes: Outcomes of pregnancies following expectant management","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe period between 20\u0026thinsp;+\u0026thinsp;0 and 25\u0026thinsp;+\u0026thinsp;6 weeks gestation, when there is a high probability of neonatal death or significant neonatal morbidity, is the earliest stage of fetal maturity and is called the periviable period (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although the prevalence of preterm prelabor rupture of membranes (PPROM) is less common before 26 or 27 weeks of gestation (0.5%) deliveries occurring during this period are associated with worse neonatal outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), infection, and neurodevelopmental impairment are some of the morbidities experienced by infants surviving extreme prematurity. Neonatal mortality and most neonatal morbidities decrease with increasing gestational age (GA) at delivery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). If the condition of the fetus and mother are stable and there is no indication for urgent delivery, such as perinatal infection, abruptio placentae, or umbilical cord compression, it has been observed that neonatal outcomes are not worse if the latency period, the interval between membrane rupture and delivery, is prolonged (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe major complicating factor of periviable PPROM is the appropriateness of expectant management or an option for pregnancy termination (especially before 22 gestational weeks) by parents due to probably poor neonatal outcomes, which causes both socioeconomically and psychologically devastating effects for parents. As a result of the advancement in neonatal intensive care, including the use of antibiotics, antenatal steroids and neuroprotective magnesium sulfate, postnatal surfactant, and optimizing respiratory support, outcomes for infants given birth following PPROM or threshold of viability were better than previously expected (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, we aimed to determine the characteristics affecting perinatal and neonatal morbidity and mortality in periviable PPROM cases by evaluating the perinatal, neonatal, and maternal outcomes of periviable PPROM cases.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThis retrospective cohort study was performed between January 2015 and December 2019 in the Maternal-Fetal Medicine Unit of Health Science University, Izmir Tepecik Research and Training Hospital. The data were obtained from the hospital's digital recording system. This study was conducted following the Helsinki Declaration Ethical Standards and was approved by the local ethics committee with the approval number 2019/15\u0026thinsp;\u0026minus;\u0026thinsp;8.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eWomen diagnosed with PPROM during the periviable period (from 20\u0026thinsp;+\u0026thinsp;0 to 25\u0026thinsp;+\u0026thinsp;6 weeks\u0026rsquo; gestation) were evaluated and patients with expectant management were included in the study. Pregnancies known to have fetal structural or chromosomal abnormalities, multiple pregnancies, the presence of labor at the time of diagnosis or giving birth within 24 hours of diagnosis were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInitial approach\u003c/h2\u003e \u003cp\u003eThe diagnosis of PPROM was based on a maternal history of leaking fluid and a sterile speculum examination. When the pooling of amniotic fluid in the posterior fornix was noted, no additional tests were used. If the amniotic fluid was not seen, an assay for placental alpha microglobulin-1 protein in the vaginal fluid was used to confirm the diagnosis (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Following the diagnosis of PPROM, all pregnancies were evaluated for the presence of labor, infection and fetal well -being, fetal presentation, and amniotic fluid status on ultrasound examination. Oligohydramnios was defined as an amniotic fluid index (AFI)\u0026thinsp;\u0026lt;\u0026thinsp;5 cm and/or a deep vertical pocket (DVP)\u0026thinsp;\u0026lt;\u0026thinsp;2 cm. Anhydramnios was defined as AFI\u0026thinsp;\u0026lt;\u0026thinsp;3 cm. GA was determined by the date of the last menstrual period and confirmed by a crown-rump length (CRL) at a first-trimester ultrasound.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePregnancy management\u003c/h2\u003e \u003cp\u003eWe discussed the potential risks and benefits of expectant management versus termination of pregnancy with parents for all pregnancies before 22 weeks gestation, and offered the option of pregnancy termination by induction of labor. Patients who preferred expectant management before 22 weeks and all pregnancies over 22 weeks were hospitalized and monitored for maternal and fetal well-being. Patients who refused hospitalization were discharged and scheduled for twice-weekly outpatient visits. We recommended delivery at 34 weeks gestation unless the following occurred: nonreassuring fetal heart rate, placental abruption, clinical chorioamnionitis, cord prolapse, or the presence of spontaneous labor. Inpatients were closely monitored for signs and symptoms of chorioamnionitis and fetal well- being. We performed daily non-stress tests, twice-weekly biophysical profiles and AFI status, daily maternal temperature, presence of uterine tenderness, presence of foul-smelling amniotic fluid, maternal heart rate, and twice-weekly assessment of white blood cell (WBC) count, and C-reactive protein (CRP) levels. All women were treated with prophylactic antibiotics, preferably azithromycin, 1 gram orally, plus ampicillin, 2 grams intravenously 4 times a day for 2 days, and then amoxicillin 500 mg orally 3 times daily for an additional 5 days. This resulted in a 7\u0026ndash;10 day course of prophylactic antibiotics. Women who presented between 23 and 34 weeks gestation were given two doses of betamethasone 24 hours apart. Prophylactic tocolysis was only used in selected patients to delay delivery by 48 hours to administer corticosteroids (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Only 14 patients received tocolysis, and we did not include these patients in the study. Magnesium sulfate was used for fetal neuroprotection in women with the possibility of an immediate delivery between 24 and 32 weeks gestation, and active resuscitation was performed for all infants born after 22 weeks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eMaternal demographic characteristics and pregnancy and neonatal outcomes were evaluated. Risk factors for PPROM, such as antepartum hemorrhage, PPROM and history of multiple D\u0026amp;C, smoking, cervical cerclage, and short cervix (cervix length\u0026thinsp;\u0026lt;\u0026thinsp;25 mm by transvaginal ultrasound), were examined. Maternal demographics included age, gravidity, parity, body mass index, and refugee. Maternal complications included chorioamnionitis, retained placenta, postpartum hemorrhage, sepsis, and death. Pregnancy outcomes included sonographic and laboratory findings, latency period (the days between membrane rupture and delivery), indication for delivery, GA at delivery, and delivery mode. Neonatal outcomes included gender, birth weight, admission to the neonatal intensive care unit (NICU), death, and major morbidities. Major neonatal morbidities included severe BPD, NEC\u0026thinsp;\u0026ge;\u0026thinsp;stage 2, grades III or IV IVH, ROP\u0026thinsp;\u0026ge;\u0026thinsp;stage 3, and PVL.\u003c/p\u003e \u003cp\u003eWe compared pregnancies that benefited from expectant management, those with neonatal survivors, to those which did not benefit, previable births, deaths in the delivery rooms, stillbirths, and neonatal deaths.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were evaluated using SPSS Statistics 24.0 (IBM Corp., Armonk, New York, USA) and IBM AMOS statistical package programs. Descriptive statistics, including unit number (n), percentage (%), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, smallest value (min), largest value (max), median, and interquartile range (IQR) ​​were evaluated. Data with a normal distribution of quantitative variables was evaluated by the Shapiro- Wilk normality test and Q-Q graphs. The homogeneity of group variances was evaluated with the Levene Test. Comparisons between two groups with normally distributed data used the independent sample t- test and Mann-Whitney U test. The relationship between categorical variables was evaluated in 2 x 2 and r x c tables by Fisher\u0026rsquo;s exact test, continuity correction test, and Pearson\u0026rsquo;s Chi-Square test. A p- value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Comparisons of groups with more than two subcategories were evaluated using one-way variance analysis (ANOVA) or the Kruskal-Wallis analysis depending on normality. Receiver-operator characteristic (ROC) curves were drawn for determining factors related to not-benefiting expectant management.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween January 2015 and December 2019, 142 pregnancies were diagnosed with periviable PPROM in our clinic. A total of 14 (9.8%) pregnancies were excluded based on multifetal pregnancies, 3 (2.1%) were excluded due to lethal fetal anomalies, 4 (2.8%) were lost to follow-up, and 2 (1.4%) opted for termination before 22 weeks gestation. The remaining 119 (83.8%) women were managed expectantly and included in this study. The mean maternal age was 29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6 years, and 17.6% were primigravid. The median GA at admission was 23 (IQR 2) weeks. Study flow chart and outcomes of pregnancies are shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eBenefit from expectant management\u003c/h2\u003e\n \u003cp\u003eForty-five of these pregnancies benefited from expectant management; that is, the newborns survived to discharge from NICU. The remaining 74 pregnancies resulted in pre-viable births, stillbirths, deaths in the delivery room, and neonatal deaths. A comparison of the characteristics and outcomes of those who benefited from expectation management and those who did not are presented in Table\u0026nbsp;1. The maternal demographics and risk factors were similar between the two groups. Four women from the not-benefited group had PPROM after an invasive diagnostic procedure (within 15 days after genetic amniocentesis), and four women had pregnancies with assisted reproductive techniques (ART). The rate of pregnancies with outpatient follow- up was higher in the benefited group (26.7% versus 8.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003cp\u003eThe median latency period was 7 Interquartile Range (IQR 21) days, with a range of 1\u0026ndash;80 days, and nearly half of the fetuses (47.1%) were born during the first seven days of latency. Pregnancies benefiting from expectant management had a longer latency period, [16 (IQR 35) versus 4.5 (IQR 14.2) days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05] compared with the not-benefiting group. The median AFI was similar between the two groups [30, IQR (22.5) versus 25, IQR (60), p\u0026thinsp;=\u0026thinsp;0.644]. Oligohydramnios was present at admission in 46.7% of those who benefited from expectant management, but it was present in only 27% of those who did not p\u0026thinsp;=\u0026thinsp;0.060. Among laboratory findings, only CRP levels at admission were lower in the group benefiting from expectancy management (8.5 (IQR 9.0) vs. 16.0 (IQR 27.0) mg/L; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003cp\u003eThe infants of pregnancies benefiting from expectant management were born at a more advanced GA, [26 (IQR 4.5) versus 23 (IQR 2.2) weeks, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05]; and had a higher birth weight, [910 (IQR 570) versus 590 (IQR 226) grams, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05]. The most majority of fetuses (82.3%) were born extremely preterm, \u0026lt;\u0026thinsp;28 weeks. Only two infants (1.7%) were delivered at 34 weeks gestation. The mode of delivery was different among groups and the rate of cesarean section was significantly higher in the benefiting group (75.6% versus 50%, p\u0026thinsp;=\u0026thinsp;0.010). Indications of delivery were similar between the two groups (p\u0026thinsp;=\u0026thinsp;0.153) and the most common indication of delivery before 34 gestational weeks was the spontaneous onset of labor (57.1%)\u003c/p\u003e\n \u003cp\u003eMaternal complications were similar between the two groups, and no maternal sepsis or death occurred during the expectant management period. The main causes of maternal morbidity were clinical chorioamnionitis (12/119, 10.0%), retained placenta (8/119, 6.7%), postpartum hemorrhage (2/119, 1.7%), and in one case (0.8%) hysterectomy because of placenta accreata spectrum.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eOutcomes of neonates\u003c/h2\u003e\n \u003cp\u003eOf 119 expectantly managed pregnancies, 101 (84.8%) newborns were alive and admitted to the NICU; 45 (44.5% of live births or 37.8% of the overall cohort) of these survived to discharge, and among this, 15 (33.3% of survivors or 12.6% of the overall cohort) had no major morbidities at NICU discharge. However, 30 (66.7% of survivors or 25.2% of the overall cohort) had at least one major morbidity at discharge. Table\u0026nbsp;2 shows the neonatal demographics and outcomes of neonatal survivors. The median gestational age of delivery was 26 (IQR, 4.5) weeks, and the median birth weight was 910 (IQR, 570) gr in neonatal survivors. The most common neonatal complications were associated with respiratory problems, RDS (84.4%), and severe BPD (60.0%). The other major morbidities included PDA (57.8), ROP stage 3\u0026ndash;4 (24.4%), PVL (11.1%), NEC\u0026thinsp;\u0026ge;\u0026thinsp;stage 2\u0026ndash;3 (11.1%), and IVH\u0026thinsp;\u0026gt;\u0026thinsp;grade 2 (4.4%).\u003c/p\u003e\n \u003cp\u003eA total of 56 (55.4%) infants died in the postpartum period, primarily (58.9%) in the first seven days following birth (early neonatal death). The primary cause of early neonatal deaths was pulmonary hypoplasia (79%).\u003c/p\u003e\n \u003cp\u003eReceiver operator characteristic (ROC) curve analysis was conducted to estimate the sensitivity and specificity of predicting the presence of non-beneficial expectancy management based on four indicators, including GA at admission, GA at delivery, latency period, and birth weight (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). GA at admission (weeks) can not predict of not-benefiting expectant management (p\u0026thinsp;=\u0026thinsp;0.079). GA at delivery, latency period, and birth weight were valuable predictors of adverse outcomes. Specifically, GA at delivery\u0026thinsp;\u0026le;\u0026thinsp;23 weeks, latency period\u0026thinsp;\u0026le;\u0026thinsp;9 days, and birth weight\u0026thinsp;\u0026le;\u0026thinsp;640 grams were associated with an increased risk of not benefiting from expectant management. Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e showed the cut-off points and sensitivity analysis for GA at delivery, latency period, birth weight and their combination for not-benefiting ekspectant management.\u003c/p\u003e\n \u003cp\u003eCombined ROC analysis was performed with GA at delivery, latency period and birth weight. The area under the curve was 0.78 (sensitivity 90.38%, specificity 50.00%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), showing that combination probability\u0026thinsp;\u0026gt;\u0026thinsp;0.4414 was significantly related to an increased risk of the presence of not-benefiting expectant management in the combined ROC (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we examined the association between maternal and perinatal characteristics of periviable PPROM cases with perinatal and neonatal outcomes. The controversial problem with periviable PPROM is, on the one hand, the increased rates of neonatal morbidity and mortality due to extremely preterm deliveries, and on the other hand, the high risk of maternal infections and other maternal complications during the expectant management period. Therefore providing proper counseling to families about the benefits and risks of management options is important. Our results revealed that approximately one-third of pregnancies benefited from expectant management, with newborns surviving to discharge from the NICU, and one-third of these infants had no major morbidities during discharge. Notably, the latency period, GA at delivery, and birth weight emerged as crucial factors influencing the success of expectant management. Pregnancies with longer latency periods, higher GA at delivery, and higher birth weight were more likely to benefit from expectant management, highlighting the importance of these parameters in clinical decision-making.\u003c/p\u003e \u003cp\u003eIn recent years, there have been many studies published about neonatal survival in PPROM cases. In prior studies with a similar population, the overall neonatal survival rate ranged from 45.9\u0026ndash;63.2%, and the discharge rate without major morbidity ranged from 17.9\u0026ndash;76.7% (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This suggests that our overall survival to discharge rate (37.8%) was relatively lower than previous studies despite our high live birth and NICU admission rate (84.8 %). We povided active resuscitation to infants born after 22 weeks, and noticed even if the infants respond to resuscitation, neonatal mortality rates are very high similar to the study by Anderson et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This difference in neonatal mortality may be related to postnatal care in the NICU, and the high incidence of neonatal mortality underscores the need for multidisciplinary neonatal care and emphasizes the challenges in managing extremely preterm infants deliver after PPROM. Another factor may be associated with persistent exposure to oligo-anhydramnios in the second trimester, which can be related to pulmonary hypoplasia and early neonatal deaths although the pregnancy resulted in a live birth. Lee et al.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) described the significant relationship between persistent oligohydramnios and low survival rates in their study published in 2015. A statistically significant difference was not found between the two groups according to the presence of oligo-anhydramnios, but we evaluated the admission AFI levels and the presence of anhydramnios at any time, not persistent oligo-anhydramnios, and unknown length of oligo-anhydramnios exposure. These results are related to the variability of AFI during the latency period.\u003c/p\u003e \u003cp\u003eConsidering the antenatal characteristics of the group benefiting from expectant management, higher outpatient rate, lower CRP levels at admission and higher cesarean section rate were not surprising findings. The relationship between maternal CRP levels and neonatal survival has been reported recently (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Since CRP is an inflammatory marker, it may indicate a relationship between chorioamnionitis and a short latency period and poor neonatal outcomes as a consequence of the short latency period. Similar to previous studies showing that outpatient follow-up can be safe in selected patients the benefit of expectant management was higher among women who were managed as outpatients (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Our more active approach to hospitalized women included multiple digital vaginal examinations. This may have accelerated the onset of spontaneous labor and a shortening of latency because stimulation of the cervix can cause prostaglandin release, resulting in the onset of uterine contractions earlier GA at delivery, and poorer neonatal outcomes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Nosocomial infection may be less common in patients who are followed as outpatients resulting in a longer latency period.\u003c/p\u003e \u003cp\u003eConsistent with the literature, within postpartum characteristics, we found that GA at birth, latency period, and birth weight were all higher in infants who survived than those who did not. Through ROC analysis, we established cut-off values for these three indicators and their combinations, thus identifying which pregnant women would not benefit from expectant management. Unlike previous studies, the difference between the two groups according to GA at PPROM could not be determined(\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe main limitations of our study are its retrospective nature and relatively small sample size including single center data. Additionally, our study included only short-term neonatal outcomes. Our study also had its strengths. In this study, we included all features related to PPROM, as well as maternal and pregnancy characteristics, and examined all parameters that may affect the management of periviable PPROM cases.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, expectant management can offer favorable outcomes in select cases of periviable PPROM, particularly in pregnancies with longer latency periods, higher GA at delivery, and greater birth weight. However, careful patient selection and close monitoring are essential to optimize outcomes and minimize complications. Further research is warranted to refine predictive models and improve risk stratification in this challenging obstetric population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePPROM Preterm Prelabor\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eRupture of Membranes\u003c/p\u003e\n\u003cp\u003eRDS Respiratory distress syndrome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNEC Necrotizing Enterocolitis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIVH Intraventricular Hemorrhage\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePVL Periventricular Leukomalacia \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBPD Bronchopulmonary Dysplasia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eROP Retinopathy of Prematurity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGA: Gestational Age\u003c/p\u003e\n\u003cp\u003eAFI Amniotic Fluid Index\u003c/p\u003e\n\u003cp\u003eDVP Deep Vertical Pocket\u003c/p\u003e\n\u003cp\u003eWBC White Blood Cell\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCRP C-Reactive Protein\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNICU Neonatal Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eART Assisted Reproductive Techniques\u003c/p\u003e\n\u003cp\u003eIQR Interquartile Range\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBMI Body Mass Index\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest statement:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted following the Helsinki Declaration Ethical Standards and\u0026nbsp;was approved by the\u0026nbsp;Health Science University, Izmir Tepecik Research and Training Hospital\u0026nbsp;local ethics committee with the approval number 2019/15-8.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMK designed the experiment. MK and OY analyzed and interpreted the data. MK and BKA wrote the manuscript. DA, MO and HG conceived the study and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEcker JL, Kaimal A, Mercer BM, Blackwell SC, DeRegnier RAO, Farrell RM, et al. Obstetric Care consensus No. 6: Periviable Birth. Obstetrics and gynecology [Internet]. 2017 Oct 1 [cited 2022 Sep 17];130(4):e187\u0026ndash;99. Available from: https://pubmed.ncbi.nlm.nih.gov/28937572/\u003c/li\u003e\n\u003cli\u003eHeyden J van der. Preterm prelabor rupture of membranes: different gestational ages, different problems. 2014 [cited 2022 May 28]; Available from: https://cris.maastrichtuniversity.nl/files/1321285/guid-4cb916da-43f5-40e3-ba3d-1a8d2e001b0f-ASSET1.0.pdf\u003c/li\u003e\n\u003cli\u003eAnderson JG, Baer RJ, Partridge JC, Kuppermann M, Franck LS, Rand L, et al. Survival and Major Morbidity of Extremely Preterm Infants: A Population-Based Study. Pediatrics [Internet]. 2016 Jul 1 [cited 2022 Oct 25];138(1). Available from: https://pubmed.ncbi.nlm.nih.gov/27302979/\u003c/li\u003e\n\u003cli\u003eFrenette P, Dodds L, Armson BA, Jangaard K. Preterm prelabour rupture of membranes: effect of latency on neonatal and maternal outcomes. J Obstet Gynaecol Can [Internet]. 2013 [cited 2022 Oct 25];35(8):710\u0026ndash;7. Available from: https://pubmed.ncbi.nlm.nih.gov/24007706/\u003c/li\u003e\n\u003cli\u003eLorthe E, Torchin H, Delorme P, Ancel PY, Marchand-martin L, Foix-l L, et al. Preterm premature rupture of membranes at 22\u0026ndash;25 weeks\u0026rsquo; gestation: perinatal and 2-year outcomes within a national population-based study (EPIPAGE-2). Elsevier [Internet]. [cited 2022 May 28]; Available from: https://www.sciencedirect.com/science/article/pii/S0002937818304393\u003c/li\u003e\n\u003cli\u003eCousins LM, Smok DP, Lovett SM, Poeltler DM. AmniSure placental alpha microglobulin-1 rapid immunoassay versus standard diagnostic methods for detection of rupture of membranes. Am J Perinatol [Internet]. 2005 Aug [cited 2022 Sep 16];22(6):317\u0026ndash;20. Available from: https://pubmed.ncbi.nlm.nih.gov/16118720/\u003c/li\u003e\n\u003cli\u003eACOG PRACTICE BULLETIN Clinical Management Guidelines for Obstetrician-Gynecologists Prelabor Rupture of Membranes. 2020; \u003c/li\u003e\n\u003cli\u003evan der Heyden JL, van der Ham DP, van Kuijk S, Notten KJB, Janssen T, Nijhuis JG, et al. Outcome of pregnancies with preterm prelabor rupture of membranes before 27 weeks\u0026rsquo; gestation: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol [Internet]. 2013 [cited 2022 Oct 25];170(1):125\u0026ndash;30. Available from: https://pubmed.ncbi.nlm.nih.gov/23845169/\u003c/li\u003e\n\u003cli\u003eLee JY, Ahn TG, Jun JK. Short-term and long-term postnatal outcomes of expectant management after previable preterm premature rupture of membranes with and without persistent oligohydramnios. Obstetrics and Gynecology [Internet]. 2015 Oct 20 [cited 2022 May 28];126(5):947\u0026ndash;53. Available from: https://journals.lww.com/greenjournal/Fulltext/2015/11000/Short_Term_and_Long_Term_Postnatal_Outcomes_of.6.aspx\u003c/li\u003e\n\u003cli\u003eEsteves JS, de S\u0026aacute; RAM, de Carvalho PRN, Coca Velarde LG. Neonatal outcome in women with preterm premature rupture of membranes (PPROM) between 18 and 26 weeks. Journal of Maternal-Fetal and Neonatal Medicine. 2016 Apr 2;29(7):1108\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eAzria E, Anselem O, Schmitz T, Tsatsaris V, Senat M v., Goffinet F. Comparison of perinatal outcome after pre-viable preterm prelabour rupture of membranes in two centres with different rates of termination of pregnancy. BJOG. 2012 Mar;119(4):449\u0026ndash;57. \u003c/li\u003e\n\u003cli\u003eAnderson JG, Baer RJ, Partridge JC, Kuppermann M, Franck LS, Rand L, Jelliffe-Pawlowski LL, Rogers EE. Survival and Major Morbidity of Extremely Preterm Infants: A Population-Based Study. Pediatrics. 2016 Jul;138(1):e20154434. doi: 10.1542/peds.2015-4434. Epub 2016 Jun 14. PMID: 27302979.\u003c/li\u003e\n\u003cli\u003e13. Lee J, Ahn T, Gynecology JJO\u0026amp;, 2015 undefined. Short-term and long-term postnatal outcomes of expectant management after previable preterm premature rupture of membranes with and without persistent. journals.lww.com [Internet]. [cited 2022 May 28]; Available from: https://journals.lww.com/greenjournal/FullText/2015/11000/Short_Term_and_Long_Term_Postnatal_Outcomes_of.6.aspx\u003c/li\u003e\n\u003cli\u003eRyu HK, Moon JH, Heo HJ, Kim JW, Kim YH. Maternal c-reactive protein and oxidative stress markers as predictors of delivery latency in patients experiencing preterm premature rupture of membranes. International Journal of Gynecology and Obstetrics. 2017 Feb 1;136(2):145\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eAcaia B, Crovetto F, Ossola MW, Nozza S, Baffero GM, Somigliana E, et al. Predictive factors for neonatal survival in women with periviable preterm rupture of the membranes. J Matern Fetal Neonatal Med. 2013;26(16):1628\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eBouchghoul H, Kayem G, Schmitz T, Benachi A, Sentilhes L, Dussaux C, et al. Outpatient versus inpatient care for preterm premature rupture of membranes before 34 weeks of gestation. Sci Rep [Internet]. 2019 Dec 1 [cited 2022 Oct 25];9(1). Available from: https://pubmed.ncbi.nlm.nih.gov/30862787/\u003c/li\u003e\n\u003cli\u003eGuckert M, Clouqueur E, Drumez E, Petit C, Houfflin-Debarge V, Subtil D, et al. Is homecare management associated with longer latency in preterm premature rupture of membranes? Arch Gynecol Obstet. 2020 Jan 1;301(1):61\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eAbou El Senoun G, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks\u0026rsquo; gestation. Cochrane Database of Systematic Reviews. 2014 Apr 14;2014(4). \u003c/li\u003e\n\u003cli\u003eDussaux C, Senat MV, Bouchghoul H, Benachi A, Mandelbrot L, Kayem G. Preterm premature rupture of membranes: is home care acceptable? Journal of Maternal-Fetal and Neonatal Medicine. 2018 Sep 2;31(17):2284\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eAlexander JM, Mercer BM, Miodovnik M, Thurnau GR, Goldenberg RL, Das AF, et al. The impact of digital cervical examination on expectantly managed preterm rupture of membranes. Am J Obstet Gynecol [Internet]. 2000 [cited 2022 Oct 25];183(4):1003\u0026ndash;7. Available from: https://pubmed.ncbi.nlm.nih.gov/11035354/\u003c/li\u003e\n\u003cli\u003eAdoni A, ben Chetrit A, Zacut D, Palti Z, Hurwitz A. Prolongation of the latent period in patients with premature rupture of the membranes by avoiding digital examination. International Journal of Gynecology \u0026amp; Obstetrics [Internet]. 1990 May 1 [cited 2022 May 28];32(1):19\u0026ndash;21. Available from: https://onlinelibrary.wiley.com/doi/full/10.1016/0020-7292%2890%2990976-R\u003c/li\u003e\n\u003cli\u003evan der Marel I, de Jonge R, Duvekot J, Reiss I, Bruss\u0026eacute; I. Maternal and Neonatal Outcomes of Preterm Premature Rupture of Membranes before Viability. Klin Padiatr [Internet]. 2016 Mar 1 [cited 2022 Oct 25];228(2):69\u0026ndash;76. Available from: https://pubmed.ncbi.nlm.nih.gov/26886145/\u003c/li\u003e\n\u003cli\u003eKibel M, Asztalos E, Barrett J, Dunn MS, Tward C, Pittini A, et al. Outcomes of Pregnancies Complicated by Preterm Premature Rupture of Membranes Between 20 and 24 Weeks of Gestation. Obstetrics and gynecology [Internet]. 2016 Aug 1 [cited 2022 Oct 25];128(2):313\u0026ndash;20. Available from: https://pubmed.ncbi.nlm.nih.gov/27400016/\u003c/li\u003e\n\u003cli\u003eSim WH, Araujo J\u0026uacute;nior E, da Silva Costa F, Sheehan PM. Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability. J Perinat Med [Internet]. 2017 Jan 1 [cited 2022 May 28];45(1):29\u0026ndash;44. Available from: https://www.degruyter.com/document/doi/10.1515/jpm-2016-0183/html\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Characteristics and Outcomes of Pregnancies\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.079934747145188%\" rowspan=\"2\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.789237668161434%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenefiting from expectant management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.01345291479821%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot- benefiting from expectant management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.19730941704036%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.789237668161434%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en= 45\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.01345291479821%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en= 74\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.19730941704036%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eMaternal age \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e29.6 \u003cu\u003e+\u003c/u\u003e 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e29.1 \u003cu\u003e+\u003c/u\u003e 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.735\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eMaternal age \u0026gt;35, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e9 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e1.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eGravidity (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e2 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e3 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.881***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eParity (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.850***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003ePrimipar, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e29 (64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e56 (75.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.269**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eBMI (kg/m2) \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e26 \u003cu\u003e+\u003c/u\u003e 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e27 \u003cu\u003e+\u003c/u\u003e 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.682\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eRefugee, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e6 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e10 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e1.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\" style=\"width: 68.5454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk factors of PPROM\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eAntepartum \u0026nbsp; \u0026nbsp; \u0026nbsp;hemorrhage\u003csup\u003e\u0026micro;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e10 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e1.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eHistory of PPROM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e5 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e17 (23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.170**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eHistory of multipl D\u0026amp;C, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e8 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e10 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.715**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eSmoker, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e6 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e11(14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e1.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eCervical cerclage, n\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e2 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e3 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eCervical length, mm, n:45\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e29 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e32 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.668***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eShort cervix, n= 45\u003csup\u003e\u0026eth;\u003c/sup\u003e n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e4 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e8 (29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.735*****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\" style=\"width: 68.5454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of follow up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Inpatient, n\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e33 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e68 (91.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" rowspan=\"2\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.013\u003c/strong\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Outpatient, n\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e12 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e6 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGA at admission (weeks)\u003c/strong\u003e\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e22\u003cu\u003e+\u003c/u\u003e 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e22\u003cu\u003e+\u003c/u\u003e 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.144\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLatency period (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e16 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e4.5 (14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLatency\u0026lt;7 days\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e13 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e43 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\" style=\"width: 68.5454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSonographic findings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eAFI (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e30 (22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e25 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.644***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Normal, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e7 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e22 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" rowspan=\"3\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.060****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Oligohydramnios, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e21 (46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e20 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Anhydramnios, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e17 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e32 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eAnhydramnios at any time, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e22 (48.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e39 (52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.830**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eBreech presentation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e22 (48.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e34 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.902**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\" style=\"width: 68.5454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLaboratuary findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eWBC count at admission (x10\u003csup\u003e3\u003c/sup\u003e /uL) \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e13573 \u003cu\u003e+\u003c/u\u003e 3100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e13900 \u003cu\u003e+\u003c/u\u003e 4400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.666\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eWBC\u0026gt; 15000 x10\u003csup\u003e3\u003c/sup\u003e /uL, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e15 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e27 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.880**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eCRP levels at admission (mg/L), n:90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e8.5 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e16 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010***\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003eCRP\u0026gt;5 mg/dL, n: 90 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e26 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e40 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.337**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGA at delivery (weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e26 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e23 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight (grams)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e910 (570)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e590 (226)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000***\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelivery before 28 gw, n\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e30 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e66 (89.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.017****\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\" style=\"width: 68.5454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of delivery, n\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Vaginal delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e11 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e37 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" rowspan=\"2\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010****\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Cesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e34 (75.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e37 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\" style=\"width: 68.5454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFetal gender, n\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e29 (64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e34 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" rowspan=\"2\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.077**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Male\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e16 (35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e40 (54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\" style=\"width: 68.5454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndications of delivery, n\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Clinical chorioamnionitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e8 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e4 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" rowspan=\"6\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.153****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Plasental abruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e6 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e15 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Non-reassuring fetal status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e5 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e8 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Spontane labor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e26 (57.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e42 (56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; 34. gestational weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.358674463937625%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp; Cord prolapse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.72319688109162%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.91812865497076%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e3 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.124183006535947%\" valign=\"top\" style=\"width: 20.1203%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal morbidity, n\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.26797385620915%\" valign=\"top\" style=\"width: 22.3938%;\"\u003e\n \u003cp\u003e11(24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.431372549019606%\" valign=\"top\" style=\"width: 17.2784%;\"\u003e\n \u003cp\u003e13 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.176470588235293%\" valign=\"top\" style=\"width: 8.7529%;\"\u003e\n \u003cp\u003e0.502**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBenefiting from expectant management: Survival to discharge\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot- benefiting from expectant management: Previable births, stillbirths, deaths in delivery room and neonatal deaths.\u003c/p\u003e\n\u003cp\u003eData are given as median (interquartile range), mean (SD\u003csup\u003e\u0026para;\u003c/sup\u003e, standart deviation) or n (%).\u003c/p\u003e\n\u003cp\u003eIQR, Interquartile range; BMI, Body mass index; GA, Gestational age; PPROM, Preterm premature rupture of membranes; D\u0026amp;C, Dilatation and Curetage; AFI, Amniotic Fluid Index; WBC, White Blood Cell; CRP, C-Reactive Protein\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e\u0026micro;\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003efirst and/or second trimester vaginal bleeding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026eth;\u003c/strong\u003e patients whose cervical lenght was \u0026lt;25 mm at admission\u003c/p\u003e\n\u003cp\u003e*Independent sample t test\u003c/p\u003e\n\u003cp\u003e**\u0026nbsp;Continuity Correction\u003c/p\u003e\n\u003cp\u003e***Mann- Whitney U\u003c/p\u003e\n\u003cp\u003e****Pearson chi-square\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e***** Fisher\u0026rsquo;s Exact Test\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Neonatal characteristics and outcomes of neonatal survivors\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"428\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"100%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en = 45\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGA at delivery\u003csup\u003e\u0026para;\u003c/sup\u003e (weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e26 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight (grams)\u003csup\u003e\u0026para;\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e910 (570)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAPGAR 5. minute \u0026lt;7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e21 (46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeed of NRP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e27 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of NRP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;PPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e13(29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intubated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e10 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Compression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e3 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e1(2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeed of MV\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e33 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDays of ıntubated (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e11.0 (24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeed of Nasal MV\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e41 (91.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeed of HFO\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e6 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\" style=\"width: 96.875%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeonatal morbidities\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003eRDS\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e38 (84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003eSevere BPD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e27 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003ePDA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e26 (57.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003eCultur proven sepsis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e14 (31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003eROP stage 3-4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e11 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003eNEC stage 2-3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e5 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003ePVL\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e5 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003ePulmoner hemorrhage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e4 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003eKonvulsion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e4 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003ePositional deformity \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e3 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003eIVH grade 3-4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e2 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration NICU stay (days)\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e73 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvival to discharge with no major morbidity, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e15 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.308411214953274%\" valign=\"top\" style=\"width: 55.2257%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvival to discharge with at least one major morbidity, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.691588785046726%\" valign=\"top\" style=\"width: 41.6493%;\"\u003e\n \u003cp\u003e30 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are given as median (interquartile range)\u003cstrong\u003e\u003csup\u003e\u0026nbsp;\u0026para;\u003c/sup\u003e\u003c/strong\u003e or n (%).\u003c/p\u003e\n\u003cp\u003eGA; Gestational age, NRP; Neonatal Resuscitation Program, PPV; Positive Pressure Ventilation, MV; Mechanical Ventilation, HFO; High Frequency Oscillation, RDS; Respiratory Distress Syndrome, BPD; Bronchopulmonary Dysplasia, PDA; Patent Ductus Arteriosus, ROP; Retinopathy of Prematurity, NEC; Necrotizan Enterocolitis, PVL; Periventricular Leucomalacia, IVH; Intraventricular Hemorrhage, NICU; Neonatal Intensive Care Unit\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e \u003cstrong\u003eThe sensitivity analysis for GA at delivery (weeks), latency period (days), birth weight (gram) and their combination for not-benefiting ekspectant management\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"647\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.683153013910356%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.582689335394127%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCut-off\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity (95%\u0026nbsp;CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecificity (95%\u0026nbsp;CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePPV (95%\u0026nbsp;CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69242658423493%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNPV (95%\u0026nbsp;CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.664605873261205%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAUC+-standard error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.500772797527048%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.683153013910356%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGA at delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.582689335394127%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026le;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e51,35 (39,4\u0026nbsp;-\u0026nbsp;63,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e93,33\u003c/p\u003e\n \u003cp\u003e(81,7\u0026nbsp;-\u0026nbsp;98,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e92,7\u003c/p\u003e\n \u003cp\u003e(80,6\u0026nbsp;-\u0026nbsp;97,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69242658423493%\" valign=\"top\"\u003e\n \u003cp\u003e53,8\u003c/p\u003e\n \u003cp\u003e(47,7-\u0026nbsp;59,9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.664605873261205%\" valign=\"top\"\u003e\n \u003cp\u003e0.79\u0026plusmn; 004\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.500772797527048%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.683153013910356%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLatency period\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.582689335394127%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026le;9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e71,62\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59,9-\u0026nbsp;81,5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e66,67\u003c/p\u003e\n \u003cp\u003e51,0-\u0026nbsp;80,0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e77,9\u003c/p\u003e\n \u003cp\u003e69,5-\u0026nbsp;84,5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69242658423493%\" valign=\"top\"\u003e\n \u003cp\u003e58,8\u003c/p\u003e\n \u003cp\u003e48,5-\u0026nbsp;68,4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.664605873261205%\" valign=\"top\"\u003e\n \u003cp\u003e0.71\u0026plusmn; 005\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.500772797527048%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.683153013910356%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.582689335394127%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026le;640\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e67,57\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55,7-\u0026nbsp;78,0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e82,22\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67,9-\u0026nbsp;92,0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e86,2\u003c/p\u003e\n \u003cp\u003e76,6-\u0026nbsp;92,3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69242658423493%\" valign=\"top\"\u003e\n \u003cp\u003e60,7\u003c/p\u003e\n \u003cp\u003e51,9-\u0026nbsp;68,8\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.664605873261205%\" valign=\"top\"\u003e\n \u003cp\u003e0,82+-0.04\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.500772797527048%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.683153013910356%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCombination\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.582689335394127%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0,4414\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e90,38 (79,0-\u0026nbsp;96,8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e50 (33,4-\u0026nbsp;66,6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.292117465224111%\" valign=\"top\"\u003e\n \u003cp\u003e50 (33,4-\u0026nbsp;66,6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69242658423493%\" valign=\"top\"\u003e\n \u003cp\u003e79,2(60,9-\u0026nbsp;90,3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.664605873261205%\" valign=\"top\"\u003e\n \u003cp\u003e0,78+-0.05\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.500772797527048%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGA; Gestational age, PPV; Positive predictive value, NPV; Negative predictive value, AUC; Area under curve\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Preterm premature rupture of membranes, periviable, chorioamnionitis, preterm delivery","lastPublishedDoi":"10.21203/rs.3.rs-4120696/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4120696/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Periviable preterm rupture of membranes (PPROM) is associated with increased risk of perinatal morbidity and mortality. We aimed to assess the outcomes and predictive factors of ekspectant management in pregnancies with periviable preterm prelabor rupture of membranes (PPROM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This was a retrospective study from January 2015 through December 2019. Women diagnosed with PPROM in the periviable period (20+0 to 25+6 weeks’ gestation) were included. Maternal demographics, clinical characteristics, and neonatal outcomes were reviewed. Clinical data were obtained from the medical records of a single center. Predictive factors for assessed using receiver-operator characteristic (ROC) curves.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 142 women with mid-trimester PPROM were evaluated. Among this, 119 (83.8 %) were managed expectantly and included in this study. \u0026nbsp;Forty-five (37.8%) of these pregnancies benefited from expectant management; that is, the newborns survived to discharge from NICU. The remaining 74 pregnancies (62.2%) resulted in pre-viable births, stillbirths, deaths in the delivery room, and neonatal deaths. Pregnancies benefiting from expectant management had a longer latency period, had a greater birth weight, and were born at a more advanced GA compared to women who did not benefit from expectant management. Diagnostic cut-off values were obtained by Receiver-operator characteristic (ROC) curves for this indicators and their combination. ROC curve analysis identified GA at delivery ≤23 weeks, latency period ≤9 days, and birth weight ≤640 grams as predictors of unsuccessful expectant management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Periviable PPROM is associated with poor neonatal outcomes with an overall survival rate of 37.8%. If the mother and fetus stabil during the expectant period, neonatal outcomes can be improved by increasing GA at birth, birth weight and latency period.\u003c/p\u003e","manuscriptTitle":"Periviable preterm prelabor rupture of membranes: Outcomes of pregnancies following expectant management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-26 20:28:24","doi":"10.21203/rs.3.rs-4120696/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"35da1134-3993-455f-a36b-b73172f233fc","owner":[],"postedDate":"March 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-28T06:09:02+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-26 20:28:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4120696","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4120696","identity":"rs-4120696","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}