Uncertain prelabor rupture of membranes at term and associated delivery outcomes

Uncertain prelabor rupture of membranes at term and associated delivery outcomes | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Uncertain prelabor rupture of membranes at term and associated delivery outcomes Yossi Geron, Noam Rozner Negrin, Ran Matot, Natav Hendin, Shir Danieli-Gruber, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3927382/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jun, 2024 Read the published version in International Journal of Gynecology & Obstetrics → Version 1 posted You are reading this latest preprint version Abstract Background Prelabor rupture of membranes (PROM) is a common obstetrical event, but its diagnosis is frequently challenging. The aim of the study was to determine whether equivocal PROM cases are associated with adverse outcomes. Methods A retrospective study was conducted in a tertiary medical center between July 2012 and March 2022. The cohort consisted of women diagnosed with term PROM (≥ 37 gestational weeks), divided into two groups: (1) certain PROM - suggestive history of a watery vaginal discharge confirmed by visualization of fluid leaking from the cervix or pooling in the vagina on speculum examination; (2) uncertain PROM - suggestive history of a watery vaginal discharge not supported by speculum examination. All patients were hospitalized and gave birth spontaneously or following either expectant management for up to 24 hours from PROM or induction. The primary outcome measure was cesarean delivery rate. Secondary outcome measures were adverse maternal and neonatal events. Results A total of 2012 women were included in the study, 1750 with certain PROM and 262 with uncertain PROM. The cesarean delivery rate was 5.8% in the certain PROM group and 8.8% in the uncertain PROM group; the difference was not statistically significant ( p = .074). There was a significant between-group difference in the rate of cesarean delivery due to failed induction on univariate analysis (0.69% vs 2.67%, respectively, p = .007), but it was not maintained on multivariate logistic regression (OR 0.37, 95% CI 0.117–1.172). Other maternal and neonatal outcomes were similar in the two groups. Conclusions In our study, following the same management guidelines for equivocal cases of ruptured membranes as for confirmed cases of term PROM did not compromise maternal or fetal outcomes. Prelabor rupture of membranes Term pregnancy Diagnosis Induction of labor Figures Figure 1 Figure 2 Background Prelabor rupture of membranes (PROM) at term (≥ 37 gestational weeks) complicates approximately 8% of pregnancies and is generally followed by prompt onset of spontaneous labor and delivery [ 1 ]. The most significant maternal consequence of term PROM is intrauterine infection, including chorioamnionitis and postpartum febrile morbidity. Fetal consequences include ascending infection and in utero cord compression [ 2 ]. A meta-analysis of 23 randomized controlled trials (8615 women) found that induction of labor reduced the time from rupture of membranes to birth and the rates of chorioamnionitis, endometritis, or both, and was associated with a lower likelihood for neonatal intensive care unit (NICU) admission. There was no accompanying increase in rates of cesarean delivery (CD) or operative vaginal delivery [ 1 ]. For women with term PROM who have no contraindication for labor, induction is usually recommended. As long as maternal and fetal conditions are reassuring, expectant management for a short duration may also be a reasonable choice, given that half the women with term PROM who are managed expectantly give birth within 33 hours [ 3 ]. The diagnosis of PROM is usually made by clinical assessment, which includes visualization of amniotic fluid passing from the cervical canal and pooling in the posterior vaginal fornix on speculum evaluation, higher than normal value on pH test of the vaginal fluid, or arborization (ferning) of dried vaginal fluid on microscopic evaluation. Currently, various tests are available for detecting amniotic proteins, such as placental alpha microglobulin 1 (PAMG), which is known for high sensitivity in diagnosing PROM [ 2 ]. However, several factors can influence the diagnostic accuracy and feasibility of these tests, yielding false-positive results in about one-third of cases [ 4 ]. Reasons for a false-positive may be presence of blood or semen, alkaline antiseptics, certain lubricants, trichomonas, or bacterial vaginosis. False-negative test results may arise with prolonged membrane rupture and minimal residual fluid. In ambiguous cases, sonographic evaluation of amniotic fluid volume may be a useful adjunct, but it is not diagnostic. Thus, the optimal approach to clinical assessment and diagnosis of PROM is still controversial [ 2 ]. Ladfors et al. [ 5 ] showed that even at term, speculum examination to visualize the amniotic fluid carries a 12% false-negative rate [ 5 ]. Nonconfirmatory test results in a patient with a history suggesting membrane rupture, or vice versa, creates an obstetrical dilemma. Early and accurate diagnosis of PROM allows for further interventions to optimize maternal and perinatal outcomes and minimize complications, whereas overdiagnosis may result in complications of overtreatment or unnecessary labor induction. Although labor induction is known to be beneficial in cases of PROM, whether it is also beneficial in cases of inconclusive PROM has not yet been determined. The aim of the present study was to answer the question: By offering the same treatment for uncertain PROM as for certain PROM, are we exposing patients with uncertain PROM to greater risk? Methods Study population A retrospective study was conducted at a tertiary university medical center from July 2012 to March 2022. The cohort included women with a singleton gestation who were diagnosed with ruptured membranes at ≥ 37 gestational weeks. Patients were categorized into two groups: (1) certain PROM -- women presenting with unequivocal clinical rupture of the membranes based on a suggestive history of watery vaginal discharge confirmed by speculum examination demonstrating fluid leaking from the cervix or pooling in the vagina; (2) uncertain PROM -- women for whom the diagnosis of PROM was inferred from a suggestive history of membrane rupture, although speculum examination was not supportive. No additional diagnostic methods were used in the uncertain PROM group. Exclusion criteria were non-vertex presentation, multiple gestation, fetal malformations, contraindication for vaginal delivery (such as placenta previa or > 1 previous CD), and non-reassuring fetal status at admission. Data collection Clinical data on maternal and obstetrical characteristics and maternal and early neonatal outcomes were extracted from the electronic medical records. Patient management All patients were hospitalized and managed either actively or expectantly according to our departmental protocol for PROM, taking clinical-obstetrical status and maternal preference into consideration. Expectant management entailed a period of in-hospital observation lasting up to 24 hours following membrane rupture. If spontaneous labor did not commence naturally within this timeframe, or for reasons of maternal request, suspected maternal infection, or non-reassuring fetal status, labor was induced with either oxytocin infusion or prostaglandin E2 (PGE2) slow-release vaginal insert (Propess 10mg, Ferring Pharmaceuticals AB, Kiel, Germany). Active management was defined as the initiation of labor immediately upon admission, either spontaneously or through induction using oxytocin or PGE2, or by augmentation with oxytocin. Prophylactic treatment with intravenous ampicillin (Penibrin; Sandoz, Kundl, Austria) was administered for the following indications: group B Streptococcus (GBS) carrier, previous infant with invasive GBS disease and prolonged PROM (≥ 18 hours), or intrapartum fever (≥ 37.8 0 C) when GBS carrier status was unknown. Outcome measures The primary outcome measure was the CD rate. Secondary outcome measures were duration of labor and adverse maternal and neonatal events. The adverse maternal outcomes assessed were operative vaginal delivery, intrapartum fever, clinical chorioamnionitis, and obstetrical anal sphincter injuries (OASIS). Clinical chorioamnionitis was defined as fever (≥ 37.8 0 C) accompanied by one or more of the following: maternal tachycardia (> 100 bpm), fetal tachycardia (> 160 bpm), leukocytosis (> 15,000/mm 3 ), uterine tenderness, and foul-smelling vaginal discharge. The composite adverse maternal outcome was defined as any of the following: cesarean delivery, assisted vaginal delivery, clinical chorioamnionitis, intrapartum fever, and OASIS. The adverse neonatal outcomes assessed were 5-minute Apgar score < 7, umbilical pH < 7.2, NICU admission, and/or neonatal death. Ethics The study adhered to the tenets of the Declaration of Helsinki and was approved by the local Institutional Review Board (approval no. 0089-22-RMC) which waived the need for informed consent. Statistical analysis Statistical analysis was generated with SAS software, version 34.0 (SAS Corp., Cary, NC, USA). Continuous variables were summarized by mean and standard deviation or median and interquartile range. Categorical variables were summarized by number and percent. Normality of continuous variables was assessed using the Kolmogorov-Smirnov test. T-test was used to compare the value of normally distributed continuous variables between study groups, and Wilcoxon test was used for non-normal continuous variables. Fisher's exact test was used to compare categorical variables between groups. Logistic regression was used to calculate univariate and multivariate odds ratios (OR), presented with 95% confidence interval (CI). The Kaplan-Meier procedure was applied to graph latency time from PROM until delivery. Two-sided p -values less than .05 were considered statistically significant. Results A total of 2012 women met the inclusion criteria: 1750 (87%) with certain PROM and 262 (13%) with uncertain PROM. Their demographic characteristics are presented in Table 1 . There was a marginal difference in median gestational age between the groups: 39.57 years (IQR 39-40.29) in the uncertain PROM group and 39.29 years (IQR 38.43-40) in the certain PROM group ( p < .0001). No significant between-group differences were found in maternal age, gravidity, parity, proportion of previous cesarean deliveries, neonatal gender, and birthweight. The prevalence of oligohydramnios was notably higher in the uncertain PROM group (10.3 1 % vs. 1.4 9 %; p < .001), with no significant differences between the groups in rates of hypertensive disorders, diabetes mellitus, polyhydramnios, and positive GBS carrier status. Labor management strategies differed between the groups. The uncertain PROM group had a higher incidence of active management (68.70% vs. 55.43%; p < .001) and more frequent use of PGE2 for labor induction (9.92% vs. 2.0%; p < .001). Need for Induction following expectant management did not differ significantly between the groups. Table 1 Maternal and obstetrical characteristics of cases of clinically certain and uncertain PROM Parameters Uncertain PROM N = 262 Certain PROM N = 1750 p -Value Gestational age at delivery, weeks 39.57 (39-40.29) 39.29 (38.43-40) < .0001 Gravidity 3 (1–4) 2 (1–4) 0.283 Parity 1 (0–2) 1 (0–2) 0.071 Neonatal gender, male 140 (53.44) 913 (52.17) 0.740 Neonatal birthweight, grams 3228 (2969–3494) 3198 (2934–3450) 0.078 Maternal age (years) 32.43 ± 4.64 32.04 ± 4.71 0.206 Previous cesarean delivery 24 (9.16) 162 (9.26) > .999 Hypertensive disorders a 9 (3.44) 34 (1.94) 0.163 Diabetes in pregnancy b 14 (5.34) 87 (4.97) 0.762 Polyhydramnios 6 (2.29) 25 (1.43) 0.281 Oligohydramnios 27 (10.31) 26 (1.49) < .001 Other maternal comorbidities c 32 (12.21) 212 (12.11) 0.920 GBS carrier status, positive 16 (22.22) 132 (23.36) 0.883 Meconium 26 (9.92) 215 (12.29) 0.308 Cervical dilation at admission, cm 2 (1-2.5) 1.5 (1-2.5) 0.241 Cervical effacement at admission, % 70 (60–80) 70 (60–80) 0.094 Active management 180 (68.70) 970 (55.43) < .001 Spontaneous initiation of labor 50 (19.08) 255 (14.57 0.064 Induction with oxytocin 104 (39.69) 680 (38.86) 0.839 Induction with PGE2 26 (9.92) 35 (2.0) < .001 Expectant management 82 (31.2) 780 (44.6) < .001 Need for induction after expectant management 39 (14.89) 276 (15.77) 0.785 With oxytocin 18 (6.8) 144 (8.2) 0.802 With PGE2 21 (8) 132 (7.5) 0.542 *Data are presented as mean ± standard deviation, median (interquartile range), or number (percentage). a Chronic hypertension, gestational hypertension, preeclampsia with or without severe features, superimposed preeclampsia and eclampsia. b Gestational and pregestational diabetes. c Thyroid disorders, asthma, epilepsy, smoking, alcohol or drug abuse. PROM, premature rupture of membranes; GBS, group B Streptococcus; PGE2, prostaglandin E2. Table 2 summarizes the maternal and neonatal outcomes. No significant between-group differences were found in overall rates of CD, assisted vaginal delivery, or maternal complications such as clinical chorioamnionitis, intrapartum fever, OASIS and composite maternal outcome. Similarly, neonatal outcomes including Apgar score, umbilical cord pH, NICU admission, and death were consistent across both groups. A higher rate of CD due to failed induction was observed in the uncertain PROM group (2.67% vs. 0.69%, respectively; p = .007). Table 2 Maternal and neonatal outcome in cases of clinically certain and uncertain PROM Parameter Uncertain PROM N = 262 Certain PROM N = 1750 p -Value Maternal outcome Cesarean delivery 23 (8.80) 102 (5.80) 0.074 Due to failed induction 7 (2.67) 12 (0.69) 0.007 Due to labor dystocia 1 (0.38) 22 (1.26) 0.348 Assisted vaginal delivery 19 (7.25) 168 (9.60) 0.254 Clinical chorioamnionitis 0 7 (0.40) 0.605 Intrapartum fever 0 12 (0.69) 0.385 Obstetrical anal sphincter injuries 1 (0.38) 9 (0.51) > 0.999 PROM to delivery time, hours 13.57 (7-31.08) 15.35 (9.48–26.93) 0.136 Composite maternal outcome a 43 (16.41) 280 (16.0) 0.857 Neonatal outcome 5-minute Apgar score < 7 0 8 (0.46) 0.607 Umbilical cord pH < 7.2 7 (3.50) 37 (2.81) 0.505 NICU admission 1 (0.38) 29 (1.66) 0.167 Death 0 0 - *Data are presented as mean ± standard deviation, median (interquartile range), or number (percentage). a Cesarean delivery, assisted vaginal delivery, maternal infection, intrapartum fever, Obstetrical anal sphincter injuries. PROM, premature rupture of membranes, NICU, neonatal intensive care unit. The time from PROM to delivery across all cases of certain and uncertain PROM was plotted in a Kaplan-Meier survival curve (Fig. 1 ). No statistically significant difference was noted between the groups ( p = 0.381, log-rank test). As shown in Fig. 2 , there was also no between-group difference in time to delivery within the subset of 862 women who were managed expectantly ( p = 0.128, log-rank test). Univariate and multivariate logistic regression analyses were performed to evaluate the factors associated with cesarean delivery (CD) due to failed induction. This analysis was conducted within a subset of 1,160 women who underwent labor induction. This group comprised patients following either active or expectant management strategies, including 991 women with confirmed certain PROM and 169 women with uncertain PROM. The results are shown in Table 3 . Certain PROM was associated with lower odds of CD due to failed induction in the univariate model (OR 0.321, 95% CI 0.122–0.842), but this association did not reach statistical significance in the multivariate model (OR 0.382, 95% CI 0.12–1.215). Parity (OR 0.294, 95% CI 0.088–0.983) and cervical dilation at admission (OR 0.131, 95% CI 0.049–0.35) were found to be protective. Previous CD emerged as a significant predictor for CD due to failed induction in the multivariate model (OR 7.765, 95% CI 1.313–45.912). Maternal age and gestational age at delivery were not associated with failed induction-indicated CD. Table 3 Univariate and multivariate analysis of factors associated with cesarean delivery due to failed induction Parameter Univariate OR with 95% CI Multivariate OR with 95% CI Certain PROM 0.321 [0.122–0.842, p = .021] 0.382 [0.12–1.215, p = .103] Maternal age 0.975 [0.886–1.073, p = .610] 1.064 [0.95–1.191, p = .284] Parity 0.342 [0.165–0.708, p = .004] 0.294 [ 0.088–0.983, p = .047 ] Gestational age at delivery 1.024 [0.677–1.549, p = .91] 1.009 [0.622–1.635, p = .972] Previous cesarean delivery 4.51 [1.358–14.974, p = .014] 7.765 [1.313–45.912, p = .024] Cervical dilatation at admission 0.092 [0.037–0.23, p < .0001] 0.131 [0.049–0.35, p < .0001] PROM, premature rupture of membranes; OR, Odds ratio; CI, confidence interval Discussion The present study demonstrates that women with suspected membrane rupture who were managed like women with certain (unequivocal) PROM and underwent induction or expectant management were not compromised compared to women with certain PROM. Our findings show no significant difference between the groups in maternal outcomes, including CD rates, and in short-term neonatal outcomes. In most women, the diagnosis of ruptured fetal membranes can be confirmed on the basis of a suspicious history and findings of leaking or pooling of amniotic fluid during speculum examination. However, in approximately 10% of cases, the diagnosis is difficult to establish [ 6 ]. Previous studies of diagnostic tests to confirm PROM in patients with a questionable state of the membranes reported varying efficacy. The tests investigated included the fern test [ 7 ], nitrazine test [ 8 ], fibronectin immunoassay [ 9 ], insulin-like growth factor binding protein-1 (IGFBP-1) test [ 10 ], alpha-fetoprotein (AFP) kit [ 11 ], placental α microglobulin-1 (PAMG) immunoassay [ 12 , 13 ], and dye injection [ 14 ]. A meta-analysis of studies that focused on the clinical use of biochemical marker tests in patients with suspected membrane rupture found that PAMG-1 and IGFBP-1 had high positive (98.4% and 87.9%, respectively) and negative (96.7% and 93.9%, respectively) predictive values, making them useful diagnostic aids [ 15 ]. As rupture of the membranes in the preterm period ( > 37 gestational weeks) is associated with prematurity, neonatal morbidity, and mortality, alongside an increased risk of maternal infection, a concise diagnosis is needed. In 2018, Grobman et al. [ 16 ] published the results of the ARRIVE trial which evaluated the perinatal and maternal consequences of inducing labor at 39 weeks in nulliparous women at low risk. The results showed that this approach did not lead to adverse outcomes, and indeed, even led to a reduction in CDs. Our results align with these findings, as the gestational age of most of our cohort (62.6% of the certain PROM group, 75.2% of the uncertain PROM group) was 39 weeks or more. This suggests that induction of labor following suspected and unconfirmed PROM at term would not be expected to have adverse maternal or neonatal consequences. Furthermore, the time to delivery in the two groups remained similar, even when including women who were managed expectantly. Thus, a notable portion of women with uncertain PROM may have actually experienced membrane rupture despite the absence of clear evidence of amniotic fluid loss by speculum examination. In a Cochrane review comparing planned early birth versus expectant management for term PROM, the rates of overall chorioamnionitis (either suspected or proven) and/or intrapartum fever, as reported by 14 studies, varied between 1.0% and 26.9% [ 6 ]. In the present study, rates of clinical chorioamnionitis and intrapartum fever were closer to the lower end of this range for both groups. The difference between the studies could be due to the active management approach we used for most of our patients, likely reducing the risk of these conditions. The present study has several limitations that need to be considered when interpreting the data. The retrospective design could have created a selection as well as an information bias. In addition, gestational age was more than 39 weeks in most of the women in our cohort, and it is unknown whether the results are applicable to cohorts with a lower gestational age. Our data did not include postpartum maternal and neonatal infections which are associated with PROM. Nevertheless, to our knowledge, this is the first study to examine the outcomes of equivocal cases of membrane rupture at term that were managed as PROM. This information may guide physicians facing controversial findings between anamnesis and physical examination when confirmatory tests are unavailable. In conclusion, the diagnosis of rupture of membranes should be pursued due to the associated risks. The present study suggests that the management of questionable rupture of membrane at term as PROM does not result in adverse maternal or neonatal outcomes. Abbreviations CD, cesarean delivery GBS, group B Streptococcus NICU, neonatal intensive care unit OASIS, obstetrical anal sphincter injuries PGE2, prostaglandin 2 PROM, premature rupture of membranes Declarations Ethics approval and consent to participate The study adhered to the tenets of the Declaration of Helsinki and was approved by the local Institutional Review Board (approval no. 0089-22-RMC) which waived the need for informed consent. Consent for publication Not applicable. Availability of data and materials Data is available from the corresponding author upon reasonable request, with appropriate regulatory approvals. All data relevant to the study was included in the article. Competing Interest None declared. Authors' contributions Y.G. and E.H. conceptualized and designed the study. Material preparation and data collection were performed by N.R.N., R.M. and S.D.G. Data analysis and interpretation were performed by R.M. and N.H. The manuscript was written by Y.G, N.R.N., A.S. and E.H. All authors approved the final article as submitted. Funding This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgements Not applicable. References Middleton P, Shepherd E, Flenady V, McBain RD, Crowther CA. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev. 2017;1:CD005302. Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217. Obstet Gynecol. 2020;135:e80—97. Krispin E. Management of premature rupture of membranes at term: the need to correct a recurring mistake in articles, chapters, and recommendations of professional organizations. Am J Obstet Gynecol. 2017;217:661.e1—e3. Lee SM, Lee J, Seong HS, Lee SE, Park JS, Romero R, et al. The clinical significance of a positive Amnisure test in women with term labor with intact membranes. J Matern Fetal Neonatal Med. 2009;22:305—10. Ladfors L, Mattsson LA, Eriksson M, Fall O. Is a speculum examination sufficient for excluding the diagnosis of ruptured fetal membranes? Acta Obstet Gynecol Scand. 1997;76:739—42. van der Ham DP, van Melick MJ, Smits L, Nijhuis JG, Weiner CP, van Beek JH, et al. Methods for the diagnosis of rupture of the fetal membranes in equivocal cases: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2011;157:123—7. de Haan HH, Offermans PM, Smits F, Schouten HJ, Peeters LL. Value of the fern test to confirm or reject the diagnosis of ruptured membranes is modest in nonlaboring women presenting with nonspecific vaginal fluid loss. Am J Perinatol. 1994;11:46—50. Olarinoye AO, Olaomo NO, Adesina KT, Ezeoke GG, Aboyeji AP. Comparative diagnosis of premature rupture of membrane by nitrazine test, urea, and creatinine estimation. Int J Health Sci (Qassim). 2021;15:16—22. Hellemans P, Verdonk P, Baekelandt M, Joostens M, Francx M, Gerris J. Preliminary results with the use of the ROM-check immunoassay in the early detection of rupture of the amniotic membranes. Eur J Obstet Gynecol Reprod Biol. 1992;43:173—9. Jeurgens-Borst AJ, Bekkers RL, Sporken JM, van den Berg PP. Use of insulin like growth factor binding protein-1 in the diagnosis of ruptured fetal membranes. Eur J Obstet Gynecol Reprod Biol. 2002;102:11—4. Yamada H, Kishida T, Negishi H, Sagawa T, Yamaguchi M, Sato C, et al. Comparison of an improved AFP kit with the intra-amniotic PSP dye-injection method in equivocal cases of preterm premature rupture of the fetal membranes. J Obstet Gynaecol Res. 1997;23:307—11. Vischio AT, Khulmann P, Ross L, Ovittore L, Sena S, Dodge J. AmniSure placental alpha microglobulin-1 rapid immunoassay for detection of rupture of membranes: A comparison study with clinical-based testing. Am J Clin Pathol . 2012;138 Suppl. 1:A024. Cousins 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. 2005;22:317—20. Fujimoto S, Kishida T, Sagawa T, Negishi H, Okuyama K, Hareyama H, et al. Clinical usefulness of the dye-injection method for diagnosing premature rupture of the membranes in equivocal cases. J Obstet Gynaecol (Tokyo 1995). 1995;21:215—20. Palacio M, Kühnert M, Berger R, Larios CL, Marcellin L. Meta-analysis of studies on biochemical marker tests for the diagnosis of premature rupture of membranes: comparison of performance indexes. BMC Pregnancy Childbirth. 2014;14:183. Grobman WA, Rice MM, Reddy UM, Tita ATN, Silver RM, Mallett G, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379:513—23. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Jun, 2024 Read the published version in International Journal of Gynecology & Obstetrics → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Noam","middleName":"Rozner","lastName":"Negrin","suffix":""},{"id":272590013,"identity":"094c1bee-a2d5-4783-b64c-cb053f3cced1","order_by":2,"name":"Ran Matot","email":"","orcid":"","institution":"Helen Schneider Hospital for Women, Rabin Medical Center – Beilinson Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ran","middleName":"","lastName":"Matot","suffix":""},{"id":272590014,"identity":"49a4b7a7-e8b7-418c-a279-60f3128a6af5","order_by":3,"name":"Natav Hendin","email":"","orcid":"","institution":"Helen Schneider Hospital for Women, Rabin Medical Center – Beilinson Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Natav","middleName":"","lastName":"Hendin","suffix":""},{"id":272590015,"identity":"d08dec55-6341-409d-8e0f-fff498a462b6","order_by":4,"name":"Shir Danieli-Gruber","email":"","orcid":"","institution":"Helen Schneider Hospital for Women, Rabin Medical Center – Beilinson Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shir","middleName":"","lastName":"Danieli-Gruber","suffix":""},{"id":272590016,"identity":"fe83eede-1162-44c7-9e8e-b0594428cdd6","order_by":5,"name":"Anat Shmueli","email":"","orcid":"","institution":"Helen Schneider Hospital for Women, Rabin Medical Center – Beilinson Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anat","middleName":"","lastName":"Shmueli","suffix":""},{"id":272590017,"identity":"4bd1a237-995b-44d4-a384-aa5f963a4c4b","order_by":6,"name":"Eran Hadar","email":"","orcid":"","institution":"Helen Schneider Hospital for Women, Rabin Medical Center – Beilinson Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eran","middleName":"","lastName":"Hadar","suffix":""}],"badges":[],"createdAt":"2024-02-04 11:29:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3927382/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3927382/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1002/ijgo.15735","type":"published","date":"2024-06-14T15:27:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51140279,"identity":"f54c5385-7f57-4f9b-8494-72827dd16e80","added_by":"auto","created_at":"2024-02-14 20:03:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30055,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan Meier plot for time from PROM to delivery, whole study population\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3927382/v1/8fbf5a2958b1657086b4e06e.png"},{"id":51140280,"identity":"06a4d6f4-eb1f-4425-afad-f68bd6704aa3","added_by":"auto","created_at":"2024-02-14 20:03:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":29245,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan Meier plot for time from PROM to delivery, expectantly managed patients only\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3927382/v1/408ee7e140fe52cfe8812e04.png"},{"id":58823161,"identity":"c7b1c519-ffbd-4877-bf49-bb064bb6104c","added_by":"auto","created_at":"2024-06-21 16:54:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":587793,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3927382/v1/d8dbd676-54a1-41d0-b17b-53f24f9b64b8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Uncertain prelabor rupture of membranes at term and associated delivery outcomes","fulltext":[{"header":"Background","content":"\u003cp\u003ePrelabor rupture of membranes (PROM) at term (\u0026ge;\u0026thinsp;37 gestational weeks) complicates approximately 8% of pregnancies and is generally followed by prompt onset of spontaneous labor and delivery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The most significant maternal consequence of term PROM is intrauterine infection, including chorioamnionitis and postpartum febrile morbidity. Fetal consequences include ascending infection and \u003cem\u003ein utero\u003c/em\u003e cord compression [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA meta-analysis of 23 randomized controlled trials (8615 women) found that induction of labor reduced the time from rupture of membranes to birth and the rates of chorioamnionitis, endometritis, or both, and was associated with a lower likelihood for neonatal intensive care unit (NICU) admission. There was no accompanying increase in rates of cesarean delivery (CD) or operative vaginal delivery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For women with term PROM who have no contraindication for labor, induction is usually recommended. As long as maternal and fetal conditions are reassuring, expectant management for a short duration may also be a reasonable choice, given that half the women with term PROM who are managed expectantly give birth within 33 hours [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis of PROM is usually made by clinical assessment, which includes visualization of amniotic fluid passing from the cervical canal and pooling in the posterior vaginal fornix on speculum evaluation, higher than normal value on pH test of the vaginal fluid, or arborization (ferning) of dried vaginal fluid on microscopic evaluation. Currently, various tests are available for detecting amniotic proteins, such as placental alpha microglobulin 1 (PAMG), which is known for high sensitivity in diagnosing PROM [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, several factors can influence the diagnostic accuracy and feasibility of these tests, yielding false-positive results in about one-third of cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Reasons for a false-positive may be presence of blood or semen, alkaline antiseptics, certain lubricants, trichomonas, or bacterial vaginosis. False-negative test results may arise with prolonged membrane rupture and minimal residual fluid. In ambiguous cases, sonographic evaluation of amniotic fluid volume may be a useful adjunct, but it is not diagnostic. Thus, the optimal approach to clinical assessment and diagnosis of PROM is still controversial [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLadfors et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] showed that even at term, speculum examination to visualize the amniotic fluid carries a 12% false-negative rate [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Nonconfirmatory test results in a patient with a history suggesting membrane rupture, or vice versa, creates an obstetrical dilemma. Early and accurate diagnosis of PROM allows for further interventions to optimize maternal and perinatal outcomes and minimize complications, whereas overdiagnosis may result in complications of overtreatment or unnecessary labor induction. Although labor induction is known to be beneficial in cases of PROM, whether it is also beneficial in cases of inconclusive PROM has not yet been determined.\u003c/p\u003e \u003cp\u003eThe aim of the present study was to answer the question: By offering the same treatment for uncertain PROM as for certain PROM, are we exposing patients with uncertain PROM to greater risk?\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted at a tertiary university medical center from July 2012 to March 2022. The cohort included women with a singleton gestation who were diagnosed with ruptured membranes at \u0026ge;\u0026thinsp;37 gestational weeks. Patients were categorized into two groups: (1) certain PROM -- women presenting with unequivocal clinical rupture of the membranes based on a suggestive history of watery vaginal discharge confirmed by speculum examination demonstrating fluid leaking from the cervix or pooling in the vagina; (2) uncertain PROM -- women for whom the diagnosis of PROM was inferred from a suggestive history of membrane rupture, although speculum examination was not supportive. No additional diagnostic methods were used in the uncertain PROM group.\u003c/p\u003e \u003cp\u003eExclusion criteria were non-vertex presentation, multiple gestation, fetal malformations, contraindication for vaginal delivery (such as placenta previa or \u0026gt;\u0026thinsp;1 previous CD), and non-reassuring fetal status at admission.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eClinical data on maternal and obstetrical characteristics and maternal and early neonatal outcomes were extracted from the electronic medical records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePatient management\u003c/h2\u003e \u003cp\u003eAll patients were hospitalized and managed either actively or expectantly according to our departmental protocol for PROM, taking clinical-obstetrical status and maternal preference into consideration. Expectant management entailed a period of in-hospital observation lasting up to 24 hours following membrane rupture. If spontaneous labor did not commence naturally within this timeframe, or for reasons of maternal request, suspected maternal infection, or non-reassuring fetal status, labor was induced with either oxytocin infusion or prostaglandin E2 (PGE2) slow-release vaginal insert (Propess 10mg, Ferring Pharmaceuticals AB, Kiel, Germany). Active management was defined as the initiation of labor immediately upon admission, either spontaneously or through induction using oxytocin or PGE2, or by augmentation with oxytocin.\u003c/p\u003e \u003cp\u003eProphylactic treatment with intravenous ampicillin (Penibrin; Sandoz, Kundl, Austria) was administered for the following indications: group B Streptococcus (GBS) carrier, previous infant with invasive GBS disease and prolonged PROM (\u0026ge;\u0026thinsp;18 hours), or intrapartum fever (\u0026ge;\u0026thinsp;37.8\u003csup\u003e0\u003c/sup\u003eC) when GBS carrier status was unknown.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measures\u003c/h2\u003e \u003cp\u003eThe primary outcome measure was the CD rate. Secondary outcome measures were duration of labor and adverse maternal and neonatal events. The adverse maternal outcomes assessed were operative vaginal delivery, intrapartum fever, clinical chorioamnionitis, and obstetrical anal sphincter injuries (OASIS). Clinical chorioamnionitis was defined as fever (\u0026ge;\u0026thinsp;37.8\u003csup\u003e0\u003c/sup\u003eC) accompanied by one or more of the following: maternal tachycardia (\u0026gt;\u0026thinsp;100 bpm), fetal tachycardia (\u0026gt;\u0026thinsp;160 bpm), leukocytosis (\u0026gt;\u0026thinsp;15,000/mm\u003csup\u003e3\u003c/sup\u003e), uterine tenderness, and foul-smelling vaginal discharge. The composite adverse maternal outcome was defined as any of the following: cesarean delivery, assisted vaginal delivery, clinical chorioamnionitis, intrapartum fever, and OASIS. The adverse neonatal outcomes assessed were 5-minute Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7, umbilical pH\u0026thinsp;\u0026lt;\u0026thinsp;7.2, NICU admission, and/or neonatal death.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The study adhered to the tenets of the Declaration of Helsinki and was approved by the local Institutional Review Board (approval no. 0089-22-RMC) which waived the need for informed consent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was generated with SAS software, version 34.0 (SAS Corp., Cary, NC, USA). Continuous variables were summarized by mean and standard deviation or median and interquartile range. Categorical variables were summarized by number and percent. Normality of continuous variables was assessed using the Kolmogorov-Smirnov test. T-test was used to compare the value of normally distributed continuous variables between study groups, and Wilcoxon test was used for non-normal continuous variables. Fisher's exact test was used to compare categorical variables between groups. Logistic regression was used to calculate univariate and multivariate odds ratios (OR), presented with 95% confidence interval (CI). The Kaplan-Meier procedure was applied to graph latency time from PROM until delivery.\u003c/p\u003e \u003cp\u003eTwo-sided \u003cem\u003ep\u003c/em\u003e-values less than .05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 2012 women met the inclusion criteria: 1750 (87%) with certain PROM and 262 (13%) with uncertain PROM.\u003c/p\u003e \u003cp\u003eTheir demographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There was a marginal difference in median gestational age between the groups: 39.57 years (IQR 39-40.29) in the uncertain PROM group and 39.29 years (IQR 38.43-40) in the certain PROM group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.0001). No significant between-group differences were found in maternal age, gravidity, parity, proportion of previous cesarean deliveries, neonatal gender, and birthweight.\u003c/p\u003e \u003cp\u003eThe prevalence of oligohydramnios was notably higher in the uncertain PROM group (10.3\u003cb\u003e1\u003c/b\u003e% vs. 1.4\u003cb\u003e9\u003c/b\u003e%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), with no significant differences between the groups in rates of hypertensive disorders, diabetes mellitus, polyhydramnios, and positive GBS carrier status.\u003c/p\u003e \u003cp\u003eLabor management strategies differed between the groups. The uncertain PROM group had a higher incidence of active management (68.70% vs. 55.43%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and more frequent use of PGE2 for labor induction (9.92% vs. 2.0%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Need for Induction following expectant management did not differ significantly between the groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaternal and obstetrical characteristics of cases of clinically certain and uncertain PROM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUncertain PROM\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;262\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCertain PROM\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1750\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age at delivery, weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.57 (39-40.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.29 (38.43-40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeonatal gender, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (53.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e913 (52.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeonatal birthweight, grams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3228 (2969\u0026ndash;3494)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3198 (2934\u0026ndash;3450)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.43\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.04\u0026thinsp;\u0026plusmn;\u0026thinsp;4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious cesarean delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (9.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e162 (9.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertensive disorders\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (1.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes in pregnancy\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (5.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (4.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolyhydramnios\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.281\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOligohydramnios\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (10.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther maternal comorbidities\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (12.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e212 (12.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGBS carrier status, positive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (22.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132 (23.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.883\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeconium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (9.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e215 (12.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.308\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical dilation at admission, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1-2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5 (1-2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical effacement at admission, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (60\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (60\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 (68.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e970 (55.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpontaneous initiation of labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (19.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e255 (14.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInduction with oxytocin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (39.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e680 (38.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.839\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInduction with PGE2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (9.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpectant management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (31.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e780 (44.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for induction after expectant management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (14.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276 (15.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith oxytocin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith PGE2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median (interquartile range), or number (percentage).\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eChronic hypertension, gestational hypertension, preeclampsia with or without severe features, superimposed preeclampsia and eclampsia.\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003eGestational and pregestational diabetes.\u003c/p\u003e \u003cp\u003e \u003csup\u003ec\u003c/sup\u003eThyroid disorders, asthma, epilepsy, smoking, alcohol or drug abuse.\u003c/p\u003e \u003cp\u003ePROM, premature rupture of membranes; GBS, group B Streptococcus; PGE2, prostaglandin E2.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the maternal and neonatal outcomes. No significant between-group differences were found in overall rates of CD, assisted vaginal delivery, or maternal complications such as clinical chorioamnionitis, intrapartum fever, OASIS and composite maternal outcome. Similarly, neonatal outcomes including Apgar score, umbilical cord pH, NICU admission, and death were consistent across both groups. A higher rate of CD due to failed induction was observed in the uncertain PROM group (2.67% vs. 0.69%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.007).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaternal and neonatal outcome in cases of clinically certain and uncertain PROM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUncertain PROM\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;262\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCertain PROM\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1750\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMaternal outcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (8.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (5.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDue to failed induction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDue to labor dystocia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (1.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssisted vaginal delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (7.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168 (9.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical chorioamnionitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntrapartum fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrical anal sphincter injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePROM to delivery time, hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.57 (7-31.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.35 (9.48\u0026ndash;26.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComposite maternal outcome\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (16.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e280 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeonatal outcome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5-minute Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (0.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUmbilical cord pH\u0026thinsp;\u0026lt;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (2.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.505\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (1.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median (interquartile range), or number (percentage).\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eCesarean delivery, assisted vaginal delivery, maternal infection, intrapartum fever, Obstetrical anal sphincter injuries.\u003c/p\u003e \u003cp\u003ePROM, premature rupture of membranes, NICU, neonatal intensive care unit.\u003c/p\u003e \u003cp\u003eThe time from PROM to delivery across all cases of certain and uncertain PROM was plotted in a Kaplan-Meier survival curve (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No statistically significant difference was noted between the groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.381, log-rank test). As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, there was also no between-group difference in time to delivery within the subset of 862 women who were managed expectantly (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.128, log-rank test).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUnivariate and multivariate logistic regression analyses were performed to evaluate the factors associated with cesarean delivery (CD) due to failed induction. This analysis was conducted within a subset of 1,160 women who underwent labor induction. This group comprised patients following either active or expectant management strategies, including 991 women with confirmed certain PROM and 169 women with uncertain PROM.\u003c/p\u003e \u003cp\u003eThe results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Certain PROM was associated with lower odds of CD due to failed induction in the univariate model (OR 0.321, 95% CI 0.122\u0026ndash;0.842), but this association did not reach statistical significance in the multivariate model (OR 0.382, 95% CI 0.12\u0026ndash;1.215). Parity (OR 0.294, 95% CI 0.088\u0026ndash;0.983) and cervical dilation at admission (OR 0.131, 95% CI 0.049\u0026ndash;0.35) were found to be protective. Previous CD emerged as a significant predictor for CD due to failed induction in the multivariate model (OR 7.765, 95% CI 1.313\u0026ndash;45.912). Maternal age and gestational age at delivery were not associated with failed induction-indicated CD.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariate analysis of factors associated with cesarean delivery due to failed induction\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnivariate OR with 95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultivariate OR with\u003c/p\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCertain PROM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003cp\u003e\u003cb\u003e[0.122\u0026ndash;0.842, p\u0026thinsp;=\u0026thinsp;.021]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003cp\u003e[0.12\u0026ndash;1.215, p\u0026thinsp;=\u0026thinsp;.103]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003cp\u003e[0.886\u0026ndash;1.073, p\u0026thinsp;=\u0026thinsp;.610]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.064\u003c/p\u003e \u003cp\u003e[0.95\u0026ndash;1.191, p\u0026thinsp;=\u0026thinsp;.284]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003cp\u003e\u003cb\u003e[0.165\u0026ndash;0.708, p\u0026thinsp;=\u0026thinsp;.004]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003cp\u003e[\u003cb\u003e0.088\u0026ndash;0.983, p\u0026thinsp;=\u0026thinsp;.047\u003c/b\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age at delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.024\u003c/p\u003e \u003cp\u003e[0.677\u0026ndash;1.549, p\u0026thinsp;=\u0026thinsp;.91]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.009\u003c/p\u003e \u003cp\u003e[0.622\u0026ndash;1.635, p\u0026thinsp;=\u0026thinsp;.972]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious cesarean delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.51\u003c/p\u003e \u003cp\u003e\u003cb\u003e[1.358\u0026ndash;14.974, p\u0026thinsp;=\u0026thinsp;.014]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.765\u003c/p\u003e \u003cp\u003e\u003cb\u003e[1.313\u0026ndash;45.912, p\u0026thinsp;=\u0026thinsp;.024]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical dilatation at admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003cp\u003e\u003cb\u003e[0.037\u0026ndash;0.23, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.131\u003c/p\u003e \u003cp\u003e\u003cb\u003e[0.049\u0026ndash;0.35, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePROM, premature rupture of membranes; OR, Odds ratio; CI, confidence interval\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study demonstrates that women with suspected membrane rupture who were managed like women with certain (unequivocal) PROM and underwent induction or expectant management were not compromised compared to women with certain PROM. Our findings show no significant difference between the groups in maternal outcomes, including CD rates, and in short-term neonatal outcomes.\u003c/p\u003e \u003cp\u003eIn most women, the diagnosis of ruptured fetal membranes can be confirmed on the basis of a suspicious history and findings of leaking or pooling of amniotic fluid during speculum examination. However, in approximately 10% of cases, the diagnosis is difficult to establish [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies of diagnostic tests to confirm PROM in patients with a questionable state of the membranes reported varying efficacy. The tests investigated included the fern test [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], nitrazine test [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], fibronectin immunoassay [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], insulin-like growth factor binding protein-1 (IGFBP-1) test [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], alpha-fetoprotein (AFP) kit [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], placental α microglobulin-1 (PAMG) immunoassay [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and dye injection [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A meta-analysis of studies that focused on the clinical use of biochemical marker tests in patients with suspected membrane rupture found that PAMG-1 and IGFBP-1 had high positive (98.4% and 87.9%, respectively) and negative (96.7% and 93.9%, respectively) predictive values, making them useful diagnostic aids [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As rupture of the membranes in the preterm period (\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;37 gestational weeks) is associated with prematurity, neonatal morbidity, and mortality, alongside an increased risk of maternal infection, a concise diagnosis is needed.\u003c/p\u003e \u003cp\u003eIn 2018, Grobman et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] published the results of the ARRIVE trial which evaluated the perinatal and maternal consequences of inducing labor at 39 weeks in nulliparous women at low risk. The results showed that this approach did not lead to adverse outcomes, and indeed, even led to a reduction in CDs. Our results align with these findings, as the gestational age of most of our cohort (62.6% of the certain PROM group, 75.2% of the uncertain PROM group) was 39 weeks or more. This suggests that induction of labor following suspected and unconfirmed PROM at term would not be expected to have adverse maternal or neonatal consequences. Furthermore, the time to delivery in the two groups remained similar, even when including women who were managed expectantly. Thus, a notable portion of women with uncertain PROM may have actually experienced membrane rupture despite the absence of clear evidence of amniotic fluid loss by speculum examination.\u003c/p\u003e \u003cp\u003eIn a Cochrane review comparing planned early birth versus expectant management for term PROM, the rates of overall chorioamnionitis (either suspected or proven) and/or intrapartum fever, as reported by 14 studies, varied between 1.0% and 26.9% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the present study, rates of clinical chorioamnionitis and intrapartum fever were closer to the lower end of this range for both groups. The difference between the studies could be due to the active management approach we used for most of our patients, likely reducing the risk of these conditions.\u003c/p\u003e \u003cp\u003eThe present study has several limitations that need to be considered when interpreting the data. The retrospective design could have created a selection as well as an information bias. In addition, gestational age was more than 39 weeks in most of the women in our cohort, and it is unknown whether the results are applicable to cohorts with a lower gestational age. Our data did not include postpartum maternal and neonatal infections which are associated with PROM. Nevertheless, to our knowledge, this is the first study to examine the outcomes of equivocal cases of membrane rupture at term that were managed as PROM. This information may guide physicians facing controversial findings between anamnesis and physical examination when confirmatory tests are unavailable.\u003c/p\u003e \u003cp\u003eIn conclusion, the diagnosis of rupture of membranes should be pursued due to the associated risks. The present study suggests that the management of questionable rupture of membrane at term as PROM does not result in adverse maternal or neonatal outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCD, cesarean delivery\u003c/p\u003e\n\u003cp\u003eGBS, group B Streptococcus\u003c/p\u003e\n\u003cp\u003eNICU, neonatal intensive care unit\u003c/p\u003e\n\u003cp\u003eOASIS,\u0026nbsp;obstetrical anal sphincter injuries\u003c/p\u003e\n\u003cp\u003ePGE2, prostaglandin 2\u003c/p\u003e\n\u003cp\u003ePROM, premature rupture of membranes\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study adhered to the tenets of the Declaration of Helsinki and was approved by the local Institutional Review Board (approval no. 0089-22-RMC) which waived the need for informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available from the corresponding author upon reasonable request, with appropriate regulatory approvals. All data relevant to the study was included in the article.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.G. and E.H.\u0026nbsp;conceptualized and designed the study. Material preparation and data collection were performed by N.R.N., R.M. and S.D.G. Data analysis and interpretation were performed by R.M. and N.H. The manuscript was written by Y.G, N.R.N., A.S. and E.H. All authors approved the final article as submitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMiddleton P, Shepherd E, Flenady V, McBain RD, Crowther CA. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev. 2017;1:CD005302. \u003c/li\u003e\n\u003cli\u003ePrelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217. Obstet Gynecol. 2020;135:e80\u0026mdash;97. \u003c/li\u003e\n\u003cli\u003eKrispin E. Management of premature rupture of membranes at term: the need to correct a recurring mistake in articles, chapters, and recommendations of professional organizations. Am J Obstet Gynecol. 2017;217:661.e1\u0026mdash;e3. \u003c/li\u003e\n\u003cli\u003eLee SM, Lee J, Seong HS, Lee SE, Park JS, Romero R, et al. The clinical significance of a positive Amnisure test in women with term labor with intact membranes. J Matern Fetal Neonatal Med. 2009;22:305\u0026mdash;10. \u003c/li\u003e\n\u003cli\u003eLadfors L, Mattsson LA, Eriksson M, Fall O. Is a speculum examination sufficient for excluding the diagnosis of ruptured fetal membranes? Acta Obstet Gynecol Scand. 1997;76:739\u0026mdash;42. \u003c/li\u003e\n\u003cli\u003evan der Ham DP, van Melick MJ, Smits L, Nijhuis JG, Weiner CP, van Beek JH, et al. Methods for the diagnosis of rupture of the fetal membranes in equivocal cases: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2011;157:123\u0026mdash;7. \u003c/li\u003e\n\u003cli\u003ede Haan HH, Offermans PM, Smits F, Schouten HJ, Peeters LL. Value of the fern test to confirm or reject the diagnosis of ruptured membranes is modest in nonlaboring women presenting with nonspecific vaginal fluid loss. Am J Perinatol. 1994;11:46\u0026mdash;50.\u003c/li\u003e\n\u003cli\u003eOlarinoye AO, Olaomo NO, Adesina KT, Ezeoke GG, Aboyeji AP. Comparative diagnosis of premature rupture of membrane by nitrazine test, urea, and creatinine estimation. Int J Health Sci (Qassim). 2021;15:16\u0026mdash;22. \u003c/li\u003e\n\u003cli\u003eHellemans P, Verdonk P, Baekelandt M, Joostens M, Francx M, Gerris J. Preliminary results with the use of the ROM-check immunoassay in the early detection of rupture of the amniotic membranes. Eur J Obstet Gynecol Reprod Biol. 1992;43:173\u0026mdash;9. \u003c/li\u003e\n\u003cli\u003eJeurgens-Borst AJ, Bekkers RL, Sporken JM, van den Berg PP. Use of insulin like growth factor binding protein-1 in the diagnosis of ruptured fetal membranes. Eur J Obstet Gynecol Reprod Biol. 2002;102:11\u0026mdash;4. \u003c/li\u003e\n\u003cli\u003eYamada H, Kishida T, Negishi H, Sagawa T, Yamaguchi M, Sato C, et al. Comparison of an improved AFP kit with the intra-amniotic PSP dye-injection method in equivocal cases of preterm premature rupture of the fetal membranes. J Obstet Gynaecol Res. 1997;23:307\u0026mdash;11. \u003c/li\u003e\n\u003cli\u003eVischio AT, Khulmann P, Ross L, Ovittore L, Sena S, Dodge J. AmniSure placental alpha microglobulin-1 rapid immunoassay for detection of rupture of membranes: A comparison study with clinical-based testing.\u003cem\u003e Am J Clin Pathol\u003c/em\u003e. 2012;138 Suppl. 1:A024.\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. 2005;22:317\u0026mdash;20. \u003c/li\u003e\n\u003cli\u003eFujimoto S, Kishida T, Sagawa T, Negishi H, Okuyama K, Hareyama H, et al. Clinical usefulness of the dye-injection method for diagnosing premature rupture of the membranes in equivocal cases. J Obstet Gynaecol (Tokyo 1995). 1995;21:215\u0026mdash;20.\u003c/li\u003e\n\u003cli\u003ePalacio M, K\u0026uuml;hnert M, Berger R, Larios CL, Marcellin L. Meta-analysis of studies on biochemical marker tests for the diagnosis of premature rupture of membranes: comparison of performance indexes. BMC Pregnancy Childbirth. 2014;14:183. \u003c/li\u003e\n\u003cli\u003eGrobman WA, Rice MM, Reddy UM, Tita ATN, Silver RM, Mallett G, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal\u0026ndash;Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379:513\u0026mdash;23. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Prelabor rupture of membranes, Term pregnancy, Diagnosis, Induction of labor","lastPublishedDoi":"10.21203/rs.3.rs-3927382/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3927382/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrelabor rupture of membranes (PROM) is a common obstetrical event, but its diagnosis is frequently challenging. The aim of the study was to determine whether equivocal PROM cases are associated with adverse outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted in a tertiary medical center between July 2012 and March 2022. The cohort consisted of women diagnosed with term PROM (\u0026ge;\u0026thinsp;37 gestational weeks), divided into two groups: (1) certain PROM - suggestive history of a watery vaginal discharge confirmed by visualization of fluid leaking from the cervix or pooling in the vagina on speculum examination; (2) uncertain PROM - suggestive history of a watery vaginal discharge not supported by speculum examination. All patients were hospitalized and gave birth spontaneously or following either expectant management for up to 24 hours from PROM or induction. The primary outcome measure was cesarean delivery rate. Secondary outcome measures were adverse maternal and neonatal events.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 2012 women were included in the study, 1750 with certain PROM and 262 with uncertain PROM. The cesarean delivery rate was 5.8% in the certain PROM group and 8.8% in the uncertain PROM group; the difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.074). There was a significant between-group difference in the rate of cesarean delivery due to failed induction on univariate analysis (0.69% vs 2.67%, respectively, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.007), but it was not maintained on multivariate logistic regression (OR 0.37, 95% CI 0.117\u0026ndash;1.172). Other maternal and neonatal outcomes were similar in the two groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e In our study, following the same management guidelines for equivocal cases of ruptured membranes as for confirmed cases of term PROM did not compromise maternal or fetal outcomes.\u003c/p\u003e","manuscriptTitle":"Uncertain prelabor rupture of membranes at term and associated delivery outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-14 20:03:47","doi":"10.21203/rs.3.rs-3927382/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":"8f809fbd-c5ec-44ad-bd6a-f8306269c74b","owner":[],"postedDate":"February 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T15:27:17+00:00","versionOfRecord":{"articleIdentity":"rs-3927382","link":"https://doi.org/10.1002/ijgo.15735","journal":{"identity":"international-journal-of-gynecology-and-obstetrics","isVorOnly":true,"title":"International Journal of Gynecology \u0026 Obstetrics"},"publishedOn":"2024-06-14 15:27:17","publishedOnDateReadable":"June 14th, 2024"},"versionCreatedAt":"2024-02-14 20:03:47","video":"","vorDoi":"10.1002/ijgo.15735","vorDoiUrl":"https://doi.org/10.1002/ijgo.15735","workflowStages":[]},"version":"v1","identity":"rs-3927382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3927382","identity":"rs-3927382","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}