1. Outcomes following prolonged preterm premature rupture of membranes

    Dear Editor

    We read with interest the article by Everest et al (1). We support the authors conclusion regarding the improvement in the outcome for the live born infants delivered following membrane rupture occurring before 24 weeks gestation and of at least 14 days duration.

    We analysed a cohort of 21 babies over the past 7 years in our institution. The mean gestation age was 28.3 ± 6 weeks and birth weight 1340 ± 860 grams. 5 were still births all prior to 24 weeks. 16 were live births, one baby died immediately after birth at 24 weeks gestation and one did not require intensive care. Fourteen infants were admitted to the Neonatal Intensive Care Unit, of which 11(79%) survived. 3 babies required only supplemental oxygen, 3 required conventional mechanical ventilation and 5 babies received high frequency ventilation (HFV) for an average of 72 hours. Five had an echocardiogram recorded; all had proven persistent pulmonary hypertension of newborn (PPHN) on day 1 of life. All these infants had an oxygenation index (OI) >18 and were receiving 100% oxygen with high mean airway pressure, received HFV and were treated with surfactant. 3 infants with PPHN were also treated with inhaled nitric oxide (iNO). All responded to treatment and survived to discharge.

    Modern neonatal intensive care practices have transformed our management of this group of infants (2, 3). In our unit the use of early HFV and institution of iNO in such babies often resulted in dramatic improvements in oxygenation, despite a presumed diagnosis of underlying severe pulmonary hypoplasia. We would also strongly emphasize the importance of early echocardiography, usually performed by the neonatologist at the point of care, in diagnosing pulmonary hypertension associated with oligohydramnios and prolonged premature membrane rupture. We have found that early echocardiography has resulted in earlier recognition of pulmonary hypertension which is often reversible by use of appropriate ventilation and especially iNO. In the past this group of infants would have died from presumed respiratory failure, but early echocardiography (or a trial of iNO) now usually results in improvement in respiratory function and survival in the immediate postnatal period. The mortality rate from extreme premature rupture of membranes has markedly improved over the last few years to about 20%, with newer modalities available to assist in management of these infants.

    References: 1. Peliowski AP, Finer NN, Etches PC, Tierney AJ, Ryan CA. Inhaled nitric oxide for premature infants after prolonged rupture of membranes. J Pediatrics 1995;126(3):450-453. 2. Kabra NS, Kluckow MR, Powell J. Nitric oxide in preterm infants with pulmonary hypoplasia. Indian J Pediatrics 2004;71(5):427-429. 3. Everest NJ, Jacobs SE, Davis PG, Begg L, Rogerson S. Outcomes following prolonged preterm rupture of the membranes. Arch Dis Child Fetal Neonatal Ed 2008;93:F207-F211.

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