Role of Trans cervical Application of Fibrin Glue on Reaccumulation of Amniotic Fluid in Pregnant Women with Very Early (Midtrimester) Spontaneous Preterm Prelabor Rupture of the Membranes

Abstract

Summary P relaborruptureofthemembranes(PROM)isdefinedasruptureofthefetalmembranesbeforeonsetoflabor.PretermPROM(PPROM)isdefinedasPROMthatoccursbefore37weeksofgestation.Veryearlyor‘midtrimester’PPROMreferstoPPROMthatisencounteredbeforetheageoffetalviability.PPROMmayoccureitherspontaneously,duringorafteraninvasiveprocedure(e.g.amniocentesis)(WatersandMercer,2009). MidtrimesterPPROMcomplicates0.4to0.7%ofpregnancies(ManuckandVamer,2014).ThemajorriskfactorforPPROMisapriorhistoryofpretermlabororPPROM.Otherriskfactorsincludecervicalinsufficiency,multiplepregnanciesandantepartumbleeding(McElarthetal.,2008). VeryearlyormidtrimesterPPROMisassociatedwithseriousneonatalmorbidityandmortality.Presenceofanaverageliquorvolumeatgestationsbetween20and28weeksisessentialforproperbronchopulmonaryandmusculoskeletaldevelopment.Prolongeddiminishedliquorvolumeatthiscriticalgestationalageisassociatedwithbronchopulmonaryhypoplasia(BPH)andskeletaldeformities.Inaddition,theratesofperinatalsepsis,placentalabruptionandpretermlaborarequitehighwhencomparedtoPPROMthatoccursatlatergestationalages(McElarthetal.,2015). ThecurrentmanagementoptionsforPPROMaremainlyconservative,includingprophylacticantibioticsandcorticosteroidtherapytoenhancethefetallungmaturity(Rajuetal.,2014). Werecommendprophylacticantibiotics(Grade1A).OurpreferenceistogiveAmpicillin2gmintravenouslyevery6hoursfor48hours,followedbyAmoxicillin(500mgorallythreetimesdailyor875mgorallytwicedaily)foranadditionalfivedays.Inaddition,wegiveonedoseofAzithromycin(onegramorally)atthetimeofadmission. Weroutinelyadministerafullcourseofantenatalcorticosteroidstopregnanciesat≥23weeksofgestationandoffercorticosteroidtherapyinthemid22ndweek.Bythe23rdweekofgestation,weroutinelyprovideemergentcesareandeliveryinterventionforstandardobstetricindications(Grade1A). Applicationoftissue‘sealants’hasbeentriedfordecadesinmanyareasinmedicine(e.g.Duralleaks,fistularepairandmucosaldefects)(DaffordandAnderson,2015;LucasandSeeber,2015;Wuetal.,2015).ThefirstapplicationforPPROMwasin1979(Genz,1979). Amniopatch(intrauterineinjectionofcryoprecipitateandplatelets),gelatinspongeandfibringluehaveshownsomesuccessincasereportsandfewcaseseries(Devliegeretal.,2006). Fibringlueisablood-derivedbiomaterial.ItisproducedbythefractionationofhumanplasmatoobtainThrombinandFibrinogeninahighconcentration.Mixingbothproteinstogethermimicsthelaststepofthephysiologicbloodcoagulationcascadetoformastrongfibrinclot.Fibrinsealanthastheadvantage,oversyntheticgluesofbeingphysiologicallycompatiblewithhumantissues,andofnotinducingtissuenecrosisorothertissuereactions.Itistotallybiodegradableinamatterofdaystoweeks.