Amnioinfusion for third trimester preterm premature rupture of membranes

G Justus Hofmeyr; Ahizechukwu C Eke; Theresa A Lawrie

doi:10.1002/14651858.CD000942.pub3

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Figure 1

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 1 Persistant variable decelerations.

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Analysis 1.2

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 2 Severe variable decelerations per hour in first stage.

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Analysis 1.3

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 3 Caesarean section.

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Analysis 1.4

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 4 Forceps/vacuum assisted delivery.

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Analysis 1.5

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 5 1 minute Apgar score < 4.

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Analysis 1.6

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 6 Umbilical arterial pH.

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Analysis 1.7

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 7 Umbilical pH ≤ 7.20.

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Analysis 1.8

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 8 Neonatal morbidity.

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Analysis 1.9

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 9 Neonatal death.

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Analysis 1.10

Comparison 1 Transcervical amnioinfusion for preterm rupture of membranes, Outcome 10 Maternal puerperal sepsis.

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Analysis 2.1

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 1 Fetal distress.

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Analysis 2.2

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 2 Gestational age at delivery (weeks).

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Analysis 2.3

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 3 Neonatal morbidity.

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Analysis 2.4

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 4 Delivery within 7 days.

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Analysis 2.5

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 5 Time to delivery (days).

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Analysis 2.6

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 6 Admission to neonatal intensive care unit.

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Analysis 2.7

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 7 Neonatal death.

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Analysis 2.8

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 8 Birthweight (grams).

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Analysis 2.9

Comparison 2 Transabdominal amnioinfusion for preterm rupture of membranes, Outcome 9 Maternal puerperal sepsis.

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Transabdominal amnioinfusion compared with no amnioinfusion for preterm rupture of membranes (PROM)
Patient or population: pregnant women with PROM Settings: hospital Intervention: transabdominal amnioinfusion Comparison: no amnioinfusion
Outcomes	Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
Neonatal death	RR 0.30 (0.14 ‐ 0.66)	94 (two studies)	⊕⊕⊕⊝ moderate	Risk of neonatal death in the amnioinfusion group was 127 per 1000 compared to 426 per 1000 in the control group.
Neonatal sepsis/infection	RR 0.26 (0.11 ‐ 0.61)	*60 (one study)**	⊕⊕⊕⊝ moderate	*Sepsis defined as micro‐erythrocyte sedimentation rate > 5 mm, total leucocyte count < 5000, CRP > 6 mg/dL, platelet count < 100,000 or a positive blood culture within the first 48 hours.
Pulmonary hypoplasia	RR 0.22 (0.06 ‐ 0.88)	34 (one study)	⊕⊕⊝⊝ low	Pulmonary hypoplasia was diagnosed according to strict clinical and radiological criteria, however, this study was small and blinding to group allocation was not described and so we downgraded this evidence from moderate to low. More evidence is needed.
Maternal puerperal sepsis	RR 0.20 (0.05 ‐ 0.84)	60 (one study)**	⊕⊕⊕⊝ moderate	**Defined as fever > 38° C and a positive high vaginal swab culture.

GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate. CI: confidence interval; CRP: C‐reactive protein; RR: risk ratio

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Comparison 1. Transcervical amnioinfusion for preterm rupture of membranes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Persistant variable decelerations Show forest plot	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.30, 0.91]

2 Severe variable decelerations per hour in first stage Show forest plot	1	61	Mean Difference (IV, Fixed, 95% CI)	‐1.2 [‐1.83, ‐0.57]

3 Caesarean section Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

3.1 Caesarean section overall	2	147	Risk Ratio (M‐H, Random, 95% CI)	0.65 [0.25, 1.73]
3.2 Caesarean section for fetal distress	1	86	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.12, 1.55]
4 Forceps/vacuum assisted delivery Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 Overall	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	1.2 [0.58, 2.48]
4.2 For fetal distress	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.11 [0.01, 2.00]
5 1 minute Apgar score < 4 Show forest plot	1	61	Risk Ratio (M‐H, Fixed, 95% CI)	0.28 [0.03, 2.33]

6 Umbilical arterial pH Show forest plot	1	61	Mean Difference (IV, Fixed, 95% CI)	0.11 [0.08, 0.14]

7 Umbilical pH ≤ 7.20 Show forest plot	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.06, 1.11]

8 Neonatal morbidity Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Overall	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.5 [0.19, 1.34]
9 Neonatal death Show forest plot	1	61	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.05, 5.77]

10 Maternal puerperal sepsis Show forest plot	2	147	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.06, 2.18]

Comparison 1. Transcervical amnioinfusion for preterm rupture of membranes

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Comparison 2. Transabdominal amnioinfusion for preterm rupture of membranes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Fetal distress Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.27 [0.08, 0.88]

2 Gestational age at delivery (weeks) Show forest plot	2	94	Mean Difference (IV, Random, 95% CI)	‐0.49 [‐2.63, 1.65]

3 Neonatal morbidity Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Neonatal sepsis/infection	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.11, 0.61]
3.2 Pulmonary hypoplasia	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.22 [0.06, 0.88]
3.3 Abnormal neurological outcome	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.03, 2.01]
4 Delivery within 7 days Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.18 [0.05, 0.70]

5 Time to delivery (days) Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	0.57 [‐2.86, 4.00]

6 Admission to neonatal intensive care unit Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.90, 1.12]

7 Neonatal death Show forest plot	2	94	Risk Ratio (M‐H, Fixed, 95% CI)	0.3 [0.14, 0.66]

8 Birthweight (grams) Show forest plot	2	94	Mean Difference (IV, Random, 95% CI)	15.65 [‐254.02, 285.32]

9 Maternal puerperal sepsis Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.2 [0.05, 0.84]

Comparison 2. Transabdominal amnioinfusion for preterm rupture of membranes

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