Gilbert, R

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UCL Discovery

Immediate delivery for group B streptococci-colonised women withpreterm premature rupture of membranes. Don’t forget theantibioticsR GilbertUCL Institute of Child Health, London, UKLinked article: This is a mini commentary on Tajik P et al., on pp. 1263–72 in this issue. To view this article visithttp://dx.doi.org/10.1111/1471-0528.12889.Published Online 4 July 2014.The PPROMEXIL trials compared‘immediate delivery’, involvinginduction of labour (IOL) within48 hours of randomisation withexpectant management (EM) for 723women who were not in labour buthad ruptured membranes for morethan 24 hours between 34 and37 weeks of gestation (van der Hamet al. Plos Med 2012;9:e1001208; vander Ham et al. Am J Obset Gynecol2012;207:276. e1–10). No signiﬁcantreduction was found in the risk ofearly neonatal sepsis (within72 hours of birth and measured by apositive blood culture with symp-toms or laboratory measures ofinfection). In the accompanyingpaper, Tajik et al. report a post hocanalysis to determine whether theeffect of IOL differed according towhether women were colonised withgroup B streptococci (GBS) or not.Among the 13% of women(n = 103) colonised with GBS, theyfound a reduction in neonatal sepsisfrom 15.2% (7/46) in the EM groupto 1.8% (1/57) in the IOL group.Rates of neonatal sepsis were similarin the EM and IOL groups ofwomen who were not colonised withGBS (2.6%; 8/313 EM versus 2.9%9/306 IOL group). However, rates ofclinical and histological chorioam-nionitis were reduced by IOL in bothGBS colonised (clinical 10.9% EM to5.4% IOL) and noncolonised women(clinical 4.5% EM to 1.0% IOL). Allof these differences were signiﬁcantat the 5% level.A key question for practitioners iswhether women with PPROM whowere managed by EM or IOL werealready receiving prenatal antibioticprophylaxis. Based on a systematicreview of randomised trials (Kenyonet al. Cochrane Database Sys Rev2013;12:CD001058), prenatal antibi-otics are recommended for PPROMregardless of maternal GBS statusbecause they signiﬁcantly prolongpregnancy and reduce neonatal infec-tion (sepsis or pneumonia), chorio-amnionitis and abnormal neonatalcerebral ultrasound scans. However,the PPROMEXIL trials allowed prena-tal antibiotics to be administeredaccording to local protocols and inmost cases, these were administeredempirically, without knowledge ofmaternal culture results. However,substantially more GBS-colonisedwomen received antibiotics (89%; 40/45 EM versus 69% 39/56 IOL), thanthose who were not GBS colonised(37% 119/305 EM versus 37% 111/303 IOL group). Not surprisingly,given the low rates of antibiotics usedin the non-GBS-colonised womenand their larger numbers, more casesof neonatal sepsis occurred innon-GBS-colonised women (n = 17)than in the GBS-colonised women(n = 8). There were also many morecases of clinical chorioamnionitis(8 GBS, 17 non-GBS) and histologicalchorioamnionitis (27 GBS, 110 non-GBS) in the non-GBS-colonisedwomen. Chorioamnionitis is an impor-tant outcome because it is associatedwith an increased risk of cerebralpalsy of between 40% and 400% inlate preterm births, depending on theduration of membrane rupture (Wuet al. JAMA 2003;290:2677–84).Tajik et al.’s data show the conun-drum. They propose IOL in GBS-col-onised women but this would focus ona small group of high-risk, colonisedwomen and miss most cases of neona-tal sepsis. Moreover, prenatal screen-ing to detect GBS colonisation inwomen with PPROM could delaytreatment for those with GBS coloni-sation,pendingtestresults,whichhavelimited accuracy, and the large num-ber of GBS-negative women might notreceiveantibioticsatall.Thebestavail-able evidence suggests that all womenwith PPROM should be offered prena-tal antibiotics, although if maternalGBS status is known, the results fromTajik et al. suggest there may be addedbeneﬁt of early delivery.Disclosure of interestsThe author declare no conﬂicts ofinterest.&Immediate delivery in PPROMª 2014 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf ofRoyal College of Obstetricians and Gynaecologists.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use anddistribution in any medium, provided the original work is properly cited, the use is non-commercial and no modiﬁcations or adaptations are made.1273

Immediate delivery for group B streptococci-colonised women with preterm premature rupture of membranes. Don't forget the antibiotics

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