Can we predict birth asphyxia of neonates born from PPROM women?

Adly Nanda Al Fattah, Yuditiya Purwosunu, Ali Sungkar, Natasya Prameswari


Background: To develop a simple and accurate method of predicting birth asphyxia of neonates born from preterm premature rupture of membranes (PPROM) women utilizing clinical parameters that are generally available before delivery in the practical setting.

Methods: A retrospective cohort was conducted at single tertiary hospital in Jakarta between January and December 2013. Subjects were PPROM women with singleton live pregnancy who had their delivery on 24 to 34 weeks of gestational age (GA). Primary outcome was birth asphyxia defined by 5th minutes APGAR score < 7. The variables studied were leukocyte counts, gestational age at PPROM, clinical chorioamnitis, severe preeclampsia, mode of delivery, and PPROM-admission duration. Prediction model was developed using logistic regression analysis.

Results: One hundred and seventy five out of 380 PPROM women registered in our database met the inclusion criteria. The incidence of BA was 14.29% (25/175). The cutoff value for maternal leukocyte counts and gestational age to predict birth asphyxia was respectively 12,450/mm3 (area under the curve 0.68, 95%CI 0.57-0.80) and 32 weeks (area under the curve 0.81, 95%CI 0.70-0.92). A prediction model was developed consisted of GA at PPROM < 32 weeks of GA (OR=9.58, 95%CI 3.32 – 27.62) and maternal leukocyte counts > 12,450/mm3 (OR=3.6, 95%CI 1.11-11.63), (Final AUC=0.82 (95%CI 0.74-0.89). Clinical chorioamnitis, severe preeclampsia, mode of delivery, PPROM-admission duration was not associated with birth asphyxia.

Conclusions: A prediction model to predict BA among PPROM women at 24-34 weeks GA was developed consisted of GA at PPROM and maternal leukocyte counts at patient’s admission.


Birth asphyxia, Neonates, PPROM

Full Text:



Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller A-B, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162-72.

Mercer BM. Preterm Premature Rupture of the Membranes. Obstet Gynecol. 2003;101:78-93.

Newman DE, Paamoni-Keren O, Press F, Wiznitzer A, Mazor M, Sheiner E. Neonatal outcome in preterm deliveries between 23 and 27 weeks’ gestation with and without preterm premature rupture of membranes. Arch Gynecol Obstet. 2008;280(1):7-11.

Manuck TA, varner MW. Neonatal and early childhood outcomes following early vs later preterm premature rupture of membranes. Am J Obstet Gynecol. Mosby, Inc; 2014;211(3):308.e1-308.e6.

Verspyck E, Bisson V, Roman H, Marret S. Adverse respiratory outcome after premature rupture of membranes before viability. Acta Paediatr. 2013;103(3):256-61.

Golubnitschaja O, Yeghiazaryan K, Cebioglu M, Morelli M, Herrera-Marschitz M. Birth asphyxia as the major complication in newborns: moving towards improved individual outcomes by prediction, targeted prevention and tailored medical care. EPMA Journal. 2011;2(2):197-210.

Lie KK, Grøholt E-K, Eskild A. Association of cerebral palsy with Apgar score in low and normal birthweight infants: population based cohort study. BMJ. 2010;341:c4990.

Committee on Obstetrics Practice. Inappropriate use of the terms fetal distress and birth asphyxia. Int J Gynecol Obstet. 1998;61:309-10.

Ersdal HL, Mduma E, Svensen E, Perlman J. Birth asphyxia: a major cause of early neonatal mortality in a Tanzanian rural hospital. Pediatrics. 2012;129(5):e1238-43.

Jensen LV, Mathiasen R, Mølholm B, Greisen G. Low 5-min Apgar score in moderately preterm infants; association with subsequent death and cerebral palsy: a register based Danish national study. Acta Paediatr. Blackwell Publishing Ltd; 2012;101(2):e80-2.

Gezer A, Parafit-Yalciner E, Guralp O, Yedigoz V, Altinok T, Madazli R. Neonatal morbidity mortality outcomes in pre-term premature rupture of membranes. J Obstet Gynaecol. 2013;33(1):38-42.

Thibault M, Picaud J-C. Cognitive Impairment at Age 5 Years in Very Preterm Infants Born Following Premature Rupture of Membranes. J Pediatr. Elsevier Ltd; 2013;163(2):435-40.e2.

Wolf MJ, Wolf B, Bijleveld C, Beunen G, Casaer P. Neurodevelopmental outcome in babies with a low Apgar score from Zimbabwe. Dev Med Child Neurol. 1997;39(12):821-6.

White CRH, Doherty DA, Henderson JJ, Kohan R, Newnham JP, Pennell CE. Accurate prediction of hypoxic-ischaemic encephalopathy at delivery: a cohort study. J Matern Fetal Neonatal Med. 2012;25(9):1653-9.

Clinical and inflammatory markers in amniotic fluid as predictors of adverse outcomes in preterm premature rupture of membranes. Am J Obstet Gynecol. Elsevier Inc; 2011;205(2):126.e1-e8.

Kacerovsky M, Musilova I, Andrys C, Hornychova H, Pliskova L, Kostal M, et al. Prelabor rupture of membranes between 34 and 37 weeks: the intraamniotic inflammatory response and neonatal outcomes. Am J Obstet Gynecol. Elsevier, 2014;210(4):325.e1-e10.

Gibbs RS, Blanco JD, St Clair PJ, Castaneda YS. Quantitative bacteriology of amniotic fluid from women with clinical intraamniotic infection at term. J Infect Dis. 1982;145(1):1-8.

Kumari S, Sharma M, Yadav M, Saraf A, Kabra M, Mehra R. Trends in Neonatal Outcome with Low Apgar Scores. Indian J Pediatr. 2007;60:415-22.

Morales P, Bustamante D, Espina-Marchant P, Neira-Peña T, Gutiérrez-Hernández MA, Allende-Castro C, et al. Pathophysiology of perinatal asphyxia: can we predict and improve individual outcomes? EPMA Journal. 2011;2(2):211-30.

Pasquier J-C, Picaud J-C, Rabilloud M, Claris O, Ecochard R, Moret S, et al. Neonatal outcomes after elective delivery management of preterm premature rupture of the membranes before 34 weeks’ gestation (DOMINOS study). Eur J Obstet Gynecol Reprod Biol. 2009;143(1):18-23.

Pristauz G, Bauer M, Maurer-Fellbaum U, Rotky-Fast C, Bader AA, Haas J, et al. Neonatal outcome and two-year follow-up after expectant management of second trimester rupture of membranes. Int J Gynecol Obstet. 2008;101(3):264-8.

Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. The Lancet. 2008;371(9608):261-9.

Bartkeviciene D, Pilypiene I, Drasutiene G, Bausyte R, Mauricas M, Silkunas M, et al. Leukocytosis as a prognostic marker in the development of fetal inflammatory response syndrome. Libyan Journal of Medicine. 2013;8:8.

Gomez R, Romero R, Ghezzi F, Yoon BH, Mazor M, Berry SM. The fetal inflammatory response syndrome. Am J Obstet Gynecol. 1998;179(1):194-202.

Romero R, Gomez R, Ghezzi F, Yoon BH, Mazor M, Edwin SS, et al. A fetal systemic inflammatory response is followed by the spontaneous onset of preterm parturition. Am J Obstet Gynecol. 1998;179(1):186-93.

Pilypienė I, Drazdienė N, Dumalakienė I, Vezbergienė N, Bartkevičienė D, Šilkūnas M, et al. The significance of fetal inflammatory response syndrome in early and later adaptation of premature infants. Archives of gynecology and obstetrics. 2015;291(1):67-72.

Hofer N, Kothari R, Morris N, Müller W, Resch B. The fetal inflammatory response syndrome is a risk factor for morbidity in preterm neonates. Am J Obstet Gynecol. 2013;209(6):542.e1-e11.