Mini ReviewSUMMARY
This systematic review was carried out in order to find new evidence demonstrating the relationship between premature rupture of amniotic membranes during the development of twin pregnancies. Among the main elements that we can rescue, is that this complication that appears in the gestation process is strongly linked to some elements that make it particularly important and that brings with it the appearance of threats of preterm births or neonatal sepsis among its main complications.
Keywords: Premature rupture of membranes; Ovarian membranes; Twin pregnancy complications
Introduction
The routine control of a pregnant woman is increasingly important in the fields of obstetric gynecology. The main function of prenatal controls is to prevent women from suffering alterations during this period by identifying the risk factors associated with the development of pathological conditions and modifying them, if possible, if they are not modifiable, they allow taking precautionary measures during their condition. Premature rupture of membranes (PROM) is one of the most common complications in pregnant women, mainly during the third trimester, affecting 3-4% of all pregnant women. At the public health level, it is classified as a gynecological-obstetric emergency, which is why it is important to provide a comprehensive approach aimed at reducing the maternal-fetal mortality rate and avoiding preterm delivery. PROM is defined as the spontaneous disruption of the ovular membranes, after 21 weeks of the gestation period, up to one hour before the onset of labor. When it occurs before 37 weeks of gestational age, it is known as Preterm Premature Rupture of Membranes (pPRM).
The amniotic or ovular membranes appear in a strict maternalfetal relationship from 14-15 weeks and are the only barrier that exists in the third trimester between the external environment and the product, they have very important and particular functions such as protecting and containing amniotic fluid at adequate levels so that the pregnancy remains viable, in the case of a rupture the amniotic fluid begins to come out, causing oligohydramnios which in many cases can end in the termination of pregnancy, it also plays an important role in the electrolyte transport and exchange and decreases bacterial growth. Twin gestation is a condition constantly observed in our population, the recognition of recent evidence that relates twin gestation and the appearance of PROM allows the development of prevention strategies and necessary measures to prolong the gestation period and avoid preterm delivery.
Materials and Methods
A bibliographic search was carried out that spanned from 2017 to 2021 in the databases PubMed, Elsevier, scielo, Update, Medline, national and international libraries. We use the following descriptors: premature rupture of membranes, premature delivery, twin pregnancy, premature labor. The data obtained oscillate between 16 and 60 records after the use of the different keywords. The search for articles was carried out in Spanish and English, it was limited by year of publication and studies between 2017 and 2021 were used. The main exclusion criteria were articles that had more than 5 years of publication.
Results
The cause of premature rupture of membranes at the limit of
fetal viability (after 24 weeks of gestational age) is varied, having
as risk factors cervical incompetence, the use of cerclage, tobacco
consumption, history of preterm delivery and / or rupture of
membranes in previous pregnancies, decreased body mass index,
low socioeconomic status, presence of bleeding in the second and
third trimesters, nutritional deficiencies, uterine over-attendance
due to polyhydramnios or twin pregnancy. Localized infections in
external components such as the cervix, or internal intrauterine
structures can cause loss of continuity of the ovular membranes
[1]. Twin pregnancy, defined as the gestation of two fetuses within
the uterus, is associated with a higher probability of maternalfetal
complications, a 3-fold higher risk of pre-eclampsia, preterm
delivery, premature detachment of the placenta, pyelonephritis,
postpartum hemorrhage, and premature rupture of membranes
[2].
The cause of this obstetric-gynecological condition is unknown,
but it is associated with multiple pathologies causing 25-30% of
premature births, which is why it is considered the main cause of
prematurity and maternal mortality. Over the years, findings have
been mentioned in areas of rupture that show extremely altered
points of morphology: collagen II deficiency, edema with deposits
of fibrinoid material, thinning of the trophoblastic and decidual
layers and the development of contractions due to the presence of
deposits. of prostaglandins E2 and F2, product of decidual cells and
the presence of bacteria [3].
This prelude to a neonatal emergency brings severe
consequences and complications such as: chorioamnionitis,
neonatal sepsis due to colonization of microorganisms in the
amniotic fluid, prematurity and even fetal death. It is characterized
by having an affinity for women at the extremes of childbearing age,
a prevalence in women with comorbidities and a significant history
of abortions (spontaneous or induced), and high levels of morbidity
and mortality due to prematurity in multiple or twin pregnancies
[4]. The relationship between twin pregnancy and PROM has not
been demonstrated, however it is related to an estimated incidence
of 5-8% according to the WHO. Representing the premature rupture
of membranes 3% in Newborns as a result of twin pregnancies and
12% of perinatal deaths [5].
As the incidence of twin pregnancy increases, there are
numerous complications associated with perinatal morbidity and
mortality. One of the factors that could possibly affect and impact
the most is obesity; the elevated body mass index typical of twin
pregnant women was associated with a higher risk of premature
rupture of the membranes, associated with uterine over-attendance;
myometrial distention increases myometrial contractility, releases
prostaglandins, and positively regulates oxytocin receptors, which
are involved in the cascade of events that have been identified in
the development of PROM [6]. Through this thematic review, it was
shown that premature rupture of membranes has a very significant
incidence during the development of a twin pregnancy and implies
a significant cause of perinatal morbidity and mortality. In order to
cope with this problem, it is important to know the risk factors that
predispose to this disease, as well as the possible complications
that can develop depending on the management. The diagnosis is
fundamentally clinical, which is why it is of the utmost importance
to carry out an adequate clinical history that allows the patient’s
symptoms and signs to be concisely established and, depending
on the case, complementary diagnostic tests can be added to help
clarify the clinical picture if there are doubts [4-6].
Discussion
Over the past 25 years, the rates and numbers of twin and
higher-order births in the United States have increased at an
unprecedented rate [7]. As the incidence of twin pregnancy
increases, it is also observed that both maternal and perinatal
complications increase, associated with perinatal morbidity and
mortality [8]. Currently, recent evidence is recognized that relates
this obstetric circumstance with the appearance of premature rupture of membranes, so determining its association in our
environment allows us to develop prevention strategies and adopt
necessary measures with those pregnant women with a greater
probability of developing rupture of the membranes. membranes
with a reduction in the risk that this implies for the mother-fetus
binomial.
Markus L et al. in Tanzania in 2013 who recognized the
association between twin gestation and the risk of developing
premature rupture of membranes, in a retrospective cohort study
observing that the frequency of premature rupture of membranes
was 11% in the exposed group. twin gestation and only 4% in
the single gestation group (p <0.05) [9]. The study by Vogel J,
et al in Brazil in 2014 who identified the association between
twin gestation and the risk of developing premature rupture of
membranes in 279,425 pregnancies, observing that the frequency
of premature rupture of membranes was 9% in the exposed group
and 3% in the unexposed group: (p <0.05) [10]. Finally, it is worth
highlighting what was found by Chiwanga E et al. in Tanzania in
2014 who recognized the influence of twin gestation regarding the
appearance of obstetric morbidity, in a prospective cohort study
in 1644 pregnancies, observing that the frequency of premature
rupture of membranes was 4% in the exposed group and 1% in the
non-expects group, (OR = 5.6; 95% CI: 4.2-7.4) [11].
Conclusion
In twin pregnant women, the timely diagnosis of PROM is
based on the constitution of a thorough medical history, physical
examination with speculum, nitrazine test, crystallographic study
and tests based on the determination of biomarkers. The recognition
of social, economic, anatomophysiological and environmental risk
factors, allow the adequate therapeutic approach. However, it is
important to take into account the characteristics of each pregnant
woman individually since, based on this, it will be decided on the
schemes already established for the management of PROM and
prolongation of pregnancy or timely termination of the pregnancy
if none is viable. of the approaches.
Currently in Colombia two types of management are used for
premature rupture of membranes: an active management that
consists of the induction of labor and expectant management that
consists of hospitalization for surveillance for a period of time the
risk of infection, detachment of the placenta, understanding of the
umbilical cord, check fetal well-being and labor. The early approach
with antibiotics, corticosteroids, and magnesium sulfate continues
to be the cornerstone in twin pregnancies in which pregnancy
prolongation is feasible. At the moment, there is still a great need
to establish the relationship and exact cause of the appearance of
premature rupture of membranes in twin pregnancies during the
development of the third trimester to establish a protocol that
reduces the rates of maternal-fetal morbidity and mortality.
Currently in Colombia two types of management are used for
premature rupture of membranes: an active management that
consists of the induction of labor and expectant management that
consists of hospitalization for surveillance for a period of time the
risk of infection, detachment of the placenta, understanding of the
umbilical cord, check fetal well-being and labor. The early approach
with antibiotics, corticosteroids, and magnesium sulfate continues
to be the cornerstone in twin pregnancies in which pregnancy
prolongation is feasible. At the moment, there is still a great need
to establish the relationship and exact cause of the appearance of
premature rupture of membranes in twin pregnancies during the
development of the third trimester to establish a protocol that
reduces the rates of maternal-fetal morbidity and mortality.
Competing Interests
There was no competing interest among the authors.
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