Article in PDF
How to Cite
Citation Manager
Readers' Comments (0)
Audio Visual Article Statistics
Link
to PUBMED
Print this Article
Send to a Friend
Advertisers
Access Statistics Resources
Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Outcome of Active versus Expectant Management in Preterm Premature Rupture of Membranes between 34 weeks to 36 weeks Six days: A Retrospective Study
Correspondence Address :
Dr. Shilpaann Baby,
Assistant Professor, Obstetrics and Gynaecology, Believers Church Medical
College Hospital, Kuttappuzha, P.O Pin 689103, Thiruvalla, Kerala, India.
E-mail: mistobaby@gmail.com
Introduction: An important cause of neonatal morbidity and mortality is the prelabour Preterm Rupture of the Membranes (PPROM) which refers to, the rupture of the membranes before 37 weeks. There are two modes of managing PPROM, active management (immediate delivery) and expectant management (therapy directed toward extending the pregnancy to improve neonatal outcome).
Aim: To compare neonatal outcomes following active and expectant (conservative) management in PPROM cases from 34 weeks to 36 weeks six days.
Materials and Methods: This retrospective study was conducted in the Department of Obstetrics and Gynaecology at Government Medical College (tertiary care teaching hospital), Thiruvananthapuram Kerala, India, from February 2021 to July 2021. The data collection period was from January 2013 to December 2014. PPROM cases between 34 weeks and 36 weeks and six days were retrospectively studied. A total of 62 patients among the Active Management (AM) group and 62 patients among the Expected Management (EM) group were selected. The neonatal outcomes (respiratory distress syndrome, hypoglycaemia, neonatal sepsis) and maternal outcomes (caesarean section, chorioamnionitis) were compared. The latency period in conservative management and in active management was also compared. The data was analysed using the Chi-square test.
Results: In the AM group, 13 (21%) babies had respiratory distress syndrome, whereas, in the EM group it was 4 (6.5%) (p-value=0.019). In the AM group, 13 (21%) babies had hypoglycaemia, whereas, in the EM group, it was 5 (8.1%) (p-value=0.041). In the AM group, 3 (4.8%) women had signs and symptoms of chorioamnionitis, whereas, in the EM group, it was 7 (11.3%) (p-value=0.187). In the AM group, 16 (25.8%) of women had Caesarean section, whereas, in EM it was 9 (14.5%) (p-value=0.117). In AM group, 1 (1.6%) has neonatal sepsis and in EM it was 3 (4.8%) p-value=0.309. The latency period in conservative management was 119.5±31 hours and in active management, it was 51.5±13.2 hours.
Conclusion: The present study indicated that expectant management of PROM between 34 weeks to 36 weeks and six days leads to a statistically significant reduction of neonatal respiratory distress syndrome and hypoglycaemia.
Amniotic fluid, Caesarean section, Chorioamnionitis, Hyperbilirubinaemia, Neonatal sepsis, Respiratory distress syndrome
Preterm Premature Rupture of the Membranes (PPROM) refers to the rupture of the membranes before 37 weeks and before the onset of labour. PPROM is an important cause of neonatal morbidity and mortality. It complicates upto 3% of all pregnancies and is the cause of 40% of all preterm births (1),(2). The main risk factors for PPROM are previous preterm birth, nulliparity, multiple pregnancies, low Body Mass Index (BMI), infections, vitamin deficiency, antepartum bleeding and maternal habit of cigarette smoking (3).
The main neonatal complications in PPROMs include prematurity, neonatal sepsis, respiratory distress syndrome, hyperbilirubinaemia hypoglycaemia, hypokalaemia, and hypocalcaemia (4). The maternal complications include endometritis, chorioamnionitis, increased rate of caesarean section and puerperal sepsis (5). The management of PPROM is dependent upon the gestation at which rupture of the membranes occurs.
Royal College of Obstetricians and Gynaecologists recommend expectant management in women with PPROM upto 37 weeks of pregnancy (6). American College of Obstetricians and Gynaecologists recommends either active management or expectant management in PPROM between 34 weeks to 36 weeks and six days (7). Many studies have been conducted in the past with the aim of deciding whether expectant or active management is more beneficial in cases of nearterm PPROM. These studies concluded that in women with near-term PPROM, active and expectant management resulted in comparable rates of primary adverse neonatal outcomes (respiratory distress syndrome and neonatal sepsis). The effects on maternal outcomes (chorioamnionitis and mode of delivery) and secondary neonatal outcomes (hypoglycaemia and hyperbilirubinaemia) were mixed (8),(9),(10). In a developing country like India preterm neonatal care poses a severe mental and financial burden on the patient and family. So the decision to terminate a preterm pregnancy needs to done after careful consideration. The present study was conducted with an aim to find any difference in neonatal outcomes in active and expectant management of PPROM between 34 weeks to 36 weeks and six days.
This retrospective analytical study was conducted in the Department of Obstetrics and Gynaecology in a tertiary care teaching hospital, Government Medical College, Thiruvananthapuram, Kerala, India, after taking the Institutional Ethical Committee clearance (IEC. No.36/1/2013 MCT). The case records of those patients who developed PPROM (between the gestational age of 34 weeks to 36 weeks and six days) between January 2013 and December 2014 were included in the study. The data analysis was done from February 2021 to July 2021.
Inclusion criteria: Singleton pregnancy, cephalic presentation, Bishops score <5, patients not in active labour and who gave consent to participate were included in the study.
Exclusion criteria: Women who were in established labour, clinical evidence of chorioamnionitis at presentation, meconium-stained liquor, previous caesarean section, multiple pregnancies, antepartum haemorrhage, fetal/maternal distress and cephalopelvic disproportion were excluded from the study.
Participants’ data were recorded from the database of the hospital. Every alternate patient file that matched the criteria for active and expectant protocols during the study period was included, till the required sample size was achieved. Those files with missing information were discarded, and further files were taken up that matched the criteria using the above selection process.
Study Procedure
In the present study, participants were taken as two groups:
• Active Management (AM) group: Patients who underwent induction of labour/caesarean section done within 48 hours of rupture of the membranes.
• Expectant Management (EM) group: Involved observation of the mother and baby, and awaiting the spontaneous onset of labour, in the absence of any complications that may necessitate delivery (9),(11).
The diagnosis of PPROM was confirmed by sterile speculum examination of the vagina. The gold standard for diagnosis was considered the amniotic fluid leakage (12).
Chorioamnionitis diagnosis was based on the presence of one of the following signs and/or paraclinical changes, not explained by other associated conditions: foetal tachycardia, fever (above 37.8°C) present in two successive examinations at 4-6 hour intervals, maternal tachycardia (over 100 bpm) present on two successive examinations every four to six hours, foul smelling discharge pervagina and high maternal leucocytes value, over 15,000 leucocytes/mm (13).
The mode of delivery was recorded as caesarean section or vaginal delivery. Neonatal sepsis was assessed by C-reactive protein, absolute neutrophil count, micro Erythrocyte Sedimentation Rate (ESR), peripheral smear to look for band forms and blood culture or clinical signs of infection (apnoea, fever, intolerance for feeding, respiratory distress, and/or haemodynamic instability) (14).
Respiratory distress syndrome constituted tachypnoea, tachycardia, chest wall retractions, expiratory grunting, and nasal flaring during breathing efforts and who require oxygen for support (15). As per the institutional protocol, hyperbilirubinaemia in the neonates was assessed by Cockington chart for premature infants (16). Hypoglycaemia was defined as glucose values less than 40 mg/dL on the first day of life (17). The following neonatal outcomes were recorded-respiratory distress syndrome, neonatal sepsis, hyperbilirubinaemia and hypoglycaemia. The maternal complications were also recorded (chorioamnionitis, caesarean section).
Statistical Analysis
Data was entered in an Microsoft Excel sheet and analysed using Statistical Package for the Social Sciences (SPSS) software version 27.0. The Chi-square test was used to compare the maternal and fetal outcomes in active and expectant management. Student’s t-test was used to compare the interval between rupture of membranes and delivery in hours.
The baseline characteristics of women included in the study were analysed between the two groups and were found to be comparable (Table/Fig 1),(Table/Fig 2). In the Active Management (AM) group, a majority of he 25 (40.3%) patients had amniotic fluid leaking between 35 weeks to 35 weeks six days. In the expectant management (EM) group, 18 (29%) patients had amniotic fluid leaking between 35 weeks to 35 weeks six days. In active management mean gestational age at birth was 34 weeks six days and in expectant management, it was 36 weeks and two days (Table/Fig 3). The mean interval between rupture of membranes and delivery in the AM group was 51.5 hours, while in the EM group this time interval was 119.5 hours (Table/Fig 4).
In the AM group, eight patients and in the EM group, four patients reported between 11-12 hours of PPROM to the hospital (p-value of 0.226) (Table/Fig 5). In EM group respiratory distress syndrome (n=4, 6.5%) was less compared to AM group (n=13, 21%) with p-value of 0.019 which was statistically significant. In EM group hypoglycaemia (n=5, 8.1%) was less than in AM group (n=13, 21%) with (p-value=0.041). Suspected neonatal sepsis was less in AM (n=1, 1.6%) than in EM (n=3, 4.8%) with a p-value of 0.309 (Table/Fig 6). Signs and symptoms of chorioamnionitis were less in AM group (n=3, 4.8%) than women and in the EM group (11.3%) with a p-value of 0.187. Caesarean section was more in AM group n=16 (25.8%) than in EM group (n=9,14.5%) with a p-value=0.117 (Table/Fig 7).
Preterm premature rupture of the membranes is an important clinical problem and a dilemma for clinicians. On one hand, awaiting spontaneous labour may lead to an increase in infectious disease for both mother and child, whereas, induction of labour leads to preterm birth with an increase in neonatal morbidity due to prematurity (6).
The present study showed that neonatal sepsis was more in the expectant management group than in active management, though not statistically significant. This is comparable with the study of Van Der Ham D et al., which also reported an increase in neonatal sepsis in expectant management compared to active management (4.6% vs 2.6%) (8). The study by Ezzat L, also showed an increase in perinatal infection with expectant management than in active management (18% vs 10%) (18).
The present study showed that respiratory distress syndrome was less in the expectant management group compared to the active management (6.5% vs 21%) and was statistically significant (p-value=0.019). It is similar to the study by Morris J et al., (19) which showed decreased incidence of RDS (5% vs 8% with p-value=0.008) in the expectant management group when compared to the active management group. The Cochrane database systematic review by Bond D et al., also showed decreased incidence of respiratory distress syndrome in the expectant management group (5). RDS was more in the active management group (RR 1.26, 95% CI 1.05 to 1.53, 12 trials). The study by Quist-Nelson J et al., also showed a decrease in respiratory distress syndrome in the expectant management group. RDS was more in the active management group (RR 1.47, 95% CI 1.10-1.97) (9).
The present study showed an increase of caesarean section in the active management group when compared to expectant management (25.8% vs 14.5%, p-value=0.117). In the study done by Biswas S et al., in India, the rate of caesarean section was higher in the actively managed group (32% vs 28%) than the expectant group (20). The study by Bond DM et al., also showed that early birth was associated with an increased rate of caesarean section (RR 1.26, 95% CI 1.11 to 1.44, 12 trials) (5). It is also similar to the study of Rawat R et al., which showed increase in Caesarean section in the active management group (32% vs 20% p-value=0.25) (10).
The present study showed a trend toward an increased risk of clinical chorioamnionitis in women receiving expectant management for PPROM when compared to active management, although not significant statistically (11.3% vs 4.8% p=0.187). It is similar to the study of Kayem G et al., which showed an increase in chorioamnionitis in expectant management (4.8% vs 0.9% p-value=0.07) (21). The study by Sgayer I et al., also showed an increase in chorioamnionitis in the expectant management group when compared to active management (7.3% vs 2.6% p-value=0.61) (22).
In the present study, the expectant management policy was associated with a statistically significant reduction of hypoglycaemia compared with the active management policy (8.1% vs 21% p-value=0.041). The study by Kayam G et al., showed a reduction of hypoglycaemia in the expectant management group compared to active management (5.6% vs 12.3% p-value=0.07) (21).
In the present study, hyperbilirubinaemia was less in the expectant management group than in the active management group (19.4% vs 33.9% p-value=0.067). The study by Van Der Ham D et al., also showed a reduction of hyperbilirubinaemia in the expectant management group compared to active management (26% vs 38% p-value=0.004) (8). The study by Elsayed E, also shows a reduction in hyperbilirubinaemia in expectant management compared to active management (11.9% vs 28.6% p-value=0.057) (23).
This retrospective comparative analysis compared the neonatal and maternal outcomes in near-term PPROM and observed that expectant management helps to reduce respiratory distress syndrome and hypoglycaemia in PPROM patients who are presenting near-term. However, there was an increase in chorioamnionitis and neonatal sepsis in the expectant management group which was not significant statistically.
Limitation(s)
Being a referral center, many patients had antenatal complications when they report. So, all patients with PPROM between 34 weeks to 36 weeks and six days could not be included in the conservative management group and hence sample size was limited. As this was a hospital-based study it was not generalisable to the population. As it was a retrospective study it lacks the methodologic validity of randomised controlled trials, hence, more studies are needed to arrive at a definite management protocol.
The present study indicated that expectant management of preterm premature rupture of membranes between 34 weeks to 36 weeks and six days leads to a statistically significant reduction of neonatal respiratory distress syndrome and hypoglycaemia. A decrease in neonatal hyperbilirubinaemia was also noted in the expectant management group. Expectant management of pregnancies with PPROM seems to be more beneficial in terms of reducing shortterm complications in premature infants between 34 weeks and 36 weeks and six days.
DOI: 10.7860/JCDR/2022/57083.17110
Date of Submission: Apr 14, 2022
Date of Peer Review: May 27, 2022
Date of Acceptance: Aug 31, 2022
Date of Publishing: Oct 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 18, 2022
• Manual Googling: Aug 22, 2022
• iThenticate Software: Aug 29, 2022 (14%)
ETYMOLOGY: Author Origin
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com