Urine Routine Test has Potential Predictive Value in

Premature Rupture of the Membranes

Zhuo Deng
Dalian Medical University
Dan Lu (  [email protected] )
yangzhou university
Xuanqi Wang
Dalian Maritime University
Jingyi Wang
Dalian Medical University

Research article

Keywords: Routine urine test, premature rupture of membranes (PROM), preterm premature rupture of
membranes (PPROM), vaginal micro ora, bacteria

DOI: https://doi.org/10.21203/rs.3.rs-271808/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License

Page 1/13
Abstract
Background: This study was conducted to discuss predictive value of a routine urine test for premature
rupture of the membranes(PROM).

Methods: We carried out the retrospective research after collecting routine urine test data from 45 cases
of full preterm premature rupture of membranes (PPROM) and 45 cases of full-term preterm premature
rupture of membranes (fPROM). In addition 70 healthy pregnant women (Normal) and 70 non-pregnant
adult healthy women were enrolled. Parametric and Non-parametric tests was performed respectively.
The receiver operating characteristic (ROC) was established and we further calculated the area under the
ROC curve (AUC). In this study multiple cutoffs were selected, afterwords the positive predictive value
(PPV), the negative predictive value (NPV), the positive likelihood ratio (+LR) and negative likelihood ratio
(-LR) were further calculated by sensitivity and speci city with the aim of nding the best cutoff point.

Results: The results indicated that S/G and COND were signi cantly different between PROM and Non-
pregnant and Normal groups. Signi cant differences in pH, WBCs, RBCs, BAC and EC between the
PPROM and Normal groups were observed. When the cutoff for bacteria was 89.15, it had the largest AUC
of 0.744. We found that its PPV 70.6%, NPV was 74.1%, +LR was 3.79, and –LR was 0.55.

Conclusion: A routine urine test especially for bacterial counts can be used to predict the risk of PROM,
which is expected to provide considerable predictive value for PROM.

1. Background
Premature rupture of membranes (PROM) refers to rupture of membranes before delivery, which is one of
the common complications in obstetrics, with an incidence of 8%-10% [1]. Complications such as
infection, trauma increased pressure of amniotic cavity and gestational diabetes may lead to rupture of
membranes [2–3]. Preterm premature rupture of the membranes (PPROM) means the rupture of the
membranes before labor starts prior to 37 weeks of gestation, which remains a signi cant obstetric
problem that affects 3–4% of all pregnancies and precedes 40–50% of all preterm births [4]. The number
of PPROM cases exceeds that of preelampsia and gestational diabetes. According to the report, neonatal
death in newborns without chromosomal abnormality or congenital anomaly was mainly caused by
prematurity [5–6]. In addition preterm births is also related to a series of long-term effects in survivors,
including neurodevelopmental delay, cerebral palsy, blindness, hearing loss, and chronic lung disease [7,
8]. However, the empirical treatment that ignore the complexity and heterogeneity of PPROM
pathopHysiology are not satisfactory, antibiotic therapy and antenatal corticosteroid treatment are
typically administered to prolong pregnancy, prevent infection, and reduce gestational age dependent
morbidities [9], and the result is futile because probably 90% of pregnant women give birth within one
week [10–12].

PPROM results from complex, multifaceted pathways, and precise causes or risk factors of are unknown.
Some research showed the etiology of PPROM was multifactorial, such as maternal reproductive tract
Page 2/13
infections (e.g., bacterial vaginosis BV, trichomoniasis, gonorrhea, Chlamydia, and occult
chorioamnionitis), behavioral factors (e.g., cigarette smoking, substance abuse, poor nutritional status,
and coitus during pregnancy) and obstetric complications (e.g., multiple gestation, polyhydramnios,
incompetent cervix, gestational bleeding, prior cervical surgery, and antenatal trauma) [13, 14]. Among of
them, ascending bacterial invasion may lead to intrauterine infection that is the most common risk factor,
which account for up to 60% of cases with PPROM [15, 16]. There are some additional risk factors for
PPROM, history of PPROM in a previous pregnancy have been proposed [17, 18]. The pathogenesis are
still unclear and recent studies have shown both disruption of fetal membrane integrity and activation of
uterine contraction can be cauesd by in ammatory mediators. Current study showed in ammation–
oxidative stress axis plays a major role in producing pathways that can lead to membrane weakening
through a variety of processes. Bacterial products or/and pro-in ammatory cytokines can trigger that the
membrane morpHology with PPROM altered. Activation of matrix metalloproteinases (MMP) have been
implicated in the mechanism of PPROM [19]. The vaginal micro ora of a healthy asymptomatic woman
was consisted of a wide variety of anaerobic and aerobic bacterial genera and species dominated include
the facultative, microaeropHilic, anaerobic genus Lactobacillus. The activity of Lactobacillus is essential
to protect women from genital infections and to maintain the natural healthy balance of the vaginal ora.
There is more and more evidence that abnormalities in vaginal ora during pregnancy is associated with
preterm labor and delivery with potential neonatal sequelae due to prematurity and poor perinatal
outcome pregnancy [20–23].

Early diagnosis of PPROM is necessary and important. It is possible to prevent PROM if treatment can be
performed in the early stage of chorionic villous infection, but PROM is inescapable after amniotic layer
occurs infection [24], with the reason that the chorion is thicker than amnion but has less tensile strength
[25] Accurate diagnosis of PROM remains a frequent clinical problem in obstetrics. At present, there are
only several tests to con rm a diagnosis of PPROM post-facto, including microfetal cell identi cation,
amniotic uid crystallization and intra-amniotic dye injection. The disadvantages of intra-amniotic
injection are invasive, which increases the risk of infection and premature delivery. The inadequacy of
microfetal cell identi cation or amniotic uid crystallization is the long detection period and the high
false positive rate, and not any method to reliably predict PPROM [26]. It is the lack of a non-invasive gold
standard for the diagnosis of PROM that led to the appearance of several tests based on alternative
biochemical markers [27]. The diagnostic performance of traditional indicators re ecting in ammation or
infection includes leucocytes, IL-6, C-reactive protein (CRP), and procalcitonin (PCT), vaginal prolactin,
alpHa-feto-protein (AFP), fetal bronectin and insulin-like growth factor binding protein-1 (IGFBP-1), whcih
need to be improved [28, 29] As a result, the biomolecular markers with high sensitivity and speci city
that can predict PPROM plays a very important role, which is the key of early clinical diagnosis [30].

Recent studies suggested that urine test is helpful for timely screening of high-risk pregnant women with
PPROM. Urine test is a routine process for the hospitalized patients, which has good operability, low cost
and non-invasiveness. It includes 20 important indicators, named leukocytes; (BLD): occult blood; (PRO):
protein; (GLU): glucose; (KET): ketone bodies; (UBG): urobilinogen; (BIL): urobilirubin; pH; (SG): urine
speci c gravity; (NIT): nitrite; (WBCs): white blood cells; (RBCs): red blood cells; (EC): epithelial cell count;
Page 3/13
Cast; (P.CAST): pathological cast; (BAC): bacteria; (SRC): small round cells; (BYST): yeast; Crystals;
(Cond): electrical conductivity. The aim of this study was designed to investigate the value of urine test in
diagnosis and prediction of PPROM.

2. Methods
2.1 Patients
This comparative prospective study was carried out over 1 year at Subei People’s Hospital of Yangzhou
University from February 2018 to February 2019. Patients with multiple pregnancies, antibiotic therapy in
the past 2 weeks and urinary tract infection were excluded from this study. A total of 70 pregnant women
with Normal gestational age > 37 weeks and < 42 weeks, 70 healthy Non-pregnant adult healthy women
were included in this study. The 90 patients in premature rupture of membranes were divided into two
groups according to gestation; gestational age > 37 weeks were included in PROM and < 37 weeks were
included in PPROM. All patients received routine urine tests within 7 days before rupture of the fetal
membranes. Urine routine specimens were collected within 24 hours before delivery for healthy pregnant
women women. Clean midstream urine specimens in healthy women randomly collected. Diagnostic
criteria for PROM are as follows: (a)patient’s history of sudden gush of water, (b)pooling of amniotic uid,
(c)positive Ferning pattern, (d)positive Nitrazine test, (e)con rmed by visualization of uid passing from
the cervical canal during sterile speculum examination and (f)transabdominal ultrasound to measure the
amniotic uid index (AFI ≤ 5 cm in PROM) [31, 32]. This experiment has no intervention measures and
ensures the safety of personal privacy information, so informed consent and ethical approval are
exempted.
2.2 Urine sample collection and processing
The women’s clean mid-stream urine were collected by a disposable cup. The Arkray AX-4280 (Arkray
Corp., Kyoto, Japan) was used to measure dry chemical analysis of urine that included eukocytes, occult
blood, protein, glucose, ketone bodies (KET), urobilinogen, urobilirubin, pH values, urine speci c gravity
(SG), and nitrite. Urinary components were analyzed by the Iris IQTM200 (Iris Corp., USA), which included
white blood cells (WBCs), red blood cells (RBCs), epithelial cell count (EC), cast, bacterial counts (BAC),
pathological cast, small round cells, yeast, crystals, and electrical conductivity (COND). A microscopic
examination was used to con rm the numbers of WBC, RBC, EC and cast, because the samples could not
be correctly detected by an instrument.
2.3 Data analysis
Data were collected, tabulated and analyzed by Statistical Package for Social Sciences (SPSS) computer
software version 21. Before comparison of data, a general description of the data was performed. Firstly,
the normality of distribution of continuous variables was tested by the KolmogorovSmirnov, continuous
variables with a normal distribution are presented as the mean and standard deviation; non-normal
variables were shown as median (interquartile range). Then the homogeneity of variance of two samples

Page 4/13
was tested by the Levene method, the means groups of two groups continuous normally distributed
variables were compared by independent sample Student's t-test. The Mann-Whitney U-test was used to
compare the means of two groups of variables not normally distributed. P < 0.05 was considered to
indicate a statistically signi cant difference.

2.4 Establishing of ROC curve

Sensitivity is the proportional detection of individuals with the disease of interest in the population.
Speci city is the proportional detection of individuals without the disease of interest in the population.
Both of them can be used to evaluate the authenticity of the model. The PPV is the proportion of all
individuals with positive tests, who have the disease. The NPV is the proportion of all individuals with
negative tests, who are non-diseased. The prediction ability of the model can be evaluated by PPV and
NPV. Different cutoff point were used to calculate true positive rate (sensitivity) and false positive rate (1-
speci city) respectively, ROC curve was shown after the sensitivity and 1-speci city were respectively
plotted on the ordinate and the abscissa. The diagnostic values of the model was assessed via ROC
curve and the AUC. AUC was calculated to determine which indicator had the largest AUC. When the two
indicators need joint detection, the logistic regression analysis is used to generate the prediction
probability and the ROC curve is performed to generate probability.

2.5 Diagnostic value assessment

The closer to the upper left corner of the ROC curve, the better the diagnosis of the model. In practice
clinicians need a cutoff point to determine whether intervention is required after establishing the utility of
a continuous indicator. The Youden index (J) can serve as an overall index of a indicator’s accuracy, so
cutoff point corresponding to the maximizing Youden index can be utilized for decision making [33]. J
was expressed as J={ sensitivity + speci city–1} [34]. In this study multiple cutoffs were selected to
calculate sensitivity and speci city, afterwords PPV, NPV, the positive likelihood ratio (+ LR) and negative
likelihood ratio (-LR) were further calculated by sensitivity and speci city with the aim of nding the best
cutoff point, which are meaningful indicators for the effectiveness.

3. Results
3.1 The basic situation of the research object
A total of 400 women were screened, of them 230 eligible met inclusion criteria and consented to study
procedures. These numeration data, including occult blood, protein, glucose, KET, urobilinogen,
urobilirubin, nitrite and crystal are not suitable for establishing an ROC curve, which were not selected and
compared. As shown in Table 1, WBCs, RBCs, BAC, and EC do not satisfy the homogeneity of variance, α
= 0.01 as the test level. KolmogorovSmirnov method was used to test the normality, only COND are
normal distributions in the four terms, we used the mean and standard deviation to describe the data
distribution in Table 2. Similarly, α = 0.01 is the test level.

Page 5/13
 Table 1
The results of normality and homogeneity of variance test
variable Homogeneity Normality test

of variance PPROM fPROM Normal Non-pregnant

Stat. P Stat. P Stat. P Stat. P Stat. P

S/G 1.409 0.241 1.014 0.17 1.014 < 0.01 1.019 < 0.01 1.022 < 0.01

pH 2.868 0.037 6.8 < 0.01 6.8 < 0.01 6.3 < 0.01 6 < 0.01

WBC 13.891 < 147.3 < 0.01 105.8 < 0.01 47.4 < 0.01 17.6 < 0.01
0.01

RBC 14.465 < 202.1 < 0.01 432.6 < 0.01 34.9 < 0.01 26.3 < 0.01
0.01

BAC 9.964 < 305.2 < 0.01 285.6 < 0.01 809.7 < 0.01 273.5 < 0.01
0.01

EC 9.724 < 33.96 < 0.01 35.25 < 0.01 46.13 < 0.01 23.24 < 0.01
0.01

CAST 3.043 0.03 0.28 < 0.01 0.24 < 0.01 0.25 < 0.01 0.28 < 0.01

COND 1.609 0.188 15.4 0.018 14.6 0.2 17.8 0.2 18.7 0.2

SG: urine speci c gravity; WBCs: white blood cells; RBCs: red blood cells; EC: epithelial cell count;
CAST: cast; BAC: bacterial counts; Cond.: electrical conductivity
Table 2
Distribution of each group
Variable PPROM fPROM Normal Non-pregnant

S/G 1.01 + 0.07 1.01 ± 0.10 1.02 ± 0.13 1.02 ± 0.10

pH 7.00 ± 1.50 6.50 ± 0.50 6.50 ± 1.00 6.00 ± 1.00

WBC 14.40 ± 55.50 21.00 ± 60.00 32.00 ± 66.70 7.70 ± 22.90

RBC 13.50 ± 182.90 33.20 ± 45.81 7.60 ± 28.80 12.40 ± 14.20

BAC 77.70 ± 314.60 117.70 ± 281.80 413.10 ± 1286.00 69.30 ± 217.00

EC 20.10 ± 33.45 25.50 ± 34.35 55.20 ± 74.70 14.60 ± 30.70

CAST 0.14 ± 0.34 0.13 ± 0.27 0.23 ± 0.41 0.13 ± 0.28

COND 15.44 ± 6.37 13.73 ± 5.25 16.97 ± 6.90 18.65 ± 1.00

Values are mean standard deviation. SG: urine speci c gravity; WBCs: white blood cells; RBCs: red
blood cells; EC: epithelial cell count; CAST: cast; BAC: bacterial counts; Cond.:electrical conductivity.

3.2 Variable comparison

Page 6/13
The pairwise comparisons among the PPROM, fPROM, Normal, and Non-pregnant groups were
performed by the Mann-Whitney U-test. Table 3 indicated that pH was signi cantly lower in the Non-
pregnant group compared with the other three groups (all P < 0.05). In addition, there was signi cant
difference between fPROM and Non-pregnant and Normal groups regarding S/G and COND (all P < 0.05).
CAST was signi cantly lower in the Normal group compared with Non-pregnant and fPROM groups (all P
< 0.05). Statistical analysis showed that pH, WBCs, RBCs, BAC and EC were signi cantly different
between the PPROM and Normal groups (all P < 0.05), RBCs, BAC and EC were signi cantly different
between the fPROM and Normal groups (all P < 0.05). The next ROC curve was established by the
parameters with signi cant difference.

Table 3
Mann–Whitney U test for each groups
Variable fPROM vs Normal vs PPROM vs fPROM fPROM vs Normal vs
Non-pregnant Non-pregnant Non-pregnant vs PPROM PPROM
Normal

S/G < 0.01* 0.33 < 0.01* < 0.01* 0.92 0.06

pH < 0.01* < 0.01* < 0.01* 0.16 0.41 0.04*

WBC < 0.01* < 0.01* 0.08 0.16 0.26 0.02*

RBC < 0.01* 0.12 0.15 < 0.01* 0.1 0.02*

BAC 0.2 < 0.01* 0.65 < 0.01* 0.53 < 0.01*

EC 0.03* < 0.01* 0.21 < 0.01* 0.36 < 0.01*

CAST 0.71 < 0.01* 0.16 < 0.01* 0.05 0.49

COND < 0.01* 0.18 < 0.01* < 0.01* 0.23 0.16

*P < 0.05 was considered statistically signi cant. SG: urine speci c gravity; WBCs: white blood cells;
RBCs: red blood cells; EC: epithelial cell count; CAST: pathological cast; BAC: bacterial counts; Cond.:
electrical conductivity.

3.3 ROC curve

In order to meet the requirement, the ROC curve was established between PPROM and Normal groups.
According to the result of variable comparison, RBCs were excluded these inappropriate indicators, which
are easily susceptible to vaginal bleeding. We selected three indicators to establish the ROC curve,
including pH, BAC, pH + BAC (Fig. 1A,1B,1C). The ROC curve is usually used to re ect the accuracy of the
diagnostic system. The more curve to the left, the greater the area under the curve (AUC), the higher the
diagnostic accuracy. As shown in Fig. 1, the AUC of pH and BAC were respectively 0.608 and 0.744, the
joint detection of pH + BAC had the AUC (0.735), we found the AUC for BAC was the largest.

3.4 Predicted value

Page 7/13
The Youden index is a summary index for the overall performance of the ROC curve, best one of which is
equivalent to maximizing the sum of sensitivity and speci city for all the possible values, corresponding
to the cut-off point. Then the predictive value of each indicator was estimated by the sensitivity,
speci city, PPV, NPV, +LR, and -LR. Table 4 indicated that When the variable bacteria had a cutoff of
81.95, the sensitivity was 53%, the speci city was 86%, the PPV was 70.6%, the NPV was 74.1%, +LR was
3.79, and –LR was 0.55.

Table 4
Comparison of the predictive value of different indicators.
variable Youden Cut-off Sensitivity Speci city PPV NPV +LR -LR
index value

pH 0.390 81.95 53% 86% 70.6% 74.1% 3.79 0.55

BAC 0.207 6.75 58% 63% 50% 69.8% 1.57 0.67

pH + 0.311 0.3207 91% 40% 53.2% 89.5% 1.52 0.23

BAC

a
Predictive probability.

4. Discussion
More and more studies con rmed multifactorial interactions induced the occurrence of PPROM. Vaginal
infection was one of the most main risk factors for complications of pregnancy. As for women, the
microecological of urethra and reproductive tract are easy to be in uenced by exchange of bacteria. That
is to say, the amount of bacteria in a routine urine test can re ect the status of the female vagina [35].
Previous research has examined lactobacilli predominate in normal circumstances, which is essential to
protect women from genital infections and to maintain the natural healthy balance of the vaginal ora
[36, 37]. In addition, the hormonal changes of pregnancy favored an increase in the concentration of
lactobacilli [38]. However, in the patients with PPROM the normal healthy ora can be disturbed, and
dominant bacteria can be replaced by pathogenic bacteria with the result of the decrease of lactobacilli.

By analyzing the 45 cases of PPROM, 45 cases of fPROM, 70 cases of Normal and 70 cases of Non-
pregnant maternal, signi cant differences were observed among groups. pH was signi cantly higher in
the PPROM group compared with Normal group. The pH of the amniotic uid is normally 7.1–7.3,
however the vaginal secretions usually has a pH of 4.5-6.0. The change of pH have con rmed occurrence
PPROM [39, 40]. S/G and COND were signi cantly lower in the fPROM group compared with Non-
pregnant and Normal groups, which is related to an increase in secreted aldosterone for pregnant women,
further lead to the kidney reabsorb more sodium and chloride [41]. The WBCs and EC was lower in
PPROM groups than Normal groups, which cannot be used to predict PPROM with the reason that mild or
asymptomatic urethral infection may happen in pregnant women. The RBCs in the PPROM group were
signi cantly higher than Normal group, which is probably due to the explanation that vaginal bleeding
symptoms may occur in patients with PPROM. The results indicated that BAC in PPORM was
Page 8/13
signi cantly less than Normal group, which indicated a decrease in the diversity of ora and increased
the risk of PPORM [42].

In this study, non-parametric test between the PPROM and Normal groups was carried out, which screen
out the different indicators. The better indicators with high sensitivity, speci city, PPV, NPV, +LR and -LR
were selected by the establishment of ROC curve, the corresponding Youden index and cutoff point were
further worked out. However there are some limitations, the main one is the AUC values of metrics were
not high enough so that prediction value is limited. This also suggests that the urine routine only screen
out the pregnant women with high-risk of PPROM, which must be combined with other indicators to
predict PPROM.

5. Conclusions
An excellent indicator that can timely screen out pregnant women with PPROM is quietly important and
necessary to diagnosis PPROM and and chorioamnionitis, which is helpful for preventing neonatal
infection. To the best of the authors' knowledge, the research provide evidence that a routine urine
examination has potential value in early prediction of PPROM. It needs to attach great importance that a
decrease in the amount of bacteria in the urine sample is a high-risk factor, which indicates the loss of
normal bacterial oral diversity. As a result the present study suggested that routine urine may be a novel
potential indicator for early diagnosing of PPROM and the routine urine-based strip may be a helpful for
preventing chorioamnionitis and reducing the maternal and perinatal morbidity.

Abbreviations
premature rupture of membranes (PROM); preterm premature rupture of membranes (PPROM); full-term
preterm premature rupture of membranes (fPROM); the receiver operating characteristic (ROC); the area
under the ROC curve (AUC); the positive predictive value (PPV); the negative predictive value (NPV); the
positive likelihood ratio (+ LR); the negative likelihood ratio (-LR); occult blood (BLD); protein (PRO);
glucose (GLU); ketone bodies (KET); urobilinogen (UBG); urobilirubin (BIL); pH; urine speci c gravity (SG);
nitrite (NIT); white blood cells (WBCs); red blood cells (RBCs); epithelial cell count (EC); pathological cast
(P.CAST); bacteria (BAC); small round cells (SRC); yeast(BYST);electrical conductivity (Cond)

Declarations
Ethics approval and consent to participate

This study was approved by the Ethics Committee of Subei people’s Hospital of Yangzhou University. All
patients involved in the study signed informed consent forms.

Consent for publication

Not applicable

Page 9/13
Availability of data and material

The datasets used and/or analysed during the current study are available from the corresponding author
on reasonable request.

Competing interests

The authors declare no competing nancial interest.

Funding

We gratefully acknowledge support from the National Natural Science Foundation of China (No.
82072088) of Dan Lu in interpretation of data and in writing, the Traditional Chinese Medicine Science
and Technology Development Plan Project of Jiangsu Province (Project ID: YB201972) of Dan Lu in
collection; Maternal and Child Health Research Project of Jiangsu Province (Project ID: F201809) of Dan
Lu in interpretation of data.

Authors' contributions

D L Protocol/project development

Z D Manuscript writing/editing

Qq W Data analysis

Jy W Data collection or management

References
1. Yan YW, Hai BL, Guang LC., et al. Placental protein 14 as a potential biomarker for diagnosis of
preterm premature rupture of membranes. Molecular Medicine Reports, 2018 (18):113–122.
2. Liu L, Wang L, Yang W. et al. Gestational hypertension and preclampsia and risk of spontaneous
premature rupture of membranes: A population-based cohort study. International Journal of
Gynecology Obstetrics. 2019;147(7):195–2010.
3. Caballero A, Dudley D, Ferguson J. et al. Maternal Human Papillomavirus and Preterm Premature
Rupture of Membranes: A Retrospective Cohort Study. Journal of Womens Health. 2019;28(5):606–
11.
4. Menon R, Richardson LS. Preterm prelabor rupture of the membranes: A disease of the fetal
membranes. Seminars in Perinatology 2017: S0146000517300848.
5. Silverman RK, Wojtowycz M. Risk factors in premature rupture of membranes. Prim Care Update Ob
Gyns. 1998;5(4):181.
6. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet.
2008;371(9606):75–84.
Page 10/13
 7. Merenstein GB, Weisman LE. Premature rupture of the membranes: neonatal consequences. Semin
Perinatol. 1996;20:375–80.
8. Waters TP, Mercer B. Preterm PROM: prediction, prevention, principles. Clinical Obstetrics Gynecology.
2011;54(2):307.
9. Menon R. Spontaneous preterm birth, a clinical dilemma: etiologic, pathopHysiologic and genetic
heterogeneities and racial disparity. Acta Obstet Gynecol Scand. 2008;87(6):590–600.
10. Wolf MF, Miron D, Peleg D. et al. Reconsidering the current preterm premature rupture of membranes
antibiotic propHylactic protocol. Am J Perinatol. 2015;32:1247–50.
11. Al Riyami N, Al-Ruheili I, Al-Shezaw F. et al. Extreme preterm premature rupture of membranes: risk
factors and feto maternal outcomes. Oman Med J. 2013;28:108–11.
12. Macones GA, Parry S, Elkousy M, Clothier B, Ural SH. A polymorpHism in the promoter region of TNF
and bacterial vaginosis: preliminary evidence of gene-environment interaction in the etiology of
spontaneous preterm birth. Am J Obstet Gynecol. 2004;190(6):1504–8., Strauss JF III.
13. Burns DN, Landesman S, Muenz LR. et al. Cigarette smoking, premature rupture of membranes, and
vertical transmission of HIV-1 among women with low CD4 + levels. J Acquir Immune De c Syndr.
1994;7(7):718–26.
14. Silverman RK, Wojtowycz M. Risk factors in premature rupture of membranes. Prim Care Update Ob
Gyns. 1998;5(4):181.
15. Waters TP, Mercer B. Preterm PROM. Prediction, Prevention, Principles[J]. Clin Obstet Gynecol.
2011;54(2):307–12.
16. Tülay Oludag, Gode F, Caglayan E. et al. Value of maternal procalcitonin levels for predicting
subclinical intra-amniotic infection in preterm premature rupture of membranes[J]. Journal of
Obstetrics Gynaecology Research. 2014;40(4):954–60.
17. Mercer BM, Goldenberg RL, Moawad AH. et al. The preterm prediction study: effect of gestational age
and cause of preterm birth on subsequent obstetric outcome. National Institute of Child Health and
Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol. 1999;181(5 pt
1):1216–21.
18. Asrat T, Lewis DF, Garite TJ. et al. Rate of recurrence of preterm premature rupture of membranes in
consecutive pregnancies. Am J Obstet Gynecol. 1991;165(4 pt 1):1111–5.
19. Tchirikov M, Maher J, Andreas S. et al. Mid-trimester preterm premature rupture of membranes
(PPROM): etiology, diagnosis, classi cation, international recommendations of treatment options
and outcome[J]. Journal of Perinatal Medicine O cial Journal of the Wapm. 2018;46(5):465–88.
20. Donati L, Vico AD, Nucci M. et al. Vaginal microbial ora and outcome of pregnancy[J]. Archives of
Gynecology Obstetrics. 2010;281(4):589–600.
21. Witkin SS, Linhares IM, Giraldo P. Bacterial ora of the female genital tract. function immune
regulation. 2007;21(3):347–54. ().

Page 11/13
22. Lidbeck A, Nord CE. Lactobacilli and the normal human anaerobic micro ora. Clin Infect Dis.
1993;16(Suppl 4):181–7. ().
23. Hawes SE, Hillier SL, Benedetti J, Stevens CE, Koutsky LA, Wolner-Hanssen P. Hydrogen peroxide-
producing Lactobacilli and acquisition of vaginal infections. J Infect Dis. 1996;174(5):1058–63. ().
24. Gratacos E, Sanin-Blair J, Lewi L. et al. A histological study of fetoscopic membrane defects to
document membrane healing. Placenta. 2006;27:452–6.
25. Parry S, Strauss JF. Premature rupture of the fetal membranes. N Engl J Med. 1998;338:663–70.
26. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet.
2008;371(9606):75–84.
27. Abdelazim IA. Insulin-like growth factor binding protein-1 (Actim PROM test) for detection of
premature rupture of fetal membranes[J]. Journal of Obstetrics Gynaecology Research. 2014;40(4):7.
28. Jeurgens-Borst AJ, Bekkers RL, Sporken JM. Use of insulin like growth factor binding protein-1 in the
diagnosis of ruptured fetal membranes. Eur J Obstet Gynecol Reprod Biol. 2002;102:11–4., van der
Berg PP.
29. Buyukbayrak EE, Turan C, Unal O, Dansuk R, Cengizoglu B. Diagnostic power of the vaginal washing-
uid prolactin assay as an alternative method for the diagnosis of premature rupture of
membranes. J Matern Fetal Neonatal Med. 2004;15:120–5.
30. Tsakiridis I. Mamopoulos, et al. Preterm Premature Rupture of Membranes: A Review of 3 National
Guidelines. Obstet Gynecol Surv. 2018;73(6):368–75.
31. Di Renzo GC, Roura LC, Facchinetti F et al. Guidelines for the management of spontaneous preterm
labor: Identi cation of spontaneous preterm labor, diagnosis of preterm premature rupture of
membranes and preventive tools for preterm birth. J Matern Fetal Neonatal Med 2011; 24: 659–67.
32. El-Messidi A, Cameron A. Diagnosis of premature rupture of membranes: Inspiration from the past
and insights for the future. J Obstet Gynaecol Can. 2010;32:561–9.
33. Bantis LE, Nakas CT, Reiser B. Construction of con dence intervals for the maximum of the Youden
index and the corresponding cutoff point of a continuous biomarker. Biom J. 2019;61:1–19.
34. Chen x, Jin y. et al. Partial Youden index and its inferences. Journal of biopHarmaceutical statistics.
2018;28(5):1–15.
35. Witkin SS, Linhares IM, Giraldo P. Bacterial ora of the female genital tract. function immune
regulation. 2007;21(3):347– 354.
36. Lidbeck A, Nord CE. Lactobacilli and the normal human anaerobic micro ora. Clin Infect Dis.
1993;16(Suppl 4):181–7.
37. Hawes SE, Hillier SL, Benedetti J, Stevens CE, Koutsky LA, Wolner-Hanssen P. Hydrogen peroxide-
producing Lactobacilli and acquisition of vaginal infections. J Infect Dis. 1996;174(5):1058–63.
38. Read JS, Klebanoff MA. Sexual intercourse during pregnancy and preterm delivery: effects of vaginal
microorganism. The Vaginal infection and Prematurity Study Group. Am J Obstet Gynecol.
1993;168(2):514–9.

Page 12/13
39. Alexander JM, Mercer BM, Miodovnik M. et al. The impact of digital cervical examination on
expectantly managed preterm rupture of membranes. Am J Obstet Gynecol. 2000;183:1003–7.
40. Munson LA, Graham A, Koos BJ. et al. Is there a need for digital examination in patients with
spontaneous rupture of the membranes? Am J Obstet Gynecol. 1985;153:562–3.
41. Harvey BJ, Thomas W. Aldosteroneinduced protein kinase signalling and the control of electrolyte
balance. Steroids. 2018;133:67–74.
42. Liang H, Xie Z, Liu B. et al. A routine urine test has partial predictive value in premature rupture of the
membranes. J INT MED RES 2019; 47(6).

Page 13/13