Modern Management of Prolonged Rupture of Membranes

1. Modern Management of Prolonged Rupture of Membranes Joseph R. Biggio Jr., M.D. Department of Obstetrics & Gynecology Division of Maternal-Fetal Medicine University of Alabama at Birmingham

2. PROM Amniorrhexis prior to onset of active labor regardless of gestational age Premature Rupture of Membranes

3. PPROM Amniorrhexis < 37 weeks’ gestational age prior to onset of active labor Preterm Premature Rupture of Membranes

4. Latency Interval from Rupture of Membranes to Onset of Active Labor

5. Diagnosis • History • Avoid digital exam • Vaginal Pool • Nitrazine Paper • Ferning • Ultrasound • Amniocentesis/Dye Study

6. PROM near Term • Management gestational age dependent • Induction vs. awaiting spontaneous labor • Antibiotic prophylaxis per ACOG/CDC recommendations

7. Induction vs. Expectant Management • >5,000 women randomized • Oxytocin, PGE2 or expectant management up to 4 days • No difference in cesarean section or neonatal infection • Less chorioamnionitis in induction with oxytocin group Hannah, NEJM, 1996

8. Epidemiology of Preterm Birth PPROM 28 % Indicated Preterm Delivery Spontaneous Preterm Delivery 26 % 46 % Andrews, 1995

9. PPROMRisk Factors • Lower/Upper Genital Tract Infection • Proteases • Prostaglandins • History of PPROM • Incompetent Cervix • Abruption • Polyhydramnios • Multiple Gestation • Smoking

10. PPROMComplications • Maternal/Fetal Infection • Premature Labor and Delivery • Umbilical Cord Prolapse • Fetal Hypoxia 2º Cord Compression • Increased Rate of Cesarean Section • Intrauterine Growth Restriction • Abruption • Stillbirth

11. PPROMStandard Management • Confirmation of Diagnosis • Verification of Gestational Age • R/O Labor/Infection/Fetal Compromise • Avoid Digital Vaginal Examinations • In Hospital Observation • Bedrest

12. PPROMLatency 75 % Patients with Latency > 1 Week 50 25 0 Gestational Age (Weeks) Wilson, Obstetrics & Gynecology, 1982

13. PPROMVaginal Examination 20 No Exam Latency Days 15 10 5 Exam Gestational Age (Weeks) Lewis, Obstetrics & Gynecology, 1992

14. Previable PPROM • < 24 weeks • Poor prognosis for successful outcome • Outcome may be different for spontaneous vs. iatrogenic

15. Previable PPROMComplications • Uterine Infection • Pulmonary Hypoplasia • Limb Compression Deformities • Intrauterine Growth Restriction

16. Previable PPROMOutcomes

17. PPROMManagement Issues • Timing of Delivery • Tocolysis • Antibiotics • Steroids • Amniocentesis • Observation vs. Induction • Fetal Lung Maturity Testing • Fetal Surveillance

18. Timing of Delivery

19. Neonatal Morbidity/MortalityUAB (1995-1996) %

20. RNICU Survival and Morbidity Data (1995-1996) % Neonates

21. Tocolysis

22. PPROMTocolysis Weiner, AJOG, 1988

23. PPROMTocolysis Garite, AJOG, 1987

24. Antibiotics

25. 75 50 Spontaneous Preterm Labor % Patients Colonized 25 Indicated 0 £ 30 weeks 31- 34 weeks 34- 36 weeks ³ 37 weeks Preterm LaborChorioamnion Colonization Cassell, 1993

26. PPROMAntibiotic Therapy • Reduction Maternal/Perinatal Infection • Prolong Latency Period • Improve Neonatal Outcome

27. Antibiotic: PPROMNIH-MFM Network Study • PPROM between 24 and 32 weeks • IV ampicillin and erythromycin for 48 h • Oral amoxicillin/erythromycin for 5 days • Identification and Rx of GBS carriers • Tocolysis and corticosteroids prohibited Mercer, JAMA, 1997

28. Antibiotic: NIH-MFM Network Study Neonatal Morbidity * * *

29. Antibiotic: Latency PeriodNIH-MFM Network Study

30. PPROMAntibiotic Therapy • Optimal Antibiotic Regimen • Route/Duration of Administration

31. Antibiotics & PPROM: Summary • Reduction in maternal infectious morbidity • Reduction in births <48 h and <7 d • Reduction in neonatal infectious morbidity • Reduction in neonates requiring NICU and ventilation >28 d Kenyon, Cochrane Library, 1999

32. Antibiotics & PPROM: Summary • No clear reduction in perinatal death • No clear reduction in cerebral abnormalities Kenyon, Cochrane Library, 1999

33. Amniocentesis

34. PPROMAmniotic Fluid Culture • Group B Streptococcus 20 % • Gardnerella vaginalis 17 % • Peptostreptococcus 11 % • Fusobacteria 10 % • Bacteroides fragilis 9 % • Other Streptococci 9 % • Bacteroides sp. 5 %

35. Utility of Amniocentesis • Confirm/Refute diagnosis of chorioamnionitis • Glucose <15 mg/dL • Culture • Gram stain • Lung maturity testing

36. Corticosteroids

37. Corticosteroids for FLM • Betamethasone • Dexamethasone

38. Number of Patients Effect on RDS Author Steroids Control Block Taeusch Papageorgiou Young Garite Collaborative Iams Nelson Simpson Morales 43 17 17 38 80 153 38 22 112 121 26 24 19 37 80 135 35 46 105 124 PPROMCorticosteroids

39. PPROMCorticosteroids * Crowley, Ob/Gyn Clinics, 1992

40. PPROMCorticosteroids + Antibiotics * Lewis, Obstetrics & Gynecology, 1996

41. 1994 NIH Consensus Conference:Corticosteroids in PPROM • Corticosteroids reduce incidence/severity of RDS, IVH • Benefits in PPROM up to 30-32 weeks • No significant adverse outcomes for corticosteroid use in PPROM • Impact less than with intact membranes

42. Observation vs. Induction

43. Neonatal Morbidity/MortalityUAB (1995-1996) %

44. PPROMObservation vs. Induction * * Mercer, AJOG, 1993

45. PPROMObservation vs Induction Cox, Obstetrics & Gynecology, 1995

46. Fetal Lung Maturity Testing

47. 8 10 8 6 PI 6 L:S Ratio 4 % Phospholipid L:S 4 2 2 PG 0 0 20 24 28 32 36 40 Gestational Age (weeks) Fetal Lung MaturationBiologic Markers

48. Fetal Lung Maturity Evaluation in Vaginal Pool Specimen • L:S Ratio Not Reliable • TDX:FLM Assay Not Validated • PG Useful

49. Fetal Surveillance

50. PPROMFetal Surveillance • Daily Non-Stress Test (NST) • Variables • Tachycardia • Loss of reactivity • Biophysical Profile (BPP) • Contraction Stress Test (CST)