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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. PROM. Amniorrhexis prior to onset of active labor regardless of gestational age.
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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
PROM Amniorrhexis prior to onset of active labor regardless of gestational age Premature Rupture of Membranes
PPROM Amniorrhexis < 37 weeks’ gestational age prior to onset of active labor Preterm Premature Rupture of Membranes
Latency Interval from Rupture of Membranes to Onset of Active Labor
Diagnosis • History • Avoid digital exam • Vaginal Pool • Nitrazine Paper • Ferning • Ultrasound • Amniocentesis/Dye Study
PROM near Term • Management gestational age dependent • Induction vs. awaiting spontaneous labor • Antibiotic prophylaxis per ACOG/CDC recommendations
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
Epidemiology of Preterm Birth PPROM 28 % Indicated Preterm Delivery Spontaneous Preterm Delivery 26 % 46 % Andrews, 1995
PPROMRisk Factors • Lower/Upper Genital Tract Infection • Proteases • Prostaglandins • History of PPROM • Incompetent Cervix • Abruption • Polyhydramnios • Multiple Gestation • Smoking
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
PPROMStandard Management • Confirmation of Diagnosis • Verification of Gestational Age • R/O Labor/Infection/Fetal Compromise • Avoid Digital Vaginal Examinations • In Hospital Observation • Bedrest
PPROMLatency 75 % Patients with Latency > 1 Week 50 25 0 Gestational Age (Weeks) Wilson, Obstetrics & Gynecology, 1982
PPROMVaginal Examination 20 No Exam Latency Days 15 10 5 Exam Gestational Age (Weeks) Lewis, Obstetrics & Gynecology, 1992
Previable PPROM • < 24 weeks • Poor prognosis for successful outcome • Outcome may be different for spontaneous vs. iatrogenic
Previable PPROMComplications • Uterine Infection • Pulmonary Hypoplasia • Limb Compression Deformities • Intrauterine Growth Restriction
PPROMManagement Issues • Timing of Delivery • Tocolysis • Antibiotics • Steroids • Amniocentesis • Observation vs. Induction • Fetal Lung Maturity Testing • Fetal Surveillance
PPROMTocolysis Weiner, AJOG, 1988
PPROMTocolysis Garite, AJOG, 1987
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
PPROMAntibiotic Therapy • Reduction Maternal/Perinatal Infection • Prolong Latency Period • Improve Neonatal Outcome
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
PPROMAntibiotic Therapy • Optimal Antibiotic Regimen • Route/Duration of Administration
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
Antibiotics & PPROM: Summary • No clear reduction in perinatal death • No clear reduction in cerebral abnormalities Kenyon, Cochrane Library, 1999
PPROMAmniotic Fluid Culture • Group B Streptococcus 20 % • Gardnerella vaginalis 17 % • Peptostreptococcus 11 % • Fusobacteria 10 % • Bacteroides fragilis 9 % • Other Streptococci 9 % • Bacteroides sp. 5 %
Utility of Amniocentesis • Confirm/Refute diagnosis of chorioamnionitis • Glucose <15 mg/dL • Culture • Gram stain • Lung maturity testing
Corticosteroids for FLM • Betamethasone • Dexamethasone
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
PPROMCorticosteroids * Crowley, Ob/Gyn Clinics, 1992
PPROMCorticosteroids + Antibiotics * Lewis, Obstetrics & Gynecology, 1996
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
PPROMObservation vs. Induction * * Mercer, AJOG, 1993
PPROMObservation vs Induction Cox, Obstetrics & Gynecology, 1995
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
Fetal Lung Maturity Evaluation in Vaginal Pool Specimen • L:S Ratio Not Reliable • TDX:FLM Assay Not Validated • PG Useful
PPROMFetal Surveillance • Daily Non-Stress Test (NST) • Variables • Tachycardia • Loss of reactivity • Biophysical Profile (BPP) • Contraction Stress Test (CST)