PPROM Defination
– PROM: rupture membrane after 37 wk& before the onset of uterine contractions.
– PPROM: rupture membrane before 37 wk. It is the single most common identifiable factor associated with preterm delivery.
PPROM Diagnosis
1. History of a sudden gush of clear or pale yellow fluid from the vagina, PLUS
2. Sterile Speculum showing pooling of fluid in the posterior vaginal fornix. If amniotic fluid is not visible, ask the woman to push on her fundus, do Valsalva or cough to provoke leakage of AF from the cervical os.
– Laboratory tests can be used to confirm the diagnosis when you are uncertain. Nitrazine test which detect the pH of liquor or vaginal fluid is the most widely used (AF is alkaline, pH 7.0-7.3).
– Commercial tests like ROM Plus: it can diagnose ROM by detection of 2 protein
markers found in AF: placental protein 12 & alpha-fetoprotein (AFP).
– Don’t do V/E, only do if patient is highly suspicious to be in labor to avoid the risk of infection that can accelerate the preterm labor.
– U/S may confirm the diagnosis if there is oligohydraminous.
PPROM Course
– The majority of pregnancies with PPROM deliver within 1 wk of membrane rupture.
– The 3 causes of neonatal death are prematurity, sepsis & lung hypoplasia.
– The incidence of chorioamnionitis is higher at earlier GA.
PPROM Managament From 23wk Till 37wk
Hospitalization
– Hospitalization of women with PPROM who have a viable fetus from the time of diagnosis until delivery is recommended with few exceptions.
– Activity should be limited to using the bathroom & sitting up in a bedside chair with thromboprophylaxis.
– Further studies are needed to determine the safety of outpatient management.
Maternal Monitoring
– For signs of infection: monitor maternal temperature, pulse, & FHR every 4-8 hours.
– Periodically monitoring of WBCs & CRP has not proven to be useful.
Fetal Monitoring
– kick counts, CTG & biophysical profile (BPP): all have limited value in diagnosing infection.
Corticosteroids:
for pregnancies between 23-34 wk.
– It decrease neonatal death, RDS, intraventricular hemorrhage (IVH) & necrotizing enterocolitis (NEC).
– A single rescue course (2 doses of 12 mg betamethasone or 4 doses of 6 mg dexamethasone) may be considered with caution in pregnancies where the initial course was given at <26 wk& there is another obstetric indication arises later in pregnancy.
– Multiple courses of steroids are not recommended as it may lead to possible harmful effects including growth delay & brain developmental delay.
Prophylactic Antibiotic
– Reduces maternal & neonatal morbidity, delays delivery, allowing sufficient time for corticosteroids to take effect.
– Amoxicillin-clavulanate (Augmentin) is ass. with increased risk of neonatal necrotizing enterocolitis.
– RCOG recommends Erythromycin for 10 days following the diagnosis of PPROM. If group B streptococcus is isolated, give penicillin or clindamycin in women who are allergic to penicillin.
– NICHD & MFMU recommend:
… Azithromycin 1 gm oral upon admission, PLUS
… Ampicillin 2 gm IV every 6 hr for 2 days, FOLLOWED BY … Amoxicillin 500 mg oral 3 times daily for an additional 5 days.
This regimen cover Urea plasmas, Chlamydia & GBS.
Chemoprophylaxis for GBS
– Group B streptococcus (Streptococcus agalactiae) is recognised as the most frequent cause of severe early onset (<7 days of age) infection in newborn infants.
– Chemoprophylaxis for GBS is indicated if GBS test is positive or unknown & delivery is imminent, but not given to women with recent (within 5 wk) negative GBS test.
– The NICHD regimen described above cover GBS already. After completion of this regimen, antibiotics should be discontinued if patient is not in labor. If the patient’s GBS culture is positive, specific prophylaxis for GBS should be resumed when the patient subsequently goes into labor.
– RCOG recommendbenzylpenicillin 3 gm IV as soon as possible after the onset of labour&1.5 gm 4-hourly until delivery. If patient is allergic to penicillin, give clindamycin 900 mg IV 8-hourly.
Tocolysis
– As a general rule, tocolytics shouldn’t be administered for >48 hours, advanced labor (>4 cm) or any findings suggestive of subclinical or overt chorioamnionitis.
– It is given for women with PPROM & uterine activity who require antenatal steroids.
– Do not offer prophylactic tocolysis if there is no uterine activity.
Special Situations
– Women with HSV, HIV or cerclage: expectant management is controversial ???
– Meconium stained liquor: meconium release predisposes to infection by enhancing the growth of bacteria. So, these women should be evaluated for signs of chorioamnionitis. In the absence of these signs, meconium alone is not an indication for intervention.
-Tissue sealants :
(See comment down)
– Amnioinfusion: still under research evaluation.
Overt Chorioamnionitis
– Diagnosed clinically by maternal fever especially when ass. with leukocytosis, maternal & fetal tachycardia, uterine tenderness +/- malodorous AF.
– They should receive targeted antibiotics rather than the prophylactic antibiotics used above.
Delivery
– For PPROM <34 wk, RCOG recommend conservative management & delivery at 34 wk.
– For PPROM between 34-37 wk, ACOG & RCOG suggest delivery dt.the high risk of infection.
– According to ACOG, in pregnancies ≥34 wk, discuss the advantages & disadvantages of delivery versus expectant management with the patient.
– Expeditious delivery of women with PPROM is appropriate in the case of intrauterine infection, abruptio placentae or non-reassuring CTG particularly after 32 wk.
– MgSO4 is administered prior to delivery for fetal neuroprotection for pregnancies between 24-32 wk, for women at risk of imminent delivery.
– CS is performed for standard indications; otherwise, labor is induced.
What is the dose of MgSO4 for neuroprotection
– We administer MgSO4 to women whom we believe will deliver within 24 hours.
– Dose: 4 gm loading over 20 minutes & a maintenance dose of 1 gm/hour.
– Every effort should be made to reserve therapy for women who are at high risk of imminent delivery rather than women who are simply diagnosed with threatened preterm labor or PPROM without preterm labor.
– For women who will undergo scheduled CS, we administer the loading dose & then initiate maintenance therapy 6-12 hour prior to the scheduled surgery.
– If emergency or expeditious delivery is indicated because of maternal or fetal status, it should not be delayed to administer MgSO4.
– If induction of labor is likely to take >24 hours, it is reasonable to delay administration until cervical ripening is achieved & delivery is more proximate since we do not administer MgSO4 for >24 hours.
– MgSO4 is discontinued when the infant is delivered.
– We limit the MgSO4 infusion to a maximum of 24 hours, even if delivery has not occurred.
– We do not administer more than one course of magnesium sulfate for neuroprotection.