PREMATURE RUPTURE OF MEMBRANES
Arda Lembet, MD Associate Professor
Femical Women’s Clinic Istanbul
Overview, clinical significance Diagnosis
Evaluation Management
> 37 weeks
34 - 36 6/7 weeks 32 - 33 6/7 weeks 23 - 31 6/7 weeks
< 23 weeks
PROM
PPROM Management - Special Circumstances
Cerclage HSV ,HIV
Membrane resealing
Amnioinfusion, amniopatch
Prevention of recurrent PPROM Multiple pregnancy
Hospital versus outpatient management
PROM: Premature rupture of membranes
PPROM: Preterm premature rupture of membranes
LATENCY: Interval from rupture of
membranes to onset of active
labor
Overview, clinical significance
Clinical chorioamnionitis % 13-60
Endometritis % 2-13
(+) AF culture % 25-35
Maternal sepsis % 1
Fetal loss % 1-2
Abruptio placenta % 4-12
PPROM
Pathophysiology:
Collagen remodeling, cellular apoptozis Ascending infection
Clinical risk factors :
Short cervix / incompetent cervix Cervicovaginal fetal fibronectin Abruption
Polyhydramnios / multiple gestation
PPROM
(PROM ) Clinical Risk Factors
Odds ratio
H /o PPROM 3.3-6.3
H / o PTL 1.9-2.8
Smoking 2.1
Vaginal bleeding during pregnancy
1.trimester 2.4
2. trimester 4.4
3. trimester 6.4
> 1 trimester 7.4
Acute pulmonary disease 1.8
Bacterial vaginosis 1.5
PROM Diagnosis
Clinical Diagnosis:
Tests : Alkaline pH > 6- 6.5 Ferning
Biochemical markers: (placental alpha microglobulin-1 (PAMG-1) IGFBP-1, fFN, AFP, fT4, prolactin, hCG, IL-6 )
USG: AFV ?, AS ?
PPROM Evaluation- I
Cultures: Cervical cultures; Neisseria gonorrhea, Chlamydia, anovaginal culture; GBS
Urinalysis / culture Digital exam: NO
NST: For how long?, intermittent monitoring
Clinical chorioamnionitis: Fever > 38 , uterine tenderness and / or maternal and fetal
tachycardia…..Delivery
PPROM Evaluation - II
Leucocytosis: WBC > 16,000
USG / Fetal Biophysical Profile Amniocentesis:
Gram stain, WBC >30 cell/microl,
glucose < 16-20, culture (aerobic-anaerobic, mycoplazma )
PPROM Evaluation - II
Amniotic Fluid Culture:
• Group B Streptococcus 20 %
• Gardnerella vaginalis 17 %
• Peptostreptococcus 11 %
• Fusobacteria 10%
• Bacteroides fragilis 9 %
• Other streptococci 9 %
• Bacteroides sp. 5 %
PPROM Evaluation - III
CERVICAL LENGTH
Cut-off level: 2-2.4 cm Latency period
Intraamniotic infection
How does it compare to WBC, CRP ??
PPROM Evaluation - IV
Fetal Lung Maturity Evaluation in Vaginal Pool
L/S Ratio Not Reliable
TDX: FLM Assay Not Validated
PG Useful
PPROM Evaluation - V
PPROM Management
Clinical chorioamnionitis
Nonreassuring fetal well being, Severe vaginal bleeding,
Advanced labor,
Pregnancy complications ( preeclampsia etc )
DELIVERY
PROM Management
Term > 37 weeks :
Infection : 12 h %2
12-24 %6
48 %24
Labor induction / augmentation:
Prostaglandin:
GBS: > 18 h prophylaxis, culture last 6 week > -
PPROM Management
Preterm: 34 - 36 6/7 weeks :
Corticosteroids ? Prolongation of latent phase ?
Since the risk of infection and umbilical cord accidents are higher than the risk of prematurity
….DELIVERY
PPROM Management 34-37 weeks
Chorioamnionitis should we care ?
Chorioamnionitis should we care ?
PPROM Management
Preterm: 32 - 33 6/7 weeks :
Lung maturation : Vaginal pooling / AS PG, FLM or L/S if mature…DELIVERY
Immature or can not be tested
Delivery after steroids (24-48 hours later or deliver
@34 weeks ) / Broad spectrum antibiotics
PPROM Management
Preterm: 23 - 31 6/7 weeks:
Fetal / maternal monitorization Antenatal corticosteroids :
Broad spectrum antibiotics:
Amp 2 g iv / q 6 h 48 h + eritro iv 250 mg q 6 Amoxocilin 250 mg po q 8 5 d + eritro 333 po q 6 Alternative; oral amp / eritro / azithro
PPROM Management
Preterm: 23 - 31 6/7 weeks :
The relation between broad spectrum ab and NEC ??
After 7 days of ab f/u patients for GBS carriers Stop ab, treat intrapartum
After 7 days give narrow spectrum ab until delivery
Follow by anovaginal cultures ; Treat if +
PPROM Management
Preterm: 23 - 31 6/7 weeks :
Consider Mg SO4 for neuroprotection if delivery < 32 weeks
PPROM Management
Preterm: 23 - 31 6/7 weeks : Daily NST / FBPP
WBC ?? Baseline
Cervicovaginal pathogen and UTI treatment USG, oligohydroamnios ??
Tocolysis, amnioinfusion
Thromboemboli prophylaxis
PPROM Management
Preterm: < 23 weeks :
Dating and confirmation of the gestational week High complication rate:
Chorioamnionitis % 39
Endometritis % 14
Abruption % 3
Placenta ret, PPH, D&C % 12 IUFD (fetal demise) % 15
PPROM Management
Preterm: < 23 weeks :
Oligohydramnios: < 20 weeks:
Poor prognostic parameter
Pulmonary hypoplasia ( TC / AC ) Skeletal deformities
Membrane resealing:
New treatment modalities: Gelfoam,fibrin-platelet-cryo-
NICHD Extremely Preterm Birth Outcome Data
NICHD Extremely Preterm Birth Outcome Data
PPROM Management - Special Circumstances
Cerclage: Should it be removed ? When ? HSV:
HIV:
Membrane resealing:
Amnioinfusion:
Prevention of recurrent PPROM:
Progesterone , Vitamin C , E?
Multiple pregnancy:
PPROM Management - Special Circumstances
Multiple pregnancy:
Incidence: 7-8 % Latency period
Survival , morbidity, sac differs ??
Antibiotics, steroids : Same as singletons Tocolysis, MgSO4: Same as singletons Delayed interval delivery ??
Selective fetocide ??
