#217 Prelabor Rupture of Membranes Flashcards
What % of pregnancies are affected by PPROM?
2-3%
What % of pregnancies are affected by PROM (at term)?
8%
What does PROM stand for?
Prelabor rupture of membranes
What is the definition of PROM?
Rupture of membranes before the onset of labor
True or false, intraamniotic infection has been shown to be commonly associated with PPROM?
True. Especially at earlier ages.
What are risk factors for PPROM?
PPROM in prior pregnancy, short cervix, 2nd and 3rd trimester bleeding, low BMI, low socioeconomic status, cigarette smoking, illicit drug use
What is the most significant maternal consequence of term PROM?
Intrauterine infection
Regardless of obstetric management or clinical presentation, what % of patients with PPROM deliver within 1 week of membrane rupture?
At least 50%
Latency after membrane rupture in PPROM is directly or inversely correlated with gestational age?
Inversely. Low GA = longer latency
True or false, cessation of LOF with restoration of normal AFI can occur in PPROM?
True, associated with favorable outcomes
Among women with PPROM, what % have clinically evidence intraamniotic infection?
15-35%
In women with PPROM, what % develop postpartum infection?
15-25%
Is the incidence of infection in PPROM higher or lower in earlier gestational ages?
Higher
What % of cases of PPROM are complicated by abruptio placentae?
2-5%
What is the most significant risk to a fetus after PPROM?
Prematurity/complications of prematurity
What are some risks to the PPROM fetus postnatally?
Respiratory distress, sepsis, intraventricular hemorrhage, necrotizing enterocolitis, risk of neurodevelopmental impairment, risk of neonatal white matter damage
What % of pregnancies are complicated by previable prelabor rupture of membranes?
<1%
In patient with previable PROM, is it more likely to have a stillbirth or neonatal death?
More or less equal
What are the neonatal survival rates in patients expectantly managed for previable PROM after 22 weeks compared to before 22 weeks?
57.7% compared to 14.4%
What are maternal complications after previable PROM?
Intraamniotic infection, endometritis, abruptio placentae, and retained placenta
What % of women with previable PROM experience significant morbidity?
14% (including sepsis, transfusion, hemorrhage, infection, acute renal injury, readmission)
Maternal sepsis is reported in what % of cases of previable PROM?
1-5%
What % of patients with previable PROM will give birth in first week? What % within 2-5 weeks after membrane rupture?
40-50% within first week and approximately 70-80% within 2-5 weeks
What is the rate of pulmonary hypoplasia after PPROM before 24 weeks?
Range 2-20%
Pulmonary hypoplasia 2/2 to PPROM occurring after what gestational age are rarely lethal? Why?
After 23-24 weeks of gestation. Presumably because alveolar growth adequate to support postnatal development already has occurred
What are the primary determinants of pulmonary hypoplasia in PPROM?
Early gestational age at membrane rupture and low residual amniotic fluid volume
What are fetal consequences of prolonged oligohydramnios after rupture of membranes?
Fetal deformations, including Potter-like facies (eg, low-set ears and epicanthal folds) and limb contractures or other positioning abnormalities, skeletal deformations
When should a digital exam be performed in someone with PROM? Why?
When patient appears to be in active labor or delivery seems imminent. Digital cervical exam increase risk of infection and add little information to results available from speculum exam
What physical exam findings confirm rupture of membranes?
Visualization of amniotic fluid passing from cervical canal and pooling in vagina, pH test of vaginal fluid, arborization (ferning) of dried vaginal fluid
What is the normal pH of amniotic fluid? Vaginal secretions?
Amniotic fluid 7.1-7.3. Vaginal secretions 3.8-4.5.
What can cause a false positive pH test for amniotic fluid?
Blood, semen, alkaline antiseptics, certain lubricants, trichomonas, bacterial vaginosis
What can cause a false-negative pH test for rupture of membranes?
Prolonged membrane rupture and minimal residual fluid
What additional tests may aid in diagnosis of rupture of membranes if physical exam is equivocal?
Ultrasound (AFI), fetal fibronectin (sensitive, not specific), commercial test for amniotic proteins; lastly can consider instillation of indigo carmine dye transabdominally with tampon or pad that is removed 20-30 minutes later
What are indications for immediately delivery in setting of PPROM?
Abnormal fetal testing, intraamniotic infection, placental abruption
What induction agent is associated with higher risk of chorioamnionitis in setting of PROM?
Vaginal prostaglandins
Can mechanical methods of cervical ripening be used in PROM?
Insufficient data to base firm recommendation, but concern for increasing risk of infection
What is the recommendation if someone is 37+ weeks and PROM?
Induction of labor
True or false, it is reasonable to offer expectant management to PROM patient at 37+ weeks?
True, only IF certain criteria met: reassuring fetal testing, GBS negative, patient counseled on risks of prolonged PROM and limitations of available data
What % of women will go into labor within 24 hours of PROM at term?
80-95%
True or false, in GBS positive women who come in with PROM you can wait until they are around 4 hours prior to delivery to start antibiotics?
False. Immediate administration
When can you call a failed induction in the setting of PROM on pitocin?
After a sufficient period of adequate contractions (at least 12-18 hours)
What are the risks/benefits of expectant management in PPROM from 34 to 36w6d compared to immediate delivery?
Lower rates of respiratory distress and mechanical ventilation, shorter NICU stay. Higher risk of maternal hemorrhage and infection (two-fold increase), lower risk CS. No change in neonatal sepsis or composite morbidity.
If proceeding with expectant management for PPROM between 34 and 36w6d, do you give latency antibiotics?
“Latency antibiotics are not appropriate in this setting”
True or false, previable PPROM can be managed outpatient?
True, after short period of observation to check for infection, abruption, etc. This option does have significant maternal risks.
Should 17-OH progesterone be used in patient with PPROM to extend latency?
No. No difference in outcomes
Is vaginal progesterone recommended for PPROM?
No. Theoretical risk of introducing infection. Lack of data for efficacy.
What is the role of tocolytics in PPROM?
Can consider use prior to 34wks for steroid benefit to neonate or maternal transport. Avoid in case of infection or abruption. Not recommended after 34 weeks
True or false, antenatal corticosteroids are associated with increased risk of infection in setting of PPROM?
False
When would you not give a course of antenatal corticosteroids to a patient with PPROM at 34-36 weeks?
If already received a course during pregnancy (no evidence for rescue in late preterm period) or if diagnosed with clinical chorioamnionitis
What outcomes have been associated with weekly antenatal corticosteroid use?
Reduction in birth weight and head circumference
Do corticosteroids increase risk of chorioamnionitits?
No
Does magnesium sulfate administration in the setting of PPROM increase latency?
No, does not appear to affect latency
Which patients with PPROM should receive magnesium sulfate for fetal neuroprotection?
Women with PPROM before 32w0d who are thought to be at risk of imminent delivery
What are the goal of antibiotics in the setting of PPROM?
Reduce maternal and neonatal infections and gestational-age-dependent morbidity
What is the recommended antibiotic regimen/alternate for PPROM?
IV ampicillin (2g q6h) and erythromycin (250mg q6h) for 48h followed by oral amoxicillin (250mg q8h) and erythromycin (333mg q8h) for 5 days. Can substitute azithromycin 1g once.
The use of what antibiotic in the setting of PPROM is associated with necrotizing enterocolitis?
Amoxicillin-clavulanic acid
What is the use of amoxicillin-clavulanic acid in setting of PPROM associated with?
Increased rates of necrotizing enterocolitis
True or false, GBS positive patients who already received latency antibiotics for PPROM do not need intrapartum antibiotics?
False, treat them
Should women with PPROM and a viable fetus be managed inpatient or outpatient? Previable PROM?
Inpatient, no studies have established safety of outpatient management. Previable PROM may be considered for home care after period of assessment in hospital
How should a patient with PPROM and a cervical cerclage be treated?
Either removal or retention of cerclage is reasonable (no strong data). Do no prolong antibiotic prophylaxis beyond 7 days.
What is the risk of vertical transmission with delivery in patient with subclinical shedding at time of labor as a result of having acquired genital HSV in 3rd trimester?
Between 30 and 50%
What is the risk of vertical transmission of HSV in labor in cases of maternal symptomatic reactivation?
3%
What is the recommendation in terms of delivery in patients with PPROM prior to 34wks with recurrent active HSV infection?
Expectant management prior to 34 weeks. And start antiviral therapy.
When would you offer cesarean section to a women with HSV without lesions?
Primary or nonprimary first-episode genital HSV infection during 3rd trimester, possibility of prolonged viral shedding. Patient with prodromal symptoms.
How should you manage PPROM in patient with HIV?
In addition to regular standard of care. Care needs to be individualized. Have HAART. Lower risk of transmission with low copy number.
What should be offered to women with previable PROM?
Expectant management vs immediate delivery (induction vs D&E), can offer outpatient management until viability
When should latency antibiotics be administered in the setting of previable PROM?
We are not sure. Can consider at time of rupture vs at viability (previous studies only enrolled people starting at 24 weeks)
What is the risk of PROM after amniocentesis?
<1%
What are the outcomes of previable PROM after amniocentesis?
More favorable than spontaneous PROM. Reaccumulation of normal AFI and favorable outcomes are expected (72% within 1 month; perinatal survival rate of 91%)
How should you manage a patient with a history of PPROM in prior pregnancy in new pregnancy?
Offer progesterone supplementation as clinically indicated
