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Practice bulletins > #217 Prelabor Rupture of Membranes > Flashcards

#217 Prelabor Rupture of Membranes Flashcards

1
Q

What % of pregnancies are affected by PPROM?

A

2-3%

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2
Q

What % of pregnancies are affected by PROM (at term)?

A

8%

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3
Q

What does PROM stand for?

A

Prelabor rupture of membranes

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4
Q

What is the definition of PROM?

A

Rupture of membranes before the onset of labor

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5
Q

True or false, intraamniotic infection has been shown to be commonly associated with PPROM?

A

True. Especially at earlier ages.

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6
Q

What are risk factors for PPROM?

A

PPROM in prior pregnancy, short cervix, 2nd and 3rd trimester bleeding, low BMI, low socioeconomic status, cigarette smoking, illicit drug use

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7
Q

What is the most significant maternal consequence of term PROM?

A

Intrauterine infection

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8
Q

Regardless of obstetric management or clinical presentation, what % of patients with PPROM deliver within 1 week of membrane rupture?

A

At least 50%

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9
Q

Latency after membrane rupture in PPROM is directly or inversely correlated with gestational age?

A

Inversely. Low GA = longer latency

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10
Q

True or false, cessation of LOF with restoration of normal AFI can occur in PPROM?

A

True, associated with favorable outcomes

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11
Q

Among women with PPROM, what % have clinically evidence intraamniotic infection?

A

15-35%

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12
Q

In women with PPROM, what % develop postpartum infection?

A

15-25%

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13
Q

Is the incidence of infection in PPROM higher or lower in earlier gestational ages?

A

Higher

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14
Q

What % of cases of PPROM are complicated by abruptio placentae?

A

2-5%

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15
Q

What is the most significant risk to a fetus after PPROM?

A

Prematurity/complications of prematurity

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16
Q

What are some risks to the PPROM fetus postnatally?

A

Respiratory distress, sepsis, intraventricular hemorrhage, necrotizing enterocolitis, risk of neurodevelopmental impairment, risk of neonatal white matter damage

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17
Q

What % of pregnancies are complicated by previable prelabor rupture of membranes?

A

<1%

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18
Q

In patient with previable PROM, is it more likely to have a stillbirth or neonatal death?

A

More or less equal

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19
Q

What are the neonatal survival rates in patients expectantly managed for previable PROM after 22 weeks compared to before 22 weeks?

A

57.7% compared to 14.4%

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20
Q

What are maternal complications after previable PROM?

A

Intraamniotic infection, endometritis, abruptio placentae, and retained placenta

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21
Q

What % of women with previable PROM experience significant morbidity?

A

14% (including sepsis, transfusion, hemorrhage, infection, acute renal injury, readmission)

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22
Q

Maternal sepsis is reported in what % of cases of previable PROM?

A

1-5%

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23
Q

What % of patients with previable PROM will give birth in first week? What % within 2-5 weeks after membrane rupture?

A

40-50% within first week and approximately 70-80% within 2-5 weeks

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24
Q

What is the rate of pulmonary hypoplasia after PPROM before 24 weeks?

A

Range 2-20%

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25
Q

Pulmonary hypoplasia 2/2 to PPROM occurring after what gestational age are rarely lethal? Why?

A

After 23-24 weeks of gestation. Presumably because alveolar growth adequate to support postnatal development already has occurred

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26
Q

What are the primary determinants of pulmonary hypoplasia in PPROM?

A

Early gestational age at membrane rupture and low residual amniotic fluid volume

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27
Q

What are fetal consequences of prolonged oligohydramnios after rupture of membranes?

A

Fetal deformations, including Potter-like facies (eg, low-set ears and epicanthal folds) and limb contractures or other positioning abnormalities, skeletal deformations

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28
Q

When should a digital exam be performed in someone with PROM? Why?

A

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

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29
Q

What physical exam findings confirm rupture of membranes?

A

Visualization of amniotic fluid passing from cervical canal and pooling in vagina, pH test of vaginal fluid, arborization (ferning) of dried vaginal fluid

30
Q

What is the normal pH of amniotic fluid? Vaginal secretions?

A

Amniotic fluid 7.1-7.3. Vaginal secretions 3.8-4.5.

31
Q

What can cause a false positive pH test for amniotic fluid?

A

Blood, semen, alkaline antiseptics, certain lubricants, trichomonas, bacterial vaginosis

32
Q

What can cause a false-negative pH test for rupture of membranes?

A

Prolonged membrane rupture and minimal residual fluid

33
Q

What additional tests may aid in diagnosis of rupture of membranes if physical exam is equivocal?

A

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

34
Q

What are indications for immediately delivery in setting of PPROM?

A

Abnormal fetal testing, intraamniotic infection, placental abruption

35
Q

What induction agent is associated with higher risk of chorioamnionitis in setting of PROM?

A

Vaginal prostaglandins

36
Q

Can mechanical methods of cervical ripening be used in PROM?

A

Insufficient data to base firm recommendation, but concern for increasing risk of infection

37
Q

What is the recommendation if someone is 37+ weeks and PROM?

A

Induction of labor

38
Q

True or false, it is reasonable to offer expectant management to PROM patient at 37+ weeks?

A

True, only IF certain criteria met: reassuring fetal testing, GBS negative, patient counseled on risks of prolonged PROM and limitations of available data

39
Q

What % of women will go into labor within 24 hours of PROM at term?

A

80-95%

40
Q

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?

A

False. Immediate administration

41
Q

When can you call a failed induction in the setting of PROM on pitocin?

A

After a sufficient period of adequate contractions (at least 12-18 hours)

42
Q

What are the risks/benefits of expectant management in PPROM from 34 to 36w6d compared to immediate delivery?

A

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.

43
Q

If proceeding with expectant management for PPROM between 34 and 36w6d, do you give latency antibiotics?

A

“Latency antibiotics are not appropriate in this setting”

44
Q

True or false, previable PPROM can be managed outpatient?

A

True, after short period of observation to check for infection, abruption, etc. This option does have significant maternal risks.

45
Q

Should 17-OH progesterone be used in patient with PPROM to extend latency?

A

No. No difference in outcomes

46
Q

Is vaginal progesterone recommended for PPROM?

A

No. Theoretical risk of introducing infection. Lack of data for efficacy.

47
Q

What is the role of tocolytics in PPROM?

A

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

48
Q

True or false, antenatal corticosteroids are associated with increased risk of infection in setting of PPROM?

A

False

49
Q

When would you not give a course of antenatal corticosteroids to a patient with PPROM at 34-36 weeks?

A

If already received a course during pregnancy (no evidence for rescue in late preterm period) or if diagnosed with clinical chorioamnionitis

50
Q

What outcomes have been associated with weekly antenatal corticosteroid use?

A

Reduction in birth weight and head circumference

51
Q

Do corticosteroids increase risk of chorioamnionitits?

A

No

52
Q

Does magnesium sulfate administration in the setting of PPROM increase latency?

A

No, does not appear to affect latency

53
Q

Which patients with PPROM should receive magnesium sulfate for fetal neuroprotection?

A

Women with PPROM before 32w0d who are thought to be at risk of imminent delivery

54
Q

What are the goal of antibiotics in the setting of PPROM?

A

Reduce maternal and neonatal infections and gestational-age-dependent morbidity

55
Q

What is the recommended antibiotic regimen/alternate for PPROM?

A

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.

56
Q

The use of what antibiotic in the setting of PPROM is associated with necrotizing enterocolitis?

A

Amoxicillin-clavulanic acid

57
Q

What is the use of amoxicillin-clavulanic acid in setting of PPROM associated with?

A

Increased rates of necrotizing enterocolitis

58
Q

True or false, GBS positive patients who already received latency antibiotics for PPROM do not need intrapartum antibiotics?

A

False, treat them

59
Q

Should women with PPROM and a viable fetus be managed inpatient or outpatient? Previable PROM?

A

Inpatient, no studies have established safety of outpatient management. Previable PROM may be considered for home care after period of assessment in hospital

60
Q

How should a patient with PPROM and a cervical cerclage be treated?

A

Either removal or retention of cerclage is reasonable (no strong data). Do no prolong antibiotic prophylaxis beyond 7 days.

61
Q

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?

A

Between 30 and 50%

62
Q

What is the risk of vertical transmission of HSV in labor in cases of maternal symptomatic reactivation?

A

3%

63
Q

What is the recommendation in terms of delivery in patients with PPROM prior to 34wks with recurrent active HSV infection?

A

Expectant management prior to 34 weeks. And start antiviral therapy.

64
Q

When would you offer cesarean section to a women with HSV without lesions?

A

Primary or nonprimary first-episode genital HSV infection during 3rd trimester, possibility of prolonged viral shedding. Patient with prodromal symptoms.

65
Q

How should you manage PPROM in patient with HIV?

A

In addition to regular standard of care. Care needs to be individualized. Have HAART. Lower risk of transmission with low copy number.

66
Q

What should be offered to women with previable PROM?

A

Expectant management vs immediate delivery (induction vs D&E), can offer outpatient management until viability

67
Q

When should latency antibiotics be administered in the setting of previable PROM?

A

We are not sure. Can consider at time of rupture vs at viability (previous studies only enrolled people starting at 24 weeks)

68
Q

What is the risk of PROM after amniocentesis?

A

<1%

69
Q

What are the outcomes of previable PROM after amniocentesis?

A

More favorable than spontaneous PROM. Reaccumulation of normal AFI and favorable outcomes are expected (72% within 1 month; perinatal survival rate of 91%)

70
Q

How should you manage a patient with a history of PPROM in prior pregnancy in new pregnancy?

A

Offer progesterone supplementation as clinically indicated

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