Columbus: PROM and chorioamnionitis Flashcards
What is the incidence of preterm PROM?
PPROM complicates what percentage of preterm births?
3%
33%
Define PROM.
What is the prevalence?
Rupture of amniotic membranes before the onset of labor
8%
What are risk factors for PROM?
Preterm labor Intra-amniotic infection History of preterm PROM (13–32% recurrence risk) Short cervical length Second or third trimester bleeding Low BMI Low SES Cigarette smoking Illicit drug use
What are possible causes of false positive nitrazine paper testing?
Blood, semen, alkaline antiseptics, bacterial vaginosis
What is the protein detected with AmniSure testing?
Placental Alpha microglobulin-1 protein
What workup should be performed after diagnosis of PROM?
NST
GC and chlamydia cultures
GBS
WBC
What does ACOG recommend regarding term PROM?
Immediate induction of labor at the time of presentation, generally with oxytocin, to reduce the risk of chorioamnionitis
What percentage of women with term PROM will go into labor within 5 hours?
Within 28 hours?
50%
95%
What percentage of women with PPROM will deliver within one week?
At least 50%
What percentage of women with PPROM will develop intra-amniotic infection?
Postpartum endometritis?
Abruption?
Antenatal fetal demise?
15-25%
15-20%
2-5%
1-2%
What are complications of prematurity?
Respiratory distress Necrotizing enterocolitis Intraventricular hemorrhage Thermal instability Hypoglycemia Hyperbilirubinemia PDA Apnea/bradycardia
Why is inpatient hospitalization recommended for PPROM?
For immediate neonatal care
To facilitate expeditious delivery for abruption, intrauterine infection, fetal compromise, and cord prolapse or compression
When should GBS prophylaxis be given in the setting of PPROM?
Unknown culture status
Rupture of membranes greater than 18 hours
Fever greater than 100.4°F
What is the purpose of antibiotics for PPROM?
How has this been shown to affect neonatal outcome?
To prolong latency in the short-term
Studies to date show prolongation of pregnancy without improvement in neonatal outcome.
What does ACOG recommend regarding tocolysis after contractions have started?
Therapeutic tocolysis is not recommended as of 2013
How should fetal surveillance during PPROM be performed?
NST, BPP
Fetal breathing is the most predictive parameter of BPP for infection.
What signs suggest infection secondary to PPROM?
Tachycardia, fever, fundal tenderness, labor
Elevated WBC
Amniotic fluid with glucose < 20 mg/dL, positive Gram stain, positive culture, increased WBC, increased IL-6
What does ACOG say regarding antenatal steroids in the setting of PPROM?
They should be given between 24 and 32 weeks if no evidence of chorioamnionitis. Most centers give a single course up to 34 weeks 0 days if no evidence of chorioamnionitis.
What is the impact of PPROM in the setting of genital HSV?
How should this be managed?
There may be an increased risk of neonatal HSV.
Prophylactic antiviral agents should be considered if lesions are present at PPROM. Cesarean section is still recommended if lesions are present at the timing of delivery.
What antibiotics and dosing are recommended for PPROM?
Ampicillin 2 g IV Q6 hours for 48 hours, then amoxicillin 250 mg PO Q8 hours for 5 days.
Erythromycin 250 mg IV Q6 hours for 48 hours, then erythrothromycin 333 mg PO Q8 hours for 5 days.
Azithromycin may be better tolerated.
How should PPROM less than 32 weeks be managed?
Expectant management if no contraindication
Single course of corticosteroid. ACOG says insufficient evidence to recommend rescue course.
Latency antibiotics
Magnesium sulfate for neuroprotection
What are the greatest risks to the fetus of expectant management of PPROM after 34w0d?
Infection and cord prolapse
How is mid trimester PROM defined?
What is the incidence?
PPROM less than 26 weeks
0.7% of pregnancies
What percentage of women with mid trimester PPROM deliver within one week?
What percentage deliver within 28 days?
50%
88%
What features of PPROM before 26 weeks provide better prognosis?
Which provide a poorer prognosis?
After amniocentesis, AFI > 2 cm, after 24 weeks (50% survival)
Elevated AFP and bleeding, AFI < 2 cm, before 20 weeks (20% survival)
What is the rate of abruption with PPROM before 20 weeks?
Cord prolapse?
Fetal demise?
50%
2%
10%
What does ACOG say regarding PPROM and cerclage?
The optimal management is yet to be determined. It is reasonable to consider leaving the cerclage in place for very early PPROM (< 28 weeks).
What bacteria are typically involved with chorioamnionitis?
Bacteroides, Prevotella, E. coli, group B streptococci
All from ascending infection from normal vaginal flora
What is the incidence of chorioamnionitis?
How does this change in preterm delivery?
1-5%
Increases to nearly 25%
What are risk factors for chorioamnionitis?
Young age, low SES, nulliparity, prolonged labor, prolonged PROM, multiple vaginal exams, pre-existing infection
What are clinical findings of chorioamnionitis?
Fever, maternal or fetal tachycardia, uterine tenderness, purulent amniotic fluid
Increased WBC, decreased amniotic fluid glucose, increased amniotic fluid IL-6, positive amniotic fluid leukocyte esterase, positive Gram stain or culture of amniotic fluid
What are maternal complications of chorioamnionitis?
Neonatal complications?
Bacteremia 10%, wound infection with C-section 8%, pelvic abscess 1%, dysfunctional labor, increased need for induction, increased risk of C-section
Pneumonia 5-10%, bacteremia 5%, meningitis 1%
What is the drug treatment and dosage typically used for chorioamnionitis?
How would you substitute the ampicillin for penicillin allergic patients?
Ampicillin 2 g IV Q6 hours
Gentamicin 1.5 mg/kg IV Q8 hours
Clindamycin 900 mg Q8 hours or vancomycin 500 mg Q6 hours or erythromycin 1 g Q6 hours
What anabiotic treatment is added for chorioamnionitis at cesarean section?
Clindamycin 900 mg Q8 hours or metronidazole 500 mg Q 12 hours
How long should chorioamnionitis treatment be maintained?
Until afebrile and asymptomatic for 24 hours. Patients should not need oral antibiotics.
What are the maternal complications of pre-viable PPROM?
Intra-amniotic infection, endometritis, abruption, retained placenta, maternal sepsis 1%.
What is the incidence of pre-viable PPROM?
What is the survival rate PPROM after 22 weeks?
Before 22 weeks?
Less than 1%
- 7%.
- 4%
What percentage of women with pre-viable PPROM deliver within the first week?
What percentage give birth 2-5 weeks after rupture?
40-50%
70-80%
What is the rate of fetal pulmonary hypoplasia in PPROM before 24 weeks?
10-20%
What are the fetal consequences of weekly antenatal steroids administration?
Reduced birthweight and head circumference.
What is ACOG say about PPROM managed at home?
Insufficiently studied for safety and is therefore not recommended.
Why is amoxicillin-clavulanic acid (Augmentin) not recommended as a latency antibiotic?
Increased rate of necrotizing enterocolitis.
What is the risk PPROM at second trimester amniocentesis?
How often does re-accumulation of normal amniotic fluid fluid occur?
What is perinatal survival rate?
1%
72%
91%
