GTG - 73 - Care of women presenting with suspected Preterm prelabour rupture of membranes from 24 weeks of gestation.

Question 1

PPROM complications up to what % of pregnancies

Answer 1

3%

Question 1

A combination of clinical assessment and 1) which blood tests and 2) which other parameter should be used to diagnose chorioamnionitis in women with PPROM.

Answer 1

WCC, CRP AND fetal heart rate.
None of these should be used in isolation.

Question 2

PPROM is associated with what % of preterm births

Answer 2

30-40%

Question 3

What is the median latency after PPROM?

Answer 3

7 days - tends to shorten as gestational age at PPROM advances

Question 4

What is the gold standard for diagnosis of PPROM?

Answer 4

Maternal history followed by sterile speculum examination demonstrating liquor.

Question 5

If on speculum no amniotic fluid is observed. What tests could clinicians consider?

Answer 5

IGFBP-1 or PAMG-1 test of vaginal fluid.

Question 6

What is the role of US assessment of amniotic fluid volume in diagnosis of PPROM

Answer 6

It is unclear.

Question 7

What are the symptoms of clinical chorioamnionitis that women should be advised of and observed for?

Answer 7

Lower abdominal pain, abnormal vaginal discharge, fever, malaise and reduced fetal movements.

Question 8

Aside from symptoms which other parameters should be observed when clinically assessing for chorioamnionitis?

Answer 8

Pulse, blood pressure, temperature and fetal CTG.

Question 9

Following administration of steroids when should the WCC return to baseline?

Answer 9

3 days following administration

Question 10

Following administration of steroids when will the WCC rise?

Answer 10

24hrs after administration.

Question 11

Which maternal serum marker is most informative for predicting histological chorioamnionitis after PPROM?

Answer 11

CRP

Question 12

For diagnosing histological chorioamnionitis after PPROM what is the sensitivity and specificity of CRP

Answer 12

sensitivity 68.7% and specificity 77.1%

Question 13

When caring for a woman with PPROM as an outpatient what does the RCOG advise regarding frequency of reviews

Answer 13

One to two times each week.
bloods tests, observations and FHR monitoring.

Question 14

How long should antibiotics be given following diagnosis of PPROM?

Answer 14

erythromycin should be given for 10 days or until the woman is in established labour. (whichever is sooner)

Question 15

From a cochrane review what are the benefits of antibiotics following diagnosis of PPROM?

Answer 15

Reduced chorioamnionitis, prolonged latency and improved neonatal outcomes

Question 16

From the cochrane review what is the RR reduction in chorioamnionitis with antibiotics in PPROM?

Answer 16

RR 0.66

Question 17

What are the neonatal outcomes that are improved with use of antibiotics in PPROM?

Answer 17

Reduction in babies born within 48 hours and 7 days.
Neonatal infection
Surfactant use
Oxygen therapy
Abnormal cerebral ultrasound prior to discharge.

Question 18

Which outcomes did NOT see a significant improvement with antibiotic use in PPROM?

Answer 18

There was no improvement in perinatal mortality or on the health of the children at 7 years of age.

Question 19

Which group of antibiotics may be used in women who cannot tolerate erythromycin for PPROM

Answer 19

Penicillin

Question 20

Which antibiotic should be avoided in PPROM

Answer 20

co-amoxiclav - due to the association with neonatal necrotising enterocolitis.

Question 21

AN steroids with PPROM between 34-35+6?

Answer 21

Given the high number needed to treat and the potential side effects of steroids administration should be evaluated on an individual basis.

Question 22

What is the RR reduction of cerebral palsy following MgSO4 administration?

Answer 22

0.69

Question 23

What was the demonstrated effect of tocolysis in PPROM.

Answer 23

An average 73 hours latency of delivery and fewer births within 48 hours, however
Increased risk of 5 min APGAR score less than 7 and an increased need for ventilation support.
For women before 34 weeks tocolysis also increased risk of chorio.

Question 24

What is the median latency with PPROM between
1) 24 - 28/40?
2) 31+

Answer 24

1) 8-10 days
2) decreases to 5 days

Question 25

What did a case control study demonstrate with women who have reduced amniotic fluid volumes on USS

Answer 25

They are more likely to give birth within 7 days from membrane rupture.

Question 26

regarding timing of delivery. What management should be offered in pregnancies complicated by PPROM after 24 weeks and no other contraindications to continuing?

Answer 26

Expectant management until 37 weeks.
On an individual basis with careful consideration of patient preference and ongoing clinical assessment.

Question 27

Previous guidance recommended expectant management to 34 weeks. Regarding neonatal sepsis/infection, what is the difference between early birth expectant management to 37 weeks.

Answer 27

No difference

Question 28

Previous guidance recommended expectant management to 34 weeks. What is the difference in RDS incidence with early birth compared to 37 weeks expectant management

Answer 28

Higher incidence of respiratory distress syndrome. RR 1.26

Question 29

Previous guidance recommended expectant management to 34 weeks. what is the difference is LSCS rate compared to expectant management to 37 weeks

Answer 29

Increased rates of LSCS. RR 1.26

Question 30

Previous guidance recommended expectant management to 34 weeks. What is the difference in overall perinatal mortality or IUFD? compared to expectant management to 37 weeks

Answer 30

No difference

Question 31

What are the implications for any future pregnancies.

Answer 31

The risk of PPROM in subsequent pregnancies is increased.
A short inter pregnancy interval is associated with a greater risk.

Question 32

In future pregnancies who/and in what setting should women with pregnancies affected by PPROM be looked after?

Answer 32

A consultant with interest in pre-term birth and in a dedicated preterm birth clinic.