PPROM

Question 1

How do you diagnose preterm prelabor rupture of membrane (PPROM)?

Answer 1

+ fern
+ nitrazine (amniotic fluid pH 7.1 - 7.3 verses vaginal pH 3.8 - 4.5)
+ pooling
amnisure

Question 2

How do you manage a pregnant woman with PPROM after 24 weeks?

Answer 2

Latency antibiotics: ampicillin + azithromycin then amoxicillin

Question 3

How do you counsel a patient about potential complications of PPROM?

Answer 3

Chorioamnionitis 
Placental abruption 
Preterm contractions
Retained Placenta
Pph

Question 4

What are the most common complications follow PPROM

Answer 4

Preterm delivery
Infection
Abruption

Question 5

What is the role of antibiotics in the management of patients following PPROM?

Answer 5

Latency (to prolong the pregnancy)

Question 6

What antibiotic regimen do you utilize to prolong latency following PPROM?

Answer 6

Ampicillin, azithromycin and amoxicillin
-48 hours IV ampicillin 2 grams every 6 hours + azithromycin 1 gram
then
amoxicillin 250mg every 8 hours x 5 days

Alternative is erythromycin IV 250mg q6 x 48 hours then PO 333mg q8h x 5 days

Question 7

What antibiotic regimen do you utilize for a patient with a high risk penicillin allergy following PPROM?

Answer 7

Vancomycin

Question 8

What clinical findings are suspicious for chorioamnionitis?

Answer 8

Uterine tenderness
Foul smelling discharge 
Fever 
Maternal tachycardia 
Fetal tachycardia 
Leukocytosis

Question 9

How is chorioamnionitis diagnosed?

Answer 9

Maternal tachycardia
Fever
Foul smelling discharge
Uterine tenderness

Question 10

How do you confirm or exclude ruptured membranes in the setting of inconclusive initial examination?

Answer 10

Indigo carmine amnioinfusion (1ml in 5 ml of Nacl)

Assess for leakage of blue-stained fluid into the vagina 20-30 minutes

Question 11

On average, what is latency period following previable PPROM?

Answer 11

40% deliver within the week

80% deliver within 2-5 weeks

Question 12

On average, what is the latency period following PPROM 24-34 weeks?

Answer 12

1-5 weeks

Question 13

What are complications of previable PPROM?

Answer 13

maternal infection/sepsis (1-5%)
Death (1%) 
Retained placenta 
maternal hysterectomy 
bleeding/DIC 
IUFD
preterm birth
fetal dyskinesia sequence (growth restriction , aberrant facies and contoured limbs, pulmonary hypoplasia)
Pulmonary hypoplasia (2-20%)

Question 14

How do you manage a patient following previable PPROM?

Answer 14

termination of pregnancy

Question 15

How do you counsel a patient regarding likelihood of fetal pulmonary hypoplasia following PPROM?

Answer 15

• likelihood is high due to oligohydramnios

- amniotic fluid is critical to the production and function of the pneumocystis

Question 16

Risk factors for PPROM?

Answer 16

• intraamniotic infection and inflammation (triple I)
• short cervix
• low BMI
• smoking

Question 17

Why is clavulanic acid contraindicated in pregnancy?

Answer 17

Increases rate of necrotizing enterocolitis

Question 18

Do you give steroid to a PPROM patient at 34 weeks with evidence of infection?

Answer 18

No.

Question 19

How do you manage PPROM in the setting of cerclage placement?

Answer 19

• No prospective studies and retrospective studies conflicting
• Cerclage retention for >24 hrs after PPROM associated with pregnancy prolongation
• Some studies show that leaving cerclage in will increase rates of:
• Neonatal sepsis
• RDS
• Maternal chorioamnionitis
• SO WEIGHT RISKS AND BENEFITS IN YOUR CLINICAL PICTURE
• Do not extend antibiotics beyond 7 days regardless of cerclage removal decision

Question 20

How do you manage PPROM in the setting of active HSV infection?

Answer 20

• Treat with acyclovir
• Give Mag (<32 wks), abx, steroids (weight risk of infection with neonatal herpes verses pulmonary hypoplasia)
• C-section with active lesion or prodromal symptoms or first genital episode in the 3rd trimester whether primary or recurrent
• Discuss risk of prematurity with risk of neonatal herpes
• Delivery at 34 weeks (shared decision making)

Primary HSV - 30-50%
Recurrent HSV - 3%

Question 21

How do you manage PPROM in the setting of active HIV infection?

Answer 21

• Current data suggest that ROM duration not correlate w/ vertical transmission risk IF:
• Patients receive highly-active antiretroviral therapy
• Patients have a low viral load
• Patients receive antepartum and intrapartum zidovudine

Question 22

How do you manage PPROM after amniocentesis?

Answer 22

• Pts. w/ PPROM after genetic Amnio typically managed expectantly as outpatients
• Precautions regarding symptoms of chorio and miscarriage should be given
• Regular follow-up visits w/ US exam to assess AFI are recommended