PPROM Flashcards
How do you diagnose preterm prelabor rupture of membrane (PPROM)?
+ fern
+ nitrazine (amniotic fluid pH 7.1 - 7.3 verses vaginal pH 3.8 - 4.5)
+ pooling
amnisure
How do you manage a pregnant woman with PPROM after 24 weeks?
Latency antibiotics: ampicillin + azithromycin then amoxicillin
How do you counsel a patient about potential complications of PPROM?
Chorioamnionitis Placental abruption Preterm contractions Retained Placenta Pph
What are the most common complications follow PPROM
Preterm delivery
Infection
Abruption
What is the role of antibiotics in the management of patients following PPROM?
Latency (to prolong the pregnancy)
What antibiotic regimen do you utilize to prolong latency following PPROM?
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
What antibiotic regimen do you utilize for a patient with a high risk penicillin allergy following PPROM?
Vancomycin
What clinical findings are suspicious for chorioamnionitis?
Uterine tenderness Foul smelling discharge Fever Maternal tachycardia Fetal tachycardia Leukocytosis
How is chorioamnionitis diagnosed?
Maternal tachycardia
Fever
Foul smelling discharge
Uterine tenderness
How do you confirm or exclude ruptured membranes in the setting of inconclusive initial examination?
Indigo carmine amnioinfusion (1ml in 5 ml of Nacl)
Assess for leakage of blue-stained fluid into the vagina 20-30 minutes
On average, what is latency period following previable PPROM?
40% deliver within the week
80% deliver within 2-5 weeks
On average, what is the latency period following PPROM 24-34 weeks?
1-5 weeks
What are complications of previable PPROM?
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%)
How do you manage a patient following previable PPROM?
termination of pregnancy
How do you counsel a patient regarding likelihood of fetal pulmonary hypoplasia following PPROM?
- likelihood is high due to oligohydramnios
- amniotic fluid is critical to the production and function of the pneumocystis
Risk factors for PPROM?
- intraamniotic infection and inflammation (triple I)
- short cervix
- low BMI
- smoking
Why is clavulanic acid contraindicated in pregnancy?
Increases rate of necrotizing enterocolitis
Do you give steroid to a PPROM patient at 34 weeks with evidence of infection?
No.
How do you manage PPROM in the setting of cerclage placement?
- 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
How do you manage PPROM in the setting of active HSV infection?
- 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%
How do you manage PPROM in the setting of active HIV infection?
- 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
How do you manage PPROM after amniocentesis?
- 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
