Preterm Labor/PROM/PPROM

Question 1

PROM occurs in ____% pregnancies in the US
PPROM occurs in ____% pregnancies in the US

Answer 1

PROM 8% (>=37wks)
PPROM 2% (<37wks)

Question 2

_____% people with PROM will go into labor by 12 hrs

Answer 2

80%

Question 3

Indications for GBS prophylaxis (generally)

Answer 3

1) GBS+ on swab or GBS bacteriuria during the pregnancy
–OR–
2) GBS unknown AND 1 of the following:
a) PPROM, prematurity
b) h/o neonatal GBS disease in prior delivery
c) ROM >18 hours

Question 4

In term PROM, recommendation is ___________ (induction or expectant mgmt)
what risk drives this decision?

Answer 4

Induction! Lower rates of chorio, endometritis, NICU admission. Same rate of C-sections. Reasonable to wait 12 hours, as 80% will go into labor spontaneously

At term, risk of infection (with expectant management) outweighs risk of induction/delivery (b/c not preterm). With PPROM, risk of prematurity outweighs risk of infection (especially <34 wks)

Question 5

In PPROM, recommendation is ___________ (induction or expectant mgmt)

Answer 5

Expectant management! Especially if GA <34 wks. 34-37 wks, can justify either strategy. Assuming that baby looks good

At term, risk of infection (with expectant management) outweighs risk of induction/delivery (b/c not preterm). With PPROM, risk of prematurity outweighs risk of infection (especially <34 wks)

Question 6

What physical exam should be avoided if PROM/PPROM is suspected?

Answer 6

Digital exam (increases infection risk)

Question 7

How is ROM diagnosed? (6)

Answer 7

1) physical exam (sterile spec) - NO lubricant!!
2) pooling of fluid
3) Nitrazine (alkaline pH)
4) Ferning of vaginal fluid
5) If equivocal, consider ROM+ / Amnisure / FFN (in PTL)
6) If equivocal, consider US –> AFI

Question 8

4 things to consider for all PPROM cases 24-34 wks GA:

Answer 8

1) Steroids (all)
2) MgSO4 (if <32 wks)
3) ABx (to prolong latency - Amp + azithro or erythro)
4) GBS PPx (if GBS+ or unknown)

Question 9

At what GA are steroids indicated?

Answer 9

24-34 wks
34-37 wks: lower incidence of O2/PAP needs, respiratory complications (incl BPD). No difference in chorio/neonatal sepsis. Increased rate of neonatal hypoglycemia

Question 10

False positives with nitrazine

Answer 10

Anything other than amniotic fluid that makes the pH more alkaline. This includes:
- Semen
- BV/trich
- Blood
- Lubricants
- Alkaline antiseptics

Question 11

False positives with ROM+

Answer 11

• blood (significant amount)

Question 12

In PPROM, when would we recommend delivery?

Answer 12

• Abnormal results from fetal testing (FHT)
• Chorioamnionitis
• Placental abruption

Question 13

Someone comes in with possible PROM/PPROM. Aside from ROM evaluation, what other test should you do?

Answer 13

GBS rectovaginal swab