PROM and PPROM

Question 1

What is PROM?

Answer 1

Spontaneous rupture of the membranes at least 1hr prior to the onset of contractions

Question 2

What is PROM associated with?

Answer 2

lll fitting presenting part (OP) Polyhydramnios Chorioamnionitis

Question 3

What causes PROM?

Answer 3

Collagen degradation in membranes

Question 4

How long should you routinely wait after PROM before advising active management (synto or prostin)?

Answer 4

24hrs

Question 5

Should you VE a woman who presents with PROM?

Answer 5

Not unless in active labour

Question 6

What is the management of PROM?

Answer 6

Assessment of risk factors (including maternal and fetal wellbeing) If risk factors present: -CTG -Obstetric referral for care planning (likely active management) If no risk factors: Intermittent auscultation -If clear evidence of ROM no speculum examination -No vaginal examination unless in active labour Offer expectant management: -Risk of NN infection 1% ( from 0.5% with intact membranes) -60% of women will labour spontaneously within 24hrs Monitor T 4hrly, liquor colour and FMs If not in labour 24hrs after ROM advise active management (PGE2 &/or oxytocin)

Question 7

What is the management for a GBS+ woman presenting with PROM?

Answer 7

IAP (intrapartum antibiotic prophylaxis) if GBS+ve this pregnancy (or baby affected in previous pregnancy) and active management Active management of PROM if GBS+ve in a previous pregnancy Benzylpenicillin 3g IV followed by 1.5g 4hrly Clindamycin 900mg IV 8hrly if allergic to penicillin

Question 8

What is Prolonged Preterm Rupture of Membranes (PPROM)?

Answer 8

Spontaneous rupture of membranes before the onset of labour Complicates 2% of pregnancies, but associated with 40% of preterm deliveries Complications of PPROM Prematurity Sepsis Pulmonary hypoplasia (incomplete development of the lungs- abnormally low number or size of bronchopulmonary segments or alveoli. A congenital malformation) Cord prolapse Malpresentation ?APH

Question 9

How is PPROM diagnosed?

Answer 9

Positive if pool of fluid seen in vagina during sterile speculum examinationNitrazine testUSS for oligiohydramniosMicroscopic examination for:Ferning of crystalline pattern of dried amniotic fluid Presence of lanugo hairFetal epithelial cell

Question 10

What factors are associated with PPROM that you could consider in order to establish a PPROM?

Answer 10

Infection (urinary, STIs, BV) Previous PROM/PTD Polyhydramnios Multiple pregnancy Vaginal bleeding Cervical incompetence Amniocentesis Smoking Illicit drug use Nutritional deficits Low socioeconomic status BMI Abdominal trauma Domestic abuse

Question 11

What is the management of PPROM?

Answer 11

Corticosteriods – as for preterm labour Antibiotics Place of care Timing of delivery Method of delivery

Question 12

What positive things did the WHO review of 3 Cochrane reviews of Corticosteriods find?

Answer 12

Reduces risk of respiratory distress syndrome, intraventricular haemorrhage and perinatal death. Benefits were found when treatment was commenced between 26 and 35 weeks of gestation, and for babies born 1–7 days after commencing treatment, and also for subsets of women with premature rupture of the membranes and with hypertensive disorders. Combined fetal and neonatal deaths were reduced even in infants born less than 24 hours after administration of the first dose

Question 13

What negative things did the WHO review of 3 Cochrane reviews of Corticosteriods find?

Answer 13

No benefits for treatment commenced, or infants born, before 26 weeks of gestation, nor for those born more than seven days after treatment. For babies born after 36 weeks there was a trend to increase combined fetal and neonatal death. Birth weight was reduced in infants born 1–7 days, and more than seven days after the first treatment. One trial suggested that in women with severe pre-eclampsia the treated women were at increased risk of gestational diabetes. Evidence from epidemiological and animal studies suggests that there may be long-term adverse effects of prenatal corticosteroid exposure, including impaired glucose tolerance and hypertension Animal studies have also suggested impairment of brain growth. Follow-up of the offspring of one trial at age 30 years found an increase in insulin release in response to a 75-g glucose load, but no other morbidity

Question 14

What antibiotics should be used?

Answer 14

Erythromycin 250mg QDS for 10/7 or until in labour If unable to tolerate or allergic penicillin for 10/7 or until in labour Do not give augmentin/co-amoxyclav (significant increased risk of NEC) When in labour see local policy Cochrane review of 22 studies (>6800 women) prescribed antenatal antibiotics demonstrated a reduction in: Chorioamnionitis (RR 0.66 95% CI 0.49-0.96) Delivery within 48hrs (RR 0.71 95% CI 0.58-0.87) Reduction in infection (RR 0.67 95% CI 0.52-0.85) Use of surfactant (RR 0.83 95% CI 0.72-0.96) O2 therapy (RR 0.88 95% CI 0.88-0.96) Abnormal cerebral USS (RR 0.81 95% CI 0.68-0.98)

Question 15

When should should delivery be planned for?

Answer 15

Dependent on maternal and fetal wellbeing. Dependent on presentation – cephalic, breech, transverse. NICE 2015 does not make any recommendations regarding delivery gestation. ‘Delivery should be considered at 34 weeks gestation. Where expectant management is considered beyond this gestation, women should be informed of the increased risk of chorioamnionitis and the decreased risk of respiratory problems in the neonate’. RCOG, 2010

Question 16

What is amniofusion?

Answer 16

The process of instilling isotonic liquid in the uterine cavity