Preterm rupture of membranes - PowerPoint Presentation

1. Preterm rupture of membranes MD F, GHOTBIZADEHOb&gyn specialistPerinatalogist

2. The management of PPROM is among the most controversial issues in perinatal medicine. Points of contention include:Expectant management versus interventionUse of tocolyticsDuration of administration of antibiotic prophylaxisTiming of administration of antenatal corticosteroidsMethods of testing for maternal/fetal infectionTiming of delivery

3. management of PPROMat 25(23) to 37 weeks of gestationprior to 23 weeks of gestation

4. Initial approach Gestational agePresence or absence of maternal/fetal infectionPresence or absence of laborFetal presentation Fetal well-beingFetal lung maturityCervical status (by visual inspection) Availability of neonatal intensive careThe key decision is whether to induce labor (or perform cesarean delivery) or to manage the pregnancy expectantly

5. .The American College of Obstetricians and Gynecologists (ACOG) suggests delivery for all patients ≥34 weeks of gestation .Expeditious delivery of women with PPROM is clinically :appropriate if intrauterine infection, abruptio placenta non reassuring fetal testing, or a high risk of cord prolapse is present or suspected

6. Expectant management  adminestration of corticosteroidAntibiotic therapy Use of tocolysis Supplemental progesterone Hospitalization versus home care Maternal and fetal monitoring Special situations:with HSV, HIV, or cerclage 

7. Administration of antenatal corticosteroidsA course of corticosteroids should be given to pregnancies between 23 and 34 weeks of gestationThe use of rescue therapy is controversial A single course of ‘rescue’ therapy is reasonable initial course was given at <28 weeks of gestation

8. Antibiotic therapy The rationale for antibiotic prophylaxis is that infection appears to be both a cause and consequence of PPROMThe goal of antibiotic therapy is to reduce the frequency of maternal and fetal infection and thereby delay the onset of preterm labor (ie, prolong latency) and the need for preterm deliveryA 2013 systematic review of 22 placebo-controlled randomized trials,2008 Chorio amnionitisBabies born within 48 hours and 7 daysNeonatal infectionUse of surfactantNeonatal oxygen therapy and Abnormal cerebral ultrasound scan prior to hospital discharge

9. We recommend administering a seven-day course of antibiotic prophylaxis to all women with PPROM who are managed expectantly. is ampicillin 2 g intravenously every 6 hours for 48 hours, followed by amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) for an additional five days. erythromycin 250 mg IV every 6 hours for 48 hours followed by erythromycin oral 333 mg every 8 hours for five daysWomen with PPROM who have an identifiable genital tract infection (eg, gonorrhea, chlamydia, bacterial vaginosis)

10. we recommend giving one dose of azithromycin (one gram orally) upon admission. because of its ease of administration, improved gastrointestinal tolerance, favorable cost profile, and similar efficacyWomen with penicillin allergy "low risk“: cefazolin 1 g intravenously every 8 hours for 48 hours, followed by cephalexin 500 mg orally four times daily for five days. "high risk"suggest clindamycin 900 mg intravenously every 8 hours for 48 hours plus gentamicin 7 mg/kg ideal body weight for two doses 24 hours apart, followed by oral clindamycin 300 mg every eight hours for five days.

11. Use of tocolysis delay delivery for 48 hours to allow administration of corticosteroidsAs a general rule, tocolytics should not be administered for more than 48 hours. advanced labor (>4 cm dilation) or who have any findings suggestive of subclinical or overt chorio amnionitis. Non reassuring fetal testing, abruptio placentae, and significant risk of cord prolapse (eg, dilated cervix and fetal malpresentation)In a 2014 systematic review of randomized trialsan increase in chorioamnionitis (RR 1.79, 95% CI 1.02-3.14; three trials, n = 168 women) and no significant improvement in perinatal morbidity or mortality

12. Supplemental progesterone  There is no evidence that administration of supplemental progesterone extends the latent period in women with PPROM or provides other benefits.treatment had no significant effect on gestational age at delivery, interval between randomization and delivery, mode of delivery, mean birth weight, five-minute Apgar score, composite neonatal morbidity, or number of days of neonatal intensive care unit (NICU) care. In women who are on supplemental progesterone because of a prior pregnancy with preterm delivery related to preterm labor or PPROM, we discontinue the medication upon diagnosis of PPROM.

13. Hospitalization versus home care women with PPROM who have a viable fetus from the time of diagnosis until delivery, with few exceptionsActivity is limited to using the bathroom and sitting up in a bedside chair.Thrombo prophylaxis should be considered for all hospitalized pregnant women at bed rest

14. Maternal and fetal monitoringWomen with PPROM should be monitored for signs of infection; there is no consensus as to the best approach. At a minimum: maternal temperature, uterine tenderness and contractions, maternal and fetal heart rate should be monitored.Periodically monitoring white blood cell counts or other markers for inflammation/infection has not been proven useful

15. Cervical CerclagePreterm PROM complicates about one fourth of pregnancieswith a cervical cerclage and one half of pregnancies requiringan emergent cerclage.The risk for adverse perinatal outcomes does not appear to be different when PROM occurs with a cerclage or without one, removal is recommended when PROM occurs, particularly if the indication for initialcerclage placement was not strong (feto maternal)In up to date if chorio or GA >32 remove of cerclage recomended

16. If the clinical diagnosis of chorio amnionitis is uncertain and we need more information to decide about expectant management, then we perform amniocentesis to rule out infectionAmniocentesis to obtain amniotic fluid for Gram stain, culture, leukocyte esterase, and glucose concentration is more controversial. We do not routinely perform amniocentesis to screen for intraamniotic infection in asymptomatic women

17. Fetal monitoring kick counts, NSTs, biophysical profile [BPP]daily NST :If the NST is not reassuring, perform a BPP none of these tests has good sensitivity for predicting fetal infection, even when performed daily (sensitivity of daily NST and BPP: 39 and 25 percentDoppler surveillance is not useful for monitoring fetal status in PPROM

18. Twin pregnancyThe management of PPROM in twin pregnancies is similar to that in singletons.

19. Diagnosis and treatment of overt infection maternal fever, particularly when associated with leukocytosis, maternal and fetal tachycardia, uterine tenderness, and/or malodorous amniotic fluid.subclinical chorioamnionitis requires amniocentesis to identify microorganisms in the amniotic fluid (gram stain and culture) and document an abnormally low amniotic fluid glucose concentration.

20. DeliveryMagnesium sulfate for neuroprotection pregnancies at least 24 but <32 weeks of gestation at risk of imminent deliveryMode of delivery 

21. FUTURE PREGNANCIES We suggest progesterone supplementation for these women in future pregnancies.In addition, PPROM may be related to cervical insufficiency in some cases. In future pregnancies, sonographic measurement of cervical length and placement of a cerclage if cervical length is <25 mm before 24 weeks of gestation can reduce the risk of recurrent preterm birth.

22. Primary or first episode genital HSV infection and PPROM No data are available on the risk of fetal infection during expectant management of primary or first episode genital HSV infection complicated by rupture of membranes. Optimal management remains uncertain. Confirmation of the diagnosis of primary or first episode genital nonprimary infection is desirable.Given the absence of data to inform decision-making, it is difficult to weigh the risks of in utero infection against the risks of preterm delivery, which vary significantly by the week of gestation.some authors suggest prompt cesarean delivery of pregnancies ≥28 weeks of gestation in an attempt to minimize the risk of fetal infection; others use a threshold of ≥32 weeks. The neonate is then treated with acyclovir and surfactant. Before 28 (or 32) weeks, the risks of prematurity are high and may outweigh the risk of fetal infection with expectant management so acyclovir is given to the mother to shorten the duration of lesions and reduce viral shedding; there are no data showing prevention of neonatal infection.

23. Recurrent HSV infection and PPROM●No cases of neonatal HSV infection  — An observational study was performed to examine neonatal outcomes in 29 pregnancies complicated by both PPROM (at 25 to 31 weeks of gestation) and recurrent HSV infection that were managed expectantly [33]. Expectant management consisted of hospitalization and frequent vital sign monitoring; only two women received oral acyclovir for clinical symptoms. The mean gestational age at herpes lesion development after PPROM was 28.7 weeks (range 24.6 to 31.0 weeks). The mean interval from recognition of infection to delivery was 13.2 days (range 1 to 35 days). Control patients were selected who had PPROM without concomitant HSV infection. The following findings were noted:●No positive neonatal HSV cultures●Twelve infants (41 percent) had major morbidity related to prematurity and three died. Morbidity was similar for cases (PPROM with recurrent HSV) and controls (PPROM without HSV).Based upon these data, the authors calculated that the maximum risk for development of a neonatal herpes infection in the setting of PPROM and recurrent genital HSV infection was 10 percent. This risk was close to the neonatal mortality rate at 26 to 27 weeks and was significantly lower than the risk of major morbidity caused by prematurity. These findings support expectant management for PPROM in the second trimester in women with active recurrent genital herpes. Above this gestational age, the risks of prematurity (which vary by gestational age) need to be balanced with the risks of in utero infection on a case-by-case basis. If delay of delivery is appropriate because of concerns related to gestational age remote from term, we suggest administering intravenous acyclovir (5 mg/kg every 8 hours) to shorten the duration of active lesions in the mother and to decrease viral burden. However, the ability of acyclovir to prevent maternal-fetal transmission has not been proven.

24. HIV-infected patientFor women who present in labor or with ruptured membranes prior to scheduled cesarean section, management must be individualized, and take into account the duration of the rupture of membranes/labor, current ARV regimen and HIV RNA level. Only viral load above 10,000 copies/mL was an independent risk factor for perinatal transmission.Preterm premature rupture of membranes — When membrane rupture occurs before 37 weeks gestation, decisions about timing of delivery should be based on best obstetrical practices, taking into account risks of prematurity for the infant. The presence of HIV infection of the mother should not change management. Administration of antenatal corticosteroids to accelerate fetal lung maturity should be given if appropriate, as no data exist to suggest that these recommendations need be altered for HIV-infected women. 

25. Mid trimester preterm premature rupture of membranes(PPROM) typically refers to spontaneous rupture of membranes at 16 to 26 weeks complicates approximately 0.7 percent of pregnanciesPPROM after amniocentesis has a much better prognosis

26. Pregnancy complications associated with midtrimester PPROM include increased risks of infection (chorioamnionitis, endometritis), abruptio placentae, cord prolapse, fetal death, preterm birth, and need for cesarean deliveryThe neonate is at risk for morbidity/mortality related to preterm birth, infection, pulmonary hypoplasia, and musculoskeletal deformationCessation of amniotic fluid leakage with reaccumulation of amniotic fluid confers a prognosis comparable to that of pregnancies without PPROM

27. Professional standards and recommendationsBased on the recommendation that every facility that cares for high-risk pregnancies should have a consensus approach to the management of extremely premature infantsThis approach is consistent with published guidelines from the 2009 AAP Committee on Fetus and Newborn and a 2013 consensus statement from an international group of neonatologists

28. Below 22 weeks gestation – Resuscitation is not offered 220/7 to 226/7 weeks of gestation – Resuscitation is offered to parents if there is at least a small chance of survival based on available information (eg, the NICHHD outcome estimator for patients receiving mechanical ventilation) and is then provided only if requested by informed parents.230/7 to 236/7 weeks of gestation – Resuscitation is offered to parents, but provided or withheld based on the preference of informed parents.240/7 to 246/7 weeks of gestation – Resuscitation is offered to parents and may be provided or withheld based on the preference of informed parents. However, if the newborn is predicted to have greater than 50 percent chance of survival without neurodevelopmental impairment, resuscitation is provided. That likelihood is determined using the NICHHD database outcome predictor for patients given mechanical ventilation, and using best obstetrical estimate of gestational age and estimated fetal weight.25 weeks of gestation and higher – Resuscitation is provided.