PREMATURE RUPTURE OF MEMBRANES Arda Lembet, MD Associate Professor - - PowerPoint PPT Presentation

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Jul 08, 2023 259 likes •747 views

PREMATURE RUPTURE OF MEMBRANES Arda Lembet, MD Associate Professor Femical Women s Clinic Istanbul PROM Overview, clinical significance Diagnosis Evaluation Management > 37 weeks 34 - 36 6/7 weeks 32 - 33 6/7 weeks 23 - 31 6/7

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PREMATURE RUPTURE OF MEMBRANES

Arda Lembet, MD Associate Professor

Femical Women’s Clinic Istanbul

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Overview, clinical significance Diagnosis Evaluation Management > 37 weeks 34 - 36 6/7 weeks 32 - 33 6/7 weeks 23 - 31 6/7 weeks < 23 weeks PROM

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PPROM Management - Special Circumstances

Cerclage HSV ,HIV Membrane resealing Amnioinfusion, amniopatch Prevention of recurrent PPROM Multiple pregnancy Hospital versus outpatient management

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PROM: Premature rupture of membranes PPROM: Preterm premature rupture

f membranes

LATENCY: Interval from rupture of membranes to onset of active labor

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Overview, clinical significance

Clinical chorioamnionitis % 13-60 Endometritis % 2-13 (+) AF culture % 25-35 Maternal sepsis % 1 Fetal loss % 1-2 Abruptio placenta % 4-12

PPROM

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Pathophysiology: Collagen remodeling, cellular apoptozis Ascending infection Clinical risk factors : Short cervix / incompetent cervix Cervicovaginal fetal fibronectin Abruption Polyhydramnios / multiple gestation PPROM

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(PROM ) Clinical Risk Factors

Odds ratio H /o PPROM 3.3-6.3 H / o PTL 1.9-2.8 Smoking 2.1 Vaginal bleeding during pregnancy 1.trimester 2.4

2. trimester

4.4

3. trimester

6.4 > 1 trimester 7.4 Acute pulmonary disease 1.8 Bacterial vaginosis 1.5

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PROM Diagnosis

Clinical Diagnosis: Tests : Alkaline pH > 6- 6.5 Ferning Biochemical markers: (placental alpha microglobulin-1 (PAMG-1) IGFBP-1, fFN, AFP, fT4, prolactin, hCG, IL-6 ) USG: AFV ?, AS ?

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PPROM Evaluation- I

Cultures: Cervical cultures; Neisseria gonorrhea, Chlamydia, anovaginal culture; GBS Urinalysis / culture Digital exam: NO NST: For how long?, intermittent monitoring Clinical chorioamnionitis: Fever > 38 , uterine tenderness and / or maternal and fetal tachycardia…..Delivery

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PPROM Evaluation - II

Leucocytosis: WBC > 16,000 USG / Fetal Biophysical Profile Amniocentesis: Gram stain, WBC >30 cell/microl, glucose < 16-20, culture (aerobic-anaerobic, mycoplazma )

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PPROM Evaluation - II

Amniotic Fluid Culture:

Group B Streptococcus

20 %

Gardnerella vaginalis

17 %

Peptostreptococcus

11 %

Fusobacteria

10%

Bacteroides fragilis

9 %

Other streptococci

9 %

Bacteroides sp.

5 %

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PPROM Evaluation - III

CERVICAL LENGTH Cut-off level: 2-2.4 cm Latency period Intraamniotic infection How does it compare to WBC, CRP ??

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PPROM Evaluation - IV

Fetal Lung Maturity Evaluation in Vaginal Pool L/S Ratio Not Reliable TDX: FLM Assay Not Validated PG Useful

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PPROM Evaluation - V

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PPROM Management

Clinical chorioamnionitis Nonreassuring fetal well being, Severe vaginal bleeding, Advanced labor, Pregnancy complications ( preeclampsia etc ) DELIVERY

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PROM Management

Term > 37 weeks : Infection : 12 h %2 12-24 %6 48 %24 Labor induction / augmentation: Prostaglandin: GBS: > 18 h prophylaxis, culture last 6 week > -

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PPROM Management

Preterm: 34 - 36 6/7 weeks : Corticosteroids ? Prolongation of latent phase ? Since the risk of infection and umbilical cord accidents are higher than the risk of prematurity ….DELIVERY

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PPROM Management 34-37 weeks

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Chorioamnionitis should we care ?

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Chorioamnionitis should we care ?

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PPROM Management

Preterm: 32 - 33 6/7 weeks : Lung maturation : Vaginal pooling / AS PG, FLM or L/S if mature…DELIVERY Immature or can not be tested Delivery after steroids (24-48 hours later or deliver @34 weeks ) / Broad spectrum antibiotics

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PPROM Management

Preterm: 23 - 31 6/7 weeks: Fetal / maternal monitorization Antenatal corticosteroids : Broad spectrum antibiotics: Amp 2 g iv / q 6 h 48 h + eritro iv 250 mg q 6 Amoxocilin 250 mg po q 8 5 d + eritro 333 po q 6 Alternative; oral amp / eritro / azithro

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PPROM Management

Preterm: 23 - 31 6/7 weeks : The relation between broad spectrum ab and NEC ?? After 7 days of ab f/u patients for GBS carriers Stop ab, treat intrapartum After 7 days give narrow spectrum ab until delivery Follow by anovaginal cultures ; Treat if +

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PPROM Management

Preterm: 23 - 31 6/7 weeks : Consider Mg SO4 for neuroprotection if delivery < 32 weeks

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PPROM Management

Preterm: 23 - 31 6/7 weeks : Daily NST / FBPP WBC ?? Baseline Cervicovaginal pathogen and UTI treatment USG, oligohydroamnios ?? Tocolysis, amnioinfusion Thromboemboli prophylaxis

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PPROM Management

Preterm: < 23 weeks : Dating and confirmation of the gestational week High complication rate: Chorioamnionitis % 39 Endometritis % 14 Abruption % 3 Placenta ret, PPH, D&C % 12 IUFD (fetal demise) % 15

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PPROM Management

Preterm: < 23 weeks : Oligohydramnios: < 20 weeks: Poor prognostic parameter Pulmonary hypoplasia ( TC / AC ) Skeletal deformities Membrane resealing: New treatment modalities: Gelfoam,fibrin-platelet-cryo-

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NICHD Extremely Preterm Birth Outcome Data

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NICHD Extremely Preterm Birth Outcome Data

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PPROM Management - Special Circumstances

Cerclage: Should it be removed ? When ? HSV: HIV: Membrane resealing: Amnioinfusion: Prevention of recurrent PPROM: Progesterone , Vitamin C , E? Multiple pregnancy:

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PPROM Management - Special Circumstances

Multiple pregnancy: Incidence: 7-8 % Latency period Survival , morbidity, sac differs ?? Antibiotics, steroids : Same as singletons Tocolysis, MgSO4: Same as singletons Delayed interval delivery ?? Selective fetocide ??

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