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Premature
ROM/Preterm Premature ROM Quick Facts
PB172
PROM =
Rupture of membranes before onset of labor. Occurs in
~8% of term pregnancies.
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If
managed expectantly -> 50% deliver within 5 hours and
95% within 28 hours.However, IOL reduces time to
delivery, decreases rates of
chorioamnionitis/endometritis, decreases NICU
admissions WITHOUT increasing C/S or operative
delivery rates.
o
Pitocin and prostaglandins equally effective, but lower
infection risk with Pitocin.
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Mechanical methods (i.e. Foley, Cook) are not well studied
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Antibiotics for GBS only if positive of unknown with
additional indications…h/o infant with GBS disease,
maternal fever, ROM>18h
PPROM = Rupture of membranes before onset of labor and
prior to 37 weeks. Viable PPROM occurs in 3% of
pregnancies, while pre-viable occurs in <1%. Regardless
of intervention, ~50% of women deliver within 1 week.
The earlier gestational age at which PPROM occurs, the
longer the latency in most cases.
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Risk Factors for PPROM: intrauterine infection,
h/o PPROM/PTL, short CL, bleeding, low BMI, low
socioeconomic status, cigarette smoking, illicit drug
use
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Complications of PPROM: 15-25% have clinically evident
infection, 2-5% have abruption, 1-2% have fetal demise.
If pre-viable, 10-20% have pulmonary hypoplasia,
1-38% skeletal deformations, 1% maternal sepsis.
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Diagnosis of PPROM: SSE for pooling/nitrazine/ferning
(can get false+ nitrazine with
blood/semen/antiseptics/BV, false- with prolonged
rupture). If equivocal, can add ultrasound
for oligo and/or Amnisure (but placental protein tests
like Amnisure have false+ 19-30%). Can diagnose with
certainty by instilling indigo carmine into amniotic
fluid and doing a tampon test!
o
SVE
only if patient appears to be in active labor, as
increases risk of infection. Preferentially use SSE to
assess dilation/effacement. SSE also useful to inspect &
culture for
cervicitis, evaluate for cord/fetal prolapse.
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Initial Management of PPROM: Confirm GA and fetal
position. Monitor for labor. Evaluate for signs/sx of
fetal distress, infection, abruption all (indications
for delivery). Obtain GBS culture.
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Under 24 weeks – patient counseling, outpatient
expectant management vs admission for IOL, can start
latency antibiotics as early as 20 0/7, no
steroids/tocolysis/Mag/GBS prophy until viable
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24 0/7 – 33 6/7 weeks (preterm) – Expectant
management, latency abx and steroids. Magnesium if <32
weeks and at risk of imminent delivery.
Insufficient evidence re: prophylactic tocolysis, but
therapeutic tocolysis in patients who are already having
contractions is not recommended. GBS prophy, if
indicated, during labor.
Expectant management = Admission to hospital with
periodic assessment for infection (by VS/exam not labs),
abruption, cord compression, fetal well-being (both
ultrasounds and FHR monitoring) and labor. Outpatient
management NOT recommended once viable.
Latency antibiotics prolong pregnancy, decrease
maternal/neonatal infections and reduce GA dependent
morbidity. Below regimen is standard. Avoid Augmentin,
increased risk of NEC. In PCN allergic pts, consider
Erythro alone
• IV Amp 2g q6h + IV Erythro 250mg q6h x48
hours
• Then PO Amox 250 mg q8h + PO Erythro 333
mg q8h x5 days
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Steroids are not ~ with an increased risk of
maternal/neonatal infection and a single course should
always be given…however, giving a rescue course is
controversial in PPROM.
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34
0/7 – 36 6/7 weeks (late preterm) – delivery, GBS prophy
as indicated, steroids if not previously administered
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PPROM after Cerclage: Insufficient evidence re:
removal vs. retention.
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PPROM with HSV: Risk of vertical transmission during
labor is 30-50% with primary infection, 3% with
recurrent infection.
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With recurrent active infection, start treatment for
lesions/sx and continue expectant management. If
lesions/sx still present with onset of labor, then
proceed to C/S.
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With primary active infection, optimal management is
unknown.
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PPROM with HIV: Individualized based on GA,
antiretroviral therapy and viral load. Expectant
management likely appropriate if early GA,
on antiretroviral therapy with low viral load…as long as
patient still receives intrapartum Zidovudine.
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PPROM after Amniocentesis: Occurs after 1% of
procedures. Re-accumulation occurs in 72% of patients
and perinatal survival is 91%.
“Regular follow-up visits with ultrasonographic
examination to assess amniotic fluid volume are
recommended.”
Management of Patients with History of PPROM
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Women with a singleton gestation and a prior
spontaneous preterm birth (due to either labor or PPROM)
should be offered progesterone supplementation starting
b/t 16-24 weeks
gestation.
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Can consider cervical length screening. *No data to
guide initiation and frequency of testing.
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Can consider cerclage if current singleton gestation,
history of spontaneous preterm birth prior to 34 weeks
gestation AND a cervical length <25 mm prior to 24
weeks.
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