New Born OB Longitudinal

 

 

 

 

 

Premature ROM/Preterm Premature ROM Quick Facts                 PB172

 

PROM = Rupture of membranes before onset of labor. Occurs in ~8% of term pregnancies.

-          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.

        o   Mechanical methods (i.e. Foley, Cook) are not well studied

-     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.

-          Risk Factors for PPROM: intrauterine infection, h/o PPROM/PTL, short CL, bleeding, low BMI, low socioeconomic status, cigarette smoking, illicit drug use

-          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.

-          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.

-          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.

                  o   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

                  o   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

     •  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.

o   34 0/7 – 36 6/7 weeks (late preterm) – delivery, GBS prophy as indicated, steroids if not previously administered

-          PPROM after Cerclage: Insufficient evidence re: removal vs. retention.

-          PPROM with HSV: Risk of vertical transmission during labor is 30-50% with primary infection, 3% with recurrent infection.

                   o   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.

                   o   With primary active infection, optimal management is unknown.

-          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.

-          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

-          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.

-          Can consider cervical length screening. *No data to guide initiation and frequency of testing.

                   o   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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