Modern Management of Prolonged Rupture of Membranes Joseph R. Biggio Jr., M.D. Department of Obstetrics & Gynecology Division of Maternal-Fetal Medicine University of Alabama at Birmingham

PROM Amniorrhexis prior to onset of active labor regardless of gestational age Premature Rupture of Membranes

PPROM Amniorrhexis < 37 weeks’ gestational age prior to onset of active labor Preterm Premature Rupture of Membranes

Latency Interval from Rupture of Membranes to Onset of Active Labor

Diagnosis l History l Avoid digital exam l Vaginal Pool l Nitrazine Paper l Ferning l Ultrasound l Amniocentesis/Dye Study

PROM near Term l Management gestational age dependent l Induction vs. awaiting spontaneous labor l Antibiotic prophylaxis per ACOG/CDC recommendations

Induction vs. Expectant Management l >5,000 women randomized n Oxytocin, PGE2 or expectant management up to 4 days n No difference in cesarean section or neonatal infection n Less chorioamnionitis in induction with oxytocin group Hannah, NEJM, 1996

Epidemiology of Preterm Birth PPROM Spontaneous Preterm Delivery Indicated Preterm Delivery 28 % 46 % 26 % Andrews, 1995

PPROM Risk Factors l Lower/Upper Genital Tract Infection  Proteases  Prostaglandins l History of PPROM l Incompetent Cervix l Abruption l Polyhydramnios l Multiple Gestation l Smoking

PPROM Complications l Maternal/Fetal Infection l Premature Labor and Delivery l Umbilical Cord Prolapse l Fetal Hypoxia 2º Cord Compression l Increased Rate of Cesarean Section l Intrauterine Growth Restriction l Abruption l Stillbirth

PPROM Standard Management l Confirmation of Diagnosis l Verification of Gestational Age l R/O Labor/Infection/Fetal Compromise l Avoid Digital Vaginal Examinations l In Hospital Observation l Bedrest

PPROM Latency Gestational Age (Weeks) % Patients with Latency > 1 Week Wilson, Obstetrics & Gynecology, 1982

PPROM Vaginal Examination Gestational Age (Weeks) Latency Days No Exam Exam Lewis, Obstetrics & Gynecology, 1992

Previable PPROM l < 24 weeks l Poor prognosis for successful outcome l Outcome may be different for spontaneous vs. iatrogenic

Previable PPROM Complications l Uterine Infection l Pulmonary Hypoplasia l Limb Compression Deformities l Intrauterine Growth Restriction

Previable PPROM Outcomes

PPROM Management Issues Timing of Delivery l Tocolysis l Antibiotics l Steroids l Amniocentesis l Observation vs. Induction l Fetal Lung Maturity Testing l Fetal Surveillance

Timing of Delivery

Neonatal Morbidity/Mortality UAB ( ) %

RNICU Survival and Morbidity Data ( ) % Neonates

Tocolysis

PPROM Tocolysis Weiner, AJOG, 1988

PPROM Tocolysis Garite, AJOG, 1987

Antibiotics

Preterm Labor Chorioamnion Colonization 0  30 weeks weeks weeks  37 weeks % Patients Colonized Spontaneous Preterm Labor Indicated Cassell, 1993

PPROM Antibiotic Therapy l Reduction Maternal/Perinatal Infection l Prolong Latency Period l Improve Neonatal Outcome

Antibiotic: PPROM NIH-MFM Network Study l PPROM between 24 and 32 weeks l IV ampicillin and erythromycin for 48 h l Oral amoxicillin/erythromycin for 5 days l Identification and Rx of GBS carriers l Tocolysis and corticosteroids prohibited Mercer, JAMA, 1997

Antibiotic: NIH-MFM Network Study Neonatal Morbidity * * *

Antibiotic: Latency Period NIH-MFM Network Study

PPROM Antibiotic Therapy l Optimal Antibiotic Regimen l Route/Duration of Administration

Antibiotics & PPROM: Summary l Reduction in maternal infectious morbidity l Reduction in births <48 h and <7 d l Reduction in neonatal infectious morbidity l Reduction in neonates requiring NICU and ventilation >28 d Kenyon, Cochrane Library, 1999

Antibiotics & PPROM: Summary l No clear reduction in perinatal death l No clear reduction in cerebral abnormalities Kenyon, Cochrane Library, 1999

Amniocentesis

PPROM Amniotic Fluid Culture l Group B Streptococcus20 % l Gardnerella vaginalis17 % l Peptostreptococcus11 % l Fusobacteria10 % l Bacteroides fragilis 9 % l Other Streptococci 9 % l Bacteroides sp. 5 %

Utility of Amniocentesis l Confirm/Refute diagnosis of chorioamnionitis  Glucose <15 mg/dL  Culture  Gram stain l Lung maturity testing

Corticosteroids

Corticosteroids for FLM l Betamethasone l Dexamethasone

PPROM Corticosteroids Block Taeusch Papageorgiou Young Garite Collaborative Iams Nelson Simpson Morales AuthorSteroidsControl Effect on RDS Number of Patients

PPROM Corticosteroids Crowley, Ob/Gyn Clinics, 1992 *

PPROM Corticosteroids + Antibiotics * Lewis, Obstetrics & Gynecology, 1996

1994 NIH Consensus Conference: Corticosteroids in PPROM l Corticosteroids reduce incidence/severity of RDS, IVH l Benefits in PPROM up to weeks l No significant adverse outcomes for corticosteroid use in PPROM l Impact less than with intact membranes

Observation vs. Induction

Neonatal Morbidity/Mortality UAB ( ) %

PPROM Observation vs. Induction Mercer, AJOG, 1993 * *

PPROM Observation vs Induction Cox, Obstetrics & Gynecology, 1995

Fetal Lung Maturity Testing

Fetal Lung Maturation Biologic Markers Gestational Age (weeks) L:S Ratio % Phospholipid L:S PI PG 10

Fetal Lung Maturity Evaluation in Vaginal Pool Specimen l L:S RatioNot Reliable l TDX:FLM AssayNot Validated l PGUseful

Fetal Surveillance

PPROM Fetal Surveillance l Daily Non-Stress Test (NST)  Variables  Tachycardia  Loss of reactivity l Biophysical Profile (BPP) l Contraction Stress Test (CST)

Summary

UAB Management of PPROM PPROM  34 weeks Deliver Previable PROM Outpatient observation Antibiotic prophylaxis Option of termination <22wk Admission at viability

PPROM  23 weeks, <34 weeks Antibiotic prophylaxis: Amoxicillin 500 tid x 10d, Azithromycin 1gm d1 & d5 1 course Betamethasone if <32weeks Test for pool PG weekly beginning at 32 weeks Deliver at weeks UAB Management of PPROM