modern management of prolonged rupture of membranes
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Modern Management of Prolonged Rupture of
Membranes
Joseph R. Biggio Jr., M.D.Department of Obstetrics &
GynecologyDivision of Maternal-Fetal Medicine
University of Alabama at Birmingham
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PROM
Amniorrhexis prior to onset of active labor regardless of gestational age
Premature Rupture of Membranes
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PPROM
Amniorrhexis < 37 weeks’ gestational age
prior to onset of active labor
Preterm Premature Rupture of Membranes
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Latency
Interval from Rupture of Membranes
to Onset of Active Labor
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Diagnosis History Avoid digital exam Vaginal Pool Nitrazine Paper Ferning Ultrasound Amniocentesis/Dye Study
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PROM near Term
Management gestational age dependent
Induction vs. awaiting spontaneous labor
Antibiotic prophylaxis per ACOG/CDC recommendations
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Induction vs. Expectant Management
>5,000 women randomized Oxytocin, PGE2 or expectant
management up to 4 days No difference in cesarean section
or neonatal infection Less chorioamnionitis in induction
with oxytocin groupHannah, NEJM, 1996
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Epidemiology of Preterm Birth
PPROM
Spontaneous Preterm Delivery
Indicated Preterm Delivery
28 %
46 %26 %
Andrews, 1995
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PPROMRisk Factors
Lower/Upper Genital Tract Infection Proteases Prostaglandins
History of PPROM Incompetent Cervix Abruption Polyhydramnios Multiple Gestation Smoking
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PPROMComplications
Maternal/Fetal Infection Premature Labor and Delivery Umbilical Cord Prolapse Fetal Hypoxia 2º Cord Compression Increased Rate of Cesarean Section Intrauterine Growth Restriction Abruption Stillbirth
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PPROMStandard Management
Confirmation of Diagnosis Verification of Gestational Age R/O Labor/Infection/Fetal
Compromise Avoid Digital Vaginal Examinations In Hospital Observation Bedrest
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PPROMLatency
Gestational Age (Weeks)
% P
ati
en
ts w
ith
La
ten
cy
>
1 W
ee
k
25
50
75
25 25-28 29-32 33-360
Wilson, Obstetrics & Gynecology, 1982
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PPROMVaginal Examination
24-26 26-28 28-30 30-32 32-34 34-35
Gestational Age (Weeks)
20
15
10
5Lat
ency
Day
s No Exam
Exam
Lewis, Obstetrics & Gynecology, 1992
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Previable PPROM
< 24 weeks
Poor prognosis for successful outcome
Outcome may be different for spontaneous vs. iatrogenic
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Previable PPROMComplications
Uterine Infection
Pulmonary Hypoplasia
Limb Compression Deformities
Intrauterine Growth Restriction
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Previable PPROMOutcomes
Study# of
Infants Chorio. Survival
NormalNeurologicalDevelopment
Taylor 60 25% 22% 38%
Major 71 43% 65% 31%
Moretti 124 39% 32% 33%
Bengston 63 46% 51% 16%
Overall 318 39% 41% 30%
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PPROMManagement Issues
Timing of Delivery Tocolysis Antibiotics Steroids Amniocentesis Observation vs. Induction Fetal Lung Maturity Testing Fetal Surveillance
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Timing of Delivery
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Neonatal Morbidity/MortalityUAB (1995-1996)
%
23 25 27 29 31 33 35 >37
Survival100
25
50
75
Gestational Age (Weeks)
RDS IVH NEC Sepsis
0
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RNICU Survival and Morbidity Data (1995-
1996)
23 25 27 29 31 33 35 >37
Survival100
25
50
75
Weeks
RDS
IVH
NEC
Sepsis% N
eon
ates
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Tocolysis
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Tocolysis(n=33)
Bedrest(n=42)
Gestational age 30.0 29.4Days gained 6.7 5.2> 48 hr 87.9% 76.2%RDS 45.4% 52.4%Sepsis 9.1% 7.1%NEC 18.2% 23.8%Neonatal death 9.1% 11.9%
PPROMTocolysis
Weiner, AJOG, 1988
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Tocolysis(n=39)
Expectant(n=40)
Gestational age 27.9 27.3Days gained 11.5 12.0> 48 hr 77% 75%RDS 51% 58%Sepsis 3% 5%IVH 8% 5%Hospital stay 47.5 57.0
PPROMTocolysis
Garite, AJOG, 1987
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Antibiotics
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Preterm LaborChorioamnion Colonization
0 30 weeks
31- 34 weeks
34- 36weeks
37 weeks
25
50
75
% P
atie
nts
Co
lon
ized
SpontaneousPreterm Labor
Indicated
Cassell, 1993
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PPROMAntibiotic Therapy
Reduction Maternal/Perinatal
Infection
Prolong Latency Period
Improve Neonatal Outcome
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Antibiotic: PPROMNIH-MFM Network Study
PPROM between 24 and 32 weeks IV ampicillin and erythromycin for 48 h Oral amoxicillin/erythromycin for 5 days Identification and Rx of GBS carriers Tocolysis and corticosteroids prohibited
Mercer, JAMA, 1997
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Antibiotics(n=299)
Placebo(n=312) RR
RDS 40.5% 48.7% 0.83IVH 6.4% 7.7% 0.82Sepsis <72 hr 5.4% 6.4% 0.83NEC 2.3% 5.8% 0.40Death 6.4% 5.8% 1.10Composite 44.1% 52.9% 0.84
Antibiotic: NIH-MFM Network Study
Neonatal Morbidity
*
*
*
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Antibiotic: Latency PeriodNIH-MFM Network StudyDuration of Latency Antibiotics Control
48 hrs 27.3 % 36.6 %
7 days 55.5 % 73.5 %
14 days 75.6 % 87.9 %
21 days 85.7 % 93.0 %
Median 6.1 days 2.9 days
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PPROMAntibiotic Therapy
Optimal Antibiotic Regimen
Route/Duration of Administration
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Antibiotics & PPROM: Summary
Reduction in maternal infectious morbidity
Reduction in births <48 h and <7 d Reduction in neonatal infectious
morbidity Reduction in neonates requiring
NICU and ventilation >28 d
Kenyon, Cochrane Library, 1999
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Antibiotics & PPROM: Summary
No clear reduction in perinatal death
No clear reduction in cerebral abnormalities
Kenyon, Cochrane Library, 1999
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Amniocentesis
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PPROMAmniotic 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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Utility of Amniocentesis
Confirm/Refute diagnosis of chorioamnionitis Glucose <15 mg/dL Culture Gram stain
Lung maturity testing
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Corticosteroids
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Corticosteroids for FLM
Betamethasone
Dexamethasone
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PPROMCorticosteroids
BlockTaeuschPapageorgiouYoungGariteCollaborativeIamsNelsonSimpsonMorales
4317173880
1533822
112121
2624193780
1353546
105124
Author Steroids ControlEffect on
RDSNumber of Patients
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Treatment Control OR
RDS 83 / 456 149 / 421 0.44
NeonatalInfection
18 / 200 20 / 188 0.82
PPROMCorticosteroids
Crowley, Ob/Gyn Clinics, 1992
*
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Steroids(n=38)
No Steroids(n=39)
Gestation at ROM 29.3 29.7EGA at delivery 31.4 32.0RDS 18% 44%IVH ----- 8%NEC ----- 8%Sepsis 3% 5%Death 3% 3%Hospital days 24.8 29.2
PPROMCorticosteroids +
Antibiotics
*
Lewis, Obstetrics & Gynecology, 1996
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1994 NIH Consensus Conference:
Corticosteroids in PPROM
Corticosteroids reduce incidence/severity of RDS, IVH
Benefits in PPROM up to 30-32 weeks
No significant adverse outcomes for corticosteroid use in PPROM
Impact less than with intact membranes
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Observation vs. Induction
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Neonatal Morbidity/MortalityUAB (1995-1996)
%
30 32 34 36
Survival100
25
50
75
Weeks
RDS
IVH NEC Sepsis
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Induction(n=46)
Expectant(n=47)
Cesarean delivery 8.7% 6.4%Chorioamnionitis 10.9% 27.7%Survival 100% 100%Oxygen >24 hr 4.4% 2.1%IVH ----- -----NEC ----- -----Sepsis - W/U 28.3% 59.6%Sepsis - Confirmed 6.8% 4.3%
PPROMObservation vs. Induction
Mercer, AJOG, 1993
*
*
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PPROMObservation vs Induction
Delivery(n=61)
Expectant(n=68)
Cesarean delivery 23% 12%Chorioamnionitis 2% 15%Stillbirth 0 1.4%Neonatal Death 5% 0RDS 37% 33%IVH 6% 4.3%NEC 1.6% 1.4%Sepsis 3% 7%
Cox, Obstetrics & Gynecology, 1995
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Fetal Lung Maturity Testing
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Fetal Lung MaturationBiologic Markers
8
6
4
2
0 0
4
2
6
8
20 24 28 32 36 40Gestational Age (weeks)
L:S
Rat
io
% P
ho
sph
olip
id
L:S
PI
PG
10
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Fetal Lung Maturity Evaluation in Vaginal Pool
Specimen
L:S Ratio Not Reliable
TDX:FLM Assay Not Validated
PG Useful
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Fetal Surveillance
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PPROMFetal Surveillance
Daily Non-Stress Test (NST) Variables Tachycardia Loss of reactivity
Biophysical Profile (BPP) Contraction Stress Test (CST)
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Summary
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UAB Management of PPROM
•PPROM 34 weeks•Deliver
•Previable PROM•Outpatient observation•Antibiotic prophylaxis•Option of termination <22wk•Admission at viability
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•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 34-35 weeks
UAB Management of PPROM