1、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,P
2、PROM,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,History Avoid digital exam Vaginal Pool Nitrazine Paper Ferning Ultrasound Amniocentesis/Dye Study,PROM near
3、Term,Management gestational age dependent Induction vs. awaiting spontaneous labor Antibiotic prophylaxis per ACOG/CDC recommendations,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
4、 Less chorioamnionitis in induction with oxytocin group Hannah, NEJM, 1996,Epidemiology of Preterm Birth,PPROM,SpontaneousPretermDelivery,IndicatedPretermDelivery,28 %,46 %,26 %,Andrews, 1995,PPROM Risk Factors,Lower/Upper Genital Tract Infection Proteases Prostaglandins History of PPROM Incompetent
5、 Cervix Abruption Polyhydramnios Multiple Gestation Smoking,PPROM Complications,Maternal/Fetal Infection Premature Labor and Delivery Umbilical Cord Prolapse Fetal Hypoxia 2 Cord Compression Increased Rate of Cesarean Section Intrauterine Growth Restriction Abruption Stillbirth,PPROM Standard Manage
6、ment,Confirmation of Diagnosis Verification of Gestational Age R/O Labor/Infection/Fetal Compromise Avoid Digital Vaginal Examinations In Hospital Observation Bedrest,PPROM Latency,Gestational Age (Weeks),% Patients with Latency 1 Week,25,50,75,0,Wilson, Obstetrics & Gynecology, 1982,PPROM Vaginal E
7、xamination,Gestational Age (Weeks),20,15,10,5,Latency Days,No Exam,Exam,Lewis, Obstetrics & Gynecology, 1992,Previable PPROM, 24 weeks Poor prognosis for successful outcome Outcome may be different for spontaneous vs. iatrogenic,Previable PPROM Complications,Uterine InfectionPulmonary HypoplasiaLimb
8、 Compression DeformitiesIntrauterine Growth Restriction,Previable PPROM Outcomes,PPROM Management Issues,Timing of DeliveryTocolysisAntibioticsSteroidsAmniocentesis Observation vs. InductionFetal Lung Maturity TestingFetal Surveillance,Timing of Delivery,Neonatal Morbidity/Mortality UAB (1995-1996),
9、%,RNICU Survival and Morbidity Data (1995-1996),% Neonates,Tocolysis,PPROM Tocolysis,Weiner, AJOG, 1988,PPROM Tocolysis,Garite, AJOG, 1987,Antibiotics,Preterm Labor Chorioamnion Colonization,Cassell, 1993,PPROM Antibiotic Therapy,Reduction Maternal/Perinatal Infection Prolong Latency Period Improve
10、Neonatal Outcome,Antibiotic: PPROM NIH-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,Antibiotic: NIH-MFM Network Study
11、Neonatal Morbidity,*,*,*,Antibiotic: Latency Period NIH-MFM Network Study,PPROM Antibiotic Therapy,Optimal Antibiotic Regimen Route/Duration of Administration,Antibiotics & PPROM: Summary,Reduction in maternal infectious morbidity Reduction in births 28 d,Kenyon, Cochrane Library, 1999,Antibiotics &
12、 PPROM: Summary,No clear reduction in perinatal death No clear reduction in cerebral abnormalities,Kenyon, Cochrane Library, 1999,Amniocentesis,PPROM Amniotic Fluid Culture,Group B Streptococcus 20 %Gardnerella vaginalis 17 %Peptostreptococcus 11 %Fusobacteria 10 %Bacteroides fragilis 9 %Other Strep
13、tococci 9 %Bacteroides sp. 5 %,Utility of Amniocentesis,Confirm/Refute diagnosis of chorioamnionitis Glucose 15 mg/dL Culture Gram stain Lung maturity testing,Corticosteroids,Corticosteroids for FLM,Betamethasone Dexamethasone,PPROM Corticosteroids,PPROM Corticosteroids,Crowley, Ob/Gyn Clinics, 1992
14、,*,PPROM Corticosteroids + Antibiotics,*,Lewis, Obstetrics & Gynecology, 1996,1994 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
15、than with intact membranes,Observation vs. Induction,Neonatal Morbidity/Mortality UAB (1995-1996),%,PPROM Observation vs. Induction,Mercer, AJOG, 1993,*,*,PPROM Observation vs Induction,Cox, Obstetrics & Gynecology, 1995,Fetal Lung Maturity Testing,Fetal Lung Maturation Biologic Markers,Fetal Lung M
16、aturity Evaluation in Vaginal Pool Specimen,L:S Ratio Not Reliable TDX:FLM Assay Not Validated PG Useful,Fetal Surveillance,PPROM Fetal Surveillance,Daily Non-Stress Test (NST) Variables Tachycardia Loss of reactivity Biophysical Profile (BPP) Contraction Stress Test (CST),Summary,UAB Management of
17、PPROM,PPROM 34 weeks DeliverPreviable 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 34-35 weeks,UAB Management of PPROM,
