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Flashcards in PPROM Deck (21)
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1

Proportion of preterm births associated with PPROM?

30-40%

2

Risks of PPROM?

prematurity,
sepsis,
cord prolapse
pulmonary hypoplasia.

In addition, there are risks associated with chorioamnionitis and placental abruption.

3

Median latency after PPROM

7 days, decreases as gestation increases

4

How to diagnose PPROM

- History
-Sterile speculum examination
- If uncertain, perform IGFBP-1 or PAMG-1 test of vaginal fluid
- Clinical assessment for infection: observations, blood tests (WCC, CRP) and CTG

5

Management

- Steroids if <35/40
- MgSO4 if in labour and <30/40
- 10/7 erythromycin 250mg QID
- Vaginal swabs
- Confirm presentation
- Admission and assessment for infection
- If managed as an outpatient- twice weekly blood and assessment in a maternity unit - take into account past obstetric hx, support at home and distance from hospital
- IOL at 37/40
- IV Ben Pen in labour
- Offer emotional support as increased rates of PTSD in women with PPROM
- Counsel re risks of PTL, risks of chorioamnionitis and features to look out for
- Offer women chance to speak with neonatologist and inform paeds of admission

6

Results of cochrane review looking at use of antibiotics

Reduction in:
- delivery rates at 48 hours and 7/7
- Chorioamnionitis
- Neonatal infection,
- use of surfactant,
- oxygen therapy
- abnormal cerebral ultrasound prior to discharge from hospital

No reduction in:
- Neonatal mortality
- Health of children at 7 years

7

Benefit of MgSO4 24 hours around delivery, in women in established preterm labour <30/40

Reduces:
- Cerebral palsy
- Motor dysfunction in the offspring

8

Should tocolysis be offered?

Cochrane review found an increase in incidence of chorioamnionitis with no perinatal benefit

9

Cochrane review of timing of delivery with PPROM

Two trials: PPROMT multicentre and the PPROMEXIL-2 randomised controlled trials

- Compared expectant versus planned early delivery
- in women with PPROM ‘with no contraindications to continuing the pregnancy, expectant management with careful monitoring is associated with better outcomes for the mother and baby’.

No differences between early birth and expectant management in:
- neonatal sepsis or infection
- Perinatal mortality
- IUFD

Early delivery increased the incidence of:
-respiratory distress syndrome
-increased rate of caesarean section
- Neonatal death
- ventilation

10

Limitations when considering results of cochrane
review for delivery at 37/40

- Looked at late PPROM- didn't look at gestations <34/40
- Exclusion criteria: active labour,
chorioamnionitis, concerns about fetal wellbeing, monochorionic multiple pregnancy, hypertensive disorders

11

Which is more accurate- IGFBP-1 (Actim PROM) or PAMG-1 (amnisure) in detecting PPROM?

PAMG-1 (amnisure)

12

Other alternative antibiotic regimes

48 hours of IV ampicillin, followed by PO erythromycin and amoxicillin OR addition of azithromycin to target ureaplasmas

13

RANZCOG Q: A primiparous woman presents to you at 32 weeks gestation with spontaneous rupture of membranes. Her pregnancy has been uncomplicated so far and she is well.
a) Outline what assessments you would perform. (3 marks)

1. History – time, amount, colour, smell of fluid.
- confirm dates
- associated symptoms – pain, contractions, fever
- Recent infective symptoms – cough, dysuria etc.
- FM’s
- PMHx etc

2. Examination – obs
Uterine – tenderness, contractions, lie and presentation
Speculum – confirm diagnosis, assess cervcal dialation

3. Extra tests if uncertain – amnisure, ferning on microscopy, nitrizine sticks (contentious), serial pad checks

4. FBC, CRP, swab, USS – liq volume, growth, presentation, placentation.

14

b) Assuming your investigations are normal, how would you manage her? (5 marks) (PPROM at 32/40)

1. Admit for observation – chance of PTL
2. Ensure unit with NICU available
3. Maternal wellbeing – temp, pulse, pad checks q4-8 hourly
4. Fetal wellbeing – CTG daily, USS 1-2 weekly
5. Antibiotics – erythromycin 250mg PO QDS, start IV ben pen if going into labour
6. Steroids – betamethasone 11.4mg IM x2

15

The Oracle I trial (Kenyon et al. Lancet 2001; 357: 979-88) studied women with preterm prelabour rupture of membranes.

c) Briefly describe the study and its principle findings (numerical statistics not required) (4 marks)

Large multicentre double blinded placebo controlled RCT
n > 4800

Aim – to evaluate benefit of antibiotics for women with PPROM
Inclusion - <37/40, PPROM

Women randomized to:
1. augmentin + placebo
2. erythromycin + placebo
3. augmetin + erythromycin
4. placebp + placebo

1’ Outcome – composite measure of neonatal morbidity and mortality - NND, lung disease and USS evidence of CNS abnormality

Result – erythromycin:
• Prolongs pregnancy mean 10d
• Reduced 1’ outcome

Augmentin = increased NEC

16

The Oracle II study (Kenyon et al. Lancet 2001; 357: 989-94) used the same treatment options as Oracle I.

d) How did the group of women that was studied differ from the Oracle I group? (1 mark)

Women with threatened preterm delivery and membranes intact as opposed to PPROM

17

Both studies had their 7 year follow up data published in 2008 (Kenyon et al. Lancet 2008; 372: 1310–27).
e) What additional information did this follow up provide (numerical statistics not required)? (2 marks)

Neither antibiotic made a statistically significant difference to:
• Functional impairment
• Educational achievement
• Behavioural difficulties
• Specific medical conditions

In children at 7 years of age.

18

Incidence of PPROM

3%

19

PPROM associated with what percentage of preterm birth?

30-40%

20

Evidence for use of steroids in PPROM

Reduced rate of:
- Intraventricular haemorrhage
- RDS

No difference was observed for:
- necrotising enterocolitis,
- neonatal sepsis
- Apgar score of less than 7 at 5 minutes
- Perinatal mortality

No increased risk of chorioamnionitis or neonatal sepsis with maternal steroid use.

After 34/40 there is a high NNT for benefit and potential risk of giving steroids therefore decision should be made on an individual basis.

21

Results of a retrospective cohort study of women with PPROM who had planned home care?

- membrane rupture occurring before 26+0 weeks’,
- non‐cephalic presentation and
- oligohydramnios

Associated with an increased risk of ‘complication’ (defined as fetal death, placental abruption, umbilical cord prolapse, delivery outside of hospital and neonatal death).

Hospital based care should be recommended to women who have all three of these features.