PPROM Flashcards
Proportion of preterm births associated with PPROM?
30-40%
Risks of PPROM?
prematurity,
sepsis,
cord prolapse
pulmonary hypoplasia.
In addition, there are risks associated with chorioamnionitis and placental abruption.
Median latency after PPROM
7 days, decreases as gestation increases
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
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
Results of cochrane review looking at use of antibiotics
Reduction in:
- Chorioamnionitis
- delivery rates at 48 hours and 7/7
- 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
Benefit of MgSO4 24 hours around delivery, in women in established preterm labour <30/40
Reduces:
- Cerebral palsy
- Motor dysfunction in the offspring
Should tocolysis be offered?
Cochrane review found an increase in incidence of chorioamnionitis with no perinatal benefit
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
- ventilation
- Neonatal death
- increased rate of caesarean section
Limitations when considering results of cochrane
review for delivery at 37/40
- Looked at late PPROM- didn’t look at gestations <34/40, therefore unclear if early PPROM benefit from expectant Rx till 37 weeks
- Exclusion criteria: active labour,
chorioamnionitis, concerns about fetal wellbeing, monochorionic multiple pregnancy, hypertensive disorders
Evaluate nitrazine, IGFBP-1 (Actim PROM) and PAMG-1 (amnisure) for detecting PPROM?
RCT 2014 compared 3 options and found the following sensitivity, specificity, PPV, NPV for each.
PAMG-1 (amnisure)
- sensitivity, specificity, PPV NPV all = 100%
- Point of care
- Quick result
- Minimally invasive
- NOT affected by semen or trace amounts of blood
- False positive of 15-30% in threatened preterm labour
IGFBP-1 (Actim PROM)
- sensitivity, specificity, PPV NPV (93%, 99%, 97% and 98%)
- NOT affected by semen or trace amounts of blood
Nitrazine
- sensitivity, specificity, PPV NPV (93%, 94%, 85% and 98%)
- Affected by any alkaline fluid: blood, semen, soap, infections - BV
Other alternative antibiotic regimes
48 hours of IV ampicillin, followed by PO erythromycin and amoxicillin OR addition of azithromycin to target ureaplasmas
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)
- History – time, amount, colour, smell of fluid.
- confirm dates
- associated symptoms – pain, contractions, fever
- Recent infective symptoms – cough, dysuria etc.
- FM’s
- PMHx etc - Examination – obs
Uterine – tenderness, contractions, lie and presentation
Speculum – confirm diagnosis, assess cervcal dialation - Extra tests if uncertain – amnisure, nitrizine sticks (contentious), serial pad checks
- FBC, CRP, swab, USS – liq volume, growth, presentation, placentation.
b) Assuming your investigations are normal, how would you manage her? (5 marks) (PPROM at 32/40)
- Admit for observation – chance of PTL
- Ensure unit with NICU available
- Maternal wellbeing – temp, pulse, pad checks q4-8 hourly
- Fetal wellbeing – CTG daily, USS 1-2 weekly
- Antibiotics – erythromycin 250mg PO QDS, start IV ben pen if going into labour
- Steroids – betamethasone 11.4mg IM x2
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:
- augmentin + placebo
- erythromycin + placebo
- augmetin + erythromycin
- 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, did not reduce primary outcome
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
Demonstrated no improvement in outcomes when oral erythromycin or augmentin were given
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.
Incidence of PPROM
3%
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.
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.
How is PROM diagnosed?
1) Sterile speculum examination for pooling liquor
Additional tests if speculum findings uncertain:
2) Nitrazine paper for pH - turns blue in alkaline pH >6.0
3) Amnisure - uses immunochromatography. Monoclonal antibodies bind PAMG1 protein (high in amniotic fluid, but low in vaginal secretions at all gestations)
4) Actim PROM - detects insulin-like growth factor binding protein 1 (IGFBP-1)
If PPROM with GBS, how does management differ?
IOL at 34 weeks, when risks of GBS sepsis may outweigh the risks of prematurity
(RANZCOG)
What is the incidence of PPROM?
3%
RCOG
PPROM is associated with _______ of preterm births
30-40%
RCOG
