PROM/PPROM

Question 1

Diagnosis of ROM?

Answer 1

pooling, ferning (dried AF - NaCl), nitrazine (pH amnioitc fluid 7.1-7.3)

false negatives- low AFI
false positives- blood, semen, urine, BV, alkaline antiseptics

Question 2

role of fetal fibronectin?

Answer 2

high negative predictive value

Question 3

role of amniotic fluid protein?

Answer 3

high sensitivity; high false positive rate (19-30%).

should be used in ancillary manner

Question 4

risks of PPROM < 24 weeks?

Answer 4

• neonatal survival > 22 weeks much better than < 22 weeks: 57 vs 14%
• 40-50% will deliver within 1 week, 70-80% within 2 to 5 weeks
• maternal infection, retained placenta, abruption, maternal risk of sepsis 1%
• potter sequence: low set ears, prominent epicanthal folds, recessed chin, limb contractures, skeletal malformations

Question 5

management of PPROM < 24 weeks?

Answer 5

• offer delivery
• if desires expectant management, and no evidence of chorio- then outpatient management with body temp measurements. close precautions
• ANC and abx at viability (much data does not exist far before 24 w)
• NP mag may be consider as early as 23w0d
• MFM/neonatology consult

Question 6

when would you deliver in general for PROM?

Answer 6

• abnormal fetal testing
• clinical IAI
• significant abruption

Question 7

PPROM from 24w0d to 33w6d?

Answer 7

• admission
• latency abx (prolongs pregnancy, reduces maternal and noenatal infection, improves gestational age outcomes)
• ANC x 1 course
• NP mag if before 32w0d and at risk of imminent delivery

Question 8

latency antibiotic regimen?

Answer 8

no one single possible regimen

• ampicillin 2 g IV q6hr x 48 hour -> amoxicillin 250 mg q6hr x 5 days
• erythromycin 250 mg q6hr x 48 hr -> PO erythromcyin base 333 mg q6hr x 48 hours
• alternatively: azithromcyin 1 g PO x 1 if non-tolerant of erythromcyin or hospital dose not have
• no augmentin due to risk of NEC
• if patient has allergy to beta lactam abx -> can tailor to GBS susceptibilities

Question 9

management 34w0d - 36w6d PPROM?

Answer 9

• expectant management or delivery
• expectant management slightly improved fetal outcomes; delivery lower risks of maternal hemorrhage and infection
• regardless can give course of ANC (if not already received, if delivery expected in > 24 hrs but less than 7 days, no e/o IAI)

Question 10

term

Answer 10

• may allow expectant management for 12-14 hrs
• IOL with oxyctocin or prostaglandin (may have higher risk of infection though)
• if declines IOL, then counsel on risks; if maternal and fetal status stable; then “may be acceptable”

Question 11

risk of delivering in 1 week?

Answer 11

50%

Question 12

fetal risks of prematurity?

Answer 12

RDS, IVH, NEC, sepsis

Question 13

maternal risks of PPROM

Answer 13

infection - 15-25% antepartum, postpartum 15-20%

abruption in 2-5%

Question 14

risk of transmission with HSV?

Answer 14

primary = 30-50%
recurrent = 3%

Question 15

management with HSV and PPROM

Answer 15

recurrent

• expectant magagement < 34weeks
• ANC/abx/NP Mg
• at 34 weeks if active lesions/prodoromal sx -> CD
• HSV therapy

primary

• less clear expectant vs delivery
• HSV therapy
• CD if lesions present

Question 16

HIV and PPROM

Answer 16

• management unclear
• need specialist in HIV/MFM
• evidence that high dose ART with low VL likely no increased risk of transmission

Question 17

PPROM following amniocentesis - how common? prognosis?

Answer 17

• less than 1%
• 91% perinatal survival
• 72% reaccumulation of fluid
• outpt management - precautions + regular check ins

Question 18

in pregnancy with hx of PPROM or counseling for future pregnancy?

Answer 18

increased risk of PPROM

• offer vaginal progesterone starting 16-24 weeks
• consider screening cervical length for possibility of cerclage:
• -> singleton pregnancy
• -> prior spontaneous pre-term birth at less than 34 weeks of gestation
• -> shortcervical length (less than 25 mm) before 24 weeks of gestation