Preterm Prelabour Rupture of Membranes

(PPROM)

<Presentations>

<Index>

 

 Definition

-  Rupture of membranes <37 weeks gestation of pregnancy & prior to onset of labour

 

Features

-  Clinical Dx

-  PPROM <22 weeks survival rate 20%

-  2% pregnancies

 

Associated S/S

-  Rupture of membranes

-  Sensation of passing water from vagina

-  Wet pads/underwear

-  Signs of infection

-  Fever

-  Abdo pain

-  Nausea, vomiting

 

Complications

-  Chorioamnionitis

-  Preterm delivery

-  PPROM ass w 40%

-  Neonatal mortality & morbidity

-  Preterm delivery

-  Sepsis

-  Pulmonary hypoplasia

 

Ix

-  Vitals

-  Temp: Fever: chorioamnionitis

-  Abdo exam

-  Abdo Palp

-  Speculum exam

-  All women w ?PPROM

-  Amniotic fluid in vagina

-  +/- HVS + LVS for MCS: GBS status

-  +/- Amnisure

-   Esp if for T/F (PERS usually requires)

-  DO NOT perform VE

-  Risk of infection: chorioamionitis

-  CTG 20min+

-  FBE

-  +/- US

-  Reduced AFI w normal kidneys & nil IUGR = highly suggestive

-  Normal AFI does not exclude PPROM

-  Adjunt when Spec negative

 

Mx

-  Admission to birthing unit for ongoing R/V for 72hrs+ if unless obvious

-  4/24 Temp: infection: chorioamionitis

-  Patient to wear pad & to check regularly

-  Assess for abdo pain or tenderness: infection: chorioamionitis

-  D/C if not unwell, nil signs of infection & not in labour

-   TDS home temp: return if fever

-   Observation of fetal movements: return if reduced

-   Weekly R/V until labour

-  Confirmed rupture

-  HVS + LVS

-  FBE, CRP as baseline

-  +/- US: AFI, EFW, SD

-  Prophylactic antibiotics

-  Erythromycin 250mg PO QID for 7 days

-  Delays labour & decreases infection rate but no change in neonatal mortality

-  If no evidence of infection

-  Once labour commenced Mx as per GBS status

-  If GBS positive

-  Consider IOL after 32 weeks

-  If <34 weeks

-  Steroids: Betamethasone 11.4mg IM Daily x2 doses 24hrs apart: prevent RDS

-  +/- tocolysis if nil infection

-   Not routine

-   Increase risk of chorioamnionitis with minimal benefit to infant

-   Consider to allow time for steroids to effect +/- T/F

-  Aim for expectant Mx unless

-   Unstable lie

-   Vaginal bleeding

-   Chorioamnionitis

-   Cord prolapse

-   IUGR

-   Abnormal CTG

-   MSL

-   GBS positive

-  If <22 weeks: expert opinion

-  If >36 weeks

-  IOL at next opportunity

-  >34/40 consider IOL

-  +/- Transfer to unit able to Mx neonate of gestation

-  Ongoing Mx

-  4/24 vitals: fever

-  Daily CTG

-  Pad checks

-  Weekly or twice weekly FBE, CRP + HVS

-  Aim to deliver 34-37/40 unless chorioamnionitis

-  Out-pt Mx if

-   Consultant R/V

-   Hospital R/V 28-72hrs prior to D/C

-   4/24 temps

-   Daily F/U

-  If suspect chorioamnionitis expediate delivery

-  IOL

-  B/C, FBE, CRP

-  IV Cephazolin + Metrondiazole

 

 

 

References

 

RWH CPG: Rupture of Membranes: Preterm Premature, 2006

LRH Protocols: Management of PPROM

Cochrane Review: Tocolytics for PPROM, 04/09/2011

Cochrane Review: Antibiotics for Preterm Rupture of Membranes, 04/08/2010