PREMATURE RUPTURE OF

MEMBRANES

Arda Lembet, MD

Associate Professor

Femical Women’s Clinic

Istanbul

Overview, clinical significance

Diagnosis

Evaluation

Management

> 37 weeks

34 - 36 6/7 weeks

32 - 33 6/7 weeks

23 - 31 6/7 weeks

< 23 weeks

PROM

PPROM Management - Special Circumstances

Cerclage

HSV ,HIV

Membrane resealing

Amnioinfusion, amniopatch

Prevention of recurrent PPROM

Multiple pregnancy

Hospital versus outpatient management

PROM: Premature rupture of

membranes

PPROM: Preterm premature rupture

of membranes

LATENCY: Interval from rupture of

membranes to onset of active

labor

Overview, clinical significance

Clinical chorioamnionitis % 13-60

Endometritis % 2-13

(+) AF culture % 25-35

Maternal sepsis % 1

Fetal loss % 1-2

Abruptio placenta % 4-12

PPROM

Pathophysiology:

Collagen remodeling, cellular apoptozis

Ascending infection

Clinical risk factors :

Short cervix / incompetent cervix

Cervicovaginal fetal fibronectin

Abruption

Polyhydramnios / multiple gestation

PPROM

(PROM ) Clinical Risk Factors

Odds ratio

H /o PPROM 3.3-6.3

H / o PTL 1.9-2.8

Smoking 2.1

Vaginal bleeding during pregnancy

1.trimester 2.4

2. trimester 4.4

3. trimester 6.4

> 1 trimester 7.4

Acute pulmonary disease 1.8

Bacterial vaginosis 1.5

PROM Diagnosis

Clinical Diagnosis:

Tests : Alkaline pH > 6- 6.5

Ferning

Biochemical markers: (placental

alpha microglobulin-1 (PAMG-1)

IGFBP-1, fFN, AFP, fT4, prolactin,

hCG, IL-6 )

USG: AFV ?, AS ?

PPROM Evaluation- I

Cultures: Cervical cultures; Neisseria gonorrhea,

Chlamydia, anovaginal culture; GBS

Urinalysis / culture

Digital exam: NO

NST: For how long?, intermittent monitoring

Clinical chorioamnionitis: Fever > 38 , uterine

tenderness and / or maternal and fetal

tachycardia…..Delivery

PPROM Evaluation - II

Leucocytosis: WBC > 16,000

USG / Fetal Biophysical Profile

Amniocentesis:

Gram stain, WBC >30 cell/microl,

glucose < 16-20, culture (aerobic-anaerobic,

mycoplazma )

PPROM Evaluation - II

Amniotic Fluid Culture:

• Group B Streptococcus 20 %

• Gardnerella vaginalis 17 %

• Peptostreptococcus 11 %

• Fusobacteria 10%

• Bacteroides fragilis 9 %

• Other streptococci 9 %

• Bacteroides sp. 5 %

PPROM Evaluation - III

CERVICAL LENGTH

Cut-off level: 2-2.4 cm

Latency period

Intraamniotic infection

How does it compare to WBC, CRP ??

PPROM Evaluation - IV

Fetal Lung Maturity Evaluation in Vaginal Pool

L/S Ratio Not Reliable

TDX: FLM Assay Not Validated

PG Useful

PPROM Evaluation - V

PPROM Management

Clinical chorioamnionitis

Nonreassuring fetal well being,

Severe vaginal bleeding,

Advanced labor,

Pregnancy complications ( preeclampsia etc )

DELIVERY

PROM Management

Term > 37 weeks :

Infection : 12 h %2

12-24 %6

48 %24

Labor induction / augmentation:

Prostaglandin:

GBS: > 18 h prophylaxis, culture last 6 week > -

PPROM Management

Preterm: 34 - 36 6/7 weeks :

Corticosteroids ? Prolongation of latent phase ?

Since the risk of infection and umbilical cord

accidents are higher than the risk of prematurity

….DELIVERY

PPROM Management 34-37 weeks

Chorioamnionitis should we care ?

Chorioamnionitis should we care ?

PPROM Management

Preterm: 32 - 33 6/7 weeks :

Lung maturation : Vaginal pooling / AS

PG, FLM or L/S if mature…DELIVERY

Immature or can not be tested

Delivery after steroids (24-48 hours later or deliver

@34 weeks ) / Broad spectrum antibiotics

PPROM Management

Preterm: 23 - 31 6/7 weeks:

Fetal / maternal monitorization

Antenatal corticosteroids :

Broad spectrum antibiotics:

Amp 2 g iv / q 6 h 48 h + eritro iv 250 mg q 6

Amoxocilin 250 mg po q 8 5 d + eritro 333 po q 6

Alternative; oral amp / eritro / azithro

PPROM Management

Preterm: 23 - 31 6/7 weeks :

The relation between broad spectrum ab and NEC ??

After 7 days of ab f/u patients for GBS carriers

Stop ab, treat intrapartum

After 7 days give narrow spectrum ab until

delivery

Follow by anovaginal cultures ; Treat if +

PPROM Management

Preterm: 23 - 31 6/7 weeks :

Consider Mg SO4 for neuroprotection

if delivery < 32 weeks

PPROM Management

Preterm: 23 - 31 6/7 weeks :

Daily NST / FBPP

WBC ?? Baseline

Cervicovaginal pathogen and UTI treatment

USG, oligohydroamnios ??

Tocolysis, amnioinfusion

Thromboemboli prophylaxis

PPROM Management

Preterm: < 23 weeks :

Dating and confirmation of the gestational week

High complication rate:

Chorioamnionitis % 39

Endometritis % 14

Abruption % 3

Placenta ret, PPH, D&C % 12

IUFD (fetal demise) % 15

PPROM Management

Preterm: < 23 weeks :

Oligohydramnios: < 20 weeks:

Poor prognostic parameter

Pulmonary hypoplasia ( TC / AC )

Skeletal deformities

Membrane resealing:

New treatment modalities: Gelfoam,fibrin-platelet-cryo-

NICHD Extremely Preterm Birth

Outcome Data

NICHD Extremely Preterm Birth

Outcome Data

PPROM Management - Special Circumstances

Cerclage: Should it be removed ? When ?

HSV:

HIV:

Membrane resealing:

Amnioinfusion:

Prevention of recurrent PPROM:

Progesterone , Vitamin C , E?

Multiple pregnancy:

PPROM Management - Special Circumstances

Multiple pregnancy:

Incidence: 7-8 %

Latency period

Survival , morbidity, sac differs ??

Antibiotics, steroids : Same as singletons

Tocolysis, MgSO4: Same as singletons

Delayed interval delivery ??

Selective fetocide ??