Preterm premature rupture of membranes (PPROM)

Diagnosis, evaluation and management strategies

Supplement-BJOG March 2005

Introduction

Definition:

PROM: Rupture of amniotic membranes with release of AF > 1 hour prior to labor onset PPROM: PROM prior to 37 weeks of gestation

complicates 3% of pregnancies and of preterm births.

Diagnosis

Effective treatment relies on accurate diagnosis: clinical suspicion patient history simple testing Patient history 90 % accurate

Evaluation- tests
Ferning test

Midvaginal/ posterior fornix fluid Air dry for 10 mints Cervical mucous can cause false +ve Ferning unaffected by meconium, changes in pH, blood in small amount

Evaluation- tests

Nitrazine test: Can be altered by contaminants in vaginal pool (BV, cervicitis, semen, blood cause false +ve)

Avoid digital examination as latency shortened significantly: 2studies; Lewis et al, Alexander et al

PPROM- causes

Intrauterine infection; A major factor implicated in PPROM Others; Membrane stretch Abruption membranes collagen content degradation of collagen

Infection and PPROM

Subclinical in majority-no overt chorioamnionitis Upto 40% culture positivity using transabdominal amniocentesis Adverse outcome to newborn and during infancy Need to establish infection earlydelivery

Infection.

A.F. culture Definitive, but takes 48 hours More rapid tests; Gram stain W.B.C. count Leucocyte esterase assay Glucose concentration Combined-(any 1 test +ve) has a PPV of 66% and a NPV of 80%.

Management

Gestational age, fetal maturity are primary determining factors Gest. Age at which delivery is promotedneonatal care? Conservative management; Advantage; morbidity/mortality Risk; cord prolapse, abruption, infection, emergency procedures

Tocolytics in PPROM

Limited value Christensen et al-RCT (Ritrodrine vs. Placebo). Latency prolonged by 24 hours Levy and Warsof- of latency (47%) in treated against untreated(14%) No place for prophylactic tocolysis beyond 48 hours steroids) Review the need to deliver abruption, infection, fetal distress)

Corticosteroids

Ante partum-reduce perinatal morbidity/mortality Betamethazone (2 doses 12mg IM, 24 hours apart) Dexamethazone (4 doses 6mg IM, 12 hours apart)
National Institute of health-1994

No evidence of neonatal infection (Lewis) Repeated courses-Not recommended

Antibiotics

Antimicrobial action + modulation of inflammatory response (maternal, fetal) Different regimes-type of antibiotic, route, duration IV Ampicillin + Erythromycin for 48 hours followed by oral for 1 weekNICHD study. Reduction of risk of death, RDS, sepsis, IVH and severe NEC.

Lung maturity assessment

By Amniocentesis 32-34 weeks window Study- Cotton et alFetal distress more frequent in no Amniocentesis group Amniostat-FLM
Simple slide agglutination test Vaginal pool-not affected by blood / meconium PPV 95-100% NPV 35-51%

Lung Maturity cont.

TDX-FLM Reliable, reproducible Uses fluorescent polarization assay technique Expectant management involves fetal surveillance-NST, BPP

Conclusion

PPROM remains a commonly encountered clinical problem Significant health costs Management depends on accurate diagnosis and determination of gestational age. Antibiotics and corticosteroids have clear benefits >34 weeks-benefit of delivery outweigh risks.