Nodern Nanagement of

Prolonged Rupture of
Nembranes
PRON
Amniorrhexis prior to onset of active labor
regardless of gestational age
Premature Rupture of Nembranes
PPRON
Amniorrhexis < 37 weeks' gestational age
prior to onset of active labor
Preterm Premature Rupture of
Nembranes
atency
nterval from Rupture of
Nembranes to Onset of Active
Labor
agnoss
istory
Avoid digital exam
vaginal Pool
Nitrazine Paper
Ferning
Ultrasound
Amniocentesis/Dye Study
PRON near Term
Nanagement gestational age
dependent
nduction vs. awaiting spontaneous
labor
Antibiotic prophylaxis per
ACOC/CDC recommendations
nducton vs. Expectant
Nanagement
>S,000 women randomed
Oxytocn, PCE2 or expectant
management up to 4 days
No dfference n cesarean secton or
neonatal nfecton
ess choroamnonts n nducton
wth oxytocn group
Epdemology of Preterm
Brth
PPROM
Spontaneous
Preterm
DeIivery
Indicated
Preterm
DeIivery
28 %
46 %
26 %
PPRON
Rsk Factors
Lower/Upper Cenital Tract nfection
Proteases
Prostaglandins
istory of PPRON
ncompetent Cervix
Abruption
Polyhydramnios
Nultiple Cestation
Smoking
PPRON
Complcatons
Naternal/Fetal nfection
Premature Labor and Delivery
Umbilical Cord Prolapse
Fetal ypoxia 2 Cord Compression
ncreased Rate of Cesarean Section
ntrauterine Crowth Restriction
Abruption
Stillbirth
PPRON
Standard Nanagement
Confirmation of Diagnosis
verification of Cestational Age
R/O Labor/nfection/Fetal Compromise
Avoid Digital vaginal Examinations
n ospital Observation
Bedrest
PPRON
atency
estationaI Age (Weeks)
%

P
a
t
i
e
n
t
s

w
i
t
h

L
a
t
e
n
c
y

>

1

W
e
e
k
25
50
75
25 25-28 29-32 33-36
0
WiIson, Obstetrics & ynecoIogy, 1982
Prevable PPRON
< 24 weeks
Poor prognosis for successful
outcome
Outcome may be different for
spontaneous vs. iatrogenic
Prevable PPRON
Complcatons
Uterine nfection
Pulmonary Hypoplasia
Limb Compression Deformities
ntrauterine Growth Restriction
Prevable PPRON
Outcomes
Study
# of
Infants Chorio. SurvivaI
NormaI
NeuroIogicaI
DeveIopment
TayIor 60 25% 22% 38%
Major 71 43% 65% 31%
Moretti 124 39% 32% 33%
Bengston 63 46% 51% 16%
OveraII 318 39% 41% 30%
PPRON
Nanagement ssues
Timing of Delivery
Tocolysis
Antibiotics
Steroids
Amniocentesis
Observation vs. nduction
Fetal Lung Naturity Testing
Fetal Surveillance
Tmng of elvery
Neonatal Norbdty/Nortalty
UAB (133S1336)
%
23 25 27 29 31 33 35 >37
SurvivaI
100
25
50
75
estationaI Age (Weeks)
RDS IVH NEC Sepsis
0
RNCU Survval and
Norbdty ata (133S1336)
23 25 27 29 31 33 35 >37
SurvivaI
100
25
50
75
Weeks
RDS
IVH
NEC
Sepsis %

N
e
o
n
a
t
e
s
Tocolyss
TocoIysis
(n=33)
Bedrest
(n=42)
estationaI age 30.0 29.4
Days gained 6.7 5.2
> 48 hr 87.9% 76.2%
RDS 45.4% 52.4%
Sepsis 9.1% 7.1%
NEC 18.2% 23.8%
NeonataI death 9.1% 11.9%
PPRON
Tocolyss
Weiner, AJO, 1988
TocoIysis
(n=39)
Expectant
(n=40)
estationaI age 27.9 27.3
Days gained 11.5 12.0
> 48 hr 77% 75%
RDS 51% 58%
Sepsis 3% 5%
IVH 8% 5%
HospitaI stay 47.5 57.0
PPRON
Tocolyss
arite, AJO, 1987
Antbotcs
Preterm abor
Choroamnon Colonaton
0
A 30
weeks
31- 34
weeks
34- 36
weeks
K 37
weeks
25
50
75
%

P
a
t
i
e
n
t
s

C
o
I
o
n
i
z
e
d
Spontaneous
Preterm Labor
Indicated
Cassell, 1333
PPRON
Antbotc Therapy
Reduction Naternal/Perinatal nfection
Prolong Latency Period
mprove Neonatal Outcome
Antbotc: PPRON
NNFN Network Study
PPRON between 24 and 32 weeks
v ampicillin and erythromycin for 48 h
Oral amoxicillin/erythromycin for S days
dentification and Rx of CBS carriers
Tocolysis and corticosteroids prohibited
Mercer, JAMA, 1997
Antibiotics
(n=299)
PIacebo
(n=312) RR
RDS 40.5% 48.7% 0.83
IVH 6.4% 7.7% 0.82
Sepsis <72 hr 5.4% 6.4% 0.83
NEC 2.3% 5.8% 0.40
Death 6.4% 5.8% 1.10
Composite 44.1% 52.9% 0.84
Antbotc:
NNFN Network Study
Neonatal Norbdty

Antbotc: atency Perod

NNFN Network Study
Duration of Latency Antibiotics Control
A
48 hrs
27.3 36.6
A
7 days
SS.S 73.S
A
14 days
7S.6 87.3
A
21 days
8S.7 33.0
Nedan 6.1 days 2.3 days
PPRON
Antbotc Therapy
Optimal Antibiotic Regimen
Route/Duration of Administration
Antbotcs S PPRON:
Summary
Reduction in maternal infectious
morbidity
Reduction in births <48 h and <7 d
Reduction in neonatal infectious
morbidity
Reduction in neonates requiring NCU
and ventilation >28 d
Kenyon, Cochrane Library, 1333
Antbotcs S PPRON:
Summary
No clear reduction in perinatal
death
No clear reduction in cerebral
abnormalities
Kenyon, Cochrane Library, 1333
Amnocentess
PPRON
Amnotc Flud Culture
roup B Streptococcus 20 %
ardnereIIa vaginaIis 17 %
Peptostreptococcus 11 %
Fusobacteria 10 %
Bacteroides fragiIis 9 %
Other Streptococci 9 %
Bacteroides sp. 5 %
Utlty of Amnocentess
Confirm/Refute diagnosis of
chorioamnionitis
Clucose <1S mg/dL
Culture
Cram stain
Lung maturity testing
Cortcosterods
Cortcosterods for FN
Betamethasone
Dexamethasone
PPRON
Cortcosterods
BIock
Taeusch
Papageorgiou
Young
arite
CoIIaborative
Iams
NeIson
Simpson
MoraIes
43
17
17
38
80
153
38
22
112
121
26
24
19
37
80
135
35
46
105
124
Author Steroids ControI
Effect on
RDS
Number of Patients
Treatment ControI OR
RDS 83 / 456 149 / 421 0.44
NeonataI
Infection
18 / 200 20 / 188 0.82
PPRON
Cortcosterods
CrowIey, Ob/yn CIinics, 1992

Steroids
(n=38)
No Steroids
(n=39)
estation at ROM 29.3 29.7
EA at deIivery 31.4 32.0
RDS 18% 44%
IVH ----- 8%
NEC ----- 8%
Sepsis 3% 5%
Death 3% 3%
HospitaI days 24.8 29.2
PPRON
Cortcosterods + Antbotcs

Lewis, Obstetrics & ynecoIogy, 1996

1334 N Consensus Conference:
Cortcosterods n PPRON
Corticosteroids reduce
incidence/severity of RDS, v
Benefits in PPRON up to 3032 weeks
No significant adverse outcomes for
corticosteroid use in PPRON
mpact less than with intact
membranes
Observaton vs. nducton
Neonatal Norbdty/Nortalty
UAB (133S1336)
%
30 32 34 36
SurvivaI
100
25
50
75
Weeks
RDS
IVH
NEC
Sepsis
Induction
(n=46)
Expectant
(n=47)
Cesarean deIivery 8.7% 6.4%
Chorioamnionitis 10.9% 27.7%
SurvivaI 100% 100%
Oxygen >24 hr 4.4% 2.1%
IVH ----- -----
NEC ----- -----
Sepsis - W/U 28.3% 59.6%
Sepsis - Confirmed 6.8% 4.3%
PPRON
Observaton vs. nducton
Nercer, A]OC, 1333

PPRON
Observaton vs nducton
Delivery
(n=61)
Expectant
(n=68)
Cesarean delivery 23 12
Chorioamnionitis 2 1S
Stillbirth 0 1.4
Neonatal Death S 0
RDS 37 33
v 6 4.3
NEC 1.6 1.4
Sepsis 3 7
Cox, Obstetrcs S Cynecology, 133S
Fetal ung Naturty Testng
Fetal ung Naturaton
Bologc Narkers
8
6
4
2
0 0
4
2
6
8
20 24 28 32 36 40
estationaI Age (weeks)
L
:
S

R
a
t
i
o
%

P
h
o
s
p
h
o
I
i
p
i
d
L:S
PI
P
10
Fetal ung Naturty
Evaluaton n vagnal Pool
Specmen
L:S Ratio Not Reliable
TDX:FLN Assay Not validated
PC Useful
Fetal Survellance
PPRON
Fetal Survellance
Daily NonStress Test (NST)
variables
Tachycardia
Loss of reactivity
Biophysical Profile (BPP)
Contraction Stress Test (CST)
Summary
UAB Nanagement of PPRON
PPRON K34 weeks
Deliver
Prevable PRON
Outpatient observation
Antibiotic prophylaxis
Option of termination <22wk
Admission at viability
PPRON K23 weeks, <34 weeks
Antibiotic prophylaxis: Amoxicillin S00
tid x 10d, Azithromycin 1gm d1 S dS
1 course Betamethasone if <32weeks
Test for pool PC weekly beginning at
32 weeks
Deliver at 343S weeks
UAB Nanagement of PPRON