1. Modern Management of Prolonged Rupture of Membranes Joseph R. Biggio Jr., M.D. Department of Obstetrics & Gynecology Division of Maternal-Fetal Medicine University of Alabama at Birmingham

2. PROM Amniorrhexis prior to onset of active labor regardless of gestational age Premature Rupture of Membranes

3. PPROM Amniorrhexis < 37 weeks’ gestational age prior to onset of active labor Preterm Premature Rupture of Membranes

4. Latency Interval from Rupture of Membranes to Onset of Active Labor

5. Diagnosis l History l Avoid digital exam l Vaginal Pool l Nitrazine Paper l Ferning l Ultrasound l Amniocentesis/Dye Study

6. PROM near Term l Management gestational age dependent l Induction vs. awaiting spontaneous labor l Antibiotic prophylaxis per ACOG/CDC recommendations

7. Induction vs. Expectant Management l >5,000 women randomized n Oxytocin, PGE2 or expectant management up to 4 days n No difference in cesarean section or neonatal infection n Less chorioamnionitis in induction with oxytocin group Hannah, NEJM, 1996

8. Epidemiology of Preterm Birth PPROM Spontaneous Preterm Delivery Indicated Preterm Delivery 28 % 46 % 26 % Andrews, 1995

9. PPROM Risk Factors l Lower/Upper Genital Tract Infection  Proteases  Prostaglandins l History of PPROM l Incompetent Cervix l Abruption l Polyhydramnios l Multiple Gestation l Smoking

10. PPROM Complications l Maternal/Fetal Infection l Premature Labor and Delivery l Umbilical Cord Prolapse l Fetal Hypoxia 2º Cord Compression l Increased Rate of Cesarean Section l Intrauterine Growth Restriction l Abruption l Stillbirth

11. PPROM Standard Management l Confirmation of Diagnosis l Verification of Gestational Age l R/O Labor/Infection/Fetal Compromise l Avoid Digital Vaginal Examinations l In Hospital Observation l Bedrest

12. PPROM Latency Gestational Age (Weeks) % Patients with Latency > 1 Week 25 50 75 0 Wilson, Obstetrics & Gynecology, 1982

13. PPROM Vaginal Examination Gestational Age (Weeks) 20 15 10 5 Latency Days No Exam Exam Lewis, Obstetrics & Gynecology, 1992

14. Previable PPROM l < 24 weeks l Poor prognosis for successful outcome l Outcome may be different for spontaneous vs. iatrogenic

15. Previable PPROM Complications l Uterine Infection l Pulmonary Hypoplasia l Limb Compression Deformities l Intrauterine Growth Restriction

16. Previable PPROM Outcomes

17. PPROM Management Issues Timing of Delivery l Tocolysis l Antibiotics l Steroids l Amniocentesis l Observation vs. Induction l Fetal Lung Maturity Testing l Fetal Surveillance

18. Timing of Delivery

19. Neonatal Morbidity/Mortality UAB (1995-1996) %

20. RNICU Survival and Morbidity Data (1995-1996) % Neonates

21. Tocolysis

22. PPROM Tocolysis Weiner, AJOG, 1988

23. PPROM Tocolysis Garite, AJOG, 1987

24. Antibiotics

25. Preterm Labor Chorioamnion Colonization 0  30 weeks 31- 34 weeks 34- 36 weeks  37 weeks 25 50 75 % Patients Colonized Spontaneous Preterm Labor Indicated Cassell, 1993

26. PPROM Antibiotic Therapy l Reduction Maternal/Perinatal Infection l Prolong Latency Period l Improve Neonatal Outcome

27. Antibiotic: PPROM NIH-MFM Network Study l PPROM between 24 and 32 weeks l IV ampicillin and erythromycin for 48 h l Oral amoxicillin/erythromycin for 5 days l Identification and Rx of GBS carriers l Tocolysis and corticosteroids prohibited Mercer, JAMA, 1997

28. Antibiotic: NIH-MFM Network Study Neonatal Morbidity * * *

29. Antibiotic: Latency Period NIH-MFM Network Study

30. PPROM Antibiotic Therapy l Optimal Antibiotic Regimen l Route/Duration of Administration

31. Antibiotics & PPROM: Summary l Reduction in maternal infectious morbidity l Reduction in births <48 h and <7 d l Reduction in neonatal infectious morbidity l Reduction in neonates requiring NICU and ventilation >28 d Kenyon, Cochrane Library, 1999

32. Antibiotics & PPROM: Summary l No clear reduction in perinatal death l No clear reduction in cerebral abnormalities Kenyon, Cochrane Library, 1999

33. Amniocentesis

34. PPROM Amniotic Fluid Culture l Group B Streptococcus20 % l Gardnerella vaginalis17 % l Peptostreptococcus11 % l Fusobacteria10 % l Bacteroides fragilis 9 % l Other Streptococci 9 % l Bacteroides sp. 5 %

35. Utility of Amniocentesis l Confirm/Refute diagnosis of chorioamnionitis  Glucose <15 mg/dL  Culture  Gram stain l Lung maturity testing

36. Corticosteroids

37. Corticosteroids for FLM l Betamethasone l Dexamethasone

38. PPROM Corticosteroids Block Taeusch Papageorgiou Young Garite Collaborative Iams Nelson Simpson Morales 43 17 38 80 153 38 22 112 121 26 24 19 37 80 135 35 46 105 124 AuthorSteroidsControl Effect on RDS Number of Patients

39. PPROM Corticosteroids Crowley, Ob/Gyn Clinics, 1992 *

40. PPROM Corticosteroids + Antibiotics * Lewis, Obstetrics & Gynecology, 1996

41. 1994 NIH Consensus Conference: Corticosteroids in PPROM l Corticosteroids reduce incidence/severity of RDS, IVH l Benefits in PPROM up to 30-32 weeks l No significant adverse outcomes for corticosteroid use in PPROM l Impact less than with intact membranes

42. Observation vs. Induction

43. Neonatal Morbidity/Mortality UAB (1995-1996) %

44. PPROM Observation vs. Induction Mercer, AJOG, 1993 * *

45. PPROM Observation vs Induction Cox, Obstetrics & Gynecology, 1995

46. Fetal Lung Maturity Testing

47. Fetal Lung Maturation Biologic Markers 8 6 4 2 00 4 2 6 8 202428323640 Gestational Age (weeks) L:S Ratio % Phospholipid L:S PI PG 10

48. Fetal Lung Maturity Evaluation in Vaginal Pool Specimen l L:S RatioNot Reliable l TDX:FLM AssayNot Validated l PGUseful

49. Fetal Surveillance

50. PPROM Fetal Surveillance l Daily Non-Stress Test (NST)  Variables  Tachycardia  Loss of reactivity l Biophysical Profile (BPP) l Contraction Stress Test (CST)

51. Summary

52. UAB Management of PPROM PPROM  34 weeks Deliver Previable PROM Outpatient observation Antibiotic prophylaxis Option of termination <22wk Admission at viability

53. PPROM  23 weeks, <34 weeks Antibiotic prophylaxis: Amoxicillin 500 tid x 10d, Azithromycin 1gm d1 & d5 1 course Betamethasone if <32weeks Test for pool PG weekly beginning at 32 weeks Deliver at 34-35 weeks UAB Management of PPROM