Prelabor pPROM

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Prelabor pPROM

• Mohammad Badawi
• March, 01, 2005
• Perinatology Round

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Case Presentation 1

• 25 yr primip at 26 weeks with SPROM x 4 hours
• FM, mild cramping, No PV blood
• Sterile speculum nitrazine and ferning ve,
  cervix appears closed and long
• Management?

3
Case Presentation 2

• 29 yr G3P2 at 18 weeks with SPROM x2 hours
• FM, No cramping, No PV blood
• Sterile speculum nitrazine and ferning ve,
  cervix appears closed and long
• Management?

4
Objectives

• To review the current evidence about antibiotics
  in pPROM.
• To review the outcomes of infants when pPROM
  occurs in the previable phase.
• To come to a consensus of opinion in management
  of patients with earlypROM.

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Overview

• PROM rupture of membrane prior to onset of
  labor.
• - Term
• - Pretem
• -Viable
• - Previable
• Latent phase from time of rupture to
• - labor (most common definition.
• - delivery
• Prolonged PROM greater than 24 hours.

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Overview

• Occurs in 2 3.5 of pregnancies
• May be associated with sub clinical
  chorioamnionitis
• Amniotic Fluid Cultures ve in 32-35

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Overview

• Term Latent Period
• lt24 h 80-90
• Preterm Latent Period
• lt26 weeks
• lt7 d 50
• lt4 weeks 80
• 28-34 weeks
• lt24 h 50
• lt7 d 80-90
• With expectant mgmt 3-11 will stop leaking

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Mechanisms of pPROM

• Bacterial production of proteases and
  phospholipases.
• Host response to blood or bacteria with leukocyte
  activation or cytokine release.
• Weakness form over distention.
• Strain from uterine activity.
• Direct membrane trauma .
• Developmental (weak spot).c

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Associations with pPROM

• Preterm Labor
• Uterine distention
• Prior preterm delivery
• Cervical factors
• Infection
• Cigarette Smoking
• Lower SE status

• Abdominal trauma
• Amniocentesis
• Prior PROM.
• Uterine anomalies.
• Fetal malformation
• Malpresentation.
• Placental anomalies.

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Maternal Complications

• Chorioamnionitis and Ednometritis
• Occurs in 5-15 .
• Placental Abruption occurs in 8 .
• Increased risk of C/S.
• PPH.
• Retained placenta.

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Neonatal Complications

• Prematuarity.
• Infection.
• Cord prolapse.
• Pulmonary hypoplasia.
• Orthopedic compression deformities.
• Malpresentation
• Traumatic delivery.

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Neonatal Sepsis

• Term PROM
• - Occurs in 1- 2 with prolonged PROM
• - Occurs in 3- 5 with chorioamnionitis
• pPROM
• - Occurs in 3- 5 in prolonged PROM.
• - Occurs in 15- 20 in chorioamnionitis.

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Diagnosis

• History.
• Vaginal pooling.
• Valsalva.
• Nitrazine.
• Ferning
• Ultrasound.

• Indigo Carmine.
• Fluorescein dye.
• Fetal fibronectin.
• AFP
• Fetal Cells
• No pelvic exam

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ManagementCase1

• Admit
• BR with BPR
• DAT
• Temp q4h
• IV TKVO
• Blood Tests

• U/A and GBS swab.
• NST
• BPP.
• NICU
• Steroids.
• Abx???

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Microbes isolated in AF of those with IUI
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Purpose of Antibiotics

• ? deciduitis and amnionitis ?
• ? neonatal sepsis
• Prevent onset of labor ? prolonging pregnancy ? ?
  premature morbidity
• ? maternal infection

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The Evidence

• Cochrane Review, Kenyon et al, 2001
• 13 trials, total 6000 women
• Antibiotics in pPROM resulted in
• ? in maternal infection
• ? latency to delivery up to 7d
• ? neonatal infection and requirement of oxygen at
  gt28d
• But no improvement in neonatal mortality

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The Focus

• Antibiotic Therapy for Reduction of Infant
  Morbidity after pPROM. Mercer et al, JAMA, 1997.
• Broad-spectrum antibiotics for pPROM the ORACLE
  I randomized trial. Kenyon et al, Lancet, 2001.

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RCT Mercer et al, 1997

• Randomized, double blind placebo trial
• 614 women
• 24 32 weeks (mean GA 28 weeks)
• Tocolytics and Steroids were prohibited
• Amp IV 2g q6h and Erythro 250mg IV q6h for 2
  days.
• Then oral amoxicillin 250mg q8h and oral erythro
  333mg q8h for 5 days

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RCT Mercer et al, 1997

• Primary outcome fetal death, RDS, IVH, NEC or
  sepsis within 72hr of birth
• Secondary outcome prolongation of pregnancy,
  maternal outcomes, adverse effects and compliance.

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RCT Mercer et al, 1997

• In GBS ve cohort
• ? RDS RR 0.83
• ? NEC RR 0.39
• ? composite morbidity RR 0.82
• ? Sepsis gt72h RR 0.39
• ? median time to delivery (6.1 vs 2.9 d, plt0.001)
• ? infant BW (1549g vs 1457g, p0.03)

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RCT Mercer et al, 1997

• Adverse drug effects
• Nausea, vomiting and abdominal pain
• IV tx compliance was much lower in abx group
  (83.7 vs 89.2, p0.046)
• Oral tx infrequent adverse effects, excellent
  compliance.

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ORACLE I, 2001

• Multi-centre randomized controlled trial
• 4826 women with pPROM lt37 weeks
• Median GA at entry 32 weeks 76.5 received
  steroids, Tocolytics used 8.4
• Primary outcome death or major adverse outcome
  in baby (Chronic lung disease, Cerebral AbN)
  prior to discharge.

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ORACLE I, 2001

• 325mg co-amoxiclav plus 250mg erythromycin
• co-amoxiclav
• erythromycin
• placebo
• Oral, qid, x 10 days or until delivery

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ORACLE I, 2001
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Erythromycin Outcomes
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Erythromycin Outcomes
-For singletons -? Surfactant TX p0.02 -? O2
req at 28d p0.03 -? ve blood culture p0.04 -?
abN cerebral U/S p0.04 -? Composite
outcome p0.02
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Co-amoxiclav outcomes
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Co-amoxiclav Outcomes

• -For singletons
• -? NEC p0.04
• -? NICU Admission p0.005
• -? total O2 req p0.05

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ORACLE I Conclusions

• Co-amoxiclav was more effective in prolonging
  pregnancy than erythro
• Co-amoxiclav was assc with ? risk of NEC
• Erythro associated with ? neonatal morbidity

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How much

• Cost of antibiotics/day
• IV ampicillin 2g qid 12.60
• PO amoxicillin 250mg tid 0.30
• PO amoxiclav 500mg bid 2.68
• IV erythro 250mg qid 21.40
• PO erythro 250mg qid 0.18

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Antibiotic Coverage
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Proposal for new tx regime for pPROM
- PO Erythro 250mg qid and Amoxil 250mg tid -
Complete theoretical coverage
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ManagementCase 2

• Do we admit?
• Do we give Abx and steroids? And when?.
• U/S How often?
• Do we offer then termination and when?
• If we send them home what is the plan?

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Mid trimester PROM

• Major fetal morbidity is lethal pulmonary
  hypoplasia.
• Chorioamnionitis occurs in 30- 60 .
• Patients must be educated about the sings of
  infection and they should take their temp 3
  times/d

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Mid trimester PROM

• Hospitalization is not required unless vag
  bleeding or infection exists
• Hospitalization should be consider at 24 w
• AFIlt 2 and ROM more than 14d has been associated
  with a neonatal mortality rate gt90.
• Serial US Q1-2 week

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Algorithm For Previable pPROM
M. B Mercer . Clinics in Perinatology 31 (2004)
765-782
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Algorithm For Previable pPROM
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Algorithm For Previable pPROM
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Mid trimester PROM

• Number of novel treatment such gel foam and
  amnioinfusion have been preliminary investigated.
• Prognosis is dismal
• Thorough counseling and documentation are
  required.

Emedicine
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Conclusion

• Mid trimester pPROM is still a big dilemma
• The use of broad spectrum antibiotics in pPROM is
  indicated for prolonging the latent period,
  reducing chorioamnionitis, neonatal infection and
  ventilation gt28d
• The optimal antibiotic regimen remains
  controversial