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ModernManagementofProlongedRuptureofMembranesJosephR.BiggioJr.,M.D.DepartmentofObstetrics&GynecologyDivisionofMaternal-FetalMedicineUniversityofAlabamaatBirminghamModernManagementofProlongedPROMAmniorrhexispriortoonsetofactivelaborregardlessofgestationalagePrematureRuptureofMembranesPROMAmniorrhexispriortoonsePPROMAmniorrhexis<37weeks’gestationalagepriortoonsetofactivelaborPretermPrematureRuptureofMembranesPPROMAmniorrhexis<37weeks’LatencyIntervalfromRuptureofMembranestoOnsetofActiveLaborLatencyIntervalfromRuptureoDiagnosisHistoryAvoiddigitalexamVaginalPoolNitrazinePaperFerningUltrasoundAmniocentesis/DyeStudyDiagnosisHistoryPROMnearTermManagementgestationalagedependentInductionvs.awaitingspontaneouslaborAntibioticprophylaxisperACOG/CDCrecommendationsPROMnearTermManagementgestaInductionvs.ExpectantManagement>5,000womenrandomizedOxytocin,PGE2orexpectantmanagementupto4daysNodifferenceincesareansectionorneonatalinfectionLesschorioamnionitisininductionwithoxytocingroupHannah,NEJM,1996Inductionvs.ExpectantManageEpidemiologyofPretermBirthPPROMSpontaneousPretermDelivery IndicatedPretermDelivery 28%46%26%Andrews,1995EpidemiologyofPretermBirthPPPROM
RiskFactorsLower/UpperGenitalTractInfectionProteasesProstaglandinsHistoryofPPROMIncompetentCervixAbruptionPolyhydramniosMultipleGestationSmokingPPROM
RiskFactorsLower/UpperPPROM
ComplicationsMaternal/FetalInfectionPrematureLaborandDeliveryUmbilicalCordProlapseFetalHypoxia2ºCordCompressionIncreasedRateofCesareanSectionIntrauterineGrowthRestrictionAbruptionStillbirthPPROM
ComplicationsMaternal/FePPROM
StandardManagementConfirmationofDiagnosisVerificationofGestationalAgeR/OLabor/Infection/FetalCompromiseAvoidDigitalVaginalExaminationsInHospitalObservationBedrestPPROM
StandardManagementConfiPPROM
Latency
GestationalAge(Weeks)%PatientswithLatency>1Week2550750Wilson,Obstetrics&Gynecology,1982PPROM
LatencyGestationalAgePPROM
VaginalExaminationGestationalAge(Weeks)2015105LatencyDaysNoExamExamLewis,Obstetrics&Gynecology,1992PPROM
VaginalExaminationGestaPreviablePPROM<24weeksPoorprognosisforsuccessfuloutcomeOutcomemaybedifferentforspontaneousvs.iatrogenicPreviablePPROM<24weeksPreviablePPROM
Complications
UterineInfectionPulmonaryHypoplasiaLimbCompressionDeformitiesIntrauterineGrowthRestrictionPreviablePPROM
ComplicationsPreviablePPROM
OutcomesPreviablePPROM
OutcomesPPROM
ManagementIssues
TimingofDeliveryTocolysisAntibioticsSteroidsAmniocentesisObservationvs.InductionFetalLungMaturityTestingFetalSurveillancePPROM
ManagementIssuesTimingTimingofDeliveryTimingofDeliveryNeonatalMorbidity/Mortality
UAB(1995-1996)%NeonatalMorbidity/Mortality
URNICUSurvivalandMorbidityData(1995-1996)%NeonatesRNICUSurvivalandMorbidityDTocolysisTocolysisPPROM
TocolysisWeiner,AJOG,1988PPROM
TocolysisWeiner,AJOG,1PPROM
TocolysisGarite,AJOG,1987PPROM
TocolysisGarite,AJOG,1AntibioticsAntibioticsPretermLabor
ChorioamnionColonization0£30weeks31-34weeks34-36weeks³37weeks255075%PatientsColonizedSpontaneousPretermLaborIndicatedCassell,1993PretermLabor
ChorioamnionColPPROM
AntibioticTherapyReductionMaternal/PerinatalInfectionProlongLatencyPeriodImproveNeonatalOutcomePPROM
AntibioticTherapyReductAntibiotic:PPROM
NIH-MFMNetworkStudyPPROMbetween24and32weeksIVampicillinanderythromycinfor48hOralamoxicillin/erythromycinfor5daysIdentificationandRxofGBScarriersTocolysisandcorticosteroidsprohibited
Mercer,JAMA,1997Antibiotic:PPROM
NIH-MFMNetwAntibiotic:
NIH-MFMNetworkStudyNeonatalMorbidity***Antibiotic:
NIH-MFMNetworkAntibiotic:LatencyPeriod
NIH-MFMNetworkStudyAntibiotic:LatencyPeriod
NIHPPROM
AntibioticTherapyOptimalAntibioticRegimenRoute/DurationofAdministrationPPROM
AntibioticTherapyOptimaAntibiotics&PPROM:SummaryReductioninmaternalinfectiousmorbidityReductioninbirths<48hand<7dReductioninneonatalinfectiousmorbidityReductioninneonatesrequiringNICUandventilation>28dKenyon,CochraneLibrary,1999Antibiotics&PPROM:SummaryReAntibiotics&PPROM:SummaryNoclearreductioninperinataldeathNoclearreductionincerebralabnormalitiesKenyon,CochraneLibrary,1999Antibiotics&PPROM:SummaryNoAmniocentesisAmniocentesisPPROM
AmnioticFluidCultureGroupBStreptococcus 20%Gardnerellavaginalis 17%Peptostreptococcus 11%Fusobacteria 10%Bacteroidesfragilis 9%OtherStreptococci 9%Bacteroidessp. 5% PPROM
AmnioticFluidCultureGUtilityofAmniocentesisConfirm/RefutediagnosisofchorioamnionitisGlucose<15mg/dLCultureGramstainLungmaturitytestingUtilityofAmniocentesisConfirCorticosteroidsCorticosteroidsCorticosteroidsforFLMBetamethasoneDexamethasoneCorticosteroidsforFLMBetametPPROM
CorticosteroidsBlockTaeuschPapageorgiouYoungGariteCollaborativeIamsNelsonSimpsonMorales4317173880153382211212126241937801353546105124AuthorSteroidsControlEffectonRDSNumberofPatientsPPROM
CorticosteroidsBlock4326PPROM
CorticosteroidsCrowley,Ob/GynClinics,1992*PPROM
CorticosteroidsCrowley,PPROM
Corticosteroids+Antibiotics*Lewis,Obstetrics&Gynecology,1996PPROM
Corticosteroids+Antibi1994NIHConsensusConference:
CorticosteroidsinPPROMCorticosteroidsreduceincidence/severityofRDS,IVHBenefitsinPPROMupto30-32weeksNosignificantadverseoutcomesforcorticosteroiduseinPPROMImpactlessthanwithintactmembranes1994NIHConsensusConference:Observationvs.InductionObservationvs.InductionNeonatalMorbidity/Mortality
UAB(1995-1996)%NeonatalMorbidity/Mortality
UPPROM
Observationvs.InductionMercer,AJOG,1993**PPROM
Observationvs.InductioPPROM
ObservationvsInductionCox,Obstetrics&Gynecology,1995PPROM
ObservationvsInductionFetalLungMaturityTestingFetalLungMaturityTestingFetalLungMaturation
BiologicMarkers8642004268202428323640GestationalAge(weeks)L:SRatio%PhospholipidL:SPIPG10FetalLungMaturation
BiologicFetalLungMaturityEvaluationinVaginalPoolSpecimenL:SRatio NotReliableTDX:FLMAssay NotValidatedPG Useful
FetalLungMaturityEvaluationFetalSurveillanceFetalSurveillancePPROM
FetalSurveillanceDailyNon-StressTest(NST)VariablesTachycardiaLossofreactivityBiophysicalProfile(BPP)ContractionStressTest(CST)PPROM
FetalSurveillanceDailySummarySummaryUABManagementofPPROMPPROM34weeksDeliverPreviablePROMOutpatientobservationAntibioticprophylaxisOptionoftermination<22wkAdmissionatviability
UABManagementofPPROMPPROMPPROM23weeks,<34weeksAntibioticprophylaxis:Amoxicillin500tidx10d,Azithromycin1gmd1&d51courseBetamethasoneif<32weeksTestforpoolPGweeklybeginningat32weeksDeliverat34-35weeksUABManagementofPPROMPPROM23weeks,<34weeksUABModernManagementofProlongedRuptureofMembranesJosephR.BiggioJr.,M.D.DepartmentofObstetrics&GynecologyDivisionofMaternal-FetalMedicineUniversityofAlabamaatBirminghamModernManagementofProlongedPROMAmniorrhexispriortoonsetofactivelaborregardlessofgestationalagePrematureRuptureofMembranesPROMAmniorrhexispriortoonsePPROMAmniorrhexis<37weeks’gestationalagepriortoonsetofactivelaborPretermPrematureRuptureofMembranesPPROMAmniorrhexis<37weeks’LatencyIntervalfromRuptureofMembranestoOnsetofActiveLaborLatencyIntervalfromRuptureoDiagnosisHistoryAvoiddigitalexamVaginalPoolNitrazinePaperFerningUltrasoundAmniocentesis/DyeStudyDiagnosisHistoryPROMnearTermManagementgestationalagedependentInductionvs.awaitingspontaneouslaborAntibioticprophylaxisperACOG/CDCrecommendationsPROMnearTermManagementgestaInductionvs.ExpectantManagement>5,000womenrandomizedOxytocin,PGE2orexpectantmanagementupto4daysNodifferenceincesareansectionorneonatalinfectionLesschorioamnionitisininductionwithoxytocingroupHannah,NEJM,1996Inductionvs.ExpectantManageEpidemiologyofPretermBirthPPROMSpontaneousPretermDelivery IndicatedPretermDelivery 28%46%26%Andrews,1995EpidemiologyofPretermBirthPPPROM
RiskFactorsLower/UpperGenitalTractInfectionProteasesProstaglandinsHistoryofPPROMIncompetentCervixAbruptionPolyhydramniosMultipleGestationSmokingPPROM
RiskFactorsLower/UpperPPROM
ComplicationsMaternal/FetalInfectionPrematureLaborandDeliveryUmbilicalCordProlapseFetalHypoxia2ºCordCompressionIncreasedRateofCesareanSectionIntrauterineGrowthRestrictionAbruptionStillbirthPPROM
ComplicationsMaternal/FePPROM
StandardManagementConfirmationofDiagnosisVerificationofGestationalAgeR/OLabor/Infection/FetalCompromiseAvoidDigitalVaginalExaminationsInHospitalObservationBedrestPPROM
StandardManagementConfiPPROM
Latency
GestationalAge(Weeks)%PatientswithLatency>1Week2550750Wilson,Obstetrics&Gynecology,1982PPROM
LatencyGestationalAgePPROM
VaginalExaminationGestationalAge(Weeks)2015105LatencyDaysNoExamExamLewis,Obstetrics&Gynecology,1992PPROM
VaginalExaminationGestaPreviablePPROM<24weeksPoorprognosisforsuccessfuloutcomeOutcomemaybedifferentforspontaneousvs.iatrogenicPreviablePPROM<24weeksPreviablePPROM
Complications
UterineInfectionPulmonaryHypoplasiaLimbCompressionDeformitiesIntrauterineGrowthRestrictionPreviablePPROM
ComplicationsPreviablePPROM
OutcomesPreviablePPROM
OutcomesPPROM
ManagementIssues
TimingofDeliveryTocolysisAntibioticsSteroidsAmniocentesisObservationvs.InductionFetalLungMaturityTestingFetalSurveillancePPROM
ManagementIssuesTimingTimingofDeliveryTimingofDeliveryNeonatalMorbidity/Mortality
UAB(1995-1996)%NeonatalMorbidity/Mortality
URNICUSurvivalandMorbidityData(1995-1996)%NeonatesRNICUSurvivalandMorbidityDTocolysisTocolysisPPROM
TocolysisWeiner,AJOG,1988PPROM
TocolysisWeiner,AJOG,1PPROM
TocolysisGarite,AJOG,1987PPROM
TocolysisGarite,AJOG,1AntibioticsAntibioticsPretermLabor
ChorioamnionColonization0£30weeks31-34weeks34-36weeks³37weeks255075%PatientsColonizedSpontaneousPretermLaborIndicatedCassell,1993PretermLabor
ChorioamnionColPPROM
AntibioticTherapyReductionMaternal/PerinatalInfectionProlongLatencyPeriodImproveNeonatalOutcomePPROM
AntibioticTherapyReductAntibiotic:PPROM
NIH-MFMNetworkStudyPPROMbetween24and32weeksIVampicillinanderythromycinfor48hOralamoxicillin/erythromycinfor5daysIdentificationandRxofGBScarriersTocolysisandcorticosteroidsprohibited
Mercer,JAMA,1997Antibiotic:PPROM
NIH-MFMNetwAntibiotic:
NIH-MFMNetworkStudyNeonatalMorbidity***Antibiotic:
NIH-MFMNetworkAntibiotic:LatencyPeriod
NIH-MFMNetworkStudyAntibiotic:LatencyPeriod
NIHPPROM
AntibioticTherapyOptimalAntibioticRegimenRoute/DurationofAdministrationPPROM
AntibioticTherapyOptimaAntibiotics&PPROM:SummaryReductioninmaternalinfectiousmorbidityReductioninbirths<48hand<7dReductioninneonatalinfectiousmorbidityReductioninneonatesrequiringNICUandventilation>28dKenyon,CochraneLibrary,1999Antibiotics&PPROM:SummaryReAntibiotics&PPROM:SummaryNoclearreductioninperinataldeathNoclearreductionincerebralabnormalitiesKenyon,CochraneLibrary,1999Antibiotics&PPROM:SummaryNoAmniocentesisAmniocentesisPPROM
AmnioticFluidCultureGroupBStreptococcus 20%Gardnerellavaginalis 17%Peptostreptococcus 11%Fusobacteria 10%Bacteroidesfragilis 9%OtherStreptococci 9%Bacteroidessp. 5% PPROM
AmnioticFluidCultureGUtilityofAmniocentesisConfirm/RefutediagnosisofchorioamnionitisGlucose<15mg/dLCultureGramstainLungmaturitytestingUtilityofAmniocentesisConfirCorticosteroidsCorticosteroidsCorticosteroidsforFLMBetamethasoneDexamethasoneCorticosteroidsforFLMBetametPPROM
CorticosteroidsBlockTaeuschPapageorgiouYoungGariteCollaborativeIamsNelsonSimpsonMorales4317173880153382211212126241937801353546105124AuthorSteroidsControlEffectonRDSNumberofPatientsPPROM
CorticosteroidsBlock4326PPROM
CorticosteroidsCrowley,Ob/GynClinics,1992*PPROM
CorticosteroidsCrowley,PPROM
Corticosteroids+Antibiotics*Lewis,Obstetrics&Gynecology,1996PPROM
Corticosteroids+Antibi1994NIHConsensusConference:
CorticosteroidsinPPROMCorticosteroidsreduceincidence/severityofRDS,IVHBenefitsinPPROMupto30-32weeksNosignificantadverseoutcomesforcorticosteroidusein
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