PPROM


PROM that occurs < 37 wks.

Causes/Risk:

  • Intrauterine infection, placenta abruption, previous PROM, & smoking.

Labs:

  • Cath UA w/ micro & C/S, UDS, CBC, BMP, GBS, GC, Chlamydia,  fetal fibronectin, AmniSure (Placental Alpha microglobulin-1 protein = amniotic fluid protein),

Tests:

  • OB Ultrasound (oligo. is suggestive of ROM), Amniocentesis & installation of Indigo Carmine (for ambiguous cases), Lecithin/sphingomyelin ratio (assess Fetal lung maturity).
Exam:
  • EFM, NO digital cervical exam.

Treatment:

> 34 wk 32-34 wk 24-32 wk < 24wk
Deliver Lungs mature:
- DELIVER

Lungs not mature:
- Steroids
- ABx
 
- Betamethason 12mg IM q12h x 2

- ABx (7 days):
Cover GBS: Ampicillin 2g IV q6h x48 hr, then Amoxicillin 875mg PO bid x5 days.
+
Cover Mycoplasma: Azithromycin 1g on admission.

- GBS proph. x 48hrs (no additional ABx required if pt already on Ampicillin)

-Tocolytics: NOT effective in setting of ROM
- Expe. mgt.

- No need for GBS proph, ABx or Steroids.

- PPROM (no contractions) <23 wk can be d/c home for expt. mgt. and readmit at 24 wks for steroids & ABx.

Management Overview

Management Overview
Admit to L&D on EFM.
Observe for S/S of chorio (fever) and abruption (painful bleed)
DELIVER if (+) infection or non-reassuring FHT.
Prolonging preg. after ROM = intrauterine infection + neonatal sepsis.
GBS Proph, Steroids.
Steroids Helps reduce:
- Neonatal Death
- Respiratory Distress
- Interventricular Hemorrhage
- Necrotizing Enterocolitis
- Duration of Neonatal Respiratory Support/
ABx Cover GBS: Ampicillin 2g IV q6h x48 hr, then Amoxicillin 875mg PO bid x5 days.
+
Cover Mycoplasma: Azithromycin 1g on admission.
 

Penicillin Allergy:

  • Low Risk (rash w/o urticaria)
    • Cefazolin 2g IV, then 1g q8h x48hr, then Keflex 500mg PO QID x5d
      +
      Azithromycin 1g on admission
       
  • High Risk (Anaphylaxis, Angioedema, Respiratory distress, Urticaria)
    • Clindamycin 900mg IV q8h
      +
      Gentamicin 7mg/kg ideal body weight q24h x 2 doses,

      then

      Clindamycin 300mg PO q8h x5d
      +
      Azithromycin 1g x1
 

Steroids & ABx in PPROM

Corticosteroid and antibiotic management of PPROM in the absence of labor
Wks of gestation when PPROM occurs Plan Corticosteroids ABx
24-32 wks Expectant management if no evidence of chorioamnionitis or fetal compromise Yes Yes and GBS prophylaxis at delivery if indicated
> 32 but < 34 wk Deliver immediately if fetal lung maturity can be documented or there is evidence of an intraamniotic infection clinically or on amniocentesis; otherwise deliver at 34 weeks Yes, if there is evidence of fetal lung immaturity or fetal lung status is unknown Yes, if expectant management• and GBS prophylaxis at delivery if indicated
≥ Wks Deliver No GBS prophylaxis begun on admission and continued until delivery
 

Algorithm