PPROM

Question 1

PPROM complicates what % of pregnancies?

Answer 1

• Up to 3%

Question 2

PPROM is associated with what % of PTBs?

Answer 2

30-40%

Question 3

Risks of PPROM?

Answer 3

• Prematurity
• Sepsis
• Cord prolapse
• Pulmonary hypoplasia
• Chrioamnionitis
• Placental abruption

Question 4

Median latency after PPROM?

Answer 4

7 days
(tends to shorten as the gestational age at PROM advances)

Question 5

In what % of clinical examination for PPROM will the diagnosis be equivocal?

Answer 5

10-20%

Question 6

What protein tests should be undertaken if diagnosis of PPROM is equivocal?

Answer 6

• IGFBP-1
• PAMG-1
  -> high sensitivity and specificity

Question 7

CRP for supporting diagnosis of chorioamnionitis?

Answer 7

• Only has a sensitivity of 69% and specificity of 77% in diagnosing histological chorioamnionitis

Question 8

Inpt vs outpt management of PPROM? How often to monitor in outpatient management of PPROM?

Answer 8

• Inpt vs outpatient management decision, following a period of inpatient care, should be made on an individual basis, take into account markers of delivery latency (APH, amniotic fluid volume, gestational age, clinical and lab markers of infection)
• Consider: obstetric hx, support at home, distance from hospital, woman’s preferences
• Advise of sx of chorio
• Regularly review (1-2 times / week)
• Review incl: WCC, CRP, clinical recordings, and FHR monitoring
• USS: typically weekly LV and doppler USS and 2 weekly growth
• Any concerns = attend hospital immediately if
• Psychological support should be offered during pregnancy and postnatally

Question 9

Neonatologist involvement in PPROM

Answer 9

• Inform neonatologist when dx of PPROM is confirmed and delivery anticipated
• Women w PPROM should have the opportunity to meet w a neonatologist antenatally to discuss their baby’s care

Question 10

Antibiotics for PPROM

Answer 10

• Erythromycin for 10/7 following dx, or until in established labour (Whichever is sooner)
• Cochrane review found reduced chorioamnionitis, prolonged latency and improved neonatal outcomes (infection, use of surfactant, oxygen therapy and abnormal cerebral USS prior to DC from hospital all reduced)
• AVOID co-amoxiclav as associated with increased risk NEC

Question 11

RCOG recommends antenatal steroids at what gestations?

Answer 11

• 24+0 - 25+6: large cohort studies demonstrate benefits
• 26+0 - 33+6: high quality evidence that steroids reduce incidence of intraventricular haemorrhage and the need for mechanical ventilation in PPROM
• Between 34+0 and 35+6: high “number to treat” and potential side effects mean that RCOG recommends evaluating on an individual basis

Question 12

Magnesium sulfate for PPROM

Answer 12

• Given to women who have PPROM and are in established labour or having a planned PTB within 24 hours
• Should be offered between 24+0 - 29+6 weeks gestation
• Meta-analysis of RCTs shows reduction in cerebral palsy and motor dysfunction in offspring
  (RCOG also recommends considering MgSOr between 30+0 and 33+6 weeks)

Question 13

Tocolysis in PPROM

Answer 13

• Not recommended
• Cochrane review found does not significantly improve perinatal outcome (associated w increased risk of 5 min Apgar score <7, increased need for ventilation support) and might be associated w increased risk of chorio

Question 14

What is the average delivery latency in PPROM by gestation?
24+0-28+0 weeks?
>31+0 weeks

Answer 14

• 8-10 days (median)
• 5 days (median)

Question 15

PPROM at risk of “complication”?

Answer 15

• Non-cephalic presentation
• Oligohydramnios
• SROM <26+0 weeks

(higher risk of fetal death, placental abruption, umbilical cord prolapse, delivery outside of hospital and neonatal death)

Question 16

Amnioinfusion in PPROM

Answer 16

• Not recommended as part of clinical care
• Cochrane review found some benefits but evidence quality was questionable -> more evidence required

Question 17

Psychological support in PPROM

Answer 17

• Cohort studies have shown that PTSD occurs in a substantial number of women whose pregnancy is complicated by PPROM
• Offer access to additional emotional support, both during pregnancy and postnatally

Question 18

Timing of birth after PPROM

Answer 18

• Expectant management should be offered until 37+0 unless other complications arise

Cochrane review found:
- No differences between early birth and expectant management in neonatal sepsis or infection
- Early delivery increased the incidence of RDS and increased rate of CS, as well as neonatal death and need for ventilation
- Timing of birth should be discussed w each woman on an individual basis with careful consideration of patient preference and ongoing clinical assessment

Question 19

Care in a subsequent pregnancy following PPROM

Answer 19

• At increased risk of PPROM
• Short interpregnancy interval also associated w greater risk
• Ideally should be cared for in a dedicated preterm labour clinic by an obstetrician with an interest in preterm birth
• Modifiable risk factors, such as smoking and respiratory disease should be addressed.
• Screen for lower genital tract infections
• Consider serial TV US for cervical length (but evidence lacking)