PPROM & Chorioamnionitis

PPROM

Etiology of ROM

Etiology of PPROM

🏁 Dx

📗Management

Background

Chorioamnionitis

Dx

Management

Def

PROM (Premature ruptured of mb): rupture of mb before onset of labor

PPROM (Preterm PROM): Rupture of mb before labor and before 37 wks of gestation

Depends on?

GA

Clinical infection

Fetal status

PSO weakening of membranes

Shearing force from UC

Intra-amniotic infection

Hx of Preterm PROM in previous pregnancy

Similar etiology and risk of preterm

Multifetal gestation, Polyhydramnios

Short Cx length

2nd half bleeding

Low BMI, low socioeconomic status

Cigarette smoking and illicit drug use

Infection & Preterm birth

Intrauterine infection -> ascending infection fr Vx and Cx -> Maternal systemic infection -> Retrograde fr peritoneal cavity via Fallopian tubes

Hx taking

Fluid leakage

Amount of secretion

PE

Sterile speculum exam

purpose: minimize risk of introduce infection therefore, not using PV as it increase risk of infection and add a lil info for mx

✅ confirmation of ruptured membrane, assess Cx dilatation/Cervititis, Umbilical Ford prolapse, Fetal presentation, Obtain U/C (if it’s preterm)

Dx when

  1. visualization of amniotic fluid passing fr Cx (Cough test -> ⬆ intra-abdominal pressure 2. pooling amniotic fluid in Vx

Diagnostic test

pH test (Nitrazine paper)

Fern test

Nile blue test

Normal pH of Vx secretions: 4.5 - 6.0

Amniotic fluid pH: 7.1 - 7.3

FALSE ⚠

Positive when pH paper turn color into Dark blue

Positive: Blood contamination, Semen, BV

Negative: Prolonged ROM, Anhydramnios

Aware points

Sample of fluid put on Air dry slide

3 cm from Cx Os must beware of contamination

FALSE ⚠

Positive: Cervical mucosa

Negative: Prolonged ROM, Anhydramnios

Using ‘Nile blue sulphate’

Fetal fat cells will turn into 🔴

Sample + Dye -> Heat dry

FALSE ⚠

Positive: -

Negative: Early GA < 36 wks

U/S

Useful in adjunct

not diagnostic

Use to measure AFI (4 quadrants)

✏ W/U

PE

Lab

Imaging

True PROM // PPROM

Delivery at any GA

Chronologic mx (GA based)

Term & Late Preterm (≥ 34 wks)

Early term & Term (≥ 37 wks)

Proceed to delivery

GBS prophylaxis as I/C

Late Preterm (34 - 36+6 wks)

Same as Early term and Term

Early Preterm (24 - 34 wks)

Expectant Mx

ATBs rec to prolong latency if no C/I

Single course corticosteroids

GBS prophylaxis as I/C

Purpose: to prevent ascending infection so Prolong preg and Delay progession to Preterm birth

Regimens

Ampicillin 2 g IV q 6 hrs + Erythromycin 250 mg IV q 6 hrs for 48 hrs

FOLLOWED BY Amoxicillin 250 mg oral q 8 hrs + Erythromycin 333 mg oral q 8 hrs for 5 days

Periviable (< 24 wks)

⭐ Patient counseling that lung hypoplasia might happen from oligohydramnios

⭐ Expectant Mx or Induction of labor

⭐ IV given (NSS or Ringer lactate) as hope to increase AF

ATBs mayb considered as early as 20 wks

NOT RECOMMENDED before variability

GBS prophylaxis

Corticosteroids

Tocolysis

Magnesium sulfate for neuroprotection

Maternal fever > 39.0 deg Celsius
(No obvious alternative sources)

Or Maternal fever 38.0 - 38.9 deg Celsius with one additional risk

Maternal leukocytosis

Purulent cervical D/C

Fetal tachycardia

Recommended ATBs 💛

Ampicillin 2 g IV q 6 hrs + Gentamicin 2 mg/kg IV load followed by 1.5 mg/kg q 8 hrs OR Gentamicin 5 mg/kg IV q 24 hrs

If allergy to penicillin

Clindamycin/Vancomycin + Gentamicin

Doses

Clindamycin 900 mg IV q 8 hrs

Vancomycin 1 g IV q 12 hrs

Gentamicin same dose as non allergic