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PPROM from 24 Weeks Gestation (GTG 73 - Jun 2019) - Coggle Diagram
PPROM from 24 Weeks Gestation
(GTG 73 - Jun 2019)
Epidemiology
Complicates up to
3%
of pregnancies
Associated with
30-40%
of preterm births
Median latency after PPROM: 7 days
(shortens as gestational age at PPROM advances)
Delivery latency (24 to 28 weeks): 8-10 days (median)
Delivery latency (31 weeks): 5 days (median)
Diagnosis equivocal in
10-20%
based on clinical evaluation alone
Diagnosis
Maternal history
of SROM
Sterile speculum examination
demonstrating liquor (pool of fluid in vagina) in which case no further diagnostic test required
IGFBP-1
(insulin-like growth factor-binding protein 1) test
PAMG-1
(placenta alpha microglobulin-1) test
No further tests required if in established labour!
Ultrasound
demonstrating oligohydramnios can help support diagnosis
HVS
: GBS may be identified which would influence timing of birth
Risks
Neonatal
Prematurity/preterm delivery
Infection/sepsis
Cord prolapse
Pulmonary hypoplasia
Maternal
Chorioamnionitis
Placental abruption
Assessment
Maternal observations
: Pulse, blood pressure, temperature, symptoms and signs of infection, obstetric EWS
Blood tests
CRP in diagnosing chorioamnionitis
Sensitivity: 68.7%
Specificity 77.1%
WCC
: Rises 24 hours following steroids and should return to baseline 3 days following administration
Fetal heart rate
: Rise in baseline
Outpatient care
Review symptoms of chorioamnionitis, repeat bloods, and perform CTG regularly; offer emotional support
Markers of delivery latency
Presence of APH
Amnionitic fluid volume
Gestational age at PPROM
Markers of infection
Other factors
Past obstetric history
Support at home
Distance from hospital
Management
Inform Neonatologists
Inform once diagnosis made and delivery anticipated to ensure NICU has appropriate staff and facilities should delivery occur
Antibiotics
Erythromycin 250mg QDS for 10 days
following diagnosis of PPROM or until established labour (whichever sooner)
Benefit
: Associated with reduced risk of chorioamnionitis, prolonged latency, and improved neonatal outcomes
Penicillin may be used in women who cannot tolerate erythromycin
Avoid
co-amoxiclav
due to risk of neonatal necrotising enterocolitis
Do not give antibiotics unless diagnosis of PPROM is confirmed
Corticosteroids
OFFER between 24-25+6 weeks (NG25 recommends CONSIDER)
OFFER between 26 and 33+6 weeks
CONSIDER between 34 and 35+6 weeks
Benefit
: Reduced risk of intraventricular haemorrhage and respiratory distress syndrome (need for mechanical ventilation)
DO NOT
routinely offer repeat courses of steroids. Take into account interval since last course, gestational age, and likelihood of delivery within 48 hours.
Magnesium Sulphate
Benefit
: Neuroprotection; reduced risk of cerebral palsy and motor dysfunction (greatest before 30 weeks)
Offer IV magnesium sulphate between 24 and 29+6 weeks
in women with PPROM and established preterm labour, or having a planned preterm delivery within 24 hours
NG25
recommends
considering
magnesium sulphate when preterm delivery is anticipated between
30 and 33+6 weeks
Tocolysis
NOT
recommended due to increased risk of chorioamnionitis without significant improved perinatal outcomes
Delivery
Offer expectant management until 37 weeks
in women with PPROM with no contraindications to continuing the pregnancy
Discuss timing of delivery with each woman on an individual basis with consideration of patient preference and ongoing clinical assessment
Risks of planned early delivery
: Respiratory distress syndrome, Caesarean section, neonatal death, need for ventilation
Amnioinfusion
NOT
recommended as routine clinical practice
Potential benefit
: Preventing umbilical cord compression, postural deformities, pulmonary hypoplasia, and intauterine infection
Unclear evidence
: Improved fetal umbilical artery pH at delivery, reduced variable decelerations in labour, neonatal death/sepsis, pulmonary hypoplasia, and postpartum sepsis
Care of Subsequent Pregnancy
Increased risk of recurrent PPROM
Address modifiable risk factors
Dedicated preterm labour clinic