1、Modern Management of Prolonged Rupture of MembranesJoseph R.Biggio Jr.,M.D.Department of Obstetrics&GynecologyDivision of Maternal-Fetal MedicineUniversity of Alabama at BirminghamPROMAmniorrhexis prior to onset of active labor regardless of gestational agePremature Rupture of MembranesPPROMAmniorrh
2、exis 5,000 women randomizednOxytocin,PGE2 or expectant management up to 4 daysnNo difference in cesarean section or neonatal infectionnLess chorioamnionitis in induction with oxytocin groupHannah,NEJM,1996Epidemiology of Preterm BirthPPROM Spontaneous Preterm Delivery Indicated Preterm Delivery 28%4
3、6%26%Andrews,1995PPROMRisk FactorslLower/Upper Genital Tract InfectioniProteasesiProstaglandinslHistory of PPROMlIncompetent CervixlAbruptionlPolyhydramnioslMultiple GestationlSmokingPPROMComplicationslMaternal/Fetal InfectionlPremature Labor and DeliverylUmbilical Cord ProlapselFetal Hypoxia 2 Cord
4、 CompressionlIncreased Rate of Cesarean SectionlIntrauterine Growth RestrictionlAbruptionlStillbirthPPROMStandard ManagementlConfirmation of DiagnosislVerification of Gestational AgelR/O Labor/Infection/Fetal CompromiselAvoid Digital Vaginal ExaminationslIn Hospital ObservationlBedrestPPROMLatency G
5、estational Age(Weeks)%Patients with Latency 1 Week2550752525-2829-3233-360Wilson,Obstetrics&Gynecology,1982PPROMVaginal Examination24-2626-2828-3030-3232-3434-35Gestational Age(Weeks)2015105Latency DaysNo ExamExamLewis,Obstetrics&Gynecology,1992Previable PPROMl37S S u ur rv vi i v va al l1 10 00 02
6、25 55 50 07 75 5G G e es st ta at ti i o on na al l A A g ge e (W W e ee ek ks s)R R D D S SI IV V H HN N E E C CS S e ep ps si i s s0 0RNICU Survival and Morbidity Data(1995-1996)2325272931333537S Su ur rv vi i v va al l1 10 00 02 25 55 50 07 75 5W W e ee ek ks sR RD DS SI I V VH HN NE EC CS Se ep
7、ps si i s s%NeonatesTocolysisTocolysis(n=33)Bedrest(n=42)Gestational age30.029.4Days gained6.75.2 48 hr87.9%76.2%RDS45.4%52.4%Sepsis9.1%7.1%NEC18.2%23.8%Neonatal death9.1%11.9%PPROMTocolysisWeiner,AJOG,1988Tocolysis(n=39)Expectant(n=40)Gestational age27.927.3Days gained11.512.0 48 hr77%75%RDS51%58%S
8、epsis3%5%IVH8%5%Hospital stay47.557.0PPROMTocolysisGarite,AJOG,1987AntibioticsPreterm LaborChorioamnion Colonization0 30 weeks31-34 weeks34-36weeks 37 weeks255075%Patients ColonizedSpontaneousPreterm LaborIndicatedCassell,1993PPROMAntibiotic TherapylReduction Maternal/Perinatal InfectionlProlong Lat
9、ency PeriodlImprove Neonatal OutcomeAntibiotic:PPROMNIH-MFM Network StudylPPROM between 24 and 32 weekslIV ampicillin and erythromycin for 48 hlOral amoxicillin/erythromycin for 5 dayslIdentification and Rx of GBS carrierslTocolysis and corticosteroids prohibited Mercer,JAMA,1997Antibiotics(n=299)Pl
10、acebo(n=312)RRRDS40.5%48.7%0.83IVH6.4%7.7%0.82Sepsis 72 hr5.4%6.4%0.83NEC2.3%5.8%0.40Death6.4%5.8%1.10Composite44.1%52.9%0.84Antibiotic:NIH-MFM Network Study Neonatal Morbidity*Antibiotic:Latency PeriodNIH-MFM Network StudyDuration of LatencyAntibioticsControl 48 hrs27.3%36.6%7 days55.5%73.5%14 days
11、75.6%87.9%21 days85.7%93.0%Median6.1 days2.9 daysPPROMAntibiotic TherapylOptimal Antibiotic RegimenlRoute/Duration of AdministrationAntibiotics&PPROM:SummarylReduction in maternal infectious morbiditylReduction in births 48 h and 28 dKenyon,Cochrane Library,1999Antibiotics&PPROM:SummarylNo clear red
12、uction in perinatal deathlNo clear reduction in cerebral abnormalitiesKenyon,Cochrane Library,1999AmniocentesisPPROMAmniotic Fluid Culturel Group B Streptococcus20%l Gardnerella vaginalis17%l Peptostreptococcus11%l Fusobacteria10%l Bacteroides fragilis 9%l Other Streptococci 9%l Bacteroides sp.5%Uti
13、lity of AmniocentesislConfirm/Refute diagnosis of chorioamnionitisiGlucose 24 hr4.4%2.1%IVH-NEC-Sepsis-W/U28.3%59.6%Sepsis-Confirmed 6.8%4.3%PPROMObservation vs.InductionMercer,AJOG,1993*PPROMObservation vs InductionDelivery(n=61)Expectant(n=68)Cesarean delivery23%12%Chorioamnionitis2%15%Stillbirth0
14、1.4%Neonatal Death5%0RDS37%33%IVH6%4.3%NEC1.6%1.4%Sepsis3%7%Cox,Obstetrics&Gynecology,1995Fetal Lung Maturity TestingFetal Lung MaturationBiologic Markers8642004268202428323640Gestational Age(weeks)L:S Ratio%PhospholipidL:SPIPG10Fetal Lung Maturity Evaluation in Vaginal Pool SpecimenlL:S RatioNot Re
15、liablelTDX:FLM AssayNot ValidatedlPGUsefulFetal SurveillancePPROMFetal SurveillancelDaily Non-Stress Test(NST)iVariablesiTachycardiaiLoss of reactivitylBiophysical Profile(BPP)lContraction Stress Test(CST)SummaryUAB Management of PPROMPPROM 34 weeksDeliverPreviable PROMOutpatient observationAntibiotic prophylaxisOption of termination 22wkAdmission at viabilityPPROM 23 weeks,34 weeksAntibiotic prophylaxis:Amoxicillin 500 tid x 10d,Azithromycin 1gm d1&d51 course Betamethasone if 32weeksTest for pool PG weekly beginning at 32 weeksDeliver at 34-35 weeksUAB Management of PPROM
