Antibiotics & PPROM
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Transcript Antibiotics & PPROM
Modern Management of
Prolonged Rupture of
Membranes
Joseph R. Biggio Jr., M.D.
Department of Obstetrics & Gynecology
Division of Maternal-Fetal Medicine
University of Alabama at Birmingham
PROM
Premature Rupture of Membranes
Amniorrhexis prior to onset of active labor
regardless of gestational age
PPROM
Preterm Premature Rupture of
Membranes
Amniorrhexis < 37 weeks’ gestational age
prior to onset of active labor
Latency
Interval from Rupture of
Membranes to Onset of Active
Labor
Diagnosis
History
Avoid
digital exam
Vaginal Pool
Nitrazine Paper
Ferning
Ultrasound
Amniocentesis/Dye Study
PROM near Term
Management
gestational age
dependent
Induction vs. awaiting spontaneous
labor
Antibiotic prophylaxis per
ACOG/CDC recommendations
Induction vs. Expectant
Management
>5,000
women randomized
Oxytocin,
PGE2 or expectant
management up to 4 days
No difference in cesarean section or
neonatal infection
Less chorioamnionitis in induction
with oxytocin group
Hannah, NEJM, 1996
Epidemiology of Preterm
Birth
PPROM
28 %
Indicated
Preterm
Delivery
26 %
46 %
Spontaneous
Preterm
Delivery
Andrews, 1995
PPROM
Risk Factors
Lower/Upper Genital
Proteases
Prostaglandins
History
of PPROM
Incompetent Cervix
Abruption
Polyhydramnios
Multiple Gestation
Smoking
Tract Infection
PPROM
Complications
Maternal/Fetal
Infection
Premature Labor and Delivery
Umbilical Cord Prolapse
Fetal Hypoxia 2º Cord Compression
Increased Rate of Cesarean Section
Intrauterine Growth Restriction
Abruption
Stillbirth
PPROM
Standard Management
Confirmation
of Diagnosis
Verification of Gestational Age
R/O Labor/Infection/Fetal Compromise
Avoid Digital Vaginal Examinations
In Hospital Observation
Bedrest
% Patients with Latency
> 1 Week
PPROM
Latency
75
50
25
0
25
25-28
29-32
33-36
Gestational Age (Weeks)
Wilson, Obstetrics & Gynecology, 1982
PPROM
Vaginal Examination
Latency Days
20
No Exam
15
10
5
Exam
2
4
2
6
2
6
2
8
2
8
3
0
3
0
3
2
3
2
3
4
3
4
3
5
Gestational Age (Weeks)
Lewis, Obstetrics & Gynecology, 1992
Previable PPROM
<
24 weeks
Poor
prognosis for successful
outcome
Outcome
may be different for
spontaneous vs. iatrogenic
Previable PPROM
Complications
Uterine Infection
Pulmonary Hypoplasia
Limb Compression Deformities
Intrauterine Growth Restriction
Previable PPROM
Outcomes
# of
Study
Infants Chorio.
Taylor
60
25%
Major
71
43%
Moretti
124
39%
Bengston
63
46%
Overall
318
39%
Survival
22%
65%
32%
51%
Normal
Neurological
Development
38%
31%
33%
16%
41%
30%
PPROM
Management Issues
Timing of Delivery
Tocolysis
Antibiotics
Steroids
Amniocentesis
Observation vs. Induction
Fetal Lung Maturity Testing
Fetal Surveillance
Timing of Delivery
Neonatal Morbidity/Mortality
UAB (1995-1996)
R
D
S
I
V
H
N
E
C
S
e
p
s
i
s
1
0
0
S
u
r
v
i
v
a
l
7
5
% 5
0
2
5
0
2
32
52
72
93
13
33
5>
3
7
G
e
s
t
a
t
i
o
n
a
l
A
g
e
(
W
e
e
k
s
)
RNICU Survival and
Morbidity Data (1995-1996)
S
u
r
v
i
v
a
l
% Neonates
1
0
0
R
D
S
7
5
5
0
I
V
H
S
e
p
s
i
s
2
5
N
E
C
2
32
52
72
93
13
33
5>
3
7
W
e
e
k
s
Tocolysis
PPROM
Tocolysis
(n=33)
Bedrest
(n=42)
30.0
6.7
87.9%
45.4%
9.1%
18.2%
9.1%
29.4
5.2
76.2%
52.4%
7.1%
23.8%
11.9%
Tocolysis
Gestational age
Days gained
> 48 hr
RDS
Sepsis
NEC
Neonatal death
Weiner, AJOG, 1988
PPROM
Tocolysis
(n=39)
Expectant
(n=40)
27.9
11.5
77%
51%
3%
8%
47.5
27.3
12.0
75%
58%
5%
5%
57.0
Tocolysis
Gestational age
Days gained
> 48 hr
RDS
Sepsis
IVH
Hospital stay
Garite, AJOG, 1987
Antibiotics
% Patients Colonized
Preterm Labor
Chorioamnion Colonization
75
50
Spontaneous
Preterm Labor
25
Indicated
0
30
weeks
31- 34
weeks
34- 36
weeks
37
weeks
Cassell, 1993
PPROM
Antibiotic Therapy
Reduction
Prolong
Maternal/Perinatal Infection
Latency Period
Improve
Neonatal Outcome
Antibiotic: PPROM
NIH-MFM Network Study
PPROM
IV
between 24 and 32 weeks
ampicillin and erythromycin for 48 h
Oral
amoxicillin/erythromycin for 5 days
Identification
Tocolysis
and Rx of GBS carriers
and corticosteroids prohibited
Mercer, JAMA, 1997
Antibiotic:
NIH-MFM Network Study
Neonatal Morbidity
(n=299)
Placebo
(n=312)
40.5%
6.4%
5.4%
2.3%
6.4%
44.1%
48.7%
7.7%
6.4%
5.8%
5.8%
52.9%
Antibiotics
RDS
IVH
Sepsis <72 hr
NEC
Death
Composite
RR
0.83 *
0.82
0.83
0.40 *
1.10
0.84
*
Antibiotic: Latency Period
NIH-MFM Network Study
Duration of Latency
Antibiotics
Control
48 hrs
27.3 %
36.6 %
7 days
55.5 %
73.5 %
14 days
75.6 %
87.9 %
21 days
85.7 %
93.0 %
Median
6.1 days
2.9 days
PPROM
Antibiotic Therapy
Optimal
Antibiotic Regimen
Route/Duration
of Administration
Antibiotics & PPROM:
Summary
Reduction
in maternal infectious
morbidity
Reduction in births <48 h and <7 d
Reduction in neonatal infectious
morbidity
Reduction in neonates requiring NICU
and ventilation >28 d
Kenyon, Cochrane Library, 1999
Antibiotics & PPROM:
Summary
No
clear reduction in perinatal
death
No clear reduction in cerebral
abnormalities
Kenyon, Cochrane Library, 1999
Amniocentesis
PPROM
Amniotic Fluid Culture
Group B Streptococcus
20 %
Gardnerella vaginalis
17 %
Peptostreptococcus
11 %
Fusobacteria
10 %
Bacteroides fragilis
9%
Other Streptococci
9%
Bacteroides sp.
5%
Utility of Amniocentesis
Confirm/Refute
diagnosis of
chorioamnionitis
Glucose
<15 mg/dL
Culture
Gram
Lung
stain
maturity testing
Corticosteroids
Corticosteroids for FLM
Betamethasone
Dexamethasone
PPROM
Corticosteroids
Author
Block
Taeusch
Papageorgiou
Young
Garite
Collaborative
Iams
Nelson
Simpson
Morales
Number of Patients
Steroids Control
43
26
17
24
17
19
38
37
80
80
153
135
38
35
22
46
112
105
121
124
Effect on
RDS
PPROM
Corticosteroids
Treatment
Control
OR
RDS
83 / 456
149 / 421
0.44 *
Neonatal
Infection
18 / 200
20 / 188
0.82
Crowley, Ob/Gyn Clinics, 1992
PPROM
Corticosteroids + Antibiotics
Gestation at ROM
EGA at delivery
RDS
IVH
NEC
Sepsis
Death
Hospital days
Steroids
No Steroids
(n=38)
(n=39)
29.3
31.4
18% *
--------3%
3%
24.8
29.7
32.0
44%
8%
8%
5%
3%
29.2
Lewis, Obstetrics & Gynecology, 1996
1994 NIH Consensus Conference:
Corticosteroids in PPROM
Corticosteroids
reduce
incidence/severity of RDS, IVH
Benefits in PPROM up to 30-32 weeks
No significant adverse outcomes for
corticosteroid use in PPROM
Impact less than with intact
membranes
Observation vs. Induction
Neonatal Morbidity/Mortality
UAB (1995-1996)
1
0
0
S
u
r
v
i
v
a
l
7
5
%
5
0
R
D
S
2
5
N
E
C
I
V
H
3
0
3
2
3
4
W
e
e
k
s
S
e
p
s
i
s
3
6
PPROM
Observation vs. Induction
Cesarean delivery
Chorioamnionitis
Survival
Oxygen >24 hr
IVH
NEC
Sepsis - W/U
Sepsis - Confirmed
Induction
Expectant
(n=46)
(n=47)
8.7%
10.9%
100%
4.4%
--------28.3%
6.8%
6.4%
27.7% *
100%
2.1%
--------59.6% *
4.3%
Mercer, AJOG, 1993
PPROM
Observation vs Induction
Cesarean delivery
Chorioamnionitis
Stillbirth
Neonatal Death
RDS
IVH
NEC
Sepsis
Delivery
(n=61)
23%
2%
0
5%
37%
6%
1.6%
3%
Expectant
(n=68)
12%
15%
1.4%
0
33%
4.3%
1.4%
7%
Cox, Obstetrics & Gynecology, 1995
Fetal Lung Maturity Testing
8
10
6
8
PI
6
4
L:S
2
0
4
PG
20
24
28
32
36
Gestational Age (weeks)
40
2
0
% Phospholipid
L:S Ratio
Fetal Lung Maturation
Biologic Markers
Fetal Lung Maturity
Evaluation in Vaginal Pool
Specimen
L:S
Ratio
TDX:FLM
PG
Not Reliable
Assay
Not Validated
Useful
Fetal Surveillance
PPROM
Fetal Surveillance
Daily
Non-Stress Test (NST)
Variables
Tachycardia
Loss
of reactivity
Biophysical
Profile (BPP)
Contraction Stress Test (CST)
Summary
UAB Management of PPROM
•PPROM 34 weeks
•Deliver
•Previable PROM
•Outpatient observation
•Antibiotic prophylaxis
•Option of termination <22wk
•Admission at viability
UAB Management of PPROM
•PPROM 23 weeks, <34 weeks
•Antibiotic prophylaxis: Amoxicillin 500
tid x 10d, Azithromycin 1gm d1 & d5
•1 course Betamethasone if
<32weeks
•Test for pool PG weekly beginning at
32 weeks
•Deliver at 34-35 weeks