Transcript Second Trimester PPROM MT 11656xx

Second Trimester
PPROM
Good Samaritan Hospital
Perinatal M&M
March 17, 2009
Audrey Toda, PGY-2
Attending: Dr. Kjos
Learning objectives
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List management options for 2nd trimester
PROM
State the expected outcome (survival, sequelae)
of conservative management of 2nd trimester
PROM
Does the amount of fluid affect prognosis?
State recommendations for hospitalization
State the recommendations for when steriods
should be administered?
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The patient is a 30 year-old Indonesian G1P0 at
19 1/7wks’ gestation who presented to Good
Samaritan Hospital on 12/18/2008 with leakage
of fluid.
The pt described the amount of fluid as a
cupful, and denied vaginal bleeding or
contractions.
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PMH: none
Surgical Hx: none
Meds: PNV, iron, calcium
Allergies: NKDA
Social Hx: no alcohol, tobacco, or drug use
OB Hx: primigravida, received prenatal care
since 7 wks’ gestation
Physical Exam
 VS: BP 105/63, P 72, R 18, T 97.3
 Gen: NAD
 CV: RRR, S1S2, no murmurs
 Lungs: CTA bilaterally
 Abd: soft, gravid, nontender
 Ext: no edema, no calf tenderness
 SSE: +pooling/ferning
 Fetal heart rate: 140s
 U/S: severe oligohydramnios, cervix 2.6cm long
and closed.
The patient is a 30 year-old G1P0 at 19
1/7wks with confirmed PPROM, minimal
fluid.
 How would you manage the patient?
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 Induce
 Expectantly
manage
Survival and 2-Year Outcome with Expectant
Management of Second-Trimester Rupture of
Membranes
Farooqi et al.
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53 singleton pregnancies with PPROM at 14-28
wks of gestation
Measured outcome of surviving infants at 2 yrs
of corrected age.
Obstet Gynecol 1998; 92:895-901.
Characteristic or outcome
14-19 wk
20-25 wk
26-28 wk
Mothers
10
24
19
Gestational age at PROM (wk)
17.4 ±2.3
24.0 ±1.5
27.6 ±0.8
Latency period (days)
70.2 ±13.0
19.3 ±18.8
13.5 ±12.8
Gestational age at delivery (wk)
27.1 ±2.0
27.0 ±2.3
29.5 ±1.4
Chorioamnionitis
0
8
7
Cesarean (%)
5(50)
17(71)
16(84)
Infants
10
24
19
Fetal deaths
0
0
0
Live born
10
24
19
Birth weight (g)
1027 ±270
962 ±336
1462 ±406
Pulmonary hypoplasia (%)
6(60)
3(13)
0
Perinatal survival (%; 95%CI)
4(40; 12-74)
22(92; 73-99)
19(100; 82-100)
Neonatal survival (%; 95%CI)
4(40; 12-74)
21(88; 68-97)
19(100; 82-100)
Farooqi et al. Survival and 2-year outcome with expectant management of second-trimester
rupture of membranes. Obstet Gynecol 1998; 92:895-901.
Survival and Neurologic Outcome at 2 Years
Gestational age at rupture of
membranes
14-19 wk
20-25 wk
26-28 wk
Number of live-born infants
10
24
19
Alive at 2 years (%)
4 (40)
20 (83)
19 (100)
Major impairment (%)
1 (25)
4 (20)
0
MR + spastic diplegia
0
1
0
MR + CHARGE association
0
1
1
spastic diplegia
1
2
0
0
3 (15)
2 (11)
Mild to moderate motor delay
0
2
1
Delayed speech
0
1
0
Impairment of hearing
0
0
1
Survival without major impairment
3 (75;19-99)
16 (80;56-94)
19(100;82-100)
Survival without any neurologic
impairment
3 (75;19-99)
13 (65;41-85)
17 (89;67-99)
Minor impairment (%)
CHARGE = coloboma, heart defects, atresia choanae, retarded development, genital
hypoplasia, ear anomalies
Outcomes after expectant management of extremely
preterm premature rupture of the membranes
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Studied 46 patients with PPROM ≤ 24 wks,
median 22.0 wks (range 16.9-24 wks).
Median latency period was 13 days (range 0-96)
Mean gestational age at delivery was 25.8±3.4
wks.
Overall survival 47%
Ten (37%) of the survivors have serious
sequelae.
Dinsmoor et al. Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
PPROM
<24 wk
N=46 (60 fetuses)
Median GA 22 wk
Elected termination
N=3
Elected conservative
Management, N= 43 (57)
Labor, LB, N= 41 (51)
Median latency 14 d
Previable, N=35,
Mean GA 22.3 wk
NICU admit, N=35
Mean GA 27.2 wk
Survival: 47% (27/57)
Median hosp stay: 71 d
Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
IUFD
N=2
NND: N=8
median DOL = 2
Serious Sequelae 10/27 (37%)
Fetal and neonatal morbidity and mortality after
expectant management of EPPROM (n=57)
Not resuscitated or admitted to ICN
22 (39%)
Intrauterine fetal death before labor
2 (9%)
Previable delivery/intrapartum IUFD
20 (91%)
Resuscitated and admitted to ICN
35 (61%)
Gestational age at delivery (wk)
27.2 ± 2.7
Respiratory distress syndrome
29 (83%)
Sepsis
12 (34%)
Grade III-IV intraventricular hemorrhage
4 (11%)
Mortality
8 (23%)
Secondary to extreme prematurity
5 (63%)
Age at time of death (d) (median, range)
2.0 (1-69)
Dinsmoor MJ, et al. Outcomes after expectant management of extremely preterm premature
rupture of the membranes. Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
Comparison of surviving and nonsurviving infants
Surviving
(n=27)
Non surviving p-value
(n=30)
Maternal age (y) (mean±SD)
29.7 ± 7.2
31.8 ± 5.0
.20
Gestational age at ROM (wk)
21.7 ± 2.0
22.1 ± 1.3
.49
Bleeding at ROM
7 (26%)
5 (17%)
.37
Fever at ROM
1
0
.47
Contractions at ROM
2 (7%)
3 (10%)
.54
Oligohydramnios at ROM
16/23 (70%)
19/22 (86%)
.12
Multifetal pregnancy
8 (30%)
17 (57%)
.04
Intra Amniotic infection
5 (19%)
17 (56%)
.003
Gestational age at delivery
(wk)
28.0 ± 2.6
22.9 ±1.6
<.0005
Latency period (d)(med, range) 37.0 (2-96)
3.5 (1-17)
<.0005
Birth weight (g)
528 ± 161
<.0005
1126 ± 418
Dinsmoor MJ, et al. Outcomes after expectant management of extremely preterm premature rupture of the
membranes. Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
Does the amount of fluid affect
prognosis?
Premature rupture of the membranes between 20 and
25 weeks' gestation: role of amniotic fluid volume in
perinatal outcome.
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Studied 178 singleton pregnancies with PPROM 20-25 wks
managed expectantly.
Measured serial amniotic fluid volume and compared
neonatal survival, chorioamnionitis, and other outcomes.
107 pregnancies with adequate AFI after PPROM on
admission. Of these, 16 patients were delivered before 25
weeks of gestation, and the remaining 91 patients were able
to carry their pregnancies beyond 25 weeks of gestation.
This was significantly different from 71 patients who
demonstrated inadequate AFI on admission to the hospital,
of whom 58 were delivered before 25 weeks and only 13
continued the pregnancy beyond 25 weeks (p < 0.05).
Hadi, et al. Am J Obstet Gynecol. 1994 Apr;170(4):1139-44.
Role of amniotic fluid volume
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Incidence of perinatal death for pregnancies between 26
and 34 weeks:
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With adequate amniotic fluid: 2.1%
With inadequate amniotic fluid: 69.2%, (p > 0.001).
Overall survival rate: 55%
Incidence of chorioamnionitis: 26.4%
Conclusion: women with adequate amniotic fluid volume
have:
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↑ chance to continue their pregnancy beyond 25 weeks
↑ neonatal survival rate
The incidence of perinatal death and chorioamnionitis in patients
who carry a pregnancy beyond 25 weeks is correlated with
inadequate amniotic fluid volume.
Hadi HA, et al. Premature rupture of the membranes between 20 and 25 weeks' gestation: role
of amniotic fluid volume in perinatal outcome. Am J Obstet Gynecol. 1994 Apr;170(4):1139-44.
Our Patient: Labs on admission
 WBC 12.5, Hb 12.3, Hct 36.5, Plt 370
 UA: neg
Prenatal Labs
 T&S: O+, Ab Rubella: Immune
 RPR: NR
 HBsAg: neg
 HIV: neg
 GC/Chl: neg
 Pap: neg
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The patient was counseled extensively on the
likely poor prognosis for her baby, and
induction was discussed. The patient stated that
she was a Christian and that God will decide,
and that she wants everything done for her baby.
Ampicillin and Erythromycin were started.
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Since the patient requests expectant
management, where would you monitor
her?
 In
the hospital
 At home
Monitoring prior to viability
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The Farooqi study recommended bed rest at
home and weekly hospital visits including
ultrasound evaluation prior to 23 wks. After 23
wks, patients in the study were admitted to the
hospital.
The Dinsmoor study managed patients prior to
24 wks of gestation as outpatients after an initial
evaluation to rule out acute chorioamnionitis.
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When should steriods should be
administered?
 At
19 wks?
 At 23 wks?
 At 24 wks?
 When delivery is expected?
Timing of steroids after early PPROM
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The Dinsmoor study administered antenatal
corticosteroids to all patients when they reached
24 wks of gestation.
In the Farooqi study, patients received steroids
at the discretion of the attending physician. 12
of the 53 patients received steroids.
Timing of antibiotics
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The Farooqi study did not routinely administer
antibiotics to patients at the time of PPROM.
Antibiotics were generally given for
chorioamnionitis.
The Dinsmoor study reports that antibiotics
were usually administered at the time of initial
presentation.
Neither study administered tocolytics to their
patients at any time.
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The patient was kept in-house.
MFM consult obtained, recommendations were:
Continue 7-day course of antibiotics
 Daily FHT
 Betamethasone at 24 wks
 Repeat U/S for fetal growth at 24 wks
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ACOG Guidelines for PROM
Practice Bulletin #80, April 2007
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<24 wks
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Preterm
240-316 wk
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Patient counseling
Expectant management or labor induction
GBS prophylaxis not recommended
Corticosteroids not recommended
Antibiotics to ↑latency: incomplete data
Expectant management
Therapy: GBS Prophylaxis, single course Steroids,
Antibiotics to prolong latency if no contraindications
Tocolysis: no consensus
ACOG Guidelines for PROM
Practice Bulletin #80, April 2007
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Preterm
320-336 wk
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Expectant management, unless +FLM
documented
Give GBS Prophylaxis
Corticosteriods: no consensus, recommended
by some (NIH Consensus 2002)
Antibiotics to prolong latency if no
contraindications
 Proceed to delivery (induction)
Near term
340-366 wk  Give GBS prophylaxis
Term >37 wk
ACOG Guidelines for PROM
Practice Bulletin #80, April 2007
Management of PROM at home?
Potentially
viable
>24 wks
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<24 wks
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Generally recommend hospitalization and
bedrest after viabilty
Ongoing surveillance (infection, cord
compression)
Study: Only 18% if PROM eligible for
home management (no evidence labor,
infection, or fetal compromise)
Home management
Surveillance for infection
Hospital Course
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At 24 wks of gestation, the patient continued to be
afebrile, with WBC stable at 13, no signs/sx of
infection.
The patient received betamethasone x 2.
MFM U/S showed EFW 576g, breech, normal interval
fetal growth. Oligohydramnios is present. Normal
cervical length, no funneling. Dolichocephaly present.
Pt again counseled on high risk for perinatal
morbidity/mortality including pulmonary hypoplasia,
limb contractures, and opts to continue expectant
management.
What is dolichocephaly?
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It refers to a flattening of the head
longitudinally.
A 1996 study by Levine found that
dolichocephaly was associated with
oligohydramnios of long duration. It was more
common in preterm fetuses in the breech
presentation compared to cephalic.
In fetuses with PPROM it is associated with
respiratory distress syndrome, but not otherwise
with a poor neonatal prognosis.
Levine D et al. Dolichocephaly and oligohydramnios in preterm premature rupture of the
membranes. J Ultrasound Med. 1996 May;15(5):375-9.
Hospital Course
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Repeat MFM U/S at 27 0/7 wks showed
Normal interval growth
 EFW 877g
 Breech
 AFI: 0.58cm
 Asymmetric IUGR with normal umbilical doppler
analysis
 No evidence of absent end-diastolic flow.
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Hospital Course
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At 27 3/7 wks, the patient developed a fever of
100.8 and began feeling contractions q3-4 min.
Fetal tachycardia was also present to 170s with
decreased variability.
SSE showed closed os, no cord or fetal parts.
Bedside U/S showed double footling breech.
Patient taken for C-section.
Hospital Course
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1110g female in double footling breech
presentation, Apgar 1/6/6.
Venous blood gas: pH 7.37, BE -3.3
Update on Baby after One Month of Life
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Has Functional hypoplastic lungs.
Unable to wean off ventilator (several attempts)
 Moderate to severe lung disease
 may need chronic ventilator therapy and
tracheostomy in the future
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A few rounds of infection/antibiotics
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Tracheal culture +Staph, s/p triple Abx, currently on
Bactrim only, recently resolved
Head U/S negative
References
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Dinsmoor MJ, Bachman R, Haney EI, Goldstein M,
Mackendrick W. Outcomes after expectant management of
extremely preterm premature rupture of the membranes. Am J
Obstet Gynecol. 2004 Jan;190(1):183-7.
Farooqi et al. Survival and 2-year outcome with expectant
management of second-trimester rupture of membranes. Obstet
Gynecol 1998; 92:895-901.
Hadi HA, et al. Premature rupture of the membranes between 20
and 25 weeks' gestation: role of amniotic fluid volume in
perinatal outcome. Am J Obstet Gynecol. 1994 Apr;170(4):113944.
Levine D et al. Dolichocephaly and oligohydramnios in preterm
premature rupture of the membranes. J Ultrasound Med. 1996
May;15(5):375-9.
Summary of outcomes of 47 cases of EPPROM