Prelabor rupture of membranes,(PROM)-Dr- Ahmed-Walid Anwar Morad-1 , Benha University

Prelabor rupture of membranes, Term & Preterm

1. Prelabor Rupture of Membranes GTG Simplified Approach DR/ Ahmed Walid Anwar Morad Professor of OB/GYN Faculty of Medicine Benha University 2024

2. Definitions/ incidence Etiology (Risk Factors& pathogenesis) Complications Diagnosis Management PROM with Chorioamnionitis PROM without Chorioamnionitis PROM in special cases Prophylaxis Take Home Message References ; PPROM (GTG 2019/ ACOG 2015/ CDC)

3. Prelabor Rupture of Membranes (PROM) Definitions: PROM : → ROM (Amnion & Chorion) before the onset of labor. It may be: Gestational Age Type of PROM ≥ 37 wks Term PROM 24-37wks Preterm PROM 24 wks > Previable

4. Definitions: Prolonged rupture of membranes → ROM for more than 18hs before delivery. Latency period: Period from ROM to the onset of labor. The median latency after PPROM is 7 days It tends to  as the gestational age at PPROM  Interval period: Period from PROM to delivery of fetus .

5. Incidence: PROM Complicates 11% of all deliveries Preterm PROM Term PROM 3% 8% 30% of preterm births PPROM single most known cause of PTL

6. Etiology = Risk factors + Pathophysiology

7. Risk factors

8. Pathogenesis:

9. Complications of PPROM

10. Complications of PPROM

11. DD of PROM Urine Incontinence Vaginal discharge (Physiological/ Pathological) Hydrorrhea Gravidarum Chronic accidental Hemorrhage Exogenous fluids (Semen/ VD)

12. Biochemical immunoassay in Vaginal fluid :  Interpretation Detected protein Test Positive : Support diagnosis of PROM Should be used in conjunction with clinical findings Negative PPROM is unlikely Ask woman to return for checkup with any suspected finding PAMG-1 ( Placental alpha microglobulin-1 ) Amnisure: IGFBP-1 ( insulin-like growth factor binding protein-1 ) ACTIM PROM Don't perform diagnostic tests if labor is established 

13. What is about ? Ultrasound: role of liquor volume in supporting diagnosis of PPROM is unclear. AF dye instillation under US guidance then tampon test: (Indigo Carmine or sodium fluorescein)  incidence of infection, ROM and fetal trauma . Not recommended for diagnosis of PPROM

14. Management of PROM Management of PROM with chorioamnionitis Management of PROM without chorioamnionitis: Term PROM (≥ 37 weeks) Preterm PROM (≥24 & < 37 weeks) Previable PROM ( > 24)

15. Management of PROM with chorioamnionitis Termination of pregnancy irrespective of the GA. Under umbrella of broad spectrum antibiotics Antibiotics are modified according to results of culture and sensitivity for: Blood and urine sample. Placental swab at the chorion -amnion interface after delivery . Antibiotics are also given to neonate in proper doses.

16. Lines of Conservative Management A) Inpatient versus outpatient Outpatient RCOG: Decision is individualized based on: Past obstetric history Distance from home to hospital Markers of delivery latency Home support At home : avoid intercourse , temperature (4-8h )/ CRP+WBC Count (3days) & hospital visit weekly or any complaint Inpatient RCOG: if delivery is imminent ACOG: Hospitalization of all cases ; Why ? Latency is commonly short-term Infection may be present suddenly Umbilical cord compression

17. Lines of conservative management B) Advices: Rest: Complete bed rest to prevent more leakage of liquor . Controversies Avoid vaginal examination except if: patient is in labor under complete aseptic conditions to : Exclude Cord prolapse Assess degree of cervical dilatation & effacement .

18. C) Observations: Monitore for signs chorioamnionitis Definitive diagnosis of chorioamnionitis : Cultures of AF (obtained by amniocentesis) as the majority of cases are subclinical. Low AF glucose level (≤ 20 mg/Dl) A rapid test for interleukine-6 (IL-6) (Most sensitive marker for AF infection)

19. C) Observations: Fetal Wellbeing: NST and FBP , may be normal in the presence of infection as intrauterine infection does not affect placental perfusion and fetal oxygenation.  Maturity The optimal method of monitoring to predict adverse fetal outcome after PPROM has not been determined

20. 1) Prophylactic/ Latency Antibiotics Not recommended Coamoxiclav (Amoxicillin + Clavulanic acid): due to increased risk for necrotizing enterocolitis .

21. 2) Antenatal maternal corticosteroids Maximal benefit of ANC is achieved 24 hours and up to 7 days after completion of the course

22. 2) Antenatal maternal corticosteroids ANC Risks Benefits  Neonat al RDS, IVH, NEC Neonatal mortality, NICU Long-term Short-term  Risk of mental , behavior & neurocognitive disorders ??? Hypoglycemia in late preterm Transient  WBCs Count Not  risk of neonatal sepsis or chorioamnionitis

23. 3) Magnesium sulfate for neuroprotection If used > 24 hours Monitor neonatal Ca and Mg and skeletal adverse effects

24. 4) Tocolytics RCOG : Tocolysis in patients with PPROM is not recommended

25. PPROM; Labor and delivery Timing: ≥ 37 wks if no contraindications to expectant ttt Mode of birth: VD ; is the role if there are no contraindications CS; only for obstetric indications e.g., Breech Misoprostol & oxytocin are similarly effective cervical ripening agents Prostaglandin E2 is an effective alternative with no risk of infections Mechanical methods of cervical ripening are contraindicated.

26. PPROM; Labor and delivery Fetal monitoring: CTG or Intermittent auscultation Avoid ( fetal scalp electrode & fetal blood sampling ) before 34 wks Baby: At or below level of placenta Delay cord clamping for 60 sec when mother and baby are stable if no C/I Intra-partum antibiotic prophylaxis in GBS …………

27. Timing of GBS Prophylaxis in PPROM

28. D) Drugs: PROM; 24-37 Weeks PROM < 24 Weeks Yes Yes Latency Antibiotics: Yes NO GBS Prophylaxis Yes No Antenatal Corticosteroids Yes No MgSO4 for fetal neuroprotection No No Tocolytics

29. Treatment options 1) Amnioinfusion 2) Tissue sealant (e.g., fibrin glue, gelatin sponge )

30. Specific cases of PPROM HSV Infection

31. Specific cases of PPROM HIV Infection Management: Optimal obstetric management  unclear Individualized based on; Gestational age , Viral load , & Duration since the patient is on antiretroviral therapy Follow: Standard HIV guidelines by Multidisciplinary team. Vertical transmission risk: not correlated with duration of ROM in patients who are on highly active antiretroviral therapy as they have a low viral load.

32. Specific cases of PPROM Cervical Cerclage Reason Timing of removal GA To  infection risk Immediate > 23 wks Allow corticosteroid Delayed 23-34 wks To  infection risk As soon as possible Term • Send the cervical suture for culture

33. Take Home Message

34. Take Home Message PROM means ROM before onset of labor regardless of the gestational age. PPROM is a single most known cause of PTL Term PROM is usually a reflection of normal physiology, however PPROM is a reflection of pathological processes usually triggered by infection.

35. Take Home Message Accurate diagnosis of ROM is based on; history and sterile speculum examination alone. Additional tests (IGFBP-1 & PAMG-1) can be used when there is doubt about diagnosis. A digital vaginal examination in PPROM should be avoided unless advanced labor is impending. Management guidelines for PPROM should be strictly followed to minimize maternal and fetal complications

36. Take Home Message Conservative is the role in PPROM as long as there are no complications. Conservative management includes; hospitalization (home management), Rest, minimize PV, Drugs (Antibiotics, Corticosteroids, Tocolytics,& Mg SO4 ) Intra-partum GBS prophylaxis is essential for prevention of GBS related morbidity. LSCS should be done only for obstetric indications in case of PROM . Prevention of PROM can be achieved by controlling of modifiable risk factors.