prom and pprom by dr alihussein kassam

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DR ALIHUSSEIN KASSAM, INTERN DOCTOR, MNAZI MMOJA HOSPITAL, ZANZIBAR 03/17/16 1 DR ALIHUSSEIN KASSAM

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Page 1: PROM AND PPROM BY Dr Alihussein kassam

DR ALIHUSSEIN KASSAM,INTERN DOCTOR,

MNAZI MMOJA HOSPITAL,ZANZIBAR

03/17/16 1DR ALIHUSSEIN KASSAM

Page 2: PROM AND PPROM BY Dr Alihussein kassam

Premature rupture of membranes (PROM) Rupture of the chorioamnionic membrane

(amniorrhexis) prior to the onset of labor at any stage of gestation

Rupture of amniotic membranes after 37+0 and before labor

Preterm premature rupture of membranes (PPROM) PROM prior to 36+6-wk. gestation

28 weeks? (pprom versus abortion)24 weeks? (pprom versus abortion)

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PROM – 12% of all pregnancies PPROM – 30% of preterm deliveries

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History “Gush” of fluid Steady leakage of small amounts of fluid Cramping Contractions Back pain

Physical

What do you do?

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Latency period Infection

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Sterile No lubricating jelly Pooling of fluid in

posterior fornix Free flow of fluid

from cervix Cervical dilation Nitrazine Collect slide for

fern (dry 10 mins)

Asse

ss fo

r

Consider need to collect other cervical tests/cultures such fetal fibronectin while doing the SSE. 03/17/16

6DR ALIHUSSEIN KASSAM

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Test Nitrazine test

Fluid from vaginal exam placed on strip of nitrazine paper

Paper turns blue in presence of alkaline (pH > 7.1) amniotic fluid

Fern test Fluid from vaginal exam placed

on slide and allowed to dry Amniotic fluid narrow fern vs.

cervical mucus broad fern

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False positive Nitrazine test Alkaline urine Semen (recent coitus) Cervical mucus Blood contamination Vaginitis (e.g. Trichomonas)

False-Negative Nitrazine test Remote PROM with no residual fluid Minimal amniotic leakage

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Page 9: PROM AND PPROM BY Dr Alihussein kassam

fFn present in cervical secretions <22 wks, >34 wks

Used for assessment of potential PTB

Positive result (>50 ng/dl) may be indicative of PROM and represents disruption of decidua-chorionic interface

In PPROM, Sensitivity-98.2%, Specificity-26.8%.03/17/16 9DR ALIHUSSEIN KASSAM

Page 10: PROM AND PPROM BY Dr Alihussein kassam

Newer test Point of Care test Cost-up to $50 each Sensitivity-98.7-98.9% Specificity-87.5-100% Awaiting further testing prior to

recommendations

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Page 11: PROM AND PPROM BY Dr Alihussein kassam

Place Swab 2-3 in. into vaginal canal x 1 min.

Remove swab and rotate in solvent x 1 min.

Discard swab and place test stick into solvent.

Read results after 5-10 mins have passed.

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Page 12: PROM AND PPROM BY Dr Alihussein kassam

Test Ultrasound

Assess amniotic fluid level and compatibility with PROM

Indigo-carmine Amnioinfusion Ultrasound guided indigo carmine dye amnioinfusion (“Blue tap”) Observe for passage of blue fluid from vagina

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Page 13: PROM AND PPROM BY Dr Alihussein kassam

Risk Factors: Prior PROM or PPROM Prior preterm delivery Multiple gestation Polyhydramnios Incompetent cervix Vaginal/Cervical Infection

Gonorrhea, Chlamydia, GBS, S. Aureus Antepartum bleeding (threatened abortion) Smoking Poor nutrition

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Page 14: PROM AND PPROM BY Dr Alihussein kassam

Patient counseling Expectant management vs. induction of labor GBS prophylaxis NOT recommended Antibiotics

Incomplete data Corticosteriods NOT recommended

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http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/dataShow.cfm

Gestational Age

(In Completed Weeks)

Death BeforeNICU Discharge

Outcomes at 18 to 22 Months Corrected Age*

DeathDeath/ Profound

NeurodevelopmentalImpairment

Death/Moderate to Severe Neuro-developmental Impairment

22 Weeks 95% 95% 98% 99%23 Weeks 74% 74% 84% 91%24 Weeks 44% 44% 57% 72%25 Weeks 24% 25% 38% 54%

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Page 16: PROM AND PPROM BY Dr Alihussein kassam

Expectant management Deliver at 34 wks Unless documented fetal lung maturity

GBS prophylaxis Antibiotics Single course corticosteroids Tocolytics

No consensus

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Page 17: PROM AND PPROM BY Dr Alihussein kassam

Expectant management Deliver at 34 wks Unless documented fetal lung maturity

GBS prophylaxis Antibiotics Corticosteroids

No consensus, some experts recommend

Magnesium sulphate use < 32 weeks

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Proceed to delivery Induction of labor

GBS prophylaxis

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Antibiotics Prolong latency period Prophylaxis of GBS in neonate Prevention of maternal chorioamnionitis and neonatal sepsis

Corticosteroids Enhance fetal lung maturity Decrease risk of RDS, IVH, and necrotizing enterocolitis

Tocolytics Delay delivery to allow administration of corticosteroids Controversial, randomized trials have shown no pregnancy

prolongation

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Page 20: PROM AND PPROM BY Dr Alihussein kassam

Antibiotics Ampicillin 2 g IV Q6 x 48 hrs Amoxicillin 500 mg po TID x 5 days Azithromycin 1 g po x 1 Erythromycin 500mg tds 10/7

Corticosteroids Betamethasone 12 mg IM q24 x 2 Dexamethasone 6 mg IM q12 x 4 repeat 12mg if no delivery

within 7 days

Tocolytics Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs

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Page 21: PROM AND PPROM BY Dr Alihussein kassam

Typically performed after 32 wks

Tests for fetal lung maturity (FLM) Lecethin/Sphingomyelin ratio (not

commonly used, more for historic interest) L/S ratio > 2 indicates pulmonary maturity

Phosphatidylglycerol > 0.5 associated with minimal respiratory distress

Flouresecence polarization (FLM-TDx II) > 55 mg/g of albumin

Lamellar body count 30,000-40,000

If negative, proceed with expectant management until 34 wks

Courtesy of Thomas Shipp, MD.03/17/16

21DR ALIHUSSEIN KASSAM

Page 22: PROM AND PPROM BY Dr Alihussein kassam

Maternal: Monitor for signs of infection Temperature Maternal heart rate Fetal heart rate Uterine tenderness Contractions

Fetal: Monitor for fetal well-being Kick counts Nonstress tests (NST’s) Biophysical profile (BPP)

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Page 23: PROM AND PPROM BY Dr Alihussein kassam

Immediate Delivery Intrauterine infection Abruptio placenta Repetitive fetal heart rate decelerations Cord prolapse

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Expectant Management Risks:

Maternal Increase in chorioamnionitis Increase in Cesarean delivery Spontaneous labor in ~ 90% within 48 hr ROM Increased risk of placental abruption

Fetal Increase in RDS Increase in intraventricular hemorrhage Increase in neonatal sepsis and subsequent cerebral

palsy Increase in perinatal mortality Increase in cord prolapse

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Page 25: PROM AND PPROM BY Dr Alihussein kassam

ROYAL COLLEGE CURRENT GUIDELINES 2010 ON OBSTETRICS

W.H.O INTERVENTION TO IMPROVE OUT COMES IN PRETERMS @2015

K.C.M.C GUIDELINES FOR OBSTETRICS 2012

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