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(Prom) Refers to Membrane Rupture Before the Onset of Uterine Contractions (Previously Known As Premature Rupture of Membranes);

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(Prom) Refers to Membrane Rupture Before the Onset of Uterine Contractions (Previously Known As Premature Rupture of Membranes); • PRELABOR RUPTURE OF MEMBRANES (PROM) REFERS TO MEMBRANE RUPTURE BEFORE THE ONSET OF UTERINE CONTRACTIONS (PREVIOUSLY KNOWN AS PREMATURE RUPTURE OF MEMBRANES); • PRETERM PROM (PPROM) REFERS TO PROM BEFORE 37 WEEKS OF GESTATION. • IT IS RESPONSIBLE FOR, OR ASSOCIATED WITH, APPROXIMATELY ONE-THIRD OF PRETERM BIRTHS THE MANAGEMENT OF PPROM IS AMONG • : ●ACCURATE DIAGNOSIS IN PROBLEMATIC CASES ●EXPECTANT MANAGEMENT VERSUS INTERVENTION ●USE OF TOCOLYTICS ●DURATION OF ADMINISTRATION OF ANTIBIOTIC PROPHYLAXIS ●TIMING OF ADMINISTRATION OF ANTENATAL CORTICOSTEROIDS ●METHODS OF TESTING FOR MATERNAL/FETAL INFECTION ●TIMING OF DELIVERY INCIDENCE OF PPROM • 3 PERCENT OF PREGNANCIES • APPROXIMATELY 0.5 PERCENT OF PREGNANCIES <27 WEEKS, • 1 PERCENT OF PREGNANCIES 27 TO 34 WEEKS, • 1 PERCENT OF PREGNANCIES 34 TO 37 WEEKS THE STRENGTH AND INTEGRITY OF FETAL MEMBRANES DERIVE FROM EXTRACELLULAR MEMBRANE PROTEINS, • INCLUDING COLLAGENS, • FIBRONECTIN, • AND LAMININ. MATRIX METALLOPROTEASES (MMPS) DECREASE MEMBRANE STRENGTH BY INCREASING COLLAGEN DEGRADATION PATHOGENESIS SUBCLINICAL OR OVERT INFECTION, INFLAMMATION, MECHANICAL STRESS, BLEEDING INITIATE A CASCADE OF BIOCHEMICAL CHANGES THAT CULMINATE IN PROM CLINICAL FINDINGS RISK FACTORS • MATERNAL PHYSIOLOGIC • GENETIC • ENVIRONMENTAL FACTORS • A HISTORY OF PPROM IN A PREVIOUS PREGNANCY • GENITAL TRACT INFECTION • ANTEPARTUM BLEEDING • CIGARETTE SMOKING HAVE A PARTICULARLY STRONG ASSOCIATION WITH PPROM • POLYHYDRAMNIOS • ACUTE TRAUMA • SEVERAL GENETIC POLYMORPHISMS OF GENES RELATED TO INFECTION, INFLAMMATION, AND COLLAGEN DEGRADATION • FINDINGS ON PHYSICAL EXAMINATION — • DIRECT OBSERVATION OF AMNIOTIC FLUID • IF AMNIOTIC FLUID IS NOT IMMEDIATELY VISIBLE, THE WOMAN CAN BE ASKED TO PUSH ON HER FUNDUS, VALSALVA, OR COUGH TO PROVOKE LEAKAGE OF AMNIOTIC FLUID FROM THE CERVICAL OS. FOR PATIENTS WHO ARE NOT IN ACTIVE LABOR, EXAMINATION OF THE CERVIX AND VAGINA SHOULD BE PERFORMED USING A STERILE SPECULUM. • DIGITAL EXAMINATION SHOULD BE AVOIDED BECAUSE IT MAY DECREASE THE LATENCY PERIOD (IE, TIME FROM RUPTURE OF MEMBRANES TO DELIVERY) AND INCREASE THE RISK OF INTRAUTERINE INFECTION • FINDINGS ON ULTRASONOGRAPHY — FIFTY TO 70 PERCENT OF WOMEN WITH PPROM HAVE LOW AMNIOTIC FLUID VOLUME ON INITIAL SONOGRAPHY OLIGOHYDRAMNIOS CAN BE DEFINED AS THE ABSENCE OF • A SINGLE POCKET OF AMNIOTIC FLUID THAT IS >2 CM IN DEPTH • AN AMNIOTIC FLUID INDEX ≤5 CM. • APPROXIMATELY ONE-THIRD OF WOMEN WITH PPROM DEVELOP POTENTIALLY SERIOUS INFECTIONS, SUCH AS INTRA-AMNIOTIC INFECTION (CHORIOAMNIONITIS), ENDOMETRITIS, OR SEPTICEMIA. • ENDOMETRITIS IS MORE COMMON AFTER CESAREAN THAN VAGINAL DELIVERY • EARLY, SEVERE, PROLONGED OLIGOHYDRAMNIOS CAN BE ASSOCIATED WITH • PULMONARY HYPOPLASIA • FACIAL DEFORMATION • ORTHOPEDIC ABNORMALITIES • • COMPLICATIONS ARE MOST LIKELY WHEN MEMBRANE RUPTURE OCCURS AT LESS THAN 23 WEEKS OF GESTATION. LABORATORY CONFIRMATION OF CLINICALLY SUSPECTED PPROM NITRAZINE IF PPROM IS NOT OBVIOUS AFTER VISUAL INSPECTION NITRAZINE PAPER. AMNIOTIC FLUID USUALLY HAS A PH RANGE OF 7.0 TO 7.3 COMPARED WITH THE NORMALLY ACIDIC VAGINAL PH OF 3.8 TO 4.2 AND THE NORMAL ACIDIC PH OF URINE OF 5.0 TO 6.0. • FALSE-NEGATIVE AND FALSE-POSITIVE NITRAZINE TEST RESULTS OCCUR IN UP TO 5 PERCENT OF CASES FALSE-NEGATIVE TEST RESULTS CAN OCCUR WHEN • LEAKING IS INTERMITTENT • THE AMNIOTIC FLUID IS DILUTED BY OTHER VAGINAL FLUIDS. FALSE-POSITIVE RESULTS CAN BE DUE TO THE PRESENCE OF ALKALINE FLUIDS IN THE VAGINA, • BLOOD • SEMINAL FLUID • SOAP • THE PH OF URINE CAN BE ELEVATED TO NEAR 8.0 IF INFECTED WITH PROTEUS SPECIES. • FERNING FLUID FROM THE POSTERIOR VAGINAL FORNIX IS SWABBED ONTO A GLASS SLIDE AND ALLOWED TO DRY FOR AT LEAST 10 MINUTES. AMNIOTIC FLUID PRODUCES A DELICATE FERNING PATTERN, IN CONTRAST TO THE THICK AND WIDE ARBORIZATION PATTERN OF DRIED CERVICAL MUCUS • WELL-ESTROGENIZED CERVICAL MUCUS OR A FINGERPRINT ON THE MICROSCOPE SLIDE MAY CAUSE A FALSE-POSITIVE FERN TEST; • FALSE NEGATIVES CAN BE DUE TO INADEQUATE AMNIOTIC FLUID ON THE SWAB OR HEAVY CONTAMINATION WITH VAGINAL DISCHARGE OR BLOOD. • PLACENTAL ALPHA MICROGLOBULIN-1 PROTEIN ASSAY (PAMG-1 [AMNISURE]) FOR DIAGNOSIS OF RUPTURE OF MEMBRANES PAMG-1 (AMNISURE) — AMNISURE IS A RAPID SLIDE TEST PLACENTAL ALPHA MICROGLOBULIN-1 IS RELEASED FROM DECIDUAL CELLS. AN ADVANTAGE OF THIS TEST IS THAT IT IS NOT AFFECTED BY SEMEN OR TRACE AMOUNTS OF BLOOD. • GIVEN THE RELATIVELY HIGH COST OF THIS TEST, WE SUGGEST LIMITING ITS USE TO CASES WHERE THE DIAGNOSIS REMAINS UNCERTAIN AFTER PHYSICAL EXAMINATION, • NITRAZINE AND FERN TESTS, AND ULTRASOUND ASSESSMENT. • IGFBP-1, MAY BE OF VALUE IN CONFIRMING THE DIAGNOSIS OF PPROM IN PROBLEMATIC CASES. THIS PROTEIN IS SECRETED BY DECIDUAL AND PLACENTAL CELLS AND HAS A VERY HIGH CONCENTRATION IN AMNIOTIC FLUID COMPARED TO OTHER BODY FLUIDS. • THIS TEST IS POPULAR IN EUROPE • THE TEST IS NOT AFFECTED BY THE PRESENCE OF INFECTED VAGINAL SECRETIONS, URINE, SEMEN, OR SMALL AMOUNTS OF BLOOD. PLACENTAL PROTEIN 12 AND ALPHA-FETOPROTEIN (ROM PLUS) THE TEST IS PERFORMED BY PLACING THE ROM PLUS TEST SWAB IN THE VAGINA FOR 15 SECONDS, PLACING THE SWAB IN A DILUENT, AND THEN PLACING A SAMPLE OF THE DILUENT ON A SPECIAL TEST STRIP, WHICH DEVELOPS A LINE IF THE PROTEINS ARE PRESENT. TRACE AMOUNTS OF BLOOD DO NOT AFFECT THE TEST. • IMMUNOASSAY FOR ALPHA-FETOPROTEIN EMBEDDED IN A SANITARY NAPKIN • THE TEST WAS EASY TO READ BY ALL OBSERVERS • INSTILLATION OF DYE — IN THE PAST,, 1 ML OF INDIGO CARMINE DYE IN 9 ML OF STERILE SALINE WAS INJECTED TRANSABDOMINALLY INTO THE AMNIOTIC FLUID, AND A TAMPON WAS PLACED IN THE VAGINA. TWENTY MINUTES LATER, THE TAMPON WAS REMOVED AND EXAMINED FOR BLUE STAINING, WHICH INDICATED LEAKAGE OF AMNIOTIC FLUID THE MANAGEMENT BASED UPON CONSIDERATION OF SEVERAL FACTORS ●GESTATIONAL AGE ●PRESENCE OR ABSENCE OF MATERNAL/FETAL INFECTION ●PRESENCE OR ABSENCE OF LABOR ●FETAL PRESENTATION ●FETAL WELL-BEING ●FETAL LUNG MATURITY ●CERVICAL STATUS (BY VISUAL INSPECTION) ●AVAILABILITY OF NEONATAL INTENSIVE CARE • SCREENING FOR GROUP B STREPTOCOCCUS, SEXUALLY TRANSMITTED INFECTIONS, AND • POSSIBLY BACTERIAL VAGINOSIS (BV) IS USEFUL FOR GUIDING ANTIBIOTIC THERAPY ADMINISTRATION OF ANTENATAL CORTICOSTEROIDS — A COURSE OF CORTICOSTEROIDS SHOULD BE ADMINISTERED TO PREGNANCIES THAT PRESENT WITH PPROM BETWEEN 23 AND 34 WEEKS OF GESTATION. • NEONATAL DEATH • RESPIRATORY DISTRESS SYNDROME, • INTRAVENTRICULAR HEMORRHAGE • NECROTIZING ENTEROCOLITIS • DURATION OF NEONATAL RESPIRATORY SUPPORT WERE SIGNIFICANTLY REDUCED • ADMINISTRATION OF ANTENATAL STEROIDS FOR PREGNANCIES THAT PRESENT WITH PPROM IN THE 22ND WEEK OF GESTATION IS ALSO REASONABLE IF DELIVERY IN THE NEXT SEVEN DAYS IS ANTICIPATED • IN PREGNANCIES THAT FIRST PRESENT WITH PPROM AT >34 WEEKS AND <37 WEEKS, THE AUTHOR ADMINISTERS A FIRST COURSE OF ANTENATAL CORTICOSTEROIDS IF AMNIOTIC FLUID TESTING SUGGESTS FETAL PULMONARY IMMATURITY. • CHEMOPROPHYLAXIS SPECIFICALLY FOR GBS IS INDICATED IF GBS TEST RESULTS ARE POSITIVE OR UNKNOWN AND DELIVERY IS IMMINENT. • AMPICILLIN 2 G INTRAVENOUSLY EVERY 6 HOURS FOR 48 HOURS • SHOULD PROVIDE ADEQUATE TREATMENT FOR GBS-COLONIZED WOMEN WHO ARE IN LABOR AT THE TIME OF ADMISSION OR WHO GO INTO LABOR WITHIN 48 HOURS OF ADMISSION. AS NOTED, THIS REGIMEN OF INTRAVENOUS AMPICILLIN, FOLLOWED BY ORAL AMOXICILLIN, COMBINED WITH AZITHROMYCIN, IS USUALLY GIVEN FOR SEVEN DAYS. • PROPHYLACTIC ANTIBIOTICS • ARE INDICATED TO PROLONG LATENCY AND TO REDUCE THE RISK OF BOTH NEONATAL AND MATERNAL INFECTION. • THEREBY DELAY THE ONSET OF PRETERM LABOR (PROLONG LATENCY) • ANTIBIOTICS FOLLOWING PPROM BEFORE 37 WEEKS OF GESTATION COMPARED WITH NO TREATMENT, • ANTIBIOTIC USE WAS ASSOCIATED WITH SIGNIFICANT REDUCTIONS IN: ●CHORIOAMNIONITIS ●NEONATAL INFECTION ●USE OF SURFACTANT ●NEONATAL OXYGEN WE RECOMMEND ADMINISTERING A SEVEN-DAY COURSE TO ALL WOMEN WITH PPROM WHO ARE MANAGED EXPECTANTLY. AZITHROMYCIN ONE GRAM ORALLY UPON ADMISSION, PLUS ●AMPICILLIN 2 G INTRAVENOUSLY EVERY 6 HOURS FOR 48 HOURS, FOLLOWED BY ●AMOXICILLIN 500 MG ORALLY THREE TIMES DAILY OR 875 MG ORALLY TWICE DAILY FOR AN ADDITIONAL FIVE DAYS • AZITHROMYCIN SPECIFICALLY TARGETS UREAPLASMAS, WHICH CAN BE IMPORTANT CAUSES OF CHORIOAMNIONITIS IN THIS SETTING • AZITHROMYCIN ALSO PROVIDES COVERAGE OF CHLAMYDIA TRACHOMATIS, WHICH IS AN IMPORTANT CAUSE OF NEONATAL CONJUNCTIVITIS AND PNEUMONITIS. • AMPICILLIN AND AMOXICILLIN SPECIFICALLY TARGET GROUP B STREPTOCOCCUS (GBS), MANY AEROBIC GRAM-NEGATIVE BACILLI, AND SOME ANAEROBES. • NETWORK TRIAL ON ANTIBIOTIC THERAPY FOR REDUCTION OF INFANT MORBIDITY AFTER PPROM (INTRAVENOUS AMPICILLIN 2 G EVERY 6 HOURS AND ERYTHROMYCIN 250 MG EVERY 6 HOURS FOR 48 HOURS FOLLOWED BY ORAL AMOXICILLIN 250 MG EVERY 8 HOURS AND ERYTHROMYCIN 333 MG EVERY 8 HOURS FOR FIVE DAYS PROPHYLAXY • WOMEN WITH PENICILLIN ALLERGY — IF THE PATIENT'S HISTORY SUGGESTS A "LOW RISK" FOR ANAPHYLAXIS (EG, ISOLATED MACULOPAPULAR RASH WITHOUT URTICARIA OR PRURITUS), THEN WE SUGGEST CEFAZOLIN 1 G INTRAVENOUSLY EVERY 8 HOURS FOR 48 HOURS, FOLLOWED BY CEPHALEXIN 500 MG ORALLY FOUR TIMES DAILY FOR FIVE DAYS. • THESE DRUGS PROVIDE COVERAGE FOR BOTH GBS AND ESCHERICHIA COLI, THE TWO MAJOR CAUSES OF NEONATAL INFECTION. WE ALSO GIVE A SINGLE ORAL DOSE OF AZITHROMYCIN 1 G. (SEE "PENICILLIN ALLERGY: IMMEDIATE REACTIONS".) IF THE PATIENT'S HISTORY SUGGESTS A "HIGH RISK" FOR ANAPHYLAXIS (EG, ANAPHYLAXIS, ANGIOEDEMA, RESPIRATORY DISTRESS, URTICARIA, PARTICULARLY IF THESE SYMPTOMS OCCURRED WITHIN 30 MINUTES OF DRUG ADMINISTRATION), WE SUGGEST INTRAVENOUS CLINDAMYCIN 900 MG EVERY 8 HOURS FOR 48 HOURS PLUS INTRAVENOUS GENTAMICIN
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