Dr Rubab Khalid: GTG # 73 PPROM from 24+0 weeks

GTG 73 preterm labour premature rupture of membranes 2019

This blogpost is a quick overview of the latest Green Top Guideline No. 73 Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes (PPROM) from 24+0 weeks of Gestation released in June 2019

Previously this topic was covered in NICE guideline “Preterm Labour and Birth (NG25)”. Please keep in mind that the latest GTG does not replace NG25 rather it supplements it. So, both guidelines should be followed.

For summary of NG 25 please visit this page : NICE NG25 Summary

GTG # 73 Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 weeks of Gestation

Introduction

PPROM complicate 3% of pregnancies
Associated with 40% of preterm births
Can result in significant neonatal morbidity and mortality
Median delivery latency after PPROM 7 days

Diagnosis

Maternal history followed by sterile speculum examination
Liquor found:

Diagnosis confirmed; No further testing needed

Liquor not found:

Consider IGFBP-1 or PAMG-1 test (if available)
should not be used alone to decide about the management
must keep whole clinical picture in mind e.g medical and pregnancy history, gestational age

PPROM not confirmed: return the women to her routine antenatal care

Assessment

It is important because PPROM is associated with risk of ascending infection which can lead to chorioamniotis and later on fetal/neonatal infections
No parameter to be used in isloation.
Combination of clinical assessment, maternal blood test (CRP, WBC) and FHR should be used to diagnose chorioamniotis
If results not consistent with each other keep women under observation and consider repeating the tests
Observe the women for symptoms of clinical chorioamniotis (lower abdominal pain, abnormal vaginal discharge, fever, malaise and reduced fetal movements)
WBC

rises 24 hours after giving corticosteroids
should return to baseline 3 days after the administration.

Raised CRP

most informative
sensitivity 68.7% and specificity 77.1% for diagnosing histological chorioamniotis

If admitted

Use Obstetrics Early Warning Chart for monitoring

If outpatient

women should be advised of symptoms of chorioamniotis
reviewed regularly (CRP & WBCs), clinical recordings and FHR monitoring once or twice per week.
must attend hospital immediately if any concerns

As PPROM is associated with increased perinatal morbidity/mortality and preterm birth; once the diagnosis is confirmed and delivery is anticipated, neonatologist should be informed and women should be given an opportunity to discuss the baby’s care

Management

Antibiotics

Using antibiotics is associated with statistically significant reduction in

Chorioamniotis
Number of babies born within 48 hours and 7 days

Also reduces neonatal infection, use of surfactant, oxygen therapy, abnormal cerebral USG prior to discharge from hospital
No significant reduction in perinatal mortality and health of child at 7 years of age
Give Erythromycin (250 mg QID) for 10 days or until the woman is in established labour
Avoid Co-Amoxiclave
Give antibiotics only if PPROM diagnosis is confirmed

Steroids

Corticosteroids in women with PPROM reduces

RDS and intraventricular hemorrhage

No difference in necrotisisng enterocolitis, neonatal sepsis and Apgar score of <7 at 5 min
Similar perinatal mortality
No increase risk of chorioamniotis and neonatal sepsis
OFFER between 24+0 and 25+6 wks (this is a different point than NG25)
OFFER between 26+0 and 33+6 wks
CONSIDER between 34+0 and 35+6 wks

MgSO4

PPROM women plus in established labour or having a planned preterm birth within 24 hours
OFFER MgSO4 between 24+0 and 29+6 wks
CONSIDER between 30+0 and 33+6 wks (NG25)
It reduces cerebral palsy and motor dysfunction

Tocolysis

Not recommended in PPROM (not eonough evidence)
Use of tocolysis is associated with average 73 hours longer latency of delivery, fewer births within 48 hours, increased risk of 5-min Apgar score of <7 and increased need for ventilation support, increased risk of chorioamniotis before 34+0 wks
Tocolysis does not have an improved neonatal outcomes

Home Monitoring

This decision to be individualized considering past obstetrics history, home support and distance from hospital
Median delivery latency

8-10 days from 24+0 to 28+0 wks
5 days from 31+0 wks

PPROM plus reduced liquor on USG → more likely to give birth within 7 days of rupture membrane
If 26+0 wks , non-cephalic and oligohydramnios → hospital based care should be recommended
There is no optimal method of monitoring to predict adverse fetal outcomes after PPROM
If delivery is imminent → inpatient care is indicated

Amnioinfusion

It is not recommended as part of routine clinical practice (not enough evidence)
It might improve neonatal outcomes by preventing cord compression, postural deformities, pulmonary hypoplasia, intrauterine infection, improved umblical artery pH at delivery, reduced variable decelerations in labour, neonatal death, neonatal sepsis and perpetrated sepsis

Emotional support

Women with PPROM and their partners should be offered additional emotional support during pregnancy and postnatally
PTSD is more common in women whose pregnancies are complicated by PPROM

Antenatally: 14% versus 2%
Postnatal at 6wks: 17% vs 3%

Birth

Timing of delivery should be discussed with each woman on an individual basis
Must give careful consideration to patient preference and ongoing clinical assessment
PPROM 24+0 wks plus no contraindications to continuing pregnancy —> offer expectant management until 37+0 wks
Expectant management is associated with better outcomes for mother and baby
Expectant management vs early delivery

No difference in neonatal sepsis or infection, overall perinatal mortality or IUD
Early delivery increase RDS, CS rates, neonatal deaths rates and need for ventilation

Subsequent pregnancy

There is increased chance of recurrence of PPROM

OR 8.7 in White
OR 7.2 in African American

Short pregnancy interval increases the risk
Care in subsequent pregnancy to be provided the an obstetrician with an interest in preterm birth; ideally in dedicated preterm labour clinics
Address modifiable risk factors like smoking and respiratory disease
Limited evidence for offering genital tract screening for infection & TVS for cervical length