Rupture of membranes prior to onset of uterine contractions before 37 weeks of gestation. Prevalence: 1-2% and preceed about one third of preterm deliveries. The risk of chorioamnionitis is higher during the first 5-7 days after rupture of membranes indicating that infection is likely etiology. After the 1st week chorioamnionitis is around 30%. Diagnosis and Observation: Cardiotocography Sterile speculum examination: Fluid coming from cervix (when coughing) or in posterior fornix, look for umbilical cord prolapse Digital cervical examination should be avoided as it increase the risk for infection. Amniotic fluid confirmed by Nitrazine paper pH > 4, 5 or ferning Test or diamine-oxidaze/fetal fibronectin Vaginal swab Chorioamnionitis: Matenal pyrexia > 37,8 offensive vaginal discharge and fetal tachycardia > 160 beats/minut indicate clinical chorioamnionitis, fetal tachycardia predict 20-40% of cases with a false positive rate of about 3%. Uterine tendernes: Decrease fetal moments WBC and CRP increases indicate intraurine infection. Is found in 40% of cases but amniocentesis is not rcommended routinly. Ultrasound: Measurement of amniotic fluid, urinanalysis and vaginal culture Management: Conservative management if no signs of chorioamnionitis or obstetric indication for delivery Steroids 24-34 weeks: 12 mg Dexamethasone immediately and after 12 hours if not given before. Women wiwth PPROM and uterine activity should be considered for tucolysis if they require intrauterine transfer and antinatal corticosteroids. Prophylactic antibiotic. (In the Oracle health beneficial effect was only found for erythromycin). Longer duration than one week increase the risk for resistance. Erythromycin 500 mg x 3 p.o or (alternativ 1 g IV/IM the first 24 hours). Ampicillin 500 mg x 3 p.o.or (alternative IV/IM 1 g x 3 first 24 hours). The above antibiotics can be given together with Metronidazol 1 g x 4 i.v. then 500 mg p.o. every 6 hours for 1 week or suppositories 500 mg x 3. If broader spectrum of coverage is needed or patient has allergy to Ampicillin: Ceftriazone 1 gm IV daily. If ß-hemolytic streptococci colonization or patient is a known carrier (see guidelines for GBS syndrome). Antibiotics given for one week. Cerclage: Be kept in situ for 24 hours to give time for antibiotics and steroids to work. Some will Keep cerclage to avoid manipulation of the cervix. Remove if any contractions. If amnionitis: Start antibiotics 2 g Ampicillin IV every 6 hours and sup. Metronidazol 500 mg x 3. If patient is on these antibiotics change to another (resistent bacteria) (clindamycin 900 mg intravenously every 8 hours or Gentamycin 1,5 mg/kg i.v. every 8 hours) Delivery in hours (induction or Caesarean section). Prognosis: Gestational age < 20 weeks, up to 15% of the children will survive, with the risk of severe handicap of 50%. If oligohydramnios the prognosis is very dubious. 20-24 weeks gestational age. Antibiotic if one wants to give the pregnancy a chance. Steroids to be given 2 days before "active obstetrics" is indicated Tocolysis normally not indicated, can sometime be used to get steroids to work. Elective Induction: From 34 weeks with antibiotics during labor References: (1) ACOG Practice Bulletin No. 80. Premature rupture of membranes: Obstet. Gyncol. 2007;109(4):1007-19 (2) Falk SJ et al. Expectant managemenet in spontaneous preterm premature rupture of membranes bertween 14 and 24 weeks' gestation. J Perinatol. 2004 Oct;24(10):611-6 (3) Royal College of Obstetriciand and Gynecologist Guideline No. 44, Nov. 2006 (4) www.uptodate.com 2007
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