INCIDENCE OF PPROM Preterm PROM-defined as PROM prior to 37 weeks of gestation complicates 2% to 4% of all singleton 7% to 20% of twin pregnancies. It is the leading identifiable cause of premature birth ( 30%) accounts for approximately 18% to 20% of perinatal deaths in the United States. Dr. Sharda Jain Dr. jyoti Bhasker

1. MANAGEMENT OF PRETERM PROM
D.G.F.’S CME ON INDUCTION OF LABOUR ON
8TH NOVEMBER 2016
DR. JYOTI BHASKER

2. INCIDENCE OF PPROM
Preterm PROM-defined as PROM prior to 37 weeks of gestation complicates
• 2% to 4% of all singleton
• 7% to 20% of twin pregnancies.
• It is the leading identifiable cause of premature birth ( 30%)
• accounts for approximately 18% to 20% of perinatal deaths in the
United States.

3. MANAGEMENT PROTOCOL
LESS THAN 24 WEEKS ( Previable Age)
 Patient counseling
 Expectant management vs. induction of labor
 Antibiotics : Incomplete data ( start erythromycin at 24 weeks)
 Corticosteroids NOT recommended
 GBS prophylaxis NOT recommended

4.  Expectant management
 Antibiotics
 Single course corticosteroids
 Tocolytics : No consensus
 GBS prophylaxis
 Deliver electively at 34-36 weeks
MANAGEMENT PROTOCOL
24 – 34 WEEKS

5. MANAGEMENT PROTOCOL
> 34 WEEKS
• Await Spontaneous Onset of labour
• Expedite delivery after 24 to 48 hrs
• No role of tocolysis
• Antibiotic Prophylaxis against GBS
• Corticosteroids if delivery imminent within 7 days and not received
previous corticosteroids ( latest ACOG recommendation)

6. Is There a Place for Outpatient Management of
Preterm PROM?
• Expectant management of pregnancies complicated by preterm PROM
should be undertaken in hospital
• In select circumstances , outpatient management can be considered.
• compliant women who have been stable in-house for 72 hours,
• who live near a hospital
• are able to maintain bed rest and pelvic rest at home
• and who are willing to check their temperature twice daily and be seen in the office
weekly,

7. Should Cervical Cerclage be removed if present?
• The cerclage should be removed if:
 there is evidence of intrauterine infection,
 labor,
 unexplained vaginal bleeding
 a favorable gestational age (> 34 weeks).
• If not, it is reasonable to leave the cerclage in place in an attempt to
prolong latency

8. MANAGEMENT SURVEILLANCE
MATERNAL
• Temperature, Pulse .. 4 times a
day
• Twice daily abdominal palpation
for tenderness
• Daily note of vaginal loss
• Thrice weekly TLC, CRP
• ?? Weekly HVS Urine R/E C/S
FETAL WELL BEING
• Fetal Movement Chart
• NST
• 2-3 weekly growth scan
• Weekly AFI
• BPS / CTG

9. IMMEDIATE DELIVERY
 Intrauterine infection
 Abruptio placenta
 Repetitive fetal heart rate decelerations
 Cord prolapse

10. Why should fetus between 34-36 wks be
delivered?
Conservative management at 34–36 weeks' gestation is associated
with
• an eight-fold increase in amnionitis (16 vs. 2%, p = 0.001)
• prolonged maternal hospitalization (5.2 vs. 2.6 days, p = 0.006)
• without a significant reduction in perinatal morbidity related to
prematurity.
Thus, the woman with pPROM at 34–36 weeks is generally best served
by expeditious delivery.

11. MODE OF DELIVERY
If a woman has preterm prelabour rupture of membranes after 34 weeks,
the maternity team should discuss the following factors with her before a
decision is made about whether to induce labour, :
• Risks to the woman (for example, sepsis, possible need for caesarean
section)
• Risks to the baby (for example, sepsis, problems relating to preterm birth)
• local availability of neonatal intensive care facilities.

12. MODE OF DELIVERY
• With Cephalic presentation – Vaginal delivery is ideal.
• Depends on Gestational age
• Weight of the baby
• Patients counselling
• With Breech or abnormal Lie --- LSCS
• Cord Prolapse is common: < 26 weeks – expectant approach
• Restrict the number of vaginal examinations
Bishop score
> 5 – Oxytocin
< 5 – Cervigel or
misoprost sub lingual

13. RECOMMENDATIONS FOR ANTIBIOTICS IN PPROM
GA < 32 WEEKS GA > 32 - 34 WEEKS
Antibiotics should be given
who are not in labour
• in order to prolong pregnancy and
• to decrease maternal and neonatal
morbidity
Antibiotics should be given
• If delivery not planned
• Lung Maturity not proven
The use of antibiotics should be gestational-age dependent.
The evidence for benefit is greater at earlier gestational ages (< 32 weeks).

14. ANTIBIOTIC REGIMENS
• Initial Parenteral phase:
ampicillin 2 g IV every 6 hours
and erythromycin 250 mg IV
every 6 hours for 48 hours
• Oral Phase:
followed by amoxicillin 250 mg
orally every 8 hours and
erythromycin 333 mg orally every
8 hours for 5 days (I-A)
National Institute of Child Health and Human
Development Maternal-Fetal Medicine Units
Network Trial, which enrolled 614 women
with PPROM from 24 to 32 weeks’ gestation
1997
ORAL ANTIBIOTIC :
Erythromycin 250 mg orally
every 6 hours for 10 days (I-A)
ORACLE I trial, which enrolled 4826 women.
2001

15. • Amoxicillin/clavulanic acid should not be used because of an
increased risk of necrotizing enterocolitis in neonates exposed to
this antibiotic.
• Amoxicillin without clavulanic acid is safe. (I-A)
• Women presenting with PPROM should be screened for urinary tract
infections, sexually transmitted infections, and group B
streptococcus carriage, and treated with appropriate antibiotics if
positive. (II-2B)

16. Cochrane review 2013
• Routine prescription of antibiotics for women with preterm rupture of
the membranes is associated with prolongation of pregnancy
and improvements in a number of short-term neonatal morbidities,
but no significant reduction in perinatal mortality.
• Despite lack of evidence of longer-term benefit in childhood,
the advantages on short-term morbidities are such that
we would recommend antibiotics are routinely prescribed.
• The antibiotic of choice is not clear but co-amoxiclav should be avoided
in women due to increased risk of neonatal necrotising enterocolitis.

17. ROLE OF ANTENATAL STEROIDS
• A single course of corticosteroids is recommended for pregnant
women between 24 0/7 weeks and 33 6/7 weeks of gestation,
including for those with ruptured membranes and multiple gestations.
• It also may be considered for pregnant women starting at 23 0/7
weeks of gestation who are at risk of preterm delivery within 7 days,
based on a family’s decision regarding resuscitation, irrespective of
membrane rupture status and regardless of fetal number.
• A single course of betamethasone is recommended for pregnant
women between 34 0/7 weeks and 36 6/7 weeks of gestation at risk
of preterm birth within 7 days, and who have not received a previous
course of antenatal corticosteroids.
ACOG COMMITTEE OPINION OCTOBER 2016

18. • Regularly scheduled repeat courses or serial courses (more than two) are
not currently recommended.
• A single repeat course of antenatal corticosteroids should be considered
in women who are less than 34 0/7 weeks of gestation who have an
imminent risk of preterm delivery within the next 7 days, and whose
prior course of antenatal corticosteroids was administered more
than 14 days previously. Rescue course corticosteroids could be
provided as early as 7 days from the prior dose, if indicated by the clinical
scenario.
• Whether to administer a repeat or rescue course of corticosteroids
with preterm prelabor rupture of membranes (PROM) is
controversial, and there is insufficient evidence to make a
recommendation for or against.
• Continued surveillance of long-term outcomes after in utero
corticosteroid exposure should be supported.

19. DRUG AND DOSE
• Treatment should consist of either two 12-mg doses of betamethasone
given intramuscularly 24 hours apart or four 6-mg doses of
dexamethasone administered intramuscularly every 12 hours
• First dose of antenatal corticosteroids should be administered even if the
ability to give the second dose is unlikely, based on the clinical scenario
• However, no additional benefit has been demonstrated for courses of
antenatal corticosteroids with dosage intervals shorter than those
outlined previously, often referred to as “accelerated dosing,” even when
delivery appears imminent .
• The benefit of corticosteroid administration is greatest at 2–7 days after
the initial dose.
Not sufficient data to recommend one corticosteroid regimen over the other

20. TOCOLYSIS
• Preterm PROM is a relative contraindication to the use of tocolytic
agents.
• Although such agents may be able to delay delivery by 24 to 28 hours,
there is no convincing evidence that they can delay delivery beyond
this time period and no consistent evidence that they can improve
long-term perinatal morbidity or mortality.
• The benefits of tocolysis in the setting of preterm PROM appear to be
limited, and should be used only
• to allow the first course of antenatal corticosteroids to be completed
• and/or to transfer the patient to a tertiary care center

21. GROUP B beta Haemolytic Prophylaxis
• It is indicated for all women threatening to deliver preterm, unless a
negative perineal culture for GBS has been documented within the
previous 5 weeks.
• Intravenous penicillin is the treatment of choice, and a minimum of 4
hours of antibiotics is recommended prior to delivery.
• A perineal and perianal (not cervical) culture for GBS should be taken
from all women who present with preterm PROM with an unknown GBS
carrier status
• If antibiotics are started and the decision is later taken to continue
expectant management, the antibiotics can be discontinued and restarted
once the patient is in labour if the GBS culture returns positive

22. MANAGEMENT ALGORYTHM OF PRETERM PREMATURE RUPTURE OF MEMBRANES

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