PreTerm PreLabour

Rupture of Membranes

Max Brinsmead PhD FRANZCOG

February 2013

Preamble
Defined as rupture of membranes before 37 completed weeks
of gestation and not in labour
Occurs in 1:50 pregnancies
Associated with 40% of pre term births and a significant
contributor to perinatal mortality. Deaths are due to
Sepsis
Complications of prematurity
Lung hypoplasia

Causes include:
Chorioamnionitis
At least 30% associated with positive bacterial cultures from amniotic
fluid
Trauma e.g. after amniocentesis and CVS
Cervical incompetence
Connective tissue disorders
A large group are UNKNOWN

Diagnosis
History
Listen carefully to the patient
Continuing loss of fluid important

Examination
Sterile speculum
Do NOT perform a digital examination
Unless the patient is in labour

Tests
Ultrasound
Look for oligohydramnios
Cervical length is best evaluated by PV scan

Amnisure is the best available test for amniotic fluid

A place for the detection of Phosphatidyl glycerol (surfactant)?
Take a vaginal swab for gram stain C/S

Possible Sequelae
Cord Prolapse

Rare if there is a cephalic presentation

But always a risk with pre term breech and others
Can occur at any time

Pre term delivery

At term 80% of patients will labour within 24-hr of SROM

This falls to <50% at earlier gestations
Labour can be silent and delivery precipitate

Chorioamnionitis

Has both maternal and neonatal consequences

Organisms involved include
Group B Haemolytic Streptococci (GBS)
E-Coli and other gram ve coliforms
Less commonly anaerobic organisms, Chlamydia, Mycoplasma etc.

Lung Hypoplasia and Compression Deformities

Rare if membranes rupture >28w

Management
Admit for observation

Observation as an outpatient is an option if the fetus is pre-viable and

the patient is capable of self-monitoring

Observe for Signs of Chorioamnionits

Maternal temp and FHR 6 12 hourly

Watch for uterine tenderness & purulent liquor
Role of serial WCC or CRP is controversial
A limited role for amniocentesis and gram stain

CTG frequency and interpretation depends on gestation

A fetal tachycardia has a high correlation with infection
Ultrasound biophysical profile & Dopplers limited role
The amount of AF seen (& fetal breathing) is the best predictor of
lung development for very early PPROM

Monitor for Fetal Well-being

Prophylactic Antibiotics

Erythromycin or Clindamycin prolongs the PROM-Delivery interval

and improves early but not long term neonatal outcomes
Amoxil increases the risk of neonatal NEC after pre-term delivery

Management (2)
Antibiotics (contd)
Erythromycin 250 mg 6-hourly for 10 days recommended
Consider Penicillin 3G IV stat if GBS is found

Corticosteroids
Are indicated from the time of viability to 35w
May be repeated at least once. They are effective for only 7 days
Tocolysis
Not recommended prophylactically
But do have a role in delaying delivery to allow steroids effect and to
transfer the patient to a safe place for delivery
Contraindicated (and often ineffective) if there is infection

Timing of Birth
When neonatal facilities are optimal there is little point in prolonging
the gestation beyond 34 completed weeks
When to transfer a pre-viable PROM can be a dilemma

Amnioinfusions and Fibrin Glues

Unproven

Corticosteroids
Effectively reduce the risk of:

Hyaline membrane disease

Necrotising enterocolitis
Intracranial haemorrhage
Death and disability

Are safe in the short and long term

Are effective at gestations 26w 40w
Do not increase the risk of fetal or maternal infection
Must be given within 24 hrs and 7 days
Repeat once if <34 weeks or still high risk
Optimum formulation, dose & route uncertain
I prefer IM Betamethasone 11.2 mg 24 hours apart

Remember also Mg sulphate for <30 weeks. Has to be given >24

hours before birth to be effective

Infection and Prematurity

Subclinical infection implicated in 40-70% of pre

term labour
Also has a sinister role in the aetiology of cerebral
palsy
The results of therapeutic trials of antibiotics in
preventing pre term birth are conflicting
Vaginosis is a risk factor for prematurity

But screening and treatment should be reserved for those

at risk
Most studies have focused on anaerobic BV but aerobic BV
may be the more important

Erythromycin or Clindamycin is useful after PROM

Do not use Amoxil (Increases the risk of NEC)
Antibiotics with intact membranes may increase
risk of perinatal mortality (RR 1.52, CI 0.99-2.34)
and increases the risk cerebral palsy (RR 1.18, CI
1.02-1.37)
Is the source of infection outside the genital tract?