Preterm
Name 3 risk factors for PPROM (aside from prior PPROM)
Prior PPROM
Preterm labor in prior pregnancy
Short cervix
Second/third trimester bleeding
Low BMI
Low SES
Cigarette/drug use
When should you tocolyze patients with PROM?
Never
Which 2 drugs are interchangeable for PPROM latency?
Azithromycin and erythromycin
Below what gestational age do you administer magnesium for fetal neuroprotection?
32w0d
How should you approach someone who comes in with periviable PPROM?
Discuss individual factors, consider immediate delivery (termination) or expectant management
With PPROM 24 0/7 - 33 6/7 without clinical signs indicating need for delivery, what is the appropriate management (at least 3 components)?
Expectant
Latency antibiotics if no contraindications
Single course of corticosteroids, insufficient evidence for or against rescue dose
Obtain GBS swab
Magnesium sulfate for neuroprotection <32 weeks
What are options of management with PROM at term?
Expectant
Augmentation
What is the dose of BMZ for neuroprotection?
12 mg intramuscular q24h x2 doses
Latency after membrane rupture is (directly/inversely) associated with gestational age at membrane rupture
Inversely
How do you manage a patient with PPROM and HIV positive status?
Individualized; risk of vertical transmission not consistently associated with duration of rupture
Among patients with PPROM, what percentage have 1) clinically evident IAI and 2) postpartum infection?
1) 15-35%
2) 15-25%
What is the recommendation for term PROM?
Proceed to delivery
GBS prophylaxis as indicated
Treat IAI
What is the alternate steroid to BMZ that can be used/dose and route?
Dexamethasone 6 mg q6h x4 doses
What are clinical reasons to deliver someone with PPROM before 34 weeks?
Infection
Clinically significant abruption*
How should you treat someone with PPROM with a cerclage in place?
Removal or retention is reasonable
Prolonged antibiotic use not indicated even if cerclage remains
Cerclage retention >24 hours post PPROM associated with pregnancy prolongation
What additional pathology complicates 2-5% of pregnancies affected by PPROM?
Placental abruption
What does the data show regarding foley balloon usage with PROM patients?
Mixed!
What is the formal recommendation for single course of corticosteroids?
Recommended between 34 0/7 and 36 6/7 at risk of preterm birth within next 7 days, who haven't received previous course/if proceeding with induction or delivery in no less than 24 hours and "no more than 7 days"
When is infection more likely in terms of gestational age with PPROM?
Earlier gestational age
What is the recommended antibiotic regimen for latency antibiotics? ALL ANTIBIOTICS/DOSES
IV ampicillin 2g q6h/oral erythromycin 250 mg q6h for 48 hours >
Oral amoxicillin 250 mg q88h and erythromycin 333 mg q8h
Can replace erythromycin with single oral dose of azithromycin 1g
Beginning at what gestational age does ACOG recommend considering latency antibiotics for PPROM?
20w0d
The practice bulletin mentions data for PROM RCT. Among those expectantly managed, what was the interval of time from membrane rupture to delivery?
33 hours
What is the recommended antibiotic regimen for latency antibiotics? ALL ANTIBIOTICS/DOSES
IV ampicillin 2g q6h/oral erythromycin 250 mg q6h for 48 hours >
Oral amoxicillin 250 mg q88h and erythromycin 333 mg q8h
Can replace erythromycin with single oral dose of azithromycin 1g
What are the benefits of antenatal corticosteroids?
Reduce neonatal mortality, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis
For someone who PPROMs before 34w with recurrent active HSV, how should you proceed? (Expectant vs delivery, medication considerations)
Expectant management
Initiate antiviral therapy, balance risk of pulmonary immaturity and risk of neonatal herpes when considering BMZ