Second Trimester PPROMGood Samaritan HospitalPerinatal M&MMarch 17, 2009 Audrey Toda, PGY-2 Attending: Dr. Kjos
Learning objectives • List management options for 2nd trimester PROM • State the expected outcome (survival, sequelae) of conservative management of 2nd trimester PROM • Does the amount of fluid affect prognosis? • State recommendations for hospitalization • State the recommendations for when steriods should be administered?
The patient is a 30 year-old Indonesian G1P0 at 19 1/7wks’ gestation who presented to Good Samaritan Hospital on 12/18/2008 with leakage of fluid. • The pt described the amount of fluid as a cupful, and denied vaginal bleeding or contractions.
PMH: none • Surgical Hx: none • Meds: PNV, iron, calcium • Allergies: NKDA • Social Hx: no alcohol, tobacco, or drug use • OB Hx: primigravida, received prenatal care since 7 wks’ gestation
Physical Exam • VS: BP 105/63, P 72, R 18, T 97.3 • Gen: NAD • CV: RRR, S1S2, no murmurs • Lungs: CTA bilaterally • Abd: soft, gravid, nontender • Ext: no edema, no calf tenderness • SSE: +pooling/ferning • Fetal heart rate: 140s • U/S: severe oligohydramnios, cervix 2.6cm long and closed.
The patient is a 30 year-old G1P0 at 19 1/7wks with confirmed PPROM, minimal fluid. • How would you manage the patient? • Induce • Expectantly manage
Survival and 2-Year Outcome with Expectant Management of Second-Trimester Rupture of MembranesFarooqi et al. • 53 singleton pregnancies with PPROM at 14-28 wks of gestation • Measured outcome of surviving infants at 2 yrs of corrected age. Obstet Gynecol 1998; 92:895-901.
Farooqi et al. Survival and 2-year outcome with expectant management of second-trimester rupture of membranes. Obstet Gynecol 1998; 92:895-901.
Survival and Neurologic Outcome at 2 Years CHARGE = coloboma, heart defects, atresia choanae, retarded development, genital hypoplasia, ear anomalies
Outcomes after expectant management of extremely preterm premature rupture of the membranes • Studied 46 patients with PPROM ≤ 24 wks, median 22.0 wks (range 16.9-24 wks). • Median latency period was 13 days (range 0-96) • Mean gestational age at delivery was 25.8±3.4 wks. • Overall survival 47% • Ten (37%) of the survivors have serious sequelae. Dinsmoor et al. Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
PPROM <24 wk Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
Fetal and neonatal morbidity and mortality after expectant management of EPPROM (n=57) Dinsmoor MJ, et al. Outcomes after expectant management of extremely preterm premature rupture of the membranes. Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
Comparison of surviving and nonsurviving infants Dinsmoor MJ, et al. Outcomes after expectant management of extremely preterm premature rupture of the membranes. Am J Obstet Gynecol. 2004 Jan;190(1):183-7.
Premature rupture of the membranes between 20 and 25 weeks' gestation: role of amniotic fluid volume in perinatal outcome. • Studied 178 singleton pregnancies with PPROM 20-25 wks managed expectantly. • Measured serial amniotic fluid volume and compared neonatal survival, chorioamnionitis, and other outcomes. • 107 pregnancies with adequate AFI after PPROM on admission. Of these, 16 patients were delivered before 25 weeks of gestation, and the remaining 91 patients were able to carry their pregnancies beyond 25 weeks of gestation. • This was significantly different from 71 patients who demonstrated inadequate AFI on admission to the hospital, of whom 58 were delivered before 25 weeks and only 13 continued the pregnancy beyond 25 weeks (p < 0.05). Hadi, et al.Am J Obstet Gynecol. 1994 Apr;170(4):1139-44.
Role of amniotic fluid volume • Incidence of perinatal death for pregnancies between 26 and 34 weeks: • With adequate amniotic fluid: 2.1% • With inadequate amniotic fluid: 69.2%, (p > 0.001). • Overall survival rate: 55% • Incidence of chorioamnionitis: 26.4% • Conclusion: women with adequate amniotic fluid volume have: • ↑ chance to continue their pregnancy beyond 25 weeks • ↑ neonatal survival rate • The incidence of perinatal death and chorioamnionitis in patients who carry a pregnancy beyond 25 weeks is correlated with inadequate amniotic fluid volume. Hadi HA, et al. Premature rupture of the membranes between 20 and 25 weeks' gestation: role of amniotic fluid volume in perinatal outcome. Am J Obstet Gynecol. 1994 Apr;170(4):1139-44.
Our Patient: Labs on admission • WBC 12.5, Hb 12.3, Hct 36.5, Plt 370 • UA: neg Prenatal Labs • T&S: O+, Ab- • Rubella: Immune • RPR: NR • HBsAg: neg • HIV: neg • GC/Chl: neg • Pap: neg
The patient was counseled extensively on the likely poor prognosis for her baby, and induction was discussed. The patient stated that she was a Christian and that God will decide, and that she wants everything done for her baby. • Ampicillin and Erythromycin were started.
Since the patient requests expectant management, where would you monitor her? • In the hospital • At home
Monitoring prior to viability • The Farooqi study recommended bed rest at home and weekly hospital visits including ultrasound evaluation prior to 23 wks. After 23 wks, patients in the study were admitted to the hospital. • The Dinsmoor study managed patients prior to 24 wks of gestation as outpatients after an initial evaluation to rule out acute chorioamnionitis.
When should steriods should be administered? • At 19 wks? • At 23 wks? • At 24 wks? • When delivery is expected?
Timing of steroids after early PPROM • The Dinsmoor study administered antenatal corticosteroids to all patients when they reached 24 wks of gestation. • In the Farooqi study, patients received steroids at the discretion of the attending physician. 12 of the 53 patients received steroids.
Timing of antibiotics • The Farooqi study did not routinely administer antibiotics to patients at the time of PPROM. Antibiotics were generally given for chorioamnionitis. • The Dinsmoor study reports that antibiotics were usually administered at the time of initial presentation. • Neither study administered tocolytics to their patients at any time.
The patient was kept in-house. • MFM consult obtained, recommendations were: • Continue 7-day course of antibiotics • Daily FHT • Betamethasone at 24 wks • Repeat U/S for fetal growth at 24 wks
<24 wks Preterm 240-316 wk Patient counseling Expectant management or labor induction GBS prophylaxis not recommended Corticosteroids not recommended Antibiotics to ↑latency: incomplete data Expectant management Therapy: GBS Prophylaxis, single course Steroids, Antibiotics to prolong latency if no contraindications Tocolysis: no consensus ACOG Guidelines for PROMPractice Bulletin #80, April 2007
Preterm 320-336 wk Near term 340-366 wk Term >37 wk Expectant management, unless +FLM documented Give GBS Prophylaxis Corticosteriods: no consensus, recommended by some (NIH Consensus 2002) Antibiotics to prolong latency if no contraindications Proceed to delivery (induction) Give GBS prophylaxis ACOG Guidelines for PROMPractice Bulletin #80, April 2007
Potentially viable >24 wks <24 wks Generally recommend hospitalization and bedrest after viabilty Ongoing surveillance (infection, cord compression) Study: Only 18% if PROM eligible for home management (no evidence labor, infection, or fetal compromise) Home management Surveillance for infection ACOG Guidelines for PROMPractice Bulletin #80, April 2007Management of PROM at home?
Hospital Course • At 24 wks of gestation, the patient continued to be afebrile, with WBC stable at 13, no signs/sx of infection. • The patient received betamethasone x 2. • MFM U/S showed EFW 576g, breech, normal interval fetal growth. Oligohydramnios is present. Normal cervical length, no funneling. Dolichocephaly present. • Pt again counseled on high risk for perinatal morbidity/mortality including pulmonary hypoplasia, limb contractures, and opts to continue expectant management.
What is dolichocephaly? • It refers to a flattening of the head longitudinally. • A 1996 study by Levine found that dolichocephaly was associated with oligohydramnios of long duration. It was more common in preterm fetuses in the breech presentation compared to cephalic. • In fetuses with PPROM it is associated with respiratory distress syndrome, but not otherwise with a poor neonatal prognosis. Levine D et al. Dolichocephaly and oligohydramnios in preterm premature rupture of the membranes. J Ultrasound Med. 1996 May;15(5):375-9.
Hospital Course • Repeat MFM U/S at 27 0/7 wks showed • Normal interval growth • EFW 877g • Breech • AFI: 0.58cm • Asymmetric IUGR with normal umbilical doppler analysis • No evidence of absent end-diastolic flow.
Hospital Course • At 27 3/7 wks, the patient developed a fever of 100.8 and began feeling contractions q3-4 min. Fetal tachycardia was also present to 170s with decreased variability. • SSE showed closed os, no cord or fetal parts. Bedside U/S showed double footling breech. • Patient taken for C-section.
Hospital Course • 1110g female in double footling breech presentation, Apgar 1/6/6. • Venous blood gas: pH 7.37, BE -3.3
Update on Baby after One Month of Life • Has Functional hypoplastic lungs. • Unable to wean off ventilator (several attempts) • Moderate to severe lung disease • may need chronic ventilator therapy and tracheostomy in the future • A few rounds of infection/antibiotics • Tracheal culture +Staph, s/p triple Abx, currently on Bactrim only, recently resolved • Head U/S negative
References • Dinsmoor MJ, Bachman R, Haney EI, Goldstein M, Mackendrick W. Outcomes after expectant management of extremely preterm premature rupture of the membranes. Am J Obstet Gynecol. 2004 Jan;190(1):183-7. • Farooqi et al. Survival and 2-year outcome with expectant management of second-trimester rupture of membranes. Obstet Gynecol 1998; 92:895-901. • Hadi HA, et al. Premature rupture of the membranes between 20 and 25 weeks' gestation: role of amniotic fluid volume in perinatal outcome. Am J Obstet Gynecol. 1994 Apr;170(4):1139-44. • Levine D et al. Dolichocephaly and oligohydramnios in preterm premature rupture of the membranes. J Ultrasound Med. 1996 May;15(5):375-9.