Management of Pre-labour rupture of membranes (Preterm and Term)

 

 MANAGEMENT OF PRELABOUR RUPTURE OF MEMBRANE- PRETERM AND TERM

DR JUDITH KUNDODYIWA MRCOG

Table of content

1. Signs of Chorioamnionitis

2. Steroid regime

3. PROM at>/=37weeks (Management)

4. Signs and symptoms

5. Appendix 1 (Risk factors)

6. Appendix 2 (GBS risk factors)

7. Reference

 

• Spontaneous rupture of membranes complicates 2% of pregnancies
• Associated with 40% of preterm deliveries
• Associated with neonatal death in preterm deliveries due to- prematurity sepsis and pulmonary hypoplasia

PROM at < / = 36+6 weeks gestation

INITIAL ASSESSMENT

• History
• Sterile speculum examination- liquor seen
• Oligohydramnios on scan associated with history

Explain high risk of preterm delivery especially in first 72 hours

• Confirm diagnosis
• Full antenatal check
• Daily CTG whilst on admissiom if ≥ 26 weeks and auscultation if < 26weeks
• High Vagina Swab
• FBC, CRP
• Temperature+ pulse 4 hourly
• Erythromycin 250 mgs. 6 hourly for 10 days
• If allergic to erythromycin, any penicillin can be prescribed
• AVOID Co-amoxiclav – associated with fetal necrotising enterocolitis
• Antepartum steroids between 23⁺⁵ and 34⁺⁰ weeks gestation (details below)
• Tocolysis only in presence of uterine activity to administer steroids and/ or in-utero transfer if necessary (details below)
• Scan for growth + umbilical vessel dopplers if indicated
• Administer Magnessium sulphate for neuroprotection if gestation is less than 32 weeks and delivery is imminent.(dose 4gram loading dose then 1gram hourly till delivery)

(Follow Small for Gestational Age protocol if oligohydramnios or fetal growth restriction is confirmed)

• Change to Consultant care if under midwifery led care
• If not in labour, consider admission to observe for 24-48hours hours
• Discharge home for follow-up monitoring on ANDU after 24-48 hours
• Transfer to Central delivery Suite/ Labour ward if signs of labour

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Instruction To Woman

• Temperature twice daily
• Signs and symptoms of chorioamnionitis

Contact Antenatal day Unit or Delivery suite and come in if any of the above is unsatisfactory

• Avoid intercourse
• May have baths and showers

FOLLOW-UP On Ante-Natal Day Unit – twice weekly

• Review the temperature
• Check observations
• Full blood count and C-Reactive protein (CRP) weekly
• High vaginal swab weekly if signs /symptoms suggesting infection
• CTG every visit to ANDU or earlier if ↓ fetal movements
• Growth scan + dopplers (if indicated) every fortnight
• Repeat scans as per SGA guidelines if any abnormality diagnosed
• Arrange Consultant clinic appointment to discuss induction
• Consider delivery at 34- 36 weeks gestation
• Intrapartum antibiotic cover to be given to women with GBS risk- (penicillin/Clindamycin)

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Signs Of Chorioamnionitis

• Febrile
• Maternal and fetal tachycardia
• Foul smelling liquor
• Uterine irritability/ tenderness
• Suboptimal CTG
• Rising white cell count, CRP

*Admit to CDS

*inform middle-grade doctor covering CDS and Consultant covering CDS

* FBC, blood cultures, HVS before commencing antibiotics- aim to deliver

*Inform neonatal unit, paediatricians

*Commence IV Cefuroxime + Metronidazole (will also be adequate for GBS positive women)

*At delivery- swabs from placenta and baby (ear and umbilical cord)

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STEROID REGIME

• Steroid therapy reduces the risks of respiratory distress syndrome, neonatal death and intracranial haemorrhage in the neonate.
• Betamethasone is the steroid of choice to enhance lung maturation – Two doses of 12 mg Betamethasone intramuscularly 12 hours apart OR dexamethasone 12mg given 12 hours apart. (This is to be used only if betamethasone is unavailable)
• The optimal treatment-delivery interval for administration of antenatal corticosteroids is more than 24 hours but less than seven days after the start of treatment.
• In pregnancies complicated with maternal diabetes mellitus- steroids to be commenced on Central Delivery Suite with insulin sliding scale.
• Corticosteroid therapy is contraindicated in women with systemic infection including tuberculosis.
• Steroid therapy should not be repeated.

 

Tocolysis: May be required for in-utero transfer or to delay delivery until steroid is administered. Transfer to CDS for montoring if tocolysis is required.

PROM at >/= 37 weeks

• All women should be seen (either in community or triage)  after reporting Spontaneous Rupture Of Membrane to assess feto-maternal well being
•  All women with a risk factor should be reviewed in hospital and case discussed with Obs. Middle Grade/ Consultant for management plan (Appendix 1)

The following applies to low risk pregnancies

• Offer choice of induction after 24 hours
• If the woman declines IOL – strongly recommend induction at 72 hrs at the latest
• Induce immediately if signs of infection, meconium stained liquor or if Group B Stretococcus risk factors present

If the woman chooses conservative management –

• Check temperature every 4 hours during waking hours
• Advise woman to keep note of fetal movements, colour of liquor
• Report if any change in fetal movements and/ or colour of liquor
• refer to Antenatal day unit daily for review
• Advise to come to hospital of any changes to above, feeling unwell or feverish
• Avoid sexual intercourse. May have showers bath
• Report if any change to vaginal loss

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INTRAPARTUM CARE

Also see guideline for Prevention of Early Onset Neonatal Group B Streptococcal infection

• Commence intrapartum IV antibiotics (IAP) ALL women fulfilling GBS prophylaxis criteria (appendix 2) (penicillin or clindamycin)
• Commence intrapartum prophylactic antibiotics (penicillin or clindamycin) in women with history of PPROM before 37 weeks
• Antibiotic prophylaxis in labour NOT required for low risk women with PROM at or after 37 weeks irrespective of duration of PROM unless signs of infection
• Antibiotic prophylaxis may be required for women in preterm labour WITHOUT history of PPROM before 37 weeks
• Continuous electronic fetal monitoring
• Observe for signs of chorioamnionitis
• Send blood cultures and administer to Cefuroxime 1.5g and Metronidazole 500mg TDS Intravenously if temp. > /= 38°C

Also follow genital tract sepsis guideline when suspecting chorioamnionitis

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POSTNATAL CARE

• Observe mother and baby for 12 hours
• (unless fulfilling criteria for more prolonged observation as noted in Guideline for Prevention of Early Onset Neonatal Group B Streptococcal infection)

Neonatal observations

These should be commenced as soon as possible after baby’s birth and conducted 4 hourly.

• general wellbeing
• feeding
• temperature
• heart rate and respiration
• Mother should be advised to observe neonatal well-being and report any problems for the first 5 days after birth.

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Appendix 1

Risk factors include: This list is not exhaustive.

 

• Previous caesarean section
• Previous small APH in current pregnancy
• Associated medical / surgical conditions
• History of poor clinic attendance
• Alcohol/ drug dependence
• Previous attendance for reduced fetal movements
• Diabetes- pre-existing or gestational

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Appendix 2

GBS risk factors include-

• Previously affected by GBS (IAP in labour)
• Vaginal swab showing GBS in current pregnancy (IAP in labour)
• Urine showing GBS in current pregnancy  (Treat UTI + IAP in labour)

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Reference