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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Preterm Labor and Preterm Premature Rupture of Membranes
Sponsored by The Indian Health Service Clinical Support Center GUIDELINES FOR THE MANAGEMENT OF PRETERM LABOR
GUIDELINES FOR PRETERM PREMATURE RUPTURE OF MEMBRANES
1. Definition:
Rupture of the membranes prior to 37 weeks gestation and prior to the onset of labor.
NB:
This is to be distinguished from “premature rupture of membranes” prior to the onset of labor at term, and from premature rupture of membranes without labor prior to viability at 23-24 weeks, which is most commonly associated with “hour-glassing” of the membranes secondary to cervical insufficiency.
a. Associations with PPROM:
-same as for preterm birth above, current theory is that PPROM is the result of occult infection at the choriodecidual interface with production of microbial collagenases resulting in membrane rupture.
2. Management:
a. Review pregnancy dating criteria
b. Perform sterile speculum examination for fern and nitrazine testing
c. Refrain from performing a digital examination unless absolutely necessary to document advanced labor prior to transport. (Remember that if you can visualize a portion of the presenting part, the cervix is most likely significantly effaced and at least 4 cm dilated, but if it appears “closed” it may be any dilation <4cm…) Digital examination “winds the clock of infection” and significantly decreases the latency period for the onset of labor, and increases the risk of infection, and is to be avoided in this setting if at all possible!
d. Confirm presentation by Leopold’s and/or ultrasound
e. Perform level I ultrasound to assess GA, EFW, AFI, presentation, and anatomy
f. A sample of vaginal pool amniotic fluid for fetal lung maturity testing may be appropriate if the patient is between 34 and 36 weeks gestation
g. Obtain fetal monitor strip and maternal vital signs
h. Administer betamethasone 12 mg IM and repeat the dose in 24 hours
i. Administer group B strep prophylaxis with penicillin 5.0 MU IV initially and then 2.5 MU IV q6h for 48 hrs (if not allergic to penicillin). Administer with a fast flowing IV in order to reduce burning sensation during administration.
j. Tocolysis (see above) may be appropriate to facilitate transport, but is otherwise not indicated
k. Consult with ANMC OB-GYN is advised for further management and transport
l. At ANMC PPROM is managed as an in-patient
m. Daily NST should be carried out
n. After 48 hours of group B strep prophylaxis with IV penicillin, the latency period has been shown to be prolonged by administration of erythromycin 250 mg po q6h for 10 days or until delivery
o. Maternal temperature and fetal heart rate are monitored q4h, but the onset of uterine contractions is the most common sign of incipient infection. Overt chorioamnionitis mandates delivery.
p. Labor may be induced at 34 weeks documented gestation or with mature vaginal pool amniotic fluid studies after consultation with the Pediatrics service
q. Patients may be induced with either vaginal or oral misoprostol or IV oxytocin
r. Group B strep prophylaxis with IV penicillin should be re-instituted in labor
s. If chorioamnionitis is suspected, ampicillin 2g q6h and gentamicin 2 mg/kg IV q8h should also be administered to cover gram negative pathogens
t. Patients <32 weeks should be delivered at a level III nursery facility
u. Patients with rupture of membranes at term who are not in labor have a better outcome without an increase in their cesarean birth rate if induced as soon as they present.
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