预防胎膜灶破的现代管理（英文ppt）modernmanagement of prolonged rupture of

Modern Management of Prolonged Rupture of Membranes Joseph R. Biggio Jr., M.D. Department of Obstetrics & Gynecology Division of Maternal-Fetal Medicine University of Alabama at Birmingham PROM Amniorrhexis prior to onset of active labor regardless of gestational age Premature Rupture of Membranes PPROM Amniorrhexis 5,000 women randomized nOxytocin, PGE2 or expectant management up to 4 days nNo difference in cesarean section or neonatal infection nLess chorioamnionitis in induction with oxytocin group Hannah, NEJM, 1996 Epidemiology of Preterm Birth PPROM Spontaneous Preterm Delivery Indicated Preterm Delivery 28 % 46 % 26 % Andrews, 1995 PPROM Risk Factors lLower/Upper Genital Tract Infection i Proteases i Prostaglandins lHistory of PPROM lIncompetent Cervix lAbruption lPolyhydramnios lMultiple Gestation lSmoking PPROM Complications lMaternal/Fetal Infection lPremature Labor and Delivery lUmbilical Cord Prolapse lFetal Hypoxia 2 Cord Compression lIncreased Rate of Cesarean Section lIntrauterine Growth Restriction lAbruption lStillbirth PPROM Standard Management lConfirmation of Diagnosis lVerification of Gestational Age lR/O Labor/Infection/Fetal Compromise lAvoid Digital Vaginal Examinations lIn Hospital Observation lBedrest PPROM Latency Gestational Age (Weeks) % Patients with Latency 1 Week 25 50 75 0 Wilson, Obstetrics & Gynecology, 1982 PPROM Vaginal Examination Gestational Age (Weeks) 20 15 10 5Latency Days No Exam Exam Lewis, Obstetrics & Gynecology, 1992 Previable PPROM l28 d Kenyon, Cochrane Library, 1999 Antibiotics & PPROM: Summary lNo clear reduction in perinatal death lNo clear reduction in cerebral abnormalities Kenyon, Cochrane Library, 1999 Amniocentesis PPROM Amniotic Fluid Culture l Group B Streptococcus 20 % l Gardnerella vaginalis 17 % l Peptostreptococcus 11 % l Fusobacteria 10 % l Bacteroides fragilis 9 % l Other Streptococci 9 % l Bacteroides sp. 5 % Utility of Amniocentesis lConfirm/Refute diagnosis of chorioamnionitis i Glucose 15 mg/dL i Culture i Gram stain lLung maturity testing Corticosteroids Corticosteroids for FLM lBetamethasone lDexamethasone PPROM Corticosteroids Block Taeusch Papageorgiou Young Garite Collaborative Iams Nelson Simpson Morales 43 17 17 38 80 153 38 22 112 121 26 24 19 37 80 135 35 46 105 124 Author Steroids Control Effect on RDS Number of Patients PPROM Corticosteroids Crowley, Ob/Gyn Clinics, 1992 * PPROM Corticosteroids + Antibiotics * Lewis, Obstetrics & Gynecology, 1996 1994 NIH Consensus Conference: Corticosteroids in PPROM lCorticosteroids reduce incidence/severity of RDS, IVH lBenefits in PPROM up to 30-32 weeks lNo significant adverse outcomes for corticosteroid use in PPROM lImpact less than with intact membranes Observation vs. Induction Neonatal Morbidity/Mortality UAB (1995-1996) % PPROM Observation vs. Induction Mercer, AJOG, 1993 * * PPROM Observation vs Induction Cox, Obstetrics & Gynecology, 1995 Fetal Lung Maturity Testing Fetal Lung Maturation Biologic Markers 8 6 4 2 0 0 4 2 6 8 20 24 28 32 36 40 Gestational Age (weeks) L:S Ratio % Phospholipid L:S PI PG 10 Fetal Lung Maturity Evaluation in Vaginal Pool Specimen lL:S Ratio Not Reliable lTDX:FLM Assay Not Validated lPG Useful Fetal Surveillance PPROM Fetal Surveillance lDaily Non-Stress Test (NST) i Variables i Tachycardia i Loss of reactivity lBiophysical Profile (BPP) lContraction Stress Test (CST) Summary UAB Management of PPROM PPROM 34 weeks Deliver Previable PROM Outpatient observation Antibiotic prophylaxis Option of termination 22wk Admission at viability PPROM 23 weeks, 34 weeks Antibiotic pro