预防胎膜灶破的现代管理(英文)Modern-Management-of-Prolonged-Rupt.ppt

Click to edit Master title style,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,*,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,Oxytocin,PGE2 or expectant management up to 4 days,No difference in cesarean section or neonatal infection,Less 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,PPROMComplications,Maternal/Fetal Infection,Premature Labor and Delivery,Umbilical Cord Prolapse,Fetal Hypoxia 2 Cord Compression,Increased Rate of Cesarean Section,Intrauterine Growth Restriction,Abruption,Stillbirth,PPROMStandard Management,Confirmation of Diagnosis,Verification of Gestational Age,R/O Labor/Infection/Fetal Compromise,Avoid Digital Vaginal Examinations,In Hospital Observation,Bedrest,PPROMVaginal Examination,Gestational Age(Weeks),20,15,10,5,Latency Days,No Exam,Exam,Lewis,Obstetrics&Gynecology,1992,Previable PPROMComplications,Uterine Infection,Pulmonary Hypoplasia,Limb Compression Deformities,Intrauterine Growth Restriction,Previable PPROMOutcomes,Timing of Delivery,Neonatal Morbidity/MortalityUAB(1995-1996),%,RNICU Survival and Morbidity Data(1995-1996),%Neonates,Tocolysis,PPROMTocolysis,Weiner,AJOG,1988,Antibiotics,Preterm LaborChorioamnion Colonization,0,30,weeks,31-34,weeks,34-36,weeks,37,weeks,25,50,75,%Patients Colonized,Spontaneous,Preterm Labor,Indicated,Cassell,1993,PPROMAntibiotic Therapy,Reduction Maternal/Perinatal Infection,Prolong Latency Period,Improve Neonatal Outcome,Antibiotic:NIH-MFM Network Study Neonatal Morbidity,*,*,*,Antibiotic:Latency PeriodNIH-MFM Network Study,Antibiotics&PPROM:Summary,Reduction in maternal infectious morbidity,Reduction in births 48 h and 28 d,Kenyon,Cochrane Library,1999,Antibiotics&PPROM:Summary,No clear reduction in perinatal death,No clear reduction in cerebral abnormalities,Kenyon,Cochrane Library,1999,Amniocentesis,PPROMAmniotic Fluid Culture,Group B Streptococcus20%,Gardnerella vaginalis17%,Peptostreptococcus11%,Fusobacteria10%,Bacteroides fragilis 9%,Other Streptococci 9%,Bacteroides sp.5%,Utility of Amniocentesis,Confirm/Refute diagnosis of chorioamnionitis,Glucose 15 mg/dL,Culture,Gram stain,Lung maturity testing,Corticosteroids,Corticosteroids for FLM,Betamethasone,Dexamethasone,PPROMCorticosteroids,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,PPROMCorticosteroids,Crowley,Ob/Gyn Clinics,1992,*,PPROMCorticosteroids+Antibiotics,*,Lewis,Obstetrics&Gynecology,1996,1994 NIH Consensus Conference:Corticosteroids in PPROM,Corticosteroids reduce incidence/severity of RDS,IVH,Benefits in PPROM up to 30-32 weeks,No significant adverse outcomes for corticosteroid use in PPROM,Impact less than with intact membranes,Observation vs.Induction,Neonatal Morbidity/MortalityUAB(1995-1996),%,PPROMObservation vs.Induction,Mercer,AJOG,1993,*,*,PPROMObservation vs Induction,Cox,Obstetrics&Gynecology,1995,Fetal Lung Maturity Testing,Fetal Lung MaturationBiologic 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,L:S RatioNot Reliable,TDX:FLM AssayNot Validated,PGUseful,Fetal Surveillance,PPROMFetal Surveillance,Daily Non-Stress Test(NST),Variables,Tachycardia,Loss of reactivity,Biophysical Profile(BPP),Contraction 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 prophylaxis:Amoxicillin 500 tid x 10d,Azithromycin 1gm d1&d5,1 course Betamethasone if 32weeks,Test for pool PG weekly beginning at 32 weeks,Deliver at 34-35 weeks,UAB Management of PPROM,