Today we talk about the routine management of PPROM and PTL. We’ve prepared a little chart that we hope is handy for both teaching and learning! Be sure to also check out ACOB PB 171 and PB 188. For some primary literature, check out the BEAM trial on magnesium sulfate, the most recent Cochrane review on steroid administration, the ALPS trial for Antenatal Late Preterm Steroid administration, and the RCT demonstrating benefit to latency antibiotics in PPROM.
We also use the podcast to highlight a number of controversies, differing practice patterns, or areas of new and active research in these clinical topics (with help from our friends at the ObG Project!)
Delivery timing: A 2017 Cochrane review suggested better neonatal outcomes with expectant management of PPROM to 37 weeks, convincing enough to have the Royal College of Obstetrics and Gynecology to change their clinical practice guideline to allow expectant management to 37’0.
Administration of Corticosteroids: The ObG Project gives a great summary on when to administer betamethasone. In summary:
Between 24-34 weeks in all cases of PPROM and in PTL if delivery is expected within 7 days.
A single rescue course should be administered if it has been > 14 days since the last course, and delivery is again expected within the subsequent 7 days.
Between 34-36’6 weeks if PPROM or PTL occurs, no prior steroids have been administered, and delivery is expected within the subsequent 7 days.
Periviability: The management of periviable PPROM is managed very differently by institution, as resources and optimal management strategies remain to be identified. Protocols and policies should be arranged in accordance with the individual obstetrics and neonatology departments. Ideally, counseling for patients experiencing periviable PTL and PPROM should be performed in an interdisciplinary fashion.
Outpatient Management of PPROM: There have a few retrospective studies, the most recent of which came from a large series out of France and received some press attention, suggesting that outpatient management may be appropriate in select candidates. That said, this is definitely NOT the standard of care at this time; inpatient management of PPROM is still the standard set forth by ACOG in the absence of larger, prospective studies.