Re: Term PROM
From: Efrain Ramirez (eramirezt@coqui.net)
Fri Oct 19 06:22:34 2007
She did it in a private lab - small town - the problem is what do you do
if you can't gey the results - ? -
Well - baby boy was born - +/- 12 hours later (Monday morning) APGAR
score 7/9 ABG's WNL - she turned out to have abundant growth of GBS -
next step? -- I never saw the rationale of assuming a +negative+ status
-- and not treating..
Ef
Guidelines (ACOG) for term PROM management have changed - They are more
aggressive right now..
"For women with PROM at term, labor should be induced at the time of
presentation, generally with oxytocin infusion, to reduce the risk
chorioamni-onitis.
Patients with PROM before 32 weeks of gestation should be cared for
expectantly until 33 completed weeks of gestation if no maternal or
fetal contraindications exist.
A 48-hour course of intravenous ampicillin and erythromycin followed by
5 days of amoxicillin and erythromycin is recommended during expectant
management of preterm PROM remote from term to prolong pregnancy and to
reduce infectious and gestational age–dependent neonatal morbidity.
All women with PROM and a viable fetus, including those known to be
carriers of group B streptococci and those who give birth before carrier
status can be delineated, should receive intrapartum chemo-prophylaxis
to prevent vertical transmission of group B streptococci regardless of
earlier treatments."
Ef
>At Thu, 18 Oct 2007, R. Daniel Braun wrote:
>
>I would call the Pathologist at the lab doing the GBBS and tell him to get
>out of bed and get me the results. If he doesn't like that I would tell him
>that he wouldn't get any future business from me and that I would make a
>note in the chart that he refused to get me the results even though he has
>already had 3 weeks to get them to me. Then carry out my threats and send
>him the bill for any extra charges engendered by not having the results.
>
>Dan
>
>On 10/18/07, Efrain Ramirez <eramirezt@coqui.net> wrote:
>>
>> Well - in our community-- we haven't decided yet .. what would you do?
>>
>> Ef
>>
>> >At Thu, 18 Oct 2007, ainsron wrote:
>> >
>> >That is exactly why we decided (in our community) to send all GBS
>> cultures
>> >to the hospital lab, results are always available, 24/7.
>> >
>> >Ronald E. Ainsworth, MD, FACOG
>> >
>> >-----Original Message-----
>> >From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Efrain
>> >Ramirez
>> >Sent: Thursday, October 18, 2007 6:53 AM
>> >To: Multiple recipients of list OB-GYN-L
>> >Subject: Re: Term PROM
>> >
>> >Her last visit was at 35-36 weeks - no notification of GBS status..
>> >Sunday - Lab is closed ..
>> >
>> >Ef
>> >
>> >CLINICAL MANAGEMENT GUIDELINES FOR
>> >OBSTETRICIAN-GYNECOLOGISTS
>> >NUMBER 80, APRIL 2007
>> >
>> >(Replaces Practice Bulletin Number 1, June 1998)
>> >"What is the optimal method of initial management for a patient with
>> >PROM at term?
>> >Fetal heart rate monitoring should be used to assess fetal status.
>> >Dating criteria should be reviewed to assign gestational age because
>> >virtually all aspects of subsequent care will hinge on that information.
>> >Because optimal results are seen with 4 hours between group B
>> >streptococcal prophylaxis and birth, when the decision to deliver is
>> >made, group B streptococcal prophylaxis should be given based on prior
>> >culture results or risk factors if cultures have not been previously
>> >performed (60).
>> >
>> >The largest randomized study to date found that oxytocin induction
>> >reduced the time interval between PROM and delivery as well as the
>> >frequencies of chorioamnionitis, postpartum febrile morbidity, and
>> >neonatal antibiotic treatments, without increasing cesarean deliveries
>> >or neonatal infections (25). These data suggest that for women with
>> >PROM at term, labor should be induced at the time of presentation,
>> >generally with oxytocin infusion, to reduce the risk of
>> >chorioamnionitis. An adequate time for the latent phase of labor to
>> >progress should be allowed."
>> >
>> >Summary of Recommendations and Conclusions
>> >
>> >The following recommendations and conclusions are based on good and
>> >consistent scientific evidence (Level A):
>> >
>> >For women with PROM at term, labor should be induced at the time of
>> >presentation, generally with oxytocin infusion, to reduce the risk
>> >chorioamni-onitis
>> >
>> >Premature rupture of membranes at term: a meta-analysis of three
>> >management schemes.
>> >Mozurkewich EL, Wolf FM
>> >
>> >Obstet Gynecol (1997 Jun) 89(6):1035-43 ISSN: 0029-7844
>> >
>> >Fetal Membranes, Premature Rupture
>> >Clinical Protocols
>> >Female
>> >Human
>> >Pregnancy
>> > Support, U.S. Gov't, P.H.S.
>> >Meta-Analysis
>> >Medline Database
>> >Healthstar Database
>> >
>> > Abstract
>> >
>> >OBJECTIVE: To compare rates of cesarean birth, endometritis,
>> >chorioamnionitis, and serious neonatal infections among pregnancies
>> >complicated by premature rupture of membranes (PROM) at term and managed
>> >by immediate oxytocin induction, by conservative management (or delayed
>> >oxytocin induction), or by vaginal (or endocervical) prostaglandin E2,
>> >gel, suppositories, or tablets.
>> >
>> >DATA SOURCES: The English-language literature in MLD, LINE and other
>> >databases was searched through April 1996 using the terms "fetal
>> >membranes," "premature rupture," and "term." METHODS OF STUDY SELECTION:
>> >We included randomized trials comparing two or more management schemes
>> >for PROM at term.
>> >
>> >TABULATION, INTEGRATION, AND RESULTS: Twenty-three studies with a total
>> >of 7493 subjects met the inclusion criteria and were included for
>> >analysis. Data regarding chorioamnionitis, endometritis, neonatal
>> >infections, and
>> >Top of Abstract
>> >cesarean delivery were extracted. Meta-analyses were performed for the
>> >three interventions for these outcomes of interest using the
>> >Der-Simonian and Laird and Mantel-Haenszel techniques to estimate the
>> >pooled odds ratios (ORs). No statistically significant differences in
>> >cesarean deliveries or neonatal infections were noted among management
>> >schemes. Vaginal prostaglandins resulted in more chorioamnionitis than
>> >immediate oxytocin (OR 1.55, 95% confidence interval [CI] 1.09, 2.21),
>> >but less chorioamnionitis than conservative management (OR 0.68, 95% CI
>> >0.51, 0.91). Immediate oxytocin induction resulted in fewer cases of
>> >chorioamnionitis (OR 0.67, 95% CI 0.52, 0.85) and endometritis (OR 0.71,
>> >95% CI 0.51, 0.99) than conservative management, although these results
>> >achieved significance only with the Mantel-Haenszel technique.
>> >
>> >CONCLUSION: Conservative management may result in more maternal
>> >infections than immediate induction with oxytocin or prostaglandins.
>> >
>> >At Thu, 18 Oct 2007, Betsy Hyde wrote:
>> >>
>> >>On Oct 18, 2007, at 7:41 AM, Efrain Ramirez wrote:
>> >>
>> >>> 34 y/o, GI, 38 6/7 weeks - SROM at 8PM - arrives at LDR 9PM - 1-2
>> >>> cm/75%/-1- soft. almost no contractions...baby fine... last visit 35
>> >>> weeks - GBS done - results not available.. options..
>> >>
>> >>There is no indication for starting antibiotics or pitocin at this
>> >>point. With unknown GBS status, CDC recs are to treat based on risk
>> >>factors (<37 weeks, PROM >18 hours, prior GBS sepsis). It seems that
>> >>if she had been GBS +, someone would have notified her of that fact
>> >>when the results came in.
>> >>
>> >>I would give her overnight to get into labor,and if not, induce her
>> >>in the morning.
>> >>
>> >>--
>> >>Betsy Hyde CNM
>> >>Branford, CT
>> >>
>> >--
>> >" The greatest obstacle to knowledge is not ignorance,
>> >it is the illusion of knowledge." Daniel J. Boorstin - Historian
>> >
>>
>> --
>> " The greatest obstacle to knowledge is not ignorance,
>> it is the illusion of knowledge." Daniel J. Boorstin - Historian
>>
>--
>R. Daniel Braun, MD FACOG(L) CMT
>Professor Emeritus
>Dept. of Obstetrics and Gynecology
>Indiana U. School of Medicine
>
>R. Daniel Braun
>
> "Science without Religion is LAME; Religion without Science is BLIND"
> Einstein 1941
>
--
“ The greatest obstacle to knowledge is not ignorance,
it is the illusion of knowledge.” Daniel J. Boorstin - Historian
