Late preterm PROM
The biggest change to clinical management in this ACOG Practice Bulletin is for late preterm (34–36 6/7 weeks) PROM, with the recommendation for either immediate delivery or expectant management up to 37 weeks stemming from the PPROMPT study by Morris and colleagues.7
From the neonatal perspective, no difference has been demonstrated between immediate delivery and expectant management for neonatal sepsis or a composite neonatal morbidity and mortality. Expectant management may be preferred from the neonatal point of view as immediate delivery was associated with an increased rate of neonatal respiratory distress, mechanical ventilation, and length of stay in the neonatal intensive care unit. The potential for long-term neurodevelopmental outcomes of delivery at 34 versus 37 weeks also should be considered.
From the maternal perspective, expectant management has an increased risk of antepartum and postpartum hemorrhage, fever, antibiotic use, and maternal length of stay, but a decreased risk of CD.
A late preterm steroid course can be considered if delivery is planned in no less than 24 hours and likely to occur in the next 7 days and if the patient has not already received a course of steroids. A rescue course of steroids is not indicated if the patient received a steroid course prior in the pregnancy. While appropriate GBS prophylaxis is recommended, latency antibiotics and tocolysis are not, and delivery should not be delayed if chorioamnionitis is diagnosed.
Ultimately, preterm PROM management with a stable mother and fetus at or beyond 34 weeks requires comprehensive counseling of the risks and benefits for both mother and fetus/neonate. A multidisciplinary team that together counsels the patient also may help with this shared decision making.
Term PROM
For patients with term PROM, delivery is recommended. Although a short period of expectant management for 12 to 24 hours is reported as “reasonable,” the risk of infection increases with the length of rupture of membranes. Therefore, induction of labor or CD soon after rupture of membranes is recommended for patients who are GBS positive and is preferred for all others.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
- Accurate diagnosis is necessary for appropriate counseling and management of PROM.
- Delivery is recommended for term PROM, chorioamnionitis, and for patients with previable PROM who do not desire expectant management.
- If the mother and fetus are otherwise stable, expectant management of preterm PROM until 34 to 37 weeks is recommended.
- The decision of when to deliver between 34 and 37 weeks is best made with multidisciplinary counseling and shared decision making with the patient.
VTE prophylaxis in pregnancy: Regimen adjustments, CD strategies, and COVID-19 considerations
Birsner ML, Turrentine M, Pettker CM, et al. ACOG practice advisory: Options for peripartum anticoagulation in areas affected by shortage of unfractionated heparin. March 2020. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/options-for-peripartum-anticoagulation-in-areas-affected-by-shortage-of-unfractionated-heparin. Accessed December 8, 2020.
Pacheco LD, Saade G, Metz TD. Society for Maternal-Fetal Medicine Consult Series No. 51: Thromboembolism prophylaxis for cesarean delivery. Am J Obstet Gynecol. 2020;223:B11-B17
Venous thromboembolism (VTE) prophylaxis is a timely topic for a number of reasons. First, a shortage of unfractionated heparin prompted an ACOG Practice Advisory, endorsed by SMFM and the Society for Obstetric Anesthesia and Perinatology, regarding use of low molecular weight heparin (LMWH) in the peripartum period.8 In addition, SMFM released updated recommendations for VTE prophylaxis for CD as part of the SMFM Consult Series.9 Finally, there is evidence that COVID-19 infection may increase the risk of coagulopathy, leading to consideration of additional VTE prophylaxis for pregnant and postpartum women with COVID-19.
Candidates for prophylaxis
As recommended by the ACOG Practice Bulletin on thromboembolism in pregnancy, women who may require VTE prophylaxis during pregnancy and/or the postpartum period include those with10:
- VTE diagnosed during pregnancy
- a history of VTE, including during pregnancy or with use of hormonal contraception
- a history of thrombophilia with or without a personal or family history of VTE.
For these patients, LMWH has many advantages over unfractionated heparin, including ease of use and reliability of dosing. It generally is preferred in pregnancy and postpartum (for both prophylactic and therapeutic anticoagulation) by patients and providers.
The Practice Bulletin references a strategy that describes converting LMWH to unfractionated heparin at around 36 weeks’ gestation in preparation for delivery because unfractionated heparin has the advantage of a shorter half-life and the option for anticoagulation reversal with protamine sulfate. In the Practice Advisory, a global shortage of unfractionated heparin and an argument that the above conversion was less about concern for maternal hemorrhage and more about avoiding spinal and epidural hematomas led to the following recommendations for continued use of LMWH through delivery:
- LMWH heparin can be discontinued in a planned fashion prior to scheduled induction of labor or CD (generally 12 hours for prophylactic dosing and 24 hours for intermediate dosing).
- Patients in spontaneous labor may receive neuraxial anesthesia 12 hours after the last prophylactic dose and 24 hours after the last intermediate dose of LMWH.
- Patients who require anticoagulation during pregnancy should be counseled that if they have vaginal bleeding, leakage of fluid, or regular contractions they should be evaluated prior to taking their next dose of anticoagulant.
- In the absence of other complications, delivery should not be before 39 weeks for the indication of anticoagulation requirement alone.
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