Schmitz T, Sentilhes L, Lorthe E, Gallot D, Madar H, Doret-Dion M, Beucher G, Charlier C, Cazanave C, Delorme P, Garabedian C, Azria É, Tessier V, Senat M-V, Kayem G
Service de gynécologie obstétrique, hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France; Université Paris Diderot, 5, rue Thomas-Mann, 75013 Paris, France; Inserm UMR 1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), centre de recherche épidémiologie et statistique Sorbonne Paris Cité, 75005 Paris, France.
Service de gynécologie-obstétrique, hôpital Pellegrin, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France.
Gynecol Obstet Fertil Senol. 2018 Dec;46(12):998-1003. doi: 10.1016/j.gofs.2018.10.016. Epub 2018 Nov 2.
To determine management of women with preterm premature rupture of membranes (PPROM).
Bibliographic search from the Medline and Cochrane Library databases and review of international clinical practice guidelines.
In France, PPROM rate is 2 to 3% before 37 weeks of gestation (level of evidence [LE] 2) and less than 1% before 34 weeks of gestation (LE2). Prematurity and intra-uterine infection are the two major complications of PPROM (LE2). Compared to other causes of prematurity, PPROM is not associated with an increased risk of neonatal mortality and morbidity, except in case of intra-uterine infection, which is associated with an augmentation of early-onset neonatal sepsis (LE2) and of necrotizing enterocolitis (LE2). PPROM diagnosis is mainly clinical (professional consensus). In doubtful cases, detection of IGFBP-1 or PAMG-1 is recommended (professional consensus). Hospitalization of women with PPROM is recommended (professional consensus). There is no sufficient evidence to recommend or not recommend tocolysis (grade C). If a tocolysis should be prescribed, it should not last more than 48hours (grade C). Antenatal corticosteroids before 34 weeks of gestation (grade A) and magnesium sulfate before 32 weeks of gestation (grade A) are recommended. Antibiotic prophylaxis is recommended (grade A) because it is associated with a reduction of neonatal mortality and morbidity (LE1). Amoxicillin, 3rd generation cephalosporins, and erythromycin in monotherapy or the association erythromycin-amoxicillin can be used (professional consensus), for 7 days (grade C). However, in case of negative vaginal culture, early cessation of antibiotic prophylaxis might be acceptable (professional consensus). Co-amoxiclav, aminosides, glycopetides, first and second generation cephalosporins, clindamycin, and metronidazole are not recommended for antibiotic prophylaxis (professional consensus). Outpatient management of women with clinically stable PPROM after 48hours of hospitalization is a possible (professional consensus). During monitoring, it is recommended to identify the clinical and biological elements suggesting intra-uterine infection (professional consensus). However, it not possible to make recommendation regarding the frequency of this monitoring. In case of isolated elevated C-reactive protein, leukocytosis, or positive vaginal culture in an asymptomatic patient, it is not recommended to systematically prescribe antibiotics (professional consensus). In case of intra-uterine infection, it is recommended to immediately administer an antibiotic therapy associating beta-lactamine and aminoside (grade B), intravenously (grade B), and to deliver the baby (grade A). Cesarean delivery should be performed according to the usual obstetrical indications (professional consensus). Expectative management is recommended before 37 weeks of gestation in case of uncomplicated PPROM (grade A), even in case of positive vaginal culture for B Streptococcus, provided that an antibiotic prophylaxis has been prescribed (professional consensus). Oxytocin and prostaglandins are two possible options to induce labor in case of PPROM (professional consensus).
Expectative management is recommended before 37 weeks of gestation in case of uncomplicated PPROM (grade A).
确定胎膜早破（PPROM）孕妇的管理方法。
检索Medline和Cochrane图书馆数据库中的文献，并查阅国际临床实践指南。
在法国，孕37周前胎膜早破发生率为2%至3%（证据级别[LE]2），孕34周前低于1%（LE2）。早产和宫内感染是胎膜早破的两大主要并发症（LE2）。与其他早产原因相比，胎膜早破与新生儿死亡率和发病率增加无关，但宫内感染情况除外，宫内感染会增加早发型新生儿败血症（LE2）和坏死性小肠结肠炎（LE2）的发生率。胎膜早破的诊断主要依靠临床（专业共识）。在可疑病例中，建议检测胰岛素样生长因子结合蛋白-1（IGFBP-1）或妊娠相关血浆蛋白A（PAMG-1）（专业共识）。建议胎膜早破孕妇住院治疗（专业共识）。没有足够证据推荐或不推荐使用宫缩抑制剂（C级）。如果要使用宫缩抑制剂，持续时间不应超过48小时（C级）。建议在孕34周前使用产前糖皮质激素（A级），在孕32周前使用硫酸镁（A级）。建议进行抗生素预防（A级），因为这与降低新生儿死亡率和发病率相关（LE1）。可单独使用阿莫西林、第三代头孢菌素、红霉素，或联合使用红霉素-阿莫西林（专业共识），疗程7天（C级）。然而，如果阴道培养结果为阴性，提前停止抗生素预防可能是可以接受的（专业共识）。不推荐使用阿莫西林克拉维酸、氨基糖苷类、糖肽类、第一代和第二代头孢菌素、克林霉素和甲硝唑进行抗生素预防（专业共识）。住院48小时后，临床情况稳定的胎膜早破孕妇可进行门诊管理（专业共识）。在监测过程中，建议识别提示宫内感染的临床和生物学指标（专业共识）。然而，无法就监测频率提出建议。对于无症状患者，若仅C反应蛋白升高、白细胞增多或阴道培养阳性，不建议常规使用抗生素（专业共识）。如果发生宫内感染，建议立即静脉给予β-内酰胺类和氨基糖苷类联合抗生素治疗（B级）并分娩（A级）。剖宫产应根据常规产科指征进行（专业共识）。对于无并发症的胎膜早破孕妇，建议在孕37周前进行期待治疗（A级），即使阴道B族链球菌培养阳性，只要已进行抗生素预防（专业共识）。缩宫素和前列腺素是胎膜早破引产的两种可能选择（专业共识）。
对于无并发症的胎膜早破孕妇，建议在孕37周前进行期待治疗（A级）。
