Treatment of PPROM with anhydramnion colonized by multi-resistant Klebsiella pneumonia with continuous amnioinfusion and antibiotic administration through subcutaneously implanted intrauterine port system

Bacterial infection is the main cause of preterm premature rupture of membranes (PPROM) with anhydramnion leading to preterm delivery, pulmonary hypoplasia, sepsis, and joint deformities. Expectant management, broad-spectrum antibiotics and antenatal corticosteroids are routinely used in this condition with very limited success to prevent bacteraemia, chorioamnionitis, funisitis and intra-amniotic infection syndrome.

Here we report a case in which we attempted to treat the Klebsiella induced PPROM with continuous amnioinfusion and antibiotic administration through subcutaneously implanted intrauterine port system.

Method:

• Continuous hypotonic amniotic fluid infusion (amniotic fluid, 2400 mL daily) via subcutaneously implanted “Tchirikov perinatal port system”

• Intrauterine administration of antibiotics through the port system to counter the extremely low transplacental transfer.

Case:

A 34-year-old pregnant woman G2 P1 came because of PPROM at 26/3 weeks of gestation (WG) with anhydramnion. The patient received cefuroxime 750 mg TID and metronidazole 500 mg QID, RDS prophylaxis with betamethasone and tocolytic therapy with partusisten for 48 hours. Appropriate counseling was provided including conservative management versus continuous hypotonic amnioinfusion and antibiotic administration through port system. The port implantation was performed at 28/0 WG with the permission from ethics committee. Continuous hypotonic amnioinfusion and clindamycin 600 mg QD were administered into amniotic cavity through the port. At 29/6 WG, vaginal swab showed multi-resistant Klebsiella pneumonia with extended spectrum beta lactamase (ESBL). Ciprofloxacin was administered 400 mg for ten days through the port system into the amniotic cavity and 500 mg orally. The patient gave birth to a female infant at 31/1 WG with good neonatal outcome. The newborn required a day of ventilator support and another day of continuous positive airway pressure. Interleukine-6 and C-reactive protein were unremarkable. The ear, throat, rectal swab of newborn and port-catheter were also positive for multi-resistant K. pneumonia (3 MRGN: gram negative bacteria with resistance against 3 of 4 defined antibiotic classes). The newborn did not require any antibiotic treatment as there are no clinical signs of neonatal infection during the hospitalization. She was discharged with a weight of 2730 g in a stable condition and without any sign of neurological or pulmonary deficiencies. In a follow-up examination at five months of age, there were neither developmental delay nor Klebsiella colonization apparent.

Conclusion:

This is the first report of successful treatment of PPROM with anhydramnion using “flush out” with continuous amnioinfusion and antibiotic administration directly into amniotic cavity via a subcutaneously implanted port system.