Premature Rupture Of Membrane Flashcards
(13 cards)
Amniorrhexis
(Amniorrhexis) spontaneous rupture of membranes any time beyond 28th wk of preg but before onset of labor.
PROM
PROM - When rupture of membranes occur beyond 37th week but before the onset of labor
Preterm PROM (PPROM) should be used to define those patients who are
preterm with ruptured membranes, whether or not they have contractions
preterm PROM
Preterm PROM- when ROM occurs before 37 completed weeks
Prolonged rupture of membranes
Prolonged rupture of membranes- ROM for > 24 hours before delivery
Amniotic fluid functions
AF’s function are:
a) Protects fetus from infection, trauma, and umbilical cord compression
b) Allows for fetal movement and breathing
c) Facilitates musculoskeletal development
d) Promotes lung development
Aetiology / risk of PROM
Majority of aetiologies are idiopathic.
Variety of factors are purported to contribute to its occurrence such as
a) Polyhydramnios
b) Multiple pregnancy
c) Cervical incompetence
d) Uterine abnormalities
e) Antepartum haemorrhage
f) Fetal death
g) Infection- Chorioamnionitis, UTI and lower
genital tract infection(e.g., bacterial vaginosis)
h) Sexually transmissible disease
i) Cigarette smoking during pregnancy
j) Increased friability of the membranes
k) Decreased tensile strength of the membranes
l) Short cervical length < 2.5 cm
m) Prior preterm labor/ prior PROM
n) Low BMI (< 19 kg/m2) / nutritional deficiencies
Clinical features of PROM
a) Sudden painless escape of watery discharge per vaginam either in the form of a gush or slow leak
b) Others include; flecks of meconium in the fluid,
Decrease in the size of the uterus or
Change in color and consistency of fluid coming out of the vagina
If associated with infection: fever, tachycardia, dysuria, purulent offensive vaginal discharge
DDx to be excluded in the diagnosis of PROM
Exclude the following
a) Hydrorrhea gravidarum- a state where periodic watery discharge occurs probably due to excessive decidual
glandular secretion
b) Incontinence of urine especially in the later months.
c) Increased cervical discharge (e.g., infection)
d) Increased physiologic vaginal secretions during pregnancy
Investigations in PROM
a) Full blood count
b) Urine for routine analysis and culture
c) High vaginal swab for culture
d) Vaginal pool for estimation of phosphatidyl glycerol and
Lecithin: Sphingomyelin ratio
e) Ultrasonography for fetal biophysical profile
f) Cardiotocography for nonstress test
Confirmation of PROM diagnosis
Due to risk of introducing infection and long latency period
between presentation and delivery, avoid vaginal examination
for pts who is not in labor, whether preterm or term.
a) Sterile speculum examination- to inspect aseptically liquor escaping out via cervix
To evaluate the fetal membrane status and to inspect the cervix
Pooling of amniotic fluid in posterior vaginal fornix can be seen.
With Valsalva maneuver or slight fundal pressure may expel fluid from the cervical os, which is
diagnostic of PROM.
Examine collected fluid from the posterior fornix (vaginal pool) for
1. pH by litmus paper. ↑pH becomes 6–6.2 (during pregnancy normal vaginal pH y is 4.5–5.5.
2. pH by Nitrazine paper turns from yellow to blue at pH > 6
Nitrazine test uses pH to distinguish amniotic fluid from urine and vaginal secretions
Amniotic fluid is alkaline, having a pH above 7–7.5; vaginal secretions have a pH of 4.5 to 6.0,
and urine has a pH of ≤6.0
Sample of fluid obtained from the vagina during a speculum examination is placed on a strip of
paper or swab impregnated with nitrazine. If the pH is 7.1 to 7.3, reflecting that of amniotic
fluid, the paper or swab turns dark blue
False-positive nitrazine test results occur in presence of alkaline urine, blood, or cervical mucus.
3. Microscopic exam; note characteristic ferning pattern when fluid is smeared on slide
4. AmniSure test: a highly accurate test measuring placental alpha microglobulin-1 (PAMG-1), which
is present in high levels in amniotic fluid.
5. Centrifuged cells stained with 0.1% Nile blue sulfate showing orange blue
coloration of the cells (exfoliated fat containing cells from sebaceous glands of the fetus
b) Ultrasonography- to assess the fetal well being, assess gestational age, and amniotic fluid volume
If ample amniotic fluid around the fetus is visible on ultrasound examination, the diagnosis of PROM
must be questioned
c) Cardiotocography for nonstress test- Fetal heart rate and uterine activity monitoring
d) Other investigations
1) Full blood count;
2) Urine for routine analysis, M/C/S
3) HVS for M/C/S; Endocervical samples for gonorrhea and chlamydia testing if clinically indicated
Group B streptococcus cultures are obtained
4) Amniotic fluid- for Gram stain and culture.
5) Pulmonary maturation studies-
Using amniotic fluid obtained from vaginal pool or amniocentesis measures surfactant’s
phospholipid; phosphatidylcholine (lecithin), phosphatidylinositol (PI) and
phosphatidylglycerol (PG), allows prediction of risk of development of RDS in the neonate.
Lecithin (L) levels increase rapidly after 35 weeks, whereas sphingomyelin (S) levels remain
relatively constant after this GA.
Lecithin and sphingomyelin conc are measured by thin-layer chromatography and are expressed as
L/S ratio. Normal L/S ratio is 2.0 – 2.5. L/S ratio < 2 is significant for immature fetal lung
Complications of PROM
- Preterm labor and prematurity
- Ascending infection if labor fails to start within 24 hours- chorioamnionitis and fetal infection supervenes
- Cord prolapse esp when associated with malpresentation
- Dry labor if much of the liquor escape for long duration
- Placental abruption
- Fetal pulmonary hypoplasia esp in preterm PROM
- Neonatal sepsis, RDS, IVH and NEC in preterm PROM
- Perinatal morbidities (cerebral palsy) are high
Management OF PROM DEPENDS ON
Depends on
a) Gestational age of the fetus
b) Whether the patient is in labor or not
c) Any evidence of sepsis
d) Prospect of fetal survival, if delivery occurs.
PROM Management
Preliminaries of management
1) Aseptically confirm dsis on sterile speculum examination, note state of cervix and exclude cord prolapse
2) Generally avoid vaginal digital examination
3) Encourage bed rest
4) Apply sterile vulval pad to observe any leakage
5) Maternal pulse, temp and fetal heart rate are monitored 4 hourly
Term PROM: conservative management, if not in labor, no evidence of infection or fetal distress
If spontaneous labor does not ensue within 24 hours or there are reasons not to wait;
* Induce labor with oxytocin or.
* With obstetric indications, cesarean section is performed.
Preterm PROM:
For GA < 34 wks, main concern is to balance the risk of infection in expectant
management (while preg is continued) versus the risk of prematurity in active
intervention.
Risk of infection appears to increase with the duration of membrane rupture, the goal
of expectant management is to continue the pregnancy until the lung profile is mature.
In absence of any maternal or fetal indications, expectant mgt is generally acceptable
Transfer pt with “fetus in utero” to a unit able to effectively manage preterm neonates
Maintain careful surveillance- fetal and maternal
On rare occasion with bed rest, the leak seals spontaneously and pregnancy continues.
If GA is ≥ 34 weeks, perinatal mortality from prematurity is less compared to infection.
If labor does not start spontaneously within 48 hrs, institute induction with oxytocin
For presentation other than cephalic opt for cesarean section.
Tocolytic Therapy- Use of tocolytics to control preterm labor in PROM is controversial.
Use of Corticosteroids- to stimulate surfactant synthesis against RDS in preterm neonates is controversial.
PROM may accelerate fetal lung maturation presumably because of endogenous release of corticosteroids
from stress of decreased amniotic fluid volume and early infection.
Recommend in PPROM only up to 32 weeks, rather than up to 34 weeks as when membranes are intact.
Use of antibiotics: Prophylactic antibiotics to minimize maternal and perinatal risks of infection
