PROM Dr Vishal Chaudhari DEFINITION Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the onset of labor TERM PROM after 37 weeks Preterm PROM ID: 775535
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PRELABOR RUPTURE OF MEMBRANES(PROM)
Dr Vishal Chaudhari
Slide2DEFINITION
:
Spontaneous rupture of the membranes any time
beyond 28th week
of pregnancy but before the
onset of labor
TERM PROM :
after 37 weeks
Preterm PROM
: Before 37 weeks
Slide3Prolonged Rupture of membranes :
Rupture of membranes for > 24 hours before delivery
Incidence : 10% of all pregnancies
Slide4Normal events
Slide5Slide6Slide7Slide8CAUSES
Increased friability of the membranes
Decreased tensile strength of the membranes
Polyhydramnios
Cervical incompetence
Multiple pregnancy
Infection
—
Chorioamnionitis
, urinary tract infection and lower genital tract infection
Cervical length < 2.5 cm
Prior preterm labor
Low BMI (< 19 kg/m2).
Slide9Diagnosis
Classic
clinical presentation
: sudden "gush" of clear or pale yellow fluid from the vagina.
Differentiate from :
Hydrorrhea
gravidarum
—a state where periodic watery discharge occurs …probably due to excessive
decidual
glandular secretion
Incontinence of urine
Slide10Confirmation of diagnosis
Per Speculum examination
: inspect the liquor escaping out through the cervix
Leakage of amniotic fluid from the cervical
os
Pooling in the vaginal fornix is pathognomonic
Collect the fluid for tests
Slide11Tests for fluid
1. Detection of
pH -
by litmus or
Nitrazine
paper.
pH in pregnancy- 6-6.2
Normal pH – 4.5-5.5
pH of Liquor : 7-7.5
Nitrazine
paper turns from
yellow
to
blue
at pH > 6;
2. Microscopy : characteristic
ferning
pattern
when a smeared slide is examined under microscope;
Slide12Slide133. 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)
4.
AmniSure
—A rapid immunoassay is accurate
5.
Ultrasonography: 50 to 70 % of women have low amniotic fluid volume (AFI),
Fetal well being
Slide14Newer tests
Fetal
fibronectin
(
fFN
):
A negative fetal
fibronectin
result strongly supports absence of membrane rupture, but a positive result only indicates disruption of the interface between
chorion
and
decidua
, which can occur with intact membranes
Alpha-fetoprotein (AFP)
in vaginal secretions suggest the presence of amniotic fluid
Slide15INVESTIGATIONS
Full blood count;
C-reactive protein (CRP);
Urine
High vaginal swab for culture (specially for Gr.
B Streptococcus)
Ultrasonography for fetal biophysical profile
Cardiotocography
for
nonstress
test (NST)
Slide16Complications
In Term PROM
labor starts in 80–90% of cases within 24 hours.
PROM is one of the important causes of preterm labor and prematurity
Chance of
ascending infection
is more if labor fails to start within 24 hours. Liquor gets infected
(
chorioamnionitis
)
and fetal infection supervenes.
Slide17Complications
Cord Prolapse- especially when associated with malpresentation, polyhydramnios
Dry labor- Continuous escape of liquor for long duration
Placental abruption – Polyhydramnios , sudden gush /drainage of
liqour
Slide18Complications
In Preterm PROM - Fetal pulmonary hypoplasia , when associated with oligohydramniosNeonatal sepsisRDS IVH In Preterm PROM NEC
Slide19Complications
Chorioamnionitis
Placental abruption
Retained placenta
Endometritis
Maternal sepsis
Slide20MANAGEMENT
Aseptic examination
– confirm diagnosis , state of cervix- Bishop score ,
Confirm Gestational age
Diagnosis of labor
Maternal
Temperature , Pulse , FHR monitoring
Fetal
assessment
:
Gest.age
, weight , Pulmonary maturity
Slide21MANAGEMENT
Prophylactic
antibiotics
: to minimize maternal and
perinatal
risks of infection
Intravenous
ampicillin
, amoxicillin or erythromycin for 48 hours
Followed by - oral therapy for 5 days
Slide22MANAGEMENT
Use of corticosteroids
to stimulate surfactant synthesis against RDS in preterm neonates is advised.
Dexamethasone
– 6mg 12 hourly , 4 doses
Betmethasone
– 12 mg 24 hours apart
Combined use of antibiotics and corticosteroids has reduced the risks of – neonatal RDS, IVH and NEC
Slide23Slide24Chorioamnionitis
Chorioamnionitis
is a bacterial infection that occurs before or during labor.
The name refers to the
Chorion
(outer membrane) and
Amnion (fluid-filled sac).
Chorioamnionitis
occurs when bacteria infect the
chorion
, amnion, and the fluid around the fetus (amniotic fluid).
Slide25Causes
Usually develops due to an infection
Bacteria that are normally present in the vagina ascend into the uterus
Most common causes of
chorioamnionitis
E. coli, group B streptococci, and anaerobic bacteria
Slide26Risk Factors
• History of previous premature birth
• Presence of premature labor
• PSROM prior to onset of labor
• Prolonged rupture of membranes
• young maternal age
• multiple vaginal examinations during labor (only in women with ruptured membranes)
Slide27Clinical feature
• High temperature and fever
• Rapid heartbeat (The fetus might also have a rapid heartbeat.)
• Sweating
• A uterus that is tender to the touch
• A discharge from the vagina that has an unusual smell (Lochia/ vaginal discharge)
Slide28Diagnosis
Clinically
• maternal pyrexia (fever >37.5–38C)
• Abdominal pain
• Uterine tenderness,
• Foul vaginal discharge,
• Maternal tachycardia (>100 beats/min),
• Fetal tachycardia (persistent elevation of fetal heart rate >160 - beats/min)
Slide29Laboratory tests
• CBC Maternal
leucocytosis
(>15,000/mm3)
• High levels of C-reactive protein (CRP)
• An amniocentesis : a small amount of amniotic fluid is removed for testing if the amniotic fluid has a low concentration of glucose (sugar) and a high concentration of white blood cells and bacteria.
Slide30Complication
• Infections in the pelvic region and abdomen
•
Endometritis
(an infection of the
endometrium
, the lining of the uterus)
• Thrombosis and embolism
• Sepsis
•
High morbidity and mortality rates
Slide31Treatment
•
Ampicillin
2 gm IV every 6 hours, plus
•
Gentamicin
1.5 mg/kg IV every 8 hours
• Followed by a postpartum dose of each antibiotic at the appropriate drug-specific interval.
• For cesarean delivery: Add
metronidazole
500 mg IV
Slide32Alternative
•
Clindamycin
900 mg IV every 8 hours, plus
•
Gentamicin
1.5 mg/kg IV every 8 hours
• Followed by a postpartum dose of each antibiotic at the appropriate drug-specific interval.
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