PRELABOR RUPTURE OF MEMBRANES - PowerPoint Presentation

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PRELABOR RUPTURE OF MEMBRANES(PROM)

Dr Vishal Chaudhari

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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

: Before 37 weeks

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Prolonged Rupture of membranes :

Rupture of membranes for > 24 hours before delivery

Incidence : 10% of all pregnancies

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Normal events

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CAUSES

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).

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Diagnosis

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

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Confirmation 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

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Tests 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;

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3. 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

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Newer 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

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INVESTIGATIONS

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)

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Complications

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.

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Complications

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

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Complications

In Preterm PROM - Fetal pulmonary hypoplasia , when associated with oligohydramniosNeonatal sepsisRDS IVH In Preterm PROM NEC

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Complications

Chorioamnionitis

Placental abruption

Retained placenta

Endometritis

Maternal sepsis

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MANAGEMENT

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

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MANAGEMENT

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

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MANAGEMENT

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

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Chorioamnionitis

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).

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Causes

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

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Risk 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)

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Clinical 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)

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Diagnosis 

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)

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Laboratory 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.

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Complication

•  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

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Treatment

 •

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

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Alternative

•

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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