Premature rupture of membranes UE MED 518

Presented by

Dr. E. NKWABONG Pr. MBU R

Obstetricians - GynaecologistsFMBS - Yaoundé

Scheme

1) Introduction 2) Definition of PRM 3) Aetiologies 4) Pathologies 5) Clinical signs6) Differential diagnosis7) Paraclinical8) Complications9) Treatment10) Conclusion

Objectives : At the end of the lecture, the student should be

capable of:1. Defining PRM.2. Give 4 risk factors for PRM3. Cite 2 clinical signs of PRM4. Give 2 differential diagnosis of PRM5. Give 4 paralinical investigations for

confirmation of PRM6. Enumerate 3 complications of PRM

1) Introduction

• Target: Medical student, M2 level.• Presentation: * PRM is a frequent complaint in Obstetrics (6% of

all pregnancies). It is associated with increased perinatal morbidity and mortality.

*Hence, prompt diagnosis and management should be conducted.

.

2) Definition• Premature rupture of membranes (PRM) is

rupture of membranes (more than 1 hour) before unset of labour.

It can occur preterm (preterm rupture of membranes) or at term (prelabor rupture of membranes.

• If 24 h elapse between rupture of membranes and unset of labour, it is called prolonged rupture of membranes.

3) Aetiologies 3.1) Maternal causes:

• Cervicitis, vaginitis, STD• Incompetent cervix.

• Urinary tract infection• Malformed uterus (U. didelphys, U septus,…)

Maternal causes (continue)

• Undernutrition (abnormal collagen)• Grand multiparity.

• Past history of PRM (abnormal congenital collagen resistance).

3.2) Fœtal causes

• Polyhydramnios• Abnormal presentation (breech, transverse,…

• Multiple pregnancies• Chorioamnionitis.

• Placenta praevia.

3.3) Traumatic causes

4) Pathology

PRM is the most frequent cause of premature labour, cord prolapse, intra amniotic infection.

That is why there is a high perinatal mortality associated with PRM, especially when it occurs before term.

5) Clinical signs

• Vaginal flow of liquid (continuous or not).

• Speculum examination: look for fluid coming from the cervical canal.

• If there is any, do Valsalva maneuvre (increase of intra abdominal pressure)

6) Differential diagnosis• Urinary incontinence• Fissuration of membranes.

• Rupture of an amniochorial pouch• Vaginitis with increased vaginal secretion.

• Normal or premature labour (labor pain not really felt).

7) Paraclinical investigation

7.1) For diagnosis:

• Nitrazine test (brown to blue if PRM).

• Fern test (1 drop of liquid on a slide, let it dry at air, observe under microscope).

• Look for Lecithin/Sphingomyelin, phosphatidylglycerol in liquid collected from the pouch of Douglas.

Paraclinical (continue)

7.2) For treatment:

• Cervical swab (PCV)• FBC, blood parasites

• Urine culture• Ultrasound scan (amniotic fluid, gestational age,

fœtal weight)

• …

8) Complications:

• Cord prolapse• Abruptio placentae

• Chorioamnionitis (fever of 38 ° or more after PRM, leucocytosis > 16000, uterine tenderness, maternal and foetal tachycardia).

• Maternal complications are: endometritis, salpingitis, …

Complications (continue)

• Premature labour and delivery (neonatal mortality is increased: 4 times, Respiratory distress syndrom: 3 times, neonatal sepsis, intra ventricular bleeding.

• Prophylactic antibiotic seems to reduce these complications.

9) Treatment:

• The aims are to reduce the risk of infection (chorioamnionitis) and to accelerate lungs maturity if necessary before delivery.

• However, in case of chorioamnionitis, the fœtus must be delivered as soon as possible.

Treatment (continue)

• The 2 major risks are prematurity and fœtal infection.

• The treatment will depend on the gestational age and the fœtal weight.

• Before delivery, a neonatal unit and a neonatalogist should be contacted

9.1) Before 28 weeks:

• Use parenteral antibiotic for 2 days, then orally (ceftriaxone or erythromycin.

• NB: amoxicillin-clavulanic acid leads to an increased incidence of necrotizing enterocolitis).

• Before 25 weeks, there is risk of fetal lungs hypoplasia, neurological damage and limb compression deformities if PRM with oligoamnios

Treatment Before 28 weeks (continuation)

• Antibioprophylaxis reduces in newborns respiratory distress syndrome, necrotizing enterocolitis, and composite adverse outcomes.

• • The latency period is increased.

• Prolonged use of ATB increases the risk for selection of resistant bacteria.

9.2) Between 28 and 32 weeks: *ATB, *Corticotherapy (betamethasone: 12 mg IM to be

repeated after 12 to 24 hours or dexamethasone: 6 mg intramuscularly every 12 hours for four doses).

*NB: A single course of betamethasone is associated with a significantly reduced incidence of periventricular leukomalacia.

Treatment Between 28 and 32 weeks (continuation)

*No tocolysis or only for 24 to 48 h to allow lungs

maturation. Association of tocolysis and corticotherapy increases the risk of maternal pulmonary oedema .

Treatment (continuation)

9.3) Between 32 and 34 weeks: ATB, Corticosteroids (debated), if L/S is more than 1.8, then induced labour or perform C/S

9.4) After 34 weeks or fœtal weight > 2000 g: ATB, prepare for delivery.

9.5) Prevention of chorioamnionitis:

• No digital vaginal examination (only 1 is necessary when we are ready to deliver the fœtus: Bishop score, Pelvis evaluation,…). It shortens latency period.

• Change pad every 4 hours (2 for others)• No sexual intercourse

9.6) Precocious diagnosis of chorioamnionitis:

• Temperature every 6 hours (2 for others).• Appreciate the colour & odor of amniotic fluid.

• FBC, CRP.• Look for tenderness of uterine fundus

9.7) For fetal well-being: • FHR every 2 hours (or 15 min if she is in

labour)

10) Conclusion:• When premature rupture of membranes is

suspected, it must be confirmed or ruled out.

• When it is diagnosed, the treatment must be correct.

• Don’t hesitate to have the point of view of a neonatalogist if you want to deliver a premature baby.

• For neonatal better care, a neonatal unit should be available.

• Références: * Current Obstetrics & Gynaecologic diagnosis & treatment 2007 * Williams Obstetrics 2007

* Dewhurst’s textbook of Obstetrics & Gynaecology for postgraduates

• Modalités de l’évaluation: QCM, QROC, questions Rédactionnelles

• Conseils: Consulter la bibliographie, être assidu(e) pendant les stages cliniques,

• Contact: Dr Nkwabong, service de gynécologie, CHU Yaoundé, Tel. 99663843/ 77450104

Thanks for your kind attention