Premature Rupture of Membranes(PROM)

What is the membranes?

Definitions:

• PROM:Rupture of membranes (ROM) prior to the onset of

labor -contractions- at or beyond 37 weeks.

• Preterm PROM:ROM prior 37 weeks.

PROM & PPROM• Incidence:8 % of pregnancies for PROM3 % for PPROM• Causes:In general the exact causes is unknown but these are

possible ones (risk factors):1. Friability of the membranes2. Polyhydramnios3. Cervical incompetence4. Multiple pregnancy5. Infection

6. Previous condition7. APH8. Smoking9. Low BMI10. Previous preterm labour

Diagnosis:

• Hx:The classic clinical presentation is a sudden "gush" of

clear or pale yellow fluid from the vagina. However, many women describe intermittent or constant leaking of small amount.

NB:You must differentiate this from urine and hydrorrhea

gravidarum (watery discharge occurs probably due to excessive decidual secretion)

Cont..• Physical examination:

1. Observation of the amniotic fluid.

2. Sterile speculum:• Leakage of amniotic fluid from the cervical os• Pooling in the vaginal fornix is pathognomonic• Collection of the fluid

3. Ultrasonography: 50 to 70 % of women have low amniotic fluid volume

Cont..4. Laboratory:• Detection of pH by litmus paper (Normal pH during

pregnancy is 4.5–5.5 whereas that of liquor amnii is 7–7.5)

• Slide smear of the fluid giving the characteristic ferning pattern (should differentiated from cervical mucus) see later..

5. AmniSense is absorbent pad that changes color at pH >5.2

PV is contraindicated to avoid chorioamnionitis

Fern Plant السرخس نبات

Cervical mucus ferning

Amniotic fluid

Urine

AmnioSense

Cont..5. 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

6. Alpha-fetoprotein (AFP) in vaginal secretions suggest the presence of amniotic fluid

7. CBC, urine analysis, vaginal swab for culture (group beta strep.) , CTG

Management of PROM (≥37)• Depend on gestational age and mother-fetal

condition• Labor starts in 80–90% of cases within 24 hours• The key decision is whether to initiate delivery or

take an expectant approach• When time increase the risk of infection increase• Induction of labor by oxytocin and misoprostol and

it is preferable• Expectant management in non complicating

pregnancies and should not exceed 24 hr. • Antibiotic prophylaxis

Management of PPROM (23-37)• The management of PPROM is among the most

controversial issues• Based on several factors:A. Gestational ageB. Presence or absence of maternal/fetal infection (GBS)C. Presence or absence of laborD. Fetal presentationE. Fetal well-beingF. Fetal lung maturityG. Cervical status (by visual inspection)H. Availability of neonatal intensive care

Cont..• Expeditious delivery of women with PPROM is

clinically appropriate if intrauterine infection, abruptio placentae, or a high risk of cord prolapse is present or suspected

• For stable patients with PPROM <34 weeks expectant management in addition to:

1. Administering a course of antenatal corticosteroids2. Prophylactic antibiotics3. Delivery if gestational age is confirmed at ≥34 weeks

Complications:• PPROM is associated with 30-40% of preterm

deliveries• Chorioamnionitis• Endometritis• Neonatal sepsis• Oligoamnios dry labor• Placental abruption• Fetal pulmonary hypoplasia esp. in PPROM• Cerebral palsy• Fetal malpresentation

Chorioamnionitis

• Chorioamnionitis is a bacterial infection that occurs before or during labor. The name refers to the chorion (outer membrane) and the amnion (fluid-filled sac). These membranes surround the fetus.

• Chorioamnionitis occurs when bacteria infect the chorion, amnion, and the fluid around the fetus (amniotic fluid).

Causes: • Chorioamnionitis usually develops due to an

infection. The infection can occur when bacteria that are normally present in the vagina ascend into the uterus, where the fetus is located. The amniotic fluid and placenta — as well as the baby — can become infected. E. coli, group B streptococci, and anaerobic bacteria are the most common causes of chorioamnionitis.

Risk factors • 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)

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

DiagnosisA- Clinicaly by :• 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)

b) Laboratory tests• CBC Maternal leucocytosis (variously defined as

WBC >12,000/mm3 or >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.

Treatment • Ampicillin 2 gm IV every 6 hours, plus• Gentamicin 1.5 mg/kg IV every 8 hours or 5

mg/kg IV every 24 hours• Followed by a single postpartum dose of each

antibiotic at the appropriate drug-specific interval.

• For cesarean delivery:• Add a single dose of metronidazole 500 mg IV,

administered after clamping of umbilical cord

Cont.• For Penicillin allergic patients:• Clindamycin 900 mg IV every 8 hours, plus• Gentamicin 1.5 mg/kg IV every 8 hours or 5 mg/kg

IV every 24 hours• Followed by a single postpartum dose of each

antibiotic at the appropriate• drug-specific interval.• For cesarean delivery: metronidazole is not

needed.

Complication • Infections in the pelvic region and abdomen • Endometritis (an infection of the

endometrium, the lining of the uterus) • Blood clots in the pelvis and lungs • Sepsis (a life-threatening infection in the

blood)