department of gynecology and obstetrics PROM.pptx

general overview of PROM

1. PROM DR. CHIKONDE

2. PROM ( Premature rupture of membranes ) Definition : Spontaneous rupture of membranes after 28 weeks of gestation before the onset of labor. Term PROM: Rupture of membranes after 37 weeks Preterm PROM: Before 37 weeks Prolonged PROM: Longer than 18 hrs/ 12 hrs. Latency period: Time between rupture of membranes to onset of labor.

3. PROM-Cont’d Diagnosis : History: complaint of leakage of liquor as gush or slow leak;followed by intermittent leakage. -Complications of PROM: infection, PTL, etc. Physical findings: Negative discrepancy If complicated, uterine contraction, tenderness Sterile speculum examination with or without valsalva maneuver( leakage or pooling)

4. Incidence: average 5- 10% of all deliveries and up to 30% of preterm deliveries. Approximately 70% of cases of PROM occur in pregnancies at term. PROM is the clinically recognized precipitating cause of about one third of all preterm births. Incidence

5. Causes multifactorial 1. Intrinsic membrane weakness a. Infections b. Smoking c. Malnutrition d. Collagen Deficiency 2. Infection (proteolytic enzymes) 3. Mechanical stress a. Twin gestation b. Polyhydramnios c. Fetal Malformations 4. Unknown

6. Diagnosis-cont’d Investigations: Nitrazine paper test : principle is alkaline nature of amniotic fluid(accuracy of approximately 93%) Became blue False +:blood, semen, alkaline urine, bacterial vaginosis, and trichomoniasis Ferning pattern: accuracy of diagnosis of PROM of approximately 96% False +ve : contamination by semen or cervical mucus False –ve :dry swab, contamination with blood at a 1:1 dilution, or not allowing sufficient time for the fluid to dry on the slide Unaffected by meconium at any concentration and by pH alteration.

7. Ferning pattern

8. Diagnosis-cont’d Ultrasound: support diagnosis & fetal wellbeing. Dye test: indigo carmine instillation Meconium on the vulva Vernix caseosa on the vulva

9. DIAGNOSIS History Gush or Leakage of fluid PV (Duration, Smell) Is she in Labour Yes No Speculum/Digital Exam Sterile Speculum Examination ± Valsalva Man Leakage through cervix No leakage through cervix Presence of meconium/vernix Pooling at post fornix No pooling - Nitrazin paper test -Fern test Pad test for 24 hrs PROM No wetting Wetting + ve - ve Suspsious Treat as PROM - US Oligohydramnios - Dye test PROM +ve -ve Follow at OPD Level

10. PROM- investigations CBC U/A, Culture & Sensitivity High vaginal swab for culture Phosphatidylglycerol from vaginal pool Biophysical profile CTG for non-stress test

11. Differential diagnosis Urinary incontinence Leucorrhea gravidarum* Perspiration* Vaginal discharge-pathological

12. Complications of PROM Labor: In term PROM labor starts in 24 hours in about 90%. In Preterm PROM, labor starts in 70-80% of cases in one week time Ascending infection: one third Increased incidence of cord prolapse Fetal pulmonary hypoplasia Prematurity Operative delivery Abruption

13. Management of PROM Accurate diagnosis Avoid digital vaginal examination Bed rest Management depends on: GA Presence or absence of labor Infection or not Fetal condition

14. Indications for pregnancy termination in PROM Term PROM Labor Presence of infection IUFD Congenital anomalies of fetus incompatible to life Abnormal fetal surveillance

15. Preterm PROM GA > 34 weeks is controversial either conservative management or termination GA< 34 weeks, conservative management Components of conservative management: Monitor maternal PR, Temp., FHR every 4 hours CBC, U/A, ESR/CRP twice per week BPP/NST twice per week Corticosteroids if less than 32/34 weeks Administer antibiotics: ampicillin (iv)+ erythromycin X 48hrs followed by amoxacillin(po) & erythromycin to complete a total of seven days

16. Two indications for prophylactic antibiotics in PPROM: prevention of perinatal GBS infection infection is either the triggering cause of PPROM or that infection ensuing after PPROM triggers the labor

17. Chorioamnionitis Clinical or subclinical Criteria for clinical chorioamnionitis : Maternal temperature > 38 o C Uterine tenderness Foul smelling amniotic fluid High WBC count(>16000/18000) Maternal &/ or fetal tachycardia

18. Subclinical chorioamnionitis Amniocentesis: intraamniotic infection is present if: Culture: bacterial colony count > 10 2 / ml fluid Presence of bacteria on gram stain Glucose level<15 mg/dl WBC> 100/ml

19. Management of chorioamnionitis Antibiotics: Ampicillin Gentamicin clindamycin/metronidazole/chloramphenicol Ceftriaxone +/- metronidazole Terminate pregnancy: Vaginal route is preferred

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