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1. PRETERM PRELABOR RUPTURE OF MEMBRANES AND PRELABOR RUPTURE OF MEMBRANES PRESENTER: TUMWINE AMOS Intern Student University of Rwanda

2. OUTLINE INTRODUCTION/DEFINITION EPIDEMIOLOGY CAUSES/RISK FACTORS DIAGNOSIS DIFFERENTIAL DIAGNOSIS MANAGEMENT COMPLICATIONS TAKE HOME MESSAGE REFERENCES

3. CASE 1 A 19-year-old G1P0 patient at 30 weeks presents to triage with a report of clear fluid leaking from her vagina. Her exam is positive for pooling, ferning, and nitrazine. The cervix is visually closed on sterile speculum exam. FHR is reassuring, and no contractions are noted. The US shows a breech singleton fetus. What is the next step in management?

4. CASE 2 A 24-year-old G3P1102 patient at 38 weeks presents to triage with a report of leakage of fluid from the vagina. She reports good fetal movement, no vaginal bleeding, and no contractions. She is afebrile. Sterile speculum exam demonstrated a pool of fluid in the vagina which is nitrazine positive and shows ferning on glass slide exam. On exam, her cervix is 1 cm and long. Fetal heart rate (FHR) tracing is reassuring, and no contractions are noted. What is the diagnosis?

5. PRETERM PRE-LABOR RUPTURE OF MEMBRANE Pre-labor rupture of membranes (PROM) It refers to spontaneous rupture of fetal membrane before the onset of uterine contraction. Rupture of membranes at least one hour before the onset of labor. It is prolonged when it occurs more than 18 hours before labor. Preterm pre-labor rupture of membranes (PPROM) It refers to PROM before 37+0 weeks of gestation

6. EPIDEMIOLOGY ≈ 3% of pregnancies <37 weeks are complicated by ΡРRՕM. PROM occurs in 5% to 15% of all pregnancies and 30–40% of preterm labor or 8–10% of term labor worldwide

7. It can be Previable PROM (<20WA) Preterm PROM (20-37WA) Term PROM (≥37WA)

8. Causes/Risk Factors Genital tract infection ΡРRОM in a previous pregnancy Antepartum bleeding Cigarette smoking Short cervical length Uterine overdistension Maternal Trauma Low body mass index Low socioeconomic status

9. CLINICAL FINDINGS Patient presentation Leaking or a gush of watery fluid from the vagina clear or pale-yellow fluid Constant wetness in underwear Physical exam Use a sterile speculum to examine vagina and cervix Avoid digital vaginal exam in PROM

10. DIAGNOSIS Positive pooling test : amniotic fluid existing the cervix and pooling in the vaginal fornix. Nitrazine test : test strips turn blue. Fern test : fern pattern on glass slide ( vaginal fluid I placed on a slide and allowed to dry. Amniotic fluid creates a characteristic fern –like pattern under microscopy. Amnisure or Actim PROM Tests : Rapid immunoassays detecting placental alpha-microglobulin-1 (PAMG-1) or insulin-like growth factor binding protein-1 (IGFBP-1), specific markers for amniotic fluid.

11. Nitrazine Test Assesses vaginal fluid pH to detect amniotic fluid in suspected PPROM. PH Ranges : Amniotic Fluid: 7.0 - 7.3 Normal Vaginal Fluid: 3.8 - 4.2 Urine: Typically, <6.0, can rise in infections. False Negatives : Occur with intermittent leakage or dilution. False Positives : Caused by blood, seminal fluid, soap, or high pH urine.

12. Ferning test Distinguishes amniotic fluid from other vaginal secretions Method Swab fluid from the posterior vaginal fornix onto a glass slide. Allow to dry for at least 10 minutes. Amniotic Fluid : Exhibits a delicate fern pattern. Cervical Mucus : Shows a thick and wide arborization pattern.

13. Positive Ferning Test

14. INVESTIGATIONS U/S: trans- abdo and/or trans-vaginal AF Index (oligohydramnios +++) Gestational age Cervical length Addition tests Obtain cervical and vaginal samples for cultures and/or biopsies FBC, Urinalysis , CRP Amniocentesis to assess risk of RDS (assess fetal lung maturity)

15. DIFFERENTIAL DIAGNOSIS Urinary incontinence Excessive vaginal discharge (normal or related to infection) Exogenous fluid( semen)

16. MANAGEMENT Depends on the gestation age . If the fetus is clearly preterm, tocolysis may be appropriate. Tocolysis may be harmful in the case of chorioamnionitis. Tocolysis is used for 48 hours, particularly at earlier GA in order to gain time to administer corticosteroids

17. Rupture of membranes presents with: Uterine Contractions & cervix >4cm regardless to GA, NO tocolytics, induce or augment the labor Chorioamnionitis Vaginal cultures, IV ATBs (Ampicillin, Gentamycin and Flagyl), then deliver No UCs, no chorioamnionitis, no maternal and/or fetal complications Triage by GA

18. Management of PPROM PROM > 12hrs at term (>37weeks) Start Ampicillin 2g every 6 hours until delivery Induce/augment labor as indicated (depending on bishop score) PPROM 34+1 to 36+6weeks Manage as PROM > 37weeks PPROM 24 to 33+6weeks Hospitalize Prophylactic antibiotics Tocolyse if no signs of chorioamnionitis Steroids for lung maturation MgSO4 for fetal neuroprotection (for 24-32weeks) if imminent delivery in 24hrs (stop if labor ceases)

19. CORTICOSTEROIDS Effectively reduces RDS, IVH and Infant mortality at 24-34 WA Dosage : - Dexamethasone IM 6mg/12h/4doses - Betamethasone IM 12mg/24h/2doses CRETERIA: GA between 24 to 34 weeks No Contraindications to delay delivery for 24-48h: Maternal: severe pre- eclempsia or eclampsia Fetal: non reassuaringFHR Contraindications to steroids: allergy, TB

20. MANAGEMENT Monitoring Twice weekly Biophysical profile and fetal monitoring Monitor Maternal vital signs (temp, HR, RR) every 4hrs Monitor for signs of Chorioamnionitis Deliver at >34 weeks gestation unless there are signs of chorioamnionitis prior to this.

21. CONT’N PPROM <24weeks (PULMONARY HYPOPLASIA) The risks and benefits of expectant management vs pregnancy termination should be discussed. Counsel the woman about termination of pregnancy Induce labor, if not do not expose the mother to nosocomial infections, Send her home for bed rest and to come back if fever, bleeding or if contractions start.

22. Diagnosis of Chorioamnionitis Maternal fever > 38 C with any of the two: Leukocytosis Maternal tachycardia Fetal tachycardia Uterine fundal tenderness Foul vaginal smelling. Confirmed PROM Absence of UTI

23. PPROM with signs of infection (Chorioamnionitis)< 34 weeks of gestation Antibiotic therapy Ampicillin 2 g IV every 6 hours+Gentamicin 5 mg/kg IV once daily +Metronidazole IV 500mg every 8 hours for 5days and stop if the patient is afebrile for 48 hrs. REPLACE AMPICILLIN WITH CLINDAMYCIN 900MG IV/8HRLY Labour induction with Oxytocin 5 IU in Ringers lactate or Normal Saline 500 ml or Cytotec based on Bishop Score If fever (>37 C) give paracetamol 500mg. MgSO4, don’t delay delivery intermittent fetal monitoring every 30 minutes till delivery

24. COMPLICATIONS MATERNAL Preterm delivery Choriamnionitis : 15–20% Placenta abruption: 4–12% PPH FETAL Neonatal sepsis IUGR Cord compression Fetal death: 1–2%

25. Complications associated to PROM If fetus remains in- utero Perinatal conditions Infections Deformations Cord compression Pulmonary hypoplasia Matern al conditions Infections DVT Psychosocial

26. If Preterm delivery occurs Neonatal conditions RDS (Respiratory distress sd ) PDA (Patent ductus arteriosus ) IVH ( intraventricular hemorrhhage ) NEC (necrotizing enterocolitis ) ROP (retinopathy of prematurity) BPD ( bronchopulmonary dyspplasia ) CP ( cerebral palsy)

27. TAKE HOME MESSAGE Diagnosis of PPROM is clinical NO digital vaginal exam if PPROM is suspected Expectant management with antibiotics, corticosteroids, and close monitoring, or induction of labor/C-section depending on gestational age and maternal/fetal condition

28. REFERENCES uptodate First aid for the OB/GYN Clerkship 5th edition https://calgaryguide.ucalgary.ca/wp-content/uploads/2015/09/PPROM-Pathogenesis-and-clinical-findings.png https://www.who.int/news-room/fact-sheets/detail/preterm-birth William obstetrics,26th edition Blue print, 7th edition Obstetrics and gynecology Rwandan protocol 2022

29. ANSWER CASE 1 The patient has PPROM. She should be admitted to the hospital. Steroids should be administered to ↓ the risk of RDS in the fetus, and antibiotics should be given to ↑ the latency period

30. Answer case 2 Prelabor rupture of membranes (PROM) is diagnosed when the membranes rupture prior to the onset of labor. Rupture of membranes is confirmed by the sterile speculum exam. Based on the cervical exam and the absence of contractions, the patient is not in labor. Considering that the fetus is term, the next step should be induction of labor in order to prevent chorioamnionitis.