Pre term & premature rupture of membranes (prom)

Obstetrics

1. PRE-TERM & PREMATURE RUPTURE OF MEMBRANES (PROM) KASTURI RAMASAMY 1

2. Pre-term labour Labour starts before the 37 th completed week (<259 days), counting from the first day of the last menstrual period Lower limit of gestation : 20 weeks (developed) & 28 weeks (developing countries) 2

3. Aetiology *multifactorial Previous history of induced or spontaneous abortion or preterm delivery Pregnancy following assisted reproductive techniques (ART) Asymptomatic bacteriuria or recurrent UTI Low socio-economic & nutritional status Maternal stress Indicated preterm delivery d/t medical or obstetric conditions Idiopathic(Majority): Premature effacement of the cervix with irritable uterus & early engagement of the head 3

4. Aetiopathogenesis 4

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6. Diagnosis 6

7. Predictors 7

8. Management Principles Prevent the preterm onset of labour, if possible Arrest preterm labour if not contraindicated Appropriate management of labour Effective neonatal care 8

9. 1. Prevention of PTL Primary care : Reducing high risk factors. Secondary care : Screening tests for early detection and prophylactic treatment. (tocolytics) Tertiary care : Reduce perinatal morbidity & mortality after diagnosis (corticosteroids) Investigations FBC Urinalysis and C&S Cervicovaginal swab –culture & fibronectin USG –fetal wellbeing, cervical length & placental localisation Serum electrolytes and glucose levels ( for tocolytics usage) 9

10. 2. Measures to arrest PTL Only in negligible proportion of cases Bed rest (left lateral) Adequate hydration Prophylactic antibiotics –not routinely given Prophylactic cervical cerclage * Tocolytic agents Short term therapy To delay delivery for at least 48 hours for glucocorticoid therapy to enhance fetal lung maturation In utero transfer of patient >> advanced NICU For cervical incompetence –reinforces the weak cervix by non-absorbable tape, placed around the cervix at the level of internal os Shirodkar’s operation Mc Donald’s operation Fetus is not compromised Maternal conditions remain good Intact membranes 10

11. 2. Measures to arrest PTL CONTRAINDICATIONS Glucocorticoid < 34 weeks Minimize RDS, IVH & NEC Benefit persists as long as 18 days Betamethasone* 12mg IM 24 hours apart 2 doses OR Dexamethasone 6 mg IM every 12 hours for 4 doses Risks: PROM (~infection) Insulin dependent DM needs insulin readjustment Transient reduction of fetal breathing and body movements 11

12. 3. Management of labor in PTL * prevent birth asphyxia, RDS * prevent birth trauma (duration of labour : short) FIRST STAGE SECOND STAGE 1. Patient is put to bed [to prevent PPROM] 1. The birth should be gentle and slow [to avoid compression & decompression of the head] 2. Oxygen mask to mother [Adequate fetal oxygenation] 2. Episiotomy may be done [to minimise head compression d/t perineal resistance] 3. Epidural analgesia of choice. 3. Tendency to delay is curtailed by low forceps . 4. Monitor the labour carefully by using continuous Electronic Fetal Monitoring (EFM). 4. The cord is to be clamped immediately [prevent hypervolemia & hyperbilirubinemia] 5. C-section only if indicated. 5. Shift baby > NICU 6. NICU for good outcome. 12

13. Principle management of PTL 13

14. Premature Rupture of Membranes (PROM) Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the onset of labour > 37 completed weeks : term < 37 weeks of gestation: pre term Rupture of membranes > 24 hours before delivery : prolonged rupture of membrane 10% of all pregnancies 14

15. PROM -causes 15

16. PROM -diagnosis 16

17. PROM -confirmation of diagnosis pH 6-6.2 [Normal vaginal pH during pregnancy is 4.5-5.5; liquor amnii is 7-7.5] Nitrazine paper: Yellow  Blue at pH >6 Exfoliated fat containing cells from sebaceous glands of the fetus 17

18. PROM INVESTIGATIONS DANGERS FBC Urinalysis and culture High vaginal swab – culture Vaginal pool : Estimation of p hosphatidyl glycerol and L:S ratio USG : Fetal biophysical profile CTG Term PROM, labour starts in 80-90% cases within 24 hours  PTL & prematurity Ascending infection is more (if labour fails to start within 24 hours) ~choriamnionitis Cord prolapse -malpresentation Dry labour d/t continuous escape of liquor Placental abruption Fetal pulmonary hypoplasia Neonatal sepsis, RDS, IVH, NEC Perinatal morbidities (cerebral palsy) 18

19. PROM -preliminaries Aseptic examination [to confirm the diagnosis, assess the state of cervix, to detect any cord prolapse] Avoid vaginal digital speculum Patient is put to bed rest + sterile vulval pad is applied [to observe any further leakage] Diagnosis is confirmed, management depends on: Gestational age of fetus In labor or not Sepsis evidence Fetal survival *monitor maternal pulse, temperature & FHR for 4 hourly 19

20. PROM Gestational age > 34 weeks: Infection >> perinatal mortality d/t prematurity 20

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