Premature rubture of membren Premature rubture of membren

Premature rubture of membren

1. Premature Ruptures Premature Ruptures
Of Membranes Of Membranes
(PROM)(PROM)

2. Definitions
PROM - Spontaneous rupture of membranes
before onset of labor after 28 completed
weeks.
LATENCY PERIOD - interval between PROM &
onset of labor.
PROLONGED PROM - ROMs for more than 12
hrs.
TERM PROM - ROM after 37 weeks.
PRETERM PROM – ROM before 37 wks
VERY PRETERM PROM – between 28-30 wks.

3. Definitions
CHORIAMNIONITIS (CA)
•Clinical CA has the following signs:
–Fever > 38
0
C
–Uterine tenderness
–Foul smelling AF
–Increasing WBC count
–Maternal or fetal tachycardia
•Subclinical
–Diagnosed by AF study in the absence of
the above mentioned signs.

4. Etiology
•The exact cause is not known.
•Associations with:
–Incompetent Cx
–Overdistended Ux (Polyhydraminos,
multiple pregancies)
–Inherent membrane defects (genetic
conditions, low maternal serum copper,
vit. C deficiency)

5. Etiology
–Infections
•Asymptomatic bacteriuria
•UTI
•Lower GTI
•Bacterial vaginosis
•Intrauterine infections
•Chorioamnonitis
–Seminal fluid releasing collagenase
like enzyme
–Maternal connective tissue
disorders

6. Etiology
–2
nd
& 3
rd
trimester bleeding
–ECV
–Amniocentesis
–Trauma
–Maternal smoking
–Low socioeconomic status
–Family history

7. Diagnosis
•Symptoms :
–Sudden gush of fluid from the vagina/
continued leakage
•Hx :
–Duration of leakage
–Quantity of the discharge
–Type of discharge (clear/ blood stained/
green-colored)
–Consistency of the fluid
–Presence of vernix

8. Diagnosis
•Hx :
–Presence & duration of pain
–LMP for GA
–Fetal movement
–Any Hx suggestive of infections
–A detailed present & past obs., medical
& surgical Hx may help find the
pathological cause.

9. Examination
•GPE, Hydration & monitoring of vitals
•Abdominal examination
–Confirm GA by measuring the FH which
may be small for dates
–Look for uterine tenderness
–Determine fetal lie
–Auscultate Fetal heart sounds

10. Examination
•Speculum exam.
–Extent of cervical dilatation & effacement
–Cord prolapse
–Fetal presenting part
–Liquor may be seen draining through Cx os &
pooling of the amniotic fluid in post. fornix.
–If no discharge is seen, the pt is asked to
cough, apply slight fundal pressure or perform
Valsava maneuver & leak is observed.
–The fluid is collected.
–A clean sterile pad is to pt the pad is observed
after 1 hr.
–>Drawback: Vulval pads can be moisted with urine or vaginal
discharge which can be mistaken with the amniotic fluid

11. Exam. of collected AF
•Gross Exam.
–Clear, blood stained or cream/ green
color
–Foul smelling

12. Diagnostic tests in PROM
•Nitrazine paper test
pH of the vagina : 4.5 – 6.0
pH of the AF : 7.1 – 7.3
–It changes color from yellow green to dark blue at pH >
6.5
•False +ve
–Blood contamination
–Semen contamination
–Alkaline antiseptics
–Bacterial vaginosis
–Tap water
•False –ve
–Minimal residual fluid

13. Diagnostic tests in PROM
•Ferning – a drop of AF when placed
on a clean slide & allowed to dry
demonstrates ferning (microscopic
crystallization) due to interaction of
AF proteins & salts
•False +ve
–Cervical mucus
–NaCl solution

14. Special investigations
•Amniocentesis – a dilute solution of
1 ampule of indigo carmine dye is
injected in to the AF & a pad is
kept at vulva. A leak of blue fluid in
to the vagina confirms Dx.
•High vag. swab for culture &
sensitivity (for Dx of infection) &
fetal fibronectin (to Dx
prematurity)

15. •0.1% nile blue sulphate test – the
collected fluid can be centrifuged &
examined for fetal cells staining with
the dye. The cells appear orange due
to the presence of exfoliated fat
cells from the sebaceous glands of
the fetus.
•Culture & sensitivity of AF (for
infection)

16. •U/S
–GA
–Amount of AF- reduced/ absent
–Fetal presentation, number
–EFW
–Placental localization & maturity
•CBC, CRP (to predict development of
chorioamnionitis)
•Urine exam. – routine, microscopy &
culture.

17. Complications
• Preterm labor: with the risk of
prematurity.
•Infection: chorio-amnionitis,
septicemia and fetal pneumonia.
• Fetal deformities and distress: due
to oligohydramnios.

18. Management
•All pts suspected of PROM should be
admitted.
•Investigations on admission
–CBC
–Urine: routine/ microscopy exam.
–Urine: Culture & sensitivity
–2 swabs – a high vaginal swab & a
cervical for culture & sensitivity
•Determine GA for deciding further
management.

19. Management
•General Principles
1.Confirm the diagnosis
2.Determine GA
3.Evaluate for intra amniotic infection
4.Evaluate for the presence of labor
5.Evaluate fetal condition

20. •Indications for immediate delivery
–Pt in labor
–Clinical chorioamnionitis
–Fetal distress
–Features suggesting cord compression
or cord prolapse
–Gross fetal congenital abnormalities
–Immunocompromised host
–Pregnancy complications indicating
delivery (heart disease, DM)

21. Management of Term PROM
PROM
Labor
IAI
FD
IUFD
YES DELIVERY
NO
Contraindication for VD
YESCS
NO
Cx status
Favorable
DELIVERY
Unfavorable
Prostaglandin
Priming
Possible
YES
PG
DELIVERY
NO
Observe for
6-30 hr
Spon.
Labor
YES
NO
FOLLOW
INDUC-
TION

22. PROM
Gramstain + Cervical culture
U/S
For GA, EFW, Presentation, BPP
Labor, FD,IAI, IUFD
YES NO
DELIVER
NO >34 wk
<34 wk
Hospitalization
Monitor for IAI
(Clinical, AF anlysis)
Hospitalization
Antibiotics
Monitor for IAI
+ Steroids
Management of
PPROM

23. ATB use in PROM
Advantages
•Increases latency period
•Decreases the incidence of maternal
& neonatal morbidity & mortality

24. ATB use in PROM
Indications
Prophylactic
•PPROM with expectant management (<34
weeks)
–Ampicillin 2 gm iv QID/ 48 hrs
–Erythromycin 500mg iv/ 48hrs
+
–Amoxacillin 500mg PO TID for 5-7 days if
delivery doesn’t occur
–Erythromycin 500 mg PO QID for 5-7 days if
delivery doesn’t occur
•At time of delivery with prolonged PROM
–Ampicillin 2 gm iv till delivery

25. ATB use in PROM
Therapeutic
•Clinical IAI
–Ampicillin 2gm iv QID for 7-10 days
–Gentamycin 80mg iv TID for 7-10 days
–Clindamycin 900mg iv TID for 7-10 days
•IF Clindamycin is not available
–Chloramphenicol 1000mg iv QID or
–Metronidazole 500mg iv TID
•Single agent treatment
–Ceftriaxone 1gm iv BID

26. THE END