Premature rupture of membrane (PROM).pptx

musculosceletal system

1. Premature rupture of membrane (PROM) 1

2. Learning objective By the end of this lecture you are expected to: Define PROM. Identify risk factor of PROM. Recognize the sign and symptom of PROM. List investigation for PROM case. Explain the complication of PROM. 2

3. Reflective activity1 (12 min) P lease form four group near by and share your experience on the following issue. Define PROM Explain types of prom Mention risk factors Discuses diagnostic modality 7 min discussion and 5 min reflection 3

4. Definitions Spontaneous rupture of fetal membrane and leakage of amniotic fluid at least one hour or more before the onset of labor/ in the absence of contractions and after 28wks of gestation. 4

5. cont.…. Type of PROM. Term : rupture of membranes after 37 weeks of gestation but is prior to labor. Preterm: ROM Before 37 wks of GA and after 28wks of GA and before on set of labor. Prolonged PROM : before greater than 12/18/24 hrs of on set of labor. Latency Period: The interval between the ROM and the spontaneous on set of labor. 5

6. Incidence 5 to 10% of all deliveries . PROM causes about one third of all preterm births . 6

7. The specific cause is unknown. Maybe associated with: Malpresentation Weak areas in the amnion and chorion Vaginal infection(bacterial vagnosis , T.vagnalis) Incompetent cervix Previous history of PROM Etiologic and predisposing factors 7

8. Cont… Hydramnios( cause distention) Substance abuse during pregnancy Nutritional deficiency Low socio-economical status Multiple pregnancy Placenta abruptio 8

9. Clinical manifestation & Dx Hx : The classic clinical presentation of PPROM is a sudden "gush" of clear or pale yellow fluid from the vagina . Many women describe intermittent or constant leaking of small amounts of fluid or just a sensation of wetness within the vagina or on the perineum. 9

10. cont.… Physical examination: the presence of flecks of vernix or meconium. reduced size of the uterus. increased prominence of the fetus to palpation. 10

11. Cont.… The best method of confirming the diagnosis of PPROM is direct observation of amniotic fluid coming out of the cervical canal or pooling in the vaginal fornix. If amniotic fluid is not immediately visible, the woman can be asked to push on her fundus, Valsalva, or cough to provoke leakage of amniotic fluid from the cervical os . 11

12. Diagnosis … Speculum examination: Pooling:- the collection of AF at posterior Vx fornex . Nitrazine test   :- if positive the PH paper changes yellow green in to blue b/c amniotic fluid has a pH range of 7.0 to 7.3 compared to the normally acidic vaginal pH of 3.5 to 4.5. False + ve result may be occur due to tap water, blood, semen, alkalin anti septic and bacterial infection . 12

13. Cont.… 13

14. Cont .… Ferning test Fluid from the posterior vaginal fornix is swabbed onto a glass slide and allowed to dry for at least 10 minutes. + ve result will reveals fern like on slide while viewed under microscope. Well- estrogenized cervical mucus on the microscope slide may cause a false-positive fern test . 14

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17. Instillation of Indigo carmine Instillation of indigo carmine into the AF leads to a definitive diagnosis. Under ultrasound guidance, 1 mL of indigo carmine in 9 mL of sterile saline is injected trans abdominally into the amniotic fluid and a tampon is placed in the vagina . One-half hour later, t he tampon is removed and examined for blue staining, which indicates leakage of amniotic fluid. 17

18. Placental alpha microglobulin-1 protein assay (AmniSure ) Is a rapid slide test that detect trace amounts of placental alpha microglobulin-1 protein in vaginal fluid. An advantage of this test is not affected by semen or trace amounts of blood. 18

19. Cont… Procedure: A sterile swab is inserted into the vagina for one minute, then placed into a vial containing a solvent for one minute, and then an AmniSure test strip is dipped into the vial. The test result is revealed by the presence of one or two lines within the next 5 to 10 minutes ( one visible line means a negative result for amniotic fluid, two visible lines is a positive result, no visible lines is an invalid result ). 19

20. complication PROM is an important cause of: Preterm labor Cord prolapse Placental abruption Intrauterine infection 20

21. Cont.… Maternal Endomyometritis Sepsis PPH APH Cesarean delivery Fetal Chorioamnionitis Neonatal sepsis Pulmonary hypoplasia Cord prolapse Limb deformity 21

22. Reflective activity2 (12 min) 7 min discussion and 5 min reflection Discuses on management of Prom share your experience in a group 22

23. Management Termination Of pregnancy regardless of GA If chorioamnionitis develop any time . At 34wks At 32-34wks if lung maturity confirmed Cord prolapse Fetal/maternal destress Mode of delivery Based on obstetric indications. 23

24. Cont.… Chorioamnionitis is diagnosed if >or 2 criteria : Fever > 38 degree Celsius Abdominal tenderness Offensive Vx discharge Fetal tachycardia, >160 bpm maternal tachycardia, >100 bpm Leukocytosis 24

25. Mx of TERM PROM (GA > 37wk ) Most women with term PROM who are followed expectantly will go into spontaneous labor and deliver within 24, 48, and 72 hours of PROM in 70%, 85%, and 95 % of women, respectively . If the labor not start after 48hr , induce. If there is contraindications to vaginal delivery, cesarean delivery will be performed. 25

26. Mx of PPROM Depend on: Gestational age Availability of neonatal intensive care Presence or absence of maternal/fetal infection Presence or absence of labor Fetal presentation (Breech and transverse lies are unstable and may increase the risk for cord prolapse) Fetal heart rate (FHR) tracing pattern Likelihood of fetal lung maturity 26

27. Cont.… The main concern weight the risk of infection in expectant management (if Px continued) versus the risk of perinatal death due to prematurity if Px terminated. 27

28. Cont.… If GA > 34 wk : the risk of infection more than the risk of prematurity . Since the lung seems to be matured, observe for spontaneous on set of labor for 48h r. If not, induce it! but if there is any contraindication for Vx delivery, consider CS. 28

29. Cont.… If GA is b/n 32 – 33 wk : The risk of infection is less than the risk of prematurity . Hospitalization : bed rest b/c the may be spontaneously reseal and Px continue. Amniocentesis: if the lung mature deliver. if not mature, Expectant management 29

30. Management: Amniocentesis Typically performed after 32 wks Tests for fetal lung maturity (FLM) L/S ratio > 2 indicates pulmonary maturity Phosphatidylglycerol > 0.5 associated with minimal respiratory distress If imature , proceed with expectant management until 34 wks 30

31. Expectant Management Typical for GA 32 weeks or less Bed rest , Inpatient Observation Steroids for lung maturity Tocolytic if indicated for lung maturity Antibiotics Fetal Surveillance Assess for Chorioamnionitis 31

32. Antenatal steroids Dexamethasone 6mg bid ;04 doses Bethametasone 12mg daily;02doses 32

33. Tocolytic agent In the absence of delivery indication, may consider tocolysis x 48 hours to assist with benefit of sterods. Tocolysis can be achieved with magnesium sulfate, terbutaline, and nifedipine. Nifedipine 10 mg po after every 20min 3 times, then 6 hrly for 2 Mgso4 :-Loading dose: 4-6 g IV over 20 minutes; maintenance: 2-4 g/hr IV for 12-24 hours as tolerated after contractions cease. 33

34. Antibiotics Goal: Decrease maternal infection >> fetal infection Prolong latency(onset of labor) Ampicillin IV for 48hrs,then Amoxicillin po 7d. Erythromycin IV for 48hrs,Eryth IV 7d. 34

35. Rationale Antibiotics Prolong latency period Prophylaxis of GBS in neonate Prevention of maternal chorioamnionitis and neonatal sepsis Corticosteroids Enhance fetal lung maturity Decrease risk of RDS, Tocolytics Delay delivery to allow administration of corticosteroids 35

36. Resealing   Up to 14 percent of gravidas with spontaneous midtrimester PPROM eventually stop leaking amniotic fluid, presumably due to " resealing " of the fetal membrane. Cessation of leakage is probably not due to actual repair and regeneration of the membranes , but rather to changes in the decidua and myometrium that block further leakage . 36

37. Thank you 37