Premature rupture of membranes

PROM

1. PREMATURE RUPTURE OF MEMBRANES PRESENTER-DR.DIVYA JAIN MODERATOR-DR.M.SHARMA

2. DEFINITIONS Premature rupture of membranes (PROM) R upture of membranes anytime after 37weeks but before the onset of spontaneous uterine activity. Preterm premature rupture of membranes (PPROM)- R upture of fetal membranes prior to labor in pregnancies betweem 28 - 37 weeks.

3. INCIDENCE PROM-10% PPROM-3%

4. RISK FACTORS PRE-CONCEPTIONAL CAUSES- Repeated genitourinary infections Cervical incompetence Chronic cervicitis Obesity Smoking Low socioeconomic status Nutritional deficiencies

5. PREGNANCY RELATED CAUSES- Polyhydroamnios Multiple gestation Cervical cerclage Foetal abnormalities Abruption Previous history of PPROM(21 to 30%)

6. Genital tract infections- Bacterial vaginosis Group B streptococcus Candida Mycoplasma Ureaplasma hominis E.coli Staphylococcus

7. WHAT CAUSES RUPTURE OF MEMBRANES?? Rupture of the membranes near the end of pregnancy (term) may be caused by a natural weakening of the membranes or from the force of contractions.

8. DIAGNOSIS History Valsava maneuver Sterile Speculum exam (Pooling) Nitrazine testing/litmus paper test Fetal Fibronectin Ultrasonography Microscopic Fern testing Amnisure High vaginal swab Urine routine,culture

9. Nitrazine paper testing Turns blue in presence of alkaline Amniotic fluid 93.3% sensitivity False positive (1-17%) for urine, blood, semen BV

10. Fern test Fern test refers to visualization of a characteristic 'fern-like' pattern on a slide viewed under low power on a microscope A small amount of cervical mucus is allowed to air-dry on a clean, saline-free glass slide If positive for amniotic fluid, this crystal formation will be present in most microscopic fields.

11. Foetal fibronectin assay fFN present in cervical secretions <22 wks , >34 wks Used for assessment of potential PTB Positive result (>50 ng /dl) may be indicative of PROM and represents disruption of decidua-chorionic interface In PPROM, Sensitivity-98.2%

12. Ultrasonography 50-70% of women with PROM have low amniotic fluid on USG Mild reduction requires further investigation Rule out other causes (Renal agenesis, obstructive uropathy )

13. Amnisure Detects PAMG-1(placental microglobulin ) 99% sensitivity,100%specificity PAMG-1 is a protein produced by cells of decidual part of placenta and can be detected in amniotic fluid after rupture of membranes. Recently approved by FDA in US

14. MANAGMENT MANAGEMENT DEPENDS ON THE FOLLOWING FACTORS Gestational age Availability of NICU Fetal presentation FHR pattern Active distress (maternal/fetal) Cervical assessment

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16. Maternal-Fetal Distress evaluated by Maternal vitals, labs, general condition, Fetal distress assessed by FHR pattern, USG, NST. First priority is to rule out maternal-fetal distress and imminent delivery. Ensure through prenatal records that early US correlate with LMP is most accurate. Rule out infection through absence of clinical signs and symptoms of chorionamniotis in addition to assessment of lab values and amniotic fluid samples Evaluate maternal serum lab values for leukocytosis, left shift, and elevated C-Reactive Protein. Evaluate Amniotic fluid samples for gram stain,WBC count.

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18. SECONDARY ASSESSMENT Fetal position Cervical assessment Determine lung maturity Quantify amniotic fluid

19. INDICATIONS FOR DELIVERY Maternal-Fetal Distress Infection Abruption Cord Prolapse

20. EXPECTANT MANAGMENT Typical for GA 32 weeks or less Bed rest Steroids for lung maturity T ocolytic if indicated for lung maturity Antibiotics Fetal Surveillance Assess for Chorioamnionitis

21. Infection can be both a cause and a consequence of Preterm Rupture of Membranes. Most patients require close inpatient observation.Those who might qualify for outpatient management include the extreme previable gestation patients and those who have appeared to have resealed (which is approximately about 5% of PROM patients ).

22. PPROM BETWEEN 32 TO 34 WEEKS Expectant management Deliver at 34 wks (Unless documented fetal lung maturity) GBS prophylaxis Antibiotics Corticosteroids

23. MANAGEMENT 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, IVH, and necrotizing enterocolitis Tocolytics Delay delivery to allow administration of corticosteroids

24. Antibiotics Ampicillin 2 g IV 6 hrly for 2 days Amoxicillin 500 mg po TDS x 5 days Azithromycin 1 g po x 1 Erythromycin 250mg TDS for 5 days Corticosteroids Betamethasone 12 mg IM OD for 2 days Dexamethasone 6 mg IM BD for 2 days Tocolytics Nifedipine 10 mg po after every 20min 3 times, then 6 hrly for 2 days

25. RISK-BENEFIT EXPECTANT MANAGMENT RISKS Abruption Chorioamnionitis Cord Prolapse Endometritis (1/3 ) Oligohydroamnios tetrad (FLIP) BENEFITS Mature lung profile Advancing GA (reducing risks associated with PTB)