Prom

1. Prelabour rupture of membranes
Aboubakr Elnashar
Benha university hospital, Egypt
Aboubakr Elnashar

2. DEFINITION
PROM:
Rupture of the membranes with leakage of amniotic
fluid in the absence of uterine activity.
Pre-term PROM (PPROM):
Before 37W
Term PROM (TPROM)
After 37W.
Aboubakr Elnashar

3. Gest age % Latent period
26 W 50 1 w
32W 50 36 h
37 W 75 24H
Aboubakr Elnashar

4. Incidence
PLROM:
>37W: 8% of term pregnancies
<37: 3% of all deliveries
Aboubakr Elnashar

5. AETIOLOGY
Mechanical
Infective
Constitutional

Aboubakr Elnashar

6. Term PROM
Usually reflects physiological processes.
1.Apoptosis (programmed cell death) refers to the
natural deterioration and breakdown of cells and
cellular structure over time.

2. Uterine activity: As term approaches, increase
Braxton-Hicks contractions: repetitive stretching of the
membranes: weakening via
a.focal thinning
b.strain hardening (biomechanical phenomenon
associated with materials becoming less elastic and
less able to withstand stress).
Aboubakr Elnashar

7. In the absence of any intervention...
70% of patients will labour within 24 h
85% will labour within 48 h
95% will labour within 96 h
Aboubakr Elnashar

8. PPROM
usually has pathological origins.
1.History of PPROM in a previous pregnancy
2.Ascending infection
Major cause
Chorioamnionitis: membrane weakening
Majority: subclinical
2. Antepartum haemorrhage
particularly when recurrent

Aboubakr Elnashar

9. 3. Weak cervix
:It will fail as a barrier to ascending infection
:membrane prolapse: localized biomechanical
weakening
4. Smoking:
dose dependent.
reduction in smoking: reduce risk


Aboubakr Elnashar

10. CLINICAL ASSESSMENT
The correct diagnosis is crucial
{unnecessary interventions: increase maternal and
fetal morbidity}.
I. History
Gush of fluid' followed by recurrent dampness:
correctly identify over 90%of cases


Aboubakr Elnashar

11. II. Examination
Sterile speculum examination
Performed after rest supine for 30 m.
1. AF pooling in the posterior fornix
spontaneously or after fundal pressure.
Absence of any pooling is an equally important.

2. Meconium should be noted.
At preterm: suggestive but not diagnostic of intra-
amniotic infection
At term: relative contraindication to expectant tt
3. Cervical length and dilatation.
Aboubakr Elnashar

12. Digital examination
must be avoided unless the patient is thought to be
in established labour
{1. increase the incidence of chorioamnionitis,
postpartum endometritis, neonatal infection.
2. decreases the length of the latent period before
the onset of labour}.

Aboubakr Elnashar

13. PROM
Vaginal Examination
24-2626-2828-3030-3232-3434-35
Gestational Age (Weeks)
20
15
10
5
L
a
t
e
n
c
y

D
a
y
s
No Exam
Exam
Lewis, Obstetrics & Gynecology, 1992
Aboubakr Elnashar

14. III. Investigations
1.Bed side tests
Repeated dry pads argue against the diagnosis

Pads which change colour when in contact with
fluids with a pH >5.2
Aboubakr Elnashar

15. Nitrazine sticks
(relying on the higher alkaline pH of AF)
Aboubakr Elnashar

16. Ferning pattern
(when AF is dried onto a glass slide and then
viewed under a microscope).
Both:
Not reliable than basic history and examination.
{Appreciable false-positive and false-negative
rates}.
Aboubakr Elnashar

17.  Commercially available rapid bedside tests
Expensive
Indication:
confirm or refute the diagnosis of PROM in women
with negative speculum examinations.
Depend on:
Substances present in high concentrations in AF
Fetal fibronectin
Insulin-like growth factor binding protein 1
(IGFBPl),
ßhCG
alpha microglobulin-l (Amnisure)

Aboubakr Elnashar

18. Fetal Fibronectin
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%, Specificity-26.8%.
Aboubakr Elnashar

19. AmniSure
Cost-up to $50 each
Sensitivity: 98.8%, Specificity: 95%
Aboubakr Elnashar

20. 2. Ultrasound: AFV
As a primary diagnostic tool
useful in women with a strong history of PROM but a
negative speculum examination, particularly if their
symptoms persist for 48 h or more.
In TPROM:
Limited value: {normal variation ranging from 250 to
1200 mL}
In PPROM: Very limited value {variation is much
greater in preterm gestations}
 Correlate with latency in PPROM and with neonatal
mortality and morbidity in mid-trimester PROM.
Aboubakr Elnashar

21. Aboubakr Elnashar

22. MANAGEMENT
Term PROM
Risks
Foetal: ascending infection.
Maternal: uterine infection, via either chorioamnionitis
or postpartum endometritis.
Risks of induction of labour:
intrapartum complications
operative delivery
postnatal morbidity.
Aboubakr Elnashar

23. Factors linked with perinatal infection
1.increasing number of vaginal examinations after
membrane rupture
2.increasing interval between membrane rupture
and labour onset
3.increasing duration of active labour.
Aboubakr Elnashar

24. Cochrane Review
12 trials of 6814 women: active Vs expectant tt:
No significant difference in the rate of CS
Reduced risk of chorioamnionitis
Reduced risk of endometritis
No significant difference in the risk of neonatal
infection but...
Fewer infants requiring intensive/special care
Aboubakr Elnashar

25. Immediate induction:
-less maternal and neonatal infection
-shorter interval from membrane rupture to delivery
-No evidence that mode of delivery is influenced.
Aboubakr Elnashar

26.  When oxytocin is used initially:
Lower health care costs
Decrease interval to delivery.
use of epidural analgesia is increased [A].
 When prostaglandins are used initially:
infection risks marginally greater
interval to delivery slightly increased
oxytocin required subsequently in nearly half of the
women [A].
 Oxytocin should be regarded as the first option
for induction of labour in women with prelabour
rupture of membranes (WHO, 2011).
Aboubakr Elnashar

27. Use of misoprostol.
Cost : lower
Oral:
lower the risk of infection.
Induction of labour (live fetus >24 w)
Vaginal: 25 ug 4-6 hrly OR
Orally: 50 ug 4-hrly OR
20 μg oral solution 2-hrly
Do not use if previous CS.
(Weeks & Faundes 2007; WHO, 2011)
Aboubakr Elnashar

28. Immediate induction of labour using oxytocin
should be recommended for women known to be
colonized with group B Streptococcus [B].
{Expectant management: 3-4-fold increase in risk of
neonatal infection, and even immediate induction
with prostaglandins failed to lower this}.
Aboubakr Elnashar

29. Preterm PROM
Risks
1.chorioamnionitis
WBC and CRP:
poor predictive ability
used to support a clinical diagnosis.
Oligohydramnios:
select a group at higher risk of infection and/or
earlier delivery
not diagnostic.
Aboubakr Elnashar

30. Chorioamnionitis
Diagnosis.
maternal pyrexia (>38°C)
and at least 2 of either:
maternal tachycardia> 100 bpm
fetal tachycardia> 160 bpm
uterine tenderness ·
raised CRP
offensive vaginal discharge.
When clinically suspected:
delivery is almost always appropriate {antibiotic
therapy is rarely curative}.
Aboubakr Elnashar

31. Most common organisms:
anaerobes followed by
group B Streptococcus and then
other streptococci.
Aboubakr Elnashar

32. 2. PTL:
In contrast to preterm labour with intact membranes,
TVS measurements of cervical length are not
predictive of early delivery.
3. Abruption:
risk varies inversely with gestational age
5%
50%: <24 W
4. Cord prolapse
5. Operative delivery.



Aboubakr Elnashar

33. Management
1. Steroids
Although neonates born after PPROM have lower
incidences of RDS when compared to preterm
labour, maternal steroids still appear to reduce the
risk further [A].

No significant increase in maternal sepsis



Aboubakr Elnashar

34. 2. Tocolytics
relatively contraindicated
known to be less effective.
PPROM in the presence of cervical cerclage: suture
removal.



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35. 3. Antibiotics
Erthryomycin is recommended
(250 mg qds for 10 d):
significant reduction (from 14.4 to 11.2%) in the
composite primary outcome, a measure of neonatal
mortality and major morbidity [B).
Aboubakr Elnashar

36. Group B Streptococcus carriers organism:
usually sensitive to erythromycin.
After completion of a 10-day course, further
antibiotics should probably be withheld until labour
starts.
Aboubakr Elnashar

37. 4. Umbilical artery Doppler, biophysical Profile:
Value:
1.Not effective at early identification of the infected
fetus.
2. Monitoring of fetal growth
{PPROM is associated with growth restriction}
Aboubakr Elnashar

38. Pre-viable PROM below 23-24 ws
Risks:
1.Pulmonary hypoplasia
Lethal
{Lung development is partly reliant on normal AFV}.
cannot be reliably predicted by US.
2. chronic pulmonary morbidity
3. fetal limb contractures
4. extremely preterm birth with consequent co-
existent morbidity and mortality
Many parents will opt for termination of pregnancy.
Aboubakr Elnashar

39. PPROM at 34-37 w gestation
induction, as opposed to expectant management,
may lead to
less hospitalization
less perinatal infection and
less neonatal morbidity [B).

Aboubakr Elnashar

40. In-patient versus outpatient care
48-72 h:
In-patient
{many women will labour or develop clinical
chorioamnionitis}
After this:
Outpatient may be decided
Inform:
potential risks
temperature twice daily
S&S of developing chorioamnionitis.
Aboubakr Elnashar

41. Conclusions
Term PROM is usually a reflection of normal
physiology, whereas pathological processes, such as
infection and antepartum haemorrhage, often
underlie PPROM.
Aboubakr Elnashar

42. Accurate diagnosis of membrane rupture is
essential and can usually be achieved by simple
history and speculum examination alone.
A digital vaginal examination should always be
avoided after PPROM unless advanced labour is
suspected.
Aboubakr Elnashar

43. At term, early induction using oxytocin appears to
reduce perinatal infection and shorten hospital stay
without increasing operative intervention.
At term, women known to be colonized with group
B Streptococcus should be encouraged to allow
immediate induction of labour using oxytocin after
PROM.
Aboubakr Elnashar

44. After PPROM, optimal management includes
maternal steroids and oral erythromycin.
Maternal steroid use in PPROM reduces the risk of
respiratory distress syndrome.
Erythromycin used for 10 days after PPROM is
associated with a significant reduction (from 14.4 to
11.2%) in neonatal mortality and major morbidity.
Aboubakr Elnashar

45. Thank you
Aboubakr Elnashar