Premature of membranes

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Premature rupture of membranes

• Dr.Makanda

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Definition

• Premature rupture of membranes (PROM) is a
  rupture of the membranes before labor begins.
• It is called preterm premature rupture of
  membranes (PPROM) if rupture of membranes occurs
  before 37 weeks of pregnancy,.

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PROM
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PPROM

• Occurs in 3 of pregnancies causing approximately
  1/3 of preterm deliveries.
• Which can lead to significant perinatal
  morbidity
• Respiratory distress syndrome,
• Neonatal sepsis,
• Umbilical cord prolapse,
• Placental abruption, and
• Fetal death

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PPROM

• To improve neonatal outcomes
• Do appropriate evaluation and management.
• Sterile speculum examination to determine
  cervical dilatation
• NO DIGITAL EXAMINATION
• Reason
• Decreases latent period
• Associated with potential adverse sequelae

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PROM

• Is the rupture of the fetal membranes before the
  onset of labor.
• It occurs in most cases, near term, but when
  membrane rupture occurs before 37 weeks
  gestation, it is known as preterm PROM.

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Risk factors for PROM and PPROM

• The causes of PROM/PPROM are sometimes unclear.
  But some of the risk factors include
• Prior PPROM Women with a history of PPROM
  leading to preterm delivery have a 13.5 rate of
  recurrence in subsequent pregnancies.
• Prior preterm labor and delivery
• Genital tract infection the most common risk
  factor for PPROM.
• Common infections include bacterial vaginosis,
  UTI, chorioamnionitis, and Group B streptococci.
• Antepartum bleeding Bleeding in the first
  trimester is associated with an increased risk of
  PPROM.

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Risk factors for PROM and PPROM..

• Cigarette smoking smokers have a two to
  fourfold increased risk of developing PPROM
  compared to nonsmokers.
• Polyhydramnios
• Placental abruption
• Poor nutrition
• Previous cervical surgery cone biopsies or
  cerclage, amniocentesis .
• Overstretching of the uterus and amniotic sac
  Eg.multifetal pregnancy or hydramnios

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Pathophysiology

• Rupture of membranes results from a variety of
  factors that ultimately lead to accelerated
  membrane weakening.
• This is caused by an increase in local cytokines,
  an imbalance in the interaction between matrix
  metalloproteinases and tissue inhibitors of
  matrix metalloproteinases,
• Increased collagenase and protease activity, and
  other factors that can cause increased
  intrauterine pressure.

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Classification

1. Prolonged Premature Rapture of Membrane (PROM)
   is when the duration is more 24 hours prior to
   the onset of labour (acog).
2. Pre term premature rupture of membrane (PPROM)
   Rupture of membranes before term i.e. 37
   completed weeks

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Diagnosis

• The diagnosis requires
• A thorough history,
• Physical examination, and,
• Selected laboratory studies.

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Presentation

• Usually a sudden gush of fluid with continued
  leakage
• Therefore ask about
• Contraction,
• Pv bleeding,
• Any intercourse recently, or has a fever.
• Ask to verify the patients estimated due date
  because this information will direct subsequent
  treatment.

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Evaluate by

• Performing a sterile speculum examination to
  assess
• Source of the fluid Pooling of the fluid in the
  posterior fornix
• Leaking from the cervical os when the patient
  coughs or ,when the fundal pressure is applied
• Any cervical dilation and effacement.

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Evaluate by

• Avoid a digital cervical examination shown to
  increase morbidity and mortality
• Causes an average 9-day? in the latent period
  which may lead to ? infectious morbidity and
  sequelae from preterm labor

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Diagnostic tests

• Nitrazine paper and ferning tests have
  sensitivities approaching 90
• The normal vaginal pH is acidic 4.5 - 6.0,
• Whereas amniotic fluid is more alkaline, with a
  pH of 7.1 to 7.3.
• Nitrazine paper ? blue when the pH is above 6.0
  
• DDX Contaminating substances e.g., blood,
  semen, alkaline antiseptics, Bacterial vaginosis,
  give a false-positive result.

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Diagnostic tests .

• Check for ferning (arborization) under a
  low-power microscope
• Perform a DNA probe or cervical culture for
  chlamydia and gonorrhea women with these
  infections are seven times more likely to have
  PROM.
• After removing the speculum, obtain a vaginal and
  perianal (or anal) swab for group B strept.
  culture.

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Diagnostic tests .

• Amniocentesis may help determine whether the
  membranes are ruptured.
• Instill 1 mL of indigo carmine dye mixed in 9 ml
  of sterile saline observe the tampon after 30
  minutes
• Avoid methyline blue
• Reason Hyperbilirubinaemia haemolytic anaemia
  in infants.

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Diagnostic tests .

• Obstetric USS in patients with conflicting hx and
  physical examination.
• Obstetric USS help determine the
• Position of the fetus,
• Placental location,
• Estimated fetal weight, and
• Presence of any anomalies.
• Amount of liquor (AFI)

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Complications of PROM

• Too early, surviving neonates may develop
  sequelae such as
• Malpresentation ,
• Cord compression,
• Oligohydramnios,
• Necrotizing enterocolitis,
• Neurologic impairment,
• Intraventricular hemorrhage, and
• Respiratory distress syndrome

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Complications of Preterm PROM

• Preterm delivery
• Chorioamnionitis
• Respiratory distress syndrome
• Cord compression
• Abruptio placentae
• Antepartum fetal death

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General management

• Give (IV) fluids Ringers Lactate OR Normal
  saline
• Prolonged PROM for more than 12 hrs is a risk of
  ascending infection which leads to
  chorioamnionitis (infection of chorion amnion and
  amniotic fluid)
• Treatment
• PROM at term delivery within 24 hour
• PPROM If no sign of infection, wait for foetal
  maturity and give prophylaxis
• Amoxyllin 500mg (O) 6 hourly x 10days OR
• Erythromycin 500mg (O) 6 hourly 10 days.

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Treatment..

• If there are signs of infections-pyrexia, foul
  smelling liquor (chorioamnionitis)
• Ampicillin 1g (IV) stat then 500mg 6 hourly for 5
  to 7 days OR
• Ceftriaxone 1g (IV) daily for 5 days OR
• BenzylPenicilline (IV) 2MU every 6hrs OR
• Chloramphenicol (I.V) 500mg every 6 hours Plus
• Metronidazole 500mg 8hrly for 5 days

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Treatment

• For urgent Delivery irrespective of gestational
  age
• Benzylpenicillin (I.V) 2MU every 6 hours Plus
• Chloramphenicol (I.V) 500 mg every 6 hours until
  the patient is able to take oral medication

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CORTICOSTEROIDS

• Decrease perinatal morbidity and mortality after
  preterm PROM
• Reduce the risk of
• Respiratory distress syndrome,
• Intraventricular hemorrhage, and
• Necrotizing enterocolitis

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CORTICOSTEROIDS .

• The most widely used and recommended regimens
  include
• Betamethasone 12 mg i/m od x 2/7 , or
• Dexamethasone 6 mg i/m 12 hourly x2/7
• Indicated before 30 to 32 weeks gestation
  assuming fetal viability with NO intra-amniotic
  infection.
• Use of steroids between 32 and 34 weeks is
  controversial.
• Use after 34 weeks gestation is not recommended
  unless there is evidence of fetal lung immaturity
  by amniocentesis.

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CORTICOSTEROIDS

• No Multiple courses
• Reasons
• ?infant birth weight,
• ?head circumference, and
• ?body length.

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TOCOLYTIC THERAPY

• May prolong the latent period for a short time
  but do not appear to improve neonatal outcomes

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Management Based on Gestational Age
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34 TO 36 WEEKS

• Avoid the urge to prolong pregnancy.
• Labor induction clearly is beneficial at or after
  34 weeks gestation
• Conservative management between 34 and 36 weeks
  GA results in an increased risk of
  chorioamnionitis and a lower average umbilical
  cord pH.
• Prescribe appropriate antibiotics for group B
  streptococcus prophylaxis and consider maternal
  transport to a facility skilled in caring for
  premature neonates
• Preterm PROM is not a contraindication to vaginal
  delivery.

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32 TO 33 WEEKS

• With documented pulmonary maturity,
• Induction of labor and
• Transportation to a facility that can perform
  amniocentesis and care for premature neonates
• Prolonging pregnancy after documentation of
  pulmonary maturity unnecessarily increases the
  likeli-hood of
• Maternal amnionitis,
• Umbilical cord compression,
• Prolonged hospitalization, and
• Neonatal infection.

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The end