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L2 Prom

The document discusses pre-labor rupture of membranes, including its definition, incidence, etiology, clinical features, differential diagnosis, investigations, management of rupture before 24 weeks of gestation, expectant management, risks to the fetus, features suggestive of chorioamnionitis, and management of chorioamnionitis.

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9 views

L2 Prom

The document discusses pre-labor rupture of membranes, including its definition, incidence, etiology, clinical features, differential diagnosis, investigations, management of rupture before 24 weeks of gestation, expectant management, risks to the fetus, features suggestive of chorioamnionitis, and management of chorioamnionitis.

Uploaded by

hacker ammer
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Pre-labor rupture of membrane

DR.Hanaa Al-heidery
Pre-labor rupture of membrane

u Definition: it is rupture of membrane before onset of


labor. It is more accurate to call it prelabour rupture of
membrane. Preterm PROM (PPROM) should be used to
define those patients who are preterm with ruptured
membranes, whether or not they have contractions.
u Incidence: 10% of term pregnancy and more in preterm
labour.
u Etiology: the following factors are incriminated:
u 1- Cervical incompetence
u 2- Polyhydramnios
u 3- Multiple pregnancy
u 4- Malpresentation
u 5- Chorioamnionitis
u 6- Low tensile strength of membrane.
u The evidence implicating infection as an etiologic agent
in membrane weakening and rupture is robust. Positive
amniotic fluid culture (peptostreptococcus, becteroid,
fusobacterium, lactobacilluse, ureaplasma urealyticum)
as similar to those normally found in the vagina, on
other hand colonization of lower genital tract by
Chlamydia, Neisseria Gonorrhea, group B
streptococcus, trichomonous and becteroid species has
been shown to increase risk of PROM.
Clinical features of preterm pre-labour
rupture of the membranes:

u History: The most reliable diagnostic feature of PPROM


from the history is the report of a ‘gush of fluid’
vaginally, usually followed by a more-or-less continuous
dribble. This must be distinguished from leaking urine
(ask about frequency, urgency, leakage and dysuria), as
incontinence or a urinary tract infection (UTI) may
present in a similar way. The presence of any vaginal
discharge should be ascertained.
Examination:
u Infection may lead to an increased pulse and temperature and a
flushed appearance. Abdominal examination may reveal a clinical
suspicion of oligohydramnios or uterine tenderness if
chorioamnionitis is present. The definitive diagnosis of PPROM
can only be made by performing a sterile speculum examination,
preferably after the patient has been resting supine for 20–30
minutes. A pool of amniotic fluid in the posterior vagina is
diagnostic.
u It is also important at this point to visualize the cervix. Fluid may
be seen trickling through the external os and dilatation can be
assessed. Digital vaginal examinations should be avoided if
possible in PPROM, as they are associated with a significant
reduction in the latent interval before labour. This reduction is
most dramatic at the earliest gestations.
Differential diagnosis:
u Urine loss: incontinence and UTIs are both more
common in pregnancy
u Vaginal infection
u Leukorrhoea: the cervical glands often become
overactive during pregnancy
Investigations:
u Nitrazine testing
u Amniotic fluid is alkaline, whereas the vaginal secretions are
usually acidic. An elevated pH turns a nitrazine stick blue.
Some units use nitrazine sticks to define the presence of
amniotic fluid. Unfortunately, false positives occur, with
blood, semen and even urine limiting its usefulness.
However, the predictive value of a negative test is very high.
Amniotic fluid is slightly alkalined (PH 7.1-7.3), vaginal
secretion (PH 4.5-6).
Fern test
u Visualization of fern-like pattern of dried amniotic fluid
on a glass slide under microscopy due to presence of
protein.
u Laboratory analysis: for creatinine, urea and uric acid in
the fluid sample. These component are present in urine.
u Genital tract swabs
A high vaginal swab may help to guide antibiotic therapy, if
subsequently required. Screening for group B streptococcus
(GBS) can also be performed, as there is a substantial risk of
labour in the next few days.
u Ultrasound
Ultrasound can give valuable information about the amniotic
fluid volume. The presence or absence of oligohydramnios
provides further diagnostic support. In established PPROM,
there is a direct correlation between the amount of amniotic
fluid remaining and the latency period.
u Amniocentesis
u A sample of amniotic fluid can be sent for Gram stain, microscopy and culture,
to establish whether there is an intrauterine infection (chorioamnionitis). There
is, however, a risk of stimulating preterm labour by performing an invasive
test, and amniocentesis can be technically very difficult when there is little
amniotic fluid.
u Maternal well-being
u This should include regular assessment of the mother’s blood pressure, pulse
and temperature. Some advice serial white cell counts and C-reactive proteins
as early markers of infection, although this has not been shown to improve
management.
u Fetal well-being:
u Serial antepartum cardiotocography is important after PPROM, as a gradually
increasing baseline heart rate or fetal tachycardia can be the first sign of
intrauterine infection.
Clinical features of late miscarriage:

u Commonly, there will be uterine cramping and bleeding.


The membranes may be intact or ruptured. However,
events may progress rapidly without significant pain, the
mother complaining of relatively minor backache or
abdominal discomfort. Some women report only a
sudden increase in mucous vaginal discharge.
u
Examination:
u Prior to 24 weeks, fetal parts cannot be reliably felt. A hand-
held Doppler device (often referred to as a Sonicaid) should
be used to auscultate the fetal heart. There is no role for
CTG assessment. Initially, a speculum examination should
be performed. A good light and proper positioning are
important. The cervix should be visualized. It may have
started to dilate and the membranes may be seen bulging
through the external os.
u
Management of rupture membrane before
24 week:
u There are both maternal and infant risk to consider when
deciding to expectant management of rupture membrane
before 24 week. Maternal risk include consequences of
uterine infection and sepsis. Fetal risk include pulmonary
hypoplasia and limb compression deformities which has
been associated with prolong period of oligohyramnios due
to rupture membrane.
u If the gestational age is less than 34 weeks, but 24 weeks or more,
and there are no other maternal or fetal indications for delivery,
the women is observed closely in the labor and delivery unit.
Continuous fetal heart rate monitoring is employed to look for
evidence cord compression, especially if labor supervenes.

u If the fetal heart rate is reassuring, and if labor does not follow,
the women is transferred to the high risk antepartum pregnancy
unit for close observation for signs of labor, chorioamnionitis, or
fetal distress.
u If PROM occurs at 36 weeks or later and the condition of the
cervix is favorable, labor should be induced after 6 to 12 hours if
no spontaneous contractions occur. In the presence of an
unfavorable cervical condition with no evidence of infection, it is
reasonable to wait 24 hours before induction of labor to decrease
the risk of failed induction and maternal febrile morbidity.
u
Expectant management:
u If no evidence of chorioamnionitis:
u Admit to hospital (maternal and fetal monitoring).
u Inform special care baby unit (SCBU) and neonatologist.
u Maternal steroids: a single course of maternal steroids (two injections
12–24 hours apart) given between 28 and 34 weeks gestation and
received within 7 days of delivery results in markedly improved
neonatal outcomes due to a reduction in neonatal respiratory distress
syndrome (RDS). Maximum benefit is seen after 48 hours. Courses
received less than 48 hours or more than 7 days before delivery still
lead to benefit. They are not indicated below 24 weeks.
Antibiotics
u Antibiotics: use of AB reduce neonatal morbidity
u -Erythromycin if no evidence of chorioamnionitis. Coamoxiclave
associated with necrotizing enterocolitis (NEC) and should be
avoided.
u -When labor is subsequently diagnosed ampicillin 2gm given i.v
every 6 hr prior to delivery for prevention of group B
streptococcal infection in the neonate (unless screening for group
B streptococcus (GBS) is negative) or rupture memberan 18 hrs
or more.
u -Braod spectrum antibiotic cover if evidence of chorioamnionitis.
Risk to fetus from PROM:

u Prematurity
u Pulmonary hypoplasia
u Limb contracture
u significant neonatal morbidity (high incidence of sepsis, RDS, early
onset of seizure, IVH, periventricular leukomalacia) and mortality
u also associated with significant risk to the mother.
Feature suggestive of chorioamnionitis:
u Fever 38C° (100.4F°)+ 2 of the following:
u maternal tachycardia
u fetal tachycardia
u uterine tenderness
u purulent offensive vaginal discharge
u increased WBC
u CRP positive
u Avoid vaginal examination as this increase the risk of introducing infection.
u Diagnosis of chorioamnionis: fever (38C°) + 2 of the above features after
exclusion of respiratory infection and UTI.
Management of chorioamnionis:

u Steroid
u Delivered whatever the gestation as rapid as
possible
u Broad spectrum antibiotic cover.

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