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B Y : G R O U P 1
PROM
OUT LINES
• Introduction
• Definition
• Incidence
• Risk factor
• pathophysiology
• Sign and symptom
• Types
• Diagnosis
• Differential diagnosis
• Management
• Complication
• Prevention
OBJECTIVE
At the end of this lesson the learners
will be able to:
• know the definition of PROM
• identify the signs and symptoms of PROM
• understand the diagnosis and differential diagnosis of PROM
• Famiiarize the signs and symptoms of PROM
• Practice the management and preventive modalities of
PROM.
INTRODUCTION
• Pre-labor rupture of membrane (PROM) , previously
known as pre-mature rupture of membranes ,is a
breakage of the amniotic sac before the onset of
labor.
• Women usually experience a painless gush or a
steady leakage of fluid from the vagina.
• If it occurs before the 37 weaks it is known as
PPROM (pre-term pre-labor rupture of membrane).
DEFINITION
 Pre-labor rupture of membrane is a rupture of
membranes (ROM) after 28 weaks of gestation and
one hour before the onset of labor.
 PROM is the spontaneous rupture(breakage) of
amniotic sac before the onset of labor.
INCIDENCE
• About 8% of term pregnancies are complicated by
PROM.
• 30% of pre-term births are complicated by PROM.
• Before 24 weaks PROM occurs in fewer than 1% of
pregnancies.
RISK FACTOR
Among the risk factors of PROM:
infections
low socioeconomic status that leads to nutritional deficiency
previous history of PROM or preterm labor
polyhydraminos
Multiple gestation
invacive procedures e.g amniocentesis
cervical insufficiency
PATHOPHYSIOLOGY
•
SIGN AND SYMPTOM
Fluid leakage
 increased vaginal discharge
change in fetal movement
pelvic pressure
 contractions
 signs of infection
abdominal pain or cramping
Lanugo hair
TYPES
Term PROM
When the fetal membranes rupture early,at least one hour
before labor has started.
 Prolonged PROM
a case of pre-labor rupture of membrane in which more
than 18 hours has passed between the rupture and the
onset of labor.
TYPES CONT..
Preterm PROM
Prelabor rupture of membranes that occurs before 37
weaks gestation.
 Midtrimester PROM
prelabor rupture of membranes that occurs before 24
weaks gestation
DIAGNOSIS
 History
A sudden gush or intermittent or continuous leaking
of clear fluid from the vagina before the onset of
labor.
 Physical examination
 Abdominal examination: common findings include
fundal eight may be less than the GA.
 Pelvic examination: inspection of the externa
genitalia : leakage of liquor per vagina.
Note: avoid digital pelvic examination in all
cases of
preterm PROM
DIAGNOSIS CONT...
Speculm examination:
• Observation of amniotic fluid coming out of the
cervical cannal and/or presence of prolapsed
cord.
• Presence of meconium , vernix casosa or lanugo
hair in the fluid pooling indicates PROM and
presence of uriniferous smell suggests urinary
incontinency.
• Inspect for cervical dilation (open or closed).
DIAGNOSIS CONT...
Ferning test
 Obtain fluid by swabbing the posterior fornix (avoid cervical mucus
to decrease chance of false positive result).
 Spread some fluid on a slide & let it dry for at least 10 minutes.
 Examine it with a microscope and look for a fern-leaf pattern
 The test is not affected by meconium, vaginal PH & blood.
DIAGNOSIS CONT...
Nitrazine paper test
 Hold a piece of Nitrazine paper in a hemostat (artery forceps) &
touch it against the fluid pooled on the speculum blade.
 A change from yellow to blue indicates presence of amniotic fluid
 False negative tests results can occur when leaking is intermittent or
the amniotic fluid is diluted by other vaginal fluids.
 False positive results can be due to the presence of alkaline fluids in
the vagina, such as blood, seminal fluid, or soap.
DIAGNOSIS CONT...
Pad test
 Can be helpful when there is no pooling & no visible leakage from cervix.
 Place a vaginal pad over the vulva and encourage moving around.
 Examine the pad an hour later visually and by smelling (odour).
 Wetting with no urine and no vaginal discharge (vaginitis) may suggest PROM
 Dye test – it is gold standard method that provides highly accurate and
definitive results
 indigo carmine, is injected into the amniotic sac through a procedure called amniocentesis. If the
membranes have ruptured, the dye will leak into the vaginal canal and can be detected externally
DIFFERENTIAL DIAGNOSIS
 Leucorrhea gravidarum
 Vaginal discharge (excessive)
 Urinary incontinency
 Perspiration
 Ruptured cyst ( like in the vagina)
MANAGEMENT
 Management of PROM depends on:
Gestational age, duration of rupture of fetal
membranes, fetal condition (dead, fetal distress,
congenital malformations), presence of infection,
labor and previous
cesarean scar, and other obstetric indications.
MANAGEMENT CONT...
Indications for expedite delivery:
 onset of labor,
 gestation age ≥ 37wks,
 evidence for nonreassuring fetal status,
 evidence for chorioamnionitis,
 lethal congenital anomalies,
 intrauterine fetal death,
 if there is high risk of cord prolapse (e.g., transverse lie) and
 abruptio placenta
o Note that if the gestational is below 34 weeks and both the fetal and
maternal conditions are stable, expectant management can be
considered
for abruption placenta in a setting where close follow up is possible
MANAGEMENT CONT....
Expectant management
 Admit to the ward (Transfer patients with early preterm
PROM to a higher healthfacility with newborn intensive
care, if possible).
 Avoid digital cervical (pelvic) examination.
 Advise bed-rest, to potentially enhance amniotic fluid
re-accumulation & possibly delay onset of labor.
 Provide corticosteroids and antibiotics.
 Administer antenatal corticosteroids (betamethason12
mg intramuscularly 24 hours apart for two doses or
dexamethasone 6 mg IM 12 hours apart for four doses)
for lung maturity.
EXPECTANT MANA..CONT..
Note that if preterm birth is considered imminent,
treatment for short duration still improves fetal lung maturity
and chances of neonatal survival.
 Antenatal corticosteroid therapy should not be
administered in women with chorioamnionitis.
Antibiotics
Ampicillin 2gm IV QID and Erythromycin 250 mg P.O QID
for 48 hours followed by Amoxicillin 500 mg P.O TID &
Erythromycin 250 mg. P.O QID for 5 days.
 Azithromycin may be substituted for Erythromycin with
regimen of 500mg PO on day 1 followed by 250mg PO
daily for 6 days.
CONT…
Neuroprotection
 If gestational age is less than 32 weeks and preterm birth is
likely within the next 24 hours, consider magnesium sulfate
for neuroprotection
Monitoring and follow up
 Monitor the following clinical features during expectant
management of PROM:
 Maternal pulse & temperature - every 4-6 hours
 FHR - every 4-6hrs (& if possible CTG 2x daily)
 Uterine tenderness or irritability (or pain) – daily
 WBC count & differential - changes, every 2-3 days
 Amniotic fluid appearance & odor – daily
CONT…
Labor and delivery for term PROM without infection:
 If cervix is favorable, labor is induced, unless there
are contraindications to labor or vaginal delivery, in
which case cesarean delivery is performed.
 If cervix is unfavorable, ripen the cervix (preferably
with PO misoprostol).
 Institute antibiotic (Ampicillin 2gm IV QID) when the
duration of ROM >12hrs.
 Follow for features of chorioamnionitis (maternal
fever, tachycardia, leukocytosis,uterine tenderness,
offensive vaginal discharge and fetal tachycardia).
COMPLICATIONS
Maternal:
 Chorioamnionitis is the most common maternal
complication after PROM .
the risk increases as the duration of membrane
rupture more prolonged .
 APH: abruption placenta can cause PROM or
subsequent subsequent to membrane rupture.
 Preterm labor/birth
COMPLICATIONS CONT...
Fetal and neonatal complications :
Fetal distress -due to umbilical cord compression or
placental abruption.
Fetal death -complicates 1% to 2% of cases of
conservatively managed PROM
Prematurity and its complication e.g RDS,IVH,NEC
Fetal and neonatal sepsis
. PROM that is prolonged for >18 hours is a risk for
fetal and neonatal sepsis.
.PROM increases the risk of neonatal sepsis two
fold .
PREVENTION
 Regular prenatal care
 Screening for infection e.g bacterial
vaginosis and STD
 Nutritional support
 Avoid excessive physical activity
 Cervical cerclage for women's who have
cervical insufficiency.
 Limit the use of invasive procedures.
REFERENCE
 Williams obstetrics 26 th edition
 Obstetrics 20 th edition by ten teachers
 Our teacher ppt
THANK YOU

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Premature rupture of membrane.pptxshjsjsjs

  • 1. B Y : G R O U P 1 PROM
  • 2. OUT LINES • Introduction • Definition • Incidence • Risk factor • pathophysiology • Sign and symptom • Types • Diagnosis • Differential diagnosis • Management • Complication • Prevention
  • 3. OBJECTIVE At the end of this lesson the learners will be able to: • know the definition of PROM • identify the signs and symptoms of PROM • understand the diagnosis and differential diagnosis of PROM • Famiiarize the signs and symptoms of PROM • Practice the management and preventive modalities of PROM.
  • 4. INTRODUCTION • Pre-labor rupture of membrane (PROM) , previously known as pre-mature rupture of membranes ,is a breakage of the amniotic sac before the onset of labor. • Women usually experience a painless gush or a steady leakage of fluid from the vagina. • If it occurs before the 37 weaks it is known as PPROM (pre-term pre-labor rupture of membrane).
  • 5. DEFINITION  Pre-labor rupture of membrane is a rupture of membranes (ROM) after 28 weaks of gestation and one hour before the onset of labor.  PROM is the spontaneous rupture(breakage) of amniotic sac before the onset of labor.
  • 6. INCIDENCE • About 8% of term pregnancies are complicated by PROM. • 30% of pre-term births are complicated by PROM. • Before 24 weaks PROM occurs in fewer than 1% of pregnancies.
  • 7. RISK FACTOR Among the risk factors of PROM: infections low socioeconomic status that leads to nutritional deficiency previous history of PROM or preterm labor polyhydraminos Multiple gestation invacive procedures e.g amniocentesis cervical insufficiency
  • 9. SIGN AND SYMPTOM Fluid leakage  increased vaginal discharge change in fetal movement pelvic pressure  contractions  signs of infection abdominal pain or cramping Lanugo hair
  • 10. TYPES Term PROM When the fetal membranes rupture early,at least one hour before labor has started.  Prolonged PROM a case of pre-labor rupture of membrane in which more than 18 hours has passed between the rupture and the onset of labor.
  • 11. TYPES CONT.. Preterm PROM Prelabor rupture of membranes that occurs before 37 weaks gestation.  Midtrimester PROM prelabor rupture of membranes that occurs before 24 weaks gestation
  • 12. DIAGNOSIS  History A sudden gush or intermittent or continuous leaking of clear fluid from the vagina before the onset of labor.  Physical examination  Abdominal examination: common findings include fundal eight may be less than the GA.  Pelvic examination: inspection of the externa genitalia : leakage of liquor per vagina. Note: avoid digital pelvic examination in all cases of preterm PROM
  • 13. DIAGNOSIS CONT... Speculm examination: • Observation of amniotic fluid coming out of the cervical cannal and/or presence of prolapsed cord. • Presence of meconium , vernix casosa or lanugo hair in the fluid pooling indicates PROM and presence of uriniferous smell suggests urinary incontinency. • Inspect for cervical dilation (open or closed).
  • 14. DIAGNOSIS CONT... Ferning test  Obtain fluid by swabbing the posterior fornix (avoid cervical mucus to decrease chance of false positive result).  Spread some fluid on a slide & let it dry for at least 10 minutes.  Examine it with a microscope and look for a fern-leaf pattern  The test is not affected by meconium, vaginal PH & blood.
  • 15. DIAGNOSIS CONT... Nitrazine paper test  Hold a piece of Nitrazine paper in a hemostat (artery forceps) & touch it against the fluid pooled on the speculum blade.  A change from yellow to blue indicates presence of amniotic fluid  False negative tests results can occur when leaking is intermittent or the amniotic fluid is diluted by other vaginal fluids.  False positive results can be due to the presence of alkaline fluids in the vagina, such as blood, seminal fluid, or soap.
  • 16. DIAGNOSIS CONT... Pad test  Can be helpful when there is no pooling & no visible leakage from cervix.  Place a vaginal pad over the vulva and encourage moving around.  Examine the pad an hour later visually and by smelling (odour).  Wetting with no urine and no vaginal discharge (vaginitis) may suggest PROM  Dye test – it is gold standard method that provides highly accurate and definitive results  indigo carmine, is injected into the amniotic sac through a procedure called amniocentesis. If the membranes have ruptured, the dye will leak into the vaginal canal and can be detected externally
  • 17. DIFFERENTIAL DIAGNOSIS  Leucorrhea gravidarum  Vaginal discharge (excessive)  Urinary incontinency  Perspiration  Ruptured cyst ( like in the vagina)
  • 18. MANAGEMENT  Management of PROM depends on: Gestational age, duration of rupture of fetal membranes, fetal condition (dead, fetal distress, congenital malformations), presence of infection, labor and previous cesarean scar, and other obstetric indications.
  • 19. MANAGEMENT CONT... Indications for expedite delivery:  onset of labor,  gestation age ≥ 37wks,  evidence for nonreassuring fetal status,  evidence for chorioamnionitis,  lethal congenital anomalies,  intrauterine fetal death,  if there is high risk of cord prolapse (e.g., transverse lie) and  abruptio placenta o Note that if the gestational is below 34 weeks and both the fetal and maternal conditions are stable, expectant management can be considered for abruption placenta in a setting where close follow up is possible
  • 20. MANAGEMENT CONT.... Expectant management  Admit to the ward (Transfer patients with early preterm PROM to a higher healthfacility with newborn intensive care, if possible).  Avoid digital cervical (pelvic) examination.  Advise bed-rest, to potentially enhance amniotic fluid re-accumulation & possibly delay onset of labor.  Provide corticosteroids and antibiotics.  Administer antenatal corticosteroids (betamethason12 mg intramuscularly 24 hours apart for two doses or dexamethasone 6 mg IM 12 hours apart for four doses) for lung maturity.
  • 21. EXPECTANT MANA..CONT.. Note that if preterm birth is considered imminent, treatment for short duration still improves fetal lung maturity and chances of neonatal survival.  Antenatal corticosteroid therapy should not be administered in women with chorioamnionitis. Antibiotics Ampicillin 2gm IV QID and Erythromycin 250 mg P.O QID for 48 hours followed by Amoxicillin 500 mg P.O TID & Erythromycin 250 mg. P.O QID for 5 days.  Azithromycin may be substituted for Erythromycin with regimen of 500mg PO on day 1 followed by 250mg PO daily for 6 days.
  • 22. CONT… Neuroprotection  If gestational age is less than 32 weeks and preterm birth is likely within the next 24 hours, consider magnesium sulfate for neuroprotection Monitoring and follow up  Monitor the following clinical features during expectant management of PROM:  Maternal pulse & temperature - every 4-6 hours  FHR - every 4-6hrs (& if possible CTG 2x daily)  Uterine tenderness or irritability (or pain) – daily  WBC count & differential - changes, every 2-3 days  Amniotic fluid appearance & odor – daily
  • 23. CONT… Labor and delivery for term PROM without infection:  If cervix is favorable, labor is induced, unless there are contraindications to labor or vaginal delivery, in which case cesarean delivery is performed.  If cervix is unfavorable, ripen the cervix (preferably with PO misoprostol).  Institute antibiotic (Ampicillin 2gm IV QID) when the duration of ROM >12hrs.  Follow for features of chorioamnionitis (maternal fever, tachycardia, leukocytosis,uterine tenderness, offensive vaginal discharge and fetal tachycardia).
  • 24. COMPLICATIONS Maternal:  Chorioamnionitis is the most common maternal complication after PROM . the risk increases as the duration of membrane rupture more prolonged .  APH: abruption placenta can cause PROM or subsequent subsequent to membrane rupture.  Preterm labor/birth
  • 25. COMPLICATIONS CONT... Fetal and neonatal complications : Fetal distress -due to umbilical cord compression or placental abruption. Fetal death -complicates 1% to 2% of cases of conservatively managed PROM Prematurity and its complication e.g RDS,IVH,NEC Fetal and neonatal sepsis . PROM that is prolonged for >18 hours is a risk for fetal and neonatal sepsis. .PROM increases the risk of neonatal sepsis two fold .
  • 26. PREVENTION  Regular prenatal care  Screening for infection e.g bacterial vaginosis and STD  Nutritional support  Avoid excessive physical activity  Cervical cerclage for women's who have cervical insufficiency.  Limit the use of invasive procedures.
  • 27. REFERENCE  Williams obstetrics 26 th edition  Obstetrics 20 th edition by ten teachers  Our teacher ppt