Prom

PROM

Definitions

• Premature rupture of the membranes (PROM) is usually defined as rupture at any time before the onset of contractions.

• Term PROM is rupture of membranes after 37wks & before onset of contractions.

Definitions(cont’d)

• Pre term PROM is rupture of membranes before 37wks of gestational age.

• Prolonged PROM is rupture of membranes for >24hrs.

Incidence

• Five to 10% of all deliveries.

• PPROM occurs in approximately 1% of all pregnancies.

• PROM is the clinically recognized precipitating cause of about one third of all preterm births.

Fetal membranes

• Made of thin inner layer that covers amniotic cavity called amnion.

• Outer layer ,thicker that apposes the decidua called chorion.

• Both fuse together at 14weeks.

Etiology• Connective tissue disorders • Urogenital tract infection, • Low socioeconomic status, • Uterine over-distention, • Second- and third-trimester bleeding, • Low body mass index • Nutritional deficiencies • Maternal cigarette smoking, • Cervical conization or cerclage, • Pulmonary disease in pregnancy

Clinical manifestation & Dx

Hx:The classic clinical presentation of PPROM is a sudden "gush" of clear or pale yellow fluid from the vagina.

:Many women describe intermittent or

constant leaking of small amounts of fluid or just a sensation of wetness within the vagina or on the perineum.

Diagnosis

• Physical examination — The best method of confirming the diagnosis of PPROM is direct observation of amniotic fluid coming out of the cervical canal or pooling in the vaginal fornix.

• If amniotic fluid is not immediately visible, the woman can be asked to push on her fundus, Valsalva, or cough to provoke leakage of amniotic fluid from the cervical os.

Diagnosis…

• Nitrazine test — If PROM is not obvious after visual inspection, the diagnosis can be confirmed by testing the pH of the vaginal fluid, which is easily accomplished with nitrazine paper. Amniotic fluid usually has a pH range of 7.0 to 7.3 compared to the normally acidic vaginal pH of 3.8 to 4.2.

Ferning

• Fluid from the posterior vaginal fornix is swabbed onto a glass slide and allowed to dry for at least 10 minutes.

• Amniotic fluid produces a delicate ferning pattern, in contrast to the thick and wide arborization pattern of dried cervical mucus. Well-estrogenized cervical mucus or a fingerprint on the microscope slide may cause a false-positive fern test .

Ultrasound

•  Ultrasound examination may be of value in the diagnosis of PPROM. Fifty to 70 percent of women with PPROM have low amniotic fluid volume on initial sonography .

• A mild reduction of amniotic fluid volume may have many etiologies.

• combined with a characteristic history, is highly suggestive of PROM.

Instillation of Indigo carmine

• In equivocal cases, instillation of indigo carmine into the amniotic cavity can be considered and usually leads to a definitive diagnosis.

• Under ultrasound guidance, 1 mL of indigo carmine in 9 mL of sterile saline is injected transabdominally into the amniotic fluid and a tampon is placed in the vagina.

• One-half hour later, the tampon is removed and examined for blue staining, which indicates leakage of amniotic fluid.

Complications

• Maternal Endomyometritis Sepsis PPH APH Wound infection Cesarean delivery

• Fetal Chorioamnionitis Neonatal sepsis Pulmonaryhypoplasia Cord prolapse Limb deformity

Resealing

•  Up to 14 percent of gravidas with spontaneous midtrimester PPROM eventually stop leaking amniotic fluid, presumably due to "resealing" of the fetal membrane.

• Cessation of leakage is probably not due to actual repair and regeneration of the membranes, but rather to changes in the decidua and myometrium that block further leakage .

Mx of TERM PROM

• Labor is induced, unless there are contraindications to labor or vaginal delivery, in which case cesarean delivery is performed.

• Most women with term PROM who are followed expectantly will go into spontaneous labor and deliver within 24, 48, and 72 hours of PROM in 70, 85, and 95 percent of women, respectively .

Mx of PPROM

• Gestational age• Availability of neonatal intensive care• Presence or absence of maternal/fetal infection• Presence or absence of labor• Fetal presentation (Breech and transverse lies are

unstable and may increase the risk for cord prolapse)• Fetal heart rate (FHR) tracing pattern• Likelihood of fetal lung maturity

Maternal surveillance

•  All women with PPROM should be monitored for signs of infection.

• At a minimum, routine clinical parameters (eg, maternal temperature, uterine tenderness and contractions, maternal and fetal heart rate) should be monitored.

Maternal…

• Chorioamnionitis is diagnosed if >or 2 criteria: Fever Abdominal tenderness Offensive Vx discharge Fetal tachycardia mater tachycardia Leukocytosis

Fetal surveillance

• Fetal surveillance Kick counts Non stress tests Biophysical profile [BPP]) .

Antenatal steroids

• Dexamethasone 6mg bd ;04 doses• Bethametasone 12mg daily;02doses Decreases IVH NEC RDS Neonatal mortality

Antibiotics

• Goal: Decrease maternal infection >> fetal infection Prolong latency(onset of labor)• Ampicillin IV for 48hrs,Amoxicillin po 7d.• Erythromycin IV for 48hrs,Eryth IV 7d.

Termination Of pregnancy

• If chorioamnionitis develop any time.• At 34wks• At 32-34wks if lung maturity confirmed• Mode of delivery Based on obstetric indications.

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Preterm birth(PTB) or PTL

• Preterm birth (PTB) refers to a birth that occurs before 37 completed weeks (less than 259 days) of gestation.

• Subclassifications of PTB are: • Late preterm = 34 to 36 weeks • Moderately preterm = 32 to 34 weeks • Very preterm = <32 weeks • Extremely preterm = <28 weeks

Significance

•  PTB is by far the leading cause of infant mortality .• PTB is also a major determinant of short- and long-

term morbidity in infants and children. • RDS, IVH, bronchopulmonary dysplasia (BPD), PDA,

necrotizing enterocolitis (NEC), sepsis, apnea, and retinopathy of prematurity are some of morbidities.

Long term disabilities

• cerebral palsy• Vision & hearing impairment• Chronic lung disease• reduced motor performance• academic difficulties• attention deficit disorders

Survival increased

• Increase in survival due to corticosteroids mechanical ventilation exogenous surfactant• However, the reduction in mortality has not been

accompanied by a reduction in neonatal morbidity or long-term handicaps.

• 50% of all major neurologic handicaps in children result from premature births.

Incidence

• 12.8% of births are PTB.

Pathogenesis

• Approximately 70 to 80 percent of PTBs occur spontaneously.

*4o-50% are due to PTL. *20-30% are due to PPROM• The remaining 20 to 30 percent of PTBs are

due to intervention for maternal or fetal problems

Pathogenesis…

• The four primary processes are:

• Activation of the maternal or fetal hypothalamic-pituitary-adrenal axis

  • Infection  • Decidual hemorrhage • Pathological uterine distention

Pathogenesis…

• Activation of maternal/fetal hypothalamic-pituitary-adrenal

Maternal depression or stressCRH Fetal stress due to placental

vasculopathyACTHDHEAestrogen

Pathogenesis…

• InfectionInterleukensPGs• DecidualhemorrhageProteasesPPROM• Uterine overdistension Formation of gap junctions Up regulate oxytocin receptors Increase PG receptors Activate MLCK

Clinical manifestations

• Identifying women with preterm contractions who will deliver preterm is an inexact process.

• In one systematic review, approximately 30 percent of preterm labors spontaneously resolved .

• Others have reported 50 percent of patients hospitalized for PTL deliver at term .

Clinical…

• Signs and symptoms of early PTL include menstrual-like cramping, constant low back ache, mild uterine contractions at infrequent and/or irregular intervals, and bloody show.

• These signs and symptoms are non-specific and often noted in women whose pregnancies go to term.

Diagnosis…

• Regular painful uterine contractions accompanied by cervical dilation and/or effacement.

• Specific criteria, include persistent uterine contractions (four every 20 minutes or eight every 60 minutes) with documented cervical change or cervical effacement of at least 80 percent, or cervical dilatation greater than 2.

Management

• Initial evaluation Ux contractions Ux bleeding Fetal well-being Gestational age Status of membrane

Triage based on Cx length

• >30mm :low risk for PTL;observe for 4-6hrs.• 20mm-30mm:moderate risk

;fFN>50ng/mlPTL• <20mm:PTL

Mx…

• Antibiotics for GBS• Steroids• Hydration,bed rest No proven effect• Tocolytics Magnesium sulfate,Beta adrenergic agonists,Ca

channel blockers,Oxytocin rec antagonist,Cyclooxygenase inhibitors