Prom

Prelabor rupture of the membranes

Definitions

Prelabor rupture of the membranes (PROM) refers to rupture of the chorioamniotic membranes before the onset of labor

latency period: interval between PROM and the onset of labor.

term PROM preterm PROM previable PROM preterm PROM remote from term PROM near term

Frequency

Term PROM occurs in approximately 10% of patients, while the frequency of preterm PROM is 2–3.5%

Consequences of premature rupture of the membranes Preterm birth

in 50% of PPROM,labor occurs within 24 hours, and in 80–90% within 7 days.

Preterm delivery and complications of prematurity are the most important causes of perinatal mortality and morbidity; complications decrease with advancing GA.○ Respiratory distress syndrome (RDS), ○ intraventricular hemorrhage (IVH), and○ periventricular leukomalacia (PVL), ○ infection ○ necrotizing enterocolitis (NEC).

Infections: mother is at risk of chorioamnionitis, endometritis, and sepsis. Serious maternal consequences are uncommon. Mean incidence of chorioamnionitis is about 3–15%. Major neonatal infectionsoccur in 5% of PPROM, and 15–20% of cases develop chorioamnionitis.

Fetal infection can precede clinically evident chorioamnionitis, resulting in neonatal pulmonary and cerebral morbidities.

Ureaplasma urealyticum and Mycoplasma hominis) are the most frequent isolates from the amniotic fluid, followed by Streptococcus agalactiae (group B streptococcus),

abruptio placentae, cord prolapse, pulmonary hypoplasia increased need for cesarean delivery retained placenta

once an examination has been performed,

the clock of infection starts to tick

PROM ( After 37 weeks before onset of labor )

Diagnosis

There is no reason to carry out a speculum examination with a certain history of rupture of the membranes at term.

Women with an uncertain history of rupture of the membranes should be offered a speculum examination to determine whether their membranes have ruptured.

Digital vaginal examination in the absence of

contractions should be avoided.

Complete medical and Obstetric history:( special consideration to reach diagnosis of PROM).

Complete general and obstetric examination:Special consideration on signs of infection, maternal tachycardia, fever,

abdominal tenderness, foul odour vaginal discharge, fetal tachycardia)

Sterile speculum examination if diagnosis is unclear.

Avoid PV examination unless contractions are present.

Perform Obstetric U/S with special consideration to confirm the diagnosis if unclear.

Admit patients diagnosed as PROM.

Consult a senior resident if diagnosis is unclear.

PROM ( After 37 weeks before onset of labor )

Labor Ward management:

Patient is in labor or signs of infection:Deliver the patient: induction or

augmentation of vaginal birth or CS according to obstetric indications.

PROM ( After 37 weeks before onset of labor )

PROM ( After 37 weeks before onset of labor )

Labor Ward management:

Patient is not in labor nor signs of infection:

Expectant management for 12-24 hours.

Prophylactic broad spectrum antibiotics.

Expectant management:•Follow up maternal fever and foul odor vaginal discharge every 4 hours.•Fetal surveillance ( NST and Kick charts) .

If expectant management is agreed upon

Lower vaginal swabs and maternal CRP should not be offered

Maternal surveillance

Every 4 hours

Colour and smell

Fetal surveillance

PROM ( After 37 weeks before onset of labor )

Labor Ward management

If patient passed into labor : Deliver.

If patient developed signs of infection: Deliver.

Deliver patient after 24 hours of expectant management. (Induction, augmentation of vaginal delivery or CS).

PROM ( After 37 weeks before onset of labor )

Preterm- PROM Diagnosis

The diagnosis of spontaneous rupture of the membranes is best achieved by maternal history followed by a sterile speculum examination. ( B)

Ultrasound examination is useful in some cases to help confirm the diagnosis. ( B)

Preterm- PROM Diagnosis

Digital vaginal examination is best avoided unless there is a strong suspicion that the woman may be in labour.Latency between P-PROM and Labour becomes shorter by PV.

Should tocolytic agents be used?

Preterm- PROM

Tocolysis in women with PPROM is not recommended because this treatment does not significantly improve

perinatal outcome ( A)

In the absence of clear evidence that tocolysis improves neonatal outcome following PPROM, it is reasonable not to use it.

Additionally, with PPROM in the presence of uterine contractions, it is possible that tocolysis could have adverse

effects, such as delaying delivery from an infected environment, since there is an association between intrauterine infection, prostaglandin and cytokine release and delivery.

Preterm- PROMAre prophylactic antibiotics recommended?

Erythromycin should be given for 10 days following the diagnosis of PPROM. ( A)

22 trials involving…. over 6000 women ….meta-analysis

This review shows that •Routine antibiotic administration reduces maternal and neonatal morbidity. •Antibiotic therapy also delays delivery, thereby allowing sufficient time for prophylactic prenatal corticosteroids to take effect.•The data also showed that prenatal co-amoxiclav increased the risk of neonatal necrotising enterocolitis and this antibiotic is best avoided. •Erythromycin or penicillin appears the antibiotic of choice. •Erythromycin may be used in women who are allergic to penicillin.

Evidence level Ia

PROM ( 34—37 weeks)

Same as above:Give Corticosteroids.Deliver after 24 hours from corticosteroid intake, considering no signs of fetal or maternal infection , nor labor occurs.Deliver either by induction , augmentation, or C.S depending on indication.

PROM remote from term at 26–34 weeks of gestation

Initial assesment •Look for clinical signs of chorioamnionitis and abruption• Assess fetal growth, sonographic gestational age, and fetal well-being

Development of •Labour ,•Abruption•Chorioamnionitis• Nonreassuring fetal heart rate• Fetal distress

Expectatnt mamnagement •Corticosteriords.•Prophylactic antibiotics• Hospitalization and bedrest•Neonatology consult•Follow up for signs of maternal infection, abruption and fetal well-being (biophysical profile and fetal heart monitoring)

Uneventful course until 34 weeks:Deliver

PROM before 26

Consider termination of pregnancy. If patient refused …..manage as 26- 34

weeks

Cervical Circlage and Preterm PROM Occurs in 38% of women with cerclage in

place Retention of circlage for more than 24 hours

after PPROM was found to prolong pregnancy for more than 48 hours, but also to increase maternal chorioamnionitis and neonatal mortality from sepsis,

Immediate circlage removal as the usually preferred therapeutic approach. Steroids for fetal maturity before circlage removal can be considered between 24 and 33 6/7 weeks gestation

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