premature rupture of membranes

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Premature Rupture of Membranes Irwan T Rachman

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premature ruptur of membran

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  • Premature Rupture of MembranesIrwan T Rachman

  • IntroductionThe membranes surrounding the amniotic cavityThe membranes normally rupture during labor.Premature rupture of the fetal membranes is defined as rupture of the membranes before the onset of labor

  • Amniotic fluid performs many functions for the fetus Allowing the fetus freedom to move and enabling the skeleton to develop properly Allowing the lungs to develop properly Maintaining a relatively constant temperature around the fetus, thus protecting the fetus from heat loss Protecting the fetus from outside injury by cushioning sudden blows or movements

  • IntroductionTraditionally attributed ROM to physical stress, particularly that associated with labor. Recent evidence suggests that membrane rupture is also related to biochemical processes, including disruption of collagen within the extracellular matrix of the amnion and the chorion and programmed death of cells in the fetal membranes

  • TerminologyPremature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation and has presented with rupture of membranes (ROM) prior to the onset of labor.Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous premature rupture of the membranes (SPROM) is ROM after or with the onset of labor.Prolonged ROM is any ROM that persists for more than 24 hours and prior to the onset of labor.

  • EpidemiologyAt term, 8 to 10 percent of pregnant women present with premature rupture of the membranesincreased risk for intrauterine infection when the interval between the membrane rupture and delivery is prolongedPreterm premature rupture of the membranes occurs in approximately 1 percent of all pregnancies and is associated with 30 to 40 percent of preterm deliveries.

  • Schematic Representation of the Structure of the Fetal Membranes at Term

  • Structure Of The Fetal MembranesThe human amnion is composed of five distinct layersIt contains no blood vessels or nervesthe nutrients it requires are supplied by the amniotic fluidAmniotic epithelial cells secrete collagen types III and IV and noncollagenous glycoproteins (laminin, nidogen, and fibronectin) that form the basement membrane, the next layer of the amnion.

  • Structure Of The Fetal MembranesThe compact layer of connective tissue adjacent to the basement membrane forms the main fibrous skeleton of the amnionThe fibroblast layer is the thickest of the amniotic layers, consisting of mesenchymal cells and macrophages within an extracellular matrixThe intermediate layer (spongy layer, or zona spongiosa) lies between the amnion and the chorion absorbs physical stresses by permitting the amnion to slide on the underlying chorion, which is firmly adherent to the maternal decidua

  • Structure Of The Fetal MembranesAlthough the chorion is thicker than the amnion,the amnion has greater tensile strength.

  • Etiologyassociated with labor uterine contraction and repeated stretching can make weak fetal membraneprogrammed cell death and activation of catabolic enzymes (such as collagenase)mechanical forcesInfection (E. coli, B streptococci,Chlamydia trachomatis, Neisseria gonorrhoeae,Gardnerella vaginalis,genital mycoplasmas) Connective-Tissue Disorders (EhlersDanlos syndrome)Nutritional Deficiencies (copper, ascorbic acid)Tobacco smoking

  • DiagnoseAnamnesaspeculum vaginal examination of the cervix and vaginal cavity pooling of fluid in the vagina or leakage of fluid from the cervixferning test of the dried fluid under microscopic examination,alkalinity of the fluid turns Nitrazine pH indicator blueRapid test (i.e. AmniSure)

  • Management of PROM can includeBed rest and pelvic rest to enhance amniotic fluid reaccumulation and avoid infectionInduction of labor to reduce risk of infectionTocolytics prophylactic tocolysis after preterm PROM has been shown to prolong latency Corticosteroids to reduce respiratory distress syndromeAntibiotics to prolong pregnancy, reduce chorioamniotis, neonatal sepsis, postpartum endometritis, intraventricular hemorrhage

  • Management PROMMost patients (90%) enter spontaneous labor within 24 hours enter labor spontaneously or to induce labor?Hannah et alconcluded that, in women with PROM, induction of labor and expectant management resulted in similar rates of cesarean delivery and neonatal infectionThe risk of chorioamnionitis with term PROM has been reported to be less than 10% and to increase to 40% after 24 hours of PROM

  • Premature Preterm Rupture Of Membranes (PPROM)(PPROM) occurring from 24-37 weeks' gestation is far more difficult to manage Prematurity is the principal risk to the fetus, while infection morbidity and its complications are the primary maternal risks. PPROM remote from term should only be cared for in facilities where a NICU is available and capable of caring for the neonate. Because most PPROM pregnancies deliver within a week of ROM

  • PPROMWhen PPROM occurs prior to 20 weeks' gestation, the probability of reaching viability is less than 5% and the risk of pulmonary hypoplasia due to oligohydramnios and underdevelopment of alveolar structures and the tracheobronchial tree is presentMidtrimester (13-26 wk) PPROM has a dismal prognosis

  • PPROMWith appropriate therapy and conservative management, approximately 50% of all remaining pregnancies deliver each subsequent week after PPROM. Very few women remain pregnant more than 3-4 weeks after PPROMSpontaneous sealing of the membranes does occur occasionally (
  • Management PPROMsterile speculum examination to document ROM. Cervical cultures (Chlamydia trachomatis and Neisseria gonorrhoeae and anovaginal cultures for Streptococcus agalactiae)Maternal vital signs should be documented as well as continuous fetal monitoring initially to establish fetal status. Ultrasonographic documentation of gestational age, fetal weight, fetal presentation, and amniotic fluid index should be established. Digital examination should be avoided, but visual inspection of the cervix can accurately estimate cervical dilatation. Digital examination of the cervix with PPROM has been shown to shorten latency and increase risk of infections without providing any additional useful clinical information

  • Management PPROMIn certain circumstances (chorioamnionitis, advanced labor, fetal distress, and placental abruption with nonreassuring fetal surveillance), immediate delivery of the fetus with PPROM is indicated. In a noncephalic fetus with advanced cervical dilatation (more than or equal to 3 cm), the risk of cord prolapse may also outweigh the benefits of expectant management and delivery should be considered.If after initial evaluation of the mother and fetus, they are both determined to be clinically stable, expectant management of PPROM may be considered to improve fetal outcome. The primary maternal risk with expectant management of PPROM is infection. This includes chorioamnionitis (13-60%), endometritis (2-13%), sepsis (
  • MEDICAL TREATMENT OF PPROMAntibiotics broad-spectrum antibiotics Antenatal corticosteroid treatment to accelerate lung maturity should be considered in all patients with PPROM with a risk of infant prematurity from 24-34 weeks' gestation (12 mg of betamethasone IM was given twice in a 24-hour interval or dexamethasone 6 mg q12h was given for 4 doses)Tocolytics (i.e. MgSO4, indomethacine, mefenamic acid, nifedipine) corticosteroids and antibiotics, transport of the mother to a tertiary institution with a NICU

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