PROMPROM

DR. HANA AL MADANICONSULTANT OBS &GYNE

KSMC

DefinitionsDefinitions

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

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

Definitions(contDefinitions(cont’’d)d)

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

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

IncidenceIncidence

Five to 10% of all deliveries. Five to 10% of all deliveries.

PPROM occurs in approximately 1% PPROM occurs in approximately 1% of all pregnancies. of all pregnancies.

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

Fetal membranesFetal membranes

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

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

Both fuse together at 14weeks.Both fuse together at 14weeks.

EtiologyEtiology• 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 & Clinical manifestation & DxDx

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

:Many women describe intermittent :Many women describe intermittent

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

DiagnosisDiagnosis

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

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

DiagnosisDiagnosis……

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

FerningFerning Fluid from the posteriorFluid from the posterior

vaginal fornix is swabbed ontovaginal fornix is swabbed onto

a glass slide and allowed to drya glass slide and allowed to dry

for at least 10 minutes. for at least 10 minutes.

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

Placenta alpha Placenta alpha microglobin-1 protein microglobin-1 protein

assay (AmniSure)assay (AmniSure) The test is done by the provider at the The test is done by the provider at the

point of care using a commercially point of care using a commercially available kit. A sterile swab is inserted available kit. A sterile swab is inserted into the vagina for one minute, then into the vagina for one minute, then placed into a vial containing a solvent for placed into a vial containing a solvent for one minute, and then an AmniSure test one minute, and then an AmniSure test strip is dipped into the vial.strip is dipped into the vial.

Placenta alpha Placenta alpha microglobin-1 protein microglobin-1 protein

assay (AmniSure)assay (AmniSure) The test result is revealed by the presence of The test result is revealed by the presence of

one or two lines within the next 5 to 10 minutes one or two lines within the next 5 to 10 minutes (one visible line means a negative result for (one visible line means a negative result for amniotic fluid, two visible line is a positive amniotic fluid, two visible line is a positive result, no visible lines is an invalid result). result, no visible lines is an invalid result).

SensitivitySensitivity ranged from 94.4 to 98.9 percent ranged from 94.4 to 98.9 percent and and SpecificitySpecificity ranged from 87.5 to 100 ranged from 87.5 to 100 percent [33-37]. percent [33-37].

UltrasoundUltrasound

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

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

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

Instillation of Indigo Instillation of Indigo carminecarmine

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

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

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

ComplicationsComplications

MaternalMaternal

EndomyometritisEndomyometritis

SepsisSepsis

PPHPPH

APHAPH

Wound infectionWound infection

Cesarean deliveryCesarean delivery

FetalFetal

ChorioamnionitisChorioamnionitis

Neonatal sepsisNeonatal sepsis

PulmonaryhypoplasiaPulmonaryhypoplasia

Cord prolapseCord prolapse

Limb deformityLimb deformity

ResealingResealing

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

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

Mx of TERM PROMMx of TERM PROM

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

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

Mx of PPROMMx of PPROM Gestational ageGestational age Availability of neonatal intensive careAvailability of neonatal intensive care Presence or absence of maternal/fetal Presence or absence of maternal/fetal

infectioninfection Presence or absence of laborPresence or absence of labor Fetal presentation (Breech and Fetal presentation (Breech and

transverse lies are unstable and may transverse lies are unstable and may increase the risk for cord prolapse)increase the risk for cord prolapse)

Fetal heart rate (FHR) tracing patternFetal heart rate (FHR) tracing pattern Likelihood of fetal lung maturityLikelihood of fetal lung maturity

Maternal surveillanceMaternal surveillance

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

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

MaternalMaternal……

Chorioamnionitis is diagnosed if >or Chorioamnionitis is diagnosed if >or 2 criteria:2 criteria:

FeverFever

Abdominal tendernessAbdominal tenderness

Offensive Vx dischargeOffensive Vx discharge

Fetal tachycardia mater Fetal tachycardia mater tachycardiatachycardia

LeukocytosisLeukocytosis

Fetal surveillanceFetal surveillance

Fetal surveillance Fetal surveillance

Kick countsKick counts

Non stress testsNon stress tests

Biophysical profile [BPP]) .Biophysical profile [BPP]) .

Antenatal steroidsAntenatal steroids

Dexamethasone 6mg bd ;04 dosesDexamethasone 6mg bd ;04 doses Bethametasone 12mg daily;02dosesBethametasone 12mg daily;02doses

DecreasesDecreases

IVHIVH

NECNEC

RDSRDS

Neonatal mortality Neonatal mortality

AntibioticsAntibiotics

Goal: Goal:

Decrease maternal infectionDecrease maternal infection

>> fetal infection>> fetal infection

Prolong latency(onset of labor)Prolong latency(onset of labor) Ampicillin IV for 48hrs,Amoxicillin Ampicillin IV for 48hrs,Amoxicillin

po 7d.po 7d. Erythromycin IV for 48hrs,Eryth IV Erythromycin IV for 48hrs,Eryth IV

7d. 7d.

Termination Of Termination Of pregnancypregnancy

If chorioamnionitis develop any time.If chorioamnionitis develop any time. At 34wksAt 34wks At 32-34wks if lung maturity At 32-34wks if lung maturity

confirmedconfirmed Mode of deliveryMode of delivery

Based on obstetric indications.Based on obstetric indications.

THANK YOU!THANK YOU!

DR. HANA AL MADANICONSULTANT OBS &GYNE

KSMC