1. PROM

2. 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.

3. Definitions(cont’d)
• Pre term PROM is rupture of membranes
before 37wks of gestational age.
• Prolonged PROM is rupture of membranes for
>24hrs.

4. 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.

5. 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.

6. 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

7. 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.

8. 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.

9. 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.

10. 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 .

11. 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.

12. 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.

13. Complications
• Maternal
Endomyometritis
Sepsis
PPH
APH
Wound infection
Cesarean delivery
• Fetal
Chorioamnionitis
Neonatal sepsis
Pulmonaryhypoplasia
Cord prolapse
Limb deformity

14. 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 .

15. 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 .

16. 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

17. 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.

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

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

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

21. 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.

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

23. THANK YOU

25. 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

26. 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.

27. Long term disabilities
• cerebral palsy
• Vision & hearing impairment
• Chronic lung disease
• reduced motor performance
• academic difficulties
• attention deficit disorders

28. 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.

29. Incidence
• 12.8% of births are PTB.

30. 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

31. Pathogenesis…
• The four primary processes are:
• Activation of the maternal or fetal
hypothalamic-pituitary-adrenal axis
• Infection
• Decidual hemorrhage
• Pathological uterine distention

32. Pathogenesis…
• Activation of maternal/fetal hypothalamic-
pituitary-adrenal
Maternal depression or stressCRH
Fetal stress due to placental
vasculopathyACTHDHEAestrogen

33. Pathogenesis…
• InfectionInterleukensPGs
• DecidualhemorrhageProteasesPPROM
• Uterine overdistension
Formation of gap junctions
Up regulate oxytocin receptors
Increase PG receptors
Activate MLCK

34. 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 .

35. 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.

36. 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.

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

38. Triage based on Cx length
• >30mm :low risk for PTL;observe for 4-6hrs.
• 20mm-30mm:moderate risk
;fFN>50ng/mlPTL
• <20mm:PTL

39. 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