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Premature rupture of membranes

PROM

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Premature rupture of membranes

  1. 1. PREMATURE RUPTURE OF MEMBRANES PRESENTER-DR.DIVYA JAIN MODERATOR-DR.M.SHARMA
  2. 2. DEFINITIONS Premature rupture of membranes (PROM) Rupture of membranes anytime after 37weeks but before the onset of spontaneous uterine activity. Preterm premature rupture of membranes (PPROM)- Rupture of fetal membranes prior to labor in pregnancies betweem 28 - 37 weeks.
  3. 3. INCIDENCE • PROM-10% • PPROM-3%
  4. 4. RISK FACTORS • PRE-CONCEPTIONAL CAUSES- 1. Repeated genitourinary infections 2. Cervical incompetence 3. Chronic cervicitis 4. Obesity 5. Smoking 6. Low socioeconomic status 7. Nutritional deficiencies
  5. 5. • PREGNANCY RELATED CAUSES- 1. Polyhydroamnios 2. Multiple gestation 3. Cervical cerclage 4. Foetal abnormalities 5. Abruption 6. Previous history of PPROM(21 to 30%)
  6. 6. • Genital tract infections- 1. Bacterial vaginosis 2. Group B streptococcus 3. Candida 4. Mycoplasma 5. Ureaplasma hominis 6. E.coli 7. Staphylococcus
  7. 7. WHAT CAUSES RUPTURE OF MEMBRANES?? • Rupture of the membranes near the end of pregnancy (term) may be caused by a natural weakening of the membranes or from the force of contractions.
  8. 8. DIAGNOSIS • History • Valsava maneuver • Sterile Speculum exam (Pooling) • Nitrazine testing/litmus paper test • Fetal Fibronectin • Ultrasonography • Microscopic Fern testing • Amnisure • High vaginal swab • Urine routine,culture
  9. 9. Nitrazine paper testing • Turns blue in presence of alkaline Amniotic fluid • 93.3% sensitivity • False positive (1-17%) for urine, blood, semen BV
  10. 10. Fern test • Fern test refers to visualization of a characteristic 'fern- like' pattern on a slide viewed under low power on a microscope • A small amount of cervical mucus is allowed to air-dry on a clean, saline-free glass slide • If positive for amniotic fluid, this crystal formation will be present in most microscopic fields.
  11. 11. Foetal fibronectin assay • fFN present in cervical secretions <22 wks, >34 wks • Used for assessment of potential PTB • Positive result (>50 ng/dl) may be indicative of PROM and represents disruption of decidua-chorionic interface • In PPROM, Sensitivity-98.2%
  12. 12. Ultrasonography • 50-70% of women with PROM have low amniotic fluid on USG • Mild reduction requires further investigation • Rule out other causes (Renal agenesis, obstructive uropathy)
  13. 13. Amnisure • Detects PAMG-1(placental microglobulin) • 99% sensitivity,100%specificity • PAMG-1 is a protein produced by cells of decidual part of placenta and can be detected in amniotic fluid after rupture of membranes. • Recently approved by FDA in US
  14. 14. MANAGMENT • MANAGEMENT DEPENDS ON THE FOLLOWING FACTORS 1. Gestational age 2. Availability of NICU 3. Fetal presentation 4. FHR pattern 5. Active distress (maternal/fetal) 6. Cervical assessment
  15. 15. l-
  16. 16. • Maternal-Fetal Distress evaluated by Maternal vitals, labs, general condition, • Fetal distress assessed by FHR pattern, USG, NST. • First priority is to rule out maternal-fetal distress and imminent delivery. • Ensure through prenatal records that early US correlate with LMP is most accurate. • Rule out infection through absence of clinical signs and symptoms of chorionamniotis in addition to assessment of lab values and amniotic fluid samples • Evaluate maternal serum lab values for leukocytosis, left shift, and elevated C-Reactive Protein. Evaluate Amniotic fluid samples for gram stain,WBC count.
  17. 17. g
  18. 18. SECONDARY ASSESSMENT • Fetal position • Cervical assessment • Determine lung maturity • Quantify amniotic fluid
  19. 19. INDICATIONS FOR DELIVERY • Maternal-Fetal Distress • Infection • Abruption • Cord Prolapse
  20. 20. EXPECTANT MANAGMENT • Typical for GA 32 weeks or less • Bed rest • Steroids for lung maturity • Tocolytic if indicated for lung maturity • Antibiotics • Fetal Surveillance • Assess for Chorioamnionitis
  21. 21. • Infection can be both a cause and a consequence of Preterm Rupture of Membranes. • Most patients require close inpatient observation.Those who might qualify for outpatient management include the extreme previable gestation patients and those who have appeared to have resealed (which is approximately about 5% of PROM patients).
  22. 22. PPROM BETWEEN 32 TO 34 WEEKS • Expectant management • Deliver at 34 wks (Unless documented fetal lung maturity) • GBS prophylaxis • Antibiotics • Corticosteroids
  23. 23. MANAGEMENT RATIONALE • Antibiotics 1. Prolong latency period 2. Prophylaxis of GBS in neonate 3. Prevention of maternal chorioamnionitis and neonatal sepsis • Corticosteroids 1. Enhance fetal lung maturity 2. Decrease risk of RDS, IVH, and necrotizing enterocolitis • Tocolytics 1. Delay delivery to allow administration of corticosteroids
  24. 24. • Antibiotics 1. Ampicillin 2 g IV 6 hrly for 2 days 2. Amoxicillin 500 mg po TDS x 5 days 3. Azithromycin 1 g po x 1 4. Erythromycin 250mg TDS for 5 days • Corticosteroids 1. Betamethasone 12 mg IM OD for 2 days 2. Dexamethasone 6 mg IM BD for 2 days • Tocolytics 1. Nifedipine 10 mg po after every 20min 3 times, then 6 hrly for 2 days
  25. 25. RISK-BENEFIT EXPECTANT MANAGMENT RISKS • Abruption • Chorioamnionitis • Cord Prolapse • Endometritis (1/3) • Oligohydroamnios tetrad (FLIP) BENEFITS • Mature lung profile • Advancing GA (reducing risks associated with PTB)

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