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PROM

  1. 1. PROM Maru M /MD/ For Anesthesia 2nd May 9/2010 Ec
  2. 2. PRO M (Premature rupture of membranes) Definition: Spontaneous rupture of membranes after 28 weeks of gestation before the onset of labor. • Term PROM: Rupture of membranes after 37 weeks • Preterm PROM: Before 37 weeks • Prolonged PROM: Longer than 18 hrs/ 12 hrs.  Latency period: Time between rupture of membranes to onset of labor.
  3. 3. PROM-Cont’d Diagnosis: History: complaint of leakage of liquor as gush or slow leak;followed by intermittent leakage. -Complications of PROM: infection, PTL, etc. Physical findings: - Negative discrepancy - If complicated, uterine contraction, tenderness - Sterile speculum examination with or without valsalva maneuver( leakage or pooling)
  4. 4. • Incidence: average 5- 10% of all deliveries and up to 30% of preterm deliveries. • Approximately 70% of cases of PROM occur in pregnancies at term. PROM is the clinically recognized precipitating cause of about one third of all preterm births. Incidence
  5. 5. Causes multifactorial • 1. Intrinsic membrane weakness a. Infections b. Smoking c. Malnutrition d. Collagen Deficency • 2. Infection (proteolytic enzymes) • 3. Mechanical stress a. Twin gestation b. Polyhydramnios c. Fetal Malformations • 4. Unknown
  6. 6. Diagnosis-cont’d Investigations:  Nitrazine paper test: principle is alkaline nature of amniotic fluid(accuracy of approximately 93%)  Became blue False +:blood, semen, alkaline urine, bacterial vaginosis, and trichomoniasis  Ferning pattern:accuracy of diagnosis of PROM of approximately 96% False +ve: contamination by semen or cervical mucus False –ve :dry swab, contamination with blood at a 1:1 dilution, or not allowing sufficient time for the fluid to dry on the slide  Unaffected by meconium at any concentration and by pH alteration.
  7. 7. Ferning pattern
  8. 8. Diagnosis-cont’d • Ultrasound: support diagnosis & fetal wellbeing. • Dye test: indigo carmine instillation • Meconium on the vulva • Vernix caseosa on the vulva
  9. 9. DIAGNOSIS History Gush or Leakage of fluid PV (Duration, Smell) Is she in Labour Yes No Speculum/Digital Exam Sterile Speculum Examination ± Valsalva Man Leakage through cervix No leakage through cervix Presence of meconium/vernix Pooling at post fornix No pooling - Nitrazin paper test -Fern test Pad test for 24 hrs PROM No wetting Wetting + ve - ve Suspsious Treat as PROM - US Oligohydramnios - Dye test PROM +ve -ve Follow at OPD Level
  10. 10. PROM- investigations • CBC • U/A, Culture & Sensitivity • High vaginal swab for culture • Phosphatidylglycerol from vaginal pool • Biophysical profile • CTG for non-stress test
  11. 11. Differential diagnosis • Urinary incontinence • Leucorrhea gravidarum* • Perspiration* • Vaginal discharge-pathological
  12. 12. Complications of PROM  Labor: In term PROM labor starts in 24 hours in about 90%. In Preterm PROM, labor starts in 70-80% of cases in one week time  Ascending infection: one third • Increased incidence of cord prolapse  Fetal pulmonary hypoplasia  Prematurity • Operative delivery • Abruption
  13. 13. Management of PROM • Accurate diagnosis • Avoid digital vaginal examination • Bed rest • Management depends on: - GA - Presence or absence of labor - Infection or not - Fetal condition
  14. 14. Indications for pregnancy termination in PROM • Term PROM • Labor • Presence of infection • IUFD • Congenital anomalies of fetus incompatible to life • Abnormal fetal surveillance
  15. 15. Preterm PROM  GA > 34 weeks is controversial either conservative management or termination  GA< 34 weeks, conservative management  Components of conservative management: - Monitor maternal PR, Temp., FHR every 4 hours - CBC, U/A, ESR/CRP twice per week - BPP/NST twice per week  Corticosteroids if less than 32/34 weeks - Administer antibiotics: ampicillin (iv)+ erythromycin X 48hrs followed by amoxacillin(po) & erythromycin to complete a total of seven days
  16. 16. • Two indications for prophylactic antibiotics in PPROM:  prevention of perinatal GBS infection infection is either the triggering cause of PPROM or that infection ensuing after PPROM triggers the labor
  17. 17. Chorioamnionitis • Clinical or subclinical Criteria for clinical chorioamnionitis: - Maternal temperature > 38o C - Uterine tenderness - Foul smelling amniotic fluid - High WBC count(>16000/18000) - Maternal &/ or fetal tachycardia
  18. 18. Sub clinical chorioamnionitis • Amniocentesis: intramniotic infection is present if: 1. Culture: bacterial colony count > 102 / ml fluid 2. Presence of bacteria on gram stain 3. Glucose level<15 mg/dl 4. WBC> 100/ml
  19. 19. Management of chorioamnionitis • Antibiotics: 1. Ampicillin+ Gentamycin+ clindamycin/metronidazole/chloramphenicol 2. Ceftriaxone +/- metronidazole • Terminate pregnancy: Vaginal route is preferred
  20. 20. THANK YOU ?
  21. 21. QUIZE

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