1. Prelabour rupture of membranes
Aboubakr Elnashar
Benha university hospital, Egypt
Aboubakr Elnashar
2. DEFINITION
PROM:
Rupture of the membranes with leakage of amniotic
fluid in the absence of uterine activity.
Pre-term PROM (PPROM):
Before 37W
Term PROM (TPROM)
After 37W.
Aboubakr Elnashar
3. Gest age % Latent period
26W 50 1w
32W 50 36h
37W 75 24H
Aboubakr Elnashar
6. Term PROM
Usually reflects physiological processes.
1.Apoptosis (programmed cell death) refers to the
natural deterioration and breakdown of cells and
cellular structure over time.
2. Uterine activity: As term approaches, increase
Braxton-Hicks contractions: repetitive stretching of the
membranes: weakening via
a.focal thinning
b.strain hardening (biomechanical phenomenon
associated with materials becoming less elastic and
less able to withstand stress).
Aboubakr Elnashar
7. In the absence of any intervention...
70% of patients will labour within 24 h
85% will labour within 48 h
95% will labour within 96 h
Aboubakr Elnashar
8. PPROM
usually has pathological origins.
1.History of PPROM in a previous pregnancy
2.Ascending infection
Major cause
Chorioamnionitis: membrane weakening
Majority: subclinical
2. Antepartum haemorrhage
particularly when recurrent
Aboubakr Elnashar
9. 3. Weak cervix
:It will fail as a barrier to ascending infection
:membrane prolapse: localized biomechanical
weakening
4. Smoking:
dose dependent.
reduction in smoking: reduce risk
Aboubakr Elnashar
10. CLINICAL ASSESSMENT
The correct diagnosis is crucial
{unnecessary interventions: increase maternal and
fetal morbidity}.
I. History
Gush of fluid' followed by recurrent dampness:
correctly identify over 90%of cases
Aboubakr Elnashar
11. II. Examination
Sterile speculum examination
Performed after rest supine for 30 m.
1. AF pooling in the posterior fornix
spontaneously or after fundal pressure.
Absence of any pooling is an equally important.
2. Meconium should be noted.
At preterm: suggestive but not diagnostic of intra-
amniotic infection
At term: relative contraindication to expectant tt
3. Cervical length and dilatation.
Aboubakr Elnashar
12. Digital examination
must be avoided unless the patient is thought to be
in established labour
{1. increase the incidence of chorioamnionitis,
postpartum endometritis, neonatal infection.
2. decreases the length of the latent period before
the onset of labour}.
Aboubakr Elnashar
14. III. Investigations
1.Bed side tests
Repeated dry pads argue against the diagnosis
Pads which change colour when in contact with
fluids with a pH >5.2
Aboubakr Elnashar
16. Ferning pattern
(when AF is dried onto a glass slide and then
viewed under a microscope).
Both:
Not reliable than basic history and examination.
{Appreciable false-positive and false-negative
rates}. Aboubakr Elnashar
17. Commercially available rapid bedside tests
Expensive
Indication:
confirm or refute the diagnosis of PROM in women
with negative speculum examinations.
Depend on:
Substances present in high concentrations in AF
Fetal fibronectin
Insulin-like growth factor binding protein 1
(IGFBPl),
ßhCG
alpha microglobulin-l (Amnisure)
Aboubakr Elnashar
18. Fetal Fibronectin
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%, Specificity-26.8%.
Aboubakr Elnashar
20. 2. Ultrasound: AFV
As a primary diagnostic tool
useful in women with a strong history of PROM but a
negative speculum examination, particularly if their
symptoms persist for 48 h or more.
In TPROM:
Limited value: {normal variation ranging from 250 to
1200 mL}
In PPROM: Very limited value {variation is much
greater in preterm gestations}
Correlate with latency in PPROM and with neonatal
mortality and morbidity in mid-trimester PROM.
Aboubakr Elnashar
22. MANAGEMENT
Term PROM
Risks
Foetal: ascending infection.
Maternal: uterine infection, via either chorioamnionitis
or postpartum endometritis.
Risks of induction of labour:
intrapartum complications
operative delivery
postnatal morbidity.
Aboubakr Elnashar
23. Factors linked with perinatal infection
1.increasing number of vaginal examinations after
membrane rupture
2.increasing interval between membrane rupture
and labour onset
3.increasing duration of active labour.
Aboubakr Elnashar
24. Cochrane Review
12 trials of 6814 women: active Vs expectant tt:
No significant difference in the rate of CS
Reduced risk of chorioamnionitis
Reduced risk of endometritis
No significant difference in the risk of neonatal
infection but...
Fewer infants requiring intensive/special care
Aboubakr Elnashar
25. Immediate induction:
-less maternal and neonatal infection
-shorter interval from membrane rupture to delivery
-No evidence that mode of delivery is influenced.
Aboubakr Elnashar
26. When oxytocin is used initially:
Lower health care costs
Decrease interval to delivery.
use of epidural analgesia is increased [A].
When prostaglandins are used initially:
infection risks marginally greater
interval to delivery slightly increased
oxytocin required subsequently in nearly half of the
women [A].
Oxytocin should be regarded as the first option
for induction of labour in women with prelabour
rupture of membranes (WHO, 2011).
Aboubakr Elnashar
27. Use of misoprostol.
Cost : lower
Oral:
lower the risk of infection.
Induction of labour (live fetus >24 w)
Vaginal: 25 ug 4-6 hrly OR
Orally: 50 ug 4-hrly OR
20 μg oral solution 2-hrly
Do not use if previous CS.
(Weeks & Faundes 2007; WHO, 2011)
Aboubakr Elnashar
28. Immediate induction of labour using oxytocin
should be recommended for women known to be
colonized with group B Streptococcus [B].
{Expectant management: 3-4-fold increase in risk of
neonatal infection, and even immediate induction
with prostaglandins failed to lower this}.
Aboubakr Elnashar
29. Preterm PROM
Risks
1.chorioamnionitis
WBC and CRP:
poor predictive ability
used to support a clinical diagnosis.
Oligohydramnios:
select a group at higher risk of infection and/or
earlier delivery
not diagnostic.
Aboubakr Elnashar
30. Chorioamnionitis
Diagnosis.
maternal pyrexia (>38°C)
and at least 2 of either:
maternal tachycardia> 100 bpm
fetal tachycardia> 160 bpm
uterine tenderness ·
raised CRP
offensive vaginal discharge.
When clinically suspected:
delivery is almost always appropriate {antibiotic
therapy is rarely curative}.
Aboubakr Elnashar
32. 2. PTL:
In contrast to preterm labour with intact membranes,
TVS measurements of cervical length are not
predictive of early delivery.
3. Abruption:
risk varies inversely with gestational age
5%
50%: <24 W
4. Cord prolapse
5. Operative delivery.
Aboubakr Elnashar
33. Management
1. Steroids
Although neonates born after PPROM have lower
incidences of RDS when compared to preterm
labour, maternal steroids still appear to reduce the
risk further [A].
No significant increase in maternal sepsis
Aboubakr Elnashar
35. 3. Antibiotics
Erthryomycin is recommended
(250 mg qds for 10 d):
significant reduction (from 14.4 to 11.2%) in the
composite primary outcome, a measure of neonatal
mortality and major morbidity [B).
Aboubakr Elnashar
36. Group B Streptococcus carriers organism:
usually sensitive to erythromycin.
After completion of a 10-day course, further
antibiotics should probably be withheld until labour
starts.
Aboubakr Elnashar
37. 4. Umbilical artery Doppler, biophysical Profile:
Value:
1.Not effective at early identification of the infected
fetus.
2. Monitoring of fetal growth
{PPROM is associated with growth restriction}
Aboubakr Elnashar
38. Pre-viable PROM below 23-24 ws
Risks:
1.Pulmonary hypoplasia
Lethal
{Lung development is partly reliant on normal AFV}.
cannot be reliably predicted by US.
2. chronic pulmonary morbidity
3. fetal limb contractures
4. extremely preterm birth with consequent co-
existent morbidity and mortality
Many parents will opt for termination of pregnancy.
Aboubakr Elnashar
39. PPROM at 34-37 w gestation
induction, as opposed to expectant management,
may lead to
less hospitalization
less perinatal infection and
less neonatal morbidity [B).
Aboubakr Elnashar
40. In-patient versus outpatient care
48-72 h:
In-patient
{many women will labour or develop clinical
chorioamnionitis}
After this:
Outpatient may be decided
Inform:
potential risks
temperature twice daily
S&S of developing chorioamnionitis.
Aboubakr Elnashar
41. Conclusions
Term PROM is usually a reflection of normal
physiology, whereas pathological processes, such as
infection and antepartum haemorrhage, often
underlie PPROM.
Aboubakr Elnashar
42. Accurate diagnosis of membrane rupture is
essential and can usually be achieved by simple
history and speculum examination alone.
A digital vaginal examination should always be
avoided after PPROM unless advanced labour is
suspected.
Aboubakr Elnashar
43. At term, early induction using oxytocin appears to
reduce perinatal infection and shorten hospital stay
without increasing operative intervention.
At term, women known to be colonized with group
B Streptococcus should be encouraged to allow
immediate induction of labour using oxytocin after
PROM.
Aboubakr Elnashar
44. After PPROM, optimal management includes
maternal steroids and oral erythromycin.
Maternal steroid use in PPROM reduces the risk of
respiratory distress syndrome.
Erythromycin used for 10 days after PPROM is
associated with a significant reduction (from 14.4 to
11.2%) in neonatal mortality and major morbidity.
Aboubakr Elnashar
Utilize fFn as a piece of the clinical puzzle, especially if a patient is presenting with PTL symptoms.
Fetal Fibronectin is sometimes used in conjunction with cervical length measurements to determine PTB in non-ruptured patients.
