PROM

PRE-LABOUR RUPTURE OF MEMBRANES ( PROM )

2015-2016

Pre-labour rupture of membrane (PROM )

refers to spontanous rupture of membrane with leakage of amniotic fluid in the absence of uterine activity at any gestational age.

Term premature rupture of membrane (PROM) refers to a patient who is beyond 37 wks gestation & has present with rupture of membrane prior to the onset of labour

Preterm premature rupture of membrane (PPROM) is rupture of membrane prior to 37wks gestation

Aetiology

Term PROM
Rupture of membrane at term usually reflects physiological processes.

Preterm PROM

It usually has pathological origins
1-ascending infection appears one of the major causes
.2-antepartum haemorrhage (APH).
3-cervical weakness (incompetence).
4-maternal smoking.

Risk factors

1-low socioeconomic status
2-low body mass index.
3-smoking
4-history of previous preterm labour
5-UTI
6-vaginal bleeding at any time in pregnancy
7-amniocentesis.

Complications (risks) of PROM

A-Maternal risks

1-intrauterine infection

2-abruption placenta
3-PPH
4-retained placenta
5-puerperal sepsis & septic shock leading to maternal death.

B-Fetal risks

1-infection
2-prematurity & it's complications
3-increase the risk of cord prolapse
4-pulmonary hypoplasia
5-fetal or neonatal death.

HISTORY

...calculate gestational age
....past obstetric history (parity, previous history of PROM)
....gush of fluid vaginally with continued leakage from vagina sometimes or leaking in dribbles, ask about duration, odor & colour
....ask about vaginal bleeding
....ask about fever
...ask about fetal movement as it may be reduced.

Note.

the watery vaginal discharge due to rupture of membrane must be distinguished from;
*episodic urinary incontinence (so ask about freguancy, urgency, incontinence & dysuria) as UTI may present in a similar way with slight urine leakage).
*leucorrhoea (increase amount of normal vaginal discharge) is common in pregnancy , so ask about previous vaginal discharge.

EXAMINATION

General
...the woman may be flushed & her temperature & pulse rate increased if there is infection.
Abdominal
...presence of tenderness over uterus suggesting infectio...fundal height may be less than period of amenorrhoea.
...fetal heart sound.
Vaginal (sterile speculum examination).
...leakage of fluid from the cevix.
...visual inspection of cervix to estimate any cervical dilatation.
...examine for lie & presentation.


INVESTIGATIONS
1-haemoglobin
2-leukocytes count.
3-C-reactive protein.
4-general urine exam.
5-pelvic USG.
6-Nitrazine test .
7-Fern test
8-amnio dye test ot tampon test.
9-Amnisure test.
10-cervical culture including Chlamydia & Neisseria.

Diagnosis

TREATMENT
The treatment varies depending on the gestational age of the fetus.
All patients with ROM should be asked to come to hospital & the treatment options are;

1-Delivery (active management )

2-Conservative (expectant management ).


1-Delivery
Induction of labour by oxytocin if there is no contraindication for vaginal delivery. The delivery indicated if patient in active labour, or with chorioamnionitis, fetal distress & placental abruptio.

2-Consevative (expectant management ) include;

A-hospitalization
B-discussion of the risk & benifits of this management with patient & her family
.C-bed rest
D-no pelvic examination unless indicated.
E-abdominal examination to detect any abnormal lie or presentation.
F-evaluation of maternal & fetal status daily.
G-continued clinical observation of mother for signs of chorioamnionitis 12 hourly apart.

H-continued clinical observation of fetus by using CTG for fetal tachycardia & fetal movement.
I-serial investigations ( WBC count, C-reactive protein, vaginal cultures & HSG ).
J-prophylactic antibiotics; Erythromycin.
K-corticosteroids.
L-tocolysis in case of PPROM is not recommended
M- We should stop expectant & shift to delivery if there is evidence of chorioamnionitis, maturity, spontaneous onset of labour
N-neonatologist should be informed.

Treatment according to gestational age

A-Term PROM
Induction of labour with oxytocin is usually recommended as it decrease risk of infection & shorten hospital stay.If expectant management was chosen as they are waiting for spontaneous labour to begin, it should not last more than 24hr, if labour not begin, induction of labour should be done .


B-Preterm PROM (PPROM)
The management is a balance between the risk of prematurity if delivery occur vs the risk of maternal & fetal infection; before 34 wk....conservative management if there is no indication to immediate delivery. Btween 34-37wk....induction of labour is of benefit than conservative management.

Chorioamnionitis

an inflammation of the fetal membranes (amnion & chorion ) due to bacterial infection.It can be diagnosed by one or more of the following;
1-maternal pyrexia > 38C°
2-maternal tachycardia >100 beats/min.
3-uterine tenderness
4-offensive vaginal discharge.
5-fetal tachycardia >160 beats/min.
6-raise C-reactive protein
7-raise in maternal WBC count.

Delivery by induction of labour, avoid CS as much as you can because of risk of maternal infection, with IV broad spectrum antibiotic.

Complications

A-maternal
1-septicemia
2-infection in the pelvic region & abdomen.
3-endometritis (an infection of the endometrium ).


B-newborn infant
1-sepsis
2-meningitis
3-respiratory problems.

Nitrazine test

Fern test

Amnisure test

Speculum examination

THANKS