4th stage
ObstetricsLec-
د.اسماء
3/2/2016
PROMThe student at the end of this lecture should be able to:
Diagnose PROM in patient with history of gush of fluid.
Exclude the chrioamnionitis in case of PROM.
Predicting the risk of PROM .
Decide termination of pregnancy with PROM at a given gestation .
Determine the role of steroid and tocolytic drugs in patients with PROM.
Premature Rupture of the Membrane) PROM(:
Defined as : rupture of the membrane before the onset of spontaneous uterine activity.Incidence is 10% in pregnancies (majority)
Preterm premature rupture of the membrane (PPROM): if PROM occurs before 37 completed weeks.
Incidence is 2% of pregnancies.
Aetiology of PROM:
Remain unclear:
Vaginal and cervical infection.
Abnormal membrane physiology.
Incompetent cervix.
Nutritional deficiency of copper ,or ascorbic acid.
Risk of PROM
Maternal:Infection :chorioaminionitis ,rarely systemic infection.
Abruptio placentae (4-7%).
Induction of labour .
Operative delivery.
PPH.
Fetal risk:
Prematurity,75% will deliver with in 2 weeks.Neonatal sepsis.
Oligohydramnios.
Hypoxia: cord prolapse and copmression.
Morbidity from delivery because of increased incidence of malpresent. and oligohydramnios.
Pulmonary hyperplasia :in fetus with PPROM
at early gestational age (10% at gestation of 24 weeks) especially if the pool of amniotic fluid is less than 2 cm.
Positional skeletal abnormality. as talipes equinovarus(depends on duration of PROM).
Management of PROM:
Diagnosis of PPROM:
Suggestive history :gush of liquor, gestational age, uterine contraction, reducedfetal movement with oligohydramnios .
Sterile vaginal speculum examination.
-amniotic fluid draining through the cervix,sample may be obtained for pulmonary maturity test.
Check the cervix for signs of labour
vulsava maneuver or slight fundal pruture may expell the fluid from the cervix .
in case of doubt:
-vaginal fluid with alkaline PH (nitrazine test).
-ferning on microscopy.
Amniotic fluid for culture and sensitivity.
and pulmonary maturity test .(Lung profile L/S ratio is >2 and phosphotidylglycerol is present then RDS is rare).Ultrasound :for evaluation of the amniotic fluid volume.
Fetal Fibronectin immunoassay
During initial clinical assessment exclude:
Overt chorioamnionitis:
maternal tachycardia ,pyrexia ,uterine tenderness,
purulent vaginal discharge and fetal tachycardia.
Evaluation of the fetal gestational age:
history; Lmp, examination and US.
Immediate fetal well being:
Examination , CTG.Exclusion of abruptio placentae and preterm labour:
Management of PPROM
Management still controversial between :conservative management in patient before 34 weeks.
Induction of labour relatively early in those more than 36 weeks .(after 6 hour in favorable cervix or delay after 24 hours in case of unfavorable cervix)
Those in between 34-36 weeks ,there is No clear evidence on the ideal management.
Conservative management include:
Surveillance for chorioamnionitis :-temperature ,pulse ,CTG.
-WBC,C-reactive protein.
-Lower genital tract swab and culture and sensitivity,
positive culture for potential pathogen is not correlated with the risk of chorioamnionitis ,but are useful in determining the causative organisms for chorioamnionitis and fetal infection.
If choroamnionitis dx. Treatment by antibiotics and delivery (induction and even C.S.)
Corticosteroid administration.
usually not required because RDS is decreased in infants born after 16 hours after rupture of membrane and their use only increase the risk of infection
Tocolytic drugs: are contraindicated in case of infection, side effects of drugs may be mistaken for chorioamnionitis.
They are used to gain time for pulmonary maturity.
Antibiotics : not used routinely because it can
mask the symptoms of infection and can lead to
resistant infection only indicated in the presence of
B streptococci by culture (penicilline G)
Prognostic factors
Gestational age at PROM.Incidence of chorioamnionitis in the institusion.
Amount of amniotic fluid remaining after PROM.
