Vous êtes sur la page 1sur 63

of the membrane

(PROM)
The definition of PROM is rupture of
membranes before the onset of labor.
Membrane rupture before labor and
before 37 weeks of gestation is
referred to as preterm PROM

Case
A 26-year-old G2P1 woman, who is 31 weeks
gestation, presents to the labor unit
complaining of leakage of fluid and she thinks
that her bag of water broke. She reports a
gush of fluid about 2 hours ago. The fluid ran
down her leg and appeared clear with no
noticeable odor.
Her prior pregnancy was complicated by preterm
labor and premature rupture of the membranes
at 26 weeks gestation. The neonates course
was, acomplicated by necrotizing enterocolitis,
respiratory distressnd death at 28 days of life.

Clinical diagnosis
&assessment

1.History

. The most reliable diagnostic feature of PPROM from the


history is the report of a gush of fluid vaginally, usually
followed by a more-or-less continuous dribble.
. This must be distinguished from leaking urine (ask about
frequency, urgency, leakage and dysuria), as
incontinence
or a urinary tract infection (UTI) may present in a similar
way.
. Fetal movements may be reduced in strength or
frequency after PPROM, and occasionally uterine
irritability or contractions may be reported

Also from the history we can identify the patient risk factors
Which include :
Vaginal, cervical and intraamniotic infections
Prior PROM
Prior preterm delivery
Low socioeconomic status
Second and third-trimester bleeding
Low body mass index
Cervical insufficiency
Cervical conization/LEEP
Connective tissue disorders (Ehlers-Danlos syndrome)
Nutritional deficiencies of copper and ascorbic acid
Maternal cigarette smoking
Uterine overdistension
Amniocentesis

2. Examination
Abdominal examination
Abdominal examination may reveal a clinical
suspicion of oligohydramnios or uterine
tenderness if chorioamnionitis is present

Sterile speculum examinaton


The definitive diagnosis of PPROM can only
be made by performing a sterile speculum
examination, preferably after the patient
has been resting supine for 2030 minutes

A pool of amniotic fluid in the


posterior vagina is diagnostic
It is also important at this point to visualize the
cervix. Fluid may be seen trickling through the
external
os examinations
Digital
vaginal
should be avoided if possible
in PPROM, as it is known to
increase the risk of
chorioaminionitis , postpartum
endometritis , neonatal
infection

Investigarion
1. Nitrazine test
pH (Nitrazine) turns blue as the pH of
amniotic fluid is usually (7.1-7.3)

False positive Nitrazine may occur


due to
Alkaline urine
Semen
Blood
Cervical mucus
Antiseptic solutions
Bacterial vaginosis

2.Ferning
Fluid from the posterior fornix is placed on a
slide and allowed to dry aminiotic fluid will
form afern like pattern of crystallization

3. Ultrasound
Ultrasound can give valuable information
about the amniotic fluid volume. The
presence or absence of oligohydramnios
provides further diagnostic support. In
established PPROM, there is a direct
correlation between the amount of amniotic
fluid remaining and the latency period.
Normally
DVP ( 2 - 8 cm )
AFI ( 5 -25 cm )

4. Testing for gonorrhea and chlamydia


5. Group B streptococcus culture
should be send from anorectall and
vaginal areas

6. Specialized test : Vaginal swap

for
A. Fetal fibronectin
It is aglycoprotien present in large amount in
the aminiotic fluid it can be detecred by
(ELIZA )
Positive result (>50 ng/dl) may be
indicative of PROM

B. Insulin-like growth factor binding


protien 1
C. HCG
All are present in high concentration in
the aminiotic fluid

7.

Aminiocentesis

A sample of amniotic fluid can be sent for Gram


stain, microscopy and culture, to establish
whether there is an intrauterine infection
(chorioamnionitis)

Management of
preterm PROM
In many units, women
with a diagnosis of
pPROM are admitted
into hospital &
managed
conservatively until 37
completed weeks of
gestation to increase
fetal lung maturity.

A. Conservative management
include:

1. Admission: to hospital & placed in bed rest


with bath room privileges.
2. Maternal surveillance: monitor for sign &
symptoms pf infection by :
Four_ hourly measurements of maternal temp,
HR,RR,BP.
Weekly maternal WBC counts ,C-reactive protein,
culture of vaginal swabs, all in an effort to detect
intrauterine infection or chorioamnioitis

3. Fetal surveillance: by NST & biophysical profile


BPP abnormalities of these tests can be somewhat
predictive of fetal infection & umblical cord
compression related to oligohydramnios .

4. Erythromycin : (250 mg orally 6 hourly) for 10


days following the diagnosis of PPROM , co_amoxiclav is
not recommended for women with PPROM because of
concerns about necrotizing enterocolitis .
5. Corticosteroid : should be given in women with
PPROM at 24-34 weeks , to reduce the incidence of
RDS ,IVH ,NEC and lower neonatal death rate.
They dont appear to increase risk of infection in either
mother or baby.
6. Tocolytics : may be used for women with PPROM &
uterine activity who require intrauterine transfer or
antenatal corticosteroids( tocolytics 48h to allow
administration of corticosteroid ) .

7. Aminoinfusion for prolong latency : transabdominal


aminoinfusion is not recommended as amethod of
preventing pulmonary hypoplasia in very preterm PPROM .
8. Fibrin glue : fibrin sealants are not recommended as
routine for 2nd trimester oligohydromnios caused by
PPROM.
9. VIT. C & E : there is insufficient evidence to assess the
effect of vitamin supplementation in women with PPROM
,in one small trial, compared with placebo vit C 500 mg
& vit E 400 IU daily in women at 26-34 weeks was
associated with 7 day prolongation in latency but no other
effect on maternal or neonatal morbidity & mortality.

Role of outpatient managment


Out patient monitoring should be considered only after a
period of 48-72h of inpatient observation in cases :
1. If leakage of fluid stops .
2. The amniotic fluid volume normalizes .
3. The patient remain a febrile without evidence of increasing
uterine irritability .

She can be discharged home . these patients should be


monitored very closely on an outpatient basis with follow-up
appointments.
They also must take their temperature 2 daily & be counseled
on the warning sign of chorioamnionitis .
These patients should also be monitored with frequent
biophysical profiles , some sources recommend daily testing .

When is the appropriate time


to delivery
Delivery should be considered at 34 weeks of
gestation.
Pregnancies beyond 34w EGA can be
managed as a term pregnancy because there
is no evidence that antibiotics , corticosteroid ,
or tocolytics improve outcome in these
patients.
These patient can be managed expectantly as
long as they show no signs of chorioamnioitis .

Randomized trial have suggested


that a policy of induction as opposed
to expectant management may lead
to less hospitalization , less perinatal
infection & less neonatal morbidity.
Where expectant management is
considered beyond 34 w of gestation,
women should be counselled about
the increased risk of chorioamnionitis
& its consequences .

B. Indication for patient who


requires delivery in preterm
PROM
1. Patient in labour (frequent uterine
contraction ,cervix 100% effaced & 4
cm dilated or more).
2. Mature fetal lung checked by
amniocentesis (by L/S ratio,
phosphoatidyle glycerol PG).
3. Fetal malformation ( gross anomaly
incompatible with life).
4. Fetal distress.

5. Patient with subclinical amnionitis .


(amniocentesis of gram stain &
culture is accepted technique ).
6.Patient with overt infection (patient
with clinical choroioamnionitis should
received antibiotics before delivery
inform of (ampicillin 2g i.v. 4 times
daily & metronidazole 500 mg i.v. 3
times daily .

7. Patient at high risk of infection :

Pt taking immunosuppressant drugs


History of rheumatic heart d.
Sickle cell disease .
Heart valve prosthesis .
Several pelvic examination since PROM
occur .

Previable PROM bellow 2324 wk


There is significant risks of lethal
pulmonary hypoplasia a condition
that cant be reliably predicted on
prenatal U/S additional risk include
chronic pulmonary morbidity , fetal
limb contractures , many parent will
option for termination of pregnancy .

Complication:
1. Infection
chorioamnionitis .
2. Abrubtio placenta :
usually occure with in the
setting of prolonged and
severe oligohydraminos
3. Fetal distress :due to
cord compression .
4. Perinatal death 24w .

5.PPROM include premature labour


/delivery with related complication of
prematurity such as
Respiratory distress syndrome
Inraventricular hemorrage
Periventricular leukomalacia
Infection and necrotizing enterocolitis

6. Pulmonary hypoplasia : is frequent when it


occure 26 w and if the latent period prolonged
for more than 5 w
7. Compression deformities facial & skeletal
deformiti
8.Long term infant morbidities .
9. Increase need for c/s
10. Retained placenta

What treatment can this patient


be offered in a future pregnancy
to decrease her recurrence risk
for preterm PROM and preterm
delivery?
Recent studies have suggested
progesterone therapy to reduce the
risk of recurrent spontaneous
preterm birth resulting from preterm
labor or PROM.

Case2

year old female G2P1 at 30 wks-24


of gestation was admitted 2 days
ago for PROM .her antenatal hx
was unremarkable . Fetal
movement was normal and she
.denies any fever or chill
On examination :_temp 100.8 f ,
BP100/60 ,HR90 bpm , on
auscultation clear lung and no
costovertebral angle tenderness
is found Fundal height was 30 cm
and is slightly tender , no lower
extremity or cord are palpated ,
fetal heart tones is persistently in
the 170 -175 bpm without

:_-SUMMARY
A24-year old G2P1
woman at 30 wks
gestation was
admitted 2 days ago
for PROM . Her temp
is 100.8F .,the uterine
fundus is slightly
tender , there is
persistent fetal
tachycardia in the
170-175 bpm range

WHAT IS the most- 1


?likely DX
WHAT IS the best-2
?MX for such case
WHAT IS the most-3
likely etiology of this
? condition

The diagnosis is
intra aminotic
infection
(chorioaminoniti
s)

:_MX
THIS FEMALE should be given
IV antibiotics (ampicillin 2g
4times daily and
metronidaZOL 500 mg iv 3
times daily ) and should
offered induction of labour
after confermation of fetal
lung maturity by L/S ration
and phosphatidyleglycerol

The etiology of this


condition was
ascending infection
from the vagina and
the most common
organism based on the
culture of
aminocentesis are
anaerobes then GBS
THEN other
streptococci

Preterm Labour

Definition
Preterm labour is defined by WHO as Onset of
labour prior to the completion of 37 weeks of
gestation, in a pregnancy beyond 20 wks of
gestation.
The period of viability varies in different countries
from 20 to 28 wks.
Preterm labour is considered to be established if
regular uterine contractions can be documented
atleast 4 in 20 minutes or 8 in 60 minutes with
progressive change in the cervical score in the
form of effacement of 80% or more and cervical
dialatation >1cm.

If uterine contractions are perceived in the


absence of cervical change, the condition is called
Threatened Preterm Labour.
This condition tends to be over diagnosed and
over treated.
Nearly 50-60% of preterm births occur following
spontaneous labour.
30% due to preterm premature rupture of
membranes
Rest are iatrogenic terminations for maternal or
fetal benefit.

introduction
Half of all neonatal morbidity occurs in
preterm infants.
Inspite of all major advances in obstetric
and neonatal care, there has been no
decrease in incidence of preterm labour
over half a century.
On the contrary , it has been increasing in
the developed countries as more and
more high risk mothers dare to get
pregnant.

Incidence
Preterm birth occurs in 5-12% of all pregnancies
and accounts for majority of neonatal deaths
and nearly half of all cases of congenital
neurological disability, including cerebral palsy.
A neonate weighing 1000- 1500 g today has ten
times greater chance of surival then what it had
in 1960s.
The focus is hence shifting to early preterm
births(<32 weeks) which account for 1-2% of all
births but contribute to 60% of perinatal
mortality and nearly all neurological morbidity.

One of the major reasons for increase


in incidence of premature births is
the increase in numbers of multiple
pregnancies , particularly higher
order pregnancies, resulting from the
use of fertility drugs and assisted
reproduction.

Prediction of Preterm Delivery


History .
Examination .
Biochemical
Fetal fibronectin

Ultrasound
Cervical length

History
Ask about risk factor :
Obstetric complications (MultiplePregnancy,PPROM,Idiopathic
preterm labour,Pre eclampsia,Antepartum hemorrhage.......) .
Racial factors (Black women ) .

Demographic factors (low BMI,Age- women younger than 17


and older than 35 yrs-,Poor education,Minimal or no prenatal
care,Low socioeconomic status )
Psychosocial factors (Anxiety,Depression,Excessive alchohol
intake,Smoking ) .
Past obstetric history (Previous h/o preterm birth,3 or more
abortions ,Conceptions following in-vitro fertilization,Cervical
incompetence ) .

History

Infection : Result in 50% of spontaneous


preterm births and include :
Asymptomatic bacterial vaginosis
Trichomonas vaginalis
Chlamydia trachomatis
Ureaplasma urealyticum
Mycoplasma hominis
Asymptomatic bacteriuria
Genetic factors .

Examination
Abdominal examination : uterine
tenderness, suggesting abruption or
chorioamnionitis.
Speculum examination : Pooling of
amniotic fluid, blood and/or abnormal
discharge .
Visual assessment of cervical dilatation:
accurate as digital examination findings.
Cervical change/80% effacement/> 2cm
dil.

Biochemical
Fetal Fibronectin (fFN) :
Glycoprotein in amnion, decidua,
cytotrophoblast .
It can be normally present in cervicovaginal
secretions upto 20-22 wks.
the presence of fFN between 27 to 34 wks can
provide important marker of preterm labour .
A cut-off of 50ng/ml is considered positive.
Presence of fibronectin indicates increased risk of
preterm labour (89% sensive and 86% specific)
A negative fFN indicated very low risk of preterm
delivery.

Sonographic Assessment of Cervical


Length

A reduction in cervical length of >6mm

between 2 ultrasounds have higher risk.


Funneling( internal os diameter >=5mm) is

also independent risk factor.

Sonographic Assessment of Cervical


Length

Prevention
Interventions have been aimed at general

improvement in nutrition, rest , hydration and


psychological support.
Adequate antenatal care
Cervical cerclage
Nutritional intervention: iron, calcium, vit-C, zinc,
proteins
Bed rest and hydration
Antiboitics: antibiotic therapy at 24 wks and repeated
in labour reduced the incidence of bacterial vaginosis
and trichomoniasis but did not have significant effect
on preterm labour.

Management of Preterm Labor


Two goals of management:
Detection and treatment of disorders
associated with PTL
Therapy for PTL itself

First of all we should do :

Bedrest, hydration, sedation .

OPTIONS FOR
MEDICAL
MANAGEMENT

Drug

Mechanism

Efficacy

Side Effects

Contraindicatio
ns

Beta
adrenergic
receptor
agonist
(terbutaline )

Interferes w/
myosin light
chain kinase

? 48 hours.

Tachycardia,
palpitations,
hypotension,
SOB,
pulmonary
edema,
hyperglycemia

Maternal cardiac
disease,
uncontrolled
diabetes and
hyperthyroidism

Magnesium
Sulfate

Competes with Unproven


Calcium at
plasma memb
(?)

Diaphoresis,
flushing,
pulmonary
edema

Myasthesthenia
gravis, renal
failure

Ca Channel
Blocker
(nifedipine)

Directly block
influx of Ca
thru cell
membrane

Unproven

Nausea,
flushing, HA,
palpitations

Caution: LV
dysfunction, CHF

Cyclooxygen
ase
Inhibitors
(indomethaci
n)

Decrease
prostaglandin
production

Unproven

Nausea, GI
reflux, spasm
fetal DA, oligo

Platelet or hepatic
dysfunction, GI
ulcer
Renal dysfunction,
asthma

Inhibits actin
myosin
interaction

No change
in perinatal
outcome

Antenatal Steroids
Recommended for:
Preterm labor 24 34 weeks
PPROM 24 32 weeks

Reduction in:
Mortality, IVH, NEC, RDS

Mechanism of action:
Enhanced maturation lungs
Biochemical maturation

Antenatal Steroids
Dosage:
Dexamethasone 6 mg q 12 h
Betamethasone 12.5 mg q 24 h

Repeated doses - NO
Effect:
Within several hours
Max @ 48 hours

Progesterone:

Progestational agents and 17-

hydroxy progesterone caproate


reduced the incidence of preterm
births and low birth weight babies.

Cervical cerclage
Indication :
3 or more previous PTL and/or 2nd T

losses .
History of one or more spontaneous
mid-trimester losses or preterm
births +TVS: cervix is 25 mm or less .

Lifestyle modification

Stop smoking .
Sexual abstinence and/or

psychological support: should not be


recommended as a universal or
general measure in high-risk
women .

Intrapartum management

1. Monitoring: Fetal hypoxia and acidosis may


increase the risk of intraventricular hemorrhage.
The preterm fetus should be monitored closely
for signs of hypoxia during labour, preferably by
continuous electronic fetal monitoring.
2. Antibiotic prophylaxis: In countries with high
incidence of group B streptococcal infection.
3. Delivery: Delivery must be conducted in the
presence of expert neonatologist capable of
dealing with complications of prematurity.
Ventouse is contraindicated in preterm deliveries.

4. Caesarian section: only for obstetric indications.

Bottom Line Concepts


Preterm labor - Regular uterine contractions, with
cervical change or > 2 cm dilation or > 80%
effacement, occurring before 37 weeks
There are numerous risk factors both modifiable and
non-modifiable. Counsel patients regarding ways to
reduce their modifiable risk factors
Clinical assessment of risk includes consideration and
evaluation of history, cervical length and fetal fibronectin
There are a variety of tocolytic drugs available, though
most have unproven efficacy
Antenatal steroids are recommended for: Preterm labor
24 34 weeks and PPROM 24 32 weeks