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(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
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
Investigarion
1. Nitrazine test
pH (Nitrazine) turns blue as the pH of
amniotic fluid is usually (7.1-7.3)
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 )
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
7.
Aminiocentesis
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:
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 .
Case2
:_-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
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
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.
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.
Ultrasound
Cervical length
History
Ask about risk factor :
Obstetric complications (MultiplePregnancy,PPROM,Idiopathic
preterm labour,Pre eclampsia,Antepartum hemorrhage.......) .
Racial factors (Black women ) .
History
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.
Prevention
Interventions have been aimed at general
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
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:
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
Intrapartum management