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relabor upture f embranes

Zaida T. Villanobos 3/15/12

Prelabor rupture of membranes (PROM) rupture of membranes prior to onset of labor Preterm prelabor rupture of membranes (PPROM) of membranes rupture prior to 37 weeks gestation 3/15/12

DEFINITIO N

DEFINITIO N

Spontaneous prelabor rupture of membranes (SPROM) of membranes rupture after or with the onset of labor Prolonged rupture of membranes any rupture of membrane that persists for more than 24 hours and prior to onset of labor

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DEFINITIO N

PRO M

DELIVE RY
Latent Period

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Amniotic Fluid

Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12

amnion

Amniotic Fluid

Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12

chorion

Amniotic Fluid

Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12

decidua

Amniotic Fluid

Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12

amniochorialdecidual unit

Amniotic Fluid

Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12

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Schematic representation of the structure of the fetal

When do membranes normally rupture?

In a proportion of women, spontaneous rupture of membranes is a function of cervical dilatation most patients have spontaneous rupture of membranes at the:

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When do membranes normally rupture?

In a proportion of women, spontaneous rupture of membranes is a function of cervical dilatation most patients have spontaneous rupture of membranes at the:

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end of the first stage of labor

Where is the site of membrane rupture?

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Where is the site of membrane most dependent part of rupture?

the uterine cavity in close proximity to the cervix membranes apposed to the cervix have localized morphologic changes which have been referred to as : of altered zone morphology 3/15/12 (ZAM)

DEFINITIO N
Zone of Altered Morphol ogy (ZAM)
weakened area of membranes characterized by: marked swelling and disruption of the connective tissue thinning of the trophoblast layer thinning or absence of the decidua increased programmed cell death (apoptosis) significant decrease in the density of collagens (I, III, and V)

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INCIDENC P EROM 3% to 18.5%


Term PROM prior to onset of labor

8% to 10%
PPROM

25 % of all cases of PROM 3/15/12

INCIDENC P EROM 3% to 18.5%


Term PROM prior to onset of labor

8% to 10%
PPROM

responsible for 30% of all prelabor 3/15/12

ETIOLOGY Normally, fetal membranes are extremely resistant rupture early in pregnancy

to

can withstand rupture from nearly all causes of nonpenetrating forces


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Labor Increased intrauterine pressure Exert pressure over the weakened area of the membrane (ZAM) PCD + activation of catabolic enzymes(collagenases)

Rupture of membranes

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Premature activation

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Preterm Prelabor Rupture Of Membranes

ETIOLOG Y

Early PROM also appears to be linked to underlying pathologic processes. A scholarly review of the etiology of PPROM identified numerous potential causes.

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Some genital bacteria elaborate inflammation enzymes and/or proteases infection of the phospholipase membranes s decreased collagenases collagen content of the membranes (type III) decrease tensile strength of membranes

stretching of the surface area of uterine cavity

Stress membranes

Preterm Prelabor Rupture Of 3/15/12 Membrane

ETIOLOG Risk factors for PPROM: Y

Low socioeconomic status 3/15/12

Smoking

ETIOLOG Risk factors for PPROM: Y

Hx of STI 3/15/12

Previous preterm deliveries

ETIOLOG Risk factors for PPROM: Y

Vaginal bleeding 3/15/12

Uterine distension

Polyhydramni os

ETIOLOG Risk factors for PPROM: Y

Vaginal bleeding 3/15/12

Uterine distension

Polyhydramni Polyhydramni os os

ETIOLOG Risk factors for PPROM: Y

Vaginal bleeding 3/15/12

Multiple Polyhydramni gestation os


Uterine distension

ETIOLOG Risk factors for PPROM: Y

Vaginal bleeding 3/15/12

Multiple Polyhydramni gestation os


Uterine distension

SIGNIFICANC E

Prematurity:
- 15% of neonatal morbidity and mortality 3/15/12

SIGNIFICANC E

Prematurity:

PPROM = leading cause of preterm delivery

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SIGNIFICANC E

Prematurity:

PPROM = complicates 3% of all pregnancies

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DIAGNOSI Presenting Symptom (90 % S accurate):


gush of fluid from the vagina

persistent leak

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DIAGNOSI I. Speculum Exam S

confirm and evaluate cervical dilatation and effacement after PROM

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DIAGNOSI ISSpeculum Exam .

confirm and evaluate cervical dilatation and effacement after PROM

*Precaution: Avoid digital cervical exam in PPROM ! Disadvantages: - raises infection risk, other morbidities - reduces time to labor by 9 days
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I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

A.

Technique

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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Patient lies semirecumbent for 45 minutes . Consider elevating buttocks on cushioned pan . Perform speculum exam after pooling for 45 minutes
.

I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

B.

Interpretation

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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Pooling of fluid suggests ROM . If no fluid seen : - Apply gentle fundal pressure or have patient cough - Fluid may be seen passing from cervical os
.

I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.
A.

Technique

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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Obtain fluid for exam (usually after Vaginal Pool) . Place sample on glass slide .Allow sample to air dry for 10 minutes
.

I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

B. Interpretation Slide shows ferning pattern under microscopy

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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(+) Fern test

I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

B. Interpretation Slide shows ferning pattern under microscopy

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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(-) Fern test

I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

Vaginal Pooling

C. Efficacy Accuracy for amniotic fluid: 84 to 100% Test Sensitivity: 100% (when allowed to dry 10 minutes )

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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D. False positive: Cervical mucus

I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:

A.

Technique Obtain fluid for exam (usually after Vaginal Pooling) Place Nitrazine paper in fluid Paper turns bright blue in alkaline fluid

1.

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

Vaginal Pooling

B. Interpretation: Nitrazine Paper Normal Vaginal pH (4.5-6.0): Paper does not change color

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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Ruptured Vaginal pH (7.1-7.3): Suggests PROM (paper blue)

I.

DIAGNOSI S Speculum Exam


Methods to confirm ROM:
1.

Vaginal Pooling

2. Vaginal Fluid Ferning 3. Vaginal Fluid pH (Nitrazine Test)


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C. False positive results: contamination with cervical secretions & blood and secretions 2 to vaginal infections semen, antiseptic solutions

DIAGNOSI II. Ultrasound examination S

show absence or very low amounts of AF in uterine cavity Dx unclear (ex. oligohydramnios, concomitant bleeding): *Alternative invasive method: 1. Uses Indigo carmine dye 1 ml in 9 ml sterile NS 2. Instilled into uterus via amniocentesis 3/15/12 3. Vaginal tampon turns

DIAGNOSI III. Biochemical Properties S of AF


Increased concentrati on:

hCG alpha -fetoprot ein creatinin e endotheli n-1 protein molecule present in AF w/c has the capacity to: generate uterine contractions activate phospholipase A2 & phospholipases

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DIAGNOSI III. Biochemical Properties S of AF


Increased concentrati on:

hCG alpha -fetoprot ein creatinin e endotheli n-1

Presence in cervical/vag inal secretions: fetal fibronect in

insulin-like growth factor binding protein-1 (IGFBP-1)

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COMPLICATION S 1. Early delivery (prematurity) Latent period inversely proportional to


AOG at which PROM occurs: term - 1 day latency preterm - 1 week latency

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COMPLICATION S 1. Early delivery (prematurity) PROM, surviving With too early


neonates may have: malpresentation

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COMPLICATION S 1. Early delivery (prematurity) PROM, surviving With too early


neonates may have: malpresentation cord compression

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COMPLICATION S 1. Early delivery (prematurity) PROM, surviving With too early


neonates may have: malpresentation cord compression oligohydramnios

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COMPLICATION S 1. Early delivery (prematurity) PROM, surviving With too early


neonates may have: malpresentation cord compression oligohydramnios necrotizing enterocolitis

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COMPLICATION S 1. Early delivery (prematurity) PROM, surviving With too early


neonates may have: malpresentation cord compression oligohydramnios necrotizing enterocolitis neurologic impairment
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COMPLICATION S 1. Early delivery (prematurity) PROM, surviving With too early


neonates may have: malpresentation cord compression oligohydramnios necrotizing enterocolitis neurologic impairment intraventricular hemorrhage
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COMPLICATION S 1. Early delivery (prematurity) PROM, surviving With too early


neonates may have: malpresentation cord compression oligohydramnios necrotizing enterocolitis neurologic impairment intraventricular hemorrhage respiratory distress syndrome 3/15/12

COMPLICATION S 2. Intrauterine infections Chorioamionitis (usual

manifestation): inflammation of fetal membranes

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COMPLICATION S 2. Intrauterine infections Chorioamionitis (usual


manifestation): inflammation of fetal membranes organisms associated: -Ureaplasma urealyticum -Mycoplasma hominis -Gardnerella vaginalis -Peptostreptococcus -Bacteroides 3/15/12

COMPLICATION S 2. Intrauterine infections Chorioamionitis (usual


manifestation): indications -fever -leukocytosis -fetal and maternal tachycardia - foul-smelling vaginal discharge 3/15/12

COMPLICATION S 2. Intrauterine infections Chorioamionitis (usual manifestation):


definitive dx: - (+) cultures of membranes - histopathological exam of placenta fetal infection may occur as: - septicemia - pneumonia - UTI 3/15/12

COMPLICATION S 2. Intrauterine infections Chorioamionitis (usual manifestation):


definitive dx: - (+) cultures of membranes - histopathological exam of placenta fetal infection may occur as: - septicemia - pneumonia - UTI 3/15/12

COMPLICATION S 3. Perinatal complications 2 to prematurity and infection

maternal and fetal morbidity parallel to latent period: < 12 hours: best results >12 hours: morbidity (increased 20 times)

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COMPLICATION S 3. Perinatal complications to prolonged PROM fetus exposed


early in gestation: *Fetal deformation syndrome: - pulmonary hyperplasia - low set ears - sloping nose and chin - flexion contractures of extremities
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MANAGEMEN Hx suggestive of T PROM


Confirm dx of PROM AOG below neonatal survival Outpatient expectant managem ent
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Leakage stops and reaccumulation of normal AF on ultrasound Confirm resealing of membranes Discharge from hospital

Advanced active labor, clinical chorioamionitis, YE NO irreversible fetal S Mgt distress Delive depends ry principall y on AOG

MANAGEMEN T Based on gestational age At term term/near term


At 32 33 weeks AOG At 24 to 34 weeks AOG Before 24 weeks AOG

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MANAGEMEN T Ter m

Favorable Cervix induction of labor is indicated

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MANAGEMEN T Ter m

Unfavorable Cervix Option 1 (Conservative Management)


Assess fetal well being - ultrasound - fetal heart rate Obtain genital tract cultures Monitor maternal WBC and differential count everyday Vital signs esp. temperature every 4 hours

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MANAGEMEN T Ter m

Unfavorable Cervix Option 2

Mother remains afebrile, fetus is stable, cultures are negative: wait for spontaneous labor

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MANAGEMEN T Ter m

Unfavorable Cervix Option 2

Maternal fever, fetal tachycardia: administer antibiotics induce labor despite unfavorable cervix: **Latent phase of labor may be long (16-20 hours). **Vaginal and other instrumental examinations should be minimized. 3/15/12

MANAGEMEN T Ter m

Unfavorable Cervix Option 2

Mother shows signs of chorioamionitis OR Fetus displays signs of distress and Vaginal delivery is not expected within few hours: terminate pregnancy by abdominal route
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MANAGEMEN T Medicatio ns
1. 2. 3.

Corticosteroids Antibiotics Tocolytic Therapy

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MANAGEMEN T Medicatio ns
1.
.

Corticosteroids Accelerate fetal lung maturity


Decrease perinatal morbidity mortality after preterm PROM Reduce risk of : - respiratory distress syndrome - intravascular hemorrhage - necrotizing enterocolitis

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MANAGEMEN T Medicatio ns
1.
.

Corticosteroids

Recommended Regimens: betamethasone (Celestone): IM: 12 mg every 24 hrs for 2 days

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MANAGEMEN T Medicatio ns
1.
.

Corticosteroids

Recommended Regimens: betamethasone (Celestone): IM: 12 mg every 24 hrs for 2 days dexamethasone (Decadron) IM: 6 mg every 12 hrs for 2 days
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MANAGEMEN T Medicatio ns
1.
.

Corticosteroids

Recommended Regimens: betamethasone (Celestone): IM: 12 mg every 24 hrs for 2 days dexamethasone (Decadron) IM: 6 mg every 12 hrs for 2 days . Administer before 32 and 34 weeks AOG, assuming fetal viability and no 3/15/12 evidence of intra-amniotic infection

MANAGEMEN T Medicatio ns
1.
.

Corticosteroids

between 32 and 34 weeks AOG use: - controversial after 34 weeks AOG use: - not recommended unless there is evidence of fetal lung immaturity by amniocentesis
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MANAGEMEN T Medicatio ns
1.
-

Corticosteroids
Multiple courses result in : decreased birthweight head circumference body length

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MANAGEMEN T Medicatio ns

2. Antibiotics
given to patients with PPROM: - reduce neonatal infections - prolong latent period

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MANAGEMEN T Medicatio ns

2. Antibiotics
After PPROM: - Reduce postpartum endometritis, chorioamionitis, neonatal sepsis, neonatal pneumonia, and intravascular hemorrhage

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MANAGEMEN T Medicatio ns

2. Antibiotics

Recommended Regimens: IV combination of: 2 g of ampicillin + 250 mg of erythromycin - every 6 hrs for 2 days FOLLOWED BY: 250 mg of amoxicillin and 333 mg of erythromycin 3/15/12 - every 8 hrs for 5 days

MANAGEMEN T Medicatio ns

2. Antibiotics
It is advisable to administer appropriate antibiotics for intrapartum group B streptococcus prophylaxis to women who are carriers.

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MANAGEMEN T Medicatio ns

3. Tocolytics
may prolong the latent period for a short time but do not appear to improve neonatal outcomes

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MANAGEMEN T Medicatio ns

3. Tocolytics
long term tocolytic therapy in PROM pts: NOT RECOMMENDED

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MANAGEMEN T At 32 33 weeks AOG

pts with documented pulmonary maturity - induce labor - consider transferring to a facility that can give care for premature neonates

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MANAGEMEN T At 32 33 weeks AOG

prolonging pregnancy after documentation of pulmonary maturity unnecessarily increases the likelihood of: - maternal amnionitis - umbilical cord compression - prolonged hospitalization - neonatal infection

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MANAGEMEN T At 32 33 weeks AOG

There are a few data to guide the care of patients without documented pulmonary maturity. Physicians must balance the risk of respiratory distress syndrome and other sequelae of prelabor delivery with the risk of prolongation, such as neonatal sepsis and cord accidents.

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MANAGEMEN T At 32 33 weeks AOG

pts without documented fetal lung maturity: - administer a course of corticosteroids + antibiotics - consider delivery 48 hrs later OR - perform a careful assessment of fetal well- being - observe for intra-amniotic infection 3/15/12 deliver at 34 weeks -

MANAGEMEN T At 32 33 weeks AOG

Consultation with a neonatologist in the management of PPROM may be beneficial.

Patients with amnionitis require: Broad spectrum antibiotic therapy

All patients should receive appropriate intrapartum group B streptococcus 3/15/12 prophylaxis, if indicated.

MANAGEMEN T At 24 34 weeks AOG

delivery before 32 weeks AOG leads to: Severe neonatal morbidity and mortality absence of intra-amniotic infection: Prolong pregnancy until 34 weeks AOG

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MANAGEMEN T At 24 34 weeks AOG

Advice patients and family members that, despite efforts, many patients deliver within 1 week of PPROM Contraindication to conservative therapy: - chorioamnionitis - placental abruption - non-reassuring fetal testing

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MANAGEMEN T At 24 34 weeks AOG

Administer a course of corticosteroids and antibiotics Perform an assessment of fetal well being: - fetal monitoring or ultrasonography

Daily monitoring - With PPROM before 32 weeks 3/15/12 AOG, umbilical cord compression

MANAGEMEN T At 24 34 weeks AOG

Observe closely for indicators of amnionitis: - fetal or maternal tachycardia - oral temperature exceeding 38C (100.4 F) - regular contractions - uterine tenderness - leukocytosis

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MANAGEMEN T At 24 34 weeks AOG

Corticosteriod administration may lead to an elevated leukocyte count if given 57 days of PROM. Delivery is necessary for patients with evidence of amnionitis.

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MANAGEMEN T Before 24 weeks AOG

Many infants who are delivered after previable rupture of fetal membranes suffer from numerous long-term problems:
chronic lung disease developmental abnormalities neurologic abnormalities hydrocephalus cerebral palsy

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MANAGEMEN T Before 24 weeks AOG

- results in pressure deformities of the limbs and face and pulmonary hypoplasia - incidence is related to AOG at which rupture occurs and to the 3/15/12 level of oligohydramnios

Many infants who are delivered after previable rupture of fetal membranes suffer from numerous long-term problems: syndrome: **Potters

MANAGEMEN T Before 24 weeks AOG

Patients should be counseled about the outcomes and benefits and risks of expectant management which may not continue long enough to deliver a baby that will survive normally. Physicians may wish to obtain consultation with perinatologist or neonatologist.

Such patients, if they are stable, may benefit 3/15/12 transport to tertiary facility. from

Cervical Cerclage

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Cervical procedure in which a nonabsorbable suture is used for holding the cervix closed to prevent spontaneous abortion in a woman who has an

Cervical Cerclage

risk factor for PROM and other associated pregnancy outcomes As of today, there is no prospective study regarding treatment of PPROM subsequent to cervical cerclage in situ.

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