Prom and pprom
- 2. Outline • Introduction • Symptoms and signs • Investigation • Treatment • Summary
- 3. Definition • Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the onset of labor is called prelabor rupture of the membranes (PROM) • When rupture of membranes occurs before 37 completed weeks it is termed as Premature PROM
- 4. programmed cell death and activation of catabolic enzymes, such as collagenase and mechanical forces Pathogenesis ruptured membranes. At term Preterm PROM Same mechanisms and premature activation of these pathways.
- 5. Pathogenesis • However, early PROM also appears to be linked to underlying pathologic processes, (due to inflammation and/or infection of the membranes.)
- 6. INCIDENCE • PROM occurs in approximately 10% of all pregnancies.
- 7. CAUSES • In majority, the causes are not known. • The possible causes are: 1. Increased friability of the membranes; 2. Decreased tensile strength of the membranes; 3. Polyhydramnios; 4. Cervical incompetence;
- 8. Causes 5. Multiple pregnancy; 6. Infection—Chorioamnionitis, urinary tract infection and lower genital tract infection; 7. Cervical length < 2.5 cm; 8. Prior preterm labor; 9. Low BMI (< 19 kg/m2).
- 10. Chorioamnionitis Chorioamnionitis is a complication of pregnancy caused by bacterial infection of the fetal amnion and chorion membranes.
- 11. Signs and symptoms 1. Maternal fever (T>100.4°F or >37.8°C) 2. Significant maternal tachycardia (>120 beats/min) 3. Fetal tachycardia (>160-180 beats/min) 4. Purulent or foul-smelling amniotic fluid or vaginal discharge 5. Uterine tenderness 6. Maternal leukocytosis (TC>15-18,000 cells/μL)
- 13. Diagnosis: PROM Symptoms • Sudden gush of fluid per vagina or water vaginal discharge or continuous leaking through the vagina
- 14. Signs • Maternal temperature(increased in chorioamnionitis) and pulse • FHR • P/A examination Reduced size of the uterus than the period of gestation Reduced liquor volume Diagnosis
- 15. • Sterile speculam examination For demonstration of liquor To assess odour of vaginal discharge To exclude cord prolapse To take endocervical swab To perform Nitrazine test and Fern test Diagnosis Vaginal examination is generally avoided in PROM
- 16. Complications MATERNAL COMPLICATIONS • Preterm labour • Infection: Chorioamnionitis, puerperal sepsis • Cord prolapse • Dry labour • Placenta abruption
- 17. Complications FETAL COMPLICATIONS • Prematurity • Fetal pulmonary hypoplasia • Neonatal sepsis • Respiratory distress syndrome, • Increased perinatal morbidities (cerebral palsy)
- 18. Investigations • Complete Blood count • CRP • Urine R/M/E and C/S • High vaginal swab: gram stain and culture • Ultrasonography (gestational age and fetal biophysical profile) • CTG • Nitrazine test • Fern test • Nile blue sulphate test
- 19. Nitrazine test Nitrazine or phenaphthazine is a pH indicator dye Nitrazine indicates pH in the range of 4.5 to 7.5. False positives 1. If blood gets in the sample 2. If there is an infection present 3. Recent vaginal intercourse (Semen also has a higher pH)
- 20. This test involves putting a drop of fluid obtained from the vagina onto paper strips containing Nitrazine dye. The strips will turn blue if the pH is greater than 6.0. A blue strip means it's more likely the membranes have ruptured.
- 22. Fern test • To detect the rupture of membranes and the onset of labor. • Indirect evidence of ovulation and fertility • Detection of a characteristic 'fern like' pattern of cervical mucus when a specimen of cervical mucus is allowed to dry on a glass slide and is viewed under a low- power microscope. • Provide evidence of the presence of amniotic fluid
- 23. TREATMENT A. General treatment B. Obstetrical management 1.Management of PROM with chorioamnionitis 2.Management of PROM without chorioamnionitis (>37 weeks of gestation) 3.Management of pre-term PROM without chorioamnionitis
- 24. General Treatment • Hospitalization • Bed rest with bathroom privilege • Wearing of clean vulval pad • Broad spectrum antibiotics • Counseling of mother • Maternal and fetal monitoring Maternal monitoring (temp, pulse, BP, liquid volume, odor of liquor , uterine tenderness) Fetal monitoring (FHR 4 hourly, CTG daily and Biophysical profile weekly)
- 25. Management of PROM with Chorioamnionitis • Termination of pregnancy irrespective of gestational age • Mode of termination 1. Induction of labour: with oxytocin for short period (if vaginal delivery is not C/I) 2. C.S.-if vaginal delivery is C/I -If not delivered by 12? hrs of diagnosis of chorioamnionitis
- 26. Management of PROM without chorioamnionitis (>37 WOG) • Active management (best option) Induction of labour with oxytocin (if cervix is ripe) LUCS (for obstetric indication) • Expectant management (if cervix is not ripe) Non intervention (wait for 6-12 hrs to allow ripening of cervix and spontaneous onset of labour
- 27. Management of pre-term PROM without chorioamnionitis • If gestational age >34weeks but <37 weeks 1. Expectant management: as long as no sign of chorioamnionitis 2. Active management a) Induction of labour by oxytocin b) LUCS (for obstetric indication)
- 28. • Gestational age between 24 and 34 weeks • Expectant management Corticosteroid (inj. Hydrocortisone for lung maturation) Tocolytics (for 48hrs to allow lung maturity) In utero transfer of fetus to a center with neonatal support • Gestational age <24 weeks Active termination of pregnancy due to poor prognosis (best option)
- 29. Scheme for management of PROM TO MONITOR MATERNAL PULSE, TEMPERATURE, FHR AND TO START PROPHYLACTIC BROAD SPECTRUM ANTIBIOTIC AMNIONITIS, PLACENTA ABRUPTION, FETAL DEATH/ DISTRESS OR LABOUR PROCESS PRESENT ABSENT EXPEDITIOUS DELIVERY INTRAPARTUM ANTIBIOTIC NICU • Maternal health assessment • Fetal: gestational age, weight, pulmonary maturity • Septic work up( cervical swab, urine culture) • Non stress test • Biophysical profile
- 30. ABSENT PREGNANCY <34 WEEKS PREGNANCY >=37WEEKSPREGNANCY >=34WEEKS AND LESS THEN 37 WEEKS EXPECTANT MANAGEMENT TO CONTINUE FOR FETAL MATURITY. HOSPITAL WITH LIMITED SOURCES- TO TRANSFER THE PATIENT WITH ‘FETUS IN UTERO TO AN CENTER EQUIPPED WITH NICU TO WAIT FOR SPONTANTAEOUS ONSET OF LABOUR FOR 24- 48HRS FAILS INDUCTION OF LABOUR WITH OXYTOCIN(CS FOR NON- CEPHALIC PRESENTATION) TO WAIT FOR SPONTANTAEOUS ONSET OF LABOUR FOR 24HRS FAILS INDUCTION OF LABOUR WITH OXYTOCIN(CS FOR OBSTETRIC REASON)
- 31. THANK YOU
Editor's Notes
- #12: The risk of neonatal sepsis is increased when at least 2 of the above criteria are present.
- #17: Cord prolapse (specially when associated with malpresentation) Dry labour (Due to continous escape of liquor for long duration)
- #19: Hb,tc,dc,platelet CRP
- #23: Ferning occurs due to the presence of sodium chloride in mucus under estrogen effect. When high levels of estrogen are present, just before ovulation, the cervical mucus forms fern-like patterns due to crystallization of sodium chloride on mucus fibers. This pattern is known as arborization or 'ferning'.1 When progesterone is the dominant hormone, as it would be just prior ovulation, the fern pattern is no longer discernible, and the pattern is completely absent by the 22nd day of a woman's cycle. The disappearance of the fern pattern after the 22nd day suggests ovulation, and its persistence throughout the menstrual cycle suggests an-ovulation (infertility).[1]