2. Learning objective
By the end of this lecture you are expected to:
Define PROM.
Identify risk factor of PROM.
Recognize the sign and symptom of PROM.
List investigation for PROM case.
Explain the complication of PROM.
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3. Reflective activity1 (12 min)
Please form four group near by and share your experience on the following
issue.
Define PROM
Explain types of prom
Mention risk factors
Discuses diagnostic modality
7 min discussion and 5 min reflection
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4. Definitions
Spontaneous rupture of fetal membrane and
leakage of amniotic fluid at least one hour or
more before the onset of labor/ in the absence of
contractions and after 28wks of gestation.
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5. cont.….
Type of PROM.
Term : rupture of membranes after 37 weeks of
gestation but is prior to labor.
Preterm: ROM Before 37 wks of GA and after
28wks of GA and before on set of labor.
Prolonged PROM : before greater than 12/18/24
hrs of on set of labor.
Latency Period: The interval between the ROM
and the spontaneous on set of labor. 5
6. Incidence
5 to 10% of all deliveries.
PROM causes about one third of all preterm
births.
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7. The specific cause is unknown. Maybe associated with:
Malpresentation
Weak areas in the amnion and chorion
Vaginal infection(bacterial vagnosis , T.vagnalis)
Incompetent cervix
Previous history of PROM
Etiologic and predisposing factors
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8. Cont…
Hydramnios( cause distention)
Substance abuse during pregnancy
Nutritional deficiency
Low socio-economical status
Multiple pregnancy
Placenta abruptio
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9. Clinical manifestation & Dx
Hx: The classic clinical presentation of PPROM
is a sudden "gush" of clear or pale yellow fluid
from the vagina.
Many women describe intermittent or
constant leaking of small amounts of fluid or
just a sensation of wetness within the vagina or
on the perineum.
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10. cont.…
Physical examination:
the presence of flecks of vernix or meconium.
reduced size of the uterus.
increased prominence of the fetus to palpation.
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11. Cont.…
The best method of confirming the diagnosis of
PPROM is direct observation of amniotic fluid
coming out of the cervical canal or pooling in
the vaginal fornix.
If amniotic fluid is not immediately visible, the
woman can be asked to push on her fundus,
Valsalva, or cough to provoke leakage of
amniotic fluid from the cervical os.
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12. Diagnosis…
Speculum examination:
Pooling:- the collection of AF at posterior Vx fornex.
Nitrazine test :-if positive the PH paper changes
yellow green in to blue b/c amniotic fluid has a pH
range of 7.0 to 7.3 compared to the normally acidic
vaginal pH of 3.5 to 4.5.
False +ve result may be occur due to tap water, blood,
semen, alkalin anti septic and bacterial infection.
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14. Cont.…
Ferning test
Fluid from the posterior vaginal fornix is swabbed
onto a glass slide and allowed to dry for at least 10
minutes.
+ve result will reveals fern like on slide while viewed
under microscope.
Well-estrogenized cervical mucus on the
microscope slide may cause a false-positive
fern test .
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17. Instillation of Indigo carmine
Instillation of indigo carmine into the AF leads to a
definitive diagnosis.
Under ultrasound guidance, 1 mL of indigo carmine in 9
mL of sterile saline is injected trans abdominally into
the amniotic fluid and a tampon is placed in the
vagina.
One-half hour later, the tampon is removed and
examined for blue staining, which indicates leakage of
amniotic fluid.
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18. Placental alpha microglobulin-1 protein assay
(AmniSure)
Is a rapid slide test that detect trace amounts of
placental alpha microglobulin-1 protein in
vaginal fluid.
An advantage of this test is not affected by
semen or trace amounts of blood.
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19. Cont…
Procedure: A sterile swab is inserted into the vagina
for one minute, then placed into a vial containing a
solvent for one minute, and then an AmniSure test
strip is dipped into the vial.
The test result is revealed by the presence of one or
two lines within the next 5 to 10 minutes (one visible
line means a negative result for amniotic fluid, two
visible lines is a positive result, no visible lines is an
invalid result). 19
20. complication
PROM is an important cause of:
o Preterm labor
o Cord prolapse
o Placental abruption
o Intrauterine infection
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22. Reflective activity2 (12 min)
7 min discussion and 5 min reflection
Discuses on management of Prom share your experience in a group
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23. Management
Termination Of pregnancy regardless of GA
If chorioamnionitis develop any time.
At 34wks
At 32-34wks if lung maturity confirmed
Cord prolapse
Fetal/maternal destress
Mode of delivery
Based on obstetric indications.
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25. Mx of TERM PROM (GA > 37wk)
Most women with term PROM who are followed
expectantly will go into spontaneous labor and deliver
within 24, 48, and 72 hours of PROM in 70%, 85%,
and 95 % of women, respectively .
If the labor not start after 48hr , induce. If there is
contraindications to vaginal delivery, cesarean
delivery will be performed.
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26. Mx of PPROM Depend on:
Gestational age
Availability of neonatal intensive care
Presence or absence of maternal/fetal
infection
Presence or absence of labor
Fetal presentation (Breech and transverse
lies are unstable and may increase the risk
for cord prolapse)
Fetal heart rate (FHR) tracing pattern
Likelihood of fetal lung maturity
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27. Cont.…
The main concern weight the risk of infection in
expectant management (if Px continued) versus
the risk of perinatal death due to prematurity if Px
terminated.
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28. Cont.…
If GA > 34 wk :
the risk of infection more than the risk of
prematurity.
Since the lung seems to be matured, observe for
spontaneous on set of labor for 48hr.
If not, induce it! but if there is any
contraindication for Vx delivery, consider CS.
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29. Cont.…
If GA is b/n 32 – 33 wk :
The risk of infection is less than the risk of
prematurity .
Hospitalization : bed rest b/c the may be
spontaneously reseal and Px continue.
Amniocentesis: if the lung mature deliver.
if not mature, Expectant management
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30. Management: Amniocentesis
Typically performed after 32
wks
Tests for fetal lung maturity
(FLM)
L/S ratio > 2 indicates
pulmonary maturity
Phosphatidylglycerol
> 0.5 associated with minimal
respiratory distress
If imature, proceed with
expectant management until
34 wks
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31. Expectant Management
Typical for GA 32 weeks or less
Bed rest , Inpatient Observation
Steroids for lung maturity
Tocolytic if indicated for lung maturity
Antibiotics
Fetal Surveillance
Assess for Chorioamnionitis
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33. Tocolytic agent
In the absence of delivery indication, may
consider tocolysis x 48 hours to assist with benefit
of sterods. Tocolysis can be achieved with
magnesium sulfate, terbutaline, and nifedipine.
Nifedipine 10 mg po after every 20min 3 times,
then 6 hrly for 2
Mgso4 :-Loading dose: 4-6 g IV over 20
minutes; maintenance: 2-4 g/hr IV for 12-24
hours as tolerated after contractions cease.
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34. Antibiotics
Goal:
Decrease maternal infection
>> fetal infection
Prolong latency(onset of labor)
Ampicillin IV for 48hrs,then Amoxicillin po
7d.
Erythromycin IV for 48hrs,Eryth IV 7d.
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35. Rationale
Antibiotics
o Prolong latency period
o Prophylaxis of GBS in neonate
o Prevention of maternal
chorioamnionitis and neonatal sepsis
Corticosteroids
o Enhance fetal lung maturity
o Decrease risk of RDS,
Tocolytics
o Delay delivery to allow administration
of corticosteroids
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36. Resealing
Up to 14 percent of gravidas with spontaneous
midtrimester PPROM eventually stop leaking
amniotic fluid, presumably due to "resealing" of the
fetal membrane.
Cessation of leakage is probably not due to actual
repair and regeneration of the membranes, but
rather to changes in the decidua and myometrium that
block further leakage .
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