premature rupture of membranes assoc. prof. gazi yildirim
TRANSCRIPT
List the history, physical findings, and diagnostic methods to confirm the rupture of the membranes
Identify the risk factors for premature rupture of membranes
Describe the risks and benefits of expectant management versus immediate delivery, based on gestational age
Describe the methods to monitor maternal and fetal status during expectant management
Objectives
Premature rupture of membranes (PROM) Rupture of the chorioamnionic membrane (amniorrhexis)
prior to the onset of labor at any stage of gestation
Preterm premature rupture of membranes (PPROM) PROM prior to 37-wk. gestation
Definition
PROM – 12% of all pregnancies PROM – 8% term pregnancies PPROM – 30% of preterm deliveries
Incidence
• Chorioamnionitis• Vaginal infections• Cervical abnormalities• Vascular pathology (incl. abruptio)• Smoking• 1st, 2nd, 3rd, or multiple trimester bleeding• Previous preterm delivery (PPROM)• Ethnicity• Acquired or congenital connective tissue disorder• Nutritional deficiencies (Vit.C, copper, zinc)
Risk factors
PROM/PPROM: Risk Factors
Risk Factors: Prior PROM or PPROM Prior preterm delivery Multiple gestation Polyhydramnios Incompetent cervix Vaginal/Cervical Infection
Gonorrhea, Chlamydia, GBS, S. Aureus Antepartum bleeding (threatened abortion) Smoking Poor nutrition
Vaginal discharge Gush of fluid Leaking of fluid Oligo/Anhydramnios Cramping Contractions Back pain
Symptoms
• Sterile Speculum Exam (Pooling)• SSE-Free flow of fluid from cervical os• Nitrizine testing• Microscopic Fern testing• Fetal Fibronectin• AmniSure • Ultrasonography• Transabdominal Indigo dye injection
Diagnosis
History “Gush” of fluid Steady leakage of small amounts of fluid
Physical Sterile vaginal speculum exam
Minimize digital examination of cervix, regardless of gestational age, to avoid risk of ascending infection/amnionitis
Assess cervical dilation and length Obtain cervical cultures (Gonorrhea, Chlamydia) Obtain amniotic fluid samples (for fetal fibronectin ect.)
Findings Pooling of amniotic fluid in posterior vaginal fornix Fluid per cervical os
PROM/PPROM: History & Physical Exam
Test Nitrazine test
Fluid from vaginal exam placed on strip of nitrazine paper
Paper turns blue in presence of alkaline (pH > 7.1) amniotic fluid
Fern test Fluid from vaginal exam placed
on slide and allowed to dry Amniotic fluid narrow fern vs.
cervical mucus broad fern
PROM/PPROM: Diagnosis
False positive Nitrazine test Alkaline urine Semen (recent coitus) Cervical mucus Blood contamination Vaginitis (e.g. Trichomonas)
False-Negative Nitrazine test Remote PROM with no residual fluid Minimal amniotic leakage
PROM/PPROM: Diagnosis
PROM/PPROM: Diagnosis
AmniSure Detects trace amounts of placental alpha
microglobulin-1 protein in vaginal fluid. Newer test Point of Care test Cost-up to $50 each Sensitivity-98.7-98.9% Specificity-87.5-100%
Test Ultrasound
Assess amniotic fluid level and compatibility with PROM
Indigo-carmine Amnioinfusion Ultrasound guided indigo carmine dye amnioinfusion (“Blue tap”) Observe for passage of blue fluid from vagina
PROM/PPROM: Diagnosis
• Gestational age• Availability of NICU• Fetal presentation• FHR pattern • Active distress (maternal/fetal)• Labor? • Cervical assessment
PROM/PPROM: Management
Patient counseling Expectant management vs. induction of labor GBS prophylaxis NOT recommended Antibiotics
Incomplete data Corticosteriods NOT recommended
Management: PPROM(< 24 wk gestation – “previable”)
Patient counseling
Fetal complications of prolonged PPROM Pulmonary hypoplasia Skeletal malformations Fetal growth restriction IUFD
Maternal complications of prolonged PPROM Chorioamnionitis
Management: PPROM(< 24 wk gestation – “previable”)
Gestational Age(In Completed
Weeks)
Death BeforeNICU Discharge
Outcomes at 18 to 22 Months Corrected Age*
DeathDeath/ Profound
NeurodevelopmentalImpairment
Death/Moderate to Severe Neuro-developmental Impairment
22 Weeks 95% 95% 98% 99%23 Weeks 74% 74% 84% 91%24 Weeks 44% 44% 57% 72%25 Weeks 24% 25% 38% 54%
Expectant management Deliver at 34 wks Unless documented fetal lung maturity
GBS prophylaxis Antibiotics Single course corticosteroids Tocolytics
No consensus
Management: PPROM(24 – 31 wk gestation)
Expectant management Deliver at 34 wks Unless documented fetal lung maturity
GBS prophylaxis Antibiotics Corticosteroids
No consensus, some experts recommend
Management: PPROM(32 – 33 wk gestation)
Antibiotics Prolong latency period Prophylaxis of GBS in neonate Prevention of maternal chorioamnionitis and neonatal sepsis
Corticosteroids Enhance fetal lung maturity Decrease risk of RDS, IVH, and necrotizing enterocolitis
Tocolytics Delay delivery to allow administration of corticosteroids Controversial, randomized trials have shown no pregnancy
prolongation
Management: Rationale
Antibiotics Ampicillin 2 g IV Q6 x 48 hrs Amoxicillin 500 mg po TID x 5 days Azithromycin 1 g po x 1
Corticosteroids Betamethasone 12 mg IM q24 x 2 Dexamethasone 6 mg IM q12 x 4
Tocolytics Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs
Management: Drug Regimen
Typically performed after 32 wks
Tests for fetal lung maturity (FLM) Lecethin/Sphingomyelin ratio (not commonly
used, more for historic interest) L/S ratio > 2 indicates pulmonary maturity
Phosphatidylglycerol > 0.5 associated with minimal respiratory distress
Flouresecence polarization (FLM-TDx II) > 55 mg/g of albumin
Lamellar body count 30,000-40,000
If negative, proceed with expectant management until 34 wks
Management: Amniocentesis
Maternal: Monitor for signs of infection Temperature Maternal heart rate Fetal heart rate Uterine tenderness Contractions
Fetal: Monitor for fetal well-being Kick counts Nonstress tests (NST’s) Biophysical profile (BPP)
Management: Surveillance
Immediate Delivery Intrauterine infection Abruptio placenta Repetitive fetal heart rate decelerations Cord prolapse
Management: Surveillance
Expectant Management Risks:
Maternal Increase in chorioamnionitis Increase in Cesarean delivery Spontaneous labor in ~ 90% within 48 hr ROM Increased risk of placental abruption
Fetal Increase in RDS Increase in intraventricular hemorrhage Increase in neonatal sepsis and subsequent cerebral palsy Increase in perinatal mortality Increase in cord prolapse
Expectant Management vs. Preterm Delivery