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Premature Rupture Of Membranes

Central Amrica Section November 2006

PROM
It can be at term (PROM) or preterm (PPROM)

PROM: affects 5-10 % of all pregnancies P-PROM, affects 3% of all pregnancies

PROM
DEFINITIONS

PROM, spontaneous rupture of


membranes before onset of labor

P-PROM, before 37 weeks of gestation Mid trimester PROM, 14-26 weeks


gestation

PROM

Expectant Management: therapy directed


toward extending pregnancy to improve neonatal outcome

ETIOLOGY
Multifactorial 1. Intrinsic membrane weakness
a. b. c. d. Infections Smoking Malnutrition Collagen Deficency

2. Infection (proteolytic enzymes)

ETIOLOGY
3. Mechanical stress a. Twin gestation b. Polyhydramnios c. Fetal Malformations 4. Unknown

Prediction of PROM

Previous P-PROM have 3.3 fold increased risk of preterm birth by P-PROM, and 14 fold risk of PROM

DIAGNOSIS
Direct observation of amniotic fluid Amniotic fluid pH (7.0-7.5) nitrazine test Ferning Pattern (watch out for blood and
semen)

OTHERS: Indigo Carmin, Glucose, Fructose,


Diamine Oxidase, Pungent odor

CLINICAL COURSE P-PROM


1. Without treatment:
50% will deliver within 48 hours 80% will deliver within 1 week 15-20% of all cases 40-60% in mid-trimester

2. Chorioamnionitis

CLINICAL COURSE P-PROM


3. Abruptio Placentae, 4-12 % 4. Fetal Demise, 1-2%

Initial Evaluation
DO NOT TOUCH!! Cervical examination
decreases latency and increases infectious morbidity Cervical cultures, N. Gonorrhoeae, C. Trachomatis, Group B Streptococcus Establish gestational age Establish fetal well being, umbilical cord compressions up to 75% of the cases

Watch out for


Maternal fever Maternal or fetal tachycardia Uterine tendernes Vaginal discharge Flank pain Leukocyte count (>18000)

MANAGEMENT PROM
Determine whether the cervix is favorable
for induction of labor

If it is posterior, thick, closed, its


unfavorable

A score of Bishop 6 Pts. Its favorable

MANAGEMENT PROM
Favorable cervix
a. Labor should be induced by administration of oxytocin b. Administer antibiotics per protocol

MANAGEMENT PROM

Unfavorable cervix

a. Administer PgE1 or PgE2, to ripen cervix b. Oxytocin if there is a poor response to PgE. c. Minimize vaginal examinations d. Treat promptly if clinical sings of infection are present.

MANAGEMENT P-PROM
1. Confirm diagnosis 2. US to confirm gestational age, look for
anomalies

3. Cervical cultures

MANAGEMENT P-PROM
1. Amnionitis, Abruptio P., Fetal death, deliver as
soon as possible. Use broad spectrum antibiotics.

2. No pathology present, treatment depends


upon gestational age.

MANAGEMENT P-PROM
1.

< 23 weeks:
Termination may be an option - depends on GA, amt of fluid loss, etc. Initial bed rest to encourage resealing Look for infection, abruptio or labor Serial US to evaluate oligohydramnios and pulmonary hypoplasia, if so INDUCTION with oxytocin, PgE1 Or PgE2, or dilatation & evacuation If no pathology consider conservative management

MANAGEMENT P-PROM
2. 23-31 weeks
Conservative Management:

a. b. c. d. e.

Serial evaluation for amnionitis, labor, abruption, fetal well-being Bed rest to encourage resealing Administer corticosteroids and antibiotics Deliver if any pathology Deliver at 34 weeks if stable until then.

MANAGEMENT P-PROM
3. 32-33weeks

Document fetal pulmonary maturity If immature testing consider conservative management for corticosteroid benefit with concurrent antibiotics followed by delivery after 24-48 Hrs.

If mature expeditious delivery Antibiotics for GBS prophylaxis unless known negative

MANAGEMENT P-PROM
4. 34-36 weeeks
Expeditious delivery Intrapartum antibiotics for GBS unless
known negative

References

ACOG Practice Bulletin Number 1: Clinical management guidelines for Obstetrician-Gynecologists: Premature rupture of membranes. June, 1988. Artal R, Sokol RJ, Neuman M, et al: The mechanical properties of prematurely and non-prematurely ruptured membranes. Am J Obstet Gynecol 125:655, 1976 Duff P, Huff R, Gibbs RS: Management of premature rupture of membranes and unfavorable cervix in term pregnancy. Obstet Gynecol 63:697, 1984 Farooqi A, Holmgren PA, Engberg S: Survival and 2-year outcome with expectant management of second- trimester rupture of membranes. Obstet Gynecol 1998 Dec; 92(6): 895-901[Medline]. Lenihan JP: Relationship of antepartum pelvic examinations to premature rupture of the membranes. Obstet Gynecol 63:33, 1984