Premature rupture of membranes resident survival guide
|Premature rupture of membranes Resident Survival Guide Microchapters|
Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when the amniotic sac ruptures before the onset of labor irrespective of gestational age. The term pPROM stands for preterm premature rupture of the membranes which occurs when the rupture happens before 37 weeks of gestation. Risk factors include maternal vaginal infections which ascend to the amniotic membrane, vaginal bleeding during pregnancy and maternal stature among others. Rupture of the membranes typically presents as a large gush of clear vaginal fluid or as a steady trickle. The differential diagnosis includes leakage of urine, excessive vaginal discharge for example physiologic discharge or bacterial vaginosis and cervical mucus (show) as a sign of impending labor.The diagnosis of PROM is done by careful complete history and physical examination, ultrasound is done to confirm oligohydramnios. Once the membranes rupture, delivery is recommended when the risk of ascending infection outweighs the risk of prematurity. When PROM occurs at term, labor typically takes place spontaneously or is induced within 12 to 24 hours.
- Maternal risk factors:
- Previous history of PROM, recurrence risk is 16%–32% as compared with 4% in women with a prior uncomplicated term delivery.
- Chronic steroid therapy
- Abnormal bleeding during the second trimester or late in the pregnancy.
- Low body mass index (BMI < 19.8 kg/m2)
- Smoking and drug abuse
- Low socioeconomic status
- Deficiency of copper or vitamin C, along with connective tissue disorders such as Ehlers-Danlos syndrome, Systemic Lupus Erythematosus are also linked to increased risk of PROM.
- Direct abdominal trauma
- Preterm labor
- Uteroplacental Factors:
- Uterine anomalies (such as uterine septum)
- Placental abruption
- Advanced cervical dilation (cervical insufficiency)
- Prior cervical conization
- Cervical shortening in the 2nd trimester (< 2.5 cm)
- Uterine overdistention (Polyhydramnios, Multiple pregnancy)
- Intra-amniotic infection (Chorioamnionitis)
- Multiple bimanual vaginal examinations (but not sterile speculum or transvaginal ultrasound examinations)
- Fetal factors include :
Shown below is an algorithm summarizing the diagnosis of Premature rupture of membranes:
|Pregnant woman comes with Premature rupture of membranes|
|Take complete history|
Ask about previous obstetric history if she was previously pregnant :
❑ Ask about previous pregnancies including miscarriages and terminations.
❑ Length of gestation.
❑ Ask about mode of delivery.
❑ Ask if there was similar complaints during previous pregnancy?
❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?
Ask the following questions about menstrual history :
❑ Age of menarche
❑ Last menstrual period
❑ Is the menstrual flow normal? How many pads she has to use in a day?
❑ Is there any foul smell or colour change?
❑ How many days does the menstruation stay?
❑ Contraceptive history for example oral contraceptives, intrauterine device
Perform physical examination :
If above are not conclusive, do the following tests :
Amniotic protein tests have high sensitivity for PROM but false-positive rates are high.
Conclusive test – dye instillation :
❑ Intra-amniotic dye instillation is helpful for evaluation of PROM and for genetic amniocentesis in multifetal gestation. Ultrasound guided dye is passed into the vagina and detected with tampon or pad stain.
❑ Indocyanine green is used in pregnancy for other indications.
❑ Oral phenazopyridine hydrochloride may lead to a false-positive diagnosis of PROM.
❑ Evans blue and methylene blue have adverse fetal and neonatal outcomes.
|History suggestive of PROM|
(leakage of fluid from the vagina)
|Physical examination findings confirm PROM|
•Pooling of fluid
•Positive nitrazine and Ferning tests
|Sterile speculum examination assess dilation and ultrasound if indicated|
|PROM ruled-out||PROM confirmed|
Indications for delivery :
delivery depends on fetal status, amount of bleeding, the stability of mother, and gestational age.
❑ If the patient presents with vaginal bleeding, there may be a concern for a placental abruption and delivery should be considered.
|Management of PROM |
❑ Patients with preterm PROM should be admitted to hospital and periodically assessed for infection, placental abruption, umbilical cord compression, fetal well-being and labor.
Management of PROM with infections
•Recurrent active HSV
•Patient should be seen by a physician with expertise in the management of HIV in pregnancy.
PROM at less than 24 weeks :
❑ Patient counselling must be done and she should be advised about the risks and benefits of expectant management and immediate delivery.
PROM at preterm (24 0/7 – 33 6/7 weeks of gestation) :
❑ Expectant management which includes admitting the patient to the hospital admission and monitored for infection, hemorrhage, placental abruption, umbilical cord compression, fetal assessment and evidence of labor.
PROM at late preterm (34 0/7- 36 6/7 weeks of gestation) :
❑ Expectant management or immediate delivery.
PROM at early term and term patients (37 0/7 weeks of gestation or more) :
- GBS prophylaxis should be given based on prior culture results or intrapartum risk factors if cultures not performed or unavailable.
- Patient should be monitored regularly with ultrasound and counsel patients to watch for signs of infection, bleeding or miscarriage.
- Cervical cerclage should be considered for women with the following:
- Pregnant women should avoid smoking.
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