Premature rupture of membranes (prom)


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Premature rupture of membranes (prom)

  1. 1. Premature Rupture of Membranes (PROM)<br /><br />
  2. 2. Definition<br />It is rupture of membranes before onset of labour so it is more accurate to call it "prelabour rupture of membranes".<br />Incidence<br />10% of term pregnancies and more in preterm labour.<br /><br />
  3. 3. Aetiology<br />The following factors are incriminated:<br />a. Cervical incompetence.<br />b. Polyhydramnios.<br />c. Multiple pregnancy.<br />d. Malpresentations as the presenting part is not fitting against the lower uterine segment.<br />e. Chorioamnionitis.<br />f. Low tensile strength of the membranes.<br /><br />
  4. 4. Diagnosis<br />History: of gush of fluid per vagina that moistsvulval pads.<br /> >Drawback: Vulval pads can be moisted with urine or vaginal discharge which can be mistaken with the amniotic fluid<br />Nitrazine paper test:<br /> > The colour turns from yellow to deep blue due to alkalinity of the amniotic fluid.<br /><br />
  5. 5. Diagnosis<br />Laboratory analysis: for creatinine, urea and uric acid in the fluid sample.<br /> >Drawback: these components are present in the urine.<br />Fern test:<br /> > Visualization of fern-like pattern of dried amniotic fluid on a glass slide under microscopy due to presence of protein.<br /> > Drawback: protein may be present in urine.<br /><br />
  6. 6. Diagnosis<br />Sterile speculum examination:<br /> > to observe the escape of amniotic fluid from the external os.<br />Dye injection:<br /> > Through abdominal needle under ultrasonic guide into the amniotic sac and observation of its passage through the external os or even in the vulval pad.<br /> > Drawback: It carries risk of foetal trauma particularly if a large amount of the amniotic fluid was drained.<br /><br />
  7. 7. Diagnosis<br />Vernix, meconium or alpha-fetoprotein detection:<br /> >In the fluid sample is diagnostic.<br />Ultrasound:<br />> is an ideal non-invasive technique for the detection of the residual amount of amniotic fluid.<br /><br />
  8. 8. Complications<br />1. Preterm labour: with the risk of prematurity.<br />2. Infection: chorio-amnionitis, septicaemia and foetal pneumonia.<br />3. Foetal deformities and distress: due to oligohydramnios.<br /><br />
  9. 9. Management<br />Gestational age over 36 weeks<br />A. In absence of infection, foetal distress and abnormal lie, wait for 24 hours as about 90% of patients with PROM will pass into spontaneous labour. Prophylactic antibiotic can be given during this period.<br />B. PGE2 and / or oxytocin is used for induction of labour in patients did not pass into labour after 24 hours.<br /><br />
  10. 10. Management<br />Gestational age between 34-36 weeks<br />In absence of infection and foetal distress, wait for 48 hours as rupture of membrane itself will accelerates lung surfactant production and hence lung maturity.<br /> Induce labour after 48 hours with PGE2 and /or oxytocins.<br />C. Prophylactic antibiotics are given during this period.<br />D. Caesarean section is indicated in breech presentation < 36 weeks’ gestation.<br /><br />
  11. 11. Management<br />Gestational age between 28-34 weeks<br /> In absence of infection, the main aim is to manage the case conservatively till the 35th week when lung maturity mostly occurs and the baby can survive.<br /><br />
  12. 12. Conservative management <br />a. Rest in bed as long as there is escape of liquor with restriction of efforts later on particularly those that increase intra-abdominal pressure.<br />b. Temperature is recorded every 4 hours.<br />c. Observation for malaise, abdominal pain, uterine tenderness and amount of escaped liquor on sterile vulval pads.<br />d. Leucocytic count and C-reactive protein may be done every other day.<br />e. Prophylactic antibiotics may be given although this is not advised by some authors as it may lead to colonisation of resistant strains of organisms in the genital tract.<br />f .Tocolytic drugs: are given if uterine activity starts.<br />g .Corticosteroid therapy: is given for 48 hours if labour was imminent or will be induced before 35 weeks.<br /><br />
  13. 13. Management<br />Gestational age less than 28 weeks<br />There is little chance of foetal survival and the condition is usually considered as inevitable abortion.<br /><br />