Prom

1. PROM and Chorioamnionitis
Dr Bellington Vwalika
(DGO,MMED,PGDipEpid)

2. • PROM –rupture of membranes before
labour starts
• Before 37/40- pPROM
• Incidence 4-18% of pregnancies
• Responsible for 50% preterm deliveries
and 10% perinatal mortality

3. Risk factors for preterm labour
• A. Non- modifiable, major
1. Idiopathic
2. Previous preterm labour
3. Twin pregnancy
4. Uterine abnormalities
- Congenital
- Cervical damage: cone biopsy
- Cervical fibroids
5. Factors in current pregnancy
- Recurrent APH
- Intercurrent illness e.g. sepsis
- Any surgery
• A. Non-modifiable,
minor
1.Teenagers having 2nd
or subsequent babies
2.Parity (0 or > 5)
3.Ethnicity (Black race)
4.Education (not
beyond secondary)

4. B. Modifiable
1. Smoking (2 fold increase of PPROM)
2. Drugs of abuse e.g. cocaine
3. BMI < 20: underweight women
4. Inter-pregnancy interval < 1 year

5. Aetiology
• Aggressive external factors eg
amniocentesis
• Lack of resistance of membranes
– Congenital eg lack of Vit C, collagen disorders
– Acquired
• Infection
• Cone biopsy
• Twin pregnancy
• polyhydramnios

6. cont
• Mode of action of infection
– Decrease resistance of CT by direct q
– Indirectly by via response fetal and maternal
macrophage-mediated enzyme secretion
– Increase in PG production

7. Definition of BV
• Gram stain findings (Nugent Score): based on
number of:
1. Large Gram positive rods called lactobacilli
morphotypes (decrease in Lactobacillus scored as 0
to 4)
2. Increase in small Gram variable rods (Gardnerella
vaginalis morphotypes; scored as 0-4)
3. Increase in curved Gram variable rods (Mobiluncus
spp morphotypes; scored as 0 to 2)
Score range from 0 to 10.
A score of 7 to 10 is consistent with BV

8. • Clinical findings (Amsel criteria): 3 of the
following must be present:
– homogeneous vaginal discharge
– pH >4.5
– clue cells (>20%)
– amine odor on addition of KOH (+ whiff test)

9. BV and Adverse Outcomes in
Pregnancy
• Data support role for BV in promoting:
– postabortal infections
– preterm labor and delivery*
– premature rupture of membranes
– intramniotic infection
– histological chorioamnionitis
– postpartum endometritis
– spontaneous abortion in first trimester (IVF)
*infection implicated in up to 40% of cases

10. Diagnosis
• Clinical history and exam – SSE for
evidence of amniotic fluid in posterior
vaginal fornix and clothing
• Fetal fibronectin (fFN) test
• Nitrazine test
• Ferning test

11. Complications
• Maternal
– Infections(chorioamnionitis.endometritis)
– Obstetric interventions
– Anaesthesia
– Abruptio placenta
• Fetal complications
– Fetal and neonatal
infections(sepsis,meningitis,bronchopneumonia)
– Risk of fetal distress(umbilical cord
complications,abruptio,chorioamnionitis)
– Postoral deformities

12. management
• Consider
– expectant or active management
– Tocolytics
– Antibiotics
– Corticosteroid use

13. • Investigations
– Endocervical swab for m/c/s
– WCC total and differential
– ESR
– Fibronectin
– C-reative protein
– Amniocentesis for MCS to rule out
chorioamnionitis
• Fetal well being
– CTG, Kickchart, biophysical profile by USS

14. Management contd
• PROM at term or near term-best delivered
• 80% labour within first 24 hours, near to
10% next 24 hours
• Antibiotic cover after swab is taken
• Between 32 and 36 weeks give steroids
to mature lungs
• Under 32/40 aim to prolong gestation if
there no signs of fetal distress or infection

15. • Chorioamnionitis
– Monitor temp, pulse ,fetal heart rate
– Smell of liqour or pad
– Tender irritable abdomen
– Consider immediate delivery by fastest and
safest route
– Antibiotic cover: ampicillin + erythromycin

16. Drugs to give
1. Steroids e.g. dexamethasone or
beclomethasone
2. Antibiotics: ampicillin and erythromycin
3. Tocolytics
4. Analgesia