Abnormal delivery process

1. Premature Rupture Of
Membranes (PROM)

2. PRO M
Definition:
PROM is the Spontaneous rupture of membranes after
28 weeks of gestation before the onset of labor.
Occurs in ~ 10% of pregnancies
• Term PROM: after 37 weeks
• Preterm PROM: Before 37 weeks
• Latency period: Time between rupture of
membranes to onset of labor.
• Prolonged PROM: latency longer than 12 hrs.

3. PROM- cont’d
Incidence: average around 10%, ranges 3-19 %.
Causes: Not known in majority. Possible causes
include:
• Increased fragility of membranes
• Decreased tensile strength of membranes
• Polyhydraminos
• Cervical incompetence
• Multiple pregnancy
• Infection: Chorioamnionitis, UTI, lower genital
tract infection
• Emergent circlage

4. RISK FACTORS
• The pathogenesis of PPROM is not completely
understood.
• It shows association with
– A history of PPROM in a previous pregnancy,
– Genital tract infection,
– APH
– Cigarette smoking
– Low socioeconomic status
– Polyhydraminos
– Cervical incompetence
– Multiple pregnancy
– Emergency circlage

5. PROM- Dx
Diagnosis is generally clinical
History:
– a sudden "gush" of clear or pale yellow fluid from the vagina.
– Intermittent or constant leaking of small amounts of fluid or
– just a sensation of wetness within the vagina or on the perineum
Physical findings:
- Negative uterine size discrepancy
- Meconium or vernix on the vulva
- Sterile speculum examination with or without valsalva
maneuver( leakage or pooling)
direct observation of amniotic fluid coming out of the cervical
canal or pooling in the vaginal fornix
NB
Digital examination should be avoided unless induction is planned
or the woman is in labor because it may decrease the latency
period (ie, time from rupture of membranes to delivery) and
increase the risk of intrauterine infection

6. Diagnosis-cont’d
• Nitrazine paper test:
– testing the pH of the vaginal fluid (color change
– Amniotic Fluid- alkaline (PH~7.3)
– False positive result alkaline fluids in the vagina Eg
blood, semen, bacterial vaginosis, and trichomoniasis
 Ferning Test :arborization (ferning).
– Fluid from the posterior vaginal fornix is swabbed onto a glass slide and
allowed to dry for at least 10 minutes.
– Amniotic fluid produces a delicate ferning pattern ( High Na+ and
protein contents)
 Pad Test
– Perinea Pad wetting
 Dye test -a definitive dx in equivocal cases,
– Indigo caramine is instilled into the amnotic cavity,
– tampoon placed in the vagina inspected after 30 min
for blue staining
 Ultrasonography- decreased AF volume

7. Ferning Pattern

8. PROM- Differential diagnosis
• Stress Urinary incontinence
• Vaginal discharge (Leucorrhea gravidarum or
pathological)
• Perspiration

9. PROM- investigations
• CBC
• U/A, Culture & Sensitivity
• High vaginal swab for culture
• Phosphatidylglycerol from vaginal pool (for
fetal lung maturity)

10. Complications of PROM
• Preterm Labor
– In Preterm PROM, labor starts in 70-80% of cases in one
week time
• Ascending infection: one third
• Increased incidence of cord prolapse
• Fetal pulmonary hypoplasia
• Prematurity
• Operative delivery
• Abruption

11. PROM- Managemet
Management of pregnancies complicated by PROM
depends on
• Gestational age
• Availability of neonatal intensive care
• Presence or absence of maternal/fetal infection
• Presence or absence of labor
• Fetal presentation (breech and transverse lies are
unstable and may increase the risk for cord prolapse)
• Fetal heart rate (FHR) tracing pattern
• Likelihood of fetal lung maturity
• Cervical status (by visual, not digital, inspection unless
induction is planned or the woman is in labor)

12. Indications for pregnancy termination in
PROM
• Term PROM
• Labor
• Presence of infection (chorioamnionitis)
• IUFD
• Congenital anomalies of fetus incompatible to
life
• Abnormal fetal surveillance

13. Preterm PROM
 GA > 34 weeks either conservative management or
termination
 GA< 34 weeks, conservative management
 Components of conservative management:
– Avoid digital vaginal examination
– Bed rest
– Monitor maternal PR, Temp., FHR every 4 hours
– CBC, U/A, ESR/CRP twice per week
– BPP/NST twice per week
– Corticosteroids if less than 32 weeks
– Administer antibiotics: ampicillin (iv)+ erythromycin X 48hrs
followed by amoxacillin(po) & erythromycin to complete a
total of seven days

14. Chorioamnionitis
• Clinical or subclinical
• Criteria for clinical chorioamnionitis:
- Maternal temperature > 38o C
- Uterine tenderness
- Foul smelling amniotic fluid
- High WBC count
- Maternal &/ or fetal tachycardia

15. Sub clinical chorioamnionitis
• Amniocentesis: intramniotic infection is
present if:
1. Culture: bacterial colony count > 102 / ml
fluid
2. Presence of bacteria on gram stain
3. Glucose level<15 mg/dl
4. WBC> 100/ml

16. Management of chorioamnionitis
• Antibiotics:
1. Ampicillin+ Gentamycin+
clindamycin/metronidazole/chloramphenicol
2. Ceftriaxone +/- metronidazole
• Terminate pregnancy: Vaginal route is
preferred

17. PROM
( uncomplicated)
GA< 34 weeks
Conservative management
GA 34-37 weeks
Deliver/conservative
GA> 37 weeks
Deliver

18. THANK YOU