an approach to diagnosing premature rupture of membranes and managing it.

1. DR ALIHUSSEIN KASSAM,
INTERN DOCTOR,
MNAZI MMOJA HOSPITAL,
ZANZIBAR
03/17/16 1DR ALIHUSSEIN KASSAM

2.  Premature rupture of membranes (PROM)
 Rupture of the chorioamnionic membrane
(amniorrhexis) prior to the onset of labor at any stage of
gestation
 Rupture of amniotic membranes after 37+0 and before
labor
 Preterm premature rupture of membranes
(PPROM)
 PROM prior to 36+6-wk. gestation
28 weeks? (pprom versus abortion)
24 weeks? (pprom versus abortion)
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DR ALIHUSSEIN KASSAM

3.  PROM – 12% of all pregnancies
 PPROM – 30% of preterm deliveries
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4.  History
 “Gush” of fluid
 Steady leakage of small amounts of fluid Cramping
 Contractions
 Back pain
 Physical
 What do you do?
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5.  Latency period
 Infection
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6.  Sterile
 No lubricating jelly
 Pooling of fluid in
posterior fornix
 Free flow of fluid
from cervix
 Cervical dilation
 Nitrazine
 Collect slide for
fern (dry 10 mins)
Assess
Consider need to collect other
cervical tests/cultures such fetal
fibronectin while doing the SSE.03/17/16
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7.  Test
 Nitrazine test
 Fluid from vaginal exam placed
on strip of nitrazine paper
 Paper turns blue in presence of
alkaline (pH > 7.1) amniotic fluid
 Fern test
 Fluid from vaginal exam placed
on slide and allowed to dry
 Amniotic fluid narrow fern vs.
cervical mucus broad fern
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8.  False positive Nitrazine test
 Alkaline urine
 Semen (recent coitus)
 Cervical mucus
 Blood contamination
 Vaginitis (e.g.Trichomonas)
 False-Negative Nitrazine test
 Remote PROM with no residual fluid
 Minimal amniotic leakage
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9.  fFn present in cervical
secretions <22 wks,
>34 wks
 Used for assessment
of potential PTB
 Positive result (>50
ng/dl) may be
indicative of PROM
and represents
disruption of decidua-
chorionic interface
In PPROM, Sensitivity-98.2%, Specificity-26.8%.03/17/16
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10.  Newer test
 Point of Care test
 Cost-up to $50 each
 Sensitivity-98.7-98.9%
 Specificity-87.5-100%
 Awaiting further testing prior to
recommendations
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11. Place Swab 2-3
in. into vaginal
canal x 1 min.
Remove swab
and rotate in
solvent x 1
min.
Discard swab and
place test stick into
solvent.
Read
results
after
5-10
mins
have
passe
d.
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12.  Test
 Ultrasound
 Assess amniotic fluid level and compatibility with PROM
 Indigo-carmine Amnioinfusion
 Ultrasound guided indigo carmine dye amnioinfusion (“Blue tap”)
 Observe for passage of blue fluid from vagina
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13.  Risk Factors:
 Prior PROM or PPROM
 Prior preterm delivery
 Multiple gestation
 Polyhydramnios
 Incompetent cervix
 Vaginal/Cervical Infection
 Gonorrhea, Chlamydia, GBS, S. Aureus
 Antepartum bleeding (threatened abortion)
 Smoking
 Poor nutrition
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14.  Patient counseling
 Expectant management vs. induction of labor
 GBS prophylaxis NOT recommended
 Antibiotics
 Incomplete data
 Corticosteriods NOT recommended
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15. http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/dataShow.cfm
Gestational
Age
(In Completed
Weeks)
Death Before
NICU Discharge
Outcomes at 18 to 22 Months Corrected Age*
Death
Death/ Profound
Neurodevelopmental
Impairment
Death/Moderate to Severe Neuro-
developmental Impairment
22 Weeks 95% 95% 98% 99%
23 Weeks 74% 74% 84% 91%
24 Weeks 44% 44% 57% 72%
25 Weeks 24% 25% 38% 54%
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16.  Expectant management
 Deliver at 34 wks
 Unless documented fetal lung maturity
 GBS prophylaxis
 Antibiotics
 Single course corticosteroids
 Tocolytics
 No consensus
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17.  Expectant management
 Deliver at 34 wks
 Unless documented fetal lung maturity
 GBS prophylaxis
 Antibiotics
 Corticosteroids
 No consensus, some experts recommend
 Magnesium sulphate use < 32 weeks
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18.  Proceed to delivery
 Induction of labor
 GBS prophylaxis
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19.  Antibiotics
 Prolong latency period
 Prophylaxis of GBS in neonate
 Prevention of maternal chorioamnionitis and neonatal sepsis
 Corticosteroids
 Enhance fetal lung maturity
 Decrease risk of RDS, IVH, and necrotizing enterocolitis
 Tocolytics
 Delay delivery to allow administration of corticosteroids
 Controversial, randomized trials have shown no pregnancy
prolongation
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20.  Antibiotics
 Ampicillin 2 g IV Q6 x 48 hrs
 Amoxicillin 500 mg po TID x 5 days
 Azithromycin 1 g po x 1
 Erythromycin 500mg tds 10/7
 Corticosteroids
 Betamethasone 12 mg IM q24 x 2
 Dexamethasone 6 mg IM q12 x 4 repeat 12mg if no delivery
within 7 days
 Tocolytics
 Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs
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21.  Typically performed after 32 wks
 Tests for fetal lung maturity (FLM)
 Lecethin/Sphingomyelin ratio (not
commonly used, more for historic interest)
 L/S ratio > 2 indicates pulmonary maturity
 Phosphatidylglycerol
 > 0.5 associated with minimal respiratory distress
 Flouresecence polarization (FLM-TDx II)
 > 55 mg/g of albumin
 Lamellar body count
 30,000-40,000
 If negative, proceed with expectant
management until 34 wks
Courtesy of Thomas Shipp, MD.
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22.  Maternal: Monitor for signs of infection
 Temperature
 Maternal heart rate
 Fetal heart rate
 Uterine tenderness
 Contractions
 Fetal: Monitor for fetal well-being
 Kick counts
 Nonstress tests (NST’s)
 Biophysical profile (BPP)
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23.  Immediate Delivery
 Intrauterine infection
 Abruptio placenta
 Repetitive fetal heart rate decelerations
 Cord prolapse
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24.  Expectant Management Risks:
 Maternal
 Increase in chorioamnionitis
 Increase in Cesarean delivery
 Spontaneous labor in ~ 90% within 48 hr ROM
 Increased risk of placental abruption
 Fetal
 Increase in RDS
 Increase in intraventricular hemorrhage
 Increase in neonatal sepsis and subsequent cerebral
palsy
 Increase in perinatal mortality
 Increase in cord prolapse
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25.  ROYAL COLLEGE CURRENT
GUIDELINES 2010 ON OBSTETRICS
 W.H.O INTERVENTION TO IMPROVE
OUT COMES IN PRETERMS @2015
K.C.M.C GUIDELINES FOR OBSTETRICS
2012
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26. 03/17/16DR ALIHUSSEIN KASSAM
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