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  2. Definitions Premature rupture of the membranes (PROM) is usually defined as rupture at any time before the onset of contractions. Term PROM is rupture of membranes after 37wks & before onset of contractions.

  3. Definitions(cont’d) Pre term PROM is rupture of membranes before 37wks of gestational age. Prolonged PROM is rupture of membranes for >24hrs.

  4. Incidence Five to 10% of all deliveries. PPROM occurs in approximately 1% of all pregnancies. PROM is the clinically recognized precipitating cause of about one third of all preterm births.

  5. Fetal membranes Made of thin inner layer that covers amniotic cavity called amnion. Outer layer ,thicker that apposes the decidua called chorion. Both fuse together at 14weeks.

  6. Etiology • Connective tissue disorders • Urogenital tract infection, • Low socioeconomic status, • Uterine over-distention, • Second- and third-trimester bleeding, • Low body mass index • Nutritional deficiencies • Maternal cigarette smoking, • Cervical conization or cerclage, • Pulmonary disease in pregnancy

  7. Clinical manifestation & Dx Hx:The classic clinical presentation of PPROM is a sudden "gush" of clear or pale yellow fluid from the vagina. :Many women describe intermittent or constant leaking of small amounts of fluid or just a sensation of wetness within the vagina or on the perineum.

  8. Diagnosis Physical examination — The best method of confirming the diagnosis of PPROM is direct observation of amniotic fluid coming out of the cervical canal or pooling in the vaginal fornix. If amniotic fluid is not immediately visible, the woman can be asked to push on her fundus, Valsalva, or cough to provoke leakage of amniotic fluid from the cervical os.

  9. Diagnosis… Nitrazine test — If PROM is not obvious after visual inspection, the diagnosis can be confirmed by testing the pH of the vaginal fluid, which is easily accomplished with nitrazine paper. Amniotic fluid usually has a pH range of 7.0 to 7.3 compared to the normally acidic vaginal pH of 3.8 to 4.2.

  10. 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, in contrast to the thick and wide arborization pattern of dried cervical mucus. Well-estrogenized cervical mucus or a fingerprint on the microscope slide may cause a false-positive fern test .

  11. Placenta alpha microglobin-1 protein assay (AmniSure) The test is done by the provider at the point of care using a commercially available kit. A sterile swab is inserted into the vagina for one minute, then placed into a vial containing a solvent for one minute, and then an AmniSure test strip is dipped into the vial.

  12. Placenta alpha microglobin-1 protein assay (AmniSure) The test result is revealed by the presence of one or two lines within the next 5 to 10 minutes (one visible line means a negative result for amniotic fluid, two visible line is a positive result, no visible lines is an invalid result). Sensitivity ranged from 94.4 to 98.9 percent and Specificity ranged from 87.5 to 100 percent [33-37].

  13. Ultrasound Ultrasound examination may be of value in the diagnosis of PPROM. Fifty to 70 percent of women with PPROM have low amniotic fluid volume on initial sonography . A mild reduction of amniotic fluid volume may have many etiologies. combined with a characteristic history, is highly suggestive of PROM.

  14. Instillation of Indigo carmine In equivocal cases, instillation of indigo carmineinto the amniotic cavity can be considered and usually leads to a definitive diagnosis. Under ultrasound guidance, 1 mL of indigo carmine in 9 mL of sterile saline is injected transabdominally into the amniotic fluid and a tampon is placed in the vagina. One-half hour later, the tampon is removed and examined for blue staining, which indicates leakage of amniotic fluid.

  15. Complications • Maternal Endomyometritis Sepsis PPH APH Wound infection Cesarean delivery • Fetal Chorioamnionitis Neonatal sepsis Pulmonaryhypoplasia Cord prolapse Limb deformity

  16. Resealing Up to 14 percent of gravidas with spontaneous midtrimester PPROM eventually stop leaking amniotic fluid, presumably due to "resealing" of the fetal membrane. Cessation of leakage is probably not due to actual repair and regeneration of the membranes, but rather to changes in the decidua and myometrium that block further leakage .

  17. Mx of TERM PROM Labor is induced, unless there are contraindications to labor or vaginal delivery, in which case cesarean delivery is performed. Most women with term PROM who are followed expectantly will go into spontaneous labor and deliver within 24, 48, and 72 hours of PROM in 70, 85, and 95 percent of women, respectively .

  18. Mx of PPROM 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

  19. Maternal surveillance All women with PPROM should be monitored for signs of infection. At a minimum, routine clinical parameters (eg, maternal temperature, uterine tenderness and contractions, maternal and fetal heart rate) should be monitored.

  20. Maternal… Chorioamnionitis is diagnosed if >or 2 criteria: Fever Abdominal tenderness Offensive Vx discharge Fetal tachycardia mater tachycardia Leukocytosis

  21. Fetal surveillance Fetal surveillance Kick counts Non stress tests Biophysical profile [BPP]) .

  22. Antenatal steroids Dexamethasone 6mg bd ;04 doses Bethametasone 12mg daily;02doses Decreases IVH NEC RDS Neonatal mortality

  23. Antibiotics Goal: Decrease maternal infection >> fetal infection Prolong latency(onset of labor) Ampicillin IV for 48hrs,Amoxicillin po 7d. Erythromycin IV for 48hrs,Eryth IV 7d.

  24. Termination Of pregnancy If chorioamnionitis develop any time. At 34wks At 32-34wks if lung maturity confirmed Mode of delivery Based on obstetric indications.