Preterm Rupture Of Foetal Membranes

Preterm rupture of foetal membranes Presented by Dr Ikobho E.H SENIOR REGISTRAR Dept. of Obstetrics and Gynaecology. UPTH

INTRODUTION 

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Very common problem in our environment May occur at any time during pregnancy High risk of foetal wastage Leads to preterm labour and prematurity High perinatal mortality and morbidity

Definition 

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Premature rupture of membranes is -rupture of membranes before the onset of labour Preterm rupture of membranes refers to rupture of membranes before 37 completed weeks of gestation Pre labour rupture of membranes Preterm prelabour rupture of membranes

Incidence 

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Occur in about 10.7% of all pregnancies In 94% of the cases the foetus is mature Premature fetuses (1000-2500g) account for about 5% of cases While in about 0.5% of cases, the foetus is immature (less than 1000g) 4.4% in UPTH from 2004 annual report

Socio-demographic risk factors        

Exact cause is unknown Teenage pregnancy and women above 35 Low social class Malnutrition (BMI of less than 19) Single women (unmarried and unsupported) Smokers family history of PROM and pre term birth

Medical factors     

Anaemia Polycythaemia Systemic infections-malaria, UTI Cardiac disease chronic renal disease

Obstetric factors       

Cervical incompetence Polyhydramnios Multiple gestation Vaginal infections Intrauterine infections-TORCH Previous history of PROM Abnormal lie and presentation

pathology        

Preterm labour and prematurity Cord prolapse Abruptio placenta Chorioamnionitis Intrauterine infections Pulmonary hypoplasia Fetal limb position defects Increased risk of perinatal mortality

History        

Sudden gush of fluid per vaginam Continuous leakage duration Lower abdominal pain Vaginal bleeding Any predisposing factor Any complication treatment

Clinical examination  

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General examination Systemic examination (including uterine content) Avoid or minimal vaginal examination Speculum examination

Sterile speculum examination       

Necessary to confirm drainage Gush of liquor from cervical os Cervical effacement and dilatation Cord prolapse Mechonium stained liquor Offensive Collect liquor for fetal lung maturity

Other confirmatory test 

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To differentiate liquor from increased vaginal secretions, urine, or semen Pool of liquor from posterior fornix Nitrarizine test –may turn from yellow to blue(96% accurate) Ferning on glass slide (85% accurate) If all three are positive-confirmatory The absence of one indicates further

Other measures 

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Biochemical measurement of high volumes of glucose, fructose, prolactin,alpha fetoproteins, and hcG in amniotic fluid If no free fluid is found, place dry perineal pad If PROM could still not be confirmed and history is strongly suggestiveamniocentesis and dye test (Evans blue)

Other investigations      

Full blood count Urinalysis and urine culture Endocervical swab for M/C/S Blood film for malaria parasites Electrolytes urea and creatinin Ultrasound scan-liquor volume, fetal wellbeing,

Treatment 

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Aim to deliver when extrauterine survival is possible And to prevent chorioamnionitis Therefore management depends on GA and presence or absence of amnionitis

Term pregnancy with PROM 

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Majority go into spontaneous labour within 24 hours Expectant management for 12-24 hours is justified No labour-carry out induction Broad spectrum antibiotics

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Preterm PROM without amnionitis 24-32 weeks gestation

Expectant management Admit into the ward, and do investigations Broad spectrum antibiotics 4 hourly BP, pulse and temperature Fetal kick chart 4 hourly fetal heart rate Cardiotocogram twice weekly Ultrasound scan twice weekly Check state of liquor daily-sanitary pads

Prom at less than24 weeks   

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Extremely low fetal salvage rate Very high risk of chorioamnionitis Steroids, tocolytics and antibiotics have no proven benefit Management should be expectant or by active termination

PROM between 32 and 34 weeks and no amnionitis   

Test for fetal lung maturity Give corticosteroids for 24 hour Deliver by induction of labour

Prom with amnionitis        

Fever Maternal leukocytosis -daily WBC Maternal tachycardia (above100beats/m) Fetal tachycardia Uterine tenderness –check every 4 hours Offensive liquor treatment –deliver irrespective of GA (Septicaemia, endotoxic shock and DIC) Broad spectrum antibiotics

Role corticosteroids 

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Proven to be beneficial at 24-33 weeks Short course of not more than 24 hours Reduced risk of respiratory distress syndrome, necrotizing enterocolitis and interventricular hemorrhage

Role of tocolytics  

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Controversial Prophylactic tocolytics alone has not been proven to improve outcome Recommended for use for not more than 48 hours to facilitate administration of corticosteroids and antibiotics

Conclusion

Thank you