Premature rupture of membrane
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PREMATURE RUPTURE OF MEMBRANES
Asha ShresthaKhushbu Gupta
Rashmi Shrestha
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FETAL MEMBRANES
• Consists of two layers:1. Chorion
(outer)2. Amnion
(inner)
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Functions of Fetal Membranes
• Contribute to formation of liquor amnii• Intact membranes prevent ascending uterine
infection• Facilitate dilatation of the cervix during labour• Has got enzymatic activities for steroid hormonal
metabolism• Is rich source of glycerophospholipids containing
arachidonic acid
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Premature rupture of membrane (PROM)
• Spontaneous rupture of membrane any time beyond 22nd weeks of pregnancy but before the onset of labour
• Incidence: 10% of all pregnancies
• Two types- – Term PROM– Preterm PROM
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Term PROM- rupture of membranes beyond 37th weeks of gestation but before the onset of labour- incidence: 8% of all pregnancies
Preterm PROM- rupture of membranes before 37 completed weeks of gestation- incidence: 2 to 3% of all pregnancies
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ETIOLOGY• In majority, causes not known• Possible causes:
– Increased friability of the membranes– Decreased tensile strength of membranes– Polyhydramnios– Cervical incompetence– Multiple pregnancy– Infections e.g. chorio-amnionitis, UTI & lower genital tract
infections– Cervical length < 2.5 cm– Prior preterm labour– Low BMI (< 19 kg/m2 )
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DIAGNOSIS
• History• Examination• Investigations
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HISTORY
Patient complains of discharge of clear fluid (liquor) vaginally.
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EXAMINATION
• Speculum examination– shows liquor draining through cervical os
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Differential Diagnosis1. Hydrorrhoea gravidarum
a state where periodic watery discharge occurs probably due to successive decidual glandular secretion
2. Incontinence of urine3. PROM
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INVESTIGATIONS
Examination of collected fluid from posterior fornix:a. Fern test, crystallization of liquor when dried on a slideb. Nile blue sulphate (0.1%) test for orange fetal cellsc. Litmus test or Nitrazine paper test for detection of pH (pH becomes 6 to 6.2))
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HAZARDS
• Maternal- preterm labour- increased risk of infection
• Fetal– cord prolapse– intrauterine infection– fetal pulmonary
hypoplasia– neonatal sepsis– Respiratory Distress
Syndrome– Intra Ventricular
Hemorrhage– Necrotizing Enterocolitis
(NEC)
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MANAGEMENT
Management of PROM depends on:1. Gestational age of fetus2. Whether the patient is in labour or not3. Any evidence of sepsis4. Prospect of fetal survival in that institution, if delivery occurs
(Maternal pulse, temperature and fetal heart rate monitored 4 hourly and start prophylactic broad spectrum antibiotics)
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PROM
Amnionitis, Placental abruption, Fetal death or distress, labour process
Absent Present
Prompt effective delivery
Intrapartum antibiotics (Broad Spectrum)
NICU
For PPROM For TPROM
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For PPROM ( In absence of amnionitis, placental abruption etc )
Pregnancy < 34 weeks Pregnancy ≥ 34 weeks to < 37 weeks
Management to continue for fetal maturity
Transfer the patient with ‘ fetus in utero’ to an centre equipped with NICU
Wait for spontaneous onset of labour for 24-48 hrs
Induction of labour with oxytocin or CS ( for obstetric reasons)
If fails
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– If patient is not in labour or no evidence of infection or fetal distress, wait for spontaneous labour for 24 hours
– If not Induction of labour with oxytocin
Caesarean section ( for obstetric reasons)
For TPROM ( In absence of amnionitis, placental abruption etc )
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Reference
• Textbook of Obstetrics, 7th edition, D.C. Dutta
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THANK YOU