PROM

Premature rupture of membranes

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Abstract

PROM means rupture of the fetal membranes before the onset of labor

minoo bhagia - Activity on Knol

Diagnosis

There is always a history of gush of fluid or watery fluid from vagina.
Per speculum examination is done to differentiate between the urine and vaginal fluid.
‘Ferning” test of the vaginal fluid helps in diagnosis.Amnotic fluid is taken on slide and dried, if ”ferning pattern” is seen on microscopic examination, it is confirmative of the amniotic fluid.
Nitrazine paper test can also be done.Paper turns blue if it is amniotic fluid as the pH of amniotic fluid is 7-7.7
50% of the patients undergo labor within 12 hrs if it is a full term pregnancy.

Risk of PROM

Vaginal and intraamniotic infection.
Fetal distress
Oligohydramnios.and uteroplacental insufficiency
Cord accidents
Placental abruption.

Management

Duration of pregnancy is of severe concern.If the fetus is premature and there is PROM , it is really the cause of concern for the obstetrician.It depends upon the amount of leakage, whether it is continuous or intermittent, meconium stained or clear.
USG is done to see the amount of amniotic fluid.
Per vaginal examination is done to see whether the cervical OS is open or not.
Most important thing is the gestational period.
If it is less than 32 weeks, then expectant treatment can be tried.Strict bed rest, antibiotics, regular fetal monitoring with CTG or USG.
Betamethasone 12mgm IM stat and repeated after 24 hrs for 2 doses.Steroids are recommended to decrease the RDS , NEC and IVH in the fetus before 32 weeks.
Glucocorticoids decrease the risk of respiratory distress syndrome by 50%.Maximum effect is benefited within 48 hours.The effect lasts for 7 days.They also reduce the risk of necrotizing enterocolitis and intraventricular haemorrhage.Intramascular dexamethasone can be used.Prednisone does not cross the placenta.Multiple courses of steroids should not be used as they are associated with IUGR and smaller head circumference.
Oral dexamethasone is associated with 10% increase in the neonatal infection. .

There is no proven benefit if fetus is more than 34 weeks gestation.

If fetus is 34 to 36 weeks then there are tests for the fetal lung maturity like :
Abbott–TDX-FLM assay : In this a dye is put in the amniotic fluid which binds to the albumin and surfactant. Results are mgm surfactant per 1gm albumin.if it is >70==mature.
Lecithin -sphingomyelin ratio, if it is > 2 , it is mature.
Phospahtidylglycerol (PG ) if present means  :mature.
If it is mature then consider immediate dellivery.The risk of infection outweighs the risk of prematurity.
If fetus is more than 36 weeks, determination of fetal maturity is not required.Immediate delivery is indicated.
PROM is a relative contraindication for the use of tocolytic agents.
So , if a patient comes to me with premature rupture of the membranes, I will ask the history , obstetric history , whether she is a primi or multi, how many children she is having, what is the last menstrual period (LMP) .Then I will do per abdominal examination to assess the gestational age , hear the fetal heart sound with the help of doppler or stethoscope or fetoscope.Then I will do her per speculum examination and apply sterile pad over vulva to see whether the liquor is meconium stained or not.If she is complaining of abdominal pain and uterine contractions then I will do per vaginal examination taking all aseptic precautions.
I will see cervical dilatation , ripening , absence or presence of the membranes (sometimes membranes are flat over vertex ), presentation of the fetus whether vertex or breech or transverse lie ? What is the station of the presenting part ? If it is below 36 weeks, say about 34 weeks gestation but the cervix is 2 fingers , thin , membranes are absent , then I will take the consent for the induction of delivery explaining the risk.USG is to be done. Paediatrician is to be informed and NICU is to be informed.
Give injection dexona 6mgm stat and 12 hourly till the delivery occurs. Usually two doses are sufficient.One can go for oral or vaginal misoprost 25 mcg or IV oxytocin in fluids with Inj epidosine and drotaverine. If uterine contractions are strong then one can avoid all these drugs.This all depends upon the choice and experience of the obstetrician.Strict watch on FHS is required. It is better to use CTG as it gives continuous recording and simultaneously one can do non-stress test..If required one can go for C-section.Do not forget to give broad spectrum antibiotics.
If leaking is slight and cervical os is closed and it is between 32 -34 weeks then one can admit the patient for the observation , fetal surveillence, for dexona injections and antibiotics.Get the investigations done like routine haemogram and USG.Sometimes the leaking stops and one can wait till 36 wks without much oligohydramnios.
If is term pregnancy then one can go for the vaginal delivery or C- section depending upon the cervical dilatation, ripening , engagement of the presenting part etc.See for the progress of labour , if there is fetal distress and non progress of labour one has to go for C-section.Anesthetist , OT, Paediatrician should always be informed in advance.
At primary care centres there is no facility for NICU so it is better to refer the woman to higher centres rather than taking the risk of managing a preterm newborn.   
PROM is associated with 30-40% of pretem births and 10% of the perinatal mortalities.
Steroid therapy helps the best in between 32-34 weeks size fetus.
Severe oligohydramnios may be associated with umbilical cord compression leading to cesarean delivery.
Amnioinfusion with saline has been shown to improve the fetal testing.
If there is intraamniotic infection, fetal distress, vaginal bleeding , active labor then immediate augmentation of labor should be done.
Multiple pregnancy is one of the predisposing factor of the PROM.

References

  • Obgyn---ERROL R .NORWITZ , MD , phD and John O .Schorge , MD, 2001;119
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