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Prelabor rupture of membranes (PROM) rupture of membranes prior to onset of labor Preterm prelabor rupture of membranes (PPROM) of membranes rupture prior to 37 weeks gestation 3/15/12
DEFINITIO N
DEFINITIO N
Spontaneous prelabor rupture of membranes (SPROM) of membranes rupture after or with the onset of labor Prolonged rupture of membranes any rupture of membrane that persists for more than 24 hours and prior to onset of labor
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DEFINITIO N
PRO M
DELIVE RY
Latent Period
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Amniotic Fluid
Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12
amnion
Amniotic Fluid
Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12
chorion
Amniotic Fluid
Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12
decidua
Amniotic Fluid
Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12
amniochorialdecidual unit
Amniotic Fluid
Fetal Membranes
anatomic structure that includes amnion and chorion (which are of fetal origin) and portions of decidua (of maternal origin) 3/15/12
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In a proportion of women, spontaneous rupture of membranes is a function of cervical dilatation most patients have spontaneous rupture of membranes at the:
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In a proportion of women, spontaneous rupture of membranes is a function of cervical dilatation most patients have spontaneous rupture of membranes at the:
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the uterine cavity in close proximity to the cervix membranes apposed to the cervix have localized morphologic changes which have been referred to as : of altered zone morphology 3/15/12 (ZAM)
DEFINITIO N
Zone of Altered Morphol ogy (ZAM)
weakened area of membranes characterized by: marked swelling and disruption of the connective tissue thinning of the trophoblast layer thinning or absence of the decidua increased programmed cell death (apoptosis) significant decrease in the density of collagens (I, III, and V)
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8% to 10%
PPROM
8% to 10%
PPROM
ETIOLOGY Normally, fetal membranes are extremely resistant rupture early in pregnancy
to
Labor Increased intrauterine pressure Exert pressure over the weakened area of the membrane (ZAM) PCD + activation of catabolic enzymes(collagenases)
Rupture of membranes
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Premature activation
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ETIOLOG Y
Early PROM also appears to be linked to underlying pathologic processes. A scholarly review of the etiology of PPROM identified numerous potential causes.
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Some genital bacteria elaborate inflammation enzymes and/or proteases infection of the phospholipase membranes s decreased collagenases collagen content of the membranes (type III) decrease tensile strength of membranes
Stress membranes
Smoking
Hx of STI 3/15/12
Uterine distension
Polyhydramni os
Uterine distension
Polyhydramni Polyhydramni os os
SIGNIFICANC E
Prematurity:
- 15% of neonatal morbidity and mortality 3/15/12
SIGNIFICANC E
Prematurity:
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SIGNIFICANC E
Prematurity:
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persistent leak
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*Precaution: Avoid digital cervical exam in PPROM ! Disadvantages: - raises infection risk, other morbidities - reduces time to labor by 9 days
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I.
Vaginal Pooling
I.
A.
Technique
Vaginal Pooling
Patient lies semirecumbent for 45 minutes . Consider elevating buttocks on cushioned pan . Perform speculum exam after pooling for 45 minutes
.
I.
B.
Interpretation
Vaginal Pooling
Pooling of fluid suggests ROM . If no fluid seen : - Apply gentle fundal pressure or have patient cough - Fluid may be seen passing from cervical os
.
I.
Technique
Vaginal Pooling
Obtain fluid for exam (usually after Vaginal Pool) . Place sample on glass slide .Allow sample to air dry for 10 minutes
.
I.
Vaginal Pooling
I.
Vaginal Pooling
I.
Vaginal Pooling
C. Efficacy Accuracy for amniotic fluid: 84 to 100% Test Sensitivity: 100% (when allowed to dry 10 minutes )
I.
A.
Technique Obtain fluid for exam (usually after Vaginal Pooling) Place Nitrazine paper in fluid Paper turns bright blue in alkaline fluid
1.
Vaginal Pooling
I.
Vaginal Pooling
B. Interpretation: Nitrazine Paper Normal Vaginal pH (4.5-6.0): Paper does not change color
I.
Vaginal Pooling
C. False positive results: contamination with cervical secretions & blood and secretions 2 to vaginal infections semen, antiseptic solutions
show absence or very low amounts of AF in uterine cavity Dx unclear (ex. oligohydramnios, concomitant bleeding): *Alternative invasive method: 1. Uses Indigo carmine dye 1 ml in 9 ml sterile NS 2. Instilled into uterus via amniocentesis 3/15/12 3. Vaginal tampon turns
hCG alpha -fetoprot ein creatinin e endotheli n-1 protein molecule present in AF w/c has the capacity to: generate uterine contractions activate phospholipase A2 & phospholipases
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maternal and fetal morbidity parallel to latent period: < 12 hours: best results >12 hours: morbidity (increased 20 times)
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Leakage stops and reaccumulation of normal AF on ultrasound Confirm resealing of membranes Discharge from hospital
Advanced active labor, clinical chorioamionitis, YE NO irreversible fetal S Mgt distress Delive depends ry principall y on AOG
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MANAGEMEN T Ter m
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MANAGEMEN T Ter m
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MANAGEMEN T Ter m
Mother remains afebrile, fetus is stable, cultures are negative: wait for spontaneous labor
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MANAGEMEN T Ter m
Maternal fever, fetal tachycardia: administer antibiotics induce labor despite unfavorable cervix: **Latent phase of labor may be long (16-20 hours). **Vaginal and other instrumental examinations should be minimized. 3/15/12
MANAGEMEN T Ter m
Mother shows signs of chorioamionitis OR Fetus displays signs of distress and Vaginal delivery is not expected within few hours: terminate pregnancy by abdominal route
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MANAGEMEN T Medicatio ns
1. 2. 3.
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MANAGEMEN T Medicatio ns
1.
.
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MANAGEMEN T Medicatio ns
1.
.
Corticosteroids
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MANAGEMEN T Medicatio ns
1.
.
Corticosteroids
Recommended Regimens: betamethasone (Celestone): IM: 12 mg every 24 hrs for 2 days dexamethasone (Decadron) IM: 6 mg every 12 hrs for 2 days
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MANAGEMEN T Medicatio ns
1.
.
Corticosteroids
Recommended Regimens: betamethasone (Celestone): IM: 12 mg every 24 hrs for 2 days dexamethasone (Decadron) IM: 6 mg every 12 hrs for 2 days . Administer before 32 and 34 weeks AOG, assuming fetal viability and no 3/15/12 evidence of intra-amniotic infection
MANAGEMEN T Medicatio ns
1.
.
Corticosteroids
between 32 and 34 weeks AOG use: - controversial after 34 weeks AOG use: - not recommended unless there is evidence of fetal lung immaturity by amniocentesis
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MANAGEMEN T Medicatio ns
1.
-
Corticosteroids
Multiple courses result in : decreased birthweight head circumference body length
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MANAGEMEN T Medicatio ns
2. Antibiotics
given to patients with PPROM: - reduce neonatal infections - prolong latent period
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MANAGEMEN T Medicatio ns
2. Antibiotics
After PPROM: - Reduce postpartum endometritis, chorioamionitis, neonatal sepsis, neonatal pneumonia, and intravascular hemorrhage
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MANAGEMEN T Medicatio ns
2. Antibiotics
Recommended Regimens: IV combination of: 2 g of ampicillin + 250 mg of erythromycin - every 6 hrs for 2 days FOLLOWED BY: 250 mg of amoxicillin and 333 mg of erythromycin 3/15/12 - every 8 hrs for 5 days
MANAGEMEN T Medicatio ns
2. Antibiotics
It is advisable to administer appropriate antibiotics for intrapartum group B streptococcus prophylaxis to women who are carriers.
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MANAGEMEN T Medicatio ns
3. Tocolytics
may prolong the latent period for a short time but do not appear to improve neonatal outcomes
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MANAGEMEN T Medicatio ns
3. Tocolytics
long term tocolytic therapy in PROM pts: NOT RECOMMENDED
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pts with documented pulmonary maturity - induce labor - consider transferring to a facility that can give care for premature neonates
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prolonging pregnancy after documentation of pulmonary maturity unnecessarily increases the likelihood of: - maternal amnionitis - umbilical cord compression - prolonged hospitalization - neonatal infection
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There are a few data to guide the care of patients without documented pulmonary maturity. Physicians must balance the risk of respiratory distress syndrome and other sequelae of prelabor delivery with the risk of prolongation, such as neonatal sepsis and cord accidents.
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pts without documented fetal lung maturity: - administer a course of corticosteroids + antibiotics - consider delivery 48 hrs later OR - perform a careful assessment of fetal well- being - observe for intra-amniotic infection 3/15/12 deliver at 34 weeks -
All patients should receive appropriate intrapartum group B streptococcus 3/15/12 prophylaxis, if indicated.
delivery before 32 weeks AOG leads to: Severe neonatal morbidity and mortality absence of intra-amniotic infection: Prolong pregnancy until 34 weeks AOG
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Advice patients and family members that, despite efforts, many patients deliver within 1 week of PPROM Contraindication to conservative therapy: - chorioamnionitis - placental abruption - non-reassuring fetal testing
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Administer a course of corticosteroids and antibiotics Perform an assessment of fetal well being: - fetal monitoring or ultrasonography
Daily monitoring - With PPROM before 32 weeks 3/15/12 AOG, umbilical cord compression
Observe closely for indicators of amnionitis: - fetal or maternal tachycardia - oral temperature exceeding 38C (100.4 F) - regular contractions - uterine tenderness - leukocytosis
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Corticosteriod administration may lead to an elevated leukocyte count if given 57 days of PROM. Delivery is necessary for patients with evidence of amnionitis.
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Many infants who are delivered after previable rupture of fetal membranes suffer from numerous long-term problems:
chronic lung disease developmental abnormalities neurologic abnormalities hydrocephalus cerebral palsy
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- results in pressure deformities of the limbs and face and pulmonary hypoplasia - incidence is related to AOG at which rupture occurs and to the 3/15/12 level of oligohydramnios
Many infants who are delivered after previable rupture of fetal membranes suffer from numerous long-term problems: syndrome: **Potters
Patients should be counseled about the outcomes and benefits and risks of expectant management which may not continue long enough to deliver a baby that will survive normally. Physicians may wish to obtain consultation with perinatologist or neonatologist.
Such patients, if they are stable, may benefit 3/15/12 transport to tertiary facility. from
Cervical Cerclage
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Cervical procedure in which a nonabsorbable suture is used for holding the cervix closed to prevent spontaneous abortion in a woman who has an
Cervical Cerclage
risk factor for PROM and other associated pregnancy outcomes As of today, there is no prospective study regarding treatment of PPROM subsequent to cervical cerclage in situ.
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