29. Anomalies of rupture of membranes

Question 1

what is ROM?

Answer 1

rupture of membranes
it’s the rapture of the amniotic sac followed by the release of the amniotic fluid; typically occurs spontaneously during the first stage of labor (amniorrhexis) , signifying the onset of labor.

Question 2

what is Preterm ROM?

Answer 2

spontaneous ROM before 37 weeks gestation

Question 3

what is PROM?

Answer 3

premature ROM; spontaneous rupture with no labor (no uterine contractions)

Question 4

what is Prolonged ROM?

Answer 4

time from ROM to delivery of fetus > 18 h’.

Question 5

risk factors for ROM

Answer 5

• Ascending infection
• Smoking
• Multiple gestation
• Previous preterm delivery, PROM, or PPROM

Question 6

Diagnosis of ROM

Answer 6

21. History of leaking vaginal fluid (may be clear, bloody, or meconium-like).
22. Pooling of fluid in the posterior vaginal fornix on speculum examination.
23. Positive nitrazine test
24. Positive fern test
25. Ultrasound → oligohydramnios may be present.
26. Fetal heart rate monitoring
27. Maternal examination → assess for signs of infection (temperature, uterine tenderness, WBC count).

Question 7

what is a positive fern test

Answer 7

vaginal fluid is placed on a glass slide and allowed to dry; amniotic fluid creates a characteristic fern-like pattern under microscopy.

Question 8

what is a positive nitrazine test?

Answer 8

nitrazine paper serves as a pH indicator (amniotic fluid is alkaline and will turn test paper blue, vaginal secretions are normally acidic and turn test paper red).

Question 9

Complications associated with PROM and PPROM (5)

Answer 9

1. Umbilical cord prolapse
2. Placental abruption.
3. Chorioamnionitis; potentially causing preterm birth, fetal distress, fetal death, or perinatal sepsis.
4. Pulmonary hypertension, pulmonary hypoplasia, NRDS.
5. Endometritis.

Question 10

management of PROM/ PPROM in all patients

Answer 10

1. Monitor for signs of chorioamnionitis.
2. Perform fetal heart rate monitoring.
3. Consider intrapartum risk factors and GBS screening + prophylaxis, depending on whether previous antenatal GBS screening tests have been performed.

Question 11

when do we prompt delivery in a unstable patient with PROM/ PPROM?

Answer 11

1. Patient with signs of intraamniotic infection, abruptio placenta, cord prolapse.
2. Signs of fetal distress (non-reassuring fetal heart rate).

Question 12

Chorioamnionitis treatment

Answer 12

• Vaginal delivery: Ampicillin + Gentamycin.
• C-section: Ampicillin + Gentamycin + Clindamycin.
  *C-section is generally indicated if the condition of the cervix is not favorable, and there is evidence of fetal involvement.

Question 13

management of PROM at gestational age
≥ 37 weeks (term)

Answer 13

1. Delivery by induction is generally recommended.
2. Expectant management for up to 12-24 hours is reasonable in otherwise uncomplicated pregnancies and in the absence of infection (80-95% of patients begin spontaneous labor within this timeframe).

Question 14

Management of PPROM at Gestational age
34-36 weeks

Answer 14

1. Risk/benefit approach: delivery by induction vs. expectant management.
2. Consider single-course corticosteroids if not previously given and if there is no evidence of chorioamnionitis.

Question 15

Management of PPROM at Gestational age
24-33 weeks

Answer 15

1. Expectant management (bed rest, pelvic rest).
2. Prophylactic antibiotics to reduce the risk of chorioamnionitis and delay delivery.
   Ampicillin + Erythromycin or Ampicillin + Azithromycin.
3. Antenatal corticosteroids (betamethasone or dexamethasone).
4. Tocolytics can be used to delay delivery for up to 48 h’ so that antenatal corticosteroids can be administered.
5. Magnesium sulfate (neuroprotective role) if preterm delivery < 32 weeks gestation is anticipated.

Question 16

Fetal outcome in case of PPROM in <23-24 weeks of gestational age?

Answer 16

poor if PPROM occurs before 24 weeks gestation.
24 weeks is considered the cutoff for fetal viability.