Premature Rupture of Membranes Flashcards
Define premature rupture of membranes
Rupture of fetal membranes at least 1 hour prior to the onset of labour, at ≥37 weeks gestation
Occurs in 10-15% of term pregnancies, and is associated with minimal risk to the mother and fetus due to the advanced gestation
Pre-term premature rupture of membranes = rupture of fetal membranes occurring at <37 weeks gestation
Outline the pathophysiology of PROM
Fetal membrane = chorion + amnion strengthened by collagen
Early activation of normal physiological processes = higher than normal levels of apoptotic markers and MMPs in the amniotic fluid
Infection = inflammatory markers e.g. cytokines contribute to the weakening of fetal membranes. Approximately 1/3 of women with P-PROM have positive amniotic fluid cultures
Genetic predisposition
List the risk factors associated with PROM/P-PROM
Smoking (especially < 28 weeks gestation)
Previous PROM/ pre-term delivery
Vaginal bleeding during pregnancy
Lower genital tract infection
Invasive procedures e.g. amniocentesis
Polyhydramnios
Multiple pregnancy
Cervical insufficiency
Outline the clinical features of PROM
‘Broken waters’ = painless popping sensation, gush of watery fluid leaking from the vagina
Gradual leakage
Change in colour/consistency of vaginal discharge
Pooling in the posterior vaginal fornix
How should PROM be investigated?
High vaginal swabs
Ferning test = placing cervical secretion onto a glass slide, allowing to dry (forming fern-patterned crystals if there is PROM/PPROM)
Actim-PROM (Medix Biochemica) = swab test looking for IGFBP-1 (insulin-like growth factor binding protein-1) in vaginal samples. The conc in amniotic fluid is 100 – 1000 times the conc of maternal serum
Amnisure (QiaGen) = Placental alpha microglobulin-1 (PAMG-1) present in the blood, amniotic fluid (in large conc) and cervico-vaginal discharge (low conc with membranes intact)
How should PROM be managed?
Vast majority will fall into labour
<34w = aim to increase gestation
> 36w = if labour does not start, induction of labour ought to be considered at 24–48 hours. This is because the risk of infection outweighs any benefit of the fetus remaining in utero
34 – 36 weeks = aim for 34 weeks and induction of labour once there has been a course of steroids
What are the possible complications of PROM?
Chorioamnionitis = inflam of the fetal membranes, due to infection
Oligohydramnios = particularly significant if the gestational age is <24w, as it greatly increases the risk of lung hypoplasia
Neonatal death = due to complications associated with prematurity, sepsis and pulmonary hypoplasia
Placental abruption
Umbilical cord prolapse
What are the complications of prematurity?
Breathing = immature resp system, respiratory distress syndrome, bronchopulmonary dysplasia, apnoea
CVS = patent ductus arteriosus (PDA), hypotension
Neruo = intraventricular haemorrhage
Temp = prem babies lose heat rapidly, dont have stored body fat of full infant, hypothermia
GI = necrotizing enterocolitis (NEC)
Haem = anemia, newborn jaundice
Metabolism = hypoglycaemia
Immune = underdeveloped, higher risk of infection
Cerebral palsey
Impaired learning
Vision = retinopathy, retinal detachment
Hearing loss
Dental = tooth discolouration, improperly aligned teeth
Behavioural or psychological problems
Sudden infant death syndrome
What evidence based therapeutic interventions would you instigate to increase latency from PPROM to delivery and reduce the impact of prematurity?
Corticosteroids = help your fetal lungs grow and mature.
Antibiotics = prevent or treat an infection.
Tocolytic medicines = stop preterm labor
