Preterm Rupture of Membranes

Question 1

What does pre-labour rupture of membranes mean?

Answer 1

It means the rupture of membranes after 37 weeks but without contractions starting within 1 hour

Question 2

What does preterm rupture of membranes mean?

Answer 2

It means the rupture of membranes before 37 weeks without uterine contractions

Question 3

What are the consequences of preterm rupture of membranes(especially before 34 weeks?)

Answer 3

Preterm rupture of membranes causes hyaline membrane disease and other complications of prematurity

Question 4

What is the complication that often follows maternally after PROM?

Answer 4

-bacterial infection which can lead to septicaemia and septic shock

Question 5

What is the complication that often follows foetally after PROM?

Answer 5

The neonate may experience infection like pneumonia

Question 6

What is the most common cause of preterm labour and pre-term rupture of membranes?

Answer 6

1. Infection of the membranes and placenta

Question 7

What are the fetal causes of pre-term rupture of membranes?

Answer 7

1. Chorioamnionitis
2. Multiple pregnancies
3. Polyhydroamnios
4. Congenital fetal abnormalities like neural tube defects and gastro-intestinal defects

Question 8

What are the placental factors that cause pre-term rupture of membranes?

Answer 8

Placenta praevia

Question 9

What are the risk factors that can lead to pre-term rupture of membranes?

Answer 9

1. Previous PROM
2. No antenatal care
3. Poor socio-economic circumstances
4. Smoking and alcohol abuse
5. Sex in the second half of pregnancy because of high risk of STI transmission

Question 10

What is important about the history in patients with PROM?

Answer 10

-They usually present with a gush in large volume of fluid and then have a continuous small vaginal discharge

Question 11

What is the definitive diagnosis for PROM?

Answer 11

1. Pooling or when speculum examination is being done there is visible drainage of fluid that confirms the diagnosis

Question 12

What can we do if we cannot confirm the diagnosis for PROM and no fluid pools?

Answer 12

We can do a posterior fornix wet smear test to test for pH and a fern leaf test on a glass side

Question 13

How can we differentiate between a copious vaginal discharge and amniotic fluid?

Answer 13

1. Two separate wet mounts with normal saline and 3% potassium hydroxide must be prepared for microscopic examination

Question 14

If we do confirm that there is PROM , what is the next step that will help in our management?

Answer 14

1. Do an endocervical swab to culture for group B streptococcus

Question 15

How should we collect the fluid from the vagina?

Answer 15

1. With a syringe

2. If not enough fluid then use a swab at the posterior fornix

Question 16

Is vaginal secretion acidic or alkaline?

Answer 16

It is acidic <7

Question 17

Is amniotic fluid acidic or alkaline?

Answer 17

Amniotic fluid is alkaline >7

Question 18

What does it mean if red litmus paper turns blue?

Answer 18

It means that it has come into contact with amniotic fluid and it is alkaline

Question 19

What can we do to test the vaginal pH?

Answer 19

We can use red litmus paper

Question 20

What is the fern pattern test?

Answer 20

It is a test where vaginal fluid is taken with a wooden spoon and smeared on a glass slide and examined microscopically

Question 21

What are the side room investigations we can do to detect PROM?

Answer 21

1. Red litmus paper test

2. Fern pattern test

Question 22

What is the management of PROM?

Answer 22

There are two options:

1. Induction of labour for the fetus is viable-give antibiotics to prevent chorioamnionitis symptoms
2. Continue pregnancy if <34 weeks

Question 23

How many women end up going into labour 24 hours after PROM?

Answer 23

50% of women

Question 24

How many women end up going into labour at least a week after PROM?

Answer 24

90% of women

Question 25

What increases the risk of chorioamnionitis in a patient?

Answer 25

1. HIV 2. Post-coitus 3. Vaginal examination after PROM 4. No antenatal care

Question 26

What do we do if the patient is already in labour?

Answer 26

We allow the patient to deliver

Question 27

What do we if the patient is in labour but has a premature foetus?

Answer 27

We give betamethasone to at least allow lung maturity in the next 24 hours

Question 28

In which cases would we do a c/s in patient?

Answer 28

1. Foetal distress 2. Chorioamnionitis -give AB 3. Congenital fetal abnormalities

Question 29

What do we do if the patient is >34 weeks?

Answer 29

Induction of labour

Question 30

What do we do if the patient is <34 weeks?

Answer 30

1. Truly confirm gestation with ultrasound (fetal weight being less than 2000g) or if the SF height is <30 cm

Question 31

What should we do if we have a patient that is less than 26 weeks and experiences PROM?

Answer 31

We need to induce labour because the prognosis for these babies is very poor

Question 32

What is a contra-indication fro post-posing labour?

Answer 32

Chorioamnionitis

Question 33

How can we ensure better prognosis for babies?

Answer 33

1. Administer corticosteroids for lung maturity especially between 28-32 weeks This must be done for a period of 24 hours before labour

Question 34

When can we send the patient home ?

Answer 34

1. If the discharge disappears for at least 2 days and ultrasound confirms increase in amniotic fluid 2. The patient can come tho high risk clinic weekly for follow up

Question 35

When should the mother be re-admitted if they present again?

Answer 35

1. If there is a vaginal discharge with an offensive smell 2. She feels feverish and unwell 3. If she recently sat in a bath or had sex

Question 36

What are the indications for us inducing labour in patients with PROM?

Answer 36

1. Clinical signs of chorioamnionitis 2. If the patients is <26 weeks(foetus is not viable) 3. If the patient is >34 weeks(baby is viable) 4. Foetal distress 5. Cord prolapse 6. Antepartum haemorrhage 7. Intra-uterine death or severe congenital abnormalities 8. Intra-uterine growth restriction

Question 37

What two methods can be used to induce labour in patients with PROM?

Answer 37

1. Oxytocin | 2. Oral misoprotil (cytotec) 50 mcg 6 hourly with fetal heart monitoring

Question 38

Why should we not use OxyContin and misoprostol together?

Answer 38

It can cause excessive contractions and thus lead to foetal distress

Question 39

What should you tell women who present with PROM in regards to their next pregnancy?

Answer 39

1. They should start antenatal care as early a possible 2. Using condoms in the 2nd trimester helps prevent chorioamnionitis 3. Midstream urine with help screen for bacteria

Question 40

What is the management of PROM (pre-labour rupture) in district 1 hospitals?

Answer 40

In pre-labour rupture patients if it not associated with an infection it is not an emergency and we can wait 24 hours for the cervix to become more ready -induction is usually initiated early morning (around 8am)

Question 41

How many patients will go into spontaneous labour after pre-labour induction of labour?

Answer 41

80% of them

Question 42

What is the management of PROM in district 2 hospitals? These being regional and tertiary hospitals

Answer 42

-patients are induced immediately and OxyContin or misoprostol is started

Question 43

When do we start foetal heart monitoring in these babies?

Answer 43

At 28 weeks