The time period from PROM to delivery is inversely proportional to the gestational age when the membranes ruptured.
PROM between 24-34 wks is identified in 1.7% of pregnancies it contributed to 20% of perinatal deaths.
In one study, by that time they presented 75% of women were already in labor and 5% delivered for other complications another 10% delivered within 48 hrs.
Only 7% delivered in 48 hrs or more, appear to benefited from delayed delivery with no neonatal deaths.
Diagnosis of preterm PROM:
Is usually obvious when there is history of sudden escape of watery amniotic fluid.
To be differentiated with urinary incontinence, intermittent normal vaginal discharge which is mucoid and thick in consistency, infected vaginal discharge which is foul smelling and associated with itching.
In clinical examination amniotic fluid pools in to vagina, when patient coughs gush of fluid comes out from vagina.
Sterile speculum examination confirms the fluid coming through the os.
Other tests to diagnose preterm PROM:
Measurement of phosphotidyl glycerol, nitrazine test, fern test or to detect alfafetoprotien in the fluid.
Ultrasound examination showing oligohydromnios may contribute to diagnosis.
Some other tests like injecting indigo caramine or fluorescein into amniotic cavity or immunochromatographic method to detect placental microglobulin 1 can be used.
Complications of premature PROM: Most common complication is preterm delivery.
Other maternal complications : Chorioamnionitis, placental abruption , retained placenta , PPH(post partum haemorrhage) and endometritis.
Fetal complications :
Infection leading to sepsis, oligohydromnios leading to pulmonary hypoplasia and hospitalization.
Most women enter in labor within a week or less after membranes rupture.
Intentional delivery :
Prior to mid 1970s labor was usually induced in women with PROM because of fear of infection.
Neonatal mortality is seen in both intentional delivery and in expectant management.
Expectant management:
Remote from term conservative management is advisable, provided acute cord complications like prolapse and compression , placental abruption and fetal distress are excluded.
Between 20 – 24wks:
The volume of amniotic fluid remaining after rupture of membranes appears to have prognostic importance.
Women developing oligohydromnios should be delivered before 25wks.
Women with adequate amniotic fluid can be delivered in 3rd trimester.
Between 24-34wks:
If conservative management is to be done, digital vaginal examination must be avoided as it increases the risk of infection and reduces the latent period for labor.
Antibiotics should be administered as they help to prolong the latency and improve perinatal outcomes.
Corticosteroids should be given, but multiple courses may increase the risk of infection.
Short term tocolytics may be consider for administration of steroids and antibiotics and also to facilitate maternal transport.
Long term tocolytics do not have a role.
On conservative management we have to look for the features of chorioamnionitis, with signs like tachycardia, leukocytosis, fever, uterine tenderness, foul smelling liquor etc.
Delivery must be planed when there is any evidence of clinical infection.
Chorioamnionitis is a known risk factor for cerebral palsy in new borns can also develop sepsis , respiratory distress syndrome, intra ventricular hemorrhage, periventricular leukomalacia.
Fetal surveillance by NST(non stress test) and biophysical profile are to be done daily.
Other indications for terminating conservative management are non reassuring fetal monitoring, pregnancy reaching 34wks.
Between 34-36wks:
Management is controversial between 34-36wks.
Advantages of gaining fetal maturity to be balanced against chorioamnionitis.
It may be preferable to induce labor unless the fetal lung maturity or gestational age is doubtful.
Fetal membranes have very limited ability to heel spontaneously.
Fibrin glue intra cervical instillation, gelatin sponge or maternal platelets and cryoprecipitates intra amniotic instillation and endoscopic placement of collagen graft over fetal membrane defect have been tried but safety and efficacy of these methods remain unproven.
Intra partum management:
The more immature the fetus the greater the risks of labor and delivery.
Labor either induced or spontaneous, abnormalities of FHS(feta heart sounds) and uterine contractions should be sort.
Continuous electronic monitoring is preferred.
In case of ruptured membranes patient and fetal tachycardia suggest sepsis.
Umbilical artery blood PH < 7 suggest neonatal complications like respiratory distress syndrome.
Antibiotics intravenously every 6th hrly to be given until delivery.
Delivery:
Episiotomy can be given if vaginal out let is not relaxed.
Routine forceps are not recommended as pre term fetal head is fragile and can lead to intracranial hemorrhage.
If specialized personale and facilities are available the survival of preterm neonates will be good.
The problems of premature neonates:
As the body systems are functionally immature, decreased physical activities, poor suckling, swallowing and sluggish reflexes will be present.
Resuscitation is difficult because of small size and stiff lungs.
Other problems like sepsis, necrotising enterocolitis, retinopathy of prematurity and germinal matrix hemorrhage, respiratory complications like inadequate expansion of lungs , respiratory distress syndrome, hypoglycemia, hypothermia, nutritional deficiency etc may occur.
Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes
PROM between 24-34 wks is identified in 1.7% of pregnancies it contributed to 20% of perinatal deaths.
In one study, by that time they presented 75% of women were already in labor and 5% delivered for other complications another 10% delivered within 48 hrs.
Only 7% delivered in 48 hrs or more, appear to benefited from delayed delivery with no neonatal deaths.
Diagnosis of preterm PROM:
Is usually obvious when there is history of sudden escape of watery amniotic fluid.
To be differentiated with urinary incontinence, intermittent normal vaginal discharge which is mucoid and thick in consistency, infected vaginal discharge which is foul smelling and associated with itching.
In clinical examination amniotic fluid pools in to vagina, when patient coughs gush of fluid comes out from vagina.
Sterile speculum examination confirms the fluid coming through the os.
Other tests to diagnose preterm PROM:
Measurement of phosphotidyl glycerol, nitrazine test, fern test or to detect alfafetoprotien in the fluid.
Ultrasound examination showing oligohydromnios may contribute to diagnosis.
Some other tests like injecting indigo caramine or fluorescein into amniotic cavity or immunochromatographic method to detect placental microglobulin 1 can be used.
Complications of premature PROM: Most common complication is preterm delivery.
Other maternal complications : Chorioamnionitis, placental abruption , retained placenta , PPH(post partum haemorrhage) and endometritis.
Fetal complications :
Infection leading to sepsis, oligohydromnios leading to pulmonary hypoplasia and hospitalization.
Most women enter in labor within a week or less after membranes rupture.
Intentional delivery :
Prior to mid 1970s labor was usually induced in women with PROM because of fear of infection.
Neonatal mortality is seen in both intentional delivery and in expectant management.
Expectant management:
Remote from term conservative management is advisable, provided acute cord complications like prolapse and compression , placental abruption and fetal distress are excluded.
Between 20 – 24wks:
The volume of amniotic fluid remaining after rupture of membranes appears to have prognostic importance.
Women developing oligohydromnios should be delivered before 25wks.
Women with adequate amniotic fluid can be delivered in 3rd trimester.
Between 24-34wks:
If conservative management is to be done, digital vaginal examination must be avoided as it increases the risk of infection and reduces the latent period for labor.
Antibiotics should be administered as they help to prolong the latency and improve perinatal outcomes.
Corticosteroids should be given, but multiple courses may increase the risk of infection.
Short term tocolytics may be consider for administration of steroids and antibiotics and also to facilitate maternal transport.
Long term tocolytics do not have a role.
On conservative management we have to look for the features of chorioamnionitis, with signs like tachycardia, leukocytosis, fever, uterine tenderness, foul smelling liquor etc.
Delivery must be planed when there is any evidence of clinical infection.
Chorioamnionitis is a known risk factor for cerebral palsy in new borns can also develop sepsis , respiratory distress syndrome, intra ventricular hemorrhage, periventricular leukomalacia.
Fetal surveillance by NST(non stress test) and biophysical profile are to be done daily.
Other indications for terminating conservative management are non reassuring fetal monitoring, pregnancy reaching 34wks.
Between 34-36wks:
Management is controversial between 34-36wks.
Advantages of gaining fetal maturity to be balanced against chorioamnionitis.
It may be preferable to induce labor unless the fetal lung maturity or gestational age is doubtful.
Fetal membranes have very limited ability to heel spontaneously.
Fibrin glue intra cervical instillation, gelatin sponge or maternal platelets and cryoprecipitates intra amniotic instillation and endoscopic placement of collagen graft over fetal membrane defect have been tried but safety and efficacy of these methods remain unproven.
Intra partum management:
The more immature the fetus the greater the risks of labor and delivery.
Labor either induced or spontaneous, abnormalities of FHS(feta heart sounds) and uterine contractions should be sort.
Continuous electronic monitoring is preferred.
In case of ruptured membranes patient and fetal tachycardia suggest sepsis.
Umbilical artery blood PH < 7 suggest neonatal complications like respiratory distress syndrome.
Antibiotics intravenously every 6th hrly to be given until delivery.
Delivery:
Episiotomy can be given if vaginal out let is not relaxed.
Routine forceps are not recommended as pre term fetal head is fragile and can lead to intracranial hemorrhage.
If specialized personale and facilities are available the survival of preterm neonates will be good.
The problems of premature neonates:
As the body systems are functionally immature, decreased physical activities, poor suckling, swallowing and sluggish reflexes will be present.
Resuscitation is difficult because of small size and stiff lungs.
Other problems like sepsis, necrotising enterocolitis, retinopathy of prematurity and germinal matrix hemorrhage, respiratory complications like inadequate expansion of lungs , respiratory distress syndrome, hypoglycemia, hypothermia, nutritional deficiency etc may occur.
Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes
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