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APGO educational topic number 25
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premature rupture of membranes amniotic
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fluid starts to be continuously produced
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at approximately 16 weeks gestation
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remember that it is primarily dependent
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on fetal urine production amniotic fluid
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allows for fetal movement in breathing
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which are important for fetal skeletal
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lung and chest development decreased or
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absent amniotic fluid can lead to
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compression of the umbilical cord and
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decrease placental flow disruption of
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the fetal membranes leads to a loss of
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these protective effects and the
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developmental roles of amniotic fluid
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the objectives of this video are to list
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the history physical findings and
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diagnostic methods to confirm rupture of
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membranes identify risk factors for
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premature rupture of membranes describe
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the risks and benefits of expectant
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management versus immediate delivery
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based on gestational age and finally
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describe the methods to monitor maternal
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and fetal status during expectant
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management prom is premature rupture of
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membranes before the onset of labor P
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prom is preterm premature rupture of
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membranes occurring before 37 weeks
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estimated gestational age this is a
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leading cause of neonatal morbidity and
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mortality and is associated with 30% of
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preterm deliveries the consequences of P
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prom depend on the gestational age at
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the time of occurrence persistent
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illegal head Romano’s at less than
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twenty two weeks SMA gestational age
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leads to incomplete fetal alveolar
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development and the development of
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pulmonary hypoplasia infants born with a
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pulmonary hypoplasia cannot be
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adequately ventilated when P prom occurs
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between 24 and 26 weeks there is likely
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to be survival however there will be
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possible substantial morbidities from
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extreme prematurity what are risk
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factors for prom anything that weakens
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the strength of the Chorio amniotic
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membrane here is the uterus here is the
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cervix and this is the Koryo amniotic
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membrane and a sending infection from
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the vagina will weaken these membranes
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so sexually transmitted infections and
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other lower genital tract infections
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such as bacterial vaginosis play a role
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as risk factors this can be one reason
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why a short cervix is also a risk factor
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for prom the risk for prom is also
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doubled for women who
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Smok other risk factors include a
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history of prior prom polyhydramnios and
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multiple gestation x’ will basically
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descend the Chorio amniotic membranes
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other risk factors are similar to risk
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factors for preterm delivery including a
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prior preterm delivery bleeding during
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pregnancy low socioeconomic status and
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low body mass index it is very important
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to be able to accurately diagnose when a
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patient has had rupture of her membranes
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patients may describe an obvious gush of
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fluid or they may describe a study
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leakage of small amounts of fluid it can
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be confusing for during pregnancy there
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are many things that can mimic amniotic
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fluid
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it could be urine normal vaginal
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secretions of pregnancy increased
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cervical discharge semen or just
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perineal sweat for the physical exam a
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sterile speculum examination should be
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performed to visually assess the cervix
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and to swab for cervical gonorrhea and
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chlamydia a group B strep culture should
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be obtained as well
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an ultrasound should be performed to
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assess fetal position as well as to
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assess the amount of amniotic fluid
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remember to minimize digital cervical
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examinations to decrease the risk of
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infection for diagnostic testing nitrous
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and paper is used for amniotic fluid is
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alkaline with a pH greater than seven
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point one and vaginal secretions have a
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pH between four point five to six so
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amniotic fluid will appear blue on
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nitrazine paper burning refers to the
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pattern of arborization when amniotic
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fluid is placed on a slide and is
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allowed to dry and finally pooling
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refers to the filling of the speculum
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with amniotic fluid once we have
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confirmed that rupture of membranes has
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occurred then we need to move on to
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management how do we decide an expectant
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management versus immediate delivery the
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patient’s just a tional age presence of
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clinical infection placental abruption
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labor and fetal status all have to be
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taken into account if the patient is
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term greater than 37 weeks approximately
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90% of patients will go into spontaneous
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labor within 24 hours labor should be
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induced either at the time of
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presentation or the patient can be
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expectantly managed induction of labour
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reduces the time to delivery and the
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rates of chorioamnionitis endometritis
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and admission to the neonatal intensive
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care unit if the patient does not go
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into spontaneous labor on her own then
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labor induction should be performed with
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oxytocin
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for patients who are preterm or less
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than 37 weeks the risks of uterine
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infection versus the risks of
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prematurity need to be weighed carefully
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for late preterm patients from 34 to 36
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weeks and six days estimate gestational
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age the management is the same as term
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for the risks of infection outweigh the
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risks of prematurity an induction of
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labour is started for these patients
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once rupture of membranes is confirmed
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if the fetus is breached then a
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caesarean section will have to be
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performed if pea prom occurs between 24
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weeks and 33 and 6 the risk of fetal
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lung maturity from prematurity is very
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high thus it is important to administer
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corticosteroids which enhance fetal
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pulmonary maturity antibiotics are
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administered to increase the latency
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period which is the time between rupture
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of membranes and spontaneous labor note
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this important point antibiotics are
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administered because they have been
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shown to increase the amount of time
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before spontaneous labor the antibiotics
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are not to treat an infection if there
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is an infection present diagnosed by
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uterine tenderness fevers and/or
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increased white blood cell count then
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delivery needs to be initiated assuming
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that there is no evidence of uterine
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infection a patient with pea prom from
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24 to 33 and 6 estimated gestational age
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will be admitted for inpatient
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hospitalization with ultrasounds to
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assess amniotic fluid volume and
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antepartum testing such as non stress
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tests delivery will be induced between
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32 and 34 weeks
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remember again however if the patient
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develops evidence of uterine infection
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then delivery will be immediately
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initiated pre viable pea prom is rare
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occurring in less than 1% of pregnancies
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there are important risks of prematurity
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to discuss with this population
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pulmonary hypoplasia rates are
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approximately 10 to 20 percent and
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prolonged oligo hydrea nails can cause
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fetal deformations and limb contractures
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because the fetus cannot move freely
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within the amniotic sac neonatal death
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and morbidity rates decrease with a
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longer latency period and advancing
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gestational age there are also
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significant maternal complications that
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can occur with prolonged rupture of
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membranes with increased risks of
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systemic infections the management for
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patients with pre viable pea prom
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involves patient counseling and
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expectant management or induction of
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labour antibiotics and corticosteroids
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are not rare
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before viability this concludes the
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aapko video on prom we have reviewed
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risk factors diagnosis and management
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for this common obstetric condition
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remember that management depends on
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gestational age and always consider the
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risks of uterine infection versus the
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risks and prematurity