Download Preterm Premature Membrane Rubture

Preterm Premature
Membrane Rubture
PPROM
PPROM
• Membrane rupture before the onset of uterine contractions
• Preterm Premature Rupture of Membranes
• Prelabor rupture of membranes
• before 370/7thsweeks of gestation.
• PPROM occurs in one-third of preterm deliveries and most cases
occur in women without identifiable risk factors.
• 3%
• 30% of preterm births
PPROM
• Risk factors
• Similar to those for preterm labor
• Strong association
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PPROM in a previous pregnancy,
Genital tract infection,
Antepartum bleeding, and
Cigarette smoking
Preterm labor
PPROM
• The diagnosis of PPROM is clinical,
• Visualization of amniotic fluid in the vagina of a woman who presents
with a history of leaking fluid.
• Laboratory tests (eg, Nitrazine and fern or Amnisure) are used for
confirmation in cases of clinical uncertainty.
Biophysical profile
• Prenatal ultrasound evaluation of fetal well-being
• Manning's score
• The "modified biophysical profile"
• consists of the NST (nonstress testing) and amniotic fluid index only.
• 5 componenets
• Fetal
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Heart rate
Breathing
Movement
Tone
• Amniotic fluid volume
Parameter
Normal (2 points)
NST/Reactive FHR
At least two accelerations
in 20 minutes
US: Fetal breathing
movements
At least one episode of >
30s or >20s in 30 minutes
US: Fetal activity / gross
body movements
US: Fetal muscle tone
US: Qualitative AFV/AFI
At least three or
two[movements of the
torso or limbs
At least one episode of
active bending and
straightening of the limb or
trunk
At least one vertical
pocket> 2 cm or more in
the vertical axis
Abnormal (0 points)
Less than two accelerations
to satisfy the test in 20
minutes
None or less than 30s or
20s
Less than three or
two movements
No movements or
movements slow and
incomplete
Largest vertical
pocket</=2 cm
Amniotic Fluid Functions
• It is generated from maternal plasma,
• Passes through the fetal membranes by osmotic and hydrostatic
forces.
• When fetal kidneys begin to function in about week 16, fetal urine
also contributes to the fluid.
• The fluid is absorbed through the fetal tissue and skin. After the 20th25th week of pregnancy when the keratinization of an embryo's skin
occurs, the fluid is primarily absorbed by the fetal gut.
Larsen, William J. (2001). Human embryology (3. ed.). Philadelphia, Pa.: Churchill Livingstone. p. 490.
Amniotic Fluid Functions
• Allows to move
• Bone and muscle development.
• Breathes the fluid in and out
• Aid in lung development.
• Keeping heat in.
• Cushion the blow
• Swallows the amniotic fluid, it is practicing using and developing the
digestive system.
• Keeps the umbilical cord from being squeezed too hard
• Lubricant.
• webbed fingers or toes.
http://study.com/academy/lesson/what-is-amniotic-fluid-levels-function-composition.html
Amniotic Fluid Functions
• Breathes the fluid in and out
• Aid in lung development.
• Contrary to popular belief, amniotic fluid has not been conclusively shown to be inhaled and
exhaled by the fetus. In fact, studies from the 1970s show that in a healthy fetus, there is no
inward flow of amniotic fluid into the airway. Instead, lung development occurs as a result of
the production of fetal lung fluid which expands the lungs
• Observations reported now on primate pregnancies, human and rhesus, combined with
earlier studies from this laboratory, demonstrate that normally appreciable volumes of
amnionic fluid are inhaled and presumably exhaled throughout much of pregnancy. Through
use of isotope-labeled red cells and porcelain microspheres placed at varying times in the
amnionic sac, as well as fetal squames already present, it has been shown conclusively that
inhalation of amnionic fluid is not necessarily a pathologic event. The volumes of amnionic
fluid inhaled per 24 hours by human and rhesus fetuses late in pregnancy were remarkably
similar, amounting on the average to at least 200 ml per kilogram. These observations
confirm the much earlier qualitative studies of some others that previously had generally
been discounted by many fetal physiologists.
Lily A.W. Disorder of Amniotic Fluid: ASSALI, N.S. Pathophysiology of Gestation Volume II. Academic Press, New York & London. 1972
Duenhoelter JH, Pritchard JA. Fetal respiration: quantitative measurements of amnionic fluid inspired near term by human and rhesus fetuses. Am J Obstet Gynecol. 1976 Jun 1;125(3):306-9.
Pregnancy complications associated with
preterm premature rupture of membranes
(PPROM)
• Umbilical cord compression
• Obstruction of blood flow through the umbilical cord secondary to
pressure from an external object or misalignment of the cord itself.
• Cord compression happens in about one in 10 deliveries.
• (A) Typical ferning pattern of dried amniotic fluid (400).
(B, C) Urine and amniotic fluid can be distinguished by microscopic
examination of a droplet of the fluid spread and dried on a
microscope slide. The proteins in amniotic fluid give the appearance
of ferning (B) that is not observed with urine (C).
(D) Ferning pattern from amniotic fluid.
Management
• For PPROM at ≥ 34 weeks gestation
• Delivery
• recommended.
• Induction of labor
• recommended.
• Misoprostol appears comparable to oxytocin for induction of labor in women with
PPROM.
• Group B streptococcal prophylaxis
• indicated based on prior culture results if available.
• If culture results not available, provide prophylaxis since < 37 weeks gestation.
http://www.dynamed.com/topics/dmp~AN~T435299/Preterm-premature-rupture-of-membranes-PPROM
Management
• For PPROM at 24-33 weeks gestation:
• If pulmonary maturity is not proven,
• expectant management is preferred until 33 completed weeks gestation.
• Antibiotics
• 48-hour treatment with IV ampicillin and erythromycin followed by 5 days of amoxicillin
and erythromycin is recommended to prolong latency if no contraindications.
• Intrapartum group B streptococcal prophylaxis is recommended if fetus is viable.
• A single course of corticosteroids is recommended.
• Consider IV magnesium sulfate for fetal neuroprotection if there is a risk of
imminent delivery in women before 32 weeks gestation.
• Expectant management at home is not recommended.
http://www.dynamed.com/topics/dmp~AN~T435299/Preterm-premature-rupture-of-membranes-PPROM
PPROM management
• Stable patients with PPROM <34 weeks
• Expectant management
• + A course of antenatal corticosteroids to enhance fetal lung maturation in
pregnancies less than 34 weeks of gestation
• +Prophylactic antibiotics
• ampicillin 2 g intravenously every 6 hours for 48 hours, followed by amoxicillin (500 mg
orally three times daily or 875 mg orally twice daily) for an additional five days.
• one dose of azithromycin (one gram orally) at the time of admission and repeat the dose
five days later.
UptoDate
Management
• For PPROM at < 24 weeks gestation (periviable):
• Group B streptococcal prophylaxis is not recommended.
• Consider hospital admission for:
• bed rest and strict pelvic rest to increase chance of resealing amniotic membrane
• monitoring for infection or placental abruption
• ongoing monitoring once pregnancy has reached viability
• Do not use corticosteroids until fetus has reached viability.
http://www.dynamed.com/topics/dmp~AN~T435299/Preterm-premature-rupture-of-membranes-PPROM
PPROM management
• Expeditious delivery
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intrauterine infection,
abruptio placentae,
Non-reassuring fetal testing, or
a high risk of cord prolapse is present or suspected
• Umbilical cord prolapse
• Umbilical cord comes out of the uterus with or before the presenting part of
the fetus.
• Occurs in fewer than 1% of pregnancies.
• More common in women who have had rupture of their amniotic sac
Cord presenting in front of
the fetal head; may be
Complete occult prolapse
seen in the vagina
Frank breech
presentation with
prolapsed cord
• Abruptio placentae
• Premature separation of the placenta from the uterus.
• Also called placental abruption, typically present with bleeding, uterine
contractions, and fetal distress