Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 • • • • • 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 • • • • 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 • • • • 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