Preterm Premature Rupture of the Membranes

The Preterm Parturition Syndrome

Uterine Overdistension Cervical Disease Hormonal
Immunological

Vascular

Infection

Unknown

VR RR MM

Definition and Scope

Rupture of the fetal membranes prior to the completion of the 37th week of pregnancy May or may not be associated with PTL Complicates 1/3 of all preterm deliveries Around 1-2% of pregnancies Majority of patients delivery within 1 week Management is controversial

 Problems are: Fetus:

Prematurity Ascending IU Infection Abruption Cord Accident Cord prolapse Oligohydramnious Arrest of pulmonary development (Pulmonary Hypoplasia) Potters syndrome (amniotic bands) Skeletal deformities

Maternal
Infection
Intra-amniotic in 13-60% Postpartum in 2-13%

Thromboembolic disease Hemorrhage

4-12% affected by abruption Concealed hemorrhage

Initial Exam
Fetal monitoring Sterile speculum exam
Nitrizine test
Vaginal fluid is acidic Amniotic fluid is basic will turn paper blue

Ferning
Use dry slide (no slip) Use low power dont be fooled by crystals

Val-salva

DIAGNOSIS
Speculum: Flow of Liquor, specific smell, vernix Nitrazine test (Amnicator), alkaline USS Avoid Vaginal examination Prefer to do speculum to see fluid draining, HVS, cx dilatation or cord prolapse

Risk Factors
Infection seems to play a role, but no single agent has been identified Antibiotics do not seem to prevent PPROM Previous PPROM most important risk factor

MANAGEMENT
Eventually will go in labour Steroids not if infected Antibiotics Erythromycin, prolong pregnancy and decrease neonatal complications ?Tocolysis

 Considerations Management
When?
If pre-viable, may day care to return when viable; antibiotics?, monitoring? If later than 34 weeks, consider induction or expectant management literature is conflicting If <34 weeks, consider tocolysis for steroid course, then expectant management or delivery?

Associated findings
Chorioamnionitis necessitates immediate delivery Wishes of the mother may dictate action

Management Supported Interventions

Tocolysis for steroid administration if no contraindications and fetus 24 34 weeks Antibiotics for group-B strep prophylaxis AND for latency (add erythromycin) Ultrasound for fetal weight Neonatal consultation Expectant management for any gestational age

 Frank discussion with parents with mid-trimester PPROM

Some studies suggest that these patients do well if there is some fluid and pregnancy can be prolonged until after 26 weeks Expectant management is permissible as long as there are no contraindications

RISK-CHRIOAMNINITIS
Maternal pyrexia Abdominal pain Uterine tenderness Raised white cell count C reactive protein HVS, Urine culture positive for infection

Regular fetal monitoring Home/ inpatient Regular temperature White cell count and C reactive protein High vaginal swabs

Summary of PPROM
Initial Assessment
Gestational age Confirm rupture
Nitrizine Ferning Val-salva

Visual assessment of cervix Labor present / absent Infection present / absent Fetus reassuring or in distress

Summary of PPROM
Interventions
Fetal monitoring If indicated, tocolysis Steroid administration Antibiotics for latency and GBS Ultrasound Neonatal Consultation

REMEMBER
Prematurity is serious problem
Consider Steroids Tocolysis Antibiotics if PPROM

Special care baby unit is essential