Download - PROM AND PPROM BY Dr Alihussein kassam
DR ALIHUSSEIN KASSAM,INTERN DOCTOR,
MNAZI MMOJA HOSPITAL,ZANZIBAR
03/17/16 1DR ALIHUSSEIN KASSAM
Premature rupture of membranes (PROM) Rupture of the chorioamnionic membrane
(amniorrhexis) prior to the onset of labor at any stage of gestation
Rupture of amniotic membranes after 37+0 and before labor
Preterm premature rupture of membranes (PPROM) PROM prior to 36+6-wk. gestation
28 weeks? (pprom versus abortion)24 weeks? (pprom versus abortion)
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PROM – 12% of all pregnancies PPROM – 30% of preterm deliveries
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History “Gush” of fluid Steady leakage of small amounts of fluid Cramping Contractions Back pain
Physical
What do you do?
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Latency period Infection
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Sterile No lubricating jelly Pooling of fluid in
posterior fornix Free flow of fluid
from cervix Cervical dilation Nitrazine Collect slide for
fern (dry 10 mins)
Asse
ss fo
r
Consider need to collect other cervical tests/cultures such fetal fibronectin while doing the SSE. 03/17/16
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Test Nitrazine test
Fluid from vaginal exam placed on strip of nitrazine paper
Paper turns blue in presence of alkaline (pH > 7.1) amniotic fluid
Fern test Fluid from vaginal exam placed
on slide and allowed to dry Amniotic fluid narrow fern vs.
cervical mucus broad fern
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False positive Nitrazine test Alkaline urine Semen (recent coitus) Cervical mucus Blood contamination Vaginitis (e.g. Trichomonas)
False-Negative Nitrazine test Remote PROM with no residual fluid Minimal amniotic leakage
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fFn present in cervical secretions <22 wks, >34 wks
Used for assessment of potential PTB
Positive result (>50 ng/dl) may be indicative of PROM and represents disruption of decidua-chorionic interface
In PPROM, Sensitivity-98.2%, Specificity-26.8%.03/17/16 9DR ALIHUSSEIN KASSAM
Newer test Point of Care test Cost-up to $50 each Sensitivity-98.7-98.9% Specificity-87.5-100% Awaiting further testing prior to
recommendations
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Place Swab 2-3 in. into vaginal canal x 1 min.
Remove swab and rotate in solvent x 1 min.
Discard swab and place test stick into solvent.
Read results after 5-10 mins have passed.
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Test Ultrasound
Assess amniotic fluid level and compatibility with PROM
Indigo-carmine Amnioinfusion Ultrasound guided indigo carmine dye amnioinfusion (“Blue tap”) Observe for passage of blue fluid from vagina
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Risk Factors: Prior PROM or PPROM Prior preterm delivery Multiple gestation Polyhydramnios Incompetent cervix Vaginal/Cervical Infection
Gonorrhea, Chlamydia, GBS, S. Aureus Antepartum bleeding (threatened abortion) Smoking Poor nutrition
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Patient counseling Expectant management vs. induction of labor GBS prophylaxis NOT recommended Antibiotics
Incomplete data Corticosteriods NOT recommended
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http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/dataShow.cfm
Gestational Age
(In Completed Weeks)
Death BeforeNICU Discharge
Outcomes at 18 to 22 Months Corrected Age*
DeathDeath/ Profound
NeurodevelopmentalImpairment
Death/Moderate to Severe Neuro-developmental Impairment
22 Weeks 95% 95% 98% 99%23 Weeks 74% 74% 84% 91%24 Weeks 44% 44% 57% 72%25 Weeks 24% 25% 38% 54%
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Expectant management Deliver at 34 wks Unless documented fetal lung maturity
GBS prophylaxis Antibiotics Single course corticosteroids Tocolytics
No consensus
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Expectant management Deliver at 34 wks Unless documented fetal lung maturity
GBS prophylaxis Antibiotics Corticosteroids
No consensus, some experts recommend
Magnesium sulphate use < 32 weeks
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Proceed to delivery Induction of labor
GBS prophylaxis
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Antibiotics Prolong latency period Prophylaxis of GBS in neonate Prevention of maternal chorioamnionitis and neonatal sepsis
Corticosteroids Enhance fetal lung maturity Decrease risk of RDS, IVH, and necrotizing enterocolitis
Tocolytics Delay delivery to allow administration of corticosteroids Controversial, randomized trials have shown no pregnancy
prolongation
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Antibiotics Ampicillin 2 g IV Q6 x 48 hrs Amoxicillin 500 mg po TID x 5 days Azithromycin 1 g po x 1 Erythromycin 500mg tds 10/7
Corticosteroids Betamethasone 12 mg IM q24 x 2 Dexamethasone 6 mg IM q12 x 4 repeat 12mg if no delivery
within 7 days
Tocolytics Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs
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Typically performed after 32 wks
Tests for fetal lung maturity (FLM) Lecethin/Sphingomyelin ratio (not
commonly used, more for historic interest) L/S ratio > 2 indicates pulmonary maturity
Phosphatidylglycerol > 0.5 associated with minimal respiratory distress
Flouresecence polarization (FLM-TDx II) > 55 mg/g of albumin
Lamellar body count 30,000-40,000
If negative, proceed with expectant management until 34 wks
Courtesy of Thomas Shipp, MD.03/17/16
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Maternal: Monitor for signs of infection Temperature Maternal heart rate Fetal heart rate Uterine tenderness Contractions
Fetal: Monitor for fetal well-being Kick counts Nonstress tests (NST’s) Biophysical profile (BPP)
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Immediate Delivery Intrauterine infection Abruptio placenta Repetitive fetal heart rate decelerations Cord prolapse
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Expectant Management Risks:
Maternal Increase in chorioamnionitis Increase in Cesarean delivery Spontaneous labor in ~ 90% within 48 hr ROM Increased risk of placental abruption
Fetal Increase in RDS Increase in intraventricular hemorrhage Increase in neonatal sepsis and subsequent cerebral
palsy Increase in perinatal mortality Increase in cord prolapse
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ROYAL COLLEGE CURRENT GUIDELINES 2010 ON OBSTETRICS
W.H.O INTERVENTION TO IMPROVE OUT COMES IN PRETERMS @2015
K.C.M.C GUIDELINES FOR OBSTETRICS 2012
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