1-Admission and subsequent investigations:
Complete blood count CBC , CRP
Urine for routine analysis / culture
High vaginal swab for culture
Ultrasonography USG for (AFI/MVP) CTG/NST
2- Maternal evaluation
includes assessment for contractions, signs of infection (eg, fever, fetal tachycardia, maternal leukocytosis), and
oligohydramnios and current maternal status for medical and obstetric complications.
3- Fetal well-being is evaluated with a nonstress test.
4-Obstetric management
🔹
according to gestational age(active management vs expectant management)
At 37 weeks of gestation or beyond:
termination of pregnancy/expectant management antibiotic administration (controversial indication) it may be
🔹
considered if latency is long
Between 34-36 6/7 weeks of gestation:
antenatal steroidsMore recent recommendations support administration of a course of antenatal steroids between Prelabor rupture of membranes (PROM) is defined as spontaneous
34 0/7 and 36 6/7 weeks of gestation if it is not given earlier in pregnancy rupture of chorioamnionic membranes before the onset of labor at
-Antibiotics administration any stage of gestation.
Definition
🔹
-expectant management up to 37 weeks of gestation/ termination of pregnancy
PROM before 34 weeks of gestation(24-33 6/7):
Expectant management If diagnosis is made and both maternal and fetal status are reassuring a single course of
The incidence of PROM ranges from 5% to 15% of all pregnancies
worldwide
corticosteroids for enhancement of lung maturity, antibiotics to protect against ascending infection.
🔹
also, magnesium sulfate is recommended as a neuroprotectant, to reduce the risk of cerebral palsy
Pre-viable PROM(less than 24 wk):
Active management VS expectant management Prelabor rupture of membranes is classified according to the gestational age at
Antibiotic administration
Management in this scenario is highly individualized,and counselling of parents families is important in ensuring 🔹
which it occurs into:
Term pre-labor rupture of membranes:
Rupture of the membranes at or beyond 37 weeks’ gestation prior to the onset of
that they are aware of theprognosis regardless of the interventions.
Even with prolongation of pregnancy and absence of infection, the fetus still has the risk of complications like
Potter’s syndrome, chroniclung disease, neurologic abnormalities and cerebral palsy. Management Classification 🔹
labor.( 8 %)
Preterm pre-labor rupture of membranes (PPROM):
Rupture of membranes prior to 37 weeks of gestation and before the onset of
-Of note, tocolysis should not be used to prolong pregnancy in the presence of uterinecontractions because of
increased risk of chorioamnionitis .However, a physician may consider short term tocolysis if clinical situation
justifies the risk such as to allow transfer to a tertiary care center or administration of steroids. 🔹
labor.(2%)
Previable pre-labor rupture of membranes (previable PROM): rupture of
membranes that occurs before the gestational age of viability(1%)
- Two regimens of “latency” antibiotics were supported by 2 large RCTs. 1st regimen :48 hours of intravenous
therapy (ampicillin 2 g and erythromycin 250 mg every 6 hours) followed by 5 days of oral medications (amoxicillin
250 mg and erythromycin 333 mg every 8 hours). 2nd regimen: erythromycin 250 mg orally 4 times a day for 10
days.
- A 4 g intravenous bolus of magnesium sulfate over 15 minutes,followed by an intravenous infusion of 1 g per hour Rupture of membranes results from a variety of factors that ultimately lead to accelerated membrane
until the birth or for 24 hours ( PPROM 24-33 6/7)wk for neuroprotection. weakening. This is caused by an increase in local cytokines, an imbalance in the interaction between matrix
🌟 Maternal and fetal monitoring in expectant management
Digital vaginal examination and vaginal intercourse should be avoided.
metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased collagenase and
🔷
protease activity, and other factors that can cause increased intrauterinepressure
Weak membranes
-Check temperature every six hours and notify the clinician if temperature ≥100.4°F [38°C]). Report changes in weakening is a normal process that typically happens at term as the body prepares for labor and delivery.
color or odor of vaginal discharge.
-Undergo some type of fetal surveillance (eg, kick counts, nonstress tests, biophysical profile tests) to provide the
clinician and patient with some assurance of fetal well-being,on daily basis.
🔹
The natural weakening of fetal membranes is thought to be due toone or a combination of the following
Cell death :
when cells undergo programmed cell death, they release biochemical markers that are detected in higher
-Notify the clinician of any developing concerns or comp
📍 For patients who request expectant management at home until labor or a complication ensues, we believe the
Pathophysiology
🔹
concentrations in cases of PPROM.
Poor assembly of collagen :
collagen is a molecule that gives fetal membranes, as well as other parts of the human body such as the
following criteria are reasonable after initial evaluation: skin, their strength. In cases of PPROM, proteins that bind and cross link collagen to increase its tensile
●Cephalic presentation ●No clinical suspicion of intrauterine infection
●Reassuring fetal heart rate tracing ●No oligohydramnios 🔹
strength are altered.
Breakdown of collagen:
collagen is broken down by enzymes called matrixmetalloproteinases (MMPs), which are found at higher
●Patient understands and can comply with instructions
levels in PPROM amniotic fluid. This breakdown results in prostaglandin production which stimulates
●Assistance at home ●Dependable transportation uterine contractionsand cervical ripening. MMPs are inhibited by tissue inhibitors of matrix
●Travel time to the hospital of no more than 20 to 30 minutes ●Ability to check pulse and temperature every six metalloproteinases (TIMPs) which are found at lower levels in PPROM amniotic fluid
hours, with parameters for notifying their clinician (eg, pulse >100 beats per minute, temperature ≥100.4°F [38°C])
●Willingness to perform daily fetal kick counts
The etiology of PROM is multifactorial.
Prelabour rupture The final common pathway in the occurrence of PROM is disruption of fetal
Diagnosis of PROM is made by informations obtained from clinical matenal history,physical
of membranes 🔹
membranes.
Rupture of the membranes near the end of pregnancy (term) may be
🌟
examination,and paraclinical investigations .
History: 🔹
caused by a natural weakening of the membranes.
Before term, PPROM is often due to an intrauterine infection.
🔻
The classic clinical presentation of PROM is a sudden "gush" of clear or pale yellow fluid from the
vagina, which soaks through clothes. However, there may not be a gush. Many patients describe Risk factors:
Nitrazine paper leaking only small amounts of fluid either continuously or intermittently, and some just describe a • Maternal factors:
sensation of abnormal wetness of the vagina or perineum. • PROM in a prior pregnancy (recurrence riskis 16–32%
-History taking should include; time of onset of fluid leakage, description of the amount and color of • Antepartum vaginal bleeding
leaking fluid, onset of uterine contractions (if present) in relation to fluid leakage, and the presence of • Chronic steroid therapy
🌟
abdominal pain or vaginal bleeding.and history of any risk factors
Physical examination:
per speculum examination in which the fluid is seen flowing from the cervical os or pooled in the
• Collagen vascular disorders (such as Ehlers-Danlos syndrome, systemic
lupus erythematosus)
• Direct abdominal trauma
posterior fornix. • Preterm labor
Digital vaginal examination should be avoided unless delivery is appeared to be immediate because it • Cigarette smoking
may decrease the latency period (ie, time from PROM to delivery) and increase the risk of intrauterine Etiology • Illicit drugs (cocaine)
Fern 🔻
infection
Most cases can be diagnosed based on maternal history followed by a sterile speculum
examination demonstrating liquor
• Anemia
• Low body mass index (BMI <19.8 kg/m2)
• Nutritional deficiencies of copper and ascorbic acid
🔷 If the diagnosis is uncertain, confirmatory testing is performed on fluid pooled in the
• Low socioeconomic status
🔹
posterior fornixNitrazine
Nitrazine paper is used to test the pH of vaginal fluid. Nitrazine (or phenaphthazine) is a pH
indicator dye that indicates pH in the 4.5 to 7.5 range.
• Fetal factors:
• Multiple pregnancy (preterm PROM complicates 7–10% of twin
pregnancies)
Amniotic fluid usually has a pH range of 7.0 to 7.3, which is different from the normal vaginal pH of 3.8 • Uteroplacental factors:
🔹
to 4.2 and usually different from the pH of urine, which is typically <6.0 but may be higher
Fern ‒ Dried amniotic fluid shows an arborization (ferning) pattern when viewed under a
microscope. Fluid from the posterior vaginal fornix is swabbed onto a glass slide and allowed to dry
• Uterine anomalies (such as uterine septum)
• Placental abruption (may account for 10–15% of preterm PROM)
• Advanced cervical dilatation (cervical insufficiency)
for at least 10 minutes. Amniotic fluid produces a delicate fernnin pattern, in contrast to the thick and • Prior cervical conization
wide arborization pattern of dried cervical mucus. • Cervical shortening in the second trimester (<2.5 cm)
🔹 Instillation of dye (tampon test) ‒ This invasive test has been replaced by commercial
noninvasive tests.Under ultrasound guidance, 1 mL of indigo carmine dye in 9 mL of sterile saline was
• Uterine overdistention (polyhydramnios, multiple pregnancy)
• Intra-amniotic infection (chorioamnionitis
injected transabdominally into the amniotic fluid, and a tampon was placed in the vagina. Twenty
minutes later, the tampon was removed and examined for blue staining, which indicated leakage of Diagnosis
amniotic fluid. Indigo carmine dye,sodium fluorescein or phenolsulfonphthalein.
🔷 If, on speculum examination, no amniotic fluid is observed, clinicians should consider performing an
insulin-like growth factor binding protein 1(actim prom) (IGFBP-1)or and placental alpha
microglobulin-1 protein assay (AmniSure) (PAMG-1)test of vaginal fluid by using
immunochromatography dipstick method to guide further management
🔹
🔹 urinary incontinence
🔹 excessive physiological secretions of pregnancy
pathological discharge associated with vaginitis complications
🔹
or cervicitis
🔹 vesicovaginal or rectovaginal fistula Differential diagnosis
🔹exogenous
urogenital tract trauma or surgery
douches
sources, such as semen and vaginal
by fatema okoff
Complete blood count CBC , CRP
Urine for routine analysis / culture
High vaginal swab for culture
Ultrasonography USG for (AFI/MVP) CTG/NST
2- Maternal evaluation
includes assessment for contractions, signs of infection (eg, fever, fetal tachycardia, maternal leukocytosis), and
oligohydramnios and current maternal status for medical and obstetric complications.
3- Fetal well-being is evaluated with a nonstress test.
4-Obstetric management
🔹
according to gestational age(active management vs expectant management)
At 37 weeks of gestation or beyond:
termination of pregnancy/expectant management antibiotic administration (controversial indication) it may be
🔹
considered if latency is long
Between 34-36 6/7 weeks of gestation:
antenatal steroidsMore recent recommendations support administration of a course of antenatal steroids between Prelabor rupture of membranes (PROM) is defined as spontaneous
34 0/7 and 36 6/7 weeks of gestation if it is not given earlier in pregnancy rupture of chorioamnionic membranes before the onset of labor at
-Antibiotics administration any stage of gestation.
Definition
🔹
-expectant management up to 37 weeks of gestation/ termination of pregnancy
PROM before 34 weeks of gestation(24-33 6/7):
Expectant management If diagnosis is made and both maternal and fetal status are reassuring a single course of
The incidence of PROM ranges from 5% to 15% of all pregnancies
worldwide
corticosteroids for enhancement of lung maturity, antibiotics to protect against ascending infection.
🔹
also, magnesium sulfate is recommended as a neuroprotectant, to reduce the risk of cerebral palsy
Pre-viable PROM(less than 24 wk):
Active management VS expectant management Prelabor rupture of membranes is classified according to the gestational age at
Antibiotic administration
Management in this scenario is highly individualized,and counselling of parents families is important in ensuring 🔹
which it occurs into:
Term pre-labor rupture of membranes:
Rupture of the membranes at or beyond 37 weeks’ gestation prior to the onset of
that they are aware of theprognosis regardless of the interventions.
Even with prolongation of pregnancy and absence of infection, the fetus still has the risk of complications like
Potter’s syndrome, chroniclung disease, neurologic abnormalities and cerebral palsy. Management Classification 🔹
labor.( 8 %)
Preterm pre-labor rupture of membranes (PPROM):
Rupture of membranes prior to 37 weeks of gestation and before the onset of
-Of note, tocolysis should not be used to prolong pregnancy in the presence of uterinecontractions because of
increased risk of chorioamnionitis .However, a physician may consider short term tocolysis if clinical situation
justifies the risk such as to allow transfer to a tertiary care center or administration of steroids. 🔹
labor.(2%)
Previable pre-labor rupture of membranes (previable PROM): rupture of
membranes that occurs before the gestational age of viability(1%)
- Two regimens of “latency” antibiotics were supported by 2 large RCTs. 1st regimen :48 hours of intravenous
therapy (ampicillin 2 g and erythromycin 250 mg every 6 hours) followed by 5 days of oral medications (amoxicillin
250 mg and erythromycin 333 mg every 8 hours). 2nd regimen: erythromycin 250 mg orally 4 times a day for 10
days.
- A 4 g intravenous bolus of magnesium sulfate over 15 minutes,followed by an intravenous infusion of 1 g per hour Rupture of membranes results from a variety of factors that ultimately lead to accelerated membrane
until the birth or for 24 hours ( PPROM 24-33 6/7)wk for neuroprotection. weakening. This is caused by an increase in local cytokines, an imbalance in the interaction between matrix
🌟 Maternal and fetal monitoring in expectant management
Digital vaginal examination and vaginal intercourse should be avoided.
metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased collagenase and
🔷
protease activity, and other factors that can cause increased intrauterinepressure
Weak membranes
-Check temperature every six hours and notify the clinician if temperature ≥100.4°F [38°C]). Report changes in weakening is a normal process that typically happens at term as the body prepares for labor and delivery.
color or odor of vaginal discharge.
-Undergo some type of fetal surveillance (eg, kick counts, nonstress tests, biophysical profile tests) to provide the
clinician and patient with some assurance of fetal well-being,on daily basis.
🔹
The natural weakening of fetal membranes is thought to be due toone or a combination of the following
Cell death :
when cells undergo programmed cell death, they release biochemical markers that are detected in higher
-Notify the clinician of any developing concerns or comp
📍 For patients who request expectant management at home until labor or a complication ensues, we believe the
Pathophysiology
🔹
concentrations in cases of PPROM.
Poor assembly of collagen :
collagen is a molecule that gives fetal membranes, as well as other parts of the human body such as the
following criteria are reasonable after initial evaluation: skin, their strength. In cases of PPROM, proteins that bind and cross link collagen to increase its tensile
●Cephalic presentation ●No clinical suspicion of intrauterine infection
●Reassuring fetal heart rate tracing ●No oligohydramnios 🔹
strength are altered.
Breakdown of collagen:
collagen is broken down by enzymes called matrixmetalloproteinases (MMPs), which are found at higher
●Patient understands and can comply with instructions
levels in PPROM amniotic fluid. This breakdown results in prostaglandin production which stimulates
●Assistance at home ●Dependable transportation uterine contractionsand cervical ripening. MMPs are inhibited by tissue inhibitors of matrix
●Travel time to the hospital of no more than 20 to 30 minutes ●Ability to check pulse and temperature every six metalloproteinases (TIMPs) which are found at lower levels in PPROM amniotic fluid
hours, with parameters for notifying their clinician (eg, pulse >100 beats per minute, temperature ≥100.4°F [38°C])
●Willingness to perform daily fetal kick counts
The etiology of PROM is multifactorial.
Prelabour rupture The final common pathway in the occurrence of PROM is disruption of fetal
Diagnosis of PROM is made by informations obtained from clinical matenal history,physical
of membranes 🔹
membranes.
Rupture of the membranes near the end of pregnancy (term) may be
🌟
examination,and paraclinical investigations .
History: 🔹
caused by a natural weakening of the membranes.
Before term, PPROM is often due to an intrauterine infection.
🔻
The classic clinical presentation of PROM is a sudden "gush" of clear or pale yellow fluid from the
vagina, which soaks through clothes. However, there may not be a gush. Many patients describe Risk factors:
Nitrazine paper leaking only small amounts of fluid either continuously or intermittently, and some just describe a • Maternal factors:
sensation of abnormal wetness of the vagina or perineum. • PROM in a prior pregnancy (recurrence riskis 16–32%
-History taking should include; time of onset of fluid leakage, description of the amount and color of • Antepartum vaginal bleeding
leaking fluid, onset of uterine contractions (if present) in relation to fluid leakage, and the presence of • Chronic steroid therapy
🌟
abdominal pain or vaginal bleeding.and history of any risk factors
Physical examination:
per speculum examination in which the fluid is seen flowing from the cervical os or pooled in the
• Collagen vascular disorders (such as Ehlers-Danlos syndrome, systemic
lupus erythematosus)
• Direct abdominal trauma
posterior fornix. • Preterm labor
Digital vaginal examination should be avoided unless delivery is appeared to be immediate because it • Cigarette smoking
may decrease the latency period (ie, time from PROM to delivery) and increase the risk of intrauterine Etiology • Illicit drugs (cocaine)
Fern 🔻
infection
Most cases can be diagnosed based on maternal history followed by a sterile speculum
examination demonstrating liquor
• Anemia
• Low body mass index (BMI <19.8 kg/m2)
• Nutritional deficiencies of copper and ascorbic acid
🔷 If the diagnosis is uncertain, confirmatory testing is performed on fluid pooled in the
• Low socioeconomic status
🔹
posterior fornixNitrazine
Nitrazine paper is used to test the pH of vaginal fluid. Nitrazine (or phenaphthazine) is a pH
indicator dye that indicates pH in the 4.5 to 7.5 range.
• Fetal factors:
• Multiple pregnancy (preterm PROM complicates 7–10% of twin
pregnancies)
Amniotic fluid usually has a pH range of 7.0 to 7.3, which is different from the normal vaginal pH of 3.8 • Uteroplacental factors:
🔹
to 4.2 and usually different from the pH of urine, which is typically <6.0 but may be higher
Fern ‒ Dried amniotic fluid shows an arborization (ferning) pattern when viewed under a
microscope. Fluid from the posterior vaginal fornix is swabbed onto a glass slide and allowed to dry
• Uterine anomalies (such as uterine septum)
• Placental abruption (may account for 10–15% of preterm PROM)
• Advanced cervical dilatation (cervical insufficiency)
for at least 10 minutes. Amniotic fluid produces a delicate fernnin pattern, in contrast to the thick and • Prior cervical conization
wide arborization pattern of dried cervical mucus. • Cervical shortening in the second trimester (<2.5 cm)
🔹 Instillation of dye (tampon test) ‒ This invasive test has been replaced by commercial
noninvasive tests.Under ultrasound guidance, 1 mL of indigo carmine dye in 9 mL of sterile saline was
• Uterine overdistention (polyhydramnios, multiple pregnancy)
• Intra-amniotic infection (chorioamnionitis
injected transabdominally into the amniotic fluid, and a tampon was placed in the vagina. Twenty
minutes later, the tampon was removed and examined for blue staining, which indicated leakage of Diagnosis
amniotic fluid. Indigo carmine dye,sodium fluorescein or phenolsulfonphthalein.
🔷 If, on speculum examination, no amniotic fluid is observed, clinicians should consider performing an
insulin-like growth factor binding protein 1(actim prom) (IGFBP-1)or and placental alpha
microglobulin-1 protein assay (AmniSure) (PAMG-1)test of vaginal fluid by using
immunochromatography dipstick method to guide further management
🔹
🔹 urinary incontinence
🔹 excessive physiological secretions of pregnancy
pathological discharge associated with vaginitis complications
🔹
or cervicitis
🔹 vesicovaginal or rectovaginal fistula Differential diagnosis
🔹exogenous
urogenital tract trauma or surgery
douches
sources, such as semen and vaginal
by fatema okoff
