Premature Rupture of Membranes (PROM)

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Questions and Answers

The latency period is defined as the time between the rupture of membranes and the onset of labor.

True (A)

The amnion is composed of three layers including an epithelial layer, a fibroblast layer and a basal layer.

False (B)

The chorion is thinner than the amnion and offers greater resistance to traction.

False (B)

Amniotic epithelial cells secrete only collagen type III.

<p>False (B)</p> Signup and view all the answers

Amniotic fluid primarily consists of 50% water, proteins, electrolytes, carbohydrates, lipids, and hormones.

<p>False (B)</p> Signup and view all the answers

Amniotic fluid aids in fetal lung, gastrointestinal tract and musculoskeletal development through fetal swallowing and skeletal muscle movements.

<p>True (A)</p> Signup and view all the answers

Infection is not associated with preterm premature rupture of membranes.

<p>False (B)</p> Signup and view all the answers

The use of recreational drugs during pregnancy does not elevate the risk of premature rupture of membranes.

<p>False (B)</p> Signup and view all the answers

A short cervix (less than 25 mm) in nulliparous women significantly increases the risk of premature rupture of membranes, approximately threefold.

<p>False (B)</p> Signup and view all the answers

The diagnosis of premature rupture of membranes can be confirmed in most cases based on the patient's history and physical examination without further testing.

<p>True (A)</p> Signup and view all the answers

The presence of 'fern-like' crystallization is always indicative of amniotic fluid and never indicative of semen or cervical mucus.

<p>False (B)</p> Signup and view all the answers

The amnisure test identifies a protein specific to amniotic fluid and has a high degree of sensitivity in the diagnosis of premature rupture of membranes.

<p>True (A)</p> Signup and view all the answers

Nitrazine testing of vaginal fluid is always accurate due to the consistent pH levels in the vagina.

<p>False (B)</p> Signup and view all the answers

In pregnancies beyond 37 weeks with confirmed rupture of membranes, immediate delivery is recommended.

<p>True (A)</p> Signup and view all the answers

Corticosteroids are always recommended to promote fetal lung maturation irrespective of gestational age in cases of premature rupture of membranes.

<p>False (B)</p> Signup and view all the answers

Flashcards

¿Qué es RPM?

Spontaneous rupture of the amniotic membranes (amnion and chorion) before the start of labor.

Amnios

Innermost layer closest to the fetus. It consists of five layers.

Corion

Layer surrounding the amnios, thicker but less resistant to traction.

Amniotic fluid

Fluid surrounding the fetus that protects against trauma and infection, and aids in lung development.

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Causes of premature breakage

Stimulation of collagenases, bacterial proteases, and oxidative stress that weakens the membranes.

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Infection and RPM

Ascending bacteria from the vaginal canal, urinary tract, or genital area can cause an inflammation.

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Diagnostic tests for RPM

Group of tests including crystallization, nitrazine, Amnisure, and fetal fibronectin.

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Clinical Sign of RPM

Loss of clear fluid from the genitals which is distinct from urine.

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Crystallization Test

Test where sodium salts crystallize in a fern pattern.

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Nitrazine test

Determines fluid pH using reactive tape.

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Amnisure test

A rapid slide test which detects the presence of placental alpha microglobulin-1(PAMG-1).

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Complication caused by RPM

Infections, premature birth, pulmonary hypoplasia, and skeletal deformations.

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Prematurity impact

Pulmonary hypoplasia when there is loss of amniotic fluid.

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Cornerstones of Treatment

Antibiotics and corticosteroids.

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Neuroprotection

Magnesium sulfate; is used for fetal neuroprotection.

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Study Notes

  • Premature rupture of membranes (PROM) is a main concern in maternal-fetal medicine as it is a major cause of perinatal mortality

Intro to PROM

  • 75% of perinatal mortality can be attributed to premature birth (<37 weeks)
  • Globally, 9.6% of all births are premature, with 50% occurring spontaneously
  • In Chile, 8.6% of births are premature and 30% are due to premature rupture of membranes

PROM Definition

  • PROM is defined as the spontaneous rupture of the amniotic membranes (amnion and chorion) before the onset of labor

Prevalence

  • PROM occurs in 10% of term pregnancies and 2-3% of preterm pregnancies, with the latter being more concerning
  • The earlier the gestational age at which PROM occurs, the longer the latency period until delivery, with latency being the time between membrane rupture and the start of labor

Amniotic Membrane Anatomy

  • The fetal membranes are composed of the amnion and chorion and the amnion consists of five layers
  • The layers from the closest to the fetus to the outside include:
  • Inner amniotic epithelial layer
  • Basal membrane
  • Compact layer
  • Fibroblast layer
  • Intermediate layer

Chorion

  • The chorion is thicker than the amnion but has less resistance to traction
  • Amniotic epithelial cells secrete collagen types III and IV, as well as laminin and fibronectin, which help connect the amnion to the basal membrane
  • The compact layer consists of collagen types I and III secreted by the adjacent fibroblast layer
  • The fibroblast layer contains mesenchymal cells and macrophages
  • The outermost intermediate layer connects the amnion and chorion and is composed of collagen type III, proteoglycans, and glycoproteins
  • The connections between the amniotic and chorionic membranes are thin and not well-defined

Amniotic Fluid

  • Amniotic fluid surrounds the fetus during the first weeks of gestation (7-10 weeks) and is formed by fetal urine and lung fluid

Composition of Amniotic Fluid

  • 98% water, plus proteins, electrolytes, carbohydrates, lipids, and hormones

Amniotic Function

  • Trauma protection
  • Cord compression prevention
  • Antibacterial properties
  • Help in the development of the lungs and gastrointestinal tract

Pathophysiology

  • Membrane rupture occurs similarly in both term and preterm pregnancies, but the triggering factors differ

Etiology

  • Physiological or pathological factors can cause membrane rupture before term which include sterile or non-sterile inflammation, with the latter associated with infection
  • Risk factors for PROM includes maternal, fetal, and iatrogenic factors

Maternal Factors

  • Drug abuse, multiple pregnancies, and polyhydramnios and risk factors include substance abuse, multiple pregnancies, and polyhydramnios
  • Prevention and treatment is complicated due to the many potential causes

Risk Factors

  • Systemic, environmental, uterine, and fetal/utero-placental factors
  • Includes: smoking, drug abuse, low socioeconomic status, cervical issues, polyhydramnios, multiple gestations

Pathogens

  • In preterm PROM, inflammation associated with infection is common
  • Bacteria ascend from the vaginal canal, inflame the cervix, and cause rupture, or come from the urinary/genital tract

Frequent Bacteria

  • The most common bacteria include:
  • Ureaplasma urealyticum
  • Mycoplasma hominis
  • Gardnerella vaginalis
  • Streptococcus agalactiae
  • Staphyloccocal species
  • Lactobacillus species
  • Bacteroides species
  • Acinetobacter species
  • Sneathia
  • Streptococcus viridans
  • Candida albicans (DIU)
  • 30-50% of cases are polymicrobial

Risk factors

  • Cervical length, prior PPROM or preterm birth
  • Working during pregnancy, genital tract infections

Diagnosis

  • Diagnosis is based on clinical evaluation and physical examination to confirm loss of clear fluid from the genitals that is distinguishable from urine

Diagnostic Tools

  • Loss of clear fluid with a chlorine odor that cannot be contained indicates PROM
  • Amnioscopy can identify fluid output from the external cervical os (OCE)
  • Ultrasound can provide non-specific information
  • AmniSure and crystallization tests are useful

Differential Diagnosis

  • Differential diagnosis is important and includes:
  • Leukorrhea
  • Mucous plug loss
  • Urinary incontinence
  • Vaginal cyst rupture
  • Decidual hydroorrhea
  • Amniocorial sac rupture

Complications for Mother and Fetus

  • PROM can lead to maternal and fetal complications: – Intra-amniotic infection and clinical chorioamnionitis (30-50% in preterm PROM, 5-10% in term PROM)
  • Puerperal endometritis
  • Abruptio placentae
  • Maternal sepsis

Fetal complications

  • Prematurity
  • Neonatal sepsis (20%)
  • Pulmonary hypoplasia
  • Cord prolapse
  • Fetal inflammatory response syndrome
  • Skeletal abnormalities
  • Fetal death

Initial Evaluation

  • Assess gestational age via last menstrual period (LMP) and early ultrasound
  • Monitor vital signs, fetal heart rate, and uterine contractions
  • Assess fetal status through non-stress test and ultrasound
  • Always rule out clinical chorioamnionitis through lab tests such as blood counts, CRP, ESR, urine culture, and cervical-vaginal cultures

Interruption of pregnancy

  • Immediate if chorioamnionitis is present, as well as placental abruption, fetal death

PROM Management by Gestational Age

  • Management depends on gestational age which includes:
  • PROM >37 weeks: Immediate delivery is recommended when a patient at term experiences membrane rupture
  • PROM 34-37 weeks: Delivery is recommended, considering the risk of fetal morbidity versus neonatal morbidity
  • PROM 24-34 weeks: Hospitalization is required and delivery should be considered only if specified criteria are met
  • PROM <24 weeks: Rare, with high rates of maternal and perinatal morbidity; consider termination

Steroid Administration

  • Recommended between 24-34 weeks for lung maturity

Tocolytics

  • Not recommended unless needing to transport the patient

Neuroprotection

  • Magnesium sulfate is recommended for women <32 weeks at risk of imminent delivery

Antibiotics

  • Administer antibiotics to prolong latency and reduce maternal and fetal infections – Ampicillin and erythromycin – Azithromycin – Ceftriaxone and clindamycin

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