1.  subject  Premature rupture of membrans Dr shakeri

2. Premature Rupture 0f Membrane/ PROM  Definition - PROM -PPROM -Latent Period

3. INCIDENCE  1% of all pregnancy (PPROM)  5-10% of term delivery  30% of PTL  30-50% of PROM occur in PTL  50-70% of PROM occur in term

4. ETIOLOGY  Not clinically evident  Generalized decrease in tensile strength of membrane  Local defect in membrane  Decreased amniotic fluid collagen  Change in collagen structure  Uterine irritability  Collagen degradation

5. RISK FACTOR  Previous PPROM  Positive fFN at 23w  Short cervix <25mm at 23w  Subclinical infection  Cigarette smoking  Bleeding  No association between coitus and PROM

6. PLACENTAL HISTOLOGY IN PROM  Acute inflammation 43%  Vascular lesion 20%  Inflammation + vascular lesion 20%  Normal finding 14%  Other finding 3%

7. Complication and consequences of PROM 1-Onset of labor.labor occurs within 24h after PROM in 80-90%.use of tocolytics----contraversial (no benefit).long term tocolysis significantly increased chorioamnionitis and endometritis.

8. 2-Neonatal effect.RDS the most common complication 10-40%.Neonatal sepsis less than 10%.Amnionitis 3-31%. Endometritis 29%.Abruptio 5%.Subclinical infection 80%.Pulmonary hypoplesia (serious complication)

9. Recurrence  Recurrence rate 32%  Patient education and follow up in next pregnancy

10. Diagnosis  Amniotic fluid egressing from vagina  Nitrazine test.normal PH of vagina 4-4.7.PH of amniotic fluid 7.1-7.3.accuracy of diagnosis PROM 93%.false positive (blood-semen-alkaline urine- B.V-trichomoniasis  Sonography

11.  Ferning test.accuracy of diagnosis 96%.false positive (contamination by semen or cervical mucus).false negative(dry swab-contamination with blood-fluid not dry on slide).ferning is unaffected by meconium and PH  Fetal fibronectin.sensitivity 98% - specificity low  Transabdominal dye injection

12. Fetal maturity  Amniotic fluid(amniocentesis-vaginal pool)  L/S ratio determination  Phosphotidylglycerol production.abcence of PG did not necessarily mean the RDS would develop.some genital tract bacteria caused false- positive test

13. Cervical status  Sterile spaculum  Endovaginal ultrasound

14. Infection  Rectovaginal culture should be taken for GBS  Should be evaluated for chorioamnionitis.maternal or fetal tachycardia.uterine tenderness.purulent,foul-smelling discharge.elevation of T  Amniocentesis.analysis(gram stain-glucose concentration-culture.increased IL6 in amniotic fluid(most sensitive predictor of intrauterine infection)  Biophysical profil 6 or less

15. Treatment consideration  Second trimester(neonatal survival is nil /expectant management or induction)  Early in the third trimester(neonatal survival rises marketly-morbidity high)  Mild third trimester(neonatal survival is high/but there is still considerable morbidity)  Late third trimester-near term(neonatal mortality and morbidity are low

16. Use of steroids in PROM  Reduce the risk of RDS  The effect was less than with intact membrane  Reduce neonatal mortality and IVH  Appropriated in the absence of chorioamnionitis in fetus <30-32w  Steroid therapy in PROM should be limited to a single course

17. Use of prophylactic antibiotics  Two indication for prophylactic antibiotics 1.prevention of perinatal GBS infection 2.infection is the triggering cause of PROM and infection after PROM triggers the labor  Prophylactic antibiotics 1.delay delivery 2.reduction maternal infection and chorioamnionitis 3.reduction neonatal infection,sepsis and pneumonia

18. Management of PROM at or near term (35w or more)  Induction (oxytocin or PG) -on admission -on after 12-24 h  Prophylaxis for GBS -positive screen culture at 35-37 w -PROM > 18 h in patients with unknown culture status

19. PROM at 32-34 w  Expectancy  Induction (if there is evidence of lung maturity)  Prophylaxis of GBS  Broad-spectrum AB limits to earlier G.A  Don’t use tocolytics  Don’t use C.S  During expectant management, daily NST + BPP as needed

20. Management of PROM at 25-32w  Contraversial  Expectant management  Prophylaxis for GBS  Antibiotics for 7 days - Ampicillin +Erythromycin orErythromycin -Amoxicillin+Erythromycin or Ampicillin  C.S recommended  Use of tocolytic(contraversial) -if used,limited to 48h

21. Management of PROM <25w  Induction or expectancy(depend on G.A and patient desires)  Tocolytics arenot recommended  C.S arenot recommended  Acourse of AB for 7 days may prolong pregnancy and decrease complications  After a period of hospitalization,home management may be used for uncomplicated selected patients

22. Chorioamnionitis complicated PROM at any G.S  Broad-spectrum antibiotics (appropriate for aerobe and anaerobes)  +Delivery(route of delivery should be determined by obstetric consideration)  C/S rate is high -poor progression of labor -nonreassuring FHR pattern -malpresentation

23. special circumstances  Home management of PROM-Doesnot recommended  PROM after cerclage -studies have not clarified the best course of management -In evident of infection- cerclage must be removed -without evident of infection-cerclage removed when fetal viable or greater than 25w or greater PROM and clinical herpes simplex virus infection -less than30-32w(expectant management+Acyclovir or another antiviral agents -greater than 32w-C/S