premature rupture of membrane ( PROM ), or ruptured membranes before surgery, is a condition that can occur in pregnancy. This is defined as the rupture of the membranes (breakup of the amniotic sac), commonly called breaking up the mother's water, more than 1 hour before the onset of labor. The sac (consisting of 2 membranes, chorion and amnion) contains amniotic fluid, which surrounds and protects the fetus in the uterus (womb). After rupture, the amniotic fluid leaks out of the uterus, through the vagina.
Women with PROM usually experience fluid flow that is not painful out of the vagina, but sometimes a sluggish stable leakage occurs.
When premature rupture of membranes occurs on or after 37 weeks of pregnancy is completed (full term or duration), there is minimal risk to the fetus and labor usually begins soon after.
If rupture occurs before 37 weeks, it is called premature premature rupture of membranes (PPROM), and the fetus and mother are at greater risk for complications. PPROM causes one-third of all premature births, and preterm infants (before 37 weeks) can suffer from complications of prematurity, including death.
Early rupture of membranes provides a way for bacteria to enter the uterus and put the mother and fetus at risk of life-threatening infections. Low fluid levels around the fetus also increase the risk of cord compression and may interfere with the lungs and body formation early in pregnancy.
Women who suspect that they may have prematurely ruptured membranes should be evaluated promptly in the hospital to determine whether membrane rupture did occur, and be treated appropriately to avoid infection and other complications.
Video Premature rupture of membranes
Classification
- premature rupture of membranes (PROM): when the membranes rupture early, at least one hour before labor begins.
- Prolonged PROM: premature rupture of membranes in which more than 24 hours have elapsed between rupture and onset of labor.
- Premature Membranes Membrane Membrane (PPROM): premature rupture of membranes that occur before 37 weeks.
- Midtrimester PPROM or PPROM pre-viabel: premature rupture of membranes that occur before 24 weeks' gestational age is completed. Before this age, the fetus can not survive outside the mother's womb.
Maps Premature rupture of membranes
Signs and symptoms
Most women will experience painless leakage fluid out of the vagina. They may see either a different "bush" or a constant stream of small amounts of aqueous liquid in the absence of stable labor contractions. The loss of fluid can be attributed to the fetus becomes more easily felt through the abdomen (due to loss of surrounding fluid), decreased uterine size, or meconium (fetal stool) seen in the fluid.
Risk factors
The cause of premature rupture of membranes (PROM) is not clearly understood, but the following are proven risk factors that increase the likelihood of it occurring. In many cases, however, no risk factors are identified.
- Infection: urinary tract infections, sexually transmitted diseases, lower genital infections (eg bacterial vaginosis), infections inside the membranous sac membrane
- Smoking cigarettes during pregnancy
- Use of illegal drugs during pregnancy
- After having a PROM or preterm birth in previous pregnancy
- Polihydramnios: too much amnionic fluid
- Multiple pregnancies: pregnant with two or more fetuses at once
- After bleeding at any time during pregnancy
- Invasive procedure (eg amniocentesis)
- Nutritional deficit
- Cervical insufficiency: have short or premature cervical dilatation during pregnancy
- Low socioeconomic status
- Being skinny
Pathophysiology
Deteriorating fetal membrane
Fetal membranes are likely to rupture as they become weak and brittle. This attenuation is a normal process that usually occurs when the body prepares for labor. But, this can be a problem when it happens before the time (before 37 weeks). The natural weakness of the fetal membrane is thought to be due to one or a combination of the following. On premature rupture of membranes, this process is activated too early:
- Cell death: when cells undergo programmed cell death, they release detected chemical markers in higher concentrations in the case of PPROM.
- Bad collagen assembly: Collagen is a molecule that gives the membrane to the fetus its strength. In the case of PPROM, the binding protein and cross-link collagen to increase its tensile strength are altered. Collagen details: Collagen is broken down by an enzyme called metalloproteinase matrix (MMPs), which is found at higher levels in the amniotic fluid of PPROM, these MMPs break down collagen holding strength, so the production of Prostaglandins will be synthesized in high. amount to encourage uterine contractions and cervical ripening. The metalloproteinase matrix is ​​inhibited by metalloproteinase matrix tissue inhibitors (TIMPs) found at lower levels in the amniotic fluid PPROM.
Infection
Infection and inflammation may explain why the membrane ruptures earlier than expected. In the study, bacteria have been found in amniotic fluid from about one-third of PROM cases. Often, testing of amniotic fluid is normal, but subclinical infections (too small to detect) or maternal tissue infections in addition to amniotic fluid, may still contribute. In response to infection, the body creates inflammation by making chemicals (eg: cytokines) that weaken the fetal membrane and make them at risk of rupture. Early rupture of membranes is also a risk factor in the development of neonatal infection.
Genetics
Many genes play a role in the inflammation and production of collagen, therefore inherited genes can play a role in influencing a person for PROM.
Diagnosis
To know for sure whether a woman has prematurely ruptured membranes (PROM), a health care physician must prove that (1) the leaking fluid from the vagina is an amnionic fluid, and (2) that labor has not started. To do this, a health care physician will take a medical history, perform a gynecological examination using sterile speculum, and ultrasound.
- History: a person with a PROM usually remembers a sudden burst of fluid loss from the vagina, or a small amount of fluid loss.
- Sterile speculum examination: The health care physician will insert the sterile speculum into the vagina to look inside and perform the following evaluation. The digital cervical exam, in which the gloved finger is inserted into the vagina to measure the cervix, is avoided until the woman is in active labor to reduce the risk of infection.
- The merging test: Pooling is when the amniotic fluid collection can be seen at the back of the vagina (vaginal fornix). Sometimes a liquid leak from the opening of the cervix can be seen when the person coughs or performs a valsava maneuver.
- Nitrazine test: A sterile cotton is used to collect fluid from the vagina and place it on nitrazine paper (phenaphthazine). The amniotic fluid is slightly alkaline (pH 7.1-7.3) compared to the normal acidic vaginal fluid (pH 4.5-6). The basic liquid, like amniotic fluid, will turn the nitrazine paper from orange to dark blue.
- Fern Test: A piece of sterile cotton is used to collect the liquid from the vagina and place it on a microscope slide. Once dry, the amniotic fluid will form a crystallization pattern called arborization that resembles the leaves of a fern plant when viewed under a microscope.
- Fibronectin and alpha-fetoprotein
Extra test
The following tests should only be used if the diagnosis remains unclear after the standard tests above. Ultrasound: Ultrasound: Ultrasound can measure the amount of fluid remaining in the uterus surrounding the fetus. If the fluid level is low, PROM is more likely. It helps in cases when the diagnosis is uncertain, but not, by itself, definitive.
It is unclear whether different methods of assessing fetus in women with PPROM affect results.
False positives
Like amniotic fluid, blood, semen, vaginal infections, antiseptic, basic urine, and cervical mucus also have a basic pH and can also alter the nitrazine blue paper. Cervical mucus can also create patterns similar to ferning on microscope slides, but it is usually patchy and with fewer branches.
Differential diagnosis
Other things to remember that may appear similar to premature rupture of membranes are as follows:
- Urinary incontinence: leakage of a small amount of urine often occurs in the last part of pregnancy
- Normal vaginal secretion in pregnancy
- Increased sweat or moisture around the perineum
- Increased cervical discharge: this can occur when there is a genital tract infection
- Cement
- Douching
- Vesicovaginal fistula: abnormal relationship between bladder and vagina
- Loss of mucous blockage
Prevention
Women who have premature rupture of membranes (PROM) are more likely to experience it in subsequent pregnancies. There is not enough data to recommend a way to specifically prevent future PROMs. However, any woman who has a history of preterm delivery, because of PROM or not, is recommended to take progesterone supplements to prevent recurrence of preterm delivery.
Management
PROM management is still controversial, and relies heavily on fetal gestational age and other complicated factors. The risk of rapid labor (induction of labor) vs. watchful waiting in each case is carefully considered before deciding on an action.
In 2012, the Royal College of Obstetricians and Gynecologists suggest, based on expert opinion and not clinical evidence, that attempted childbirth during maternal instability, increases fetal mortality and maternal mortality, unless the source of instability is intrauterine infection.
In all women with PROM, the age of the fetus, its position in the uterus, and its well-being should be evaluated. This can be done with ultrasound, monitoring the electronic fetal heart rate, and monitoring uterine activity. It will also indicate whether uterine contractions occur or not, which may be a sign that labor is starting. Signs and symptoms of infection should be closely monitored, and, if not already done, the streptococcal B group culture (GBS) should be collected.
At any age, if the well-being of the fetus appears to be disrupted, or if intrauterine infection is suspected, the infant should be sent immediately by artificially artificial birth (induction of labor).
PROM within
Both management of pregnant (waiting for alert) and induction of labor (artificial labor) are considered in this case. 90% of women start working alone within 24 hours, and therefore it makes sense to wait 12-24 hours for no risk of infection. However, if labor does not begin immediately after membrane rupture, labor induction is recommended because it reduces infection rates, reducing the likelihood that the infant will need to stay in the neonatal intensive care unit (NICU), and not increase the cesarean section level. If a woman is very unwilling to be induced, waiting with caution is an acceptable option as long as there are no signs of infection, the fetus is not in trouble, and she is aware and accepting the risk from prolonged PROM. There is not enough data to show that the use of prophylactic antibiotics (to prevent infection) is beneficial to the mother or infant at or near the time period. Due to potential side effects and development of antibiotic resistance, the use of antibiotics without the presence of infection is not recommended in this case.
PPROM is larger than 34 weeks
When the premature fetus (& lt; 37 weeks), the risk of premature birth should be weighed against the risk of prolonged membrane rupture. As long as the fetus is 34 weeks or more, delivery is recommended as if it were a term (see above).
PPROM less than 34 weeks
Before 34 weeks, the fetus is at a much higher risk than a complication of prematurity. Therefore, as long as the fetus is okay, and there are no signs of placental infection or abruption, waiting in case (pregnant management) is recommended. The younger the fetus, the longer it takes to start labor alone, but most women will give birth within a week. Waiting usually requires a woman to stay in the hospital so that health care providers can pay careful attention to infection, placental abruption, umbilical cord compression, or other fetal emergencies that will require rapid delivery by labor induction.
Before 24 weeks, the unbalanced fetus means not being able to live outside the mother. In this case, either waiting at home or induction of labor done.
Because the risk of infection is very high, the mother should frequently check her temperature and return to the hospital if she develops signs or symptoms of infection, labor, or vaginal bleeding. These women are usually hospitalized after their fetus reaches 24 weeks and then succeeds the same as women with PPROM before 34 weeks (discussed above). Where possible, this delivery should be performed in hospitals that have expertise in the management of potential maternal and infant complications, and have the necessary infrastructure to support the care of these patients (eg, neonatal intensive care unit). Antenatal corticosteroids, latent antibiotics, magnesium sulphate, and tocolytic drugs are not recommended until the fetus reaches survival (24 weeks). In the case of pre-viabel PPROM, the likelihood of survival of the fetus is between 15-50%, and the risk of chorioamnionitis is about 30%.
Chorioamnionitis
Chorioamnionitis is a bacterial infection of the fetal membrane, which can be life-threatening to the mother and fetus. Women with PROM at any age are at high risk of being infected due to open membranes and allowing bacteria to enter. Women are frequently checked (usually every 4 hours) for signs of infection: fever (& gt; 38 ° C/100.5 ° F), uterine pain, rapid heart rate (& gt; 100 beats per minute), rapid fetal heart rate (& gt; 160 beats per minute), or foul-smelling amniotic fluid. Increased white blood cells are not a good way to predict infections because they are usually high in labor. If infection is suspected, induction of artificial labor begins at the age of pregnancy and extensive antibiotics are given. The cesarean section should not be performed automatically in case of infection, and should only be reserved for normal fetal emergencies.
Results
The consequences of PROM depend on fetal gestational age. When PROM occurs over a period of time (after 37 weeks), it is usually immediately followed by the onset of labor. About half of women will give birth within 5 hours, and 95% will give birth within 28 hours without any intervention. The younger the fetus, the longer the latent period (time between membrane rupture and onset of labor). Rarely, in the case of premature PROM, the amniotic fluid will stop leaking and amniotic fluid volume will return to normal.
Infection (any age)
At any gestation, opening in the fetal membrane provides a route for bacteria to enter the uterus. This can cause chorioamnionitis (infection of the fetal membrane and amniotic fluid) that can be life-threatening to the mother and fetus. The risk of infection increases the longer the membrane remains open and the baby is not delivered. Women with PROM prematurely will develop intramniotic infection 15-25% of the time, and the likelihood of infection increases at previous gestational age.
Pre-month births (before 37 weeks)
PROM occurs before 37 weeks (PPROM) is one of the main causes of premature birth. Thirty to 35% of all preterm deliveries are caused by PPROM. This makes the fetus at risk for many complications associated with prematurity such as respiratory distress, cerebral hemorrhage, infection, necrotizing enterocolitis (fetal gut death), brain injury, muscle dysfunction, and death. Prematurity of various causes causes 75% perinatal death and about 50% of all long-term morbidity. PROM is responsible for 20% of all fetal deaths between 24 and 34 weeks' gestation.
Fetal development (before 24 weeks)
Before 24 weeks the fetus is still developing its organs, and amniotic fluid is important to protect the fetus against infection, physical effects, and to prevent the cord from becoming compressed. It also allows for the movement of the fetus and breathing necessary for the development of the lungs, chest, and bones. Low amniotic fluid levels due to mid-trimester or pre-term PPROM (before 24 weeks) may cause fetal deformities (eg Potter-like facies), limb contractures, pulmonary hypoplasia (infectious lung), infections (especially if the mother is colonized by group B streptococcus or bacterial vaginosis), cord or compression prolapse, and placental abruption.
PROM after second trimester amniocentesis
Most cases of PROM occur spontaneously, but the risk of PROM in women undergoing second trimester amniocentesis for a prenatal diagnosis of genetic disorder is 1%. Although, no research is known to account for all cases of PROM derived from amniocentesis. This case, the possibility of the healing membrane by itself and the amniotic fluid returning to normal levels is much higher than the spontaneous PROM. Compared with spontaneous PROM, about 70% of women will have normal amniotic fluid levels within a month, and about 90% of babies will survive.
Epidemiology
PROM occurs in about 10-12% of all births in the United States. Of all term pregnancy (& gt; 37 weeks) about 8% complicated by PROM, 20% of these become prolonged PROMs. Approximately 30% of all preterm deliveries (before 37 weeks) are complicated by PPROM, and rupture of membranes before viability (before 24 weeks) occurs in less than 1% of all pregnancies. Because there is much less premature delivery than the term delivery, the number of PPROM cases accounts for only about 5% of all PROM cases.
See also
- Alpha plasental microglobulin-1 (PAMG-1)
- IGFBP1 (growth factor binding protein like insulin-1)
References
External links
- MedlinePlus Encyclopedia
Source of the article : Wikipedia
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