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    PROM Approach

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    عبد الله الحربي
    PPROM refers to premature rupture of membranes before 37 weeks gestation. Risk factors include prior PROM or preterm delivery, infection, and smoking. Management involves monitoring for signs of infection, administering steroids to accelerate lung maturity if before 34 weeks, and delivering after 34 weeks to reduce complications of prematurity in the newborn. Complications can include maternal infection as well as fetal complications such as prematurity, low birth weight, and neonatal sepsis.

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    PROM Approach

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    عبد الله الحربي
    18 views3 pages
    PPROM refers to premature rupture of membranes before 37 weeks gestation. Risk factors include prior PROM or preterm delivery, infection, and smoking. Management involves monitoring for signs of infection, administering steroids to accelerate lung maturity if before 34 weeks, and delivering after 34 weeks to reduce complications of prematurity in the newborn. Complications can include maternal infection as well as fetal complications such as prematurity, low birth weight, and neonatal sepsis.

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    PPROM refers to premature rupture of membranes before 37 weeks gestation. Risk factors include prior PROM or preterm delivery, infection, and smoking. Management involves monitoring for signs of infection, administering steroids to accelerate lung maturity if before 34 weeks, and delivering after 34 weeks to reduce complications of prematurity in the newborn. Complications can include maternal infection as well as fetal complications such as prematurity, low birth weight, and neonatal sepsis.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    18 views3 pages

    PROM Approach

    Uploaded by

    عبد الله الحربي
    PPROM refers to premature rupture of membranes before 37 weeks gestation. Risk factors include prior PROM or preterm delivery, infection, and smoking. Management involves monitoring for signs of infection, administering steroids to accelerate lung maturity if before 34 weeks, and delivering after 34 weeks to reduce complications of prematurity in the newborn. Complications can include maternal infection as well as fetal complications such as prematurity, low birth weight, and neonatal sepsis.

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    © All Rights Reserved
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    of 3

    PROM Approach – OBGYN – OSCE – Batch 12 | Dana A.

    Obeid

    GENERAL INFORMATION
    ▪ PROM: Rupture of the membranes at any time during the pregnancy before the onset of
    labor (i.e. without regular uterine contractions or appropriate cervical changes).
    ▪ P-PROM: Rupture of the membranes at any time during the pregnancy before the onset
    of labor (i.e. without regular uterine contractions or appropriate cervical changes) before
    the completion of 37 weeks of gestation.
    ▪ Triad: Posterior fornix pooling, fluid in Nitrazine +, glass slide drying fern +

    HISTORY
    ▪ Chief complaint: (Clear vaginal fluid)
    - Onset: 1st time? When? Sudden/gradual? Continues/intermittent? Progressive? What
    were you doing?
    - Characteristics: Amount, color, smell, blood, clots?
    - Associated symptoms:
    ✓ Constitutional: fever, chills, loss of appetite.
    ✓ Labor: cramps, lower back pain, pelvic pressure, fetal movements?
    ✓ Vagina: bleeding (ask about anemia sx), discharge, clear fluid gush/leak, itching?
    ✓ Urinary: dysuria, flank pain, infections?
    ✓ Preeclampsia: headache, visual disturbance, epigastric pain, lower limb swelling?

    ▪ Obstetric Hx:
    - How many weeks pregnant are you? Due date? LMP? How was it confirmed?
    - Have you been pregnant before? Number of pregnancies? Number of live births?
    Abortions? Mode of delivery? Any premature babies or still births? Fetal/maternal
    complications?
    - When was the last US? Results? Singleton or multiple gestation?
    - Antenatal screening (GBS, GDM, rubella immunization, blood type/Rh immunization)?

    ▪ Gynecological Hx:
    - Menstrual cycle: Regular periods before pregnancy, intermenstrual bleeding?
    - Contraception use, IUCD?
    - Gynecological procedures? IVF, induction of ovulation?

    ▪ Past Medical Hx/Family Hx/Medications Hx/Social Hx:


    - Medical conditions: HTN, DM, DLP, cardiac, thyroid, anemia, APS, SLE?
    - GYN: fibroids, PID, uterine anomalies?
    - Surgeries/hospitalizations/blood transfusion/ trauma?
    - Medications? Anticoagulants? Herbal supplements? Pregnancy supplements? Allergies?
    - Do you have a family history of same issue? Chronic, hematological, immunological dx?
    - Occupation, smoking, alcohol, recreational drugs, exposure to diethylstilbestrol, exercise,
    diet, BMI, stress?

    RISK FACTORS
    ▪ Previous PROM or preterm delivery.
    ▪ Ascending infection from lower genital track.
    ▪ Smoking.

    1
    PROM Approach – OBGYN – OSCE – Batch 12 | Dana A. Obeid

    PHYSICAL EXAMINATION
    ▪ General examinations + Vitals (Pulse, BP, T, RR)
    - Distress, pallor, fever, tachycardia, lightheaded, confused.
    - CVS, pulmonary and neurological exam: to assess the hemodynamic status, signs of
    - pneumonia, cardiac diseases/murmurs.

    ▪ Abdominal examination
    - Inspection: Scars, contour, fetal movements, linea nigra, striae.
    - Palpation: Tenderness, guarding, rebound, uterus, masses, contractions.
    - Fundal height.
    - Fetal lie, presentation, engagement.
    - Leopold’s maneuver.
    - Auscultation.

    ▪ Sterile speculum examination


    - Cervical dilation.
    - Amniotic fluid leakage with fundal pressure, straining or coughing.
    - Pooling + → clear watery amniotic fluid in the posterior vaginal fornix.
    - Nitrazine + → fluid turns pH-sensitive paper blue.
    - Fern + → ferning pattern when allowed to dry on a microscope glass slide.

    ▪ Chorioamnionitis
    - Fever, uterine tenderness in the presence of PROM and absence of URI or UTI.

    LABS AND IMAGING


    ▪ Labs:
    - CBC: Hg = Anemia, WBC > 18,000 = intra ammonitic infection.
    - Rh testing and blood type: to give RhoGAM.
    - Urinalysis/midstream urine sample: microscopy and culture.
    - Vaginal/cervical/rectal swab and culture: GBS (group B streptococcus).

    ▪ US:
    - Amniotic Fluid Index.
    - Placenta, GA, fetal growth, presentation, maternal structure abnormalities.

    ▪ Fetal wellbeing:
    - Continues electronic fetal heart monitoring; CTG
    - Fetal lung maturity (>32 weeks with lecithin/sphingomyelin ratio in amniotic fluid).

    2
    PROM Approach – OBGYN – OSCE – Batch 12 | Dana A. Obeid

    MANAGEMENT
    If ≥ 34 weeks
    1. Admit, continues monitor of the mother and fetus.
    2. Abx prophylaxis for GBS
    3. Deliver

    If < 34 weeks
    1. Admit to tertiary care facility, continues monitor of the mother and fetus.
    2. Tocolytics (if <32 weeks) – Controversial
    - 1st line: Indomethacin (24-32 weeks); concern of premature constriction of DA.
    - 2nd line: Nifedipine (32-34 weeks).
    - 3rd line: Terbutaline.
    3. Steroids to accelerate lung maturity (If < 34 weeks).
    - Betamethasone: 2 doses of 12 mg, IM, 24 hours apart.
    - Dexamethasone: 4 doses of 6 mg, IM, 12 hours apart.
    4. Cervical/Urine culture + → Antibiotics for GBS
    - Penicillin G: 5 million units IV, followed by 2.5-3 million units IV every 4 hours.
    - If penicillin allergic give clindamycin or vancomycin.
    5. Magnesium sulfate (if <32 weeks)
    - Neuroprotection against cerebral palsy and other motor dysfunction.
    6. Prevent chorioamnionitis
    - 1 dose of azithromycin upon admission, 1 g orally plus a 7 days course of: IV ampicillin
    (2g every 6 hours for 48h) → Oral amoxicillin (500mg 3 times/d for 5 days).

    If chorioamnionitis is present
    Clinical findings: fever, uterine fundal tenderness, maternal/fetal tachycardia, prulent/foul
    amniotic fluid.
    1. Admit to tertiary care facility.
    2. Obtain cervical cultures.
    3. Give IV Abx prophylaxis for GBS.
    4. Tx: IV ampicillin and gentamycin until delivery (+ clindamycin and metronidazole if CS).
    5. Deliver.

    COMPLICATIONS
    ▪ Maternal:
    - Chorioamnionitis, endometritis, DVT.
    - Maternal sepsis/death.
    - Abruptio placenta.

    ▪ Fetal:
    - Prematurity: RDS, IVH, CP, NEC, Retinopathy.
    - Oligohydramnios: Umbilical cord compression, pulmonary hypoplasia.
    - Metabolic: Hypoglycemia, hypocalcemia, hypomagnesemia, hyperbilirubinemia.
    - Neonatal sepsis.

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