What is amniotic fluid leakage and what does it threaten? Premature rupture of membranes during full-term pregnancy. Infection Risk Assessment
Description:
Premature rupture of the membranes (PROM) is a complication of pregnancy, characterized by a violation of the integrity of the membranes of the membranes and the outflow of amniotic fluid (before the onset of labor) at any stage of pregnancy.
Often, water leaves at once in large quantities, and the diagnosis of PROM is not difficult, but in 47%23 of cases, when microcracks or lateral ruptures occur without massive effusion, doctors doubt the correct diagnosis, which threatens with overdiagnosis and unreasonable hospitalization, or vice versa, with infectious complications when late discovery.
PROM accompanies almost every third, and as a result is the cause of a significant proportion of neonatal diseases and deaths. The three main causes of neonatal death associated with PROM in preterm pregnancy are prematurity and hypoplasia (underdevelopment) of the lungs.
Symptoms:
The clinical picture of PRPO depends on the degree of damage to the membranes.
Clinical picture with massive rupture of amniotic fluid.
If there was a rupture of the fetal bladder, then:
a woman notes the release of a large amount of fluid not associated with urination;
the height of the uterine fundus may decrease due to the loss of a significant amount of amniotic fluid;
labor begins very quickly.
Clinical picture with high lateral ruptures.
It is more difficult when there are microscopic cracks and amniotic fluid leaks literally drop by drop. Against the background of increased vaginal secretion during pregnancy, excess fluid often goes unnoticed. A woman may notice that in the supine position, the amount of discharge increases. This is one of the signs of PRPO. Symptoms that should alert: a change in the nature and amount of discharge - they become more abundant and watery; in addition to pain, pain in the lower abdomen and or spotting joins (but it is worth noting that pain and spotting are not a permanent symptom and they may be absent). It is worth alerting if the above symptoms appeared after an injury or a fall, or against the background of a multiple pregnancy and/or an infectious process in the mother.
But in most cases, such gaps occur in the absence of obvious risk factors and after an hour the clinical manifestations are significantly reduced, which greatly complicates the initial diagnosis and requires additional methods, and a delay in diagnosis and timely treatment by 24 hours greatly increases the likelihood of perinatal morbidity and mortality. A day later, or even earlier, chorioamnionitis develops - one of the most formidable complications of PROM, the signs of which also indirectly indicate that there is a rupture of the membranes. This condition is characterized by an increase in body temperature (above 38), chills, tachycardia in the mother (above 100 bpm) and fetus (above 160 bpm), uterine tenderness on palpation and purulent discharge from the cervix during examination 40.
PROM due to cervical insufficiency (BMI less than 19.8)4 is more common in preterm pregnancy, although it also occurs at later stages. The failure of the cervix leads to a protrusion of the fetal bladder, and therefore its lower part is easily infected and torn even with little physical exertion.
Instrumental medical intervention
It should be noted that only procedures associated with instrumental examination of the amniotic fluid or chorion are accompanied by risk, and examination in mirrors or sexual intercourse cannot in any way lead to PPROM. But at the same time, multiple bimanual studies can provoke a rupture of the membranes.
Bad habits and diseases of the mother
It has been noted that women suffering from systemic connective tissue diseases, underweight, anemia, beriberi, with insufficient intake of copper, ascorbic acid, as well as those taking hormonal drugs for a long time, are more at risk of developing PROM. The same group should also include women with low socioeconomic status, abusing nicotine and narcotic substances.
Anomalies in the development of the uterus and multiple pregnancy
These include the presence of a uterine septum, conization of the cervix, shortening of the cervix, isthmic-cervical insufficiency, placental abruption, and multiple pregnancies.
Most often, blunt trauma to the abdomen is caused by a fall of the mother or a blow to the rupture.
Treatment:
To draw up an algorithm for managing pregnant women with PROM, one should have a clear understanding of the obstetric situation, decide on the place and time of delivery and the need to prevent infectious complications and/or. This requires the following.
Confirm the diagnosis of ruptured membranes.
Determine the exact gestational age and the estimated weight of the fetus. With a period of less than 34 weeks and a fetal weight of up to 1500 grams, the pregnant woman should be hospitalized in a third-level hospital.
Determine the contractile activity of the uterus.
Assess the condition of the mother and fetus;
Detect the presence of intramniotic infection.
Determine if there are any contraindications for expectant management
Choose the tactics of conducting a pregnant woman or a method of delivery.
Conduct infection prevention.
In the case of conservative management1, the patient is placed in a specialized room with bactericidal lamps, where wet cleaning should be carried out 3-4 times a day. Daily change of bed linen and change of sterile linen 3-4 times a day. The state of the fetus and mother is constantly monitored, medication is prescribed for the appropriate period and strict bed rest is prescribed.
Premature rupture of the membranes is especially dangerous in the early stages. But even with full-term pregnancy, it can be detrimental to the child if the mother delays hospitalization, the onset of labor is delayed. Let's talk about what causes premature rupture of the membranes and what to do if the water begins to break.
Most often, the causes of this pathology remain unexplained. However, it is believed that isthmic-cervical insufficiency (ICI) and various infections of the genital tract can become provocateurs. With the first problem, the cervix begins to shorten and open much earlier than the birth, which leads to a gradual movement of the presenting part of the child's body down, as a result of which the fetal bladder is under pressure and breaks. Pathogenic bacteria, viruses, which, figuratively speaking, corrode the membrane of the bladder, can also contribute to the rupture, provoking premature rupture of amniotic fluid in a pregnant woman.
How can this be avoided? The answer immediately suggests itself - it is necessary to prevent infectious diseases, as well as any injuries of the cervix - the most common cause of isthmic-cervical insufficiency. However, sometimes this does not help when the causes of cervical weakness are hormonal imbalances.
But the development of ICI can be prevented if you visit a gynecologist on time. It is also mandatory to measure the length of the cervix using a vaginal probe on ultrasound. Only in this way can you find out its exact length. If it is less than 3 cm, then the woman can be offered 2 options: installing a pessary ring on the cervix or suturing the cervix - this reduces the risk of premature rupture of the amniotic sac, labor will begin prematurely, and the child will die. Gynecologists pay special attention to those women who have already been diagnosed with ICI in the past, or amniotic fluid has departed at an early stage.
What to do if amniotic fluid begins to leak? First you need to make sure it's her. This is best done in the doctor's office using a special test, for which a swab is taken from the vagina. If leakage is confirmed, further tactics are largely determined by the gestational age. With a period of less than 22-24 weeks, unfortunately, it is most often recommended to induce premature birth, since carrying a child even up to 30-32 weeks will be accompanied by a huge risk of infection of the membranes - and this is detrimental to the fetus, and threatens blood poisoning for the mother.
If the gestational age is more than 28-30 weeks, doctors prescribe a course of antibiotic therapy to prevent infection, and treat it like preterm birth prevention (reduce uterine tone, etc.). All this is carried out in a hospital under the close supervision of a doctor. Pregnancy is carried out to the maximum possible period in order to allow the child and his lungs to mature.
If the fetal bladder ruptured a month or less before the birth, then doctors often decide on an urgent delivery. If the contractions do not start on their own, the cervix is long and closed, a special medical preparation is carried out, after which the onset of labor is stimulated.
Prenatal rupture of amniotic fluid
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2014
Premature rupture of membranes (O42)
obstetrics and gynecology
general information
Short description
Approved by the Expert Commission
For Health Development
Ministry of Health of the Republic of Kazakhstan
(DRPO) - spontaneous rupture of the amniotic membranes before the onset of regular uterine contractions in a period of 37 weeks or more.
(PDRPO) - spontaneous rupture of the amniotic membranes before the onset of regular uterine contractions in the period of 22 - 37 weeks.
Three major causes of neonatal death are associated with PPROM: prematurity, sepsis, and pulmonary hypoplasia. The risk to the mother is associated primarily with chorioamnionitis.
I. INTRODUCTION
Protocol name: Premature rupture of membranes
Protocol code:
ICD-10 code:
O42 Premature rupture of membranes
O42.0 Premature rupture of membranes, onset of labor within 24 hours
O42.1 Premature rupture of membranes, onset of labor after 24 hours of anhydrous period
O42. 2 Premature rupture of membranes, delayed labor associated with ongoing therapy
O42.9 Premature rupture of membranes, unspecified
Abbreviations used in the protocol:
DRPO - prenatal rupture of membranes
DIV - prenatal outpouring of water
PRPO - premature rupture of membranes
PDRPO - premature prenatal rupture of membranes
Ultrasound - ultrasonography
CTG - cardiotocography
HR - heart rate
IUGR - intrauterine growth retardation
EPA - epidural anesthesia
LE - level of evidence
Protocol development date: year 2014.
Protocol Users: obstetricians - gynecologists, resident doctors, midwives.
Class (level) I (A) - designed large, randomized, controlled trials, data from meta-analysis or systemic reviews, characterized by the highest level of reliability.
Class (level) II (B) - cohort studies and case-control studies in which statistics are based on a small number of patients.
Class (level) III (C) - non-randomized clinical trials in a limited number of patients.
Class (level) IV (D) - development of a consensus by a group of experts on a specific issue.
Classification
Clinical classification
Premature prenatal rupture of membranes
Occurs between 22 and 37 weeks of gestation.
Prenatal rupture of membranes
Occurs at 37 weeks or more weeks of pregnancy.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
The main diagnostic measures:
Blood type and Rh factor
General urine analysis
Complete blood count (hemoglobin, hematocrit, platelets)
Biochemical blood test (total protein, albumin, creatinine, ALaT, ASAT, urea, bilirubin (total, direct)
Coagulogram
Blood for HIV, hepatitis, RW
Chest fluorography
Smear for purity
smear for oncocytology
Therapist's consultation
Ultrasound of the pelvis and abdomen
Additional diagnostic measures:
Complete blood count with leukoformula count
fetal ultrasound
Temperature measurement
Measurement of blood pressure, pulse
Monitoring of fetal heart rate, CTG according to indications (meconium amniotic fluid, prematurity, IUGR, vaginal delivery with a uterine scar, preeclampsia, oligohydramnios, diabetes, multiple pregnancy, breech presentation, abnormal Doppler results of blood flow velocity in the artery, induction of labor, EPA)
Diagnostic criteria
Complaints and anamnesis:
In many cases, the diagnosis is obvious in connection with a clear liquid with a characteristic odor that suddenly gushed out of the vagina, subsequently - its continued small secretions.
Physical examination
If PRPO is suspected, speculum examination [EL B] . In some cases, additional confirmation of the diagnosis is achieved with ultrasound [LEC]. If the rupture of the membranes occurred long ago, the diagnosis of PROM can be difficult.
Laboratory research
The following diagnostic tests may be performed after a thorough history taking:
Offer the patient a clean pad and assess the nature and amount of
Discharge after 1 hour.
Perform an examination on a gynecological chair with sterile mirrors
Fluid leaking from the cervical canal or in the posterior vaginal fornix confirms the diagnosis.
Fetal fibronectin test (94% sensitivity) may be offered
Instrumental research:
Ultrasound - oligohydramnios in combination with an indication of the outflow of fluid from the vagina confirms the diagnosis of PROM.
Indications for expert advice- a therapist in case of an increase in body temperature, indications for a consultation with a geneticist - in case of detection of fetal malformations.
Differential Diagnosis
|
Diagnosis |
Symptoms | Individual symptoms |
|
Premature fetal rupture bubble |
Watery vaginal discharge |
1. Sudden violent outpouring or intermittent outflow of fluid 2. Fluid is visible at the entrance to the vagina 3. No contractions for 1 hour from the beginning of the discharge of water |
| Amnionitis |
1. Foul smelling watery discharge from the vagina after 22 weeks of pregnancy 2. High fever/chills 3. Abdominal pain |
1. In history - discharge of water 2. Painful uterus 3. Fetal palpitations 4. Blood secretions |
| Vaginitis/cervicitis |
1. Foul smelling vaginal discharge 2. There is no indication of water discharge in the anamnesis |
1. Itching 2. Foamy/curd secretions 3. Abdominal pain 4. Dysuria |
|
Prenatal bleeding |
Bloody issues |
1. Abdominal pain 2. Decreased fetal movement 3. Heavy, prolonged vaginal bleeding |
| Term delivery |
Blood-stained, mucus or watery discharge from the vagina |
1. Opening and smoothing the cervix 2. Contractions |
Medical tourism
Get treatment in Korea, Israel, Germany, USA
Medical tourism
Get advice on medical tourism
Treatment
Treatment Goals- the birth of a viable newborn
Treatment tactics
Non-drug treatment: not carried out.
Medical treatment
Management tactics for PROM up to 34 weeks of pregnancy is determined after providing maximum information about the condition of the mother and fetus, the advantages and disadvantages of expectant and active tactics, and the obligatory receipt of informed written consent from the patient for the chosen management tactics.
List of essential drugs:
Betamethasone
Dexamethasone
Erythromycin
Benzylpenicillin
Gentamicin
Cefazolin
Clindamycin
Metronidazole
Nifedipine
Sodium chloride
Misoprostol
Oxytocin
Magnesium sulfate
Procaine
Indomethacin
List of additional medications:
Atosiban
Mifepristone
Management of PDRPO in gestational age from 22 to 24 weeks of pregnancy:
When choosing expectant tactics, the pregnant woman is informed about the high risk of purulent-septic complications, hypoplasia of the lung tissues in the fetus and questionable outcomes in the newborn.
If the pregnant woman refuses active management, amnioinfusion may be offered as an alternative method [LEO A]
Amnioinfusion- an operation to introduce a solution similar in composition to the composition of the amniotic fluid into the amniotic cavity. Theoretically, the fetus may benefit from amnioinfusion, as it may prevent the development of pulmonary hypoplasia and joint contracture. However, the benefit of repetitive transabdominal amnionfusion for the treatment of PROM appears to be modest.
The main problems arising from this manipulation were:
Failure to retain fluid within the uterine cavity after an amniotransfusion procedure, and therefore minimal effectiveness of the procedure,
The need for multiple punctures of the membranes, which increase the risk of preterm birth and intrauterine infection.
In this regard, the researchers proposed the installation of a port system, when the catheter is installed in the amniotic cavity. The special shape of this catheter prevents it from being expelled from the uterus. Using this system, fluid can be continuously injected into the uterus. The port system has been successfully implanted in people with PPROM. The main results of previous studies have shown that the use of a subcutaneously implanted AFR port system for long-term amnioinfusion in the treatment of PPROM is effective in prolonging pregnancy and in preventing pulmonary hypoplasia. Percutaneous port implantation provides the clinician with the opportunity to administer frequent and long-term infusions, thereby allowing the physician to replace fluid loss due to PROM and, as a result, prolong gestational age. The flushing effect of continuous intra-amniotic infusion of hypotonic saline may also protect the patient from developing amniotic infection syndrome.
Conditions for the operation of amnioinfusion:
From the mother's side
Written informed consent
Singleton pregnancy
Gestational period from 22 weeks + 0 days to 25 weeks + 6 days
Severe oligohydramnios (amniotic fluid index< 5th centile или минимальный амниотический пакет < 2cm) .
From the side of the fetus
The presence of PPROM, confirmed by clinical and laboratory studies
Contraindications
Fetal malformations incompatible with life, intrauterine fetal death, chorioamnionitis, childbirth.
This operation can only be performed by specially trained medical personnel.
Operation technique Implantation of a port system
Port implantation must be performed according to a specific protocol.
Step 1: Premedication. Intravenous administration of magnesium sulfate at a rate of 2 g / h and indomethacin in the form of rectal suppositories at a dose of 100 mg twice a day, before the procedure, to avoid uterine contractions.
Step 2: Amnioinfusion. After ultrasound diagnosis of the localization of the placenta and local anesthesia with 20 ml of 0.25% solution of novocaine, amnioinfusion of 300 ml of saline is carried out with a 22G needle under ultrasound guidance.
Step 3: Preparing the bed for the port. A small skin incision is made with a scalpel under local anesthesia with 20 ml of 0.25% novocaine solution, after preparing the subcutaneous receptacle for the port capsule with scissors.
Step 4: Insertion of the catheter into the amniotic cavity. After puncturing the amniotic cavity with an ultrasound-guided 19G retrieval needle, through the prepared receptacle and a radiopaque (1.5 French) rubber infusion catheter with a removable (1.0 French) stylet, is inserted through the needle into the amniotic cavity. The thin stylet is removed and the catheter is reduced. Correct positioning of the catheter is checked by aspirating a small amount of amniotic fluid.
Step 5: Implantation of the port capsule. The port capsule is first flushed with saline using a 25G atraumatic needle (9 mm long) to fill the port system. The port capsule associated with the catheter is flushed again with saline. Subsequently, the port is inserted into the prepared pocket, where it is attached to the subcutaneous fat and closed by the skin.
Saline is injected into the port of the system under color Doppler ultrasound guidance through a 25G atraumatic needle to check for correct catheter placement. After implantation of the port system, a hypotonic solution is infused intermittently at an infusion rate of 50 ml/h to 100 ml/h with periodic ultrasound monitoring in order to ensure a constant amount of fluid in the amniotic cavity.
Active tactics:
Assessment of the state of the cervix
With an immature cervix (Bishop score< 6 баллов) - показано использование простагландинов Е1 (мизопростол трансбукально, перорально, интравагинально) . Начальная доза 50 мкг, при отсутствии эффекта через 6 часов 50 мкг, при отсутствии эффекта последующая доза 100мкг. Не превышать общую дозу 200 мкг.
Oxytocin infusion not earlier than 6-8 hours after the last dose of misopristol.
With a mature cervix - infusion of oxytocin(See protocol "Induction of labor").
Management of DIV at 25-34 weeks gestation
Expectant tactics carried out in the absence of contraindications to the prolongation of pregnancy. Observation of the patient can be carried out in the ward of the obstetric department (control of body temperature, pulse, heart rate of the fetus, secretions from the genital tract, every 4-8 hours in the first 48 hours; the level of blood leukocytes every 12 hours. In the future, control of body temperature, pulse, heart rate fetus, discharge from the genital tract at least every 12 hours, a detailed analysis of the mother's blood at least once a week and according to indications, with a list of observations in the history of childbirth.
With the onset of regular labor activity - transfer to the maternity ward.
In individual cases, monitoring can be carried out outside the hospital only after a thorough examination by an obstetrician-gynecologist and 48-72 hours of observation in a hospital. In this case, the woman should be informed about the symptoms of chorionamnionitis, if identified, it is necessary to seek medical help. Patients should take their temperature at home 2 times a day and visit the doctor according to the exact schedule.
Tocolytics in case of premature birth, they are indicated for a period of not more than 48 hours for a course of corticosteroids - prevention of distress - syndrome. Prophylactic tocolysis in women with PIOV without active uterine activity is not recommended [LE-A].
The drug of choice for tocolytic therapy is calcium channel blockers (nifedipine), since its advantages over other drugs have been proven.
Scheme of using nifedipine: 10 mg orally if uterine contractions persist, 10 mg every 15 minutes for the first hour. Then 10 mg every 3-8 hours for 48 hours until the contractions disappear.
The maximum dose is 160 mg.
Side effects:
Hypotension, however, is extremely rare in patients with normal blood pressure levels;
The likelihood of hypotension increases with the combined use of nifedipine and magnesium sulfate;
Other side effects: tachycardia, flushing, headaches, dizziness, nausea.
After stopping labor, further tocolysis is not recommended due to unproven efficacy and safety.
Atosiban is the drug of choice.
Antibiotic prophylaxis begins immediately after diagnosis of PROM with oral erythromycin 250 mg every 6 hours for 10 days [LEA].
With the onset of labor, the starting dose of benzylpenicillin is 2.4 g, then every 4 hours, 1.2 g until birth; if you are allergic to penicillin, cefazolin is prescribed, the initial dose is 2 g intravenously, then 1 g every 8 hours until birth or clindamycin 600 mg IV every 8 hours until birth.
Used to prevent fetal RDS corticosteroids(dexamethasone 6 mg every 12 hours IM for 2 days, course dose 24 mg or betamethasone 12 mg every 24 hours IM, course dose 24 mg) [LEA - A]. Corticosteroids are contraindicated in the presence of chorioamnionitis (link).
The duration of the waiting policy depends on:
gestational age;
Fetal condition;
The presence of an infection.
Signs of chorioamnionitis:
Maternal fever (>37.8° C)
Deterioration of the fetus according to CTG or auscultatory tachycardia in the fetus
Maternal tachycardia (>100 bpm)
sore uterus
Vaginal discharge with a putrid odor
Leukocytosis
The appearance of signs of infection or the addition of severe complications on the part of the mother is an indication for the termination of expectant management and early delivery (induction of labor, caesarean section).
Management of DIV at gestational age from 34 to 37 weeks of gestation
Active or expectant tactics are possible.
Tactics is determined after providing the maximum information about the condition of the mother and fetus, the advantages and disadvantages of expectant and active tactics, the obligatory receipt of informed written consent from the patient for the chosen management tactics.
Expectant tactics after 34 weeks is not advisable, since the prolongation of pregnancy is associated with an increased risk of developing chorioamnionitis. There is little evidence that active management after 34 weeks adversely affects neonatal outcomes.
Active tactics:
Observation for 24 hours without vaginal examination, control of fetal heart rate, body temperature, mother's pulse, discharge from the genital tract, uterine contractions every 4 hours with the maintenance of a special observation sheet in the history of childbirth) followed by induction of labor (see Protocol "Induction childbirth").
Antibiotic prophylaxis should be started with the onset of labor - the starting dose of benzylpenicillin is 2.4 g, then every 4 hours, 1.2 g until birth, if you are allergic to penicillin, cefazolin is prescribed, the initial dose is 2 g intravenously, then 1 g every 8 hours before birth or clindamycin 600 mg IV every 8 hours until birth.
Management of DIV at gestational age 37 weeks or more
Tactics in the absence of indications for immediate induction:
Observation for 24 hours without vaginal examination, (control of fetal heart rate, body temperature, maternal pulse, discharge from the genital tract, uterine contractions every 4 hours with the maintenance of a special list of observations in the history of childbirth), followed by induction of labor (see Protocol "induction of childbirth")
Antibiotic prophylaxis should be started with PROM with an anhydrous period of more than 18 hours, with the onset of labor, the starting dose of benzylpenicillin is 2.4 g, then every 4 hours, 1.2 g before birth, if there is an allergy to penicillin, cefazolin is prescribed, the initial dose is 2 g per day c, then 1 g every 8 hours until birth or clindamycin 600 mg IV every 8 hours until birth.
Antibiotic therapy indicated only in the presence of clinical signs of chorioamnionitis.
Chorioamnionitis- an absolute indication for rapid delivery and is not a contraindication to operative delivery by the usual method.
Hospitalization
Indications for hospitalization indicating the type of hospitalization***
Indications for planned hospitalization: not carried out.
Indications for emergency hospitalization: the pregnant woman should be hospitalized when the fact of DIV is established.
Risk factors: There is evidence indicating an association of ascending infection from the lower genital tract and the development of PROM.
Primary prevention: Sanitation of foci of infection of the lower genital tract outside of pregnancy.
Information
Sources and literature
- Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
- 1) Preterm prelabour rupture of membranes – Green-Top Guideline, RCOG, 2010 2) Ramsey PS, Lieman JM, Brumfield CG, Carlo W. Chorioamnionitis increases neonatal morbidity in pregnancies complicated by preterm premature rupture of membranes. Am J Obstet Gynecol. 2005 Apr;192(4):1162-6. 3) Carroll SG, Sebire NJ, Nicolaides KH. Preterm prelabour amniorrhexis. NewYork/London: Parthenon; 1996. 4) Gyr TN, Malek A, MathezLoic, Altermatt HJ, Bodmer R, Nicolaides, et al. Permeation of human chorioamniotic membranes by Escherichia coli in vitro. Am J Obset Gynecol 1994;170:2237. 5) Ramsey PS, Andrews WW Biochemical predictors of preterm labor: fetal fibronectin and salivary estriol. Clinics in Perinatology - December 2003 Vol. 30, Issue 4 6) Cox S, Leveno KJ. Intentional delivery versus expectant management with preterm ruptured membranes at 30–34 weeks’ gestation. Obstet Gynecol 1995;86:875–9. 7) Michael Tchirikov. Gauri Bapayeva, Zhaxybay. Sh. Zhumadilov, Yasmina Dridi, Ralf Harnisch and Angelika Herrmann. Treatment of PPROM with anhydramnion in humans: first experience with different amniotic fluid substitutes for continuous amnioinfusion through a subcutaneously implanted port system // J. Perinat. Med. - 2013. - P. 657-622. 8) De Santis M, Scavo M, Noia G, et al. Transabdominal amnioinfusion treatment of severe oligohydramnios in preterm premature rupture of membranes at less than 26 gestational weeks. Fetal Diagn Ther 2003;18:412–417 9) Tchirikov M, Steetskamp J, Hohmann M, Koelbl H. Long-term amnioinfusion through a subcutaneously implanted amniotic fluid replacement port system for treatment of PPROM in humans. Eur J Obstet Gynecol Reprod Biol. 2010 Sep;152:30-3 10) Tchirikov M, Strohner M, Gatopoulos G, Dalton M, Koelbl H. Long-term amnioinfusion through a subcutaneously implanted amniotic fluid replacement port system for treatment of PPROM in humans. J Perinat Med 2009. 37s1:272. 11) Dare MR, Middleton P, Crowther CA, Flenady VJ, Varatharaju B. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005302. 12) Tan BP, Hannah ME. Prostaglandins versus oxytocin for prelabour rupture of membranes at term. Cochrane Database Syst Rev. 2007 Jul 18;(2):CD000159. Mobile application "Doctor.kz" | AppStore
Attached files
Attention!
- By self-medicating, you can cause irreparable harm to your health.
- The information posted on the MedElement website cannot and should not replace an in-person medical consultation. Be sure to contact medical facilities if you have any diseases or symptoms that bother you.
- The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
- The MedElement website is an information and reference resource only. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
- The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.
Premature rupture of the membranes is a complication during pregnancy, during which the rupture of the fetal bladder occurs, from which amniotic fluid flows (in everyday life this is called discharge of water). This situation can occur at any month of pregnancy. Previously, when the membrane was ruptured, doctors tried as much as possible to induce premature birth. But now it is not necessary to do this, because if there is no infection, then the woman in labor is prescribed bed rest and is treated with magnesium sulfate, which reduces uterine contractions.
Premature rupture of the membranes can cause a number of complications, such as: infection, lung hypoplasia,. The infection can be caused by microorganisms in the vagina and group B streptococci.
According to statistics, about 10-12% of all pregnancies are accompanied by a rupture of the membranes. Premature birth in 40% of cases begins with premature rupture of amniotic fluid. The death of newborns is observed in 40% of cases, the main causes are infections, underdevelopment of the lungs of the child and prematurity of the fetus.
Causes
Causes of shell rupture:
- If a woman in labor has already had pregnancies in the past that ended in premature birth, then the probability that these births will end is also 23%.
- If the genital tract is inflamed in the mother's body, then a weak spot appears on the membrane of the bladder, which can subsequently cause a rupture.
- medical intervention.
- Great risk of rupture with oligohydramnios or polyhydramnios of amniotic fluid.
- Injuries or falls.
- The presence of bad habits in the mother.
- Multiple pregnancy.
Symptoms
- Strong discharge of fluid.
- Leaks - in this case, it is very difficult to understand that a premature rupture of the membranes has occurred. Since the amount of fluid flowing out is not so large and does not cause anxiety. In this case, you should pay attention to the color of the liquid, it may contain blood clots. You should also be wary if the size of the abdomen has changed, it becomes smaller. Allocations may increase with a change in body position.
- The appearance of cramping pains in the lower abdomen.
- An increase in temperature and fever indicates that there is an infection in the body.
Diagnostics
There are a number of procedures that should be performed to detect a ruptured membrane.
- First of all, cervical dilatation is assessed using medical mirrors. The procedure must be completely sterile. Next, samples of the amniotic fluid are taken, which allows you to find out about the maturity of the lungs of the fetus.
- In another way to detect a tear, vaginal fluid is taken and applied to a glass slide to detect fern syndrome. But this method is less accurate.
- Oligohydramnios can be detected using ultrasonography.
- A few years ago, proteins were found that are present only in the amniotic fluid. So if such proteins are found, then this indicates that a 100% gap has occurred. Such a test is called Amnishur. Its advantage is that it can be issued at any clinic, it looks like a pregnancy test. Any girl can easily make it at home. Diagnostics with its help last no more than 5 minutes, and gives a result with 99% accuracy. This is the most efficient method at the moment.
Treatment
Basically, if the situation allows, namely if the baby's lungs are well developed, doctors try to induce premature birth. To prevent infection and prevent possible death of the fetus. Often this procedure is performed at a gestational age of no more than 34 weeks.
But it is completely contraindicated if the child's lungs did not have time to develop enough for independent life. In this case, a woman is prescribed bed rest with the use of a large number of medications. To reduce the risk of developing sepsis, erythromycin and ampicillin are prescribed. It is used for 7 days. Glucocorticoids are also prescribed. During the entire bed rest, the patient's temperature is measured at least 3 times a day.
Premature rupture of membranes
Premature rupture of the membranes is a formidable complication of pregnancy, accompanied by a violation of the integrity of the fetal bladder and characterized by a massive outpouring or leakage of amniotic fluid at any stage of pregnancy.
Some statistics
Premature rupture of membranes accompanies 10-12% of all pregnancies, and 40% of all preterm births begin with premature rupture of amniotic fluid. Up to 20% of newborns die due to complications associated with premature rupture of the membranes. These are sepsis (infectious complications), immaturity of the lungs (impossibility of independent breathing) and prematurity of the fetus.
Causes of premature rupture of the membranes
There are many causes and risk factors they have not been fully studied and it is impossible to answer with accuracy which of them is the provoking. The most common and confirmed risk factors are listed below.
The presence in the past of pregnancy (s) ended prematurely with the outflow of amniotic fluid. The most significant factor. The chance that the current pregnancy will end the same way is about 23%.
Infectious and inflammatory processes of the genital tract. The focus of inflammation forms a “weak spot” on the wall of the fetal bladder, in place of which a crack or rupture may form over time..
Isthmic-cervical insufficiency. Protrusion of the fetal bladder into the lumen of the dilated cervix leads to easy infection of its wall and rupture.
Medical instrumental interventions. Amniocentesis and chorionic biopsy. Contrary to legend, sexual intercourse, examination in mirrors or vaginal examination cannot provoke premature rupture of the membranes..
Quantitative changes in amniotic fluid. Polyhydramnios, oligohydramnios.
Injuries. This includes both direct abdominal injuries and falls.
Multiple pregnancy.
Bad habits of the mother.
What should alert
The rupture of the membranes, depending on their size, can be accompanied by both the outpouring of a large amount of fluid and imperceptible leakage, when the amniotic fluid, mixing with normal secretions, may go unnoticed. With a massive effusion, it is easy to understand what is happening, and in the second case, you need to pay attention to the following manifestations, especially if you have a multiple pregnancy or they appeared after an injury.
Changed the number and nature of the discharge. They became more plentiful and watery. Discharge is colorless and odorless.
Perhaps the discharge becomes larger when the position of the body changes.
If the discharge is more or less intense, a decrease in the size of the abdomen is possible due to the loss of amniotic fluid.
Cramping pain and/or spotting may also occur.
But all these manifestations are subjective, and even 47% of doctors doubt the correct diagnosis, even after a gynecological examination and a number of diagnostic tests, so premature rupture of the membranes requires a specific diagnosis with a high percentage of sensitivity.
Diagnosis of premature rupture of membranes
There are a number of diagnostic measures aimed at detecting a rupture of the shells. Among them are a gynecological examination, and a smear for amniotic fluid, and various tests to determine the acidity of the vagina, but all of them are uninformative an hour after the rupture. Impurities of sperm, urine, blood affect their result, and they give a high percentage of errors - from 20 to 40, both false positive and false negative, which is very high and fraught. In the first case, unjustified hospitalization, drug therapy and labor stimulation, and in the second case, the entire list of complications characteristic of premature rupture of amniotic fluid.
Until a certain time, amniocentesis with indigo carin dye remained the only reliable diagnostic method, but given its high invasiveness, it cannot be used as a method of choice.
Just a few years ago, biological markers were found - proteins that are present only in the amniotic fluid, thanks to which an accurate diagnosis of premature rupture of the membranes became possible. Their detection in the vagina indicates a 100% rupture. The protein is called a-microglobulin-1, and the sensitive test designed to detect it is called PAMG-1. Commercial name for the Amnishur test.
Diagnosis of premature rupture of the fetal bladder using the Amnishur test
The Anishur test strip looks like a pregnancy test and is used in almost the same way, that is, it is available for any woman at home. Diagnosis takes 5-10 minutes and allows you to make a diagnosis, both in hospital and at home with an accuracy of 99%, even 12 hours after the rupture, even with lateral ruptures, when there are only a few drops of amniotic fluid in the vagina. The test has no analogues yet, it is successfully used in many clinics and thanks to it, more than one pregnancy has been saved.
PAMG-1 tests are produced only under the trademark Amnisure® ROM Test (Amnishur). All other brands are not related to this diagnostic method and cannot guarantee a reliable result.
To determine if you are at risk of preterm rupture of membranes and assess how high your risk of amniotic fluid leakage is, we suggest that you take our