Premature Rupture of Membranes

Obstetrics

Clinicals - History

Fact Explanation
History of sudden onset gush of fluid leaking from the vagina/ recurrent dampness/ constant leak This is the typical presentation of rupture of membranes. Here history should cover the amount of leak, duration of leak, any suspected incidence( eg: uterine blunt trauma) prior to leak and any bleeding per vaginally. History of sudden onset gush of fluid leaking from the vagina/ recurrent dampness/ constant leak
This is the typical presentation of rupture of membranes. Here history should cover the amount of leak, duration of leak, any suspected incidence( eg: uterine blunt trauma) prior to leak and any bleeding per vaginally.
Period of gestation This is useful in further management as, premature rupture of membranes refers to rupture of membranes beyond 37 weeks of gestation. Preterm premature rupture of membranes is rupture of membranes before 37 weeks gestation. Rupture of membranes after or with the onset of labor is termed as spontaneous premature rupture of the membranes is Period of gestation
This is useful in further management as, premature rupture of membranes refers to rupture of membranes beyond 37 weeks of gestation. Preterm premature rupture of membranes is rupture of membranes before 37 weeks gestation. Rupture of membranes after or with the onset of labor is termed as spontaneous premature rupture of the membranes is
Features of normal labour like increasing intensity and frequency of contractions, pain As majority of patient(60%) with premature rupture of membranes will spontaneously go into labor within 24 hrs. Prolonged rupture of the membranes is termed when the onset of labor doesn't occur within this period. Features of normal labour like increasing intensity and frequency of contractions, pain
As majority of patient(60%) with premature rupture of membranes will spontaneously go into labor within 24 hrs. Prolonged rupture of the membranes is termed when the onset of labor doesn't occur within this period.
Present obstetric history History of previously diagnosed( in this pregnancy) multiple pregnancy, polyhydramnios, malpresentation and any congenital abnormality of the foetus. Present obstetric history
History of previously diagnosed( in this pregnancy) multiple pregnancy, polyhydramnios, malpresentation and any congenital abnormality of the foetus.
Surgical history of cervical cerclage and invasive procedures like amniocentesis in this pregnancy. Cervical cerclage and amniocentesis can induce preterm rupture of membranes. Surgical history of cervical cerclage and invasive procedures like amniocentesis in this pregnancy.
Cervical cerclage and amniocentesis can induce preterm rupture of membranes.
Past obstetric history of premature rupture of membranes, pre term labours and vaginal bleeding These can be associated with recurrences. Past obstetric history of premature rupture of membranes, pre term labours and vaginal bleeding
These can be associated with recurrences.
Social history of socioeconomical status and tobacco/ drugs use Social factors associated with Premature Rupture of Membranes include low socioeconomic status and tobacco/ cocaine(increased
tone) use.
Social history of socioeconomical status and tobacco/ drugs use
Social factors associated with Premature Rupture of Membranes include low socioeconomic status and tobacco/ cocaine(increased
tone) use.
Past history of urinary tract infection or symptoms suggestive of UTI like- pain during passing urine(dysuria), lower abdominal pain, red colour urine( haematurea) Urinary tract infections are known to cause premature rupture of membranes. Past history of urinary tract infection or symptoms suggestive of UTI like- pain during passing urine(dysuria), lower abdominal pain, red colour urine( haematurea)
Urinary tract infections are known to cause premature rupture of membranes.
Past medical history of complicated pregnancy by pregnancy induced hypertension, gestational diabetes mellitus. Several complications of pregnancy like
pregnancy induced hypertension and gestational diabetes mellitus can associated with premature rupture of membranes.
Past medical history of complicated pregnancy by pregnancy induced hypertension, gestational diabetes mellitus.
Several complications of pregnancy like
pregnancy induced hypertension and gestational diabetes mellitus can associated with premature rupture of membranes.
Age More common in teenagers Age
More common in teenagers
History of fever, malaise, smelly discharge or bleeding from vagina following rupture of membranes. Following rupture of membranes infections can introduce causing systemic illness and sepsis if goes for long time.
if the patient is having polyhydramnios following rupture of membranes placental abruption can take place.
History of fever, malaise, smelly discharge or bleeding from vagina following rupture of membranes.
Following rupture of membranes infections can introduce causing systemic illness and sepsis if goes for long time.
if the patient is having polyhydramnios following rupture of membranes placental abruption can take place.

Clinicals - Examination

Fact Explanation
In speculum examination will show watery discharge from the cervical os and/or pooling in upper vagina. Coughing/ straining (valsalva manoeuvre) may help in demonstrating the fluid leak from the cervical os. Digital cervical examinations should be avoided as it can introduce infections (chorioamnionitis and neonatal infection) unless patient is in labour. No need to carry out a speculum examination if the patient is in labour. Speculum examination often confirms the leakage of amniotic fluid. During the examination colour, smell and volume of discharge should be observed. In speculum examination will show watery discharge from the cervical os and/or pooling in upper vagina. Coughing/ straining (valsalva manoeuvre) may help in demonstrating the fluid leak from the cervical os.
Digital cervical examinations should be avoided as it can introduce infections (chorioamnionitis and neonatal infection) unless patient is in labour. No need to carry out a speculum examination if the patient is in labour. Speculum examination often confirms the leakage of amniotic fluid. During the examination colour, smell and volume of discharge should be observed.
Check vital paremeters like temperature, blood pressure, respiratory rate and pulse As premature rupture of membranes can be a result of an infections(eg: UTI) as well as rupture of membranes can result in infections( chorioamnionitis causes maternal tachycardia, pyrexia) , measurement of vital parameters are essential. Check vital paremeters like temperature, blood pressure, respiratory rate and pulse
As premature rupture of membranes can be a result of an infections(eg: UTI) as well as rupture of membranes can result in infections( chorioamnionitis causes maternal tachycardia, pyrexia) , measurement of vital parameters are essential.
Examine for signs of labour like presence of contractions, frequency of contractions, progressive cervical dilatation. This is useful in further management of the patient. Examine for signs of labour like presence of contractions, frequency of contractions, progressive cervical dilatation.
This is useful in further management of the patient.
Obstetric examination should be done including lie, no of fetuses, presentation, amount of liquor and foetal heart sounds This is useful in assessing the condition of the baby and useful in identifying the cause for rupture of membranes. Polyhydramnios, malpresentation and multiple pregnancy can result in this. Obstetric examination should be done including lie, no of fetuses, presentation, amount of liquor and foetal heart sounds
This is useful in assessing the condition of the baby and useful in identifying the cause for rupture of membranes. Polyhydramnios, malpresentation and multiple pregnancy can result in this.
Lower abdominal tenderness Chorioamnionitis can increase uterine tenderness and urinary tract infections associated with cystitis also can present with lower abdominal tenderness. Lower abdominal tenderness
Chorioamnionitis can increase uterine tenderness and urinary tract infections associated with cystitis also can present with lower abdominal tenderness.
BMI and Nutritional state of the patient Low body mass index and poor nutritional status(vitamin C, Cu, Zn deficiency) can associated with premature rupture of membranes. BMI and Nutritional state of the patient
Low body mass index and poor nutritional status(vitamin C, Cu, Zn deficiency) can associated with premature rupture of membranes.

Investigations - Diagnosis

Fact Explanation
Assess the pH of the discharge with litmus/ nitrazine The diagnosis is mainly a retrospective clinical diagnosis. There for no investigations are needed for diagnosis unless in a case of doubt. Checking the pH of the discharge can be done either with litmus or nitrazine. Amniotic fluid is alkaline. Presence of blood, semen and trichomonas infection can interfere with the results. Assess the pH of the discharge with litmus/ nitrazine
The diagnosis is mainly a retrospective clinical diagnosis. There for no investigations are needed for diagnosis unless in a case of doubt. Checking the pH of the discharge can be done either with litmus or nitrazine. Amniotic fluid is alkaline. Presence of blood, semen and trichomonas infection can interfere with the results.
Assess the content of the discharge Amniotic fluid contains high concentration of proteins. Assess the content of the discharge
Amniotic fluid contains high concentration of proteins.
Barbarization test When a sample of fluid dry on a slide, amniotic fluid produces a characteristic fern( arborization) pattern. Barbarization test
When a sample of fluid dry on a slide, amniotic fluid produces a characteristic fern( arborization) pattern.
Microscopic examination of the fluid Amniotic fluid will contain lanugo hair and squamous cells. Microscopic examination of the fluid
Amniotic fluid will contain lanugo hair and squamous cells.
Cytology Nile blue staining of a sample of discharge will show desquamated fetal cells. Cytology
Nile blue staining of a sample of discharge will show desquamated fetal cells.

Investigations - Management

Fact Explanation
Ultra sound scan and Doppler scan This is useful in assessing the fetus's well being. Ultra sound scan and Doppler scan
This is useful in assessing the fetus's well being.
Cardiotocography (CTG) This is also useful in assessing the condition of the fetus. Foetal heart rate will be high in presence of chorioamnionitis. Cardiotocography (CTG)
This is also useful in assessing the condition of the fetus. Foetal heart rate will be high in presence of chorioamnionitis.
Ultrasonography Helpful in confirming the gestational age and the estimated fetal weight, presentation, fetal anatomy and amniotic fluid index. Ultrasonography
Helpful in confirming the gestational age and the estimated fetal weight, presentation, fetal anatomy and amniotic fluid index.
Urine Full Report and urine culture (if organisms are present) This is useful in assessing the presence of urinary tract infection. Urine Full Report and urine culture (if organisms are present)
This is useful in assessing the presence of urinary tract infection.
Full Blood Count White blood cell will be high in presence of chorioamnionitis. Full Blood Count
White blood cell will be high in presence of chorioamnionitis.
ESR, CRP These will rise in presence of any infection. ESR, CRP
These will rise in presence of any infection.
Full Blood Count This useful in screening for the presence of any ongoing infection. Full Blood Count
This useful in screening for the presence of any ongoing infection.
Amniotic fluid culture and ABST This is also helpful in assessing the presence of chorioamnionitis. Amniotic fluid culture and ABST
This is also helpful in assessing the presence of chorioamnionitis.

Management - Supportive

Fact Explanation
Monitor for maternal well being Monitor vital parameters of the mother. Record temperature, blood pressure, respiratory rate and pulse on admission and monitor temperature every 4 hourly during waking hours. Monitor for maternal well being
Monitor vital parameters of the mother. Record temperature, blood pressure, respiratory rate and pulse on admission and monitor temperature every 4 hourly during waking hours.
Monitor for foetal well being Ultrasonographic evaluation of Amniotic fluid index and growth and well being of the fetus. CTG is useful in assessing the foetal well being. Monitor for foetal well being
Ultrasonographic evaluation of Amniotic fluid index and growth and well being of the fetus. CTG is useful in assessing the foetal well being.
Look for evidence of labour Progressive uterine contractions, cervical dilatation, descend of the foetus will give evidence of going in to labour. Look for evidence of labour
Progressive uterine contractions, cervical dilatation, descend of the foetus will give evidence of going in to labour.

Management - Specific

Fact Explanation
Educate mother about the condition Mother should be offer the choice between immediate induction and expectant management. Advantages and disadvantages of both methods should be explained to the mother. Educate mother about the condition
Mother should be offer the choice between immediate induction and expectant management. Advantages and disadvantages of both methods should be explained to the mother.
Conservative management until going into labour Advice the patient to rest after assessing the signs and symptoms of labour and cord proplapse need to be excluded. Educate mother to report any change/ offensive smell of the discharge or reduction of foetal movements. Advice to avoid sexual intercourse as it can introduce infections but showering and bathing will be okay. Conservative management until going into labour
Advice the patient to rest after assessing the signs and symptoms of labour and cord proplapse need to be excluded. Educate mother to report any change/ offensive smell of the discharge or reduction of foetal movements. Advice to avoid sexual intercourse as it can introduce infections but showering and bathing will be okay.
Induction of labour This should be consider if no spontaneous labour for 24 hours. Induction of labour
This should be consider if no spontaneous labour for 24 hours.
Antibiotic therapy The use of antibiotics is controversial. Some guidelines are not recommend prophylactic antibiotics even the rupture of membrane is more than 24 hours. But regular maternal observations should be done to pick up signs of infections early and to go for early antibiotic treatments.
If clinically evident infection is present broad spectrum IV antibiotics should be given after sending blood and high vaginal swab for culture and immediate induction should be done.
Antibiotic therapy
The use of antibiotics is controversial. Some guidelines are not recommend prophylactic antibiotics even the rupture of membrane is more than 24 hours. But regular maternal observations should be done to pick up signs of infections early and to go for early antibiotic treatments.
If clinically evident infection is present broad spectrum IV antibiotics should be given after sending blood and high vaginal swab for culture and immediate induction should be done.

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