Premature discharge of amniotic fluid. Premature rupture of the membranes of the amniotic sac
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 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 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 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 less intense, a decrease in the size of the abdomen is possible due to 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 gynecological examination and a number of diagnostic tests, so preterm 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 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 sensitive test developed 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 stationary 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 for premature rupture of membranes and assess how high your risk of amniotic fluid leakage is, we suggest that you take our
The fetal bladder limits the intrauterine space in which the child develops. A special environment is formed inside it, protecting the fetus from mechanical and physiological damage. Rupture of the fetal bladder signals the beginning labor activity and soon the baby will be born. Sometimes this process happens earlier than expected.
Causes of premature rupture of membranes
Premature rupture of the fetal bladder is provoked by a number of external factors and impacts.
Reasons for the opening of the bubble:
- Pathology of the structure of the tissues from which the bladder is formed. They are not flexible enough and durable. Consequently, with the growth of the fetus, the tissues of the bubble do not withstand the tensile force and burst.
- Inflammatory processes occurring in the vagina can cause thinning of the membranes of the bladder. This causes the bladder to begin to leak amniotic fluid.
- Mother's presence.
- Incorrect and pathological presentation of the fetus. In this case, there is an excessive stretching of any one area of the bubble, and it bursts.
- Insufficiency.
- Medical intrusion during the analysis or.
- Lack of minerals in the mother's body.
- Smoking of a pregnant woman.
- in the uterine cavity.
- Pathologies and anomalies of the structure and functioning of the uterus.
- Mechanical injuries and lifting heavy objects.
Sometimes the reverse situation happens and women do not understand why the amniotic sac does not burst.
This is not a pathology, and doctors artificially pierce it with a special thin needle. This procedure painless and safe for mom and her baby.
Symptoms and signs
When and how the amniotic sac bursts, a pregnant woman can determine on her own.
This condition is characterized by the following symptoms:
- the release of a large amount of fluid from their genital tract;
- fluid is poured out of their vagina, and not from the urethra;
- decrease in the height of the fundus of the uterus and lowering of the abdomen;
- start of labor activity.
If the rupture of the bubble occurred on the side, then clinical picture will be somewhat different. The symptoms in this case are not so pronounced and the woman does not immediately notice the problem.
High lateral rupture of the fetal bladder is characterized by the following features:
- vaginal discharge becomes more voluminous when lying down;
- vaginal discharge is watery;
- pain in the lower abdomen;
- bloody issues.
When diagnosing yourself similar symptoms it is necessary to get to the perinatal center as soon as possible under the round-the-clock supervision of doctors.
Risks of premature rupture
premature rupture amniotic sac provokes the development of pregnancy complications. They arise due to a shortage or total absence amniotic fluid.
The main complications as a result of this pathology are:
- respiratory distress syndrome against the background of underdevelopment of lung tissue in children;
- inflammatory processes in a child;
- inflammatory processes in the mother;
- hypoxia;
- fetal asphyxia;
- detachment of the fetal bladder and placenta;
- inflammation of the membranes;
- deformation of the skeletal bones in a child;
- self-amputation of limbs in a child;
- intraventricular hemorrhage in a child.
Diagnostics
Diagnose ruptured membranes characteristic symptoms in most cases, a woman can independently. If we are talking about cracks and partial leakage of water, the help of a specialist is required: 
- detection of amniotic fluid visually;
- detection of leaking amniotic fluid with the help of special ones;
- oligohydramnios.
After establishing the fact of rupture of the amniotic sac, a decision is made on the further management of the pregnancy.
If the child is viable, future mother hospitalized. In case of a negative outcome, the process of delivery is provoked.
Treatment
Treatment options for prenatal rupture of amniotic fluid depend on the gestational age at which this complication occurred.
If the gestational age is less than 32 weeks, special medications are prescribed that accelerate the process of maturation of the fetal lungs.
For a period of more than 34 weeks, there are 2 treatment options for this condition:
- if the child's condition is severe, delivery is possible with established lung maturity;
- if nothing threatens the life and health of the child, bed rest is also prescribed.
When there is no threat to the child, doctors choose expectant tactics.
The longer the baby stays in the womb, the better his organs will form, the risk of developing pathologies after his birth will be reduced.
If the gestational age is more than 38 weeks, the rupture of the bladder does not pose a danger to the mother and her baby. In this case, the natural process of the birth of a child begins.
Delivery by caesarean section
At perinatal terms of more than 34 weeks, as a rule, the birth of a child occurs naturally.
If there are no others medical indications To surgical intervention, the woman perfectly copes with this process even a little ahead of schedule.
If the outflow of water occurred at an earlier date, artificial labor may not work. This is due to the fact that the reproductive organs and the hormonal system of the mother are not yet ready.
In such a situation, a decision is made on the need for an operation.
This operation is prescribed in cases where it is necessary to remove the child from the uterine cavity as soon as possible in order to save his life.
Premature rupture of the membranes and the outflow of amniotic fluid is a serious complication during pregnancy. It may cause serious deviations in the state of health of the child and even him.
Timely therapy, as a rule, saves pregnancy.
During pregnancy, it is necessary to exclude all factors provoking this pathology.
If the discharge of amniotic fluid occurred too early, the likelihood of malformations in the child is very high.
Useful video: what is early rupture of membranes or premature birth
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
ZVUR - delay prenatal development fetus
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, with 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
Main diagnostic measures:
Blood type and Rh factor
General analysis urine
Complete blood count (hemoglobin, hematocrit, platelets)
Biochemical analysis blood ( 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
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, long vaginal bleeding |
| Term delivery |
Blood-stained, mucus or watery discharge from the vagina |
1. Opening and smoothing the cervix 2. Contractions |
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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 main medications:
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 following amniotransfusion, and therefore minimal the 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 option of administering frequent and long-term infusions, thereby allowing the physician to replace fluid loss due to PROM and, as a result, prolong gestational age. Effect of flushing by continuous intra-amniotic infusion of hypotonic saline solution also able to protect the patient from the development of 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 research
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 in the amount of 2 g / h and indomethacin in the form 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% novocaine solution, 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.
Physiological saline is injected into the system port under color control. doppler ultrasound 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
At immature cervix uterus (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, fetal heart rate, 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 level blood pressure;
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 CTG data or auscultatory fetal tachycardia
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 state 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 increased risk development of chorioamnionitis. There is little evidence that active management after 34 weeks adversely affects neonatal outcomes.
Active tactics:
Observation for 24 hours without vaginal examination, monitoring of fetal heart rate, body temperature, mother's pulse, discharge from the genital tract, uterine contractions every 4 hours with 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 before 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, (monitoring of fetal heart rate, body temperature, mother's pulse, secretions 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")
Start antibiotic prophylaxis for PPROM anhydrous period 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 until birth, if you are allergic to penicillin, cefazolin is prescribed, the initial dose is 2 g IV, then 1 g every 8 hours before birth or clindamycin 600 mg IV every 8 hours until birth.
Antibiotic therapy shown only if available clinical signs 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 app"Doctor.kz" | AppStore
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Premature rupture of membranes (PROM) and related to it is one of the main problems in modern obstetrics.
This is a complication that occurs in 10% of women with a normal pregnancy and ranks first among the causes leading to premature birth. About 38% of all preterm births are provoked by PROM, and 20% of all perinatal deaths occur as a result of complications associated with amniotic fluid leakage and preterm birth.
Why do so many complications arise, how to determine that you are at risk, and most importantly, what to do in this case? We will try to understand everything, starting with the most basic.
The role of amniotic fluid
Amniotic (amniotic) fluid is produced by the inner layer of the amniotic sac, the amnion, which forms a closed hermetic cavity. The outer shell - the chorion - is denser and protects the amnion from damage.
Amniotic fluid plays the role of a kind of shock absorber, protecting the child from shock when the mother turns or falls, and does not allow strong uterine muscles to squeeze the fetus and umbilical cord. Amniotic fluid is involved in the nutrition and development of the child. But most importantly, the amniotic fluid is sterile. The fetal bladder is an obstacle in the way of microorganisms that can harm the developing baby. That is why the violation of the integrity of the bubble is so dangerous.
Causes of premature rupture of membranes
- Infectious diseases of the genital organs and inflammatory diseases of other organs and systems in the mother.
This is one of the main reasons why PROM develops. Toxins released by bacteria during their life activity lead to thinning of the walls and, as a result, to microcracks or ruptures of the fetal membrane. Often women are not even aware that they have an infection, but even a common one can already cause PROM.
- Clinically narrow pelvis and wrong position child
The rupture of the bladder occurs already in the process of childbirth. In the normal position of the child, when the head is inserted, a contact zone is formed, and the waters are divided into anterior and posterior. With transverse or breech presentation child, the contact belt is not formed, and all the waters rush into lower part fetal bladder. This leads to the fact that the shells do not withstand pressure and burst.
- Cervical insufficiency
In this case, the cervix is not completely closed, which leads to the fact that the fetal bladder protrudes into the cervical canal, is easily infected and can rupture even with little physical exertion.
- Amniocentesis and chorionic biopsy
These diagnostic methods can sometimes lead to rupture of the membranes.
- mother's bad habits
Women who smoke and abuse alcohol are more at risk of PROM.
- Multiple pregnancy and malformations of the uterus
Any developmental anomaly or multiple pregnancy at times increases the likelihood of PROM.
How to recognize that PRPO has occurred and there is leakage of amniotic fluid?
If a massive outflow of amniotic fluid has occurred, it is difficult to confuse it with anything else. But the problem is that when examining a woman with suspected PPROM, 47% of doctors doubt the correct diagnosis. With microcracks or lateral ruptures, water can leak drop by drop almost imperceptibly, and it is quite difficult to determine that this is PRPO.
Signs to watch out for
- Normal discharge became more abundant and watery.
- The discharge increases with a change in the position of the body.
- The abdomen visually decreases in size or the height of the uterine fundus becomes lower.
In the event of the above symptoms, it is necessary to exclude the leakage of amniotic fluid as soon as possible.
Complications
Premature rupture of membranes increases infant mortality by 4 times. The most common complications of PROM are infection and respiratory distress syndrome.
- Respiratory distress syndrome. Most severe complication in premature babies. The lungs of a child have not yet developed and cannot independently participate in the act of breathing. They stick together from the inside, not allowing air to circulate. These children require expensive surfactant injections and artificial ventilation lungs.
- Infectious complications in mother and child. Most common complication. It develops regardless of the gestational age 6-32 hours after the rupture, causing severe consequences. Sometimes so serious that it is not possible to save the child.
In addition, children suffer from hypoxia, premature or abnormal labor activity may begin.
Standard diagnosis of amniotic fluid leakage
To date, there are several methods for determining leakage.
- The most common and known to many women is the nitrazine test, or litmus strip. This indirect diagnostic method determines the acidity of the vagina. A healthy vagina has an acidic environment, and when amniotic fluid enters, it shifts to the neutral side, as indicated by the test. But the acidity of the vagina also changes with infection, the presence or leakage of urine. Therefore, in 30-40% of cases, tests give false positive result, and the woman is subjected to unreasonable hospitalization.
- Arbreization symptom. The contents of the vagina are taken. In the presence of impurities of amniotic fluid, it crystallizes with the formation of a pattern similar to fern leaves. The result of the test can also be affected by infection, the presence of semen, or leakage of urine.
- Amniocentesis. If other diagnostic methods gave negative result, but the condition of the pregnant woman is of concern, an amniocentesis with a dye is performed. A harmless dye is injected into the cavity of the amniotic sac, and a clean swab is placed in the vagina. If the tampon is stained, it means 100% that there is leakage. This method is used very rarely and in extreme cases, since in itself it can provoke a rupture.
Modern immunological diagnostic method using the Amnishua test (AmniSure).
Unlike previous methods, the test does not require the assistance of medical personnel and can be carried out by the woman herself at home.
The principle of the test is based on the determination of placental alpha-1-microglobulin (PAGM-1), which is present in amniotic fluid in large quantities from early pregnancy and is not found in other body fluids. The Amnishua test even reacts to traces of PAMG-1 in the vagina. Its sensitivity is 98.9% and is comparable in accuracy to dye amniocentesis.
How to use the test?
Diagnosis takes about 5 minutes and does not require the use of mirrors. The Amnishua kit includes a test strip (outwardly similar to a pregnancy test), a reagent bottle and a sterile swab. With the help of a tampon, a small amount of vaginal discharge is taken, after which the tampon must be placed in a vial, shaken slightly, then the test strip is lowered into the vial, and you can read the results. Two red lines - there is a gap, one line - there is no gap. Even if one of the lines has a faint pink tint, this also indicates that there is leakage.
Is a test necessary if there is no suspicion of leakage?
It is desirable for every pregnant woman to have such a test in her purse, especially if she travels out of town or on vacation. The rupture may occur spontaneously, and the nearest medical center will be too far away. If the test gives a positive result, then there is a 100% gap, and you need to urgently go to the maternity hospital. And if the test is negative, then you can safely enjoy your vacation further. The fact is that during pregnancy, under the influence of progesterone, vaginal secretion increases, and sometimes it can be so abundant that some women confuse it with amniotic fluid. In this case, adequate diagnosis is also needed to avoid unnecessary hospitalization and preventive measures aimed at eliminating leakage.
It is worth noting that the test determines only the fact of the gap, and does not indicate the degree and presence of complications. The Amnishua test is not curative or preventive - it is only a diagnosis, and if the result is positive, you should immediately seek medical help.
Management of pregnant women in PROM
There are two management strategies for pregnant women with PROM.
- Preterm pregnancy before
Pregnancy is kept for as long as possible. In some cases, up to two months or more. But only in a hospital! The woman is in a sterile maternity unit, where the condition of the fetus is constantly monitored. Antibiotics, drugs that accelerate the maturation of the lungs and tocolytic drugs that prevent uterine contractions are introduced. If the condition of the fetus worsens, infection occurs or detachment begins, the woman is delivered on an emergency basis.
- Term pregnancy and more
In this case, the woman is also placed in a hospital and observed. Carry out a thorough sanitation of the vagina and monitor the condition of the child. Stimulation is carried out only if the child's condition worsens.
Remember that amniotic fluid leakage is not the norm! Water cannot seep or accumulate. If the test showed a positive result, be sure to seek help from doctors - they will help maintain the pregnancy and give birth to a healthy baby.
Irina Topal doctor of the highest category, medical
AmniSure International Consultant
Discussion
Yeah, very good test. I was tormented so much. Either some papers were poked, then all sorts of smears. It is not clear what they did there. They advised Amnishur - they bought it. The result is positive. They immediately placed me in a sterile ward, where I stayed until the very birth, for which I bow to the doctors. My daughter was born healthy and without complications.
Very interesting, albeit a long article. My colleagues from the Center for Obstetrics and Gynecology are very satisfied with the use of the described test. It is better to stock up on them just in case, especially now, before the summer period.
05/31/2011 18:28:09, RamaComment on the article "What is amniotic fluid leakage and what does it threaten?"
A common practice is to give a pregnant woman a referral for hospitalization at 40 weeks. A woman often does not even know that she can refuse him. Obediently following the doctor's instructions, she goes to the maternity hospital and, even without labor activity, ends up in the prenatal ward (because the term is the same!), where they try to stimulate labor activity with the help of instruments and medicines. What is happening? The baby did not give a signal to the mother's body about being ready for childbirth, the cervix is also often ...
What is low water? This is a special condition during pregnancy of a woman, of a pathological nature, in which the amniotic fluid surrounding and protecting the child in the amniotic cavity is much less than its recommended values. As a rule, the diagnosis of oligohydramnios is made in pregnant patients much less often than polyhydramnios. The low content of amniotic fluid, in the vast majority of cases, indicates various abnormalities occurring in the development of the fetus, and can cause ...
Pregnancy at 37-40 weeks is full-term and labor can begin at any time. And there are three main signs that indicate their imminent approach. Removal of the mucous plug. It can occur 2 weeks before delivery, but most often a day. The cork looks like a small lump of pinkish, brown or yellowish color. Often the cork leaves not entirely, but in parts. During pregnancy, it closes the entrance to the cervical canal, protecting the fetal bladder from ...
Video [link-1] In the video, the professor describes in detail all the existing methods for diagnosing amniotic fluid leakage, dwelling on each in detail and considering the advantages and disadvantages. In short, the most accurate diagnostic method in world practice is the Amnishur test. Everything else is a waste of time and money. The professor is not ours, but the head of the European College of Obstetricians and Gynecologists. The video is small, I recommend watching it - very informative and removes many questions.
Amnishur [link-1] According to various authors, the frequency of preterm birth is from 5 to 12% per year and has been on the rise over the past 20 years, despite the rapid development of medicine. About 40% of all preterm births are the result of early rupture of amniotic fluid, which leads to functional underdevelopment of organs and systems, perinatal mortality, and in more than half of cases to intrauterine infection fetus. However, you can avoid all unwanted...
Source [link-1] Also on this site there are a large number of other useful articles and there are free consultation doctor in the chat or advisory section Pregnancy is not a disease, and if there are no contraindications in each individual case, a woman can lead a contented active lifestyle for up to a certain period. Go in for sports, take long walks and go to rest in the country or even abroad, and the optimal period for this is the period from 14 to 30 weeks ...
If the pregnancy is normal, it is possible for future parents to have sex, it will not harm the child, and with the approach of the due date, it is even advisable to do this. The ban on having sex during pregnancy, if imposed, is most often temporary, and it is better to check with your doctor how long you need to maintain abstinence. Doctors of antenatal clinics usually warn expectant mothers if sex is contraindicated for them, and when everything is going well, they do not always explain that intimate relationship not dangerous...
Source [link-1] Traditional Methods Inspection in the mirrors Technique: Visual determination of leakage of amniotic fluid in the posterior vaginal fornix. During the study, the woman is asked to cough. Accuracy: Subjective Disadvantages: Requires examination in mirrors for examination. Urine, semen, and other fluids can easily be confused with amniotic fluid. Nitrazine (pH) (all existing tests various manufacturers, gaskets and litmus papers that react to leakage ...
What is amniotic fluid leakage and what does it threaten? Amniotic fluid during pregnancy and childbirth: how much and why? This is called amniotic fluid leakage.
Discussion
Nothing good, if the waters are really sagging, there may be infection of the waters. Go to a paid diagnostic center and do a water test. But I personally had in the later stages heavy discharge, bought and did an amnio test.
By the way girls, infa for Muscovites. Yesterday I tried to get through to the gynecological ambulance ... So I continuously dialed for half an hour, it was busy !! In the end, I never got through ... So keep in mind ..
In addition to the joyful expectation of the birth of a baby, 9 months of pregnancy also bring a lot of worries and worries about his condition. But is he comfortable in his stomach, will he be born on time, and what do all the changes that occur throughout this time with a woman's body mean? Which of them can be attributed to normal, and which ones signal danger and require immediate medical intervention? All these and many other questions worry pregnant women, causing some ...
All 9 months, a baby is growing under your heart, which is surrounded not only by your love and affection, but also reliable protection from amniotic membranes and amniotic fluid. The fetal bladder forms a sealed reservoir with a sterile environment, thanks to which the child is protected from infection. Normally, the rupture of the membranes and the outflow of amniotic fluid occurs before childbirth (when the cervix is fully open) or directly during childbirth. If the integrity of the bladder has been compromised before, it's...
Discussion
11. When examining a doctor, can a doctor always make a diagnosis of premature rupture of water with certainty?
With a massive rupture, it is not difficult to make a diagnosis. But, unfortunately, in almost half of the cases, doctors even at leading clinics doubt the diagnosis if they rely only on examination data and old research methods.
12. Is it possible to make a diagnosis of premature rupture of water using ultrasound?
An ultrasound examination makes it possible to tell whether a woman has oligohydramnios or not. But the cause of oligohydramnios can be not only a rupture of the membranes, but also a violation of the function of the kidneys of the fetus and other conditions. On the other hand, there are cases when a small rupture of the membranes occurs against the background of polyhydramnios, for example, in the pathology of the kidneys of a pregnant woman. Ultrasound is an important method for monitoring the condition of a woman who has had a premature rupture of the membranes, but does not answer the question of whether the membranes are intact.
13. Is it possible to determine the leakage of water using litmus paper?
Indeed, there is such a method for determining amniotic fluid, based on determining the acidity of the vaginal environment. It is called the nitrazine test or amniotest. Normally, the vaginal environment is acidic, and the amniotic fluid is neutral. Therefore, the entry of amniotic fluid into the vagina leads to the fact that the acidity of the vaginal environment decreases. But, unfortunately, the acidity of the vaginal environment also decreases in other conditions, such as infection, urine, sperm. Therefore, unfortunately, a test based on determining the acidity of the vagina gives a lot of both false positive and false negative results.
14. In many women's consultations take a smear on the water, how accurate is this method of diagnosing premature outflow of water?
Vaginal discharge containing fetal water, when applied to a glass slide and dried, forms a pattern resembling fern leaves (fern phenomenon). Unfortunately, the test also gives a lot of inaccurate results. In addition, in many medical institutions, laboratories work only during the day and on weekdays.
15. What are the modern methods for diagnosing premature rupture of membranes?
Modern methods for diagnosing premature rupture of the membranes are based on the determination of specific proteins, which are abundant in the amniotic fluid and are not normally found in the vaginal discharge and other body fluids. To detect these substances, an antibody system is developed, which is applied to the test strip. The principle of operation of such tests is similar to a pregnancy test. The most accurate test is a test based on the detection of a protein called placental alpha microglobulin. The commercial name is Amnishur (AmniSure®).
16. How accurate is the Amnishur test?
The accuracy of the Amnishur test is 98.7%.
17. Can a woman perform the Amnishur test on her own?
Yes, unlike all other research methods, the Amnishur test does not require examination in the mirrors and a woman can put it at home. Everything you need to set up the test is included in the kit. This is a tampon that is inserted into the vagina to a depth of 5-7 cm and held there for 1 minute, a test tube with a solvent, in which the tampon is washed for 1 minute and then a test strip is thrown out, which is inserted into the test tube. The result is read after 10 minutes. In the case of a positive result, as with a pregnancy test, 2 strips appear. With a negative result - one strip.
18. What if the test result is positive?
If the test turned out to be positive, you need to call an ambulance or go to the maternity hospital if the pregnancy is more than 28 weeks and to the gynecological department of the hospital if the pregnancy is less than 28 weeks. The sooner treatment is started, the greater the chance of avoiding complications.
19. What if the test is negative?
If the test is negative, you can stay at home, but at the next visit to the doctor, you need to talk about the disturbing symptoms.
20. If more than 12 hours have passed since the alleged rupture of the membranes, is it possible to test?
No, if more than 12 hours have passed since the alleged rupture and the signs of outflow of water have stopped, then the test may show an incorrect result.
Questions and answers about premature amniotic fluid leakage
1. How common is premature rupture of membranes?
True premature rupture of membranes occurs in about one in ten pregnant women. However, almost every fourth woman experiences some kind of symptoms that can be confused with premature rupture of the membranes. This is a physiological increase in vaginal secretion, and slight urinary incontinence in later pregnancy and profuse discharge during genital tract infections.
2. How does premature rupture of membranes manifest itself?
If a massive rupture of the membranes has occurred, then it cannot be confused with anything: a large amount of a clear, odorless and colorless liquid is immediately released. However, if the gap is small, which doctors also call a subclinical or high lateral gap, then it can be very difficult to make a diagnosis.
3. What is the danger of premature rupture of membranes?
There are 3 types of complications that can lead to premature rupture of the membranes. The most frequent and severe complication is the development of an ascending infection, up to sepsis of the newborn. In preterm pregnancy, premature rupture of the membranes can lead to premature birth with all the consequences of birth premature baby. With a massive outflow of water, mechanical injury to the fetus, prolapse of the umbilical cord, placental abruption is possible.
4. Who is more likely to rupture the membranes?
Risk factors for premature rupture of the membranes are infection of the genital organs, overstretching of the membranes due to polyhydramnios or multiple pregnancies, abdominal trauma, incomplete closure of the uterine os. An important factor risk is premature rupture of membranes during a previous pregnancy. However, in almost every 3rd woman, rupture of the membranes occurs in the absence of any significant risk factors.
5. How quickly does labor occur in case of premature rupture of the membranes?
This is largely determined by the duration of pregnancy. At full-term pregnancy, half of the women spontaneous labor occurs within 12 hours and more than 90% within 48 hours. With a premature pregnancy, it is possible to keep the pregnancy for a week or longer if the infection does not join.
6. Can a small amount of amniotic fluid be released normally?
Normally, the fetal membranes are airtight and no, even the smallest penetration of amniotic fluid into the vagina occurs. Women often mistake increased vaginal secretion or slight urinary incontinence for leakage of amniotic fluid.
7. Is it true that in case of premature rupture of water, pregnancy is terminated regardless of the term?
Premature rupture of the membranes is indeed a very dangerous complication of pregnancy, but with timely diagnosis, hospitalization and timely treatment premature pregnancy it is often possible to prolong if there is no infection. With a full-term pregnancy and close to full-term, as a rule, they stimulate the onset of labor. Modern methods of diagnostics and treatment in this case allow you to smoothly prepare a woman for childbirth.
8. If there was a premature rupture of the membranes, but the mucous plug did not come off, does it protect against infection?
The mucous plug does protect against infection, but if the membranes rupture, the protection of the mucous plug alone is not enough. If treatment is not started within 24 hours of the rupture, serious infectious complications may occur.
9. Is it true that the waters are divided into anterior and posterior, and the outpouring of the anterior waters is not dangerous, is it often normal?
The fetal waters are indeed divided into anterior and posterior, but no matter where the rupture occurs, it is a gateway for infection.
10. What precedes a breakup?
By itself, the rupture of the membranes occurs painlessly and without any precursors.
I read on the Internet about the leakage of amniotic fluid and now I am horrified. Didn't find what you were looking for? See other discussions: What is amniotic fluid leakage and what are the risks?
Discussion
Pharmacies sell a test for the determination of amniotic fluid, called an amniotest. If you are very worried - it’s worth it IMHO to go to the RD, they will test you there (such a test is done in RD 17, in RD at 7 gkb - for sure). Leakage of water is not good - infection of the fetus is possible
I forgot to add that the watery discharge is about a little more than a teaspoon.
All the same, how can this be determined and what it threatens. Leakage of amniotic fluid during pregnancy. Print version. 4.2 5 (169 ratings) Rate the article.
Discussion
You can order an AmniSure test on the Internet, it is done at home, the issue price is 900-1000 rubles, I had a similar paranoia, starting from your period until 32-33 weeks. I did this test three times - the water is in order)))
a week ago I was discharged from the maternity hospital ... I got there on the same suspicion ..
it was like this: from 2 am to 12 noon four times after going to the toilet, I didn’t have time to get to bed, as something poured down my legs. called her doctor. She recommended not to sit at home, go to the hospital and do a water test. I arrived, the test showed a negative result, but they did not let me go, they hospitalized me. For 11 days, they observed me, did an ultrasound, everything was ok there too, the bubble was intact. TTT.
It seems to me that it is better not to take risks, but to see a doctor as soon as possible! because if it's really leaking water, then it's very bad. I was told that it might lead to premature birth! therefore, for your own peace of mind, it is better to lie in the taxiway.
Also, are your kidneys healthy? it may not be water, but the reaction of sick kidneys. My kidneys on the ultrasound were in order, that it was not clear! didn't happen again.
