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Timely and untimely discharge of amniotic fluid. Causes of premature rupture of amniotic fluid during full-term pregnancy. Pregnant women with HIV infection

Normally, the fetal bladder should burst in the 1st phase of labor. At the same time, the fetal membranes soften, a large number of enzymes responsible for the timely detachment of the placenta. With various pathological conditions such a mechanism changes, and this causes premature effusion water. It can happen at any time.

TO premature rupture fetal membrane at premature pregnancy cause inflammatory diseases of the female genital organs, intra-amniotic infections. It has been proven that there is an association between ascending infection in a woman and premature rupture amniotic fluid. Every third patient with premature pregnancy has positive cultures from the genital organs for bacteriological cultures. In preterm pregnancy, premature rupture membranes is very dangerous, threatening the life of a woman and a fetus.

Causes of premature rupture of amniotic fluid during full-term pregnancy

The cause of premature rupture of the membranes during full-term pregnancy is a clinically narrow pelvis, pathology of the position of the fetus. In this case, labor has already begun, but the cervix has not dilated enough. Normally, the presenting part of the fetus should fit snugly against the bones of the woman's pelvis. In this case, it forms the so-called "contact belt", dividing conditionally amniotic fluid into anterior and posterior.

If a woman has a narrow pelvis or she develops presentation pathologies, such a belt does not form. As a result, most of the amniotic fluid accumulates in the lower part of the bladder, which leads to a rupture of its membranes. IN this case Negative influence premature rupture of amniotic fluid on the health of the woman and the fetus is minimal.

Other causes of premature rupture of amniotic fluid

Premature rupture of the membranes can also occur as a result of cervical insufficiency. This condition is characteristic of preterm pregnancy, but it can also occur in more later dates. It can be provoked by repeated bimanual studies, bad habits mothers, multiple pregnancy, abnormal development of the uterus, trauma.

Women with systemic connective tissue pathologies, underweight, beriberi, anemia, long-term hormonal agents are at risk of developing premature rupture of the membranes. This group also includes patients with low social status who abuse drugs, alcohol, nicotine.

Premature rupture of amniotic fluid is a common problem that can be dangerous for mother and baby. Why is it so important for a baby to be in a liquid environment and in a whole amniotic sac? Let's talk about this topic.

Throughout pregnancy, the fetus swims in amniotic fluid filling the fetal bladder. She performs big set functions. Amniotic fluid is involved in the metabolism of the baby, protects him from external influences(mechanical, sound, light) and various infectious diseases. In addition, with its help, the child’s digestive and respiratory systems are trained. Amniotic fluid is constantly updated. Its amount can also tell about the condition of the fetus inside the womb.

outpouring amniotic fluid normally occurs during birth process. When the cervix matures, the membranes soften and enzymes are released that help the placenta to separate. The fetal bladder loses elasticity and strength and bursts. Amniotic fluid leaks out. After the amniotic fluid breaks, contractions usually intensify.

If the fetal bladder loses its integrity until the fetus ripens and is ready for natural childbirth, then they speak of premature rupture of the fetal membrane. The degree of threat to the mother and child is assessed depending on the duration of pregnancy. The main risks are due to preterm birth and infection of both the fetus and the pregnant woman.

The causes of premature rupture of amniotic fluid are numerous. The most common is infection of the genital organs of a pregnant woman. This results in softening of the cervix due date, and the released enzymes thin the fetal bladder, lead to the separation of the placenta. In this case, the infection of the baby is most likely.

To PRPO (premature rupture of the membranes) can also lead to structural features of the pelvis, the condition of the cervix, and the position of the fetus. A weak neck creates conditions for protrusion of the bladder and violation of its integrity. narrow pelvis and the unusual position of the fetus creates a threatening condition, when most of the water accumulates at the bottom of the bladder and bursts it. Normally, the fetus is tightly adjacent to pelvic floor and creates a belt of contact that does not allow the bulk of the water to pass to the bottom of the bubble.

Medical intervention associated with a puncture of the bladder for fluid analysis can provoke further violation of the integrity. Uterine anomalies such as the presence of a septum, placental abruption, polyhydramnios, and multiple pregnancies are risk factors. Provoke premature rupture of amniotic fluid during full-term pregnancy can physical activity, with premature blunt abdominal trauma and bad habits of the mother associated with the use of alcohol and nicotine, drugs. Taking certain potent drugs can also have a negative effect.

Finding the symptoms of amniotic fluid rupture is quite easy. During this process, a fairly large amount of liquid is released so that it can be confused with something else. The waters are normally colorless and have a slightly sweet smell. It is more difficult to determine the presence of shell cracks. After all, then the amniotic fluid flows out drop by drop and is easily taken for vaginal discharge. Another premature rupture of amniotic fluid has signs in the form of an increase in the amount of discharge in the supine position.

If there is a suspicion of leakage of amniotic fluid, tests are prescribed - a smear for pH, ultrasound. They may suggest amniocentesis with staining or some other technique. The Amnishur test has proven itself well. After establishing the fact of violation of the integrity of the shell, a decision is made on next steps depending on the duration of pregnancy and the presence of complications.

Doctors, depending on the timing at which premature rupture of amniotic fluid occurred, suggest various ways reduce the risk of complications. If the pregnancy is full-term, then usually childbirth occurs on its own within the next two days. In this case, the woman is placed in a hospital and is under observation. Rehabilitation of the genital tract is carried out to avoid infection, the birth canal is prepared. The decision to wait natural childbirth helps reduce the risk birth trauma and other negative consequences.

For periods up to 22 weeks, PROM is usually an indication for termination of pregnancy due to too high risks of complications of infection of the fetus and mother. If the pregnancy has exceeded the specified period, then many factors are taken into account. The more the baby has developed, the better the prognosis. The main indicator of the possibility of having a viable child is the maturation of his lungs. For this, the woman is placed in almost sterile conditions. Provide bed rest and antibiotic prophylaxis. Everything is done to save the life and health of mother and baby.

The composition and volume of amniotic fluid is one of the main components of a normal pregnancy. Being in this liquid, the fetus is protected from the action of many negative factors: from noise, from infections, from mechanical influences. In addition to protection, amniotic fluid provides the unborn child nutrients And comfortable conditions. Therefore, throughout pregnancy, its constant balance is so important. If there are changes in the volume of fluid (oligohydramnios, polyhydramnios), then both the mother and the child suffer, various complications arise.

Normally, amniotic fluid should flow out only before the onset of labor after a rupture. amniotic sac. If a slow or copious outflow of fluid occurs during gestation and long before the onset of childbirth, then various complications for the health of the fetus and woman are possible. This is the situation in which nothing depends on the desires and actions of a woman. A survey is needed and further recommendations from the side of specialists, how the pregnancy will proceed in the future.

Signs of amniotic fluid leakage

If the fetal bladder has a small tear or crack in the fundus or side of the uterus, the fluid will leak slowly. This process can continue long time and will remain unobtrusive as the fluid is constantly renewed and regenerated. It is difficult for a woman to notice the onset of the problem and is easily confused with vaginal discharge or urinary incontinence. But over time, she can pay attention to such changes in her body:

    the discharge became liquid and constant;

    appeared aching pain lower abdomen;

    fetal movements have changed - they have become slow and irregular.

The amniotic fluid has no color, and its smell has nothing to do with the smell of urine. With incontinence, urine flows from small physical efforts: when coughing, laughing, straining. Amniotic fluid seeps spontaneously, without external influences.

With abundant water leakage, it is already difficult to confuse the problem with other ailments:

    secretions of a light liquid (may be a brownish, greenish tint) strongly wet the linen, can drain down the legs;

    the stomach decreased in size, became more dense;

    fetal movement almost stopped;

    contractions started.

In the first and second cases, the instruction is the same: immediately consult a doctor.

Amniotic fluid leak test

Most women prefer to make sure that there is a problem on their own and only then go to the doctor with a complaint. What can a woman do at home if she suspects water leakage? First, make sure that the fluid that comes out is not urine or vaginal discharge. If light-colored knitted underwear and pads are regularly used, then it will be easier to detect extraneous unusual discharge. Urine has specific smell, which is difficult to mistake for some other. Dark underwear will help establish vaginal discharge. It will leave a light residue of whiter. If the linen is damp, odorless and slimy whitish residue, most likely it is amniotic fluid.

Another recommendation to test leakage at home is to loosen as much as possible. bladder, wash the genitals and wipe dry. After that, use a light clean napkin as a pad. If after half an hour it remains wet spot, there is every reason to suspect leakage of amniotic fluid. Also, after a shower, you can lie down on a clean sheet, turn on your side. IN lying position amniotic fluid seeps out faster. If you find a wet spot, you need to contact the hospital for help.

More precise information can be given special tests which can be purchased at a pharmacy. Test pads impregnated special reagent showing a high levelpH. Normally, the discharge from the vagina in a pregnant woman should be sour. When water leaks, the levelpHwill be neutral or alkaline. The gasket indicator will turn blue-green if there is a problem.

The disadvantage of such tests is false positive results if a woman has vaginal dysbacteriosis, inflammation of the mucosa, or douching or sexual intercourse took place shortly before diagnosis. In all similar situations level changespH.

Tests for the detection of protein-1 and placental microglobulin will be more reliable, since they are based on the detection of components that are found only in the amniotic fluid.

Only a doctor can make a definitive diagnosis. He will also test, examine the woman using mirrors, and send her for an ultrasound scan. Based on all the data obtained, the tactics of further pregnancy management will be chosen.

Causes of amniotic fluid leakage

Loss of amniotic fluid occurs through cracks in the amniotic sac. Damage to its shells can occur for many reasons:

    inflammation of the vaginal mucosa, which is based on an infection. The most common pathogens are mycoplasmas, chlamydia, trichomonas, streptococci. Many women hope that the body will cope with the disease on its own, and do not seek treatment. Bacteria continue to develop, penetrate into the area of ​​the amniotic sac and dissolve its membrane. In 30% of cases of amniotic fluid leakage, infections are the culprit;

    infections that enter the fetal membrane through the blood or from the genital tract without damaging the bladder. Continuing to develop already inside, pathogens violate the integrity of the shell and provoke leakage;

    falls, injuries, blows to the abdomen. Any mechanical impact can provoke the appearance of a rupture of the shell;

    Normally, the baby's head is at the bottom, and the anterior waters (before exiting the uterus) do not accumulate very much. In other positions of the fetus, the volume of fluid in the lower region is increased and constantly presses on the shell, causing cracks. For the same reason, leakage is possible with multiple pregnancy And ;

    pathological structure of the uterus and cervix. These conditions cause wrong position fetus, and the short cervix allows the fetal bladder to protrude outward and be affected by infections. For this reason, leakage is observed mainly in the third trimester;

    the study of amniotic fluid, which consists in the puncture of the fetal bladder and the collection of amniotic fluid. For this reason, cracks occur very rarely.

Treatment for leakage of amniotic fluid

When choosing a method of treatment, the gestational age, the size or number of cracks, the volume of fluid flowing out, and the condition of the fetus are taken into account. If the problem arose in the first trimester, there is almost no chance of saving the pregnancy. The constant loss of amniotic fluid will prevent the fetus from developing normally. Therefore, pregnancy up to 22 weeks is interrupted in the hospital.

In the second trimester, when water leakage is detected, a woman is placed in a hospital under constant supervision. Prolongation of pregnancy is associated with a risk to the fetus. Babies born at 25 weeks are not yet fully formed. They have little chance of surviving. And the surviving children may remain disabled. In this situation, the decision to prolong such a pregnancy is made by the woman.

After 25 weeks, with a slight leakage of water, specialists in a hospital monitor the health of the woman and the condition of the fetus. According to the results of ultrasound, readiness is assessed internal organs child for life outside the mother's body. If necessary, the pregnancy is extended to the maximum possible term. A woman is prescribed antibiotic therapy aimed at protecting the fetus from infection through breaks, and bed rest. In this situation, you will have to eat, wash and defecate in bed, as there is a risk of an increase in the gap under the own weight of the amniotic fluid. If the situation does not change in the worst side, and the child continues to develop normally, obstetricians continue to wait and see.

If, despite all the measures taken, the outflow of fluid continues, a decision is made to induce labor. Childbirth can be independent if contractions begin after the puncture of the membranes, or by caesarean section if all stimulations labor activity do not lead to results.

If the outflow of water occurs 2 weeks before delivery, and a large amount of fluid flows out, the pregnancy does not persist. This is usually followed by contractions. Such a pregnancy is considered full-term, and should not cause panic in the expectant mother.

During pregnancy, the uterine cavity is filled with a special fluid - amniotic fluid. The name itself explains that this liquid surrounds the fetus. It is necessary to protect the growing baby from external influences - bruises, squeezing, hypothermia and overheating, protects him from the penetration of viruses and bacteria. In addition, the presence of water allows the child to move freely enough, which contributes to proper development.

Danger of prenatal rupture of amniotic fluid
Normally, the rupture of the membranes and the outflow of water occurs in the first stage of labor. However, in some cases, the fetal bladder ruptures long before the onset of labor. At more than 22 weeks, this is called prenatal rupture of amniotic fluid (PAI). It is divided into two types: DIV before the start premature birth- with rupture of the membranes before the full 37 weeks of pregnancy - and DIV before the onset of urgent labor, if this occurs later.
Actually, prenatal outflow of water complicates the course of preterm pregnancy only in 2% of cases, however, it is associated with 40% of preterm births and, as a result, is the cause of a significant part of neonatal morbidity and mortality. The risk for the mother is associated primarily with chorioamnionitis - inflammation of the fetal membranes (chorion and amnion), resulting from their infection.
The frequency of prenatal outflow of water during full-term pregnancy is about 10%. In most women after DIV, labor activity develops independently:
. almost 70% - within 24 hours;
. 90% - within 48 hours;
. in 2-5%, labor does not begin even within 72 hours;
. in almost the same proportion of pregnant women, childbirth does not occur even after 7 days.
In 1/3 of cases, the cause of DIV during full-term pregnancy is infection (subclinical forms).
There is a proven association between ascending infection from the lower genital tract and prenatal rupture of amniotic fluid. Every third patient with DIV during preterm pregnancy has positive tests for the presence of a urogenital infection, moreover, studies have shown the possibility of bacteria penetration even through intact membranes.

Further gestation or childbirth?
They say about a high rupture of the membranes when the fetal bladder does not break in the lower pole, but above. If there is any doubt whether it is water or just liquid leucorrhea from the vagina (a typical situation with a high lateral rupture of the membranes), it is necessary to urgently visit a gynecologist, after placing a “control” diaper, so that the doctor evaluates the nature of the discharge. In doubtful cases, a vaginal swab is taken for the presence of amniotic fluid or an amniotest is performed.
If the leakage of amniotic fluid is confirmed, but there are no contractions, the doctor decides on the further management of the pregnancy, depending on its duration. Until 34 weeks, obstetricians do everything possible to prolong it, since the lungs of the fetus are immature and after delivery, respiratory disorders may be detected in the newborn.
The woman is under constant supervision (body temperature is measured, a study of the content of leukocytes in the blood is carried out, clinical analysis blood, ultrasound, CTG - a study of the cardiac activity of the fetus, a study of secretions from the genital tract for infections). The expectant mother is prescribed strict bed rest in a hospital, if necessary, antibiotic therapy is carried out, drugs are introduced that accelerate the maturation of the fetal lungs (Dexamethasone, Betamethasone). If it is not possible to prolong the pregnancy and childbirth occurs before 35-36 weeks, then a surfactant is used to treat respiratory disorders in newborns.
In the absence of signs of infection and a sufficient amount of water in the fetal bladder by ultrasound, pregnancy can be extended up to 35 weeks. If, as a result of the study, it is found that the uterus tightly covers the fetus, and there are no waters, it is impossible to wait more than 2 weeks even if there are no signs of infection (however, this situation is extremely rare). With a period of 34 weeks or more, with leakage of water, a woman is prepared for the upcoming birth.

Two tactics for early discharge of water
When amniotic fluid breaks prematurely, doctors choose between expectant and active tactics, while the patient and her loved ones should receive full information about the benefits and risks of both approaches.
Yes, advantage expectant tactics consists in the development of spontaneous labor activity, a decrease in the proportion of births by caesarean section and the complications of anesthesia associated with it, the operation itself and postoperative period. However, this significantly increases the likelihood of infection.
The use of active tactics prevents infection. But then the risks that are inevitable during labor induction increase significantly: hyperstimulation, an increase in the frequency of caesarean sections, pain, discomfort and the development of septic complications in the mother. Planned C-section, compared with vaginal delivery, does not improve outcomes for premature baby and increases maternal morbidity. Therefore, the birth naturally for premature fetus in cephalic presentation is preferred, especially after 32 weeks prenatal development. The decision to choose a method of delivery is made strictly on an individual basis based on clinical data, and surgical intervention carried out according to the usual obstetric indications.

The importance of prolonging pregnancy
The problem of premature birth has an important social aspect. The birth of a prematurely sick child is a psychological trauma for the family. About 5% of premature babies are born before 28 weeks of pregnancy (deep prematurity), with extremely low body weight up to 1000 g; 15% appear on the 28-31st week with a weight of up to 1500 g (severe prematurity); 20% - at 32-33 weeks. In all these groups, pronounced immaturity of the lungs is noted. And what less term pregnancy, the more pronounced symptoms of respiratory failure. Finally, 60-70% of babies are born at 34-36 weeks. Prolongation of pregnancy indirectly contributes to the preparation of a premature fetus for birth. Therefore, the specialists of the St. Petersburg Maternity Hospital No. 16 adhere to a wait-and-see approach. At full-term and immature birth canals, therapeutic tocolysis is prescribed (long-term, about 6 hours, intravenous drip of Ginipral).

Our many years of experience in the management of preterm labor with DIV shows that it is possible to achieve good results according to the survival rate of fetuses with extreme body weight, namely the maximum possible extension of pregnancy. Among other things, qualified prenatal care is used, effective prevention development of respiratory distress syndrome, antibiotic therapy and gentle delivery. About 5,000 children are born in the 16th maternity hospital every year, of which approximately 10% are due to premature births. In almost half of the cases, the pregnancy of their mothers was extended, including for the maximum possible period - from the 23rd to the 27th week. In addition, we have accumulated experience of long-term prolongation of twin pregnancy in case of premature discharge of water in the first fetus during the period of deep prematurity. This allows babies to be born, though ahead of time but quite viable. Moreover, the longer the anhydrous interval lasted, the more mature the lungs of the fetus turned out to be. Premature babies, and sometimes fetuses with extremely low body weight, could breathe on their own.

Analysis of the expectant management of labor at full-term pregnancy and DIV revealed a sharp decrease in birth traumatism of newborns associated with labor stimulation, carried out earlier with an increase in the anhydrous interval of more than 2 hours, and the absence of labor activity. The percentage of operative delivery among women who underwent prolongation of pregnancy decreased by 4 times. Women went into labor on their own, without additional stimulation. Experience shows that expectant management at full-term pregnancy can be carried out up to 4 days, and only a longer anhydrous period is fraught with serious problems.

In conclusion, I would like to note that premature discharge of amniotic fluid is not a reason for panic, but for an early visit to the doctor. If you quickly take the necessary measures, pregnancy in most cases can be extended to a period when life is even premature baby is out of danger. Therefore, for future mother the main thing is to know where and to whom to turn for qualified medical assistance.

Vladimir Shapkaits, chief physician SPb GUZ " Maternity hospital No. 16",

doctor of medical sciences, professor, obstetrician-gynecologist of the highest qualification category

Elena Rukoyatkina, Deputy Chief Physician for Medical Affairs, St. Petersburg State Healthcare Institution "Maternity Hospital No. 16",

Candidate of Medical Sciences, obstetrician-gynecologist of the highest qualification category

General information. Premature is called the outflow of amniotic fluid when the membranes rupture before the onset of labor, regardless of the gestational age. If the amniotic fluid was poured out shortly after the onset of labor, but before the cervix was completely or almost completely dilated, they speak of an early discharge of amniotic fluid. The time between the rupture of the membranes and the appearance of contractions is called the latent period, and between the rupture of the membranes and the birth of the fetus, the anhydrous period. The prevalence of premature rupture of amniotic fluid has been reported to be 3-19%. Premature rupture of amniotic fluid is accompanied by up to 35% of preterm births.

1. Etiology

A. Infection (amnionitis, cervicitis, vaginitis of streptococcal or other etiology).

b. Overstretching of the uterus (polyhydramnios and multiple pregnancy).

V. Sexual intercourse.

d. Fetal malformations.

e. Low socio-economic status of the pregnant woman.

e. Hereditary diseases in a pregnant woman (for example, Ehlers-Danlos syndrome).

and. Structural tissue changes due to insufficient intake ascorbic acid and trace elements, in particular copper.

h. Injury.

And. Addiction.

Management tactics depend on the gestational age. The rupture of amniotic fluid at less than 37 weeks of gestation significantly increases the risk of infectious and obstetric complications than the outpouring of waters after this period. Some authors believe that the main cause of premature rupture of amniotic fluid is infection, since bacterial enzymes reduce the strength and elasticity of the membranes. However, it is still not clear whether the infection is a cause or a consequence of premature rupture of amniotic fluid.

2. Features of the flow. The shorter the gestational age at the time of the outflow of amniotic fluid, the longer the latent period. In full-term pregnancy, in 80-90% of cases, contractions begin within a day after the outflow of amniotic fluid, in less than 10% of cases the latent period is delayed up to 2 days. With the outflow of amniotic fluid before the 37th week of pregnancy, childbirth during the day begins only in 60-80% of cases, in other cases, the latent period can last up to 7 days.

A. Complications include cord prolapse, chorioamnionitis, and postpartum endometritis. With the outflow of amniotic fluid before the 37th week of pregnancy, premature detachment of the placenta occurs in 4.0-6.3% of cases. This is 2-3 times more often than with the timely discharge of amniotic fluid. If the previous day was observed bloody issues from the genital tract, risk premature detachment placenta against the background of premature rupture of amniotic fluid is even higher. A pronounced decrease in the volume of amniotic fluid, regardless of the duration of the anhydrous period, increases the risk of fetal compression in the uterus with the subsequent development of anomalies of the facial skeleton, contractures of the limbs, and lung hypoplasia is possible. With the outflow of amniotic fluid before the 22nd week of pregnancy, the risk of lung hypoplasia is 25-30%. The risk of complications of premature rupture of amniotic fluid depends on the gestational age, the volume of effluent and the duration of the anhydrous period.

b. Morbidity and mortality. In the past, the tactics of managing pregnant women with premature rupture of amniotic fluid consisted of labor induction and delivery. Later they began to use waiting tactics. This allowed the collection and evaluation of statistical data on maternal and perinatal morbidity and mortality due to premature rupture of amniotic fluid.

1) According to van Dongen, with premature rupture of amniotic fluid at a gestational age of less than 34 weeks, perinatal mortality reaches 29% (14 out of 48 newborns died). Four newborns died due to lung hypoplasia. At the same time, in 3 cases, the outflow of amniotic fluid occurred at a period of less than 20 weeks, in the fourth - at a period of 26 weeks of pregnancy. The authors concluded that premature rupture of amniotic fluid at less than 20 weeks of gestation is always accompanied by lung hypoplasia in the fetus.

2) According to Blott and Greenough, in 30 cases of rupture of amniotic fluid during the second trimester of pregnancy, 36% of newborns died, and 27% were born with limb contractures.

3) Thibeault et al. showed that when prolonging pregnancy after premature rupture of amniotic fluid for more than 5 days, 28% of newborns develop limb contractures, which, however, can be eliminated with the help of physiotherapy and massage.

4) Taylor and Garite, having studied 53 cases of premature rupture of amniotic fluid at a gestational age of 16-25 weeks, found that the viability of the fetus depends mainly on its weight and term of delivery, and not on the time of rupture of amniotic fluid. According to their data, out of 18 children born after the 26th week of pregnancy, 13 survived.

V. The prognosis for rupture of amniotic fluid before the 37th week of pregnancy is unclear in most cases. However, this does not serve as a reason for abandoning the expectant management of pregnancy and the prevention of complications in the fetus. With the outflow of amniotic fluid before the 20th week of pregnancy and prolonged oligohydramnios, the chances of having a viable baby are very small. In 5% of cases, the outflow of amniotic fluid stops, and their volume is restored. This mainly applies to cases of amniotic fluid leakage, usually after amniocentesis.

3. Diagnostics. Premature rupture of amniotic fluid significantly affects the outcome and management of pregnancy. In this regard, if a discharge or decrease in the volume of amniotic fluid (with ultrasound) is suspected, a thorough examination is indicated. The cervix and vagina are examined in the mirrors (before the examination, the pregnant woman should lie on her back for 20-30 minutes). First examine the posterior fornix of the vagina. If there is no amniotic fluid, the pregnant woman is asked to strain or cough. When the membranes rupture at the time of coughing or straining, amniotic fluid flows out of the external pharynx. Vaginal examination is not carried out.

A. Examination of vaginal contents. Material for research is taken from the posterior fornix of the vagina or from the cervical canal. To detect amniotic fluid in the vaginal contents, dry smear microscopy is performed and the pH of the secretions is determined using a test strip. Other methods are also used - cytological and biochemical examination of the vaginal contents. Cytological examination of the smear can reveal scales of the fetal epidermis and droplets of fat. The disadvantage of the method is that it requires special dyes. In addition, a cytological study performed long before delivery often gives false negative results. At biochemical research the presence of amniotic fluid in the vaginal contents is confirmed by the presence of fetal fibronectin, prolactin, alpha-fetoprotein and placental lactogen.

1) Microscopy of a dry smear. During examination of the cervix and vagina in the mirrors, a sterile cotton swab is taken from the posterior fornix of the vagina or external os and thin layer applied to a clean glass slide, after which the drug is dried in air. When it is completely dry, it is examined under a microscope at low magnification (ґ 5-10). Detection of crystallization in the form of a fern branch or tree structure confirms the presence of amniotic fluid. To avoid false negative result the preparation is allowed to dry completely and the entire smear area is examined under a microscope. The discovery of the fern phenomenon at least in one area indicates a positive result. False positive results occur when you touch the drug with your finger or get on the glass of saline.

2) Determination of pH using a test strip. The method is based on the fact that the amniotic fluid is alkaline (pH 7.0-7.5), and the vaginal discharge is normally acidic (pH 4.5-5.5). Vaginal discharge is taken with a sterile cotton swab and applied to the test strip. The coloration of the strip in blue-green (pH 6.5) or blue (pH 7.0) color most likely indicates the presence of amniotic fluid in the test material. False-positive results are possible with blood, urine, semen or antiseptics.

b. Volume of amniotic fluid. If, during the examination of the vaginal discharge, amniotic fluid is not found in it, and anamnestic and clinical data indicate premature rupture of amniotic fluid, further examination is indicated. Ultrasound is performed to determine the volume of amniotic fluid. Even with the outflow of amniotic fluid in the amniotic cavity, free areas larger than 3-3 cm can be found. If severe oligohydramnios is detected, regardless of whether confirmed diagnosis outflow of amniotic fluid or not, the kidneys and bladder of the fetus are carefully examined, since one of the causes of oligohydramnios may be agenesis of the kidneys of the fetus. Despite the similarities external manifestations, the tactics of conducting pregnancy in these cases is significantly different.

V. Amniocentesis. If the results of all the studies listed above are doubtful, 1-2 ml of a sterile dye is injected intraamnially, after which the vagina is tamponed. The pregnant woman lies on her back for 30-40 minutes, then the swab is removed. Staining of the swab confirms the outflow of amniotic fluid. It must be remembered that in the future, regardless of the state of the fetal membranes, the dye begins to be excreted in the urine.

1) Technique. Amniocentesis is performed under ultrasound guidance. The procedure should be performed only by an experienced doctor. The main contraindication for amniocentesis is pronounced oligohydramnios, since in this case, loops of the umbilical cord can be taken for the accumulation of amniotic fluid and injure them. If technical difficulties arose during the operation, continuous CTG is performed for some time after it.

2) Dye. It is best to use indigo carmine or Evans blue. Less commonly used is Evans Blue T1824. Indigocarmine is administered strictly intraamnially, since its intravenous administration is accompanied by side effect. Methylene blue is no longer used, since the introduction of large doses of this dye can cause hemolytic anemia, hyperbilirubinemia, methemoglobinemia and skin staining in the fetus.