00:01
Now let's discuss preterm
premature rupture of membranes.
00:05
First let's go with
some definitions.
00:08
Preterm rupture of membranes
means rupture of membranes
that happens before 37 weeks
of gestation.
00:16
Premature rupture of membranes
means rupture of membranes
that happens before the onset
of labor.
00:24
So there are some key
issues to address.
00:26
The first is to confirm
rupture of membranes.
00:29
So there are four ways that we
confirm rupture of membranes.
00:32
Then we're going to talk about
which one of these is the best.
00:35
So the nitrazine test.
00:36
This is similar to litmus paper.
00:38
So litmus paper and nitrazine
paper is placed inside
the vagina and we expect
it to change color
because of the PH of amniotic fluid.
00:47
The thing that you need to know
however, is that the litmus
paper or the nitrazine paper
will also change colors
because of infections with
bacterial vaginosis,
blood and semen.
00:57
So this cannot be used by itself
to determine if a patient has
rupture of membranes.
01:03
Another test we can do to
confirm the rupture of membranes
is the ferning test.
01:08
To perform this test we take a
small amount of fluid that we
see in the vagina that we
expect to be amniotic fluid.
01:14
Place it on a slide.
01:15
Allow it to dry.
01:16
And we look under
the microscope.
01:20
This is an example of ferning.
01:22
This is kind of what we would
see for a patient that has
rupture of membranes.
01:25
But as the slide indicates there
other things that can cause
feming such as cervical mucus.
01:30
So again ferning should be
used along to confirm
rupture of membranes.
01:36
Another test we
can do is pooling.
01:38
To do the pooling test we place
a speculum inside the vagina.
01:42
And we ask for the mom
to cough or to bare down.
01:46
With that pressure on the uterus
we expect to see fluid
coming out of the cervix.
01:50
If we see that we can be pretty
sure that patient has
rupture of membranes.
01:55
This is the most diagnostic
test for confirming
rupture of membranes.
02:00
The 4th test is ultrasound.
02:02
When we do ultrasound we expect
to see a maximum vertical pocket
of 2 centimeters in
a normal pregnancy.
02:08
If we see less fluid
than that,
we can suspect rupture
of membranes.
02:12
However, we can also have
that finding in the setting
of oligohydramnios.
02:17
So ultrasound alone should not
be used to confirm rupture
of membranes.
02:22
So here's a question.
02:24
When confirming rupture of
membranes, which examination
is the most accurate?
Is it
A. Nitrazine
B. Ferning
C. Pooling.
02:33
or D. Amniotic fluid volume via ultrasound.
02:37
Well the answer is pooling.
02:38
And we've just said there are
other things beside amniotic
fluid that make the nitrazine
test positive.
02:43
We can see ferning with amniotic
fluid and with cervical mucus.
02:48
And a low amniotic fluid volume
can be seen in rupture of
membranes as well as in
the case of oligohydramnios.
02:53
Therefore, pooling is
the best answer
in this question.
02:58
So some other key
issues to address.
03:01
Antibiotics to
prevent infection.
03:05
So at term, if a patient is
ruptured, and then again this
may be premature rupture of
membranes if they have rupture
before the onset of labor.
03:12
And if the patient is GBS
positive, so a carrier of GBS,
we do want to give antibiotics.
03:19
However, if they are GBS
negative or GBS unknown
and term, we do not give antibiotics.
03:27
For late preterm and we're
talking about 34 to the 36 weeks
of gestation, we will
give antibiotics
to prevent GBS infection.
03:35
Unless we for some reason had
a culture that said the patient
was GBS negative.
03:41
So preterm and we're talking
about our deliveries
that had happened
before 34 weeks.
03:46
We want to give antibiotics
for two different reasons.
03:49
We want to give antibiotics to
increase the latency period.
03:52
And that's the period from
the time of rupture of membranes
to when a patient actually
delivers.
03:57
And we also want to give antibiotics
if delivery
is eminent, to prevent GBS
transmission if GBS is unknown.
04:05
The next key issue to address in
preterm in rupture of membranes
is steroids.
04:13
Now there are three areas of
concern for fetus when they are
born early.
04:17
Intraventicular hemorrhage.
04:19
Respiratory distress syndrome.
04:21
And necrotizing enterocolitis.
04:24
We give the steroids to help
in all three areas but most
specifically for respiratory
distress syndrome.
04:30
When we give steroids that helps
the type 2 pneumocytes to mature
and to increase surfactant
production to recruit
more alveoli.
04:38
So this will help for our babies
when they are born early
and they have small lungs.
04:43
This will recruit more alveolis
so they can have better
respiratory function.
04:49
The next issue that we need to
address is magnesium sulphate.
04:53
It is recommended that we
give magnesium sulphate
for neuroprotection.
04:56
And so this helps to prevent
cerebral palsy
in our very preterm events.
05:03
So let's go over the overview
of how we manage
by some of the gestational age.
05:08
So for patients that are 12 to
24 weeks of gestation
so that means before viability
we do expectant management.
05:15
If they have premature rupture
of membranes
or we induce their labor.
05:19
Now unfortunately, this is a
pregnancy that's going to result
in an infant that's
not going to be viable.
05:24
However, because rupture
membranes poses a risks to mom
because of chorioamnionitis,
we do not want that pregnancy
to continue.
05:32
At 24 weeks to 33 weeks
and 6 days,
we give antibiotics to increase
the latency period.
05:39
And just as a reminder that's
the period from the time
the patient rupture membranes
to when they go into labor.
05:45
And then we also give
antibiotics for GBS prophylaxis.
05:48
We give steroids specifically
for lung maturity but also to
help with intraventicular
hemorrhage and necrotizing
enterocolitis.
05:56
And we give magnesium
sulphate for neuroprotection.
05:58
For these patients we
recommend delivery at 34 weeks.
06:02
For patients that are between
the gestational age of 34 weeks
to 36 weeks and 6 days of
gestation, we want to give
antibiotics for GBS prophylaxis.
06:13
And we would recommend delivery.
06:16
In addition, steroids
would be recommended during this period as well.
06:20
For our patients that are over
37 weeks we give antibiotics for
GBS prophylaxis, if their GBS
positive by culture,
and we will recommend delivery.
06:31
So here's another question.
06:34
When treating patients with
premature rupture of membranes,
which medication should
not be used long term?
A. Antibiotics.
06:43
B. Magnesium sulphate.
06:46
C. Tocolytics
or D. None of the above.
06:51
The answer is C.
06:52
Now this may seem
a little tricky.
06:54
But the question indicates
which of these should not be
used long term.
06:58
Tocolytics are often used in
the first 48 hours after rupture
of membranes as we are
administering the steroids.
07:05
We would like the patient to not
establish into labor during that
time to allow the steroids to
have the greatest affect for
long maturity for the fetus.
07:13
We often give tocolytics
during this time.
07:16
However, we don't want to
give tocolytics long term.
07:19
Again our big concern with
premature rupture of membranes
is chorioamnionitis.
07:24
One of the first ways that we
know that infection is taking
place is moms
starts to contract.
07:29
This will happen before
she has a fever,
before the baby is tachycardic,
before we see the other signs
of chorioamnionitis.
07:36
We don't want to mask
that by giving tocolytics.
07:39
So that's we don't give it
beyond the 48 hours.