Description:
Premature rupture of the membranes (PRPO) is a complication of pregnancy, characterized by a violation of the integrity of the membranes of the membranes and the outflow of amniotic fluid (before the onset of labor) at any stage of pregnancy.
Often, water flows out at once in large quantities, and the diagnosis of PRPO is not difficult, but in 47% 23 cases, when microcracks or lateral ruptures occur without massive effusion, doctors doubt the correct diagnosis, which threatens overdiagnosis and unreasonable hospitalization, or vice versa, infectious complications in late discovery.
PRPO accompanies almost every third, and as a consequence is the cause of a significant part of neonatal diseases and deaths. The three main causes of neonatal mortality associated with PROM in premature pregnancies are prematurity and hypoplasia (underdevelopment) of the lungs.
Symptoms:
The clinical picture of PRPO depends on the degree of damage to the membranes.
The clinical picture with massive rupture of amniotic fluid.
If there was a rupture of the fetal bladder, then:
the woman notes the release of a large amount of fluid, not associated with urination;
the height of the standing of the fundus of the uterus may decrease due to the loss of a significant amount of amniotic fluid;
labor begins very quickly.
The clinical picture with high lateral ruptures.
It is more difficult when there are microscopic cracks and amniotic fluid flows literally drop by drop. Against the background of increased vaginal secretion during pregnancy, excess fluid often goes unnoticed. A woman may notice that while lying down, the amount of discharge increases. This is one of the hallmarks of the PRPO. Symptoms that should alert you: a change in the nature and amount of discharge - they become more abundant and watery; in addition to pain, pain in the lower abdomen and or spotting (but it is worth noting that pain and spotting are not a permanent symptom and they may be absent). It is worthwhile to be wary if the above symptoms appeared after an injury or fall or against the background multiple pregnancy or an infectious process in the mother.
But in most cases, such breaks occur in the absence of obvious risk factors and within an hour the clinical manifestations are significantly reduced, which greatly complicates the primary diagnosis and requires additional methods, and a 24-hour delay in diagnosis and timely treatment started multiplies the likelihood of perinatal morbidity and mortality. A day later, or even earlier, chorioamnionitis develops - one of the most formidable complications of PRPO, the signs of which also indirectly indicate that there is a rupture of the membranes. This condition is characterized by an increase in body temperature (over 38), chills, tachycardia in the mother (over 100 udmin) and fetus (over 160 udmin), soreness of the uterus on palpation and purulent discharge from the cervix during examination 40.
PRPO as a result of cervical insufficiency (BMI less than 19.8) 4 is more typical for preterm pregnancy, although it occurs at a later date. Inconsistency of the cervix leads to protrusion of the fetal bladder, and therefore its lower part is easily infected and ruptures even with little physical exertion.
Instrumental medical intervention
It should be noted that the risk is accompanied only by procedures associated with instrumental examination of the amniotic fluid or chorion, and examination in the mirrors or sexual intercourse in no way can lead to PRPO. But at the same time, multiple bimanule studies can provoke rupture of the membranes.
Bad habits and diseases of the mother
It is noted that women suffering systemic diseases connective tissue, underweight, anemia, vitamin deficiency, with insufficient intake of copper, ascorbic acid, as well as long-term use hormonal drugsare more at risk of developing PRPO. This group also includes women with low socioeconomic status, abuse of nicotine and drugs.
Uterine anomalies and multiple pregnancies
This includes the presence of a uterine septum, conization of the cervix, shortening of the cervix, ischemic-cervical insufficiency, placental abruption, and multiple pregnancies.
Most often, blunt abdominal injuries from the mother's fall or impact lead to rupture.
Treatment:
To draw up an algorithm for the management of pregnant women with PRPO, one should have a clear idea of \u200b\u200bthe obstetric situation, decide on the place and time of delivery and the need to prevent infectious complications or. This requires the following.
Confirm the diagnosis of ruptured membranes.
Define exact date pregnancy and estimated fetal weight. With a period of less than 34 weeks and a fetal weight of up to 1500 grams, the pregnant woman should be hospitalized in a third-level hospital.
Determine the contractile activity of the uterus.
Assess the condition of the mother and fetus;
Identify the presence of intramniotic infection.
Determine the presence of contraindications for expectant tactics
Choose the tactics of managing the pregnant woman or the method of delivery.
Conduct infection prevention.
In the case of conservative management1, the patient is placed in a specialized ward with bactericidal lamps, where wet cleaning should be carried out 3-4 times a day. Daily change of bed linen and change of sterile underlays 3-4 times a day. Constant monitoring of the condition of the fetus and the mother is carried out, medication appropriate for the period and strict bed rest are prescribed.
Leakage or early rupture of amniotic fluid is a problem for many pregnant women. Delaying treatment is often dangerous for both the unborn child and the mother.
What is amniotic fluid?
The amniotic fluid (amniotic fluid) is a clear and pale straw-colored fluid that surrounds the fetus, providing protection and nutrient supply. It also helps in the development of the muscular and skeletal system of the unborn child.
There is amniotic fluid in the fetal bladder (amniotic sac), the walls of which consist of two membranes: the amnion and the chorion. These shells keep the unborn baby in this airtight bag containing amniotic fluid. The bubble begins to fill her a few days after conception. The baby will regularly release a small amount of urine into the amniotic fluid starting in the tenth week of pregnancy (when the kidneys begin to work).
Together with the placenta and umbilical cord, it is such a natural support system for the life of the embryo.
How important are they?
The amniotic fluid allows the baby to breathe properly. He begins to swallow liquid in the second trimester. Its main function is to protect the unborn child from injury.
The fluid contains essential nutrients that aid in the development of the fetus's digestive system, lungs, muscles and limbs. This allows the child to kick and move without any hindrance. It also provides protection against infections.
The fruit uses this liquid for many functions. The water level will rise every day. Their number will increase from a few cubic milliliters to about a thousand as pregnancy progresses, and reaches its highest level at thirty-six weeks. Then the number will begin to decline from the thirty-eighth week to the day of birth.
Premature loss of amniotic fluid is a serious threat to the unborn child and the mother herself.
What is premature rupture or leakage of amniotic fluid?
Normally, spontaneous rupture of membranes and rupture of amniotic fluid occurs during childbirth, i.e. with full or almost complete dilatation of the cervix and the presence of regular contractions.
If the outflow (leakage) of water occurs earlier, then this condition is premature and refers to complications of pregnancy. In medicine, this is called premature rupture of the membranes (PRPO). This can occur at any stage of pregnancy and can be in the form of a stream of fluid or a slow drip. This problem is a common cause of premature birth or miscarriage, depending on the timing.
If the premature rupture occurs before the 24th week, the fetus is still completely unable to survive outside the mother's womb. But even before the 37th week, this puts the mother and fetus at high risk of complications.
Premature rupture of amniotic fluid is a problem that is often ignored by many pregnant women. The effusion usually feels like a painless stream of fluid, but it can also appear as a small stream or a slight discharge.
Symptoms
It can be difficult to determine if the vaginal discharge is amniotic fluid when the membranes of the sac do not completely rupture, but cracks in them. However, there are several differences.
Amniotic fluid:
- Usually odorless
- Mostly transparent. Sometimes it may be mucus, blood-streaked, or white discharge
- Leaks continuously. Has a very steady flow from time to time
- Leakage cannot be controlled
- Pads and underwear have to be changed frequently as the leak is persistent
- Some discomfort and cramping may occur
It may not be amniotic fluid if:
- There is a yellow tinge like urine
- Smell like urine
- Sudden leakage, accompanied by movement of the baby in the uterus, but which was short-lived and stopped.
- The discharge has a slimy consistency, which requires a change of pads for hygiene purposes. Such a leak will not seep through the gaskets. This is a sign that yours is simple.
Slow Drip Symptoms
We can talk about leakage of amniotic fluid during pregnancy if:
- You notice a sudden stream of fluid moving along the length of your legs
- Your underwear is wet
- Slight leakage or trickle
The cause of small leaks can be difficult to determine. Therefore, it is better to go and consult a gynecologist on this issue. Continuous flow indicates leakage.
Amniotic fluid leaking can also be indicated by continuing to experience moisture even after your bladder has emptied.
Early leakage of amniotic fluid
A miscarriage is the loss of a fetus in the early weeks of pregnancy. According to the American Pregnancy Association, many miscarriages occur in the first thirteen weeks. About 10-25% of all confirmed pregnancies usually end in miscarriage.
It is important to recognize the signs as it allows you to seek medical attention as soon as possible.
It is important to pay attention to:
- Isolation of gray or light pink matter
- Discharge of an unexpected large amount of liquid
- Passage of large pieces of tissue
- Pinkish discharge
According to the Mayo Clinic, the release of tissue or fluid during early pregnancy may be a sign of a miscarriage. The secreted tissue or fluid may or may not contain any blood.
The above symptoms may be normal signs of hormonal changes in your body. But they can also indicate problems during pregnancy. You should always keep in touch with your gynecologist.
Leakage in middle pregnancies
Leakage of amniotic fluid at 16 weeks
Usually, the waters drain at the beginning of labor. Any leakage that has occurred earlier is considered premature. Leaks occurring between weeks 15 and 16 usually require urgent medical attention.
Treatment includes:
- Arrival at a medical facility for a thorough examination
- Checking for the likelihood of miscarriage
- After observing you for some time, the doctor will discuss next steps.
Leakage of amniotic fluid in the 2nd trimester
Leaking in the second trimester means you have a ruptured amniotic bladder. The gap may or may not heal over time.
A scan must be performed to determine what may be causing the leak. It is important to note that many different and unusual changes occur in the body during pregnancy, so it is difficult to establish what is normal and what is not.
Regular checkups with a gynecologist will help the expectant mother to be calm. Several tests must be performed to establish what is behind the oozing amniotic fluid.
Leakage of amniotic fluid at 37-38 weeks
If rupture of the membranes occurs 37 weeks after the last menstrual cycle (called gestational age of the fetus), the risks of complications are minimal and contractions usually begin soon thereafter.
But still, such a gap is premature and, like earlier cases, may be associated with such factors:
- Bacterial infection
- Cases of premature drainage of water in previous pregnancies
- Having a defect in the development of your fetus
- An infection in the vagina, uterus, or cervix.
- Bad habits such as smoking, drugs, and alcohol abuse
- Tension of the fetal bladder due to a large baby or twins
- Poor nutrition
- Preliminary operations in the area of \u200b\u200bthe cervix or uterus
Leakage tests
It is most correct to contact a gynecologist, and he will conduct an examination and prescribe the necessary tests to confirm the leakage of amniotic fluid in case of suspicion. But it will also be helpful to have simple pharmacy tests on hand to play it safe or reassure yourself. They can sometimes give a false positive, but when used correctly, they should not give a false negative.
Ph strip test
Litmus strips are the easiest and cheapest test. You can even use strips designed for aquarium water to save money To determine water leakage at home, you can use litmus test strips, which are sold in almost every pharmacy and have an affordable price. Litmus paper helps to establish the pH level of suspicious secretions.
The strip is applied to the vaginal wall after opening, and then it will show the acidity (pH) level. Normal vaginal pH is between 4.5 and 6.0. Amniotic fluid has a higher level - from 7.1 to 7.3. Therefore, if the sac lining is ruptured, the pH of the vaginal fluid sample will be higher than normal. This will be indicated by a change in the color of the strip, which must be compared with the scale that comes with the test. An increased acidity level will indicate that you have an infection or amniotic fluid leaking.
Test strip to determinethe pH of the aquarium water is also suitable for testing amniotic fluid leakage and can be cheaper.
Nitrazine test
The most common type of tests. The price for one tampon is from 2 dollars. Popular brands are AmnioTest, Amnicator. It requires applying a drop of fluid from the vagina to paper strips containing nitrazine as an indicator, a substance more sensitive than litmus. These tests are commercially available in the form of special tampons or pads to facilitate testing.
The indicator changes color depending on the acidity of the liquid. They will turn blue if the pH is greater than 6.0. This means that the bladder shells are likely to burst.
However, this test can also give false positive results... If blood gets into the sample or there is an infection in the vagina, the acidity level may be higher than normal. Male semen also has a higher pH, so recent intimacy may affect the outcome.
Alpha 1 microglobulin test
The most accurate but also the most expensive test - over $ 30 This is a modern and more accurate test, but its cost is several times more expensive (over 30 shares). It also does not require special laboratory conditions, but more often it is performed by an obstetrician-gynecologist on an outpatient basis. The bottom line is to detect a biomarker such as placental alpha-1-microglobulin. This substance is found in the amniotic fluid and is not normally present in the vagina. To take a sample, a swab is used, which is then placed in a test tube with a special liquid, and then a test strip is put there in its place. According to the results of the number of stripes that appeared on it (1 or 2), it is possible to say with an accuracy of 97% about the presence of leakage of amniotic fluid.
Other tests the hospital might do
The so-called "fern" symptom is the marks on the microscope slide after the amniotic fluid has dried. After the urine dries, there are no such traces Inspection of the liquid under a microscope. If leakage occurs, the amniotic fluid mixed with estrogen, when dried due to salt crystallization, will create the "fern" symptom (it will resemble its leaves). For holding, a few drops of liquid are placed on the microscope slide for examination.
Dye test. A special dye is injected into the amniotic sac through the abdominal cavity. If the membranes are torn, the colored fluid will be found in the vagina within 30 minutes.
Tests to measure levels of chemicals that are present in amniotic fluid but not in vaginal secretions. These include prolactin, alpha-fetoprotein, glucose, and diamine oxidase. High levels of these substances mean a rupture has occurred.
Amniotic fluid, urine, or vaginal discharge?
Three main types of fluid can come out of the vagina: urine, and amniotic fluid. While noting the differences between them, you can use the following tips to identify one of them.
Leakage of amniotic fluid
It will have the following properties:
- May contain clear or whitish mucous spots
- Odorless and colorless. May have a sweetish odor in some cases
- The presence of bloody specks
- Has no urine odor
Constant discharge means that the fluid is truly amniotic.
Urine
Urine usually has the following properties:
- Ammonia smell
- Dark or pure yellowish color
Bladder leakage will occur primarily in the second and third trimester. The fetus will already press on the bladder during these periods.
Vaginal discharge
Vaginal discharge during pregnancy is also not uncommon. They have the following properties:
- The smell may or may not be present. However, they do not have a urine-like ammonia odor.
- May be yellowish or whitish
- Are denser than urine or amniotic fluid (No ratings yet)
The amniotic fluid has many functions during pregnancy and ideally is released after the onset of regular contractions. Premature rupture of amniotic fluid or premature rupture of the membranes is a situation where the water leaves before the onset of labor.
Moreover, there are two fundamentally different situations: the rupture of the membranes occurs after 37 weeks, that is, with a full-term pregnancy, or the water leaves before this period. Naturally, in the first situation, the forecast is more favorable.
What is the danger of premature discharge of water.
Premature discharge of water at any stage of pregnancy is dangerous by infection of the fetus. A certain number of microorganisms normally live in the vagina, which can enter the uterus and lead to inflammation of the membranes, inflammation of the lining of the uterus.
Hospital microbes are especially dangerous, therefore, after rupture of the membranes, gynecological examinations are tried not to be carried out or done as rarely as possible. With a prolonged anhydrous period (more than 24 hours), the risk of infection of the fetus and the risk of complications in the mother, in particular, postpartum endometritis (inflammation of the uterine lining), significantly increase.
Since the rupture of amniotic fluid often ends in labor in the next few days, there is a high risk of having a premature baby when the amniotic fluid flows before 37 weeks of gestation.
Premature passage of water before pregnancy increases the risk of placental abruption. With a large volume of amniotic fluid and a prolonged anhydrous period, there is a risk of compression of the fetus in the uterus, hypoplasia of the fetal lungs.
After premature rupture of amniotic fluid, an ultrasound scan with a Doppler is mandatory, the volume of water and the condition of the fetus are determined.
Causes of premature outpouring of water.
The reasons for the premature outpouring of water are not fully understood. Predisposing factors are considered: smoking, drug use, low socio-economic status, low body weight, infections of the urinary system and vagina, uterine overstretching due to polyhydramnios or multiple pregnancies.
Also, risk factors for premature rupture of the membranes are invasive procedures during pregnancy (amniocentesis), injuries of the pregnant woman.
Premature rupture of amniotic fluid during full-term pregnancy.
If the pregnancy is full-term, then in most cases, within a day after the premature rupture of amniotic fluid, labor spontaneously begins. If there are no regular contractions, then after 12-24 hours the woman is offered delivery, cesarean or induction of labor, depending on the condition of the child and mother.
In a full-term pregnancy, antibiotics are usually prescribed 12 hours after the water has passed to prevent infection in the baby and mother.
When the amniotic fluid leaves or leaks, the woman should immediately go to the hospital and stay there until the very birth.
Early discharge of water.
With an early discharge of water, that is, before 37 weeks, medicine faces a difficult choice: if the pregnancy is maintained, then the risk of infection of the child increases every day, and if childbirth is allowed, the premature baby does not always survive.
The tactics depend on the duration of pregnancy, the condition of the fetus, the amount of amniotic fluid. If the amount of water is sufficient, the condition of the fetus is normal, then they try to prolong the pregnancy. This is not always possible, about half of women with premature rupture of the membranes give birth within a few days after the outpouring of water.
That is why after the passage of water from 24 to 34 weeks of pregnancy, all women are prescribed injections of dexamethasone or betamethasone (hormonal drugs) to ripen the lungs of the fetus.
One of the leading causes of death in premature babies is respiratory distress, a syndrome that occurs due to immaturity of the lungs. Glucocorticoid hormone therapy significantly increases the survival rate of a premature baby.
If a decision is made to prolong the pregnancy, then antibiotics are necessarily prescribed to prevent infection, usually with a course of seven days.
The woman is in the hospital, where the condition of the fetus is being monitored. Strict bed rest is generally not recommended as it increases the risk of thrombosis.
Sometimes the discharge of amniotic fluid stops, and their volume is restored. Small breaks can heal on their own and the woman carries the pregnancy to term.
Premature rupture of amniotic fluid is a serious complication of pregnancy that cannot be ignored. Nevertheless, if the membranes rupture in the third trimester, the chances of having a healthy baby are quite high if you seek medical help in time and take the necessary measures.
If the gestation period is less than 34 weeks, then in case of premature rupture of amniotic fluid, it is advisable to immediately go to a specialized institution where premature babies are born.
In the absence of pathologies, pregnancy ends with delivery at 37-42 weeks. When the baby is formed, the body begins to prepare the birth canal. The uterus changes its structure so that the cervix can open up to the diameter of the fetal head, the tissues soften and stretch. The contractions of the walls press on the amniotic bladder, which soon bursts. If the rupture of the membrane occurred before the onset of contractions, premature rupture of amniotic fluid is diagnosed. At 37-42 weeks, there is no danger if the mother gets to the hospital in 2-3 hours.
Norms and terms
Amniotic bladder fluid during pregnancy protects the fetus from bacteria and infections, creating a sterile, safe environment. As soon as the integrity of the membranes is violated, the baby becomes vulnerable to external harmful intrusions. Since the microflora of the genital tract is 30% infected with fungi (even if they do not appear externally), the risk of infection remains. The bacteria will enter the uterus in 8-10 hours. During this time, you need to give birth.
One in three women experience premature rupture of amniotic fluid during full-term pregnancy. After 2-3 hours, contractions come, the baby is born in 4-6 hours. The main thing is to be in the hospital on time in order to exclude complications.
Normal flow:
- uterine tissues loosen, soften;
- walls thicken (fibers overlap);
- the ligaments of the uterus are stretched, the cervix opens;
- the fetus descends to the lower segment, presses on the inner pharynx;
- the hole opens, the plug is separated;
- the head is inserted into the neck, pulling the bladder;
- the shell breaks under pressure;
- water is pouring out.
If the bladder bursts before the contractions occur, it means that the membrane has ruptured due to thin walls or infection on the tissues. From 37 weeks, labor will begin within 4-6 hours. If the water has departed at 6 months, or there is a risk of leakage, you need to lie on your left side, do not move, call an ambulance. With complete outpouring at an early date, there is no chance of saving the fetus.
9-12% of pregnant women need a puncture of the fetal bladder, since the uterus opens, and the water does not leave. An expectant tactic is chosen, monitoring the diameter of the cervical canal.
At what opening of the neck does the water escape? 7-10 cm if the pregnancy is full-term. With a closed or poorly prepared neck, bubble rupture will manifest itself as a leak.
Can water drip early? Yes, in any of the 3 trimesters. If the bladder ruptures before 22 weeks, an abortion is recommended. For example, if the waters have departed at 4 months, the fetus will stop developing in the womb and die within 12 hours. After 23 weeks, there is a chance of salvation, urgent hospitalization is needed.
The prognosis of the course of labor depends on the period of premature rupture of amniotic fluid. A rupture of the bladder in the second trimester of pregnancy in 94% of cases means fetal death. Continuing pregnancy in the period 22-24 weeks will affect physical development organs of the child in the future.
For a period of 25-34 weeks, expectant tactics, a pastel mode, regularly CTG, ultrasound of the fetus are recommended. Depending on readiness internal organs child, a decision is made on further tactics. If the lungs are sufficiently formed to be readjusted to direct oxygen, delivery by cesarean section is prescribed.
Until 37 weeks, the baby is born prematurely. In 63% of cases, the consequences of an early rupture of the bladder will manifest themselves on the mental and physical development of the child in the future.
The reasons
The physiological structure of the amniotic membrane provides for a dense structure that does not break even under intense movements from the inside. Therefore, integrity is always violated due to an external stimulus.
A common cause of premature rupture of amniotic fluid is an infection of the genital tract in an advanced stage. The pathogenic organism penetrates to the uterus, eroding the walls of the amniotic membrane.
It is believed that antibacterial drugs affect the bladder membrane. Proven antimicrobial and anti-inflammatory drugs will not rupture the amniotic membranes. In particular, amniotic fluid cannot leave Depantol, since the components contained in it act selectively on pathogenic organisms.
Why is there premature discharge of water?
- isthmic - cervical insufficiency (ICI);
- hormonal imbalance;
- punch in the stomach;
- multiple pregnancy;
- polyhydramnios.
ISN - the reason for the discharge of water ahead of time in 10% of cases. Due to the weakened muscles of the uterine ring, the neck opens, the fetus tends to the opening of the cervical canal. The shell stretches under pressure and breaks. ICI occurs more often in the first and second trimesters, causing fetal death. After 26 weeks, the risk of developing pathology is 04-0.9%, the prognosis is favorable.
With a lack of progesterone, the cervix is \u200b\u200brelaxed, the tissues soften. The more pressure on the cervical canal, the higher the risk of premature birth. If the waters have departed, and the cervix does not open, in the third trimester, stimulation of labor or a caesarean section is prescribed.
Before the onset of labor, patients feel a surge of energy, go shopping, carry heavy bags, move the bed. In the 3rd trimester, it is better to postpone long-term physical activity. If after 37 weeks the waters have receded, but there is no disclosure, every fifth case is provoked by walking for more than 2 hours in a row.
Symptoms of ICI, hormonal disruptions, stretching of the membranes are little or do not appear at all. Therefore, it is unacceptable to interrupt the observation of pregnancy by a gynecologist, sometimes the complication develops in 3-5 days, followed by a fatal outcome for the mother and fetus.
Symptoms and Diagnosis
The rupture of amniotic fluid is difficult not to notice. A powerful stream rushes outward about 300 ml. water, the woman feels it flow down the inner thigh. But if the bladder membrane is damaged, then the water leaves slowly, the discharge is similar to secretion.
Signs:
- the pad is wet but colorless;
- no smell;
- discharge is liquid;
- the leakage stops in a horizontal position;
- the belly falls in diameter (up to 1 cm).
Symptoms portend a successful birth if the period is from 37 weeks. If you suspect a leak, you need to monitor for further signs, prepare the bag for the hospital, probably contractions will occur within 2-4 hours.
To determine the nature of the discharge, there are research methods that are carried out at home. Such a diagnosis of premature outpouring of water is done using pads or litmus strips. The application scheme is the same. The inside contains control tissue, which changes color when injected with amniotic fluid. The amniotic fluid consists of a unique protein that is not found in any other secretion of the female body.
Home diagnostics:
- the lining (strip) is inserted into the panties;
- analysis after 2 hours;
- if the color of the control tissue is blue (green tint), water leaks;
- color has not changed - vaginal secretion.
Tests are not 100% sure. If infections develop in the genital area, the unique protein will oxidize and will not manifest itself on the control tissue. The reason to go to the hospital is the premature discharge of water during pregnancy without contractions (within 2-3 hours). Doctors will take tests for leakage, determine further tactics.
Diagnostics in the hospital
- secret analysis;
- amnioscopic examination;
- manual inspection with a mirror.
Analysis of the smear determines the expanded composition of the secretion. When amniotic water leaks, the reagent will detect the protein within 15 minutes. If the test is positive, if the cervix is \u200b\u200bnot open, drug stimulation will be prescribed.
Amnioscopy and manual examination determine damage to only the lower part of the bladder, when the cervical canal is opened by at least 2.5 cm. In case of infection, the wall can be damaged in any segment of the uterus, the rupture is not accessible from the outside. The methods are not applied for up to 37 full weeks.
If diagnosed in the first hour after the start of the leak, the chances of a successful outcome are high. In the absence of damage to the bladder, doctors keep the pregnancy with drugs or allow childbirth (after 35 weeks).
Treatment and features of childbirth
Therapy is selected depending on the period of rupture of the membrane and the duration of pregnancy. If the water has completely departed before 37 weeks, you need to lie on your side, not get up, wait for an ambulance. Leakage gives more time for diagnosis and treatment.
Until 34 weeks, expectant tactics are chosen, corticosteroids are prescribed, the patient is in the pathology department. Goal: development of the fetus to the minimum.
At 34-37 weeks, the protocol for the management of labor in case of premature rupture recommends a wait-and-see method, manual examination of the vagina is excluded. Stay in pathology. Observation every 4 hours: fetal heartbeat, uterine contractions, discharge, body temperature. Clucocorticoids are given up to 36 weeks of gestation.
From 37 weeks of gestation, the fetus with prenatal rupture of amniotic fluid is considered full-term, the tactics are chosen based on the duration of the anhydrous period. For the first 4-8 hours, expectant tactics are prescribed, with an analysis of the condition of the fetus and the patient - CTG, body temperature, discharge, contractions. For the ripening of the neck, prostaglandins and oxytocin are prescribed, before opening by 5-7 cm.
With a wait-and-see tactic, manual inspection is unacceptable. Only hardware research and control of secretions. Antibiotics are prescribed for an anhydrous period of 18 hours or more (in practice, doctors do not wait so long) or if an infection is suspected.
If premature and early rupture of amniotic fluid occurs, then in 70% of cases, childbirth occurs within 24 hours. But doctors of maternity hospitals do not take risks and stimulate labor after 6-8 hours. This reduces the risk of dangerous consequences - infection, hypoxia.
Complications for mom and fetus
If the mother does not notice how the water has departed, labor will begin at home, there will be no time to travel to the hospital. In 16-18% of cases, the amniotic bladder bursts, but the cervix is \u200b\u200bnot ready, more than 48 hours can pass before contractions. A long anhydrous period threatens with anomalies in childbirth and development of the baby, so it is necessary to monitor the discharge on the pad.
What is the danger of water discharge:
- hypoxia;
- prematurity;
- getting an infection;
- separation of the placenta;
- prolonged painful labor (up to 24 hours);
- ruptures of the birth canal.
If the baby is not yet fully formed, hypoxia in 45% of cases causes hemorrhage in the brain ventricles. Oxygen starvation of organs and tissues develops, work slows down due to edema. The risk of cerebral palsy increases in the future.
A dangerous sign of prematurity is distress syndrome, which is diagnosed in 80% of cases in infants born before 34 weeks. The lungs are not formed, the lobes do not collapse, oxygen is not processed. The respiratory organs swell, pneumonia develops, more often with a fatal outcome.
Every 10th premature baby is diagnosed with retinopathy. Blood circulation in the vessels is disturbed, as a result - loss of vision and hearing. Pathology manifests itself one month after birth.
The bacteria get to the baby from the vagina. Even pathogens normal for the PH of the genital tract do not adapt to the sterile environment of the amniotic sac. The particle is perceived as dangerous, alien, defense mechanisms are turned on, indicating infection. Endometritis begins in every fifth patient.
Choriamnionitis is a common infection with early rupture of the amniotic sac that develops within 24 hours. Threatens with vascular necrosis, funiculitis for the baby.
Premature placental abruption, which develops with early outflow of water, threatens uterine bleeding. It is more often diagnosed after 8-10 hours, after the rupture of the bladder. Often it is impossible to stop the flow of blood, only the removal of a part of the uterus or complete amputation of the organ can save.
The main role belongs to the medical response, much depends on the choice of tactics, the speed of decision-making. But a woman should also be conscious and proactive. Early diagnosis of leakage, an emergency call for an ambulance, even in critical situations, save the lives of mom and baby.
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)
Unspecified premature rupture of membranes (O42.9)
general information
Short description
Antepartum rupture of amniotic fluid - spontaneous rupture of the amniotic membranes before the start of regular uterine contractions (1).
Antenatal effusion of water (PIV) in preterm pregnancy complicates the course of pregnancy in only 2% of cases, but is associated with 40% of preterm births and is the cause of a significant part of neonatal morbidity and mortality.
Three main causes of neonatal mortality are associated with RIV in preterm pregnancies: prematurity, sepsis, and pulmonary hypoplasia. The risk to the mother is associated primarily with chorioamnionitis. The link between ascending infection from the lower genital tract and DIV has been proven.
Every third patient with DIV with a premature pregnancy has positive results of cultures of the genital tract, moreover, studies have shown the possibility of bacteria penetration through intact membranes.
There are many publications that discuss the identification of fetuses with IUI, the role of prophylactic antibiotics, tocolytics and corticosteroids, the optimal gestational age for delivery, etc.
This protocol assesses the evidence of the effectiveness of existing methods for the diagnosis and treatment of conditions associated with DIV, and also offers practical recommendations for their management.
Protocol code: H-O-015 Antepartum Amniotic Fluid
For obstetric and gynecological hospitals
Code (codes) according to ICD-10:
O42 Premature rupture of membranes
O42.0 Premature rupture of membranes, onset of labor in the next 24 hours
O42.1 Premature rupture of membranes, onset of labor after 24 hours of anhydrous period
O42. 2 Premature rupture of the membranes, delayed labor associated with therapy
O42.9 Premature rupture of membranes, unspecified
Classification
| Clinical diagnosis | ICD-10 |
|
Rupture of amniotic fluid before labor begins activities with gestational age from 22 to 27 weeks |
O42; O42.0; O42.2; O42.1; ABOUT42.9 |
|
"Outpouring of amniotic fluid before the onset of prematurechildbirth "- in case of rupture of fetalshells from 28 to 37full weeks of pregnancy |
O42; O42.0; O42.2; O42.1; ABOUT42.9 |
|
"Outpouring of amniotic fluid before the onset of urgent labor" - withrupture of membranes from 37 weeks of gestation |
O42; O42.0; O42.2; O42.1; ABOUT42.9 |
Diagnostics
Diagnostic criteria
Complaints and anamnesis
In many cases, the diagnosis is obvious in connection with a clear liquid with a characteristic odor that suddenly gushes out from the vagina, subsequently - its continued small discharge.
Physical examination
If DIV is suspected, digital vaginal examination is contraindicated, as it increases the risk of infection spread (2b) and is unlikely to be useful for determining the tactics of further pregnancy and childbirth. If the membranes have ruptured a long time ago, diagnosis can be difficult.
The following diagnostic tests may be performed after a thorough history taking:
1. Offer the patient a clean pad and evaluate the nature and amount of discharge after 1 hour.
2. Make an examination on the gynecological chair with sterile mirrors - the fluid flowing from the cervical canal or located in the posterior fornix confirms the diagnosis.
3. Conduct a "nitrazine test" (15% false positives).
4. Conduct a cytological test - a "fern" symptom (the frequency of false negative responses is more than 20%).
5. Conduct an ultrasound scan - oligohydramnios in combination with an indication of the outflow of fluid from the vagina confirms the diagnosis of DIV (2b).
6. Data of an objective obstetric examination, confirming the presence of low water.
DIV management for gestational periods up to 34 weeks of gestation:
1. Transfer to an obstetric hospital of the III level or, in the absence of such, to any hospital of the II level, where qualified assistance can be provided to premature babies.
2. Expectant tactics (without vaginal examination).
3. Observation of the patient can be carried out in the ward of the pregnancy pathology department (control of body temperature, pulse, fetal heart rate, discharge from the genital tract, uterine contractions every 4 hours with a special observation sheet in the birth history). When labor occurs, transfer to the maternity ward.
5. Antibiotic prophylaxis begins immediately after the diagnosis of DIV and continues until the baby is born, but no more than 7 days.
6. Corticosteroids are used to prevent fetal RDS. Corticosteroids are contraindicated if there are signs of infection.
The duration of wait and see tactics depends on:
1. Gestational period (at 22-31 weeks - every week is valuable, at 32-34 weeks - every 2-3 days).
2. Condition of the fetus.
3. The presence of infection.
Signs of infection:
Maternal fever (\u003e 38 ° C);
Fetal tachycardia (\u003e 160 beats / min.);
Maternal tachycardia (\u003e 100 beats / min.) - all three symptoms are not pathognomonic;
Vaginal discharge with a putrid odor;
Increased uterine tone (both of the latter symptoms are late signs of infection).
| Tactics | Risk | Benefits |
| Active |
1. Labor arousal: hyperstimulation; increase in the frequency of the COP, pain, discomfort 2. Prematurity: RDS; intracranial hemorrhage; fetal distress; necrotizing enterocolitis newborn 3. Development of septic complications in the mother |
Infection prevention |
| Expectant | Development of infection |
1. Accelerates maturation lungs in the fetus. Implementation actions of corticosteroids 2. Buying time for transfer to hospital III level. 3. The fruit grows 4. Development of spontaneous generic activity with reduced risk complications from the introduction oxytotics |
The appearance of signs of infection is an indication for the termination of expectant management and early delivery.
Management of DIV at gestational period 34-37 weeks of pregnancy
1. Possible expectant tactics (without vaginal examination).
2. Observation of the patient is carried out in the ward of the pregnancy pathology department (control of body temperature, pulse, fetal heart rate, discharge from the genital tract, uterine contractions every 4 hours with a special observation sheet in the birth history).
3. Antibiotic prophylaxis begins immediately after the diagnosis of DIV (see above).
4. The feasibility of prophylaxis of RDS with glucocorticoids can be considered if the gestational age cannot be accurately calculated.
| Tactics | Risk | Benefits |
| Active |
1. Labor arousal: hyperstimulation; increase cS frequency; pain, discomfort 2. Prematurity: RDS; intracranial hemorrhage; distress fetus; necrotizing enterocolitis of newborns 3. Development of septic complications in the mother |
Infection prevention |
| Expectant | Development of infection |
Development of spontaneous reduced risk of labor complications from the introduction oxytotic agents; Buying time for transfer to hospital III level |
DIV at a gestational age of more than 37 weeks of pregnancy
The incidence of DIV in full-term pregnancies is about 10% (6-19%). In most women, after a premature outpouring of water, labor independently develops:
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 RIV in full-term pregnancy is an infection of the genitals (subclinical forms).
Maintaining:
Expectant and active tactics are possible. The patient and her family should receive maximum information about the condition of the mother and the fetus and the advantages of one or another tactic - it is imperative to obtain informed written consent from the patient for the chosen management tactics.
| Tactics | Risk | Benefits |
| Active |
1. Labor arousal: hyperstimulation; increase cS frequency; pain, discomfort; fetal distress 2. Development of septic complications in the mother |
Warning infections |
| Expectant | Development of infection |
Development of spontaneous labor with reducing risk complications from the introduction oxytotics |
Expectant tactics (up to 24 hours of anhydrous period):
1. Without vaginal examination.
2. Observation of the patient can be carried out in the ward of the pregnancy pathology department (control of body temperature, pulse, fetal heart rate, discharge from the genital tract, uterine contractions every 4 hours), with the development of labor, transfer to the obstetric department.
3. Antibiotic prophylaxis for an anhydrous period of more than 18 hours - every 6 hours until delivery.
When signs of infection appear, stop the expectant management tactics and take measures for the earliest possible delivery, taking into account
Fetal condition.
The incidence of infection and CS increases with labor induction after a 72 hour anhydrous period (3a)
Active tactics:
1. Assessment of the state of the cervix with digital vaginal examination.
2. With an immature cervix (Bishop score)< 6 баллов) - показано использование простагландинов (только интравагинально).
3. With a mature cervix - labor induction is possible with both prostaglandins and oxytocin.
4. Operative delivery is carried out according to obstetric indications according to the usual method, regardless of the duration of the anhydrous period and the presence of signs of chorioamnionitis.
5. Antibiotic prophylaxis is carried out after 18 hours of anhydrous period. Antibiotic therapy is indicated only if there are clinical signs of chorioamnionitis.
Chorioamnionitis is an absolute indication for rapid delivery and is not a contraindication to surgical delivery according to the usual method (1).
Postpartum management:
In the absence of signs of chorioamnionitis in childbirth, antibiotic therapy in the postpartum period is not prescribed.
If there are signs of infection, antibiotic therapy is prescribed.
Therapy lasts up to 48 hours of normal temperature.
Laboratory research:
1. At the level of the emergency room - a smear of the vaginal contents taken on the mirrors for the detection of o / water ("fern" symptom).
2. UAC with calculation of leukoformula. The frequency of this analysis every 12 hours, until delivery.
3. OAM. In the absence of pathological changes (proteinuria, microscopy), repeat in the postpartum period upon discharge from the hospital.
4. Blood group and Rh factor.
5. Research on HIV, RW.
6. In the case of a combination with somatic or obstetric pathology that complicates the outcome of childbirth, it is necessary to additionally conduct a biochemical blood test (total bilirubin, total plasma protein, ALT, AST, creatinine, urea, coagulogram).
Instrumental research:
1. Ultrasound of the fetus with an assessment of its biometrics, degree of maturity (with gestational age up to 37 weeks), amniotic fluid volume, dopplerometry (according to indications).
2. Monitoring the body temperature of the pregnant woman every 4 hours (recording in the observation sheet in the birth history).
3. Measurement of blood pressure, heart rate of the pregnant woman every hour (recording in the observation sheet in the birth history).
4. Control of urine output (recording in the observation sheet in the history of childbirth).
5. Fetal heart rate control with a stethoscope once every 30 minutes or periodic CTG.
With the outpouring of o \\ water with an admixture of fresh meconium, during labor arousal with oxytocin, during labor management against the background of EDA - continuous CTG.
Indications for specialist consultation
In the presence of additional obstetric or extragenital pathology that affects the outcome of labor, consultation with a specialized specialist is indicated.
The list of basic and additional diagnostic measures:
1. A smear of the vaginal contents taken on the mirrors for the detection of o / water (symptom of "fern").
2. UAC with calculation of leukoformula.
4. Blood group and Rh factor.
5. Research on HIV, RW.
6. Biochemical blood test (total bilirubin, total plasma protein, ALT, AST, creatinine, urea, coagulogram).
7. Ultrasound of the fetus.
Differential diagnosis
| Symptoms | Individual symptoms | Diagnosis |
|
Watery vaginal discharge |
1.Sudden severe effusion or intermittent expiration liquids 2. The liquid is visible at the entrance to vagina 3. No contractions for 1 hour from the beginning of water discharge |
Premature rupture of fetal bladder |
|
1. Foul-smelling watery vaginal discharge after 22 weeks of pregnancy 2. High fever / chills 3. Stomach pain |
1. Anamnesis - discharge of water 2. Painful uterus 3. Rapid heartbeat fetus 4. Light vaginal bleeding |
Amnionitis |
|
1. Foul-smelling discharge from the vagina 2. There is no history of discharge of water |
1. Itching 2. Foamy / curd discharge 3. Stomach pain 4. Dysuria |
Vaginitis / cervicitis |
| Bloody issues |
1. Stomach pain 2. Weakening of fetal movement 3. Severe, prolonged vaginal bleeding |
Prenatal bleeding |
|
Blood-stained mucous membranes or watery from the vagina |
1. Expanding and smoothing cervix 2. Contractions |
Urgent labor |
Treatment
Treatment tactics
Treatment goals: prevention of fetal RDS up to 34 weeks, prevention of infection. In case of immaturity of the cervix, apply prostaglandins intravaginally in order to prepare the body of a pregnant woman for childbirth. For the purpose of labor induction - the use of oxytocin or prostaglandins IV.
Non-drug treatment: mode number 3, there are no restrictions on food and liquid intake. Personal hygiene. Change of underwear 1-2 times a day, change of underwear every hour.
Medical treatment:
2. Antibiotic prophylaxis in the period from 28 to 37 weeks of gestation begins immediately after the diagnosis of DIV and continues until the baby is born, but not more than 7 days (erythromycin in tablets of 0.5 after 8 hours (1a).
Antibiotic prophylaxis for an anhydrous period of more than 18 hours in the case of DIV with a gestation period of more than 37 weeks - ampicillin 2 g IV (preferably) or IM every 6 hours until delivery.
With active tactics of DIV management, antibiotic therapy is indicated only in the presence of clinical signs of chorioamnionitis (ampicillin 2 g IV after 6 hours (can be administered before childbirth) + gentamicin 5 mg / kg IV 1 time per day after childbirth; metrogil 500 mg after 8 hours). Therapy lasts up to 48 hours of normal temperature.
3. Tocolytics (Ginipral, 4 ml infusion in saline sodium chloride 0.9% 400 ml) in preterm labor are indicated for a period not exceeding 48 hours (2a).
4. In order to prepare the body for childbirth, prostaglandins are introduced into the posterior fornix of the cervix, for example, prepidil gel (1).
5. Labor arousal - oxytocin (1).
Preventive measures DIV: timely sanitation of foci of infection in a pregnant woman.
General algorithm
|
Gestational age activity |
Less than 34 weeks | 34-37 weeks | Over 37 weeks |
| Tactics | Expectant |
Expectant; Active |
Active; Expectant |
| Hospitalization |
Hospital III - II level |
Hospital level III - II |
Hospital II level |
|
Specific therapy |
Tocolytics 48 hours, antibiotics before giving birth Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of 28.12.2007)
InformationSM Temkin, chief physician of the City Maternity Hospital No. 3, Astana. PS Inyakin, deputy chief physician of the City Maternity Hospital No. 3, Astana. OA Fekete, head of the maternity department of the City Maternity Hospital No. 3, Astana. Attached filesAttention!
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