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Premature Membrane Rupture (Early water discharge of pregnancy)
Premature membrane rupture (PMR) is the early discharge of water due to amniotic membrane tear before the onset of labor pains. Preterm PMR is tearing of the membranes without labor pains before the 37th week. Subsequent to water discharge, labor pains also begin in 24 hours; however, the earlier the discharge is, the later onset of labor pains will be. For example, in case of water discharge before the 26th week, it takes minimum a week in %30-40 of patients until child labor while in cases between 28-36th weeks %70-80 of patients give birth within a week.
Risk factors in Premature Membrane Rupture
Among the risk factors of PMR, socioeconomic level, nutritional insufficiency, smoking, some connective tissue diseases such as Ehlers-Danlos, genital system infections (such as bacterial vaginosis), conditions that tense the uterus excessively, vaginal bleedings that occur especially in the second or third month and prior PMR history take place.
Membrane rupture usually occurs just as urinary incontinence and sudden discharge of water from vagina and subsequent uncontrolled leakage. Sometimes it causes symptoms such as leakage with intervals or wetness in perineal area. In suspicion of PMR, doctors must be consulted immediately and it should be made clear whether the water is discharged or not. Along with PMR, cordon may hang off and sometimes placenta may get dislocated, causing bleeding.
- Ref: http://prettymomguide.com/risks-in-pregnancy-rupture-of-membranes.html
What should be done to Patients with Premature Membrane Rupture, Examination
Manual vaginal examination is not done to patients who are suspected of water discharge if there are no labor pains and no expectation of birth in 24 hours because it increases risk of infections. With the help of sterile tool called speculum which is also used for routine examination, it is checked whether amniotic fluid is coming out or not by straining or coughing when necessary. Also, pH value pf the fluid which accumulated in the vagina is evaluated with nitrasine paper and it is checked if it is amniotic fluid or not. Nitrasine test may give false results in case of infection, blood, sperm presence and contact with mucus in the cervix. Additionally, pad follow-up should be done in order to check for amniotic fluids. If it could not be decided whether or not water is being discharged, this examination might be repeated. Subsequently, the amount of amniotic fluid, baby’s growth, weight and position of placenta is checked via USG. Also, heart beats of the baby and contractions are evaluated with cardiotocography (NST). Infection of the membranes called corioamnionitis may accompany to premature membrane rupture; thus mother’s fever, vitals, sensitivity presence in the uterus must checked; blood count, CRP and blood cultures must be ordered. In case of water discharge before the 30th-32nd weeks, corioamnionitis is common and it carries a risk for both mother and the baby.
Management of PMR is defined by pregnancy week and infection presence.
Before the 24th week, if diagnosis is definite, family will be informed about the case and pregnancy may be ended if family wants to. In case of PMR before the 26th week, hypoplasia of the lungs is spotted in one baby out of four. Hypoplasia risk was found to be related with pregnancy age in time of PMR, level of oligohydramnios (lack of amniotic fluid) and its time. Oligohydramnios may also cause skeletal deformities in the baby.
In order to be protected from PMR related infection and non-infectious risks, childbirth is chosen as a treatment option in cases above 34th week because no serious problem is expected after 34 weeks in the baby.
In between the weeks 24 and 34, if there is no condition that requires emergent childbirth for the mother or baby, infection symptoms are followed closely and it is aimed to make it to the 34th week as long as conditions allow it. In this period, antibiotic treatment is made, steroids are applied in order to speed up lung development of the baby, baby’s health is evaluated with NST, amniotic fluid amount is checked and mother is followed for infection symptoms. It is known that antibiotics postpone the labor and steroid administration along with antibiotics reduces the risks for both mother and the baby.
- Ref: http://nurse-practitioners-and-physician-assistants.advanceweb.com/f
Use of drugs which stop the contractions of uterus (tocolytic drugs) is not advised in patients of PMR. Only in selected cases, it may be used in order to complete the treatment for baby’s lung development or maintain transfer to centers with newborn ICU.
Primary risks and complications of PMR are premature birth and prematurity related breathing problems, brain hemorrhage, intestinal problems, eye problems; also due to both prematurity and PMR, sepsis, fetal distress, cordon hanging, ablatio placenta, corioamnionitis and sepsis in mother.
The important things are a professional center with adequate newborn ICU and an experienced team that can make right decisions and manage the patient properly without giving unnecessary hope to parents.