Outcome of Preterm Premature Rupture of Membranes

Outcome of Preterm Premature Rupture of Membranes Hend Salah El Din Mohamed, Amina Saad Gonied and Amany Samy Badawy From the Maternal and Newborn Hea...
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Outcome of Preterm Premature Rupture of Membranes Hend Salah El Din Mohamed, Amina Saad Gonied and Amany Samy Badawy From the Maternal and Newborn Health Nursing Departments, Zagazig University, Egypt

Abstract: Preterm premature rupture of membranes is commonly used to refer to rupture of the membranes when it occurs before term. The period between preterm rupture of membranes and the onset of labor is called latency period.1 Membrane rupture may occur for a variety of reasons: weakening of the membranes or intrauterine infection.2,3 The complications resulting from premature rupture of membranes include preterm labor and delivery, intra uterine infection, and umbilical cord compression secondary to umbilical cord prolapse or oligo hydramnios.4 This study was conducted to identify the optimal outcome preterm premature rupture of membranes. A sample of fifty women was selected from the maternity hospital at Zagazig University hospitals with the following criteria: women with gestational age range from 32-36 weeks and with the diagnosis of preterm premature rupture of membranes. Setting: the women where selected from delivery unit. The study tools included a questionnaire sheet, maternal observation sheet until delivery, mode of delivery, and neonatal assessment using Apgar scoring and weight. The data were collected over period of 6 months starting from May 1st, 2003. The results revealed that in more than three quarter (80%) of the women the temperature was up to 37Co and only 10% of them had high blood pressure (140/90). Also, more than half of the women were delivered by Caesarian section (CS), the most common cause for CS was fetal distress. Regarding neonatal outcome, the results illustrated that 24% of the neonates needed NICU care, and 20% of them had high temperature. So, it is recommended that women with premature rupture of membranes (PROM) should be counseled regarding the potential hazards and risks involved for both maternal and neonatal outcome and they must be observed and managed at hospital with adequate intensive care facilities.

Introduction : Preterm Premature Rupture of Membranes (PPROM) is defined by Gibret and Harmon,1 in 2003, as rupture of membrane prior to term, when membrane rupture occurs before 37 weeks of gestation. The period between preterm rupture of membranes and onset of labor is called the latency period. The incidence of preterm premature rupture of membranes as reported by Mercer,5 in 1992, is corresponding to 2.7% to 17% depending on the length of latent period used in making diagnosis. Regarding the risk factors that may lead to rupture of membranes, as stated by Allens,6 in 1991; Ekwo et al.,7 in 1993., and McGregor and French,8 in 1997, were weakness in the chorioamnion membranes (relative as absolute, localized or generalized), intra uterine infection, lower socio-economic status, sexually transmissible infection, prior term delivery, vaginal bleeding and cigarette smoking during pregnancy. Novack-antolic et al.,9 in 1997, mentioned that the uterine distention (hydramnios, twins) and emergency cervical cerclage also may be associated with PPROM. The most significant maternal risk of PPROM is intra uterine infection; while fetal risks

include umbilical cord compression and ascending infection.3 The complications resulting from PPROM include preterm labor and delivery, intra uterine infection and umbilical cord compression secondary to prolapse of umbilical cord or oligohydramnios.4 The optimal management of PPROM is still controversial. Some obstetricians believe that expectant management in the hospital rather than at home (or waiting for labor to begin spontaneously) is preferable for mothers if there is no evidence of fetal or maternal compromise.3 The problems encountered among women with PPROM are numerous and vast. Therefore, the present study will be carried out to identify the optimal outcome of PPROM.

Subjects and Methods: Setting : This prospective study was carried out at delivery unit, Zagazig University hospital in Zagazig city during the period from the May 1st, 2003 to the end of October 2003. Sample: Fifty women were selected from the labor unit at maternity hospital at Zagazig University Hospitals with the following criteria: women with an age range from

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c) Investigation for urine was done by the researcher. d) Sonar to estimate fetal movement FHS, B.PP by on-duty physician. Women were admitted to the hospital and followed up until delivery. Follow up care was provided to every woman separately according to her medical condition. This consists of maternal care, i.e. measuring women vital signs, giving medication, good rest, nutrition, etc. Danger signals were reported immediately to the doctor. Immediate baby care : The researcher performed baby care for each baby. This started with cleaning air way and maintaining it patent, cutting umbilical cord, cleaning eyes, measuring body temperature and measuring body weight. Apgar scoring was evaluated at one and at five minutes after delivery, five parameters were examined and scored by the researcher.

20-35 years, diagnosed as having preterm premature rupture of membranes, with gestational age ranging from 32-36 weeks gestation. After explaining the study objectives, approval of 50 parturient women willing to participate in the study were obtained in the previously mentioned setting. In selecting the study sample certain criteria were used as follows: women with normal pregnancy, singleton fetus, gestational age less than 36 weeks, and diagnosed as having PPROM. The women age ranged from 20-35 years. Tools of data collection: Data collection was carried out using the following tools by the researcher to collect the data: 1. A structured interviewing questionnaire sheet. 2. Assessment sheet, both maternal and neonatal. 3. Apgar scoring at first and five minutes. 1) A structured questionnaire was developed in order to obtain data about personal characteristics (age, education, occupation and income), past and present obstetric history (gravida, para, losses, previous labor). The questionnaire included as well, data about present pregnancy such as present complain (leakage of fluid, duration of leakage, amount, color and odor of amniotic fluid). 2) Maternal assessment sheet included: Assessment of general condition of the woman on admission (vital signs temperature, pulse and blood pressure) done by the researcher while obstetric examination (PV) fundal level, auscultation of fetal heart sound was done by the on-duty physician and researcher. Investigation for urine and finally sonar was done by the on-duty physician to determine the adequacy of the amniotic fluid and to assess any danger signal. Moreover, assessment of progress of labor was done by using partograph and the mode of delivery. 3) Neonatal assessment sheet included information about neonatal physical assessment, measuring temperature, both weight and Apgar scoring at 1st and 5th minute. Crying and suckling reflexes were tested as well by the researcher. Data collection method : Assessment of patient condition was done by physician and the researcher, these included: a) History taking, i.e. personal, obstetrical and medical data as well as present complaint. b) Physical examination including general, local and abdominal examination was performed by the researcher on admission as well as identification of the date and time of membranes rupture.

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Results : Table I illustrates the socio demographic characteristics of the included women. It is clear from this table that the women age ranged from less than 20 to more than 30 with their mean age ± SD= 25.54± 6.9. Regarding the educational level, only 12 percent (12%) were highly educated. Also this table shows that the mean gravida among chosen women were 2.34 ± 1.74 and the mean parity was 1.72 ± 1.47. Concerning maternal condition on admission, table II shows that a small percent (10%) of the women have high blood pressure (140/90). More than three quarters (80%) of women had a temperature up to 37oC. Table III reveals the maternal outcome after PPROM. It was found that 60% of the women were delivered by CS and the causes of CS were fetal distress (n= 30). Table IV illustrates neonatal condition. As shown from table IV, the mean gestational age of the infants was 34.4±1.2 weeks and the mean birth weight of the neonates was 2048± 450 gm. The same table also indicates that 36% of the neonates have an Apgar scoring at one min less than 7 and only 6% of them had neonatal infection. Table V indicates a statistically significant relation between odor of amniotic fluid and Apgar scoring evaluation at first minutes X2= 9, P= 0.02.

Discussion : Several studies have evaluated women with premature rupture of membranes at term. Three studies have been undertaken on patients with

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Table I : Number and percent distribution of the study sample by their characteristics Maternal characteristics Age

Number 26 9 15

20-24 25-30 30 - 35 Mean ± SD

Educational level

Occupation No of gravida

No of para

Pervious preterm delivery

% 42 18 30 25.54±6.902

Illiterate Primary or preparatory Secondary University Worker mothers House wife 1 2 3 Mean ± SD 1 2 3

30 28 30 12 58 42 48 20 32

15 14 15 6 29 21 24 10 16 2.34±10745

Mean ± SD Yes No

24 15 11

48 30 22

1.72±1.471 10 40

20 80

Table II: Maternal condition on admission after PROM at 32 to 36 weeks gestation Maternal condition on admission (50) Pulse (b/m) Less than 90 More than 90 Up to 110 Systolic BP (mm HG) 111-139 140 or more Temperature Urine analysis

Up to 37.4 37.5or more Normal Abnormal

Number 45 5 25 20 5

% 90 10 50 40 10

40 10 45 5

80 20 90 10

Table III: Maternal out come after premature rupture of membranes at 32-36 weeks gestation Type of delivery (50) Causes of CS (30) Maternal distress ( 50) Hospital stay

Maternal outcome SVD CS Previous CS Fetal distress Failed induction No Yes > 7 day ≥ 14 day < 14 day

Number 20 30 8 18 4 45 5 20 15 15

% 40 60 26.6 60.0 13.3 90.0 10.0 40 30 30

Table IV: Neonatal out come after premature rupture of membranes at 32 to 36 weeks gestation Apgar scoring Temperature Crying Suckling Neonatal morbidity Neonatal infection (3) Hospital stay Survival/Deaths Mean gestational age Mean birth weight

Neonatal outcome 1 min < 5 5 min < 7 Normal Abnormal Normal Abnormal Good Weak Infection Normal Confirmed Suspected > 7 days ≥ 14 days Survival Deaths

Number 18 32 47 3 30 20 30 20 3 47 2 1 40 10 48 2 34.4± 1.2 weeks gestation 2408 ± 450 gm.

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% 36 64 94 6 60 40 60 40 6 94 66.6 33.4 80 20 96 4

Alex J Pediatr, 19(2), July 2005

Table V: The relation between odor of amniotic fluid and neonatal health condition Odor of fluid Normal Apgar score after 1 min Apgar score after 5 min Infant weight I.C.U Live/Death

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