Case Presentation - Pprom

CASE PRESENTATION -
PPROM
Presented by :- Dr Janvi, Dr Baljinder,
Dr Jaspreet, Dr Ameen
HISTORY TAKING
● NAME : xyz
● AGE : 29 YRS
● SEX : female
● ADDRESS : HNO ## LUDHIANA
● OCCUPATION : House wife
● EDUCATION : Graduate
● BOOKED CASE AT DMCH
● DATE OF ADMISSION : 22/11/23
● LMP : 30/3/23
● EDD :7/1/24
● POG : 34 WEEKS 0 DAYS
CHIEF COMPLAINTS
Amenorrhea since 8.5 months corresponding to 34 weeks

1 episode of leaking per vaginum since 1 day ( 21/11/23 since
8 pm )
HISTORY OF PRESENT ILLNESS
Pt was apparently normal 1 day ago when she developed leaking per vaginum which was sudden in
onset
The fluid was clear , serous in consistency , non foul smelling , and about two cups in amount associated
with soakage of clothing.
Fetal movements were perceived well

● no h/o lower abdominal pain
● No h/o fever
● No h/o burning micturition
● No h/o discharge pv
● No h/o bleeding per vaginum
● No h/o polyphagia, polydipsia,polyuria
● No h/o abdominal distension
● no h/o trauma/travel/intercourse
● no h/o altered bowel or bladder habits
● no h/o previous similar episode
● no h/o manipulation performed on uterus prior to onset of leaking
● No h/o invasive procedures
HOSPITAL COURSE
1. Vitals were regularly monitored
2. On admission Non Stress Test was done
3. Continuous fetal heart rate monitoring was done
4. High risk of prematurity was explained to attendants and pt.
5. USG FWB + DOPPLER was done
6. Expectant management :
● Blood , urine and all other relevant investigations sent
● IV antibiotics and drips started
● Steroid cover administered
HISTORY OF PRESENT PREGNANCY
● Urine pregnancy test was done one week after missing her periods by pt at
home.
● H/o nausea, vomiting present diagnosed at first 3 months which did not
interfere with routine activities and was relieved on medication .
● H/o increased frequency of micturition present but it was not associated with
burning micturition and pain abdomen .
● No h/o fever with rashes
● No h/o spotting or bleeding per vaginum
● No h/o discharge per vaginum
● No h/o pain abdomen
● No h/o exposure to radiation and drug intake
● No h/o drug / alcohol abuse
● She consulted qualified doctor and was advised blood and urine tests which
were found out to be normal .
● First trimester dating scan was done at 9 weeks and revealed single
intrauterine pregnancy and corresponding to gestational age
● She was given folic acid daily and had regular ANC monthly .
● No scan or investigations were done between 11 - 14 weeks
● Pt had quickening at end of 5 months of gestation .
● She received 2 doses of TT vaccine one month apart in 4th and 5th month .
● No h/o fever with rashes
● No h/o spotting or bleeding per vaginum
● No h/o discharge per vaginum
● No h/o pain abdomen
● No h/o exposure to radiation and drug intake
● No h/o pedal edema , headache
● No h/o increased BP recordings
● No h/o polyphagia,polyuria , polydipsia
● Pt was advised to get a blood test done 2 hrs after drinking 75 g of glucose
and was informed that it was normal .
● At end of 5th month Anomaly scan was done and it was normal.
● She was given Iron and calcium tablets which she took regularly.
● Fetal movements were well perceived
● Her Weight gain in pregnancy was about 12 kg
● Growth scan done at 32 weeks and showed normal development.
● No h/o leaking pv until 33 plus 6 weeks when she developed leaking per
vaginum and went to local practitioner where she was administered iv
medications and steroid cover was started .She was referred to DMCH for
further management
Menstrual history
● Menarche : 12 years
● Date of LMP : 30/3/23
● Menstrual cycles were regular lasting for 3-4 days , average flow , no
dysmenorrhea
OBSTETRIC HISTORY
● MARRIED FOR 3 YRS
● NON CONSANGUINEOUS MARRIAGE
● OBSTETRICAL FORMULA : PRIMIGRAVIDA
● SPONTANEOUS CONCEPTION
● BARRIER METHOD OF CONTRACEPTION USED FOR 2 YEARS
● LMP : 30/3/23
● EDD :7/1/24
● POG :34 WEEKS 0 DAYS
PAST HISTORY
No h/o bleeding disorder HTN , thyroid ds , TB , asthma , heart ds , epilepsy or
surgeries in past .
No h/o previous blood transfusions
No h/o hospitalisation
FAMILY HISTORY
● NO h/o HTN/DM/CAD/HTN in siblings
● NO h/o consanguineous marriage or congenital malformation in
family .
DIETARY HISTORY
● She consumes vegetarian diet about 1800 kcal , adequate
proteins .
● Her prepregnancy BMI was 23
PERSONAL HISTORY
● Adequate sleep and appetite .
● No h/o suggestive of intake of alcohol , smoking , drug abuse
● No h/o domestic violence
SOCIOECONOMIC HISTORY
● Lower Middle class according to Modified Kuppuswamy scale

SUMMARY
29 yrs old female primigravida at 8 ½ months amenorrhea comes with one
episode of leaking per vaginum 1 day ago.
It was sudden in onset .
Fetal movements were well perceived
EXAMINATION
• PHYSICAL EXAMINATION
• On admission, She was calm, conscious, cooperative and well oriented to time, place
and person.
• Moderately built, well nourished.
• BMI of 24.6
• Pulse- 88 bpm, regular, good volume, no specific character, no radioradial and
radiofemoral delay.
• BP-120/70 mm Hg right arm sitting position.
• RR-16/min,regular
• Afebrile to touch.
• Vas score =0
• Orodental hygiene was normal
• No pallor, Icterus, Cyanosis
• JVP not raised
• Trachea central
• No lymphadenopathy, clubbing or pedal edema.
• CNS = Higher motor functions were normal, reflexes were normal
• Thyroid :Not Palpable.
• BREAST = NAD
• CHEST:- B/L air entry present
• CVS:- S1 S2 present
OBSTETRIC EXAMINATION
PREPARATORY PROCEDURES
• Verbal consent taken
• Patient was asked to empty the bladder.
• Stand on right side of patient
• Patient made supine with legs flexed, abducted
• Abdomen exposed from xiphisternum till pubic symphysis.
• INSPECTION
• Abdomen spherical in shape ,uniformly distended.
• Umbilicus everted
• Linea nigra present.
• Striae gravidarum present.
• No superﬁcial dilated veins.
• No localised swelling.
• All hernia sites normal.
• All quadrants moving equally with respiration
• PALPATION
• After centralising the uterus,
• No local rise of temperature.
• Fundal Height corresponded to 32-34 weeks of POG(corresponding to pog)
• Symphysio-fundal height : 33 cms
• Abdominal girth= 30 Inches
• Single fetus, longitudinal lie
• Cephalic presentation
• Uterus relaxed
• FHS = variable 140 to 148bpm
• Non tense, non tender.
• Liquor seems decreased.
OBSTETRIC GRIPS
• FUNDAL GRIP: Broad soft irregular part s/o breech
• LATERAL OR UMBILICAL GRIP:
Uniform , continuous curved resistance s/o back
Multiple knob like structures s/o limbs
• PAWLIK’S GRIP: Hard round ballotable mass s/o fetal
head
• PELVIC GRIP: Fingers are converging
VAGINAL EXAMINATION
• INSPECTION OF VULVA
Discharge present from vaginal introitus with
10%soakage of vulval pad
• SPECULUM EXAMINATION
under all aseptic conditions , speculum examination
done and clear, non foul smelling liquor present.
EXAMINATION IN PPROM
• Vitals monitoring –Pulse, blood pressure,temperature
measurement and urine analysis
• Abdominal palpation for fetal size,presentation,liquor
volume,uterine tenderness,multiple gestation.
• Vaginal speculum examination esp with cusco’s
a)demonstrate gush of amniotic fluid in upper vagina
b) gives information about effacement and
dilatation of cervix.
c)For taking endocervical and high vaginal swab for culture
sensitivity
d)Exclude cord prolapse
• Assess uterine cavity and fetal viability-CTG preferred.
• Vaginal examination should be avoided to avoid infections but
can be done in advanced labour.
DIAGNOSIS
29 years old primi at 34 weeks of gestation
single live intrauterine pregnancy
Cephalic presentation
Provisional diagnosis :- PPROM
DIAGNOSIS OF
PPROM
PPROM is diagnosed when vaginal leak of
amniotic fluid is demonstrated
• Digital cervical examination should be avoided as
it increases the risk of infections.
• PER SPECULUM EXAMINATION

It is done by taking aseptic precautions to inspect
the liquor coming out through the cervix.
To examine the collected fluid
from the posterior
fornix( vaginal pool)for:
DETECTION OF pH: by
using litmus paper on Nitrazine
paper.
▪ The ph becomes 6-6.2
▪ Normal vaginal pH during
pregnancy is 4.5-5.5.
▪ pH of liquor amnii is 7-7.5
▪ SENSITIVITY: 97.7%
▪ SPECIFICITY: 90%
b) Characteristic (ferning pattern ) of
amniotic fluid when smeared
under the microscope.
This ferning pattern is due to NaCl in
amniotic fluid.
SENSITIVITY:98.3%
SPECIFICITY: 100%
• Centrifuged cells
stained with 0.1%
nile blue
sulphate.
• AMNISURE
It is a rapid slide test using chromatographic methods
to detect traces of PAMG-1 in cervicovaginal fluid.
Threshold for diagnosis is >5ng/ml
SENSITIVITY: 98.7-98.9%
SPECIFICITY: 98- 100%
• ROM plus test : it is combination of
monoclonal/polyclonal Ab test detecting
placental proteins
• SENSITIVITY : 99%
• SPECIFICITY: 91%
INVESTIGATIONS
• Complete blood count
for leukocytosis
• C-reactive protein
sensitivity:60-70%
specificity:86%
• Urine routine and culture
• High vaginal swab
sensitivity: 98%
specificity: 84.4%
• Endocervical swab
neisseria gonorrhoea
chlamydia trachomatis
• Ultrasonography
fetal well being
amniotic fluid measurement
• Indigo carmine dye test:
needle is used to inject dye into the amniotic fluid that
remains in the uterus, blue dye can be stained on
tampon or pad after 10-15 mins.
Obselete nowadays.
Management of PPROM
Expectant Management
Diagnosis uncertain
Admit the patient
Perform regular perineal pad checks
Perform USG for FWB esp AFI
Observe for signs of chorioamnionitis
Diagnosis certain
Admit the patient
<34weeks gestation, conservative management.
Contact NICU
Deliver
Chorioamnionitis
Onset of spontaneous labour
Foetal compromise
Foetal maturity is achieved
Antenatal corticosteroids
In uncomplicated PPROM, antenatal corticosteroids
should be offered.
Prophylactic antibiotics
● To prevent chorioamnionitis
● Reduce neonatal mortality & Sepsis
● Prophylaxis of group B streptococcus
ORACLE 1 trial
Ampicillin 2g stat i/v followed by 1g 6hourly
Amoxycillin 500mg 8hourly
Erythromycin 250mg 6 hourly
Tocolysis
PPROM is not a contraindication to tocolysis.
Mode of delivery
Cephalic- vaginal delivery is ideal
Induction can be achieved by dinoprostone
gel(PGE2)
Oxytocin can be started.
Cesarean may be indicated

Preterm breech presentation/ abnormal lie.
Cord prolapse >26 weeks
Thank you

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CASE PRESENTATION -

Amenorrhea since 8.5 months corresponding to 34 weeks

Fetal movements were perceived well

● Lower Middle class according to Modified Kuppuswamy scale

• PER SPECULUM EXAMINATION

Cesarean may be indicated

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