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Premature Rupture of Membranes

Premature rupture of membranes (PROM), is defined as rupture of membranes (breakage of the amniotic sac), commonly called breaking of the mother’s waters, more than 1 hour before the onset of labour. The sac (consisting of 2 membranes, the chorion and amnion) contains amniotic fluid, which surrounds and protects the fetus in the uterus (womb). After rupture, the amniotic fluid leaks out of the uterus, through the vagina. The foetal membranes serve as a barrier to ascending infection. Once the membranes rupture, both the mother and fetus are at risk of infection and of other complications.
Women with PROM usually experience a painless gush of fluid leaking out from the vagina, but sometimes a slow steady leakage occurs instead.
Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks’ gestation and has presented with rupture of membranes (ROM) prior to the onset of labour. Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks’ gestation. Prolonged ROM is any ROM that persists for more than 24 hours prior to the onset of labour.
Eighty-five percent of neonatal morbidity and mortality is a result of prematurity. PPROM is associated with 30-40% of preterm deliveries and is the leading identifiable cause of preterm delivery. PPROM complicates 3% of all pregnancies and occurs in approximately 150,000 pregnancies yearly in the United States
Despite the common TV image of ROM occurring in every pregnancy, PROM occurs in approximately 10% of pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. Most patients (90%) enter spontaneous labour within 24 hours when they experience ROM at term. The major question regarding management of these patients is whether to allow them to enter labour spontaneously or to induce labour. The management of these patients depends on a number of factors including patient’s wishes, however, the major maternal risk at this stage is intrauterine infection. The risk of intrauterine infection increases with the duration of ROM. Evidence supports the idea that induction of labour, as opposed to expectant management, decreases the risks.
Premature preterm rupture of membranes (PPROM) occurring from 24-37 weeks’ gestation is far more difficult to manage than premature rupture of membranes (PROM) at term. Prematurity is the principal risk to the fetus, while infection morbidity and its complications are the primary maternal risks. The initial evaluation of premature preterm rupture of membranes (PPROM) should include a sterile speculum examination to document ROM. Cervical cultures including Chlamydia trachomatis and Neisseria gonorrhoeae should be obtained. ROM diagnosis needs to be confirmed. Digital vaginal examinations should be avoided. Ultrasonography should be performed to confirm gestational age,
Maternal vital signs should be documented as well as continuous foetal monitoring initially to establish foetal status. Once the decision to manage a patient expectantly has been made, the institution of broad-spectrum antibiotics should be considered. Multiple trials have examined the advantages and disadvantages of using antibiotics and the choice of antibiotics. In most studies, use of antibiotics has been associated with prolongation of pregnancy and reduction in infant and maternal morbidity. However, a few studies have reported increased neonatal morbidity.
The RCOG recommends –
Antenatal prophylactic antibiotics for women with PPROM
• Offer women with PPROM oral erythromycin 250 mg 4 times a day for a maximum of 10 days or until the woman is in established labour (whichever is sooner).
• For women with PPROM who cannot tolerate erythromycin or in whom erythromycin is contraindicated, consider oral penicillin for a maximum of 10 days or until the woman is in established labour (whichever is sooner).
• Do not offer women with PPROM co amoxiclav as prophylaxis for intrauterine infection.

The use of corticosteroids to accelerate lung maturity should be considered in all patients with PPROM with a risk of infant prematurity from 24-34 weeks’ gestation. A single course of corticosteroids is recommended for pregnant women 24-34 weeks’ gestation who are at risk of preterm delivery within 7 days.

Several techniques have been developed in an attempt to artificially reseal the foetal membranes and prevent leakage of amniotic fluid including, among others, intra-amniotic injection of platelets and cryoprecipitate (amnio-patch), sealing the cervical canal, and laser coagulation. However, there is as yet no effective and safe technique to achieve this goal.

References
1. Mercer BM, Arheart KL. Antimicrobial therapy in expectant management of preterm premature rupture of the membranes. Lancet. 1995;346:1271–9.
2. Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL, et al. Induction of labor compared with expectant management for prelabor rupture of the membranes at term. N Engl J Med. 1996;334:1005–10.
3. Schucker JL, Mercer BM. Midtrimester premature rupture of the membranes. Semin Perinatol. 1996;20:389–400.
4. American College of Obstetricians and Gynecologists. Premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. ACOG practice bulletin no. 1. Int J Gynaecol Obstet. 1998;63:75–84.
5. Mercer BM. Preterm premature rupture of the membranes. Obstet Gynecol. 2003;101:178–93.
6. Smith CV, Greenspoon J, Phelan JP, Platt LD. Clinical utility of the nonstress test in the conservative management of women with preterm spontaneous premature rupture of the membranes. J Reprod Med. 1987;32:1–4.
7. Cox SM, Leveno KJ. Intentional delivery versus expectant management with preterm ruptured membranes at 30–34 weeks’ gestation. Obstet Gynecol. 1995;86:875–9.
8. ACOG Committee on Practice Bulletins-Obstetrics, authors. Clinical management guidelines for obstetrician-gynecologists. (ACOG Practice Bulletin No. 80: premature rupture of membranes).Obstet Gynecol. 2007;109:1007–1019.
9. Spinillo A, Montanari L, Sanpaolo P, et al. Fetal growth and infant neuro-developmental outcome after preterm premature rupture of membranes. Obstet Gynecol. 2004;103:1286–1293
10. Healy AJ, Veille JC, Sciscione A, et al. The timing of elective delivery in preterm premature rupture of the membranes: a survey of members of the Society of Maternal-Fetal Medicine. Am J Obstet Gynecol. 2004;190:1479–1481.
11. Lee SE, Park JS, Norwitz ER, et al. Measurement of placental alpha-microglobulin-1 in cervicovaginal discharge to diagnose rupture of membranes. Obstet Gynecol. 2007;109:634–640
12. Mercer BM. Preterm premature rupture of the membranes: current approaches to evaluation and management. Obstet Gynecol Clin North Am. 2005;32:411–428.
13. Gold RB, Goyert GL, Schwartz DB, et al. Conservative management of second-trimester postamniocentesis fluid leakage. Obstet Gynecol. 1989;74:745–747.
14. Lewi L, Van Schoubroeck D, Van Ranst M, et al. Successful patching of iatrogenic rupture of the fetal membranes. Placenta. 2004;25:352–356.
15. Bonanno C, Fuchs K, Wapner RJ. Single versus repeat courses of antenatal steroids to improve neonatal outcomes: risks and benefits. Obstet Gynecol Surv. 2007;62:261–271.
16. Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol. 2004;104:1051–1057.

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Teen Pregnancy

The rate of teenage pregnancy in the United Kingdom is relatively high, when compared with other developed countries; the only other Western countries with higher teenage pregnancy rates are the United States and New Zealand. The rate of teenage pregnancy is higher in more economically deprived areas. In 2008 the number of births to girls under 20 in England & Wales was 44,690, a provisional rate of 26.2 per thousand teenage women in the population.
The UK government tracks teenage pregnancy rate using the age of the girl at conception, unlike pregnancy statistics in other countries. Which use the age of girl at the outcome of her pregnancy. In reporting teenage pregnancy rates, the number of pregnancies per 1,000 females aged 15 to 19 when the pregnancy ends is generally used. The teen pregnancy rate is the sum all live births, abortions, and miscarriages (or foetal losses) per 1,000 adolescent females ages 15-19 in a given year. Worldwide, teenage pregnancy rates range from 143 per 1000 in some sub-Saharan African countries to 2.9 per 1000 in South Korea.
Approximately 16 million girls aged 15 to 19 years and 2.5 million girls under 16 years give birth each year in developing regions. Complications during pregnancy and childbirth are the leading cause of death for 15 to 19 year-old girls globally. Every year, some 3.9 million girls aged 15 to 19 years undergo unsafe abortions

In the USA in 2016, there were 20.3 births for every 1,000 adolescent females ages 15-19, or 209,809 babies born to females in this age group. Births to teens ages 15-19 accounted for 5.3 percent of all births in 2016. Although the teen birth rate has declined the teen birth rate in the United States remains higher than that in many other developed countries, including Canada and the United Kingdom. Teen birth rates differ substantially by age, racial and ethnic group, and region of the country. Most adolescents who give birth are 18 or older; in 2016, 74 percent of all teen births occurred to 18- to 19-year-olds.1 Birth rates are also higher among Hispanic and black adolescents than among their white counterparts. In 2016, Hispanic adolescent females ages 15-19 had a higher birth rate (31.9 births per 1,000 adolescent females) than black adolescent females (29.3) and white adolescent females (14.3).
Not all teen births are first births. In 2016, one in six (17 percent) births to 15- to 19-year-olds were to females who already had one or more births.

School
There are a number of specific problems with adolescent pregnancy, social as well as medical. Education is a particular concern, in the UK a pregnant teenager is expected to stay at school and continue education until the end of Year 11, with a maximum 16-week break immediately before and after the birth.
Medical
Pregnancy in women less than 18 years old is associated with increased risk of preterm labour before 32 weeks’ gestation, maternal anaemia, chest infection and urinary tract infection. Rates of ectopic pregnancy, pre-eclampsia, eclampsia, preterm labour, premature rupture of membrane and caesarean section are significantly higher among adolescents less than 15 years of age; the risk then decreases steadily with age.
The high risk of adverse pregnancy outcome in the adolescent has been attributed to gynaecological immaturity and the growth and nutritional status of the mother. Gynaecological immaturity undoubtedly predisposes adolescent girls to poor pregnancy outcome in that the rates of spontaneous miscarriage and of very preterm birth (<32 weeks of gestation) are highest in girls aged 13–15 years. Adolescent pregnant women not only face pregnancy related problem but also they are prone to have obstructed labour due to their developing pelvic bones. Obstructed labour is one of the most common and preventable causes of maternal and perinatal deaths and disabilities.
Maternal and prenatal health is of particular concern among teens who are pregnant or parenting. The worldwide incidence of premature birth and low birth weight is higher among adolescent mothers.
Research indicates that pregnant teens are less likely to receive prenatal care, often seeking it in the third trimester, if at all. Studies show that one-third of pregnant teens receive insufficient prenatal care and that their children are more likely to have health issues in childhood or be hospitalized than those born to older women.
Young mothers who are given high-quality maternity care have significantly healthier babies than those who do not. Many of the health-issues associated with teenage mothers appear to result from lack of access to adequate medical care.
Many pregnant teens are at risk of nutritional deficiencies from poor eating habits common in adolescence, including attempts to lose weight through dieting, and food faddism.
Inadequate nutrition during pregnancy is an even more marked problem among teenagers in developing countries. Complications of pregnancy result in the deaths of an estimated 70,000 teen girls in developing countries each year. Young mothers and their babies are also at greater risk of contracting The World Health Organization estimates that the risk of death following pregnancy is twice as high for women aged 15–19 than for those aged 20–24. The maternal mortality rate can be up to five times higher for girls aged 10–14 than for women aged 20–24. Illegal abortion also holds many risks for teenage girls in areas such as sub-Saharan Africa.
Risks for medical complications are greater for girls aged under 15, as an underdeveloped pelvis can lead to difficulties in childbirth. Obstructed labour is normally dealt with by Caesarean section in industrialized nations; however, in developing regions where medical services might be unavailable, it can lead to eclampsia, obstetric fistula, infant mortality, or maternal death. Complications from pregnancy and childbirth are the leading cause of death in young women aged 15 to 19 in developing countries. A pelvis that is less than fully developed in adolescents, as assessed by pelvic size, may also contribute to lower birth weight in adolescent mothers. For mothers who are older than fifteen, age in itself is not a risk factor, and poor outcomes are associated more with socioeconomic factors rather than with biology.
During labour and delivery where age is the only risk factor, management is usually the same as for other labouring women. However, in very young adolescents there is an increased likelihood of obstructed labour because of a small, immature pelvis.
Teenage pregnancy today represents one of the most important public health problems. There is no doubt that the obstetrical problems can be managed by modern medicine and so the risk of teenage pregnancy can be diminished. The health care provider should consider teenage pregnancy as a ‘high risk’ pregnancy and should educate pregnant teenagers to have more antenatal visits so that the signs and symptoms of various complications of teenage pregnancy could be recognized at the earliest opportunity.

References
1. Sedgh, Gilda (2015). “Adolescent Pregnancy, Birth, and Abortion Rates Across Countries: Levels and Recent Trends”. Journal of Adolescent Health.
2. “Teenage Conceptions By Small Area Deprivation In England and Wales 2001-2” (Spring 2007)Health Statistics Quarterly Volume 33
3. “Conception Statistics 2006 ” Office for National Statistics
4. Trevor Smith (1993). “Influence of socioeconomic factors on attaining targets for reducing teenage pregnancies”. British Medical Journal. 306 (6887): 1232–5.
5. Mayor S (2004). “Pregnancy and childbirth are leading causes of death in teenage girls in developing countries”. BMJ. 328 (7449): 1152.
6. Makinson C (1985). “The health consequences of teenage fertility”. Family Planning Perspectives. 17 (3): 132–139. doi:10.2307/2135024. Jump up ^ Loto OM, Ezechi OC, Kalu BK, Loto A, Ezechi L, Ogunniyi SO (2004). “Poor obstetric performance of teenagers: Is it age- or quality of care-related?”. Journal of Obstetrics & Gynaecology. 24 (4): 395–398.
7. Fraser AM, Brockert JE, Ward RH Association of young maternal age with adverse reproductive outcomes N Engl J Med 1995 332 1113–7
8. Jolly MC, Sebire N, Harris J, Robinson S, Regan L. Obstetric risks of pregnancy in women less than 18 years old. Obstet Gynecol 2000;96(6):962-966.
9. Martinez, G., Copen, C. E., & Abma, J. C. (2011). Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006-2010 National Survey of Family Growth. Vital Health Statistics, 23(31).
10. Martin, J.A., Hamilton, B.E., Osterman, M.J., Driscoll, A.K., & Drake, P. (2018). Births: Final data for 2016. Hyattsville, MD: National Center for Health Statistics.
11. UNESCO. Early and Unintended Pregnancy & the Education Sector: Evidence Review and Recommendations. Paris: UNESCO; 2017.
12. Kawakita T, et. al. Adverse Maternal and Neonatal Outcomes in Adolescent Pregnancy. Journal of Pediatric and Adolescent Pregnancy. April 2016.
13. Neal S, Matthews Z, Frost M, et al. Childbearing in adolescents aged 12–15 years in low resource countries: a neglected issue.
14. Department of Health. Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health 2004 London: DOH
15. Elfebein DS, Felice ME Adolescent pregnancy Pediatr Clin North Am 2003 50 781–800.