الفهرس 
PREMATURE RUPTURE OF MEMBRANE AT TERMOnly 14 pages are availabe for public view
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Abstract
Premature or prelabor rupture of membrane (PROM) is defined as rupture of membranes before the onset of labor. It occurs in 5-10% of all pregnancies, 60% of which occur at term.
PROM is multifactorial and complex as it may occur in patients with an incompetent cervix, which can result from previous genital tract surgery or laceration. Also, it occurs with increased frequency in women who smoke or who have unstable lie, multiple gestation, polyhydramnios, or antepartum hemorrhage. However, in the majority of cases, there is no obvious cause (s). Subclinical intrauterine infections have been proposed as a predisposing factor for PROM.
The clinical management of PROM in term patients remains controversial. Expectant management compared with labor induction in women with term PROM demonstrated that expectant management was associated with a significantly increased incidence of clinical chorioamnionitis, postpartum fever, longer maternal hospital stay, and infant days spent in the neonatal intensive care unit. With these potential risks, induction of labor seems to be the optimal management for women with term PROM. However, induction of an unfavorable cervix causes prolonged labor and increases cesarean section rates.
Patients with unfavorable cervices probably are best managed by induction of labor with prostaglandin compounds.
Misoprostol, a synthetic prostaglandin E1 analogue. A number of published controlled trials have shown that misoprostol is an effective agent for cervical ripening and labor induction in patients at term.
The aim of this study is to compare the efficacy, safety and maternal satisfaction of a dose of 25 µg versus 50 µg vaginal misoprostol in cases of premature rupture of membranes at term.
This study included 100 pregnant women admitted to the casualty ward of the department of Obstetrics & Gynecology at Ain Shams University Maternity Hospital presenting with PROM at term in the period from March 2010 to February 2010.
All patients were subjected to full history taking with special regards to symptoms suggestive of PROM, full clinical examination (general, abdominal and local examinations), investigations (U/S scan and admission CTG).
The inclusion criteria: Age < 35 years, Primigravida singleton living fetus, gestational age of ≥37 weeks, vertex presentation, no evidence of active labor, reassuring fetal heart rate pattern, no evidence of intrauterine infection and Bishop score of ≤ 6.
The exclusion criteria: previous uterine scar, macrosomic fetuses, malposition and malpresentation, IUGR, congenital fetal malformations, contraindications to prostaglandins use e.g. bronchial asthma, glaucoma or sickle cell disease etc., cardiac disorders as valvular lesion, cardiomyopathies and heart failure, thick or dark meconium stained liquor, placenta previa or active vaginal bleeding or any condition that contraindicate vaginal delivery.
The 100 woman were randomly assigned to one of the two equal groups (A or B) each consisted of 50 women and each woman was posted in each group consequently. The time was noted & recorded before starting. Group A, received 25 µg misoprostol placed in the posterior vaginal fornix every 4 hours for a maximum of 3 doses. Group B, received 50 µg misoprostol placed in the posterior vaginal fornix every 4 hours for a maximum of 3 doses.
The primary study outcome was Induction-delivery interval (I.D.I). Secondary study maternal outcomes were, mode of delivery, maternal side effects including, uterine hyperstimulation.( six or more contractions in 10 min or sustained contractions over two minutes). nausea, vomiting. pyrexia ( maternal temperature of 38C ). The secondary fetal outcomes were. Apgar score at 5 minutes, birth weight, meconium aspiration and NICU admissions was documented.
The two groups had similar demographic and antepartum variables. Maternal age, gestational age, parity, PROM duration, admission temperature and Bishop Score were similar in the two groups.
The study demonstrated that the time intervals from induction to delivery (I.D.I) were reduced in group B compared to group A (15.919+2.300 and 14.234+2.186) respectively, however the difference between was not statistically significant.
There was no difference between the two groups as regards the mode of delivery as the number of cases that delivered vaginaly was the same in both groups 47 in each group and the number of cases that delivered by CS 3 cases in each group.
There was a significant difference between the study groups as regards the need for analgesia. As there was 8 cases (36.4%) in group (A) Vs 14 cases (63.6%) in group (B), p = 0.024.
It was found that more women in group(A) required oxytocin augmentation than in group (B) [12 cases (24%) Vs 7 cases (14%) respectively], the difference was significant as the P-value was (0.024).
The study demonstrated that there was a significant difference between the two groups as regards the occurrence of hyperstimulation, as there was only one case in group (A) Vs two cases in group (B).
Olso There was a significant difference between the two groups as regards the occurrence of nausea and vomiting as there was only one case in group (A) Vs two cases in group (B).
Olso There was a significant difference between the two groups as regards the occurrence of pyrexia, as there was only one case in group (A) Vs two cases in group (B).
There was no significant difference between the study groups as regards the occurrence of Fetal distress, as there was one case in each group.
There was no significant difference between the study groups as regards the occurrence of Meconium stained liqor, as there was one case in each group.
There was only one case admitted to NICU in group (B).
There was no significant difference between the study groups as regards the Birth weight.
Apgar score at 5 minutes is an important neonatal outcome that must be considered in labor induction. There was no significant difference between the study groups as regards the five minutes APGAR score. As it was ( 8.00+0.349 ) in group (A) Vs (7.820+0.595 ) in group (B) with p. value =0.067