General information. Premature is the rupture of amniotic fluid when the membranes rupture before the onset of labor, regardless of the duration of pregnancy. If the amniotic fluid is released soon after the onset of labor, but before the cervix is ​​fully or almost completely dilated, we speak of early rupture of amniotic fluid. The time between the rupture of the membranes and the appearance of contractions is called the latent period, and the time between the rupture of the membranes and the birth of the fetus is called the anhydrous interval. The prevalence of premature rupture of membranes has been reported to be 3–19%. Premature rupture of amniotic fluid is accompanied by up to 35% of premature births.

1. Etiology

A. Infection (amnionitis, cervicitis, vaginitis of streptococcal or other etiology).

b. Overstretching of the uterus (polyhydramnios and multiple pregnancies).

V. Sexual intercourse.

d. Malformations of the fetus.

d. Low socio-economic status of the pregnant woman.

e. Hereditary diseases in a pregnant woman (for example, Ehlers-Danlos syndrome).

and. Structural changes in tissue due to insufficient consumption of ascorbic acid and trace elements, in particular copper.

h. Injury.

And. Addiction.

Management tactics depend on the stage of pregnancy. The rupture of amniotic fluid at less than 37 weeks of pregnancy significantly increases the risk of infectious and obstetric complications than the rupture of water after this period. Some authors consider infection to be the main cause of premature rupture of amniotic fluid, since bacterial enzymes reduce the strength and elasticity of the membranes. However, it has not yet been precisely established whether the infection is the cause or consequence of premature rupture of amniotic fluid.

2. Features of the flow. The shorter the gestational age at the time of rupture of amniotic fluid, the longer the latent period. In full-term pregnancy, in 80-90% of cases, contractions begin within 24 hours after the rupture of amniotic fluid; in less than 10% of cases, the latent period lasts up to 2 days. When amniotic fluid ruptures before the 37th week of pregnancy, labor begins within 24 hours only in 60-80% of cases; in other cases, the latent period can last up to 7 days.

A. Complications include cord prolapse, chorioamnionitis, and postpartum endometritis. When amniotic fluid ruptures before the 37th week of pregnancy, premature placental abruption occurs in 4.0-6.3% of cases. This is 2-3 times more likely than with timely rupture of amniotic fluid. If observed the day before bloody issues from the genital tract, the risk of premature placental abruption against the background of premature rupture of amniotic fluid is even higher. A pronounced decrease in the volume of amniotic fluid, regardless of the duration of the anhydrous interval, increases the risk of compression of the fetus in the uterus with the subsequent development of anomalies of the facial skeleton, contractures of the limbs, and possible pulmonary hypoplasia. If amniotic fluid ruptures before the 22nd week of pregnancy, the risk of pulmonary hypoplasia is 25-30%. The risk of complications from premature rupture of amniotic fluid depends on the duration of pregnancy, the volume of fluid released and the duration of the anhydrous interval.

b. Morbidity and mortality. In the past, the management of pregnant women with premature rupture of amniotic fluid consisted of labor induction and delivery. Later they began to use wait-and-see tactics. This made it possible to collect and evaluate statistical data on maternal and perinatal morbidity and mortality due to premature rupture of amniotic fluid.

1) According to van Dongen, with premature rupture of amniotic fluid at a gestational age of less than 34 weeks, perinatal mortality reaches 29% (14 out of 48 newborns died). In four newborns, death occurred due to pulmonary hypoplasia. Moreover, in 3 cases, rupture of amniotic fluid occurred at a period of less than 20 weeks, in the fourth - at 26 weeks of pregnancy. The authors concluded that premature rupture of amniotic fluid at less than 20 weeks of pregnancy is always accompanied by pulmonary hypoplasia in the fetus.

2) According to Blott and Greenough, in 30 cases of rupture of amniotic fluid during the second trimester of pregnancy, 36% of newborns died, and 27% were born with contractures of the limbs.

3) Thibeault et al. showed that when pregnancy is prolonged after premature rupture of amniotic fluid for more than 5 days, 28% of newborns develop contractures of the limbs, which, however, can be eliminated with the help of physiotherapy and massage.

4) Taylor and Garite, having studied 53 cases of premature rupture of amniotic fluid at 16-25 weeks of pregnancy, found that the viability of the fetus depended mainly on its weight and delivery date, and not on the time of rupture of amniotic fluid. According to their data, out of 18 children born after the 26th week of pregnancy, 13 survived.

V. The prognosis for rupture of amniotic fluid before the 37th week of pregnancy is in most cases unclear. However, this does not serve as a reason to abandon expectant management of pregnancy and the prevention of complications in the fetus. If amniotic fluid ruptures before the 20th week of pregnancy and prolonged oligohydramnios, the chances of having a viable baby are very low. In 5% of cases, the discharge of amniotic fluid stops, and its volume is restored. This mainly applies to cases of leakage of amniotic fluid, usually after amniocentesis.

3. Diagnostics. Premature effusion amniotic fluid significantly affects the outcome and management of pregnancy. In this regard, if there is a suspicion of rupture or a decrease in the volume of amniotic fluid (ultrasound), a thorough examination is indicated. The cervix and vagina are examined in speculums (before the examination, the pregnant woman should lie on her back for 20-30 minutes). First, the posterior vaginal fornix is ​​examined. If there is no amniotic fluid, the pregnant woman is asked to push or cough. When the membranes rupture during coughing or straining, amniotic fluid leaks from the external os. A vaginal examination is not performed.

A. Examination of vaginal contents. Material for research is taken from the posterior vaginal fornix or from the cervical canal. To detect amniotic fluid in the vaginal contents, dry smear microscopy is performed and the pH of the discharge is determined using a test strip. Other methods are also used - cytological and biochemical examination of vaginal contents. A cytological examination of the smear can reveal scales of the fetal epidermis and droplets of fat. The disadvantage of this method is that it requires special dyes. In addition, cytological examination performed long before birth often gives false negative results. In a biochemical study, the presence of amniotic fluid in the vaginal contents is confirmed by the presence of fetal fibronectin, prolactin, alpha-fetoprotein and placental lactogen.

1) Dry smear microscopy. During examination of the cervix and vagina in the speculum, a sterile cotton swab is used to take material from the posterior vaginal fornix or external os and apply a thin layer to a clean glass slide, after which the preparation is dried in air. When it is completely dry, it is examined under a microscope at low magnification (ґ 5-10). Detection of crystallization in the form of a fern branch or tree-like structure confirms the presence of amniotic fluid. To avoid a false negative result, the drug is allowed to dry completely and the entire area of ​​the smear is examined under a microscope. The detection of the fern phenomenon in at least one area indicates positive result. False-positive results occur when you touch the drug with your finger or get saline solution on the glass.

2) Determination of pH using a test strip. The method is based on the fact that amniotic fluid has an alkaline reaction (pH 7.0-7.5), and vaginal discharge is normally acidic (pH 4.5-5.5). Vaginal discharge is taken with a sterile cotton swab and applied to a test strip. The coloring of the strip in blue-green (pH 6.5) or blue (pH 7.0) most likely indicates the presence of amniotic fluid in the test material. False-positive results are possible due to contact with blood, urine, semen or antiseptics.

b. Volume of amniotic fluid. If, when examining vaginal discharge, no amniotic fluid is found in it, and anamnestic and clinical data indicate premature rupture of amniotic fluid, further examination is indicated. An ultrasound is performed to determine the volume of amniotic fluid. Even with the rupture of amniotic fluid, free areas larger than 3 x 3 cm in size may be found in the amniotic cavity. If severe oligohydramnios is detected, regardless of whether the diagnosis of rupture of amniotic fluid is confirmed or not, carefully examine the kidneys and bladder of the fetus, since one of the causes of oligohydramnios may be be agenesis of the fetal kidneys. Despite the similarities external manifestations, pregnancy management tactics in these cases are significantly different.

V. Amniocentesis. If the results of all the above studies are doubtful, 1-2 ml of sterile dye is injected intraamnially, after which the vagina is tamponed. The pregnant woman lies on her back for 30-40 minutes, then the tampon is removed. Staining the tampon confirms the release of amniotic fluid. It must be remembered that in the future, regardless of the condition of the membranes, the dye begins to be excreted in the urine.

1) Technique. Amniocentesis is performed under ultrasound guidance. The procedure should only be performed by an experienced doctor. The main contraindication to amniocentesis is severe oligohydramnios, since in this case the umbilical cord loops can be mistaken for the accumulation of amniotic fluid and can be injured. If technical difficulties arise during the operation, continuous CTG is performed for some time after the operation.

2) Dye. It is best to use indigo carmine or Evans blue. Less commonly used is Evans blue T1824. Indigo carmine is administered strictly intraamnially, since its intravenous administration is accompanied by side effect. Methylene blue is no longer used, since the administration of large doses of this dye can cause hemolytic anemia, hyperbilirubinemia, methemoglobinemia and skin discoloration in the fetus.

1. Premature rupture of amniotic fluid - rupture of the membranes and rupture of amniotic fluid before the onset of labor.

Early rupture of amniotic fluid - rupture of the membranes and rupture of amniotic fluid after the onset of labor, but before the opening of the pharynx by 7 - 8 cm.

The above-mentioned complications are most often associated with the high location of the presenting part of the fetus (anatomical narrowing of the gas, large fetus, extensor presentation of the head, hydrocephalus, breech presentation of the fetus, oblique or transverse position of the fetus with functional inferiority of the lower segment of the uterus, when there is no well-defined contact belt), except In addition, the causes of prenatal and early discharge of amniotic fluid may be anatomical changes in the cervix, inflammatory processes in the cervix, changes in the membranes.

Prenatal rupture of membranes is diagnosed on the basis of anamnestic data (leakage of water), detection of fetal scales in amniotic fluid and examination of the presenting part using an anammoscope. In doubtful cases, discharge from the genital tract is collected in a tray or examined without staining under a microscope (hairs are found in the waters) or, placing them on a glass slide, mixed with saline solution (amniotic fluid gives an arborization reaction). When the uterine os opens, the absence of the amniotic sac can be detected by palpation.

If the pregnant woman’s body is ready for childbirth (mature cervix, no positive oxytocin test data), prenatal rupture of amniotic fluid can interfere with the normal course of labor. Usually in such cases, labor develops after 5 - 6 hours

after rupture of membranes. An uncomplicated course of labor is observed with early release of water in women in labor with good labor and the presenting part inserted into the pelvic inlet.

Premature and early rupture of amniotic fluid leads to the development of serious complications: weakness of labor forces. protracted labor, hypoxia and intracranial injury to the fetus, chorioamniitis during childbirth, prolapse of the umbilical cord and small parts of the fetus.

Treatment is carried out only in a hospital. If amniotic fluid is discharged in the presence of an immature fetus, treatment is aimed at maintaining the pregnancy. I appoint! bed rest, strict control over temperature 1C and blood pressure pattern, and means used to prevent uterine contractions.

During pregnancy of 36 weeks or more, the doctor’s tactics should also be individual:

in a group of pregnant women and women in labor who do not have signs of labor incompatibility and complications are observed that indicate the possibility of developing weakness of their labor forces. should be expanded!, indications for caesarean section;

If the issue of expectant management of labor is being decided, it is necessary to create a strogen-vitamin-glucose-calcium background. In six hours, in the absence of good labor activity, I begin! introduces! - means that contract the uterus. If a woman in labor is tired, it is necessary to provide her with timely rest by administering appropriate pharmacological agents; 11 times without water! If there is an interval of more than 10 hours, when the end of labor is not expected to end soon, antibiotics are administered. During the process of childbirth, accompanied by premature and early rupture of amniotic fluid. systematically implement measures to combat fetal hypoxia.

Prevention: "prohibition of sexual intercourse in the last 1.5-2 months of pregnancy; exclusion of heavy physical activity:

hospitalization of pregnant women in whom rupture of the membranes can be expected before birth, for 1 weeks before delivery. With the onset of labor, such women in labor should be in a lying position.

2. Late rupture of the membranes - preservation of the integrity of the membranes despite the complete opening of the uterine os. ., Reasons - excessive density of the membranes, excessive elasticity of the membranes, a very small amount of anterior amniotic fluid (flat, dense bladder). :

The clinical course of labor with delayed opening of the membranes is characterized by a protracted period of expulsion, painful contractions of the uterus, slow advancement of the presenting part, and the appearance of bloody discharge from the genital tract. There is a danger of placental abruption and fetal hypoxia.

The diagnosis is based on palpation data during vaginal examination. If the presence of a flat bubble causes difficulties in determining the integrity of the membranes, an inspection should be made using mirrors.

Treatment consists of artificial opening of the membranes of the fetal bladder (amniotomy) with the index finger or using bullet forceps under the control of the fingers of the right hand or mirrors. If the head is not fixed at the pelvic inlet, amniotic fluid should be released slowly to avoid prolapse of the umbilical cord or small parts of the fetus.

The outpouring of water is considered:

• early, if it occurs in the first stage of labor until complete or almost complete (7-8 cm) dilation,
• premature if the amniotic sac ruptures before regular contractions occur,
• belated if, when the uterine os is fully dilated, the fetal bladder remains intact for some time.

Causes

The exact causes of early or premature rupture of water are not known. However, in those women who were prepared for childbirth, such cases are less common. This is largely due to the woman’s emotional state, her ability to relax and her general attitude towards a successful birth.

What to do?

In the event of a sudden break of water, even if there are no contractions yet or they are weak and at large intervals, it is necessary to go to the maternity hospital immediately, without delay. It should be remembered that the more time passes after the water breaks, the higher the likelihood of complications. After all, the fetus is no longer protected by the membranes, and the risk of infection increases.

Be sure to note the time when your water broke. Pay attention to their color and smell. Normally, the waters are clear or slightly pink, odorless. Slightly greenish, dark brown or black color of the amniotic fluid indicates that the baby is experiencing oxygen starvation and he needs urgent help. The unusual color of the waters is associated with the ingress of meconium (original feces), which is released from the intestines of the fetus during hypoxia.

Course of labor

Typically, labor develops 5-6 hours after rupture of the membranes. If contractions do not begin soon after the water breaks, they are stimulated.

The course of labor largely depends on the readiness of the woman’s body (cervix) for it, on the strength of labor and the location of the presenting part of the fetus. If the cervix is ​​ready for labor, premature rupture of amniotic fluid may not interfere with its normal flow.

Consequences

In some cases, premature or early rupture of amniotic fluid can lead to:

• weakness of labor,
• protracted course of labor,
• fetal hypoxia,
• fetal intracranial injury,
• inflammatory processes of the membranes and muscles of the uterus.

At belated outpouring of water Doctors perform an artificial opening of the fetal bladder - amniotomy.

Leakage or early rupture of amniotic fluid is a problem for many pregnant women. Delaying treatment often poses a danger for both the unborn child and the mother.

What is amniotic fluid?

Amniotic fluid (amniotic fluid) is a clear, pale-straw-colored fluid that surrounds the fetus, providing it with protection and a supply of nutrients. It also helps in the development of the muscular and skeletal system of the unborn child.

Amniotic fluid is located in the fetal bladder (amniotic sac), the walls of which consist of two membranes: amnion and chorion. These membranes hold the unborn child in this sealed sac containing amniotic fluid. The bladder begins to fill with it a few days after conception. The baby will regularly release small amounts of urine into the amniotic fluid from the tenth week of pregnancy (when the kidneys begin to work).

Together with the placenta and umbilical cord, this is a natural support system for the life of the embryo.

How important are they?

Amniotic fluid allows the baby to breathe properly. He begins to swallow liquids in the second trimester. Its main function is to protect born child from injury.

The fluid contains essential nutrients that help in development digestive system fetus, lungs, muscles and limbs. This allows the baby to kick and move without any hindrance. It also provides protection against infections.

The fruit uses this fluid for many functions. The water level will rise every day. Their number will increase from a few cubic milliliters to about a thousand as pregnancy progresses, and reaches its highest level at the thirty-sixth week. The amount will then begin to decrease from the thirty-eighth week until the day of delivery.

Premature loss of amniotic fluid is a serious threat to the unborn child and the mother herself.

What is premature rupture or leakage of amniotic fluid?

Normally, spontaneous rupture of membranes and rupture of amniotic fluid occurs during childbirth, i.e. with complete or almost complete dilatation of the cervix and the presence of regular contractions.

If the discharge (leakage) of water occurs earlier, then this condition is premature and is a pregnancy complication. In medicine, this is called premature rupture of membranes (PROM). This can happen at any stage of pregnancy and can be either a stream of fluid or a slow leak. This problem is a common cause of premature birth or miscarriage, depending on the term.

If premature rupture occurs before the 24th week, the fetus is still completely unable to survive outside the mother's womb. But even before the 37th week, this puts mother and fetus at great risk of complications.

Premature rupture of amniotic fluid is a problem that is often ignored by many pregnant women. The effusion is usually felt as a painless stream of fluid, but may also appear as a small stream or slight discharge.

Symptoms

It can be difficult to determine whether vaginal discharge is amniotic fluid when there is not a complete rupture of the membranes of the sac, but cracks in them. However, there are a few differences.

Amniotic fluid:

• Usually odorless
• Mostly transparent. May sometimes have mucus, streaks of blood, or white discharge
• Leaks continuously. Has a very steady flow at times
• Unable to control leakage
• Have to change pads and underwear frequently because leakage is persistent
• Some discomfort and cramping may occur

It may not be amniotic fluid if:

• Present yellow tint like urine
• Smells like urine
• Sudden leakage accompanied by movement of the baby in the uterus, but which was short-lived and stopped.
• The discharge has a mucous consistency, which requires changing pads for hygienic purposes. Such leakage will not seep through the gaskets. This is a sign that you simply have.

Symptoms of slow leakage

We can talk about leakage of amniotic fluid during pregnancy if:

• You notice a sudden flow of liquid moving along the length of your legs
• Your underwear is wet
• Slight discharge or trickle

The cause of a small leak may be difficult to determine. Therefore, it is better to go and consult with a gynecologist on this issue. Continuity of flow indicates leakage.

Leaking amniotic fluid may also be indicated if you continue to experience wetness even after you have emptied your bladder.

Early leakage of amniotic fluid

A miscarriage is the loss of a fetus early weeks pregnancy. According to the American Pregnancy Association, many miscarriages occur in the first thirteen weeks. About 10-25% of all confirmed pregnancies usually end in miscarriage.

It is important to recognize the signs so that you can seek medical attention as soon as possible.

It is important to pay attention to:

• Discharge of gray or light pink substance
• Outpouring of the unexpected large quantity liquids
• Passage of large pieces of tissue
• Pinkish discharge

According to the Mayo Clinic, the release of tissue or fluid during early pregnancy may be a sign of miscarriage. The tissue or fluid that comes out may or may not contain any blood.

The above symptoms may be normal signs of hormonal changes in your body. But they can also indicate problems during pregnancy. You should always keep in touch with your gynecologist.

Leakage in middle pregnancy

Amniotic fluid leakage at 16 weeks

The water usually breaks at the beginning of labor. Any leakage that occurs earlier is considered premature. Leaks that occur between the 15th and 16th weeks usually require urgent medical attention.

Treatment includes:

• Admission to a medical facility for a thorough examination
• Checking for the possibility of miscarriage
• After monitoring you for a while, your doctor will discuss next steps.

Leakage of amniotic fluid in the 2nd trimester

Leaking in the second trimester means you have a ruptured amniotic sac. The rupture may heal over time, or it may not heal.

A scan should be performed to determine what may be causing the leak. It is important to note that many different and unusual changes occur in the body during pregnancy, so it is difficult to establish what is normal and what is not.

Regular examinations with a gynecologist will help the expectant mother to be calm. Some tests must be performed to determine what is behind the leaking amniotic fluid.

Leakage of amniotic fluid at 37-38 weeks

If rupture of membranes occurs 37 weeks after the last menstrual cycle(known as the fetus's gestational age), the risks of complications are minimal and contractions usually begin soon after.

But still, such a break is premature and, like earlier cases, may be associated with the following factors:

• Bacterial infection
• Cases of premature rupture of water in previous pregnancies
• The presence of a defect in the development of your fetus
• Infection in the vagina, uterus, or cervix.
• Bad habits such as smoking, drugs and alcohol abuse
• Amniotic sac tension due to large baby or twins
• Poor nutrition
• Preliminary operations in the cervix or uterus

Leak tests

The best thing to do is contact a gynecologist, and he will conduct an examination and prescribe the necessary tests to confirm leakage of amniotic fluid if there is suspicion. But it will also be useful to have simple pharmacy tests on hand to be on the safe side or to reassure yourself. They can sometimes give a false positive result, but when used correctly they should not give a false negative result.

pH strip test

Litmus strips are the simplest and cheapest test. You can even use strips designed for aquarium water to save money.

To determine water leakage at home, you can use litmus test strips, which are sold in almost every pharmacy and have affordable price. Litmus paper helps determine the pH level of suspicious secretions.

The strip is applied to the vaginal wall after opening and will then show the acidity level (pH). Normal vaginal pH is between 4.5 and 6.0. Amniotic fluid has a higher level - from 7.1 to 7.3. Therefore, if the lining of the sac is ruptured, the pH of the vaginal fluid sample will be higher than normal. This will be indicated by a change in the color of the strip, which must be compared with the scale that comes with the test. Increased level acidity will indicate that you have an infection or leaking amniotic fluid.

Test strip for determinationThe pH of the water in the aquarium is also suitable for testing for amniotic fluid leakage, and they may cost less.

Nitrazine test

The most common type of tests. Price for one tampon from 2 dollars.

Popular brands are AmnioTest, Amnicator. It requires applying a drop of vaginal fluid to paper strips containing nitrazine as an indicator, a substance more sensitive than litmus. Such tests are commercially available in the form of special tampons or pads, which make it easier to carry out.

The indicator changes color depending on the acidity of the liquid. They will turn blue if the pH is greater than 6.0. This means that there is a high probability that the bubble shells have ruptured.

However, this test can also give false positive results. If blood gets into the sample or there is an infection in the vagina, the acidity level may be higher than normal. Men's semen also has a higher pH, so recent intimacy may affect the results.

Alpha-1-microglobulin test

The most accurate, but also the most expensive test - more than $30

It's modern and more accurate test, but its cost is several times more expensive (more than 30 shares). It also does not require special laboratory conditions, but is more often performed by an obstetrician-gynecologist on an outpatient basis. The point is to detect a biomarker such as placental alpha-1-microglobulin. This substance is found in amniotic fluid and is not normally present in the vagina. To take a sample, a swab is used, which is then placed in a test tube with a special liquid, and then a test strip is placed in its place. Based on the number of stripes that appear on it (1 or 2), we can say with 97% accuracy that there is leakage of amniotic fluid.

Other tests that may be done in the hospital

The so-called “fern” symptom is marks on a microscope slide after the amniotic fluid has dried. After the urine dries, there are no such traces

Examination of liquid under a microscope. If leakage occurs, the amniotic fluid mixed with estrogen, when dried due to salt crystallization, will create a "fern" symptom (resembling fern leaves). To carry out this procedure, a few drops of liquid are placed on a microscope slide for examination.

Dye test. A special dye is injected into the amniotic sac through abdominal cavity. If the membranes are ruptured, colored fluid will be found in the vagina within 30 minutes.

Tests to measure levels of chemicals that are present in amniotic fluid but not in vaginal secretions. These include prolactin, alpha-fetoprotein, glucose and diamine oxidase. High levels of these substances mean that a rupture has occurred.

Amniotic fluid, urine or vaginal discharge?

Three main types of fluid can come out of the vagina: urine, and amniotic fluid. While noting the differences between them, you can use the following tips to identify one.

Leakage of amniotic fluid

It will have the following properties:

• May contain clear or whitish mucus patches
• Odorless and colorless. In some cases it may have a sweetish odor
• Presence of bloody spots
• Does not smell of urine

Constant discharge means that the fluid is indeed amniotic.

Urine

Urine usually has the following properties:

• Ammonia smell
• Dark or clear yellowish color

Bladder leakage will occur mainly in the second and third trimester. The fetus will already put pressure on the bladder at this stage.

Vaginal discharge

Vaginal discharge during pregnancy is also not uncommon. They have the following properties:

• The smell may or may not be present. However, they do not have an ammonia-like odor similar to urine.
• May be yellowish or whitish
• Have a denser consistency than urine or amniotic fluid
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Leakage of amniotic fluid or premature rupture of amniotic fluid (PIV or PIOV in different sources) is the rupture of the membranes and the rupture of amniotic fluid before the onset of regular labor with dilatation of the cervix up to 7 - 8 cm.

Normally, the discharge of amniotic fluid occurs spontaneously in the first stage of labor, when the cervix reaches 7–8 cm dilatation; during the next contraction, the woman notices a copious flow of fluid not associated with urination. After the water breaks, contractions usually intensify and birth process accelerates.

Premature rupture of water can occur at any stage of pregnancy, as there are many factors that provoke this condition.

Predisposing factors for leakage of amniotic fluid:

1. Invasive diagnostic methods (amniocentesis)

Amniocentesis is a diagnostic method that involves puncture of the amniotic sac through the anterior abdominal wall under anesthesia and ultrasound control and sampling amniotic fluid for biochemical and chromosomal analysis.

In approximately 1% of cases, this procedure is complicated by termination of pregnancy, you will be warned about this in advance and the final decision is always made by the patient.

2. Untreated colpitis of various etiologies

Inflammation of the genital tract progresses without treatment; bacteria (most often a mixed infection) have an invasive ability and, with the help of their enzymes, dissolve the membranes. The connection between infection and premature rupture of amniotic fluid has been proven by many clinical studies; in about a third of cases, leakage of water is the main cause.

3. Intra-amniotic infection

Intra-amniotic infection acts in the same way (damages the membranes) only from the inside. Infection is introduced into the amniotic sac in different ways, both through the blood and ascending from the genital tract (infection from the vagina penetrates into the amniotic fluid without damaging the amniotic sac and already develops massively inside).

4. Clinically narrow pelvis, abnormal fetal positions (oblique, transverse, pelvic), multiple pregnancy, polyhydramnios

Normally, the fetal head at full term is pressed against the bony ring of the entrance to the pelvis, and thereby divides the amniotic fluid into anterior (in front of the fetal head) and posterior (all others). In these conditions, the head of the fetus/the first fetus of twins/triplets is high and there is a lot of water in the lower pole of the amniotic sac, which mechanically puts pressure on the membranes and the risk of leakage of amniotic fluid increases significantly.

ICI is a shortening of the cervix and expansion of the internal uterine os that does not correspond to the gestational age (premature). The expansion of the internal os of the uterus can lead to prolapse (protrusion) of the fetal bladder outward, which leads to infection and rupture of the membranes.

Symptoms of amniotic fluid leakage

I. Rupture of membranes(this is an obvious condition, which is accompanied by the rupture of anterior amniotic fluid)

1) Copious painless discharge of light (turbid/greenish/straw-colored, etc.) fluid not associated with urination

2) Decrease in the height of the uterine fundus (the outpouring of water reduces the intrauterine volume and the abdomen becomes smaller in size and denser)

3) The development of labor after the rupture of water (does not always occur; the rupture of amniotic fluid is early stages, as a rule, does not provoke the immediate development of labor)

4) Changes in fetal movements (slowing down movements, as the volume of the uterus has decreased and its tone has increased)

II. High/lateral opening of membranes(this condition may go unnoticed, as it occurs with subtle symptoms and is extended over time)

1) Magnification vaginal discharge, which become more liquid, watery, soak the laundry and do not stop. They also get worse when coughing and lying down (for the majority).

2) Nagging pain in the lower abdomen, bleeding (does not always happen)

3) Change in fetal movements

Complications of premature water leakage

- termination of pregnancy (most often we are talking about late miscarriage up to 22 weeks)

- premature birth. Premature birth occur between 22 weeks and 36 weeks and 5 days and entail many complications for the mother and fetus, the severity of the condition depends on the duration of pregnancy.

Abnormalities of labor (weakness of labor, discoordination of labor, etc.)

- hypoxia and asphyxia of the fetus (a long anhydrous period and anomalies of labor lead to disruption of the blood supply to the fetus through the umbilical cord and oxygen starvation of the fetus of varying severity develops)

Respiratory distress syndrome in a newborn (the surfactant in the baby’s lungs matures closer to 35 - 36 weeks, earlier rupture of water and childbirth entail inferior lung function)

Infectious and inflammatory complications in a newborn (inflammatory skin diseases, congenital pneumonia)

Intraventricular hemorrhages, cerebral (cerebral) ischemia in a child

Skeletal deformation and self-amputation of limbs in a child during a long anhydrous period (amniotic cords are formed that injure the fetus)

Chorioamnionitis (inflammation of the membranes during a long anhydrous period)

Postpartum endometritis. Endometritis (or metroendometritis) is an inflammation of the internal uterine wall, which most often develops in women with premature rupture of water, and the longer the anhydrous period (without antibiotic prophylaxis), the higher the risk of the disease. If chorioamnionitis develops during childbirth, then in the postpartum period there is an extremely high probability of developing endometritis.

Obstetric sepsis. Obstetric sepsis is the most serious infectious and inflammatory complication in the postpartum period with high mortality.

How to detect water leakage

1. How can you determine premature rupture of water at home?

If you noted unclear abundant watery discharge, then you should urinate, take a shower, dry yourself (dry the crotch thoroughly) and put a clean, dry white pad (a white cotton diaper is best) between your legs, after 15 minutes you should check the pad. Or lie down on a dry sheet without underwear. A wet spot on the sheet or a wet lining indicates possible leakage of amniotic fluid. In this case, you should collect a minimum of things in maternity hospital and call " Ambulance"(or go to the emergency room of the maternity hospital yourself).

- if you suspect water leakage, but the discharge is not abundant, does not wet the laundry, does not have a special smell or color, then you can do it at home placental microglobulin test(PAMG – 1), on this moment it is produced only under one brand name: Amnisure ROM Test (Amnishur).

This is a test - a system intended for independent use; all the necessary items indicated are included in the kit.

How to do a water leak test:

Place a tampon into the vagina to a depth of 5–7 cm for a period of one minute
Immerse the swab in the solvent tube for 1 minute and rinse well with a rotating motion.
Place the test strip in the tube for 15 - 20 seconds
Place the strip on a clean, dry surface and after 5 - 10 minutes you can evaluate the result
One strip – there is no leakage of water, two stripes – there is leakage of amniotic fluid
Test reliability 98.7%
Do not read the result if more than 15 minutes have passed

Test pads for leakage of amniotic fluid (Frautestamnio, Al-sense) are a pad with a reagent-impregnated area (indicator) or liner. The indicator contains a colorimetric indicator that changes yellow in blue – green when in contact with liquids with high pH. Normally, the pH in the vagina is 3.8-4.5, the pH of amniotic fluid is 6.5-7. The test pad changes color when it comes into contact with a liquid that has a pH level greater than 5.5.

The pad should be attached to the underwear as usual, with the yellow indicator facing the vagina. The pad is used for about half an hour, or until sufficiently moistened, it can be used for up to 12 hours, and then the color is assessed and compared with the color scale on the packaging. Blue – green color may indicate leakage of amniotic fluid. The indicator color remains stable for up to 48 hours. If after drying the color turns yellow again, this most likely means that there was a reaction with ammonia in the urine. But only a doctor will give you a final conclusion.

There are also gaskets on sale with a removable indicator liner (Al - Rekah), after using the gasket as described above, the liner is removed by pulling the protruding tip, placed in a bag and wait for the result for about 30 minutes. The color will also change to blue-green.

The gaskets are easy to use and accessible, but their information content is somewhat lower than the test systems.

A false positive result can be caused by:

Colpitis of any etiology
- bacterial vaginosis
- recent sexual intercourse
- douching

In all these cases, the pH of the vaginal secretion changes and a false positive result is possible.

2. Obstetric diagnosis of water leakage

Gynecological examination in speculum with cough test

When examined in the speculum, the cervix is ​​exposed, and the doctor asks the patient to cough; if the amniotic sac ruptures, the amniotic fluid will leak in portions with a cough impulse. Sometimes, when examined in the mirrors, a clear leakage of water is visible, the fluid is in the posterior fornix, then a cough test may not be performed.

The nitrazine test (amniotest) shows the most reliable result within 1 hour after the water is poured out. The amniotest is a swab with a cotton tip soaked in a reagent, which must be placed in the posterior vaginal fornix and the color change assessed. However, a false positive result can be caused by the same factors as when using test pads.

Ultrasound (the ultrasound doctor measures the level of amniotic fluid, also known as the amniotic fluid index - AIF, and compares it with the data of the previous ultrasound; after the rupture of water, it decreases sharply).

Oligohydramnios (severe oligohydramnios) in combination with fluid leakage confirmed by gynecological examination confirms the diagnosis of PIV.

Treatment for leakage of amniotic fluid

Tactics for the expiration of amniotic fluid at different times.

Up to 22 weeks

Prolonging pregnancy is not advisable due to the minimal chance of fetal survival and the frequency of purulent-septic complications on the part of the mother. The patient is subject to hospitalization in the gynecological department, where the pregnancy is terminated for medical reasons.

22–24 weeks

Hospitalization of the patient to the pregnancy pathology department and explanation of the risks and consequences for the mother and fetus.

The prognosis for the fetus at this stage is still extremely unfavorable. Parents are warned that children born at this stage are unlikely to survive, and those that survive will not be healthy (the risk of cerebral palsy, blindness, deafness and other neurological disorders is high). If the patient categorically insists on prolonging pregnancy, despite these risks, antibiotic prophylaxis is carried out as indicated below.

25 – 32 weeks

Up to 34 weeks, in the absence of contraindications, expectant management is indicated, taking into account the duration of pregnancy. Waiting tactics in the period 25 – 32 weeks no more than 11 days.

32 – 34 weeks

Watchful waiting is indicated for no more than 7 days.

34 – 36 weeks

Waiting strategy is indicated for no more than 24 hours.

37 weeks or more

Expectant management is indicated for no more than 12 hours, then the beginning of labor induction is indicated. In this case, antibiotic prophylaxis begins after an 18-hour water-free period.

Contraindications to watchful waiting:

Chorioamnionitis
- preeclampsia/eclampsia
- premature abruption of a normally located placenta
- bleeding with placenta previa
- decompensated condition of the mother
- decompensated condition of the fetus

If there is a contraindication to expectant management, the method of delivery is selected on an individual basis.

Waiting tactics

1. Examination of the cervix in speculum, vaginal examination is carried out only upon admission, not further

2. During the initial examination in the speculum - culture for flora and sensitivity to antibiotics

When the fact of ruptured water is established, immediate initiation of antibiotic prophylaxis for purulent-septic complications of the mother and fetus (chorioamnionitis, neonatal sepsis, obstetric sepsis)

Erythromycin peros 0.5 g every 6 hours to 10 days;

Ampicillin peros 0.5 g every 6 hours up to 10 days;

or when beta-hemolytic streptococcus is detected in microbiological cultures

Penicillin 1.5 g IM every 4 hours

3. Prophylaxis of respiratory distress syndrome (RDS) with dexamethasone (8 mg IM No. 3 under the supervision of a physician with monitoring of fetal movements and heartbeat), it should take about two days to obtain an effect. Dexamethasone is a glucocorticoid hormone that accelerates the maturation of surfactant in the baby's lungs. Prevention of SDR is carried out within 24–34 weeks.

4. Thermometry every 4 hours

5. Monitoring the fetal heart rate, discharge from the genital tract, and uterine contractions at least 2 times a day

6. Complete blood count upon admission and subsequently at least once every 2-3 days;

7. Ultrasonography Once every 7 days with determination of the amniotic fluid index and Doppler blood flow in the uterine arteries and umbilical cord artery

8. Cardiotocography with assessment of a non-stress test (reaction of the fetal heartbeat to its own movements) at least 1 time per day

9. If there are uterine contractions with a frequency of more than 3-4 in 10 minutes - tocolysis (introduction medicines, which relieve contractile activity of the uterus, the drug hexoprenaline is most often used; the dose and rate of administration are chosen by the attending physician)

10. If labor develops no less than 48-72 hours after the first injection of dexamethasone, tocolysis is not performed.

After the maximum waiting period has expired, a consultation of doctors is examined to select a method of delivery. Preparation of the cervix and labor induction or caesarean section are possible. Both methods have their advantages and risks, so in each case the issue is resolved strictly individually.

Pregnant women with HIV infection

1. For PIV after 32 weeks - immediate induction of labor.

2. For PIV up to 32 weeks, expectant management is indicated, aimed at preventing fetal SDR and chorioamnionitis (antibiotic prophylaxis, as indicated above).

3. Prevention of vertical transmission of the virus.

4. Labor induction is indicated 48 hours after the start of fetal SDR prophylaxis.

5. With premature rupture of amniotic fluid C-section does not reduce the risk of transmission of the virus from mother to fetus.

Despite the simplicity and availability of home diagnostic methods, you should not neglect an emergency visit to your doctor if you suspect leakage of amniotic fluid. The earlier the diagnosis is made, the more favorable the result at any stage of pregnancy. We wish you have a safe pregnancy and easy delivery on time. Take care of yourself and be healthy!

Obstetrician-gynecologist Petrova A.V.