General information. Premature is called the outflow of amniotic fluid when the membranes rupture before the onset of labor, regardless of the gestational age. If the amniotic fluid was poured out shortly after the onset of labor, but before the cervix was completely or almost completely dilated, they speak of an early discharge of amniotic fluid. The time between the rupture of the membranes and the appearance of contractions is called the latent period, and between the rupture of the membranes and the birth of the fetus, the anhydrous period. The prevalence of premature rupture of amniotic fluid has been reported to be 3-19%. Premature rupture of amniotic fluid is accompanied by up to 35% of preterm births.

1. Etiology

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

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

v. Sexual intercourse.

d. Fetal malformations.

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

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

well. Structural changes in tissues due to insufficient intake of ascorbic acid and trace elements, in particular copper.

h. Injury.

and. Addiction.

Management tactics depend on the gestational age. The rupture of amniotic fluid at a period of less than 37 weeks of gestation significantly increases the risk of infectious and obstetric complications than the rupture of water after this period. Some authors believe that the main cause of premature rupture of amniotic fluid is infection, since bacterial enzymes reduce the strength and elasticity of the membranes. However, it is still not clear whether the infection is a cause or a consequence of premature rupture of amniotic fluid.

2. Features of the flow. The shorter the gestational age at the time of the outflow of amniotic fluid, the longer the latent period. In full-term pregnancy, in 80-90% of cases, contractions begin within a day after the outflow of amniotic fluid, in less than 10% of cases the latent period is delayed up to 2 days. With the outflow of amniotic fluid before the 37th week of pregnancy, childbirth during the day begins 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. With the outflow of amniotic fluid before the 37th week of pregnancy, premature detachment of the placenta occurs in 4.0-6.3% of cases. This is 2-3 times more often than with the timely discharge of amniotic fluid. If bloody discharge from the genital tract was observed the day before, the risk of premature detachment of the placenta 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 period, increases the risk of fetal compression in the uterus with the subsequent development of anomalies of the facial skeleton, contractures of the limbs, and lung hypoplasia is possible. With the outflow of amniotic fluid before the 22nd week of pregnancy, the risk of lung hypoplasia is 25-30%. The risk of complications of premature rupture of amniotic fluid depends on the gestational age, the volume of effluent and the duration of the anhydrous period.

b. Morbidity and mortality. In the past, the tactics of managing pregnant women with premature rupture of amniotic fluid consisted of labor induction and delivery. Later they began to use waiting tactics. This allowed the collection and evaluation of 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). Four newborns died due to lung hypoplasia. At the same time, in 3 cases, the outflow of amniotic fluid occurred at a period of less than 20 weeks, in the fourth - at a period of 26 weeks of pregnancy. The authors concluded that premature rupture of amniotic fluid at less than 20 weeks of gestation is always accompanied by lung 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 limb contractures.

3) Thibeault et al. showed that when prolonging pregnancy after premature rupture of amniotic fluid for more than 5 days, 28% of newborns develop limb contractures, 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 a gestational age of 16-25 weeks, found that the viability of the fetus depends mainly on its weight and term of delivery, 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 unclear in most cases. However, this does not serve as a reason for abandoning the expectant management of pregnancy and the prevention of complications in the fetus. With the outflow of amniotic fluid before the 20th week of pregnancy and prolonged oligohydramnios, the chances of having a viable baby are very small. In 5% of cases, the outflow of amniotic fluid stops, and their volume is restored. This mainly applies to cases of amniotic fluid leakage, usually after amniocentesis.

3. Diagnostics. Premature rupture of amniotic fluid significantly affects the outcome and management of pregnancy. In this regard, if a discharge or decrease in the volume of amniotic fluid (with ultrasound) is suspected, a thorough examination is indicated. The cervix and vagina are examined in the mirrors (before the examination, the pregnant woman should lie on her back for 20-30 minutes). First examine the posterior fornix of the vagina. If there is no amniotic fluid, the pregnant woman is asked to strain or cough. When the membranes rupture at the time of coughing or straining, amniotic fluid flows out of the external pharynx. Vaginal examination is not carried out.

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

1) Microscopy of a dry smear. During the examination of the cervix and vagina in the mirrors, a sterile cotton swab is taken from the posterior fornix of the vagina or external pharynx and applied in a thin layer to a clean glass slide, after which the drug 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 structure confirms the presence of amniotic fluid. To avoid a false negative result, the preparation is allowed to dry completely and the entire smear area is examined under a microscope. The detection of the fern phenomenon at least in one area indicates a positive result. False-positive results occur when touching the drug with a finger or getting saline on the glass.

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

b. Volume of amniotic fluid. If, during the examination of the vaginal discharge, amniotic fluid is not found in it, and anamnestic and clinical data indicate premature rupture of amniotic fluid, further examination is indicated. Ultrasound is performed to determine the volume of amniotic fluid. Even with the outflow of amniotic fluid in the amniotic cavity, free areas larger than 3 x 3 cm can be found. be fetal kidney agenesis. Despite the similarity of external manifestations, the tactics of conducting pregnancy in these cases differ significantly.

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

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

2) Dye. It is best to use indigo carmine or Evans blue. Less commonly used is Evans Blue T1824. Indigocarmine is administered strictly intra-amniotically, since its intravenous administration is accompanied by side effects. Methylene blue is no longer used, since the introduction of large doses of this dye can cause hemolytic anemia, hyperbilirubinemia, methemoglobinemia and skin staining in the fetus.

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

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

The above complications are most often associated with a 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 a 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 can be anatomical changes in the cervix, inflammatory processes in the cervix, changes in the fetal membranes.

Prenatal rupture of the fetal bladder is diagnosed on the basis of anamnestic data (leakage of water), the detection of fetal scales in the amniotic iodine, and examination of the presenting part using an amnoscope. In doubtful cases, secretions from the genital tract are 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 (amniotic fluid gives an arborization reaction). When opening the uterine os, the absence of the fetal bladder can be detected by palpation.

If the body of a pregnant woman is ready for childbirth (mature cervix, data from a coliucitologist or a positive oxytocin test), prenatal rupture of amniotic fluid can interfere with the normal course of childbirth. Usually in such cases, labor activity develops after 5-6 hours.

after rupture of membranes. An uncomplicated course of childbirth is observed with an early outflow of water in women in labor with good labor activity and the presenting part inserted into the entrance of the small pelvis.

Premature and early discharge of amniotic fluid leads to the development of serious complications: weakness of the birth forces. protracted course of childbirth, hypoxia and intracranial trauma of the fetus, chorioamnioitis 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 shed in the presence of an immature fetus, treatment is aimed at maintaining the pregnancy. I appoint! bed rest, strict control of the temperature 1C.S and the picture of the blood, preventive uterine contractions are used.

With a pregnancy of 36 weeks or more, the doctor's tactics should be individual:

in the group of pregnant women and women in childbirth who do not have signs of dystocia for childbirth and complications are observed that indicate the possibility of developing weakness in their birth forces. should expand!, indications for caesarean section;

if the issue of expectant management of childbirth is being resolved, it is necessary to create a > strictly vitamin-glucose-calcium background. In b hours, in the absence of a good labor activity, I begin! introduces! - funds that reduce the uterus. If the woman in labor is tired, it is necessary to give her rest in a timely manner by introducing appropriate pharmacological agents; 11 times without water! For a period of more than 10 hours, when the imminent end of labor is not expected, antibiotics are administered. In the process of childbirth, accompanied by premature and early discharge of amniotic fluid. systematically carry out 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 delivery, for 1 weeks before delivery. With the onset of childbirth, such women in labor should be in a prone position.

2. Belated rupture of the membranes - preservation of the integrity of the membranes despite the complete opening of the uterine os. ., Causes - 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 childbirth with a belated opening of the membranes is characterized by a protracted period of expulsion, painful uterine contractions, slow advancement of the presenting part, and the appearance of bloody discharge from the genital tract. There is a risk of placental abruption and fetal hypoxia.

The diagnosis is based on palpation data during vaginal examination. If the presence of a flat bubble makes it difficult to determine the integrity of the shells, an examination using mirrors should be made.

Treatment consists in the artificial opening of the membranes of the fetal bladder (amniotomy) with the index finger or with the help of bullet forceps under the control of the fingers of the right hand or mirrors. If the head is not fixed in the pelvic inlet, the 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 full or almost complete (7-8 cm) disclosure,
• premature if the fetal bladder opens before the onset of regular contractions,
• belated if, with the full opening of the uterine pharynx, the fetal bladder remains intact for some time.

Causes

The exact causes of early or premature outflow of waters are not known. However, in those women who were preparing for childbirth, such cases are less common. This is largely due to the emotional state of the woman, her ability to relax and the general mood for a successful birth.

What to do?

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

Be sure to note the time when the waters broke. Pay attention to their color and smell. Normal water is 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 needs urgent help. The unusual color of the waters is associated with the ingestion of meconium (original feces), which is released from the intestines of the fetus during hypoxia.

The course of childbirth

Usually, labor activity develops 5-6 hours after the rupture of the membranes. If shortly after the waters break, contractions do not begin, they are stimulated.

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

Consequences

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

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

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

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

What is amniotic fluid?

Amniotic fluid (amniotic fluid) is a clear and straw-colored fluid that surrounds the fetus, providing protection and nutrition to the fetus. 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: the amnion and the chorion. These membranes keep the unborn child in this sealed bag containing amniotic fluid. Her bubble begins to fill 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 start working).

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

How important are they?

The amniotic fluid allows the baby to breathe properly. He starts to swallow liquid in the second trimester. Its main function is to protect the unborn child from injury.

The fluid contains essential nutrients that aid in the development of the fetus's digestive system, lungs, muscles, and limbs. This allows the child to kick and move without any interference. It also provides protection against infections.

The fetus 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 the pregnancy progresses, reaching its highest level at the thirty-sixth week. Then the number will 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 the outflow of amniotic fluid occurs during childbirth, i.e. with full or almost complete disclosure of the cervix and the presence of regular contractions.

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

If a premature rupture occurs before the 24th week, the fetus is still absolutely not able to survive outside the mother's womb. But even before the 37th week, this puts the 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 discharge is usually felt as a painless flow of fluid, but may also appear as a small stream or a slight discharge.

Symptoms

It can be difficult to determine if 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 several differences.

amniotic fluid:

• Usually odorless
• Mostly transparent. Sometimes may be mucus, blood-streaked, or white discharge
• It leaks continuously. Has a very steady flow from time to time
• Unable to control leakage
• Have to change pads and underwear frequently as leakage is persistent
• Some discomfort and spasms may occur

It may not be amniotic fluid if:

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

Symptoms of a slow leak

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

• You notice a sudden stream of fluid moving along the length of your legs.
• Your underwear is wet
• Small amount of fluid or trickle

The cause of a small leak can 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 by the fact that you continue to experience moisture even after emptying your bladder.

Early leakage of amniotic fluid

A miscarriage is the loss of a fetus in the early weeks of 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 as this allows you to seek medical attention as soon as possible.

It is important to pay attention to:

• Isolation of a gray or light pink substance
• Spilling an unexpected large amount of fluid
• Passage of large pieces of tissue
• pinkish discharge

The release of tissue or fluid during early pregnancy could be a sign of a miscarriage, according to the Mayo Clinic. The released tissue or fluid 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 pregnancies

Leakage of amniotic fluid at 16 weeks

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

Treatment includes:

• Arrangement in a medical institution for a thorough examination
• Checking for a miscarriage
• After observing you for a while, the doctor will discuss the next steps.

Leakage of amniotic fluid in the 2nd trimester

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

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

Regular examinations by 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 the rupture of the membranes occurs 37 weeks after the last menstrual cycle (the so-called gestational age of the fetus), then the risks of complications are minimal and contractions usually begin soon after.

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

• bacterial infection
• Cases of premature discharge of water in previous pregnancies
• Having a defect in the development of your fetus
• Infection in the vagina, uterus, or cervix.
• Bad habits such as smoking, drugs and alcohol abuse
• Straining of the amniotic sac due to a large baby or twins
• Poor nutrition
• Preliminary operations in the area of ​​the cervix or uterus

Leak tests

It is most correct to contact a gynecologist, and he will conduct an examination and prescribe the necessary tests to confirm the leakage of amniotic fluid if there are suspicions. But it will also be useful to have simple pharmacy tests on hand to play it safe or reassure yourself. They can occasionally give a false positive, but should not give a false negative if used properly.

ph strip test

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

To determine the leakage of water at home, you can use litmus test strips, which are sold in almost every pharmacy and have an affordable price. Litmus paper helps to establish 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 pouch membranes are 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 acidity will indicate that you have an infection or amniotic fluid is leaking.

Test strip for determinationThe pH of the aquarium water is also suitable for amniotic fluid leakage testing, and they can be cheaper.

Nitrazine test

The most common type of test. The price for one tampon is from 2 dollars.

Popular brands are such as AmnioTest, Amnicator. It requires the application of a drop of vaginal fluid to paper strips containing nitrazine as an indicator, a substance more sensitive than litmus. On sale, such tests are available in the form of special swabs or pads, which facilitates its implementation.

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 with a high probability the shells of the bubble have ruptured.

However, this test can also give false positive results. If blood enters the sample or if there is an infection in the vagina, the acidity level may be higher than normal. Male sperm also has a higher pH, so recent intimacy may affect the outcome.

Alpha 1 microglobulin test

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

This is a modern and more accurate test, but its cost is many times more expensive (more than 30 shares). It also does not require special laboratory conditions, but more often it is performed by an obstetrician-gynecologist on an outpatient basis. The bottom line is the detection of such a biomarker 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. According to the results of the number of stripes that appeared on it (1 or 2), it can be said with an accuracy of 97% about the presence of amniotic fluid leakage.

Other tests that may be done in the hospital

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

Inspection of liquid under a microscope. If leakage occurs, then the amniotic fluid mixed with estrogen, when dried due to salt crystallization, will create a “fern” symptom (will resemble fern leaves). For holding, a few drops of liquid are placed on a microscope slide for examination.

Dye test. Inject a special dye into the amniotic sac through the abdominal cavity. If the membranes are torn, 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 hints to identify one of them.

Leakage of amniotic fluid

It will have the following properties:

• May contain clear or whitish mucous patches
• Odorless and colorless. May have a sweet smell in some cases
• Presence of blood spots
• Does not smell like urine

Constant discharge means that the fluid is indeed amniotic.

Urine

Urine usually has the following properties:

• Ammonia smell
• Dark or pure yellowish color

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

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 smell similar to urine.
• May be yellowish or whitish
• Have a firmer consistency than urine or amniotic fluid
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Leakage of amniotic fluid or premature rupture of amniotic fluid (PIV or PIOV in various sources) is a rupture of the membranes, an outpouring of amniotic fluid before the onset of regular labor activity with cervical dilatation up to 7-8 cm.

Normally, the outflow of amniotic fluid occurs spontaneously in the first stage of labor, upon reaching the opening of the cervix by 7-8 cm, in the next contraction, the woman notes a copious outflow of fluid that is not associated with urination. After the outflow of waters, contractions, as a rule, intensify and the 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 amniotic fluid leakage:

1. Invasive diagnostic methods (amniocentesis)

Amniocentesis is a diagnostic method that consists in puncturing the fetal bladder through the anterior abdominal wall under anesthesia and ultrasound control and taking amniotic fluid for biochemical and chromosomal analysis.

In about 1% of cases, this procedure is complicated by an abortion, you will be warned about this in advance and the patient always makes the final decision.

2. Untreated colpitis of various etiologies

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

3. Intra-amniotic infection

Intra-amniotic infection acts in the same way (damages the membranes) only from the inside. Infection in the fetal bladder is introduced 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 fetal bladder and already massively develops inside).

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

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

ICI - shortening of the cervix and expansion of the internal uterine os, not corresponding to the gestational age (early term). 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 the fetal bladder(this is a clear condition that is accompanied by the outflow of anterior amniotic fluid)

1) Abundant painless discharge of light (cloudy / greenish / straw, etc.) fluid not associated with urination

2) Reducing the height of the fundus of the uterus (the outflow of water reduces the intrauterine volume and the stomach becomes smaller and denser)

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

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

II. High / lateral opening of the amniotic sac(this condition may go unnoticed, as it proceeds with implicit symptoms and is extended in time)

1) Increased vaginal discharge, which becomes thinner, watery, soaks underwear and does not stop. They are also aggravated by coughing and lying down (in most).

2) Pulling pains in the lower abdomen, spotting (there are not always)

3) Change in fetal movements

Complications of premature water leakage

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

- premature birth. Preterm births occur between 22 weeks and 36 weeks and 5 days of gestation and involve many complications for the mother and fetus, the severity of the condition depending on the gestational age.

Anomalies of labor activity (weakness of labor activity, discoordination of labor activity and others)

- hypoxia and asphyxia of the fetus (a long anhydrous period and anomalies of labor activity lead to impaired 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 (surfactant in the baby's lungs matures closer to 35-36 weeks, earlier outflow of water and childbirth entail inferior functioning of the lungs)

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

Intraventricular hemorrhages, cerebral (cerebral) ischemia in a child

Deformation of the skeleton and self-amputation of limbs in a child with 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 inner uterine wall, more often it develops in women with premature outflow of water and the longer the anhydrous period (without antibiotic prophylaxis), the higher the risk of the disease. If chorionamnionitis has developed during childbirth, then in the postpartum period, the likelihood of developing endometritis is extremely high.

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

How to identify water leakage

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

If you notice vague profuse watery discharge, then you should urinate, take a shower, dry yourself (dry the perineum thoroughly) and put a clean, dry white pad (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, wetting of the lining indicates a possible leakage of amniotic fluid. In this case, you should collect a minimum of things to the maternity hospital and call an ambulance (or contact the emergency room of the maternity hospital yourself).

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

This test is a system designed for self-use, all the required items are included in the kit.

How to do a water leak test:

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

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

The pad should be attached to the underwear, as usual, the yellow indicator should be facing the vagina. The pad is used for about half an hour, or until sufficient moisture can be used up to 12 hours, and then the color is evaluated and compared with the color chart on the package. Blue - green color may indicate the outflow of amniotic fluid. The indicator color is stable for up to 48 hours. If, after drying, the color turns yellow again, then this most likely means that there was a reaction with urine ammonia. But the final conclusion will be given to you only by a doctor.

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

Gaskets are easy to use and affordable, but their information content is somewhat lower than test systems.

A false positive result can be caused by:

Colpitis of any etiology
- bacterial vaginosis
- recent 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 the mirrors with a cough test

When viewed in the mirrors, the cervix is ​​exposed, and the doctor asks the patient to cough, if the fetal bladder ruptures, the amniotic fluid will leak in portions with a cough shock. Sometimes, when viewed in the mirrors, a clear outflow of water is visible, the liquid 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 outflow of water. The amniotest is a cotton-tipped stick soaked in a reagent that must be placed in the posterior fornix of the vagina and the color change assessed. However, a false positive result can be caused by the same factors as when using test pads.

Ultrasound (an ultrasound doctor measures the level of amniotic fluid, also known as the amniotic fluid index - IAF and compares it with the data of the previous ultrasound; after the outflow 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 in the expiration of amniotic fluid at different times.

Up to 22 weeks

Prolongation of pregnancy is impractical 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 pregnancy is terminated for medical reasons.

22–24 weeks

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

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

25 - 32 weeks

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

32 - 34 weeks

Expectant tactics are shown no more than 7 days.

34 - 36 weeks

Expectant tactics are shown no more than 24 hours.

37 weeks or more

Expectant tactics are shown for no more than 12 hours, then the onset of labor induction is shown. In this case, antibiotic prophylaxis begins after 18 hours of the anhydrous period.

Contraindications to expectant management:

Chorioamnionitis
- preeclampsia/eclampsia
- premature detachment 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 chosen on an individual basis.

Expectant tactics

1. Examination of the cervix in the mirrors, vaginal examination is carried out only upon admission, then it is not carried out

2. During the initial examination in the mirrors - sowing on the flora and sensitivity to antibiotics

When establishing the fact of outflowing waters - the immediate start of antibiotic prophylaxis of 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 if beta-hemolytic streptococcus is detected in microbiological crops

Penicillin 1.5 g IM every 4 hours

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

4. Thermometry every 4 hours

5. Control of the fetal heart rate, secretions from the genital tract, uterine contractions at least 2 times a day

6. Complete blood count upon admission and in the future at least 1 time in 2-3 days;

7. Ultrasound examination 1 time in 7 days with the determination of the amniotic fluid index and Doppler blood flow in the uterine arteries and umbilical 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. In the presence of uterine contractions with a frequency of more than 3-4 in 10 minutes - tocolysis (the introduction of drugs that relieve the contractile activity of the uterus, hexoprenaline is most often used, the dose and rate of administration is chosen by the attending physician)

10. With the development of labor activity not less than 48-72 hours after the first injection of dexamethasone, tocolysis is not performed.

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

Pregnant women with HIV infection

1. With PIV after 32 weeks - immediate labor induction.

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

3. Prevention of vertical transmission of the virus.

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

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

Despite the simplicity and availability of home diagnostic methods, do not neglect an extraordinary visit to your doctor in case of suspected amniotic fluid leakage. The earlier the diagnosis is made, the more favorable the result in any period of pregnancy. We wish you a safe pregnancy and easy delivery at term. Look after yourself and be healthy!

Obstetrician-gynecologist Petrova A.V.