Dribble of amniotic waters
Dribble of amniotic waters — the pathological state caused by a high rupture of fetal covers or formation of microcracks in them. It is shown by constant allocation of a small amount of watery amniotic liquid. Survey with mirrors, amniotesta, amniocentesis with safe dye, a research of vaginal dab under a microscope, transabdominal ultrasonography is applied to diagnostics. Obstetric tactics is defined by the pregnancy term, a condition of mother and a fruit, existence of complications. At waiting maintaining appoint antibiotics, glucocorticoids, tokolitik. Active tactics provides termination of pregnancy or induction of patrimonial activity.
Dribble of amniotic waters
Damage of fetal egg with insignificant dribble of waters is observed almost in half of cases of a premature rupture of an amnion. According to different authors, such pathological state arises in 2-5% of pregnancies and is the reason of nearly 10% of cases of perinatal mortality. Due to the minimum clinical manifestations dribble is not revealed often in time that significantly increases risk of infectious and other complications. The rupture of covers provokes premature birth, is the main reason for prematurity, a hypoplasia of lungs and sepsis of a fruit — three key factors increasing risk of death of the newborn. Use of modern methods of diagnostics and rational maintaining pregnant women with the damaged fetal covers allows to improve significantly the forecast for mother and the child.
Reasons of dribble of amniotic waters
Constant allocation of insignificant amount of amniotic liquid is observed at violation of integrity of covers of a fruit. Unlike plentiful premature the izlitiya of amniotic waters as a result of a rupture of the lower pole of fetal egg, dribble usually arises at a so-called high side anguish or formation of microcracks. There are several groups of the reasons leading to damage of an amniotic cover:
- Infectious processes. The spontaneous rupture of covers of a fruit is more often observed at the pregnant women having an endometritis, a colpitis tservitsity, adneksity. Durability of an amnion significantly decreases at a horioamnionita.
- Violations in uterine and placentary system. The probability of damage of an amniotic bag increases in the presence of the two-horned or doubled uterus, ITsN, placentary insufficiency, obolochechny fastening or a premature otsloyka of a placenta.
- Yatrogenny influences. Dribble of waters can become result of repeated bimanualny researches, transvaginal ultrasonography, amniocentesis, a biopsy of a horion and strengthening of a neck of a uterus seams at ITsN.
- Fetal factors. Walls of an amniotic bubble are under elevated pressure at polycarpous pregnancy, fruit hydrocephaly, anomalies of its situation and insertion of the prelying part.
- Pathology of covers. Excessive stretching of an amnion arises at a mnogovodiya, caused by primary and secondary hyperproduction of amniotic waters or violation of their resorption. Elasticity of covers also decreases at their hyaline regeneration (a premature degeneration).
- Stomach injuries. Covers of a fruit can be broken off at sharp blow in a stomach, the getting wounds of an abdominal cavity and uterus.
Experts in the sphere of obstetrics and gynecology allocate a number of the contributing factors which increase risk of spontaneous destruction of covers of a fruit. The probability of dribble is higher at women with premature izlitiy than amniotic waters during the previous pregnancy (the recurrence is observed in 20-30% of cases), in the presence of chronic inflammatory diseases of genitals and cicatricial deformation of a neck of a uterus. Pathology is more often diagnosed for patients, is long using glucocorticoid medicines, with system diseases of connecting fabric, anemia, nicotine addiction. According to some authors, a certain provocative role is played by low welfare of the woman which leads to unbalanced food, considerable physical and psychoemotional activities.
Key value in pathogenesis of dribble of amniotic waters is played by the reasons leading to damage of an amnion. A starting link of process usually are the structural changes in fruit covers caused by an inflammation, degenerate changes or considerable stretching. Excessive increase in pressure of amniotic waters or sharp traumatic influence (blow, a rough palpation, a puncture) breaking integrity of covers becomes the starting moment of a gap with the subsequent dribble.
At a high side arrangement defect of an amniotic bag is over an internal uterine pharynx therefore the speed of an effluence of amniotic waters is limited at the expense of an adjunction of the damaged site to a uterus wall. As ruptures of an amnion do not cicatrize, protective function of a fetal bubble decreases, increases risk of infection of a fruit. Besides, enzymes which contain in amniotic liquid are capable to provoke an otsloyka of a placenta and, depending on gestational term, spontaneous abortion or premature birth.
At the choice of tactics of maintaining the pregnant woman the defining role is played by time of damage of covers of a fruit. On the basis of this criterion allocate the following types of dribble of waters:
- At a premature prenatal gap — till 37th week of pregnancy (dribble at premature pregnancy);
- At a prenatal gap — since the 37th week of gestational term (dribble at the full-term pregnancy);
- At an early side gap — at the time of delivery before disclosure of a neck on 4 cm and more.
Symptoms of dribble of amniotic waters
If the effluence of amniotic liquid is not combined with other obstetric or gynecologic pathology – subjective feelings are absent, the state in some cases can remain unnoticed. Stomach volume, as a rule, does not decrease. Usually the pregnant woman complains of constant allocation from a vagina of watery liquid without color and a smell which amount increases at change of a pose, tension of an abdominal tension during cough, sneezing, physical activities and in horizontal position.
If the woman suspects dribble of waters, she can use a simple method of "a pure diaper". Emergence of a damp spot on fabric after lying on a back within 30-60 minutes is a reason for the urgent appeal to antenatal clinic. At gaps lasting more than days signs of infection of a uterus, a fruit and/or its covers arise and accrue. Body temperature of the patient increases to 38 and more degrees, there is a fever, pains in the bottom of a stomach which amplify at a palpation. In allocations from a vagina impurity of pus and an ichor can appear.
Long dribble of amniotic waters represents considerable threat both for the pregnant woman, and for a fruit. According to a number of researchers, at this pathology at 8-13 times the risk of a still birth increases, perinatal mortality increases by 4 times, and neonatal incidence — in 3. The main complications with high risk of death of a fruit and the death of the newborn are a respiratory distress syndrome, horioamnionit, nekrotiziruyushchy enterokolit, intra ventricular hemorrhages. Owing to violation of uterine and placentary blood circulation there is a fruit hypoxia. The premature otsloyka of an afterbirth and congenital anomalies is possible (a retinopathy, an open arterial channel, deformation of a skeleton, self-amputation of extremities, etc.). At pregnant women with the leaking amniotic waters weakness of patrimonial activity, postnatal bleedings and an endometritis is observed more often.
Dribble of amniotic waters — one of the most difficult pathological states in respect of diagnostics at pregnancy. The poor clinical symptomatology and high risk of the subsequent complications demand especially careful inspection of patients with suspicion on damage of covers of a fruit. Diagnostic actions are directed to confirmation of amniotic nature of allocations and identification of possible complications. The plan of inspection usually includes:
- Survey in mirrors. In the back arch a small amount of transparent liquid which leaks at the pregnant woman's tussiculation is defined.
- Transabdominal ultrasonography. At dribble this method is less informative, however allows to diagnose possible complications in time — an otsloyka of a placenta, signs of suffering of a fruit, etc.
- Microscopy of vaginal dab. Availability of amniotic liquid is demonstrated by crystallization in the form of characteristic leaves of a fern. However this method is considered insufficiently sensitive and specific.
- . Changes of color of test strips are revealed by alkalization of acidic environment of a vagina amniotic waters, and detection in releases of placentary microglobulin in 99,9% of cases demonstrates damage of fetal covers.
- Amniocentesis with dye. The method is high-invasive and assumes introduction to an amniotic bag of safe dye through a puncture of a belly wall. If in 20-30 minutes after introduction the tampon established in a vagina is painted, the diagnosis of a rupture of covers is considered confirmed.
Differential diagnostics is carried out with inflammatory diseases of female genitals (vaginity, tservitsity, an endometritis, salpingoofority), amnionity, a premature otsloyky placenta. At identification of complications involve in maintaining the patient the intensivist, a neonatolog, the therapist.
Treatment of dribble of amniotic waters
At the choice of the scheme of maintaining the pregnant woman first of all gestation term is considered. Taking into account frailty of a fruit and high risk of dangerous complications pregnancy to 22 weeks is recommended to be interrupted. Patients on later terms are hospitalized in obstetric hospitals of the 3rd level and provide the maximum physical rest. From 22 to 34 week inclusive tactics is waiting. Prolongation of pregnancy is contraindicated at a horioamnionita, rough malformations, a sharp hypoxia or death of a fruit, the beginning of patrimonial activity, a preeklampsiya and eklampsiya, an otsloyka of a placenta and some other states. In other cases are recommended:
- Preventive antibacterial therapy. For decrease in risk of infectious complications antibiotics are appointed a course from the first day of hospitalization.
- Medicines for prevention of RDS. To accelerate synthesis of surfactant and maturing of pulmonary fabric, apply glucocorticoids.
- Tokolitichesky therapy. Use selective β2-, sulfate magnesia, inhibitors of a tsiklooksigenaza, blockers of slow calcic channels and oksitotsinovy receptors the miometriya reduces sokratitelny activity.
- Amniotransfuziya. It is applied in exceptional cases upon the demand of the pregnant woman on 22-24 week at large volumes of allocations and considerable decrease in amount of amniotic waters.
Treatment is carried out against the background of regular monitoring of a condition of a fruit and the pregnant woman: thermometry, assessment of indicators of blood and haemo dynamics, daily kardiotokografiya, weekly ultrasonography, dopplerometriya of a fetoplatsentarny blood-groove each 3 days. At the same time special attention is paid to prevention of an intrahospital infection.
At identification of dribble of waters at the woman with 34-36 weeks pregnancy use both waiting, and active tactics. As there are no reliable data that induction of patrimonial activity in this term worsens a neonatal outcome, the second option is preferable. Waiting often provokes development of a horioamnionit and a compression of an umbilical cord. Observation duration usually does not exceed 1 days. After the beginning of childbirth with the preventive purpose appoint antibiotics.
On 37 and more than a week of a gestation at identification in releases of amniotic waters and lack of patrimonial activity stimulation of childbirth is shown. Antibacterial therapy is applied at diagnostics of a horioamnionit. Preventive prescription of antibiotics is recommended only when the estimated duration of dribble of waters exceeds 18 hours.
Forecast and prevention
The forecast at dribble of amniotic waters depends on pregnancy term. Rational use of waiting tactics allows a fruit to ripen as much as possible and minimizes risk of infectious complications. The termination of dribble at 22-33 weeks pregnancy allows to prolong it to the full-term terms if the condition of the woman and a fruit is satisfactory, and the amount of amniotic liquid remains at the normal level. At continuation of dribble of waters, lack of signs of an inflammation, satisfactory condition of the pregnant woman and a fruit prolongation is possible no more than for 1-3 weeks. The risk of perinatal mortality significantly decreases at premature birth about 31-33 weeks of pregnancy, and incidence of newborns — with 34 and more. Prevention of premature dribble of waters provides restriction of heavy physical activities, refusal of smoking, timely registration and regular visits of the obstetrician-gynecologist, reasonable purpose of invasive diagnostic procedures (especially at detection of risk factors).