DIAGNOSTICO DE RUPTURA PREMATURA DE MEMBRANAS (PRUEBAS BIOQUIMICAS)

Dr. Juan Ramn Sigenza R1 GINECOLOGIA Y OBSTETRICIA

RUPTURA PREMATURA DE MEMBRANAS

Salida de liquido amniotico

antes del inicio de labor de parto

RPM

Comunicacin cavidad amniotica con vagina y endocervix

6 horas antes de inicio trabajo de parto

Unitat de Prematuritat. Servei de Medicina Maternofetal. Institut Clnic de Ginecologia, Obstetrcia i Neonatologia, Hospital Clnic de Barcelona 2007

RPM
EPIDEMIOLOGIA

El 80% a trmino
El 20% son pretrmino y representan el 10% de los partos prematuros.

Embarazo gemelar 7- 20%

Unitat de Prematuritat. Servei de Medicina Maternofetal. Institut Clnic de Ginecologia, Obstetrcia i Neonatologia, Hospital Clnic de Barcelona 2007

COMPLICACIONES
PARTO PRETERMINO SDR 10-40 % INFECCION INTRAAMNIOTICA 15-30% HIPOPLASIA PULMONAR 26 % DEFORMIDADES ESQUELETICAS 12 % OLIGOHIDRAMNIOS SEVERO COMPRESION DEL

CORDON

INFECCION MATERNA 13-60%

COMPONENTES DE LAS MEMBRANAS OVULARES

Revista chilena de Ginecologia y Obstetricia 2004; 69(3) 249-295

Infeccin

Tabaquismo

traumatismos

Patologa fetal

ETIOLOGA (RPM)

Hemorragias de la gestacin

Dficit vitaminas

aumento presin amnitica

Revista chilena de Ginecologia y Obstetricia 2004; 69(3) 249-295

RPM FISOPATOLOGIA

Revista chilena de Ginecologia y Obstetricia 2004; 69(3) 249-295

RPM DIAGNOSTICO
10-20 %
prdida de lquido intermitente.

80- 90%

Salida de liquido amnitico (especulo + m. valsalva)

Contaminaci n secreciones cervicales, semen, sangre, orina

No se evidencia hidrorrea en vagina en ex. fsico

Unitat de Prematuritat. Servei de Medicina Maternofetal. Institut Clnic de Ginecologia, Obstetrcia i Neonatologia, Hospital Clnic de Barcelona 2007

RPM DIAGNOSTICO
Test de nitrazina Cristalografia Ecografia

NITRAZINA TEST (pH)

El LA es alcalino , el papel de Nitrazina (amarillo) cambia a color azul (pH 6) La sensibilidad: 90.7% La especificidad: 77.2% Falsos positivos 17.4% Falsos negativos 12.9%

Desventajas: exploracin con espculo falsos positivos vaginosis , la orina alcalina, la sangre, el esperma, o los antispticos.
Fuente: Contemp Ob/GYN, Sept 15 2005, Joong Shin Park and Errol R. Norwitz

CRISTALOGRAFIA
Cristalizacin de LA seco , observacin

miscroscopio Sensibilidad 51.4% Especificidad 70.8% Falso positivo 5-30% Falso negativo 12.9%

Fuente: Contemp Ob/GYN, Sept 15 2005, Joong Shin Park and Errol R. Norwitz

CRISTALOGRAFIA
Desventajas: Espculo microscopio. Falsos positivos: huellas dactilares, esperma o moco cervical. Falsos negativos: torundas secas o a la contaminacin con sangre o pus
Contemp Ob/GYN, Sept 15 2005, Joong Shin Park and Errol R. Norwitz TUESTA NOLE, JORGE ISAAC

Ultrasonido
Puede detectar un oligohidramnios, y confundirse como prdida de liquido amniotico debido a ruptura de membrana Precision: No constituye una prueba confiable Ayuda a confirmar el diagnostico. Desventajas: Requiere equipo personal experto. Solo detecta prdida significativa de liquido. No se puede confirmar la causa de la prdida.

Contemp Ob/GYN, Sept 15 2005, Joong Shin Park and Errol R. Norwitz TUESTA NOLE, JORGE ISAAC

PRUEBAS BIOQUIMICAS RPM

Desde 1970 proteinas en el LA

Alfa Microglobulina-1 Placentaria

(PAMG-1) IGFBP-1 Fibronectina Fetal (fFn)

PAMG-1( PLACENTA ALFA MICROGLOBULINA)

la parte decidual de la placenta

Protena que es producida por las clulas de

Liquido amnitico concentraciones 2.000-

25.000ng/ml
Sangre materna 5-25 ng/ml

til en diagnostico de RPM

FIBRONECTINA FETAL
Es una protena producida por las clulas fetales Se localiza entre el corion y la decidua til en el diagnostico de ruptura de membranas Se relaciona con APP

(IGFBP-1): INSULIN-LIKE GROWTH FACTOR BINDING PROTEIN-1.

Es una glicoprotena Producida en el trofoblasto Su concentracin en LA es 1000 veces mayor

a la de otros tejidos.

AMNISURE
Prueba inmunocromatografica Detecta niveles mnimos de PAMG-1 (5ng/ml) No requiere de especulo

Mas alta sensibilidad y especificidad

PROM test (IGFBP-1): Insulinlike growth factor binding protein-1.

Prueba inmunocromatografica Detecta presencia de (IGFBP-1) en

secreciones vaginales Tira reactiva Necesita de especulo Los resultados se deben leer a los 5 minutos

EVIDENCIA ACTUAL

Comparison of two bedside tests performed on cervicovaginal fluid to diagnose premature rupture of membranes]. Marcellin L, Anselem O, Guibourdenche J, De la Calle A, DeputRampon C, Cabrol D, Tsatsaris V.

OBJECTIVO: Comparar la efectividad dx RM en liquido cervicovaginal , con AmniSure() y ActimProm test METODOS: Estudio caso control (prospectivo ) Mujeres embarazadas 24 a 41sem (grupo 1) con escurrimiento (grupo 2) otras sintomatologia , sin RM . AmniSure() test (PAMG-1) sin especulo y luego (IGFBP-1)con especulo en la misma visita. Journal Gynecol Obstet Biol Reprod (Paris). 2011 Nov;40(7):651-6. doi:
10.1016/j.jgyn.2011.06.007. Epub 2011 Oct 17. (PUBMED)

Comparison of two bedside tests performed on cervicovaginal fluid to diagnose premature rupture of membranes]. Marcellin L, Anselem O, Guibourdenche J, De la Calle A, DeputRampon C, Cabrol D, Tsatsaris V.

RESULTADOS: Ochenta sujetos (40 en cada grupo).

AmniSure () sensibilidad 95% , especificidad de 94,8% ACTIM Prom sensibilidad 97,5% , especificidad de 97,4% CONCLUSIN: Ambas pruebas tienen un rendimiento similar para diagnosticar la rotura prematura de membranas.
Journal Gynecol Obstet Biol Reprod (Paris). 2011 Nov;40(7):651-6. doi: 10.1016/j.jgyn.2011.06.007. Epub 2011 Oct 17. (PUBMED)

Fetal fibronectin (Quick Check fFN test()) for detection of premature rupture of fetal membranes.
SOURCE Department of Obstetrics and Gynecology, Ain Shams University, Abbassia, Cairo, Egypt, OBJECTIVES:
accuracy of the fetal fibronectin (Quick Check fFN test) in

diagnosing premature rupture of fetal membranes.

STUDY DESIGN: comparative prospective study was carried out over 1 year in Ahmadi Kuwait Oil Company (KOC) Hospital, March 2011 - March 2012.

Fetal fibronectin (Quick Check fFN test()) for detection of premature rupture of fetal membranes.

PATIENTS AND METHODS: (220) pregnant 34-37 weeks two groups 110 patients with PROM , 110 patients without PROM .

Arch Gynecol Obstet 287(2):205-10. doi: 10.1007/s00404-012-2548-3. Epub 2012 Sep 12.

Fetal fibronectin (Quick Check fFN test()) for detection of premature rupture of fetal membranes.

The diagnosis was based on patient's history

of sudden gush of water, positive ferning pattern, positive nitrazine test, confirmed by visualization of fluid passing from the cervical canal during sterile speculum examination and Trans-abdominal ultrasound (AFI 5 cm in PROM).
Arch Gynecol Obstet 287(2):205-10. doi: 10.1007/s00404-012-2548-3. Epub 2012 Sep 12.

Fetal fibronectin (Quick Check fFN test()) for detection of premature rupture of fetal membranes.
FETAL FIBRONECTIN 94.5 % Sensitivity 89.1 % Specificity FERNING TEST 84.5 % sensitivity 78.2 % specificity NITRAZINE TEST 87.3 % sensitivity 80.9 % specificity

Fetal fibronectin was more accurate (91.8 %) for detection of PROM than Ferning (81.4 %) or Nitrazine (84.1 %) tests.
Arch Gynecol Obstet 287(2):205-10. doi: 10.1007/s00404-012-2548-3. Epub 2012 Sep 12.

Fetal fibronectin (Quick Check fFN test()) for detection of premature rupture of fetal membranes.

CONCLUSION: The Quick Check fFN test() for detection of the fetal fibronectin in the vaginal fluid is a simple bedside test, more sensitive, and specific than Ferning and Nitrazine tests

Arch Gynecol Obstet 287(2):205-10. doi: 10.1007/s00404-012-2548-3. Epub 2012 Sep 12.

Comparative analysis of insulin-like growth factor binding protein1 (IGFBP-1), placental alpha-microglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membranes in pregnancy.

SOURCE Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899. PURPOSE: to compare insulin-like growth factor binding protein-1 (IGFBP-1) , placental alphamicroglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membrane
J Perinat Med. 2010 Nov;38(6):609-12. doi: 10.1515/JPM.2010.099. Epub 2010 Aug 13. (PUBMED)

Comparative analysis of insulin-like growth factor binding protein1 (IGFBP-1), placental alpha-microglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membranes in pregnancy.

METHODS: we recruited 100 women with signs or symptoms of premature rupture of membranes (PROM), between 17 and 37 weeks at a tertiary referral center

J Perinat Med. 2010 Nov;38(6):609-12. doi: 10.1515/JPM.2010.099. Epub 2010 Aug 13. (PUBMED)

Comparative analysis of insulin-like growth factor binding protein-1 (IGFBP-1), placental alpha-microglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membranes in pregnancy.

RESULTS: PAMG-1-100 WOMEN sensitivity was 92.7% specificity was 100%, (PPV) 100% , (NPV) 95.2%. IGFBP-1-94 WOMEN sensitivity was 87.5% ,specificity was 94.4% PPV 92.1% and NPV 91.1%. NITRAZINE TEST-98 WOMEN sensitivity 85%, specificity was 39.7% PPV was 49.3% and NPV was 79.3%. J Perinat Med. 2010 Nov;38(6):609-12. doi: 10.1515/JPM.2010.099. Epub 2010 Aug 13. (PUBMED)

Comparative analysis of insulin-like growth factor binding protein1 (IGFBP-1), placental alpha-microglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membranes in pregnancy.

CONCLUSION PAMG-1 was the most accurate test in diagnosing rupture of membranes and had the highest sensitivity, specificity, PPVs and NPVs.

J Perinat Med. 2010 Nov;38(6):609-12. doi: 10.1515/JPM.2010.099. Epub 2010 Aug 13. (PUBMED)