Fetal membranes are important for amniotic fluid homestasis.

It protects the growing fetus against infection, trauma and provides space for movement and growth. Strength of the tissue is provided by collagen in amnion, although amnion and chorion together are stronger than either layer1. Etiology PROM Premature rupture of membranes (PR !" complicates appro#imately 1$%1&' of pregnancies and may happen in $.(%1' post amniocentesis. Rate of fetal morbidity and mortality with PR ! is very high due to preterm delivery, infection, miscarriage or pulmonary hypoplasia due to chronic oligohydramnios. )he clinical approach to the situation lies in waiting for spontaneous closure of the rupture, which is a rare possibility or terminating the pregnancy. It has been postulated that chronic infection and inflammation increases the production of hormones and cyto*ines& along with repeated stretching of amnio%chorion induces a phenomenon *nown as strain hardening. )his ma*es the membranes less elastic and more susceptible to preterm PR !. +ocal alteration in both amnion and chorion has been identified ad,acent to the rupture site-. +ittle is *nown regarding the growth and healing capacity of the fetal membrane. .s the membranes are not innervated and poorly vasculari/ed, the response of inflammation, scar formation and tissue repair does not happen in amnion and chorion. !ost cases of post amniocentesis amniorrhe#is are self%limiting and resolve spontaneously0. 1ritical point is the detachment of chorion from amnion, which is common in iatrogenic rupture and thus a simple amnio%infusion increases the intraamniotic pressure and helps in fusing of both the membranes together and sealing the amniochoriodal lea*.

Case Series
2e present a case series of 3 cases ()able 4 1", with premature rupture of membranes ranging from 13 to &0 wee*s. )hese cases were treated at Fetal and 5enetic !edicine unit at !a# super speciality 2est. ut of this 6 cases were spontaneous PR ! and 1 case was iatrogenic post amniocentesis. 7iagnosis of PR ! was made by history of sudden lea*age of amniotic fluid, lea*ing per vaginum by speculum e#amination and confirmed by ultrasound e#amination of amniotic fluid inde# less than 1 cm. .ll the defined cases were free from clinical signs of overt chorioamnionitis li*e infection, fever, increased 1 reactive protein (1RP", white blood cells and uterine tenderness. 7etailed informed counselling regarding the potential ris*s and benefits of continuing pregnancy and about the procedure of amnioP.)18 was done. .utologous platelet aphersis was done and an ali9uot of -$ ml were made. :nder all aspectic conditions, spinal needle no &$ gauge was inserted intraamniotically, small

9uantity of amniotic fluid was aspirated and sent for culture and sentivity. )hrough the same needle the autologous platelets were transfused followed by freshly thawed cryoprecipitate via three way stopcoc*. )he entire transfusion ta*es around 1;%&$ minutes. For first 3 days, fetus was monitored for amniotic fluid inde#, fetal heart rate and fetal movements.

Discussion
+onger the lapse after PR ! leads to less well defined, torned, rolled up membranes and thus a larger defect than original which shows the tissue response to rupture. Infusion of platelets followed by cryoprecipitate which provides fibrinogen, fibronectin, growth factors platelet derived growth factors, )5F 4 beta, von 2illebarnd facor, factor <III and factor =III in high concentrations restore the amnio%chorial lin*. ther authors have also tried the procedure and have achieved success;. Success may be complete which is defined as restoration of amniotic fluid inde# (.FI" to ;$th centile for the gestational age with complete closure of the rent, no lea*ing per vaginum within a span of 1$%10 days and delivery at term ()able %&". It may be partial with partial closure of the amniotic lea* with .FI upto ;th centile for the gestational age and delivered by around -& wee*s. .mniopatch mimics blood patch which is used in cases of spinal headache after iatrogenic cerebrospinal fluid lea*age. It is supported by the fact that the activated platelets adhere to the area of lea* in amnion and chorion forming a platelet plugs which is subse9uently stabili/ed by cryoprecipitate6. Table 1 Description of the cases which underwent !nioP TC" 5estational age 1( wee*s PR ! .mnio Patch 7elivery -& wee*s !iscarriage Success Partial success Failure

>umber 1 &

Spontaneous &

1(%1? wee*s@ Spontaneous & cAo bleeding PA< 1( wee*s with Spontaneous & 7.71 twins cAo bleeding PA< &0 wee*s with Spontaneous & cAo lea*ing B 0 wee*s

!iscarriage

Failure

!iscarriage

Failure

&0 wee*s with Spontaneous & cAo lea*ing B 0 wee*s &0 wee*s with Spontaneous & cAo chronic oligohdramnio s with PR ! B 1& wee*s 1( wee*s Iatrogenic & (post amniocentesi s"

-1 wee*s

Partial success Failure

1ontinuing

1ontinuing

Success C

)able 4 & 7escribing the gradual increase in .FI post .mnioP.)18 Iatrogenic Post amniocentesis Post .mniopatch .FI 7ay 6.1 cm 7ay 6 7ay 1& (.0 cm 11.- cm +ea*ing PA< >o >o >o

PR ! 1( wee*s .FI 4 1.0 cm

Conclusion
)here are too few cases to draw a conclusion and formulate a corrective treatment modality. It is still in e#perimental stages but ample evidence is there to suggest that amnioP.)18 seals the chorioamniotic lea*, able to significantly prolong the pregnancy and improve the neonatal outcome. Spontaneous PR ! invariably has underlying chorioamnionitis and might e#plain failure of amnioP.)18s. Further research has to be underta*en to delineate the fundamental defect in preterm PR ! and to identify the intrinsic repair mechanism. )his shall help in optimi/ing the intervention to repair, heal or seal the amniochorionic repair.

References 1. Bryant-Greenwood GD. The extracellular matrix of the human fetal membranes: structure and function. Placenta 1998 19:1!11. ".Gome# $% $omero $% Ghe##i &% 'oon B(% )a#or )% Berry *). The fetal inflammatory res+onse syndrome. ,m - .bstet Gynecol 1998 1/9:190!"1". 2.3a4ery -P% )iller 56% 7ni8ht $D. The effect of labor on the rheolo8ic res+onse of chorioamniotic membranes. .bstet Gynecol 198" 91:8/!9" 0.*in8er ,-% 5lar: $,&. 5utaneous wound healin8. ; 6n8l - )ed 1999 201:/28!09. <.,mnio+atch% a re+airin8 techni=ue for +remature ru+ture of amniotic membranes in second trimester 5ontino B% ,rmellino 5% Bro:a> 3 etal ,5T, B?. )6D?5, ,T6;6. P,$)6;*6 "110 /< *u++l. 1: "/-21 9.$eddy @)% *hah **% ;emiroff $3% Ballas *7% (yslo+ T% 5hen -% et al. ?n 4itro sealin8 of +unctured fetal membranes: +otential treatment for mid trimester +remature ru+ture of membranes. ,m - .bstet Gynecol "111 18<:1191!2. rticle sourceD httpDAAfetalandgeneticclinic.comAamniopatch%way%forward%midtrimester% premature%rupture%membrane%promA