الفهرس 
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Abstract
One the most recent amniotic fluid markers in vaginal environment hypothesized by Ebru kale et al., 2008 is measuring vaginal fluid Aspartate amino-transferase enzyme, also measuring thyroid hormones levels for diagnosis of PPROM.
Liver enzyme aspartate aminotransferase (AST) is produced by the fetus. These levels do not correlate with maternal level. The Concentration of AST increases with gestational age.
Also measurement of free thyroid hormones free T3 and free T4 in cervicovaginal wash fluid were significantly higher in patients with PPROM. So measuring of thyroid hormones can be also used as a diagnostic indicator for PPROM.
The objective of this study was to evaluate the reliability of vaginal fluid AST versus free thyroid hormones for the diagnosis of premature rupture of membranes.
This study was conducted in Ain Shams University Maternity Hospital in the time between June 2010 to February 2011.
A total of 100 pregnant women were included in this study, between 26-37 weeks of gestation, and were divided into two groups:
• 50 pregnant women with confirmed PPROM group (Cases)
• 50 normal pregnant women (control group).
5ml of sterile saline irrigating the posterior vaginal fornix using a sterile Cusco speculum and 3ml of the irrigated saline was aspirated with the same syringe and the sample was sent immediately to the laboratory for assay of AST and free T3 and free T4, After confirming the absence of amniotic fluid pooling and blood in the posterior fornix for the control group,
The sampling method and AST and free T3 and free T4 assays will be performed as previously described for PPROM pregnant women.
• The median vaginal fluid free T3 was significantly higher in women of group I (PPROM Group) when compared to women of group II (Control Group):
[1.41pg/ml (range: 0.72 – 2.34 pg/ml) vs 0.81 pg/ml (range: 0 – 1.8 pg/ml), respectively, p<0.001]
• The median vaginal fluid free T4 was significantly higher in women of group I (PPROM Group) when compared to women of group II (Control Group):
[0.61ng/dl (range: 0.04 – 0.64 ng/dl) vs. 0.05 ng/dl (range: 0 – 0.8 ng/dl), respectively, p<0.001]
• The median vaginal fluid AST was significantly higher in women of group I (PPROM Group) when compared to women of group II (Control Group):
[5 U/L (range: 1 – 54 U/L) vs. 3 U/L (range: 0 – 10 U/L), respectively, p=0.001].
• Receiver operator characteristics (ROC) curves were constructed for vaginal fluid free T3, free T4 and AST as diagnostic of PPROM.
All of them shows large significant area under the curve (AUC) denoting significant association between higher levels an diagnosis of PPROM; with the vaginal fluid free T4 being the most significantly associated by having the larger AUC
Vaginal fluid free T3 was the most sensitive [88%], while vaginal fluid free T4 was the most specific [72%]. Vaginal fluid AST has less diagnostic accuracy parameters when compared to either free T3 or free T4.
Among women of group I [PPROM Group], there was a significant positive correlation between vaginal fluid free T3 level and each of vaginal fluid free F3 level [rs=-0.488, p<0.001] and gestational age [rs=0.345, p<0.001]. There was no significant correlation between each of vaginal fluid free T3, free T4 and AST, and any of the other variables.
Among women of group II [Control Group], there was no significant correlation between each of vaginal fluid free T3, free T4 and AST, and any of the other variables.
The best cut-off value for vaginal fluid free T3 concentration for detection of PPROM was 1.06 pg/ml showing:
1. Sensitivity 88%.
2. Specificity 70%.
3. PPV (Positive predicitve value) 74.6%.
4. NPV (Negative predicitve value) 85.4%.
5. Overall accuracy 79%.
6. LR+ (Positive likelihood ratio) 2.9.
7. LR- (Negative likelihood ratio) 0.17.
The best cut-off value for vaginal fluid free T4 concentration for detection of PPROM was 0.063 ng/dl showing:
1. Sensitivity 86%.
2. Specificity 72%.
3. PPV (Positive predictive value) 75.4%.
4. NPV (Negative predicitve value) 83.7%.
5. Overall accuracy 79%.
6. LR+ (Positive likelihood ratio) 3.1.
7. LR- (Negative likelihood ratio) 0.19.
The best cut-off value for vaginal fluid AST (aspartate amnioferase enzyme) concetration for detection of PPROM was 4.5 u/l showing:
1. Sensitivity 56%.
2. Specificity 70%.
3. PPV (Positive predictive value) 65.1%.
4. NPV (Negative predicitve value) 61.4%.
5. Overall accuracy 63%.
6. LR+ (Positive likelihood ratio) 1.9.
7. LR- (Negative likelihood ratio) 0.63.
So that we can conclude that vaginal fluid free T3 ≥ 1.06 pg/ml, when present in women between 26 and 37 weeks’ gestation, can identify PPROM in approximately 88% of women.
They speculated that this test had a high negative predictive value for PPROM; its use could at least limit unnecessary patient hospitalization.
According to these results thyroid hormones could be useful indicator to predict PPROM and more useful than aspartat-aminotransferase, so it is considered a good screening test for detection PPROM as:
• Vaginal fluid free T3 was the most sensitive [88%],
• while vaginal fluid free T4 was the most specific [72%].
• Vaginal fluid AST has less diagnostic accuracy parameters and negative predictive value when compared to either free T3 or free T4.
• Vaginal AST and thyroid hormones assay are cheap and fast method, but free T3 it has a high sensitivity and negative predictive values for detection of PPROM so it is considered a good screening test for detection of PPROM
According to these results vaginal free T3and free T4 could be applied on patients with suspected preterm prelabor rupture of membranes (PPROM) this could limit unnecessary patient hospitalization and intervention