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PREMATURE RUPTURE OF
of
Membranes
MEMBRANES (PROM)
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Definisi
Premature rupture of membranes (PROM)
Ketuban pecah/selaput ketuban robek sebelum inpartu/
Partus kala I fase laten
Incidence
PROM 12% of all pregnancies
PROM 8% term pregnancies
PPROM 30% of preterm deliveries
PROM/PPROM:
Anamnesa
keluar air-air (jumlah, warna, bau)
Air ketuban merembes
Pemeriksaan fisik
Pemeriksaan Spekulum
MinimalisiarVaginal Toucher
Keluar cairan amnion dari osteum uteri eksternum
Mengetahui warna, bau
Mengetahui pembukaan
PROM/PPROM: Diagnosis
Test
Nitrazine test/lakmus
Lakmus merah biru
Lakmus biru biru (pH > 7.1)
PROM/PPROM: Diagnosis
False positive Nitrazine test
Alkaline urine
Semen (recent coitus)
Cervical mucus
Blood contamination
Vaginitis (e.g. Trichomonas)
Management: PPROM
(< 24 mgg)
Patient counseling
Expectant management vs. induction of labor
GBS prophylaxis NOT recommended
Antibiotics
Incomplete data
Management: PPROM
Patient counseling
Outcomes at 18 to 22 Months Corrected Age*
Gestational Age
(In Completed
Weeks)
Death Before
NICU Discharge
22 Weeks
23 Weeks
24 Weeks
25 Weeks
95%
74%
44%
24%
Death
Death/ Profound
Neurodevelopmental
Impairment
95%
74%
44%
25%
98%
84%
57%
38%
99%
91%
72%
54%
Pulmonary hypoplasia
Skeletal malformations
Fetal growth restriction
IUFD
Management: PPROM
(24 33 wk gestation)
Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Corticosteroids
No consensus, some experts recommend
Management: PROM
(> 34 wk gestation)
Proceed to delivery
Induction of labor
GBS prophylaxis
Management: Rationale
Antibiotics
Prolong latency period
Prophylaxis of GBS in neonate
Prevention of maternal chorioamnionitis and neonatal sepsis
Corticosteroids
Enhance fetal lung maturity
Decrease risk of RDS, IVH, and necrotizing enterocolitis
Tocolytics
Delay delivery to allow administration of corticosteroids
Controversial, randomized trials have shown no pregnancy
prolongation
Corticosteroids
Betamethasone 12 mg IM q24 x 2
Dexamethasone 6 mg IM q12 x 4
Tocolytics
Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs
Management: Amniocentesis
Typically performed after 32 wks
Tests for fetal lung maturity (FLM)
Lecethin/Sphingomyelin ratio (not commonly
used, more for historic interest)
L/S ratio > 2 indicates pulmonary maturity
Phosphatidylglycerol
> 0.5 associated with minimal respiratory distress
Management: Surveillance
Maternal: Monitor for signs of infection
Temperature
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions
Management: Surveillance
Immediate Delivery
Intrauterine infection
Abruptio placenta
Repetitive fetal heart rate decelerations
Cord prolapse
Expectant Management
vs. Preterm Delivery
Expectant Management Risks:
Maternal
Increase in chorioamnionitis
Increase in Cesarean delivery
Spontaneous labor in ~ 90% within 48 hr ROM
Increased risk of placental abruption
Fetal
Increase in RDS
Increase in intraventricular hemorrhage
Increase in neonatal sepsis and subsequent cerebral palsy
Increase in perinatal mortality
Increase in cord prolapse
Expectant Management
vs. Preterm Delivery
Preterm Delivery Risks: use NICHD calculator
http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_ep
bo/epbo_case.cfm
Gestation
(w)
Weight
Sex
Steroids
Survival
Survival w/o
profound ND
impairment
25
550
Female
Yes
64%
50%
24
500
Male
Yes
35%
22%
23
450
Male
Yes
16%
9%
22
401g
Female
No
2%
1%