Premature Rupture

of Membranes

Definition
Premature rupture of membranes (PROM)
Rupture of the chorioamnionic membrane
(amniorrhexis) prior to the onset of labor at any
stage of gestation

preterm
term
(TPROM)

< 37 weeks (PPROM)

37 weeks

Periode Laten
waktu saat pecahnya ketuban hingga dimulainya
persalinan
semakin muda usia kehamilan semakin lama
periode laten
pada kehamilan aterm 90% akan memulai
persalinan dalam 24 jam
pada kehamilan 28-34 minggu

50% bersalin dalam waktu 24 jam

80-90% bersalin dalam waktu 1 minggu

Incidence
PROM 12% of all pregnancies
PROM 8% term pregnancies
PPROM 30% of preterm deliveries

Cause of PROM
Idiopatik
Trauma (abdominal striked intensely)
Sexual intercourse(particularly in the
late gestational weeks)
Vaginal infection
due to
bacteria virus TOXO CMV HP
V and HSV,et al

Smoking

PROM/PPROM: History & Physical

Exam
History
Gush of fluid
Steady leakage of small amounts of fluid
Physical
Sterile vaginal speculum exam
Minimize digital examination of cervix, regardless of
gestational age, to avoid risk of ascending
infection/amnionitis
Assess cervical dilation and length
Obtain cervical cultures (Gonorrhea, Chlamydia)
Obtain amniotic fluid samples

Findings
Pooling of amniotic fluid in posterior vaginal fornix
Fluid per cervical os

PROM/PPROM: Diagnosis
Test
Nitrazine test
Fluid from vaginal exam
placed on strip of nitrazine
paper
Paper turns blue in
presence of alkaline (pH >
7.1) amniotic fluid

Fern test
Fluid from vaginal exam
placed on slide and
allowed to dry
Amniotic fluid narrow fern

PROM/PPROM: Diagnosis
Test
Ultrasound
Assess amniotic fluid level and compatibility with PROM,
comfirm with oligihidramnion

Indigo-carmine Amnioinfusion
Ultrasound guided indigo carmine dye amnioinfusion
(Blue tap)
Observe for passage of blue fluid from vagina

The Patient

Vaginal discharge
Gush of fluid
Leaking of fluid
Oligo/Anhydramnios
Cramping
Contractions
Back pain

Affect of PROM on the

mothers and infants
Mothers:
(1) Infection : intrauterine
puerperal
(2) Placental abruption
(3) Preterm delivery

Infants:
(1) Preterm Baby and their Complications :
(RDS / Fetal and Neurologic dysfunction
Intracranial hemorrhage)
(2) neonatal pneumonia sepsis
(3) Pulmonary hypoplasia and fetal
compression syndrone
(4) Prolapse or compression of umbilical
cord
(5) Abruptio placenta

Management: PPROM
(< 24 wk gestation previable)

Patient counseling
GBS prophylaxis NOT recommended
Corticosteriods NOT recommended

Management: PPROM
(24 31 wk gestation)

Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity

GBS prophylaxis
Antibiotics
Single course corticosteroids
Tocolytics
No consensus

Management: PPROM
(32 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

Management: Drug Regimen

Antibiotics
Ampicillin 2 g IV Q6 x 48 hrs
Amoxicillin 500 mg po TID x 5 days
Azithromycin 1 g po x 1

Corticosteroids
Betamethasone 12 mg IM single dose for two days
Dexamethasone 6 mg IM every 6 hours 4 times

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

Flouresecence polarization (FLM-TDx II)

> 55 mg/g of albumin

Lamellar body count

30,000-40,000

If negative, proceed with expectant

management until 34 wks

Courtesy of Thomas Shipp, MD.

Management: Surveillance
Maternal: Monitor for signs of infection

Temperature
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions

Fetal: Monitor for fetal well-being

Kick counts
Nonstress tests (NSTs)
Biophysical profile (BPP)

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
Increase
Increase
Increase
Increase

in
in
in
in
in

RDS
intraventricular hemorrhage
neonatal sepsis and subsequent cerebral palsy
perinatal mortality
cord prolapse

complications

Preterm labor
Infection
Hipoxia and asfixia
Fetal deformitas syndrom