PREMATURE RUPTURE OF THE

MEMBRANES (PROM)
Premature rupture of the membranes (PROM) is
defined as the rupture of the chorion and amnion one
hour or more before the onset of labour.
With PROM amniotic fluid leaks from the vagina in
the absence of contractions.
preterm < 37 weeks’ gestation (PPROM)
term  37 weeks’ gestation (PROM)
If prolonged, presents risks for both mother and
fetus.
 Etiologic and predisposing factors

• The precise cause of PROM is unknown, and

specific predisposing factors have not been
identified. However it is known to be
associated with
• Malpresentations
• Weak areas in the amnion and chorion
• Vaginal infection
• Incompetent cervix
 Management
• Diagnosis
– Speculum examination
– Nitrazine test
– Ferning test,
– Ultrasound
• Gestational age
• Presence of labour
• Infection
 Treatment
• The obstetric management of PROM is based on the
assessment of the risks to mothers and fetus.
- Active management of PROM involves induction of
labor or caesarean delivery if labor doesn’t begin
within 24 hours.
- Expectant or conservative management involves
careful observation without intervention unless signs
of amnionitis or fetal distress are seen.
- When the risk of morbidity associated with PROM is
greater than that associated with pregnancy
termination, active management is indicated.
• When risk associated with terminating the pregnancy
is considerable, as is the case of premature,
conservative management is indicated.
• In management of PROM with signs of advanced
infection, delivery of the infant is the first priority.
• In such cases the mother will be given antibiotics and
labour induction will be attempted.
• Prophylactic administration of antibiotics is intended
to prevent maternal infection when PROM has
occurred
• Vaginal examinations should be kept to a minimum
• The patient’s temperature, pulse, and respiration rate
should be assessed on admission and hourly
• The color, amount, and odor of fluid from the vagina
should be noted.
 Complications

• Maternal infection
• Abruptio placenta
• Prematurity
• Fetal distress
• Fetal infection
PRETERM BIRTH
 What is a Preterm birth
 Any birth occurring before 37 weeks’ gestation

 Subdivisions of Preterm birth:

-Late preterm birth (34 to 36 weeks)
-Early preterm (<34 weeks)
-Very preterm (<32 weeks)
Threatened PTL - presence of uterine contractions in
absence of cervical changes.
 Prematurity Risks
• Preterm infants are more likely to suffer:
– Neurologic impairment
– Chronic lung disease
– Cerebral palsy
– Developmental delay
 Risk Factors for Preterm Birth
 Previous preterm birth
 Short interpregnancy interval
 Assisted reproduction
 Multifetal gestation
 Decidual hemorrhage
 Infection and inflammation
A term birth decreases the risk of preterm birth in
subsequent pregnancies
 Causes
Maternal
– Fever
– Acute pyelonephritis
• Chronic disease
– Hypertension, nephritis, diabetes, severe anemia,
heart disease
• Pregnancy complications
– Pregnancy induced hypertension
– Antepartum hemorrhage
• Uterine anomalies
– Cervical incompetence
– Malformation of uterus
• Foetal
– Multiple pregnancy
– PROM
– Hydramnios
– Congenital fetal malformation
• Idiopathic
Signs / Symptoms

• Persistent contractions (painful or painless)

associated with cervical changes

• Intermittent abdominal cramping, pelvic

pressure or backache

• Increase in vaginal discharge

• Vaginal spotting or bleeding

 management
• Tocolytics if cx has not dilated (short term use)e.g.
-Beta sympathomimetics- salbutamol, terbutaline
-NSAIDS- indomethacin
-Calcium channel blockers- nifedipine
-Magnesium sulphate
-Oxytocin antagonists e.g. Atosiban
• Steroids e.g. dexamethaxone to allow fetal lung
maturity
• First stage
Emotional support
Monitor maternal fetal conditions
Nutrition
Infection control
 Second stage
In addition to the usual second preparation add the
following:
• Prepare resuscitation equipment
• Dextrose 10%
• Episiotomy can be performed to prevent fetal injury
• Warmth- incubator depending on the gestation age,
kangaroo method is vital after delivery
• If able to suckle attach onto the breast, if un able
nasal gastric feeding is done
• Give vitamin K to prevent intracranial hemorrhage
• Infection prevention is vital
 Characteristics of a preterm baby
• Appearance depends up on the gestation age
• Posture appears flattened with hips abducted, knees
and ankles flexed
• Generally hypotonic with a weak feeble cry
• Head in proportional with the body
• Skull bones are soft,with large fontanelle and wide
sutures
• The chest is small and narrow, appears underveloped
due to minimal lung expasion during fetal life
• Abdomen is prominent because the liver and spleen
are large and muscle tone is poor
• The skin is red and transparent due sparse
subcutaneous fat
• Vernix caseosa is abundant
• Flat ear pinna with little curve
• Orbital ridges prominent
• Nipple areola poorly developed
• Plantar creases absent
• In girls labia majora doesnot cover the minora
• In boys undescended testes into the scrotal sac
• Prematures sleep most of the time
Prevention of PTB
Primary Prevention
1.improve quality of life and nutritional status
2.reduction in physical and emotional stress. bed rest.
3.education programs for signs and symptoms,
contractions, pelvic pressure, vaginal discharge
4.hydration
7.cerclage
8.diagnosis & treatment of infections
9.role of ART - twins and high order multiples
Secondary prevention

1.cerclage

2.antibiotics

3.tocolysis
Summary

• Although tocolytics may prolong pregnancy

they don’t improve perinatal outcomes, but
do have adverse maternal effect

• As a rule they should be given with

corticosteroids

• Most do not recommend use of tocolytics >34

weeks

• No role of maintenance tocolysis