PREMATURE RUPTURE OF MEMBRANES

Asha ShresthaKhushbu Gupta

Rashmi Shrestha

FETAL MEMBRANES

• Consists of two layers:1. Chorion

(outer)2. Amnion

(inner)

Functions of Fetal Membranes

• Contribute to formation of liquor amnii• Intact membranes prevent ascending uterine

infection• Facilitate dilatation of the cervix during labour• Has got enzymatic activities for steroid hormonal

metabolism• Is rich source of glycerophospholipids containing

arachidonic acid

Premature rupture of membrane (PROM)

• Spontaneous rupture of membrane any time beyond 22nd weeks of pregnancy but before the onset of labour

• Incidence: 10% of all pregnancies

• Two types- – Term PROM– Preterm PROM

Term PROM- rupture of membranes beyond 37th weeks of gestation but before the onset of labour- incidence: 8% of all pregnancies

Preterm PROM- rupture of membranes before 37 completed weeks of gestation- incidence: 2 to 3% of all pregnancies

ETIOLOGY• In majority, causes not known• Possible causes:

– Increased friability of the membranes– Decreased tensile strength of membranes– Polyhydramnios– Cervical incompetence– Multiple pregnancy– Infections e.g. chorio-amnionitis, UTI & lower genital tract

infections– Cervical length < 2.5 cm– Prior preterm labour– Low BMI (< 19 kg/m2 )

DIAGNOSIS

• History• Examination• Investigations

HISTORY

Patient complains of discharge of clear fluid (liquor) vaginally.

EXAMINATION

• Speculum examination– shows liquor draining through cervical os

Differential Diagnosis1. Hydrorrhoea gravidarum

a state where periodic watery discharge occurs probably due to successive decidual glandular secretion

2. Incontinence of urine3. PROM

INVESTIGATIONS

Examination of collected fluid from posterior fornix:a. Fern test, crystallization of liquor when dried on a slideb. Nile blue sulphate (0.1%) test for orange fetal cellsc. Litmus test or Nitrazine paper test for detection of pH (pH becomes 6 to 6.2))

HAZARDS

• Maternal- preterm labour- increased risk of infection

• Fetal– cord prolapse– intrauterine infection– fetal pulmonary

hypoplasia– neonatal sepsis– Respiratory Distress

Syndrome– Intra Ventricular

Hemorrhage– Necrotizing Enterocolitis

(NEC)

MANAGEMENT

Management of PROM depends on:1. Gestational age of fetus2. Whether the patient is in labour or not3. Any evidence of sepsis4. Prospect of fetal survival in that institution, if delivery occurs

(Maternal pulse, temperature and fetal heart rate monitored 4 hourly and start prophylactic broad spectrum antibiotics)

PROM

Amnionitis, Placental abruption, Fetal death or distress, labour process

Absent Present

Prompt effective delivery

Intrapartum antibiotics (Broad Spectrum)

NICU

For PPROM For TPROM

For PPROM ( In absence of amnionitis, placental abruption etc )

Pregnancy < 34 weeks Pregnancy ≥ 34 weeks to < 37 weeks

Management to continue for fetal maturity

Transfer the patient with ‘ fetus in utero’ to an centre equipped with NICU

Wait for spontaneous onset of labour for 24-48 hrs

Induction of labour with oxytocin or CS ( for obstetric reasons)

If fails

– If patient is not in labour or no evidence of infection or fetal distress, wait for spontaneous labour for 24 hours

– If not Induction of labour with oxytocin

Caesarean section ( for obstetric reasons)

For TPROM ( In absence of amnionitis, placental abruption etc )

Reference

• Textbook of Obstetrics, 7th edition, D.C. Dutta

THANK YOU