Prematurely Ruptured of Membranes -PROM

8/12/2019 Prematurely Ruptured of Membranes -PROM

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Premature Ruptured of

Membranes (PROM)

R. Afrilianti


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Definition

PROM is defined as spontaneous rupture of

the membranes (amniorrhexis) before labor at

any stage of gestation

If the rupture happened prior to 37 weeks, it

called preterm prematurely rupture of the

membranes (PPROM)


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Epidemiology

In normal condition, 810 % of term

pregnancy woman happened PROM

PPROM occurs in about 1 % of all pregnancy


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Etiology

The cause of

PROM is a wide

array ofpathological

mechanisms.

PROM PPROMWeakness power of

membranes in term

pregnancy, cause of:

-Enlarge uterus

-Uterus contraction

-Movement of fetal

External factors included:

-Vaginal infection

-Trauma

-Increased of intra-uterine

pressure (such as multiple

pregnancy and hydraminios)

-Solutio placenta

-Cervix incompetent

Change biochemistry process

of membranes

Low socioeconomic status

Low body mass indexless than19.8

Nutritional deficiencies

Cigarette smoking


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Physiology

Amniotic sac

Inner layer (amnion)isformed by embryo-

blasts.

Outer layer (chorion)isformed by tropho-blasts

As a metabolic organ, it is part of the production andResorption of the amniotic fluid


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The fetal kidney and the fetal lung produce

the amniotic fluid. Resorption occurs via the

amniotic sac and the gastrointestinal system

when the fetus drinks the amniotic fluid.


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Function

Shelter from dehydration, compression of the

umbilical cord, traumatic external influences

and gives room for the child to move and grow

and necessary for the development of the

lungs


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Patophysiology

PROM is correlated with change ofbiochemistry process of component themembranes including collagen matrix

extracellular amnion, chorionic, and apoptosisof fetal membranes

In normal condition, rupture of membranes indelivery commonly happened by uteruscontraction and stretching repeated ofmembranes


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Synthesis and degradation matrix extracellular

must be in balance condition.

Collagen degradation is mediated by

metaloproteinase matrix (MMP).

Its inhibited by specific tissue inhibitor and

protease inhibitor


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While delivery approached, degradation

activity is increased. In infection condition

occurs increase of MMPstimulating matrix

degrading enzymePROM


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Manifestation

Fluid passing through the vagina suddenly,

and then small amounts of fluid flow through

the vagina intermitently, particularly when the

increased of abdominal pressure (cough,

sneeze, et al)

Intermittent urinary leakage is common

during pregnancy, especially near term

Increased vaginal secretions in pregnancy


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Perineal moisture

Increased cervical discharge

Urinary incontinence Speculum examination appears loss of

amniotic fluid from the endocervical canal

Nitrazin paper changed from red to blue Lanugo and vernix casseosa by microscope


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Evaluation

1. History

The time of rupture and consistency of the

fluid leakage is important.

An accurate gestational age to

appropriately manage the patient


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2. Examination

- Vital sign

- Sterile speculum examination (SSE)

When visualizing the cervix, the dilation andeffacement should be noted

Nitrazin and fern tests are used to confirmrupture. Nitrazin should show a pH between

7,17,3. False positive test can be observedwith blood, semen, trichomonas, cervicalmucus, and urine


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Ferning can be falsely negative in the

presence of blood.

Cervical culture for chlamydia and

gonorrhea, and anovaginal culture for group

B streptococcus should be obtained

- Fundal tenderness

Evaluation for possible chorioamnionitis orplacenta abruption


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- Laboratory assessment

Complete blood count and urinalysis

- Ultrasound (USG)Amnion fluid index, fetal presentation,

estimated fetal weight, and gestaional age

- Fetal heart rate and contraction monitoring


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Maternal and fetal risks

Maternal risk Fetal risk

Amniotic infection syndrome (AIS)

Sepsis

Placental abruptionPostpartal atonia

Fever and endomyometritis in

peurperium

Increase CS insidency

Preterm brith

Neontal sepsis

Pulmonary hypoplasiaRDS

Contractures and deformities


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Treatment guidelines in preterm

rupture of membranes


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Conservative management

Antibiotic

- ampicillin 4x500mg/erytromicin 4x500mg

- metronidazole 2x500 mg to 7 days GA32-34 weeks hospitalize until amniotic

fluid stop to loss


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GA 32-37 weeks no in labour and infection,

administer dexamethasoneobservation

termination at 37thweek

GA 32-37 weeks in labour and non infection tocolytic agent (salbutamol), dexamethasone do

induction after 24 hours


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GA 32-37 weeks infection administer

antibiotic and induction

GA 32-37 weeks administer steroid

(Betametasone 12 mg/day single dose for 2

days), Dexametasone IM 5 mg/6hours 4X.


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Active management

GA >37 weeks do induction with oxitocin if

failed CS

Misoprostol 25g - 50g intravagina/6 hours

4X. If any infection give high dose of antibiotic

and termination pregnancy

If pelvic score 5 induction


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References

Mohr T. Premature Rupture of Membrane.Gynakol Geburtsmed Gynakol Endokrinol2009; 5(1):2836.

Prawirohardjo S. Ilmu Kebidanan. Ed 4th.Jakarta: PT. Bina Pustaka SarwonoPrawirohardjo, 2009.

Mercer BM. Premature Rupture of Themembrane in Maternal fetal Medicine:Elsevier 2010

Prematurely Ruptured of Membranes -PROM

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