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Premature rupture of

membranes
By : Ida Yosopa

Preceptor :
dr. H. Sigit Nurfianto, Sp. OG (K)

Department Obstetrics and Gynecology


Doris Sylvanus Hospital
Palangka Raya
2015

exordium

Premature rupture of membranes occurred at aroun

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)

Premature Rupture of Membrane. Clinical Management Guidelines For Obstetrician Gynecologists: From Practice Bulletin.

Epidemiology
In the literature the incidence of premature rupture

of membranes stated ranges between 4-14% of


pregnancies . The incidence of PPROM declared
between 2-3% . 30-40% of preterm births with a
history of premature rupture of membranes .
Journal Of Health Sciences Management And Public Health. 2006 : 192. Diunduh Dari Http://www.Medportal.ge.

Etiology
PROM

PPROM

Weakness 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 hydramnions)
-Solutio placenta
-Cervix incompetent

Change biochemistry process Low socioeconomic status


of membranes

The cause of
PROM is a wide
array of
pathological
mechanisms.

Low body mass indexless


than 19.8
Nutritional deficiencies
Cigarette smoking
Panduan Praktik Obstetri dan Ginekologi. Jakarta : EGC; 2009

Physiology

As a metabolic organ, it is part of the


production and Resorption of the amniotic
fluid

...Physiology

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.

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.

Patophysiology

...Patophysiology

PROM is correlated with change of


biochemistry process of component the
membranes
including
collagen
matrix
extracellular amnion, chorionic, and apoptosis
of fetal membranes
In normal condition, rupture of membranes in
delivery commonly happened by uterus
contraction and stretching repeated of
membranes

...Patophysiology

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.

...Patophysiology

While

delivery

approached,

degradation

activity is increased. In infection condition


occurs increase of MMP stimulating matrix
degrading enzyme PROM

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

...Manifestation

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

Evaluation
1. History
. The time of rupture and consistency of the

fluid leakage is important.


. An accurate gestational age to appropriately

manage the patient.

...Evaluation

1. Physical Examination
o.Vital sign
o.Sterile speculum examination (SSE)
. When visualizing the cervix, the dilation and
effacement should be noted.
. Nitrazin and fern tests are used to confirm rupture.
Nitrazin should show a pH between 7,1 7,3. False
positive test can be observed with blood, semen,
trichomonas, cervical mucus, and urine.

...Evaluation

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 or
placenta abruption

...Evaluation

o Laboratory assessment
o Complete blood count and urinalysis
o Ultrasound (USG)
o Amnion fluid index, fetal presentation, estimated fetal

weight, and gestaional age


o Fetal heart rate and contraction monitoring

Maternal and fetal risks


Maternal risk

Fetal risk

Amniotic infection syndrome


(AIS)
Sepsis
Placental abruption
Postpartal atonia
Fever and endomyometritis in
peurperium
Increase CS insidency

Preterm brith
Neontal sepsis
Pulmonary hypoplasia
RDS
Contractures and deformities

Treatment guidelines in
preterm rupture of
membranes

Conservative
management
Antibiotic
ampicillin 4x500mg/erytromicin 4x500mg
metronidazole 2x500 mg to 7 days
GA 32-34 weeks hospitalize until amniotic fluid
stop to loss

...Conservative management

GA 32-37 weeks no in labour and infection, administer

dexamethasone observation termination at 37th


week.
GA 32-37 weeks in labour and non infection tocolytic

agent (salbutamol), dexamethasone do induction after


24 hours.

...Conservative management

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.

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, favorable cervix then
induction. If failed SC
If pelvic score >5 induction

complication

Prognosis
Prognosis depends on the age of the womb, the
mother and the state as well as the presence of
infection or not .

Premature Rupture of Membrane. The Medscape Journal of Medicine. 2011. Diunduh dari
http://www.emedicine.medscape.com

References
1. Mohr T. Premature Rupture of Membrane. Gynakol
Geburtsmed Gynakol Endokrinol 2009; 5(1):2836.
2. Prawirohardjo S. Ilmu Kebidanan. Ed 4th. Jakarta: PT. Bina
Pustaka Sarwono Prawirohardjo, 2009.
3. Mercer BM. Premature Rupture of The membrane in Maternal
fetal Medicine: Elsevier 2010