CASE REPORT

Premature Rupture of Membranes

Supervised by:

dr. Hesty Duhita Permata, Sp.OG

Presented by:

Fauziyyah Ramadhani 130112170683

Tiwi Harjanti Cakranita 130110150212
Stevan D.M. Sitompul 130110150234

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

RSUD R. SYAMSUDIN, S.H., KOTA SUKABUMI
FACULTY OF MEDICINE
PADJADJARAN UNIVERSITY
2019
 CHAPTER I
INTRODUCTION

Premature rupture of membranes is defined as rupture of membranes before the

onset of labor which divided into two categories. The first category is rupture of membrane
before 37 weeks of gestation which referred as preterm premature rupture of membranes
(PPROM) while the second category is rupture of membranes after 37 weeks of gestation
which then referred as premature rupture of membranes (PROM). Membrane rupture
relatively has high prevalence, approximately 6,46-15,6% for aterm gestation in PROM
and 2-3% for single gestation in PPROM. In general, rupture of membrane happen around
10% in all pregnancy.1-3
Membrane rupture can result from a normal physiologic weakening of the
membranes combined with shearing forces created by uterine contractions, preterm PROM
can result from a wide array of pathologic mechanisms that act individually or in concert.
Such rupture may has various causes such as oxidative stress-induced DNA damage, and
premature cellular senescence are major predisposing events. Other predisposing factors
can be a history of membrane rupture is last pregnancy, urogenital tract infection,
antepartum hemorrhage, and smoking. Obesity is considered as a risk factor for both local
and systemic infections, and it is associated with a low-grade chronic pro-inflammatory
state. Other associated risk factors also include low socioeconomic status.2-5
The diagnosis of membrane rupture typically is confirmed by the visualization of
amniotic fluid passing from the cervical canal then pooling in the vagina and a basic pH
test of vaginal fluid. A chief complaint of water leakage is often reported by patient. The
risk of rupture develops into chorioamnionitis is less than 10%, but increased up to 40%
after 24 hours of the events. Therefore administration of broad spectrum antibiotic should
be considered.2,6

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 CHAPTER II
CASE REPORT

2.1. Patient’s Identity

Name : Mrs. R.S
Date of birth/Age : February 3rd 1991/ 28 years old
Address : Kp. Selawi RT 19 RW 5
Marital Status : Married
Occupation : Housewife
Religion : Islam
Date of admission : 22nd August 2019
Date of examination : 22nd August 2019

2.2. History Taking

Chief Complaint
Leakage of clear fluid
History of Present Illness
A 28-year-old G3P1A1 feeling 9 months pregnant was referred by a midwife to
R.Syamsudin Hospital because of leakage of clear fluid since 10 hours before going
to hospital. The fluid was described as a clear, constant stream, odorless, and
damped her panty. No regular painful uterine contractions. No leakage of bloody
mucus. There were still fetal movements. History of fever, vaginal discharge,
vaginal bleeding, and low abdominal pain are denied. History of amniocentesis,
LEEP, or conization procedure are denied. History of trauma is denied. Recent
sexual intercourse was 2 weeks ago.

History of Past Illnesses

History of abortion : 1x in year 2016, without curettage
History of hypertension : Denied
History of asthma : Denied
History of diabetes mellitus : Denied
History of allergy : Denied
History of trauma : Denied
History of past surgery : Denied
History of tuberculosis : Denied
Family History
History of same pregnancy : Denied
History of diabetes mellitus : Denied
History of kidney disease : Denied
History of tuberculosis : Denied
Habitual History
 Smoking : denied
 Alcohol consumption : denied
 Drugs and herbs : denied

Menstruation History
Menarche : 13 years old
Menstrual cycle : regularly every 28 days, 7 days of duration
and without history of pain during
menstruation
Amount of menstrual blood : 3 pads/day, full (± 60 cc)
1st day of last menstrual cycle : November 16th 2018
Due date : August 23rd 2019

Contraception History : 1 month injection contraception for once

Marital History
Married once, been married for 7 years when her husband was 26 years old.

Obstetric History
Pregnancy
No Year Helper Labor History Baby’s condition
Outcome
A boy, birth weight
1. 2013 Midwife Aterm Spontaneous
3300 gram, alive, age 6
2. 2016 - Abortus No curettage
3. Present

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 Antenatal Care History : check to midwife regularly, 9 times in total
Medication History :-

2.3. Physical Examination

General condition : moderately ill
Consciousness : compos mentis
Blood pressure : 100/70 mmHg
Heart rate : 88 bpm
Respiratory rate : 20x/minute
Temperature : 36.40C
Weight : 77.8 kg
Height : 158 cm
BMI : 31.16 kg/m2 (obese II)

General Examination
Eyes : anemic conjunctiva -/-, icteric sclera -/-
Mouth : wet oral mucosa membrane
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing -/-

Obstetrics Examination
External obstetric examination
 Inspection : soft, concave
 Palpation :
His :-
Leopold I : breech, fundal height: 30 cm
Leopold II : single fetus, back on the right side
Leopold III : head
Leopold IV : divergent
 Fetal heart rate:142-146 bpm

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Inspeculo Examination:
 Vagina : fluxus (-), fluor albus (-)
 Portio : clear discharge from EUO (+), fluxus (-), fluor albus
(-)
 Cervical dilation : no dilatation

Other examination:
 Nitrazine test : positive (+)
 USG : not performed
 CTG : baseline 145 bpm, variability (+), acceleration (+),
deceleration (-) (stage I)

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2.4 Laboratory Results

Types Results Units Normal Value

Hematology (22/08/2019)
Hemoglobin 11,5 g/dL 12 – 14
Hematocrit 34 % 37-47
Leucocyte 8.300 /uL 4.000 – 10.000
Thrombocyte 202.000 /uL 150.000-450.000
Erythrocyte 3,9 Millions/ uL 3.8-5.2
MCV 87 fL 80-100
MCH 29 pg 26-34
MCHC 34 g/dl 32-36

2.5. Working Diagnosis

G3P1A1 gravida 39-40 weeks; PROM

2.6. Management
● Ceftriaxone 2x1 gr IV
● Induction of labor with misoprostol 50 mcg intravaginal (given at 3 PM)
● Evaluation of vital signs, His, fetal heart rate, and labor progression
● Inform consent to patient and her family

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Observation of labor progression (in VK)

A baby girl is born spontaneously

at 9.30 PM, date 22/08/2019
Birth weight 3750 gram
Length 50 cm

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9
Observation for stage IV labor (in VK)

Date, time Subjective Objective Assessment Planning

22/08/19 Compos mentis, BP P2A1 partus  Cefadroxil

10 PM 110/70, HR 83 bpm, Temp maturus 2x500 mg
36,5, fundal height 2 cm pervaginam po for 3-5
below umbilicus, uterine days
contraction (+),  Mefenamic
spontaneous urination (-), acid 3x500
bleeding ± 200 cc mg po prn

22/08/19 Compos mentis, BP

10.15 PM 110/70, HR 83 bpm, Temp
36,5, fundal height 2 cm
below umbilicus, uterine
contraction (+),
spontaneous urination (-),
bleeding ± 100 cc

22/08/19 Compos mentis, BP

10.30 PM 110/70, HR 70 bpm, Temp
36,5, fundal height 2 cm
below umbilicus, uterine
contraction (+),
spontaneous urination (-),
bleeding ± 10 cc

22/08/19 Compos mentis, BP

10.45 PM 110/70, HR 76 bpm, Temp
36,5, fundal height 2 cm
below umbilicus, uterine
contraction (+),
spontaneous urination (-),
bleeding ± 10 cc

22/08/19 Compos mentis, BP

11.15 PM 110/70, HR 82 bpm, Temp
36,5, fundal height 2 cm
below umbilicus, uterine
contraction (+),
spontaneous urination (-),
bleeding ± 10 cc

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 22/08/19 Compos mentis, BP
11.45 PM 110/70, HR 72 bpm, Temp
36,5, fundal height 2 cm
below umbilicus, uterine
contraction (+),
spontaneous urination (-),
bleeding ± 10 cc

2.7 Final Diagnosis

P2A1 partus maturus pervaginam

2.8 Management
Observation of vital signs and puerperium

Follow up in Melati in-patient ward

Date, time Subjective Objective Assessment Planning

23/08/19 - Compos mentis, BP P2A1 partus  Cefadroxil

5 AM 120/80, ASI +/+, maturus 2x500 mg po
abdomen flat and pervaginam for 3-5 days
soft, fundal height 2  Mefenamic
cm below umbilicus, acid 3x500
uterine contraction mg po prn
(+), spontaneous  Planning for
urination (+) out-patient
service

2.9 Prognosis
 Ad vitam : Maternal : ad bonam; fetal: ad bonam
 Ad functionam : Maternal : ad bonan; fetal: ad bonam
 Ad sanationam : Maternal : dubia ad bonam

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 CHAPTER III
CASE ANALYSIS

3.1. Diagnosis
Theory Case
History  Premature rupture of membranes  G3P1A1 gravida 39-40
(PROM) is rupture of fetal membranes weeks (aterm) came with
before the onset of labor (with chief complaint clear
gestational age ≥ 37 weeks) discharge from birth
 Patient usually comes with clear passage, but there was
discharge form birth passage but denies still no regular
feeling of regular contractions. contractions.

Risk factors Maternal Maternal

 No history of fever;
 infection excessive, grayish-white,
 vaginal bleeding foul-smelling vaginal
 obesity discharge
 history ofprevious  No vaginal bleeding
PROM/PPROM/preterm birth  Obese (BMI 31.16
 amniocentesis kg/m2)
 cervical incompetence  No history of previous
 trauma PROM/PPROM/ preterm
 nutritional deficiencies birth
 smoking  No history of
Fetal amniocentesis
 twin pregnancy  No history of
 polyhidroamnion LEEP/conization
 macrosomia procedure
 No history of trauma
 No information about
nutritional deficiencies
 The patient doesn’t smoke

Fetal
 Single pregnancy
 No information about
poplyhydramnion
 The baby birth weight is
3750 gram
Diagnosis History taking : History taking :
 LMP : 16/11/2018
 Gestational age : aterm (gestational age 39-40
 Clear and odourless vaginal discharge, weeks); fundal height 30
coming as a constat stream cm (smaller than the
 No regular contractions gestational age)
 Leakage of clear fluid,

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 odourless, coming as a
Physical Examination : constant stream; damped
her panty
BMI ≥ 25 kg/m2  No regular contractions
Obstetrical examination :
Physical examination :
His (-) BMI 31.16 kg/m2 (obese)
Inspeculo examination : Obstetrical examination :
- Watery discharge from OUE His (-)
- Pooling on posterior fornix
Inspeculo examination :
Nitrazine test(+) Watery discharge form EUO
(+)
USG :
Oligohydramnion Nitrazine test (+) :

USG : not performed

Complication Maternal Maternal
 Chorioamnionitis  No yellowish to greenish,
 Endometritis purulent discharge with
 Cord Prolapse foul-smelling; afebris;
 Solutio placenta eucardia; no leukocytosis
 Afebris; low abdominal
Fetal pain (-); vaginal bleeding
 Fetal distress (-), purulent discharge (-)
 No vaginal bleeding, cord
prolapse (-)
 Low abdominal pain (-),
abdominal tenderness (-),
uterus en bois (-), vaginal
bleeding (-)

Fetal
 FHR : 142-146 bpm
 There were still fetal
movements

3.2 Treatment
Theory Case
 Conservative  Ceftriaxone 2x1 gr
If there is no other complication and the gestational  Labor induction with
age is between 28 – 37 weeks, patient admitted into misoprostol 50 mcg
care for a minimum 2 days. During inpatient :
intravaginal
1. Vital sign observation:notice if there’s a sign of
infection which may indicating amnionitis  Observation for vital signs
(febrile, leucocytosis, tachycardia, foul smell and labor progression

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 odor of amnion fluid.)
2. Observation of labor sign
3. Broad spectrum antibiotics
4. USG to assess fetal well-being
5. Lung maturation protocol
 Active management (less than 28 weeks or more
than 37 weeks)

Rupture of
Membrane

<28 weeks 28 - 36 weeks ≥37 weeks

Active Active
Conservative
Management Management

Fetal Distress
Without His (+)
Complication Infection

Outpatient
Active
sign of infection=>
Management
control immediately

Management for PROM and PPROM6

3.3 Prognosis
 Advitam : Maternal : ad bonam; fetal: ad bonam
 Adfunctionam : Maternal : ad bonan; fetal: ad bonam
 Adsanationam : Maternal : dubia ad bonam

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 CHAPTER IV
CONCLUSION

During prenatal care visit, mother needs to be informed about PROM/PPROM to

help her identify the occurrence of PROM/PPROM, thus shorten duration of subsequent
visit to evaluate maternal and fetalwell-being. This aids to prevent unfavourable outcome
for the two. The diagnosis can be made based on history taking, physical examination and
additional examination such as nitrazine test and USG. Management of PROM/PPROM,
active and conservative, will be based on gestational age and fetal and maternal well-being.

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 REFERENCES
1. Pedoman Nasional PelayananKedokteranKetubanPecah Dini. 2016. POGI.

2. Premature rupture of membranes. Practice Bulletin No. 172. American College of

Obstetricians and Gynecologists. ObstetGynecol 2016; 128:e165–77.
3. KetubanPecah Dini. 2014. ElearningMateriPembekalanCalonPeserta PPDS by
PUSTANSERDIK. Available from
http://edunakes.bppsdmk.kemkes.go.id/images/pdf/Obsgin_4_Juni_2014/Blok%20
7/KPD%20ppt.pdf. [Accessed 24 August 2019]
4. Lina Salman, Amir Aviram, RoieHolzman, Hadar Hay-Azogui, EranAshwal,
EranHadar, RinatGabbay-Benziv. (2019) Predictors for cesarean delivery in
preterm premature rupture of membranes. The Journal of Maternal-Fetal &
Neonatal Medicine 0:0, pages 1-6.
5. Cunningham, et al. Obstetrical Hemorrhage.Williams Obstetrics 22nd. 2005.
MacGraw-Hill Companies, Inc.
6. PanduanPraktikKlinikObstetri&Ginekologi.DeptObestetri&Ginekologi RSUP Dr.
Hasan Sadikin Bandung. 2018.

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