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Case Report

Premature Rupture of Membrane

Supervised by: dr. Mutawakkil J. Paransa, Sp.OG


Presented by: Renandha Septaryan Yustira 201706010119
Introduction
Premature rupture of membrane (PROM) is the
rupture of chorioamniotic membrane before the
onset of labor

Preterm premature rupture of membrane


(PPROM) defined as PROM that occurs before
37 weeks of gestational age
● PROM events occur around 6,46-15,6% of term pregnancies
and PPROM occur in approximately 2-3% of pregnancies

● PROM leading to preterm delivery is associated with


neonatal complications of prematurity such as respiratory
distress syndrome, intraventricular hemorrhage, neonatal
infection, necrotizing enterocolitis, neurologic and
neuromuscular dysfunction, and also sepsis.
Anamnesis
Patient’s Identity
● Name : Mrs. T
● Age : 34 years old
● Address : Cimuncang
● Marital Status : Married
● Occupation : Housewife
● Date of admission : September 23th, 2018
● Date of examination : September 23th, 2018
History Taking

Chief complaint
• Irresistible liquid leakage since one
day before admission.
History of Present Illness
● G3P2A0, 34 years old, gravid 39-40 weeks of gestation
according to first day of last menstrual period, came to
RSUD R. Syamsudin SH because of irresistible liquid coming
from her vagina since 1 day before admission. The liquid was
clear and flow continuously with the volume about 20-30 cc
and didn’t smell
History of Present Illness
● The patient also felt stomachache and referred to her back
with duration less than 30 seconds and the frequency was
also rare. Patient also complaint there was some bloody
mucus coming out from her vagina with the volume ±10 cc.
● Patient denied any fever for this past few days and also
denied any complaint in her urination and defecation. The
patient didn’t experience any white discharge or traumatic
event
History of Present Illness
● Patient said that she had sexual activity with her husband
two days ago. The fetal movement was active and the patient
had done the antenatal care about 7 times and never had
complaint.
History of Past Illnesses

● History of chronic hypertension : denied


● History of kidney disease : denied
● History of diabetes mellitus : denied
● History of asthma : denied
● History of allergy : denied
● History of surgery : denied
Familial History
● History of hypertension : denied
● History of kidney disease : denied
● History of diabetes mellitus : denied
● History of allergy : denied

Life style
● Patient didn’t smoke, but her husband smoke 1 pack of
cigarettes everyday at their house. Patient never drink
alcohol.
Menstruation History
● Menarche : 13 years old
● Menstrual cycle : regular every 28 days, with
duration of 7 days
● Amount of menstrual blood: 2-3 normal pads / day ( ± 60 cc )
● LMP : December 20th, 2018

Contraception History
● The patient used pill contraception, last used in 2017 because
she want to have another child.
● Marital history: she married once in 2004
● Obstetric history:
Gestational Birth
No Date Labor History Sex
Age Weight
1. 2007 Aterm Spontaneous Female 3200 gr
Vaginal delivery

2. 2011 Aterm Spontaneous Male 3400 gr


vaginal delivery
3. 2018 This pregnancy
Physical Examination
● General condition : moderately ill appearance
● Consciousness : compos mentis
● Blood pressure : 120/70 mmHg
● Heart rate : 88 bpm
● Respiratory rate : 20 x/minute
● Temperature : 36,5°C
● Weight before pregnancy : 65 kg
● Current weight : 74 kg
● Height : 159 cm
● BMI : 25,79 kg/m2
General examination
● Eyes : anemic conjunctiva -/-, icteric sclera -/-
● Mouth : wet oral mucosa membrane
● Nose : secret -/-, deformity -/-
● Ear : secret -/-, deformity -/-
● Neck : thyroid enlargement (-), trachea is in the middle,
lymph node enlargement (-)
● Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
● Lung
Inspection : symmetric chest expansion in breathing
Palpation : symmetric on both lungs
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing
-/-
● Mammae : Areola hyperpigmentation +/+, nipple retraction
-/-, breast milk -/-
● Abdomen
Inspection : convex, striae gravidarum +, linea nigra +
Auscultation : bowel sound (+) 8x/minute
Palpation : supple in all abdominal region, abdominal
tenderness (-)
● Extremities: warm, edema -/-/-/-, CRT < 2 seconds
Obstetric examination
● Fundal height : 33 cm, 3 fingers below xiphoid process
● Expected birth weight: (33-13) x 155 = 3100 gram
● Fetal heart rate : 154 x/minute
● His : one time/10 minutes with duration of 20 seconds
● Leopold 1 : buttocks
● Leopold 2 : back on the left, extremity on the right
● Leopold 3 : head
● Leopold 4 : convergent
● Inspection : vulva edema (-), secrete (+), bloody show (+)
● Vaginal Toucher : anterior cervix, soft and thick in
consistency; cervical dilatation was 3 cm with effacement was
40%; hodge 1 with the denominator was occiput, amniotic sac
(-), litmus test (+)
● Inspeculo : not performed
Supporting
Examination
Laboratory (September 23th, 2018)
Test Result Normal Range
Haematology
Hemoglobin 12,5 g/dL 12-14 g/dL
Hematocrit 39% 37-47%
Leucocyte count 13,100/μL (H) 4000-10.000/μL
Thrombocyte count 374000/μL 150,000-450,000/μL
Erythrocyte 4,9 millions/μL 3.8-5.2 millions/μL
MCV 80 fL (L) 80-100 fL
MCH 26 pg (L) 26-34 pg
MCHC 32 g/dL 32-36 g/dL
Ultrasound findings
● BPD: 9,47 cm
● HC: 33,08 cm
● AC: 32,87 cm
● FL: 7,75 cm
● SDP: 2,87 cm
● EFW: 3373 gram
CTG
Working Diagnosis

Mrs. T, 34 years old, G3P2A0, parturient aterm first stage


latent phase with premature rupture of membrane.
Management
● Spontaneous vaginal delivery
● Observe the vital sign
● Observe the labor process
● Ringer lactate 2000 cc
● Drip oxytocin 5 IU
● Cefotaxime 2x1 gram IV
● Furamin 1 ampule IV
Final Diagnosis

Mother: Mrs. T, 34 years old, P3A0, postpartum


spontaneous vaginal delivery with premature rupture of
membrane

Baby: Term male neonate, with birth weight 3275 grams,


birth length 51 cm, APGAR 7/9. Diagnose as healthy
neonate.
Post Delivery Management
● Observe vital signs
● Observe the puerperium
● RL + oxytocin 20 IU
● Mefenamic acid 3 x 500 mg PO
● Cefadroxil 2 x 500 mg PO
● Education about personal hygiene, mobilization, and diet
Prognosis
● Quo ad vitam : bonam
● Quo ad functionam : bonam
● Quo ad sanationam : bonam
Follow up (September 24th, 2018)
S O A P
abdominal pain General condition: mildly ill P3A0, 34 years Observe general
with VAS 2, Consciousness: compos mentis old, post partum condition and vital sign
breast milk +, Vital signs: spontaneous RL + oxytocin 20IU
mobilization  BP: 110/60 mmHg vaginal delivery Mefenamic acid 3 x 500
active,  HR: 80 x/minute with premature mg
spontaneous  RR: 21 x/minute rupture of Cefadroxil 2 x 500 mg
urination (+),  Temperature: 36,7oC membrane
defecation (-), eat Abdomen:
and drink (+)  supple, abdominal tenderness
(+) at regio suprapubic
Puerperium examination:
Fundal height 2 fingers below
umbilicus with adequate
contraction
Lochia rubra (+)
Follow up (September 25th, 2018)
S O A P
abdominal pain (-), General condition: mildly ill P3A0, 34 years Outpatient with the
breast milk +, Consciousness: compos mentis old, post partum pharmacotherapy as the
mobilization active, Vital signs: spontaneous patient give before.
spontaneous  BP: 110/70 mmHg vaginal delivery
urination (+),  HR: 84 x/minute with premature
defecation (+), eat
 RR: 20 x/minute rupture of
and drink (+)
 Temperature: 36,6oC membrane
Abdomen:
 supple, abdominal tenderness
(-)
Puerperium examination:
Fundal height 2 fingers below
umbilicus with adequate
contraction
Lochia rubra (+)
Case Analysis
Comparison Theory Case
Definition Premature rupture of membrane The patient experienced
(PROM) is the rupture of the irresistible liquid coming from
chorioamniotic membrane her vagina since 1 day before
before the onset of labor. PROM admission. The liquid was
is generally followed by the clear and flow continuously
onset of labor. If rupture of and didn’t smell, and also
membrane occuring before 37 followed by stomachache and
weeks of gestational age, it’s bloody mucus.
called preterm premature In this case, because there
rupture of membrane. was irresistible liquid coming
from her vagina before the
onset of labor and the
gestational age was 39-40
weeks, so there was
premature rupture of
membrane.
Anamnesis Fluid passing through the vagina must be In this patient
presumed to be amniotic fluid until proven there was two
m otherwise. At times, patients describe a risk factor:
gush of fluid, whereas at other times the - Smoking
note a history of steady leakage of small - Recent
amounts of fluid. sexual
As for the risk factor: activity
- History of PPROM
- Smoking
- Trauma
- Sexual activity
- Urinary tract infection
- Low body mass index
- Second and third trimester bleeding
- Illicit drug
Physical - From inspection, there’s secrete coming In this patient, we can
examination out from vagina and from inspeculo, the found secrete coming
pooling test will be positive. out from her vagina.
- Amniotic fluid can be confirmed with For the nitrazine test,
nitrazine test where a litmus paper will be the litmus paper(+)
change into blue color if pH above 7.1 From vaginal toucher,
- Fern test will be (+). The result is we can found anterior
resemble to leaves of a fern plant. cervix, soft and thick in
- Indigo carmine also will be (+). In the consistency; cervical
case of PROM, blue dye can be seen on dilatation was 3 cm with
a stained tampon after about 15-30 effacement was 40%;
minutes hodge 1 with the
denominator was
occiput, amniotic sac (-)
Supporting USG can be used to see the amount of In this patient,
examination amniotic fluid within the uterus. we can found
Volume is typically assessed the SDP was
semiquantitatively, by measuring either 2,87 cm and
a single deepest pocket or amniotic it’s still within
fluid index. Normal range of amniotic normal range.
fluid index is 5-24 cm and normal range
for single deepest pocket is 2-8 cm. In
case of PROM, the amniotic fluid will be
reduced and caused oligohydramnion.
Management If the gestational age is term, In this patient, the
proceed to delivery. Give antibiotic gestational age is term
prophylaxis for Group B (39-40 weeks) so we can
streptococcal as indicated: proceed to delivery with
- Penicillin G 5 million units IV for induction using oxytocin.
initial dose, then 2.5 – 3.0 million Antibiotic for this patient
units every 4 hours is cefotaxime which is a
- Ampicillin 2 g IV for initial dose, broad spectrum antibiotic
then 1 g IV every 4 hours and the third generation
If the patient allergic to penicillin: of cephalosporin
- Cefazolin 2 g IV initial dose, then
1 g IV every 8 hours
- Vancomycin 1 g IV every 12
hours
- Clindamycin 900 mg IV every 8
hours
Reference
1. Casanova R, Chuang A, Goepfert AR, Hueppchen NA. Beckmann and Ling’s
obstetrics and gynecology. 8th ed. Wolters Kluwer; 2018.
2. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, et al.
Williams obstetrics. 24th ed. McGraw-Hill Education; 2014.
3. Callahan TL, Caughey AB. Blueprints obstetrics & gynecology. 6th ed. Wolters
Kluwer; 2013.
4. Pedoman Nasional Pelayanan Kedokteran: Ketuban pecah dini. 2016.