PROM

ABEBE.M (CMW)
Objective
At the end of this class the students will be able
 To define PROM
 To describe risk factors for PROM
 To describe diagnostic methods for PROM
 To manage options of PROM
 To mention complications of PROM
Definition
Premature rupture of membranes (PROM) refers to rupture of
the fetal membranes prior to the onset of regular uterine
contractions.
It may occur at term: ≥37 weeks of gestation
=Term PROM
 Pre term: <37 weeks of gestation
= preterm PROM (PPROM).
 Mid trimester PROM typically refers to PPROM at
16 to 26 weeks of gestation.
Cont…
The frequencies of term, preterm, and midtrimester
PROM are approximately 8, 3, and less than 1 percent of
pregnancies, respectively.

 PPROM associated with, approximately

one-third of preterm births.
Anatomy of Fetal membrane
The fetal membrane is derived from fetal tissue and is
composed of two layers: the amnion (inner layer) and the
chorion (outer layer).

 The amnion is a translucent structure adjacent to the

amniotic fluid, which provides necessary nutrients to the
amnion cells.

The chorion is a more opaque membrane that is attached to

the decidua.
Cont… 
Fetal membranes are genetically identical to the fetus.

The membranes contain many cell types, but are

avascular and without nerve cells.
Cont…
Amnion: loosely composed of three layers of cells
 1.The inner compact layer: consists of epithelial cells.
 2.The mesenchymal cell layer: the thickest part and
consists fibroblasts.
 3.The outer intermediate layer: also known as the spongy
layer is adjacent to the chorion.
 Cont…
Chorion: is composed of two layers
1. An outer reticular: made up of fibroblasts and
macrophages.
 2. Inner cytotrophoblast layer.

Although chorion is thicker than the amnion, it plays

minor role in maintaining the tensile strength of the fetal
membranes.
FACTORS THAT CONTROL FMS
Fetal membrane strength is influenced by:
 1.Extracellular matrix (ECM) proteins: that confer both
strength and elasticity to the fetal membranes.
 2. Matrix metalloproteinases (MMPs).
had collaginolysis effect
 3. Tissue inhibitors of metalloproteinases (TIMPs).
shut down the activity of MMPs.
Cont….
1. Extracellular membrane proteins: The strength and
integrity of fetal membranes derive from ECM proteins
including:
A. collagens
B. fibronectin
C. laminins
 Cont..
A. Collagens 
 located primarily in the compact layer of amnion play a
critical role in maintaining the integrity and tensile
strength of the fetal membranes.
Cont…
Provides a scaffolding on which to attach and assemble
other components of the basement membrane, such as
laminin and heparin.
It stabilizes the fetal membranes by creating anchoring
fibrils that link the basal lamina of the amnion to the ECM
components.
Cont…
B. Fibronectin 
 The fibronectin present in basement membranes of the
amnion and chorion is fetal fibronectin (onfFN) .
 onfFN is "trophoblast glue" that promotes cellular
adhesion at uterine-placental and decidual-fetal
membrane interfaces.
 Clinically, the determination of oncofetal fibronectin
levels in the cervical and vaginal secretions of pregnant
women may be a biochemical marker to predict PTL.
Cont…
C. Laminins 
 Laminins interact with collagen to stabilize fetal
membranes.
 They anchor cells to the basement membrane and the
basement membrane to the underlying layers.
Cont…
2. Matrix metalloproteinases  
 Family of enzymes that decrease membrane strength by
increasing collagen and fibronectin degradation.
Cont…
 3.TIMMPs
 Tissue inhibitors of MMPs (TIMPs) bind to MMPs and
shut down proteolysis, thereby helping to maintain
membrane integrity.
 Thus cells above and below compact layer collagens
secrete TIMMPs that block the activity of proteolysis.
PATHOGENESIS OF RUPTURE  
 The fetal membranes normally remain undisturbed until
late in gestation, most likely due to low MMPs activity
and high levels of TIMPs.
 When contractions begin or the membranes rupture, MMP
activity in the amnion and chorion increases and levels of
interstitial and basement membrane collagens decrease.
Cont…
 MMPs and interstitial collagenase activities in fetal
membranes and amniotic fluid rise near delivery.
 In comparison, the level of TIMPs dramatically falls at
these sites in association with labor.
 This suggests that MMP activation breaks fetal membranes
that leads to physiological rupture at term or pathological
rupture at preterm.
Cont…
Apoptosis: programmed cell death is induced in amnion
and chorion of fetal membranes late in gestation, in
conjunction with or after activation of MMPs.

 Reduction of cellular adhesion is another trigger to

apoptosis. E.g at cervical region
Why MMPs activity increased at term???
 Although the precise etiology of MMP activation prior to
parturition is not known.
 Possible etiologies:
 Compounds: such as tumor necrosis factor-alpha,
interleukin-1 and prostaglandins E2 and F2 alpha appear to
increase collagenase activity and activate inflammatory
pathways in fetal membranes at parturition.
 Relaxin: block the suppressive actions of progesterone
and estradiol and may activate MMPs
Cont…
 Mechanical stretching of fetal membranes activates MMP

 CRH and urocortin in neuro- and placental may induce

local MMP activity.

 NB. Genetic or epigenetic factors that predispose women to

membrane rupture and preterm delivery may be
superimposed on these biochemical pathways.
Cont…
 RISK FACTORS:
 Multiple etiologies: mechanical and physiological,
probably share a final common pathway leading to
membrane rupture.
 A history of PPROM
 Genital tract infection
Ante partum bleeding
 Cigarette smoking
Cont…
Cervical incompetency
Poly hydrominios
Multiple pregnancies
 Abdominal trauma
Nutritional deficit
Familial history of PROM
Cont…
A short cervical length
Prior preterm delivery
Mal presentations as the presenting part is not fitting
against the lower uterine segment.
Chorioamnionitis
Low tensile strength of the membranes
CLINICAL MANIFESTATIONS AND
DIAGNOSIS 
History:  
 sudden "gush" of clear or pale yellow fluid from the
vagina.
 However, many women describe intermittent or constant
leaking of small amounts of fluid or just a sensation of
wetness within the vagina or on the perineum.
Physical examination :
 Sterile speculum examination:
 Observation of amniotic fluid coming out of the cervical
canal.
 If amniotic fluid is not immediately visible, the woman
can be asked to push on her fundus, valsalva, or cough to
provoke leakage of amniotic fluid from the cervix.
cont,,,
Pooling in the vaginal fornix needs further evaluation as
the collection may be due to excessive vaginal discharge
or urine.
Presence of meconium, vernix caseosa or lanugo hair in
the fluid pooling indicates PROM while presence of
urinferous smell suggests urinary incontinence.
 Note: sterile speculum examination can also help to
check for the presence of cord prolapse and to assess
cervical status.
Cont…
Amniotic fluid can also be sent for maturity tests (if
available).
Digital examination should be avoided because it may
decrease the latency period and increase the risk of
chorioamnionitis.
If PROM is not obvious after visual inspection, examine
the fluid for ferning or PH.
Cont..
Nitrazine paper test :  
 Amniotic fluid usually has a pH range of 7.0 to 7.3
compared to the normally acidic vaginal pH of 3.8 to 4.2.
 False nitrazine test results occur in up to 5% of cases.
Nitrazine paper test:
Hold a piece of nitrazine paper in a hemostat (artery forceps) &
touch it against the fluid pooled on the speculum blade.
 A change from yellow to blue indicates presence of amniotic
fluid (a PH >6 - 6.5).
 False negative: results can occur when leaking is intermittent
or the amniotic fluid is diluted by other vaginal fluids.
False positive: results can be due to the presence of alkaline
fluids in the vagina, such as blood, seminal fluid, or soap.
In addition, the pH of urine can be elevated to near 8.0 if
infected with Proteus species.
Fern tests
Visualization of fern-like pattern of dried amniotic fluid on
a glass slide under microscopy .
 False-positive: caused by well-estrogenized cervical
mucus or a fingerprint on the microscope slide.
 False negatives: can be due to inadequate amniotic fluid
on the swab.

 The test is not affected by meconium, vaginal PH &

blood.
Cont…
Ultrasound:
 Is an ideal non-invasive technique for the detection of the residual
amount of amniotic fluid.
 Oligohydramnios is diagnosed if the measurements of the largest
pocket of the amniotic fluid are less than 2 cm.
Fifty to 70 percent of women with PPROM have low
amniotic fluid volume on initial sonography.
Cont…
Instillation of indigo carmine: 
 It leads to a definitive diagnosis.
 Through abdominal needle under ultrasonic guide into the
amniotic sac and observation of its passage through the
external os or even in the vulvar pad.
Drawback: It carries risk of fetal trauma
Differential diagnosis
 Urinary incontinence
 Sever vaginal discharge
 Perinial perspiration
MANAGEMENT
Management of PPROM
 Points of controversies in the management of PPROM

Expectant management versus intervention

Use of tocolytics
Duration of administration of antibiotic prophylaxis
Timing of administration of antenatal corticosteroids
Methods of testing for maternal/fetal infection
Timing of delivery.
Cont…
Factors to be considered in management of PPROM
GA
Availability of NICU
Presence or absence of maternal/fetal infection
Presence or absence of labor
Fetal presentation
Fetal heart rate (FHR) tracing pattern
Likelihood of fetal lung maturity
Cervical status
Cont…
Expeditious delivery is required in women with
PPROM if the ff conditions are observed.
Intrauterine infection
 Abruptio placentae
Repetitive FHR decelerations
High risk of cord prolapse.
Expectant management
1.Hospitalization:
 We hospitalize women with PPROM who have a viable
fetus from the time of diagnosis until delivery.
Resuscitate her with IV fluid
 Keept at bed rest and frequently assessed for evidence of
infection or labor.
 Avoid digital examination-it decrease latency period and
increase ascending infection
Follow her with PROM chart.
2.Surveillance for infection
 Monitoring and Follow up Monitor the following clinical
features during expectant management of PROM:
 Maternal pulse & temperature - every 4-6 hours
 FHR - every 4-6hrs (& if possible CTG 2x daily)
 Uterine tenderness or irritability (or pain) – daily
 WBC count & differential - changes, every 2-3 days
 Amniotic fluid appearance & odor – daily
 If possible, examine for presence of subclinical
intraamniotic infection with amniocentesis.
Cont…
3. Tocolysis: to delay delivery for 48 hours to allow
administration of corticosteroids.
As a general rule, tocolytics should not be administered
 For more than 48 hours. 
 For patients who are in advanced labor (>4 cm dilation)
or
 Who have any findings suggestive of subclinical or overt
chorioamnionitis.
Cont…
4. Antibiotics for prophylaxis:  
Goal of antibiotic therapy:
 To reduce the frequency of maternal and fetal infection
and
Delay the onset of preterm labor (ie, prolong latency).
Cont…
 Using AB was associated with significant reductions
in:
Chorioamnionitis
Preterm delivery
Neonatal infection
Use of surfactant
Neonatal oxygen therapy
Cont…
Seven-day course of prophylaxis antibiotic.
  Ampicillin 2gm IV QID and Erythromycin 250 mg
P.O QID for 48 hours
followed by Amoxicillin 500 mg P.O TID &
Erythromycin 250 mg. P.O QID for 5 days.

 Azithromycin may be substituted for Erythromycin

with regimen of 500mg PO on day 1 followed by
250mg PO daily for 6 days. .
Cont…
 Ampicillin specifically targets
Group B streptococcus
Aerobic gram-negative bacilli and E.coli
Some anaerobes.
Azithromycin or erythromycin specifically targets
Genital mycoplasmas: important causes of
chorioamnionitis and
 Chlamydia trachomatis: important cause of neonatal
conjunctivitis and pneumonitis.
Cont…
5.Antenatal corticosteroids :  A course of corticosteroids
should be given to pregnancies less than 32 weeks of
gestation.
 Neonatal death, RDS, IVH, NEC, and duration of neonatal
respiratory support were significantly reduced by
antenatal glucocorticoid treatment, without an increase in
either maternal or neonatal infection.
 Mean risk reduction for these adverse events ranged
from 30 to 60 percent.
Cont…
Dexamethasone 6mg IM BID for 2 days or
Betamethasone 12 mg IM daily for 2 days
Cont…
6.Fetal surveillance: Some type of fetal surveillance is
generally employed
 Kick counts
 Non stress tests
 Biophysical profile [BPP] to provide the clinician and
patient some assurance of fetal well-being.
 Neither test had good sensitivity for predicting
maternal or fetal infection.
Time of delivery
Various recommendation
If conditions are safe we can wait until term
Deliver at ≥32 wks of GA if lung maturity assured.
Delivery at 34 wks of GA without lung maturity because
of fear of intrauterine infection is also possible.
But expectant management is also permitted according to
EFMOH management guideline 2021 G.C in near term
pregnancy (34-37 wks of GA) if the conditions are safe.
Management of term PROM
 PROM at term:

1. Awaiting the onset of spontaneous labor for 12 hrs

2. Termination of pregnancy after 12 hours

3. To start antibiotics after 12 hours of PROM mainly ampicilline 2
gm IV QID until delivery and at least one dose in PPP.
NB. Women with term PROM who are followed expectantly go
into spontaneous labor and deliver within 24, 48, and 72 hours of
PROM in 70, 85, and 95 percent of cases respectively.
Mode of delivery
  In the absence of contraindications to labor and vaginal birth,
most patients will deliver by spontaneous or induced vaginal
delivery.
 Cesarean delivery is performed for standard indications; otherwise
labor is induced.
 We perform a digital cervical examination to determine cervical
ripening if delivery is planed.
 If the cervix is favorable, oxytocin is administered for induction
according to standard protocols and if the cervix was not favorable
we use prostaglandine first then oxytocine to induce the labor.
Diagnostic features of chorioamnionitis:
 Fever with chills
 Abdominal pain
 Offensive amniotic fluid
 Tachycardia
 Uterine tenderness
 Fetal tachycardia
 Increased WBC count
Management of chorioamnionitis
Option 1: Ampicillin 2 g IV every six hours PLUS
gentamycin 5 mg/kg body weight IV every 24 hours ±
metronidazole 500 mg IV TID
Option 2: Ceftriaxone 1 gm IV BID for 10 days ±
metronidazole 500 mg IV TID
After delivery: shift the antibiotics to PO medication
after the symptoms and signs of infection have subsided
for 48 hours.
Cont…
Immediately resuscitate her.
Terminate pregnancy by the appropriate way
Transfer the neonate to neonatal ward.
Management of PROM
Complication of PROM
Maternal
 Chorioamnionitis
 Funisitis
 Endometritis and
 Septicemia
 These complications were developed in one third of
PROM patients.
Cont..
Neonatal complication
 HMD
 IVH
 Sepsis
 Pneumonia
 Meningitis and
 NEC
Cont…
Prolapse or compression of umbilical cord
 Abruptio placenta 2-5%
 Preterm delivery
Mal presentation
The fetus and neonate are at greater risk of PPROM-
related morbidity and mortality than the mother.
The rates of these morbidities vary with gestational age
and are higher in the setting of chorioamnionitis.
References
1. Management protocol on selected obstetrics topics,
EFMOH, January 2021
2. Up todate 21.2
3. Gabbe: Obstetrics: Normal and Problem Pregnancies,
7th edition.
4. Williams Obstetrics 24th edition.