Premature Ruptures

Of Membranes
(PROM)
By Dr. Amir Z.

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 Definitions
PROM - Spontaneous rupture of membranes
before onset of labor after 28 completed
weeks.
LATENCY PERIOD - interval between PROM &
onset of labor.
PROLONGED PROM – if ROMs for more than
12hrs
TERM PROM - ROM after 37 weeks.
PRETERM PROM – ROM before 37 wks
VERY PRETERM PROM – between 28-30 wks.

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 Definitions
CHORIAMNIONITIS (CA)
• Clinical CA has the following signs:
– Fever > 380C
– Uterine tenderness
– Foul smelling AF
– Increasing WBC count
– Maternal or fetal tachycardia
• Subclinical
– Diagnosed by AF study in the absenceof
the above mentioned signs.

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 Etiology
• The exact cause is not known.
• Associations with:
– Incompetent Cx
– Overdistended Ux (Polyhydraminos,
multiple pregancies)
– Inherent membrane defects (genetic
conditions, low maternal serum copper,
vit. C deficiency)

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 Etiology
– Infections
• Asymptomatic bacteriuria
• UTI
• Lower GTI
• Bacterial vaginosis
• Intrauterine infections
• Chorioamnonitis
– Seminal fluid releasing collagenase
like enzyme
– Maternal connective tissue
disorders
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 Etiology
– 2nd & 3rd trimester bleeding
– ECV
– Amniocentesis
– Trauma
– Maternal smoking
– Low socioeconomic status
– Family history

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 Diagnosis
• Symptoms :
– Sudden gush of fluid from the vagina/
continued leakage

• Hx :
– Duration of leakage
– Quantity of the discharge
– Type of discharge (clear/ blood stained/
green-colored)
– Consistency of the fluid
– Presence of vernix

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 Diagnosis
• Hx :
– Presence & duration of pain
– LMP for GA
– Fetal movement
– Any Hx suggestive of infections
– A detailed present & past obs., medical
& surgical Hx may help find the
pathological cause.

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 Examination
• GPE, Hydration & monitoring of vitals
• Abdominal examination
– Confirm GA by measuring the FH which
may be small for dates
– Look for uterine tenderness
– Determine fetal lie
– Auscultate Fetal heart sounds

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 Examination
• Speculum exam.
– Extent of cervical dilatation & effacement
– Cord prolapse
– Fetal presenting part
– Liquor may be seen draining through Cx os &
pooling of the amniotic fluid in post. fornix.
– If no discharge is seen, the pt is asked to
cough, apply slight fundal pressure or perform
Valsava maneuver & leak is observed.
– The fluid is collected.
 Pad chart ;if no free fluid
– A clean sterile pad is given to pt, the pad is
observed after 1 hr.
– >Drawback: Vulval pads can be moisted with urine or vaginal
discharge which can be mistaken with the amniotic fluid

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 Exam. of collected AF
• Gross Exam.
– Clear, blood stained or cream/ green
color
– Foul smelling

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Diagnostic tests in PROM
• Nitrazine paper test
pH of the vagina : 4.5 – 6.0
pH of the AF : 7.1 – 7.3
– It changes color from yellow green to dark blue at pH >
6.5
• False +ve
– Blood contamination
– Semen contamination
– Alkaline antiseptics
– Bacterial vaginosis
– Tap water
• False –ve
– Minimal residual fluid

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Diagnostic tests in PROM
• Ferning – a drop of AF when placed
on a clean slide & allowed to dry
demonstrates ferning (microscopic
crystallization) due to interaction of
AF proteins & salts
• False +ve
– Cervical mucus
– NaCl solution

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 Special investigations
• Amniocentesis – a dilute solution of
1 ampule of indigo carmine dye is
injected in to the AF & a pad is
kept at vulva. A leak of blue fluid in
to the vagina confirms Dx.
• High vag. swab for culture &
sensitivity (for Dx of infection) &
fetal fibronectin (to Dx
prematurity)

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• 0.1% nile blue sulphate test – the
collected fluid can be centrifuged &
examined for fetal cells staining with the
dye. The cells appear orange due to the
presence of exfoliated fat cells from the
sebaceous glands of the fetus.
• Culture & sensitivity of AF (for infection)

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• U/S
– GA
– Amount of AF- reduced/ absent
– Fetal presentation, number
– EFW
– Placental localization & maturity
• CBC, CRP (to predict development of
chorioamnionitis)
• Urine exam. – routine, microscopy &
culture.

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 Complications
• Preterm labor: with the risk of
prematurity.
• Infection: chorio-amnionitis,
septicemia and fetal pneumonia.
• Fetal deformities and distress: due
to oligohydramnios.

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 Management
• All pts suspected of PROM should be
admitted.
• Investigations on admission
– CBC
– Urine: routine/ microscopy exam.
– Urine: Culture & sensitivity
– 2 swabs – a high vaginal swab & a
cervical for culture & sensitivity
• Determine GA for deciding further
management.
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 Management
• General Principles
1. Confirm the diagnosis
2. Determine GA
3. Evaluate for intra amniotic infection
4. Evaluate for the presence of labor
5. Evaluate fetal condition

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• Indications for immediate delivery
– Pt in labor
– Clinical chorioamnionitis
– Fetal distress
– Features suggesting cord compression
or cord prolapse
– Gross fetal congenital abnormalities
– Immunocompromised host
– Pregnancy complications indicating
delivery (heart disease, DM)

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Management of Term PROM
Labor
IAI YES
PROM DELIVERY
FD
DELIVERY
IUFD

NO
PG
Contraindication for VD YES CS
NO YES

Prostaglandin
Favorable Cx status Unfavorable Possible
Priming

DELIVERY
NO
FOLLOW YES
Spon. Observe for
INDUC- Labor 6-30 hr
NO
TION 21
Management of
PPROM PROM

Gramstain + Cervical culture

U/S
For GA, EFW, Presentation, BPP

Labor, FD,IAI, IUFD

YES <34 wk NO >34 wk

DELIVER Hospitalization
Hospitalization
Antibiotics Monitor for IAI
Monitor for IAI (Clinical, AF anlysis)
+ Steroids

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 ATB use in PROM
Advantages
• Increases latency period
• Decreases the incidence of maternal
& neonatal morbidity & mortality

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 ATB use in PROM
Indications
Prophylactic
• PPROM with expectant management (<34
weeks)
– Ampicillin 2 gm iv QID/ 48 hrs
– Erythromycin 500mg iv/ 48hrs
+
– Amoxacillin 500mg PO TID for 5-7 days if
delivery doesn’t occur
– Erythromycin 500 mg PO QID for 5-7 days if
delivery doesn’t occur
• At time of delivery with prolonged PROM
– Ampicillin 2 gm iv till delivery

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 ATB use in PROM
Therapeutic
• Clinical IAI
– Ampicillin 2gm iv QID for 7-10 days
– Gentamycin 80mg iv TID for 7-10 days
– Clindamycin 900mg iv TID for 7-10 days
• IF Clindamycin is not available
– Chloramphenicol 1000mg iv QID or
– Metronidazole 500mg iv TID
• Single agent treatment
– Ceftriaxone 1gm iv BID

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THE END

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