CASE REPORT

Preterm Premature Rupture

of the Membranes
and Breech Presentation
Supervised by: dr. Ismu Setyo Djatmiko, Sp.OG

Presented by:
CLINICAL CLERKSHIP OF OBSTETRICS AND GYNAECOLOGY
Agita Kartika Sari
Muhammad Alma Wijaya R. SYAMSUDIN, SH HOSPITAL SUKABUMI
Nadine Monarista Rikkers MEDICINE FACULTY OF UNIVERSITAS PADJADJARAN
Wigmar Nadia Armani JULY 23RD – AUGUST 3RD 2017
 INTRODUCTION

Breech presentation is defined as a fetus in a

longitudinal lie with the buttocks or feet closest
to the cervix.

What causes breech presentation?

• Idiopathic (most common).
• Preterm delivery.
• Previous breech presentation.
• Uterine abnormalities, e.g. Müllerian duct
abnormalities.
• Placenta previa and obstructions to the
pelvis.
• Fetal abnormalities.
• Multiple pregnancy Collins, S., & Arulkumaran, S. (2008). Oxford
Handbook of Obstetrics and Gynaecology. Oxford:
Oxford University Press.
 INTRODUCTION
A
higher percentage Extended breeches
(frank breech) (70%):
of breech both legs
presentations extended with feet by
head; presenting part
occurs with less is the buttocks.
Breech advanced
presentation gestational age. At
32 weeks, 7% of
occurs in 3% to fetuses are
4% of all term breech, and 28
pregnancies. weeks or less,
25% are breech. Types
of
Flexed breeches
breech
(complete breech) Footling breeches
(15%): (incomplete breech)
legs flexed at the (15%):
knees so that both one leg flexed and
buttocks and feet are one extended.
presenting.
 INTRODUCTION

ROM

Premature rupture of membranes

(PROM)
Preterm premature rupture of
refers to a patient who is beyond membranes (PPROM)
37 weeks' gestation and has
is ROM prior to 37 weeks'
presented with rupture of
gestation.
membranes (ROM) prior to the
onset of labor.
 CASE REPORT
History Taking
Date of Admission : July 25th, 2018 (06.32 a.m.)
Date of Examination : July 25th, 2018 (15.00 p.m.)
 IDENTITY

Patients Husband

Initial Name Mrs. SL Mr. YD

Age 34 years old 37 years old

Date of Birth 03-07-1984 05-09-1981

Address Kp Cicadas Girang RT 1/RW 3 Kec. Baros Kota Sukabumi

Ethnic Group Sundanese

Religion Islam

Occupation Housewife Security

Education High School High School

Marital Status Married

Chief Complaint

• Fluid discharge since 2,5 hours before admission.

History of Present Illness

• Fluid discharge is clear, without pain & bleeding

• Patient also complaint a reduced fetal movement
• 7th month pregnancy USG result showed breech presentation
 HISTORY OF :
Past Illness Family

• History of hypertension : denied • History of STD in husband : denied

• History of asthma : denied • History of hypertension : denied
• History of DM : denied • History of asthma : denied
• History of tuberculosis : denied • History of diabetes mellitus : denied
• History of allergy : denied • History of allergy : denied
• History of trauma : denied • History of smoking : passive
• smoker
History of past surgery : denied
Menstruation History

• Menarche : 14 years old

• Menstrual cycle : regular, with duration of 7 days, dysmenorrhea (-)
• Total pads : 3 pads/day
Contraception History

• She used hormonal contraceptive injection (2016-2017)

Marital History

• Married once, been married for 13 years now

Obstetric History
• G5P1A3 35-36 weeks pregnancy
• 1st day of last menstrual cycle : November 20th 2017
• Estimated due date : August 27th 2018
Pregnancy Helper Pregnancy Type of Labor Baby's
Outcomes condition
1 (9 yo) Midwife Aterm (with PROM) Spontaneous delivery Male, 2.400g
2 RSUD R. Syamsudin,SH Abortion Curettage
3 RSUD R. Syamsudin,SH Abortion Curettage
4 RSUD R. Syamsudin,SH Abortion Curettage
5
 CASE REPORT
Physical Examination
• General condition : mildly ill
• Consciousness : compos mentis
• Vital signs
– Blood pressure : 110/70 mmHg
– Heart rate : 88 bpm
– Respiratory rate: 21 x/minute
– Temperatur : 36.6°C
• Nutritional Status
– Weight : 56 kg
– Height : 148 cm
– Body Mass Index (BMI) : 25.56 kg/m2
 General Examination
• Head : normocephaly, deformity (-)
• Mammae :
• Eyes : anemic conjunctiva -/-, icteric sclera -/-
• Ear & Nose : deformity (-)
hyperpigmentation of areola
• Mouth : wet oral mucosa membrane
+/+, nipple retraction -/-,
• Neck : thyroid enlargement (-), trachea is in the breast milk -/-
middle • Abdomen
• Heart : regular 1st and 2nd heart sounds, murmur -, – Inspection : convex
gallop - – Palpation : supple in all
• Lung abdominal region, tenderness
– Inspection : symmetric chest expansion in both – defense muscular (-)
static and dynamic breathing – Auscultation : bowel sound
– Percussion : sonor on both lungs +
– Auscultation : vesicular breath sounds +/+ regular, • Extremities : warm, CRT<
rhonchi -/-wheezing -/-
2s, edema -/-/-/-
 Obstetric Examination

FH : 28 cm
Leopold 1 : head
Leopold 2 : back and left
Leopold 3 : breech
Leopold 4 : convergent
Fetal heart sound : 151 bpm

Vaginal toucher :
a. Vulva/vagina = no abnormalities
b. Portio = soft, thick
c. Cervical dilatation = 3 to 4 cm
d. Cervical effacement = 70 percent
e. Amniotic membrane = not intact, amniotic fluid leak from cervical opening
 Lab Examination
25th Jule 2018 (06:49)

Hb : 10.9 g/dL (12-14)

Hematrocrite : 34 % ( 36-46 )
Leukocyte : 14.300 /mm3 (4000-18.000)
Erythrocyte : 4.000.000 /mm3 (3.8-5.2 juta)
Thrombocyte : 234.000 /mm3 (150k-400k)
 LABOR REPORT
18. 18. foll 18 18.
• Stage 2 and 18 3 labor
10 37 ow .4 45
.3 the
Co ed 0 pla
0 Manual aid
bre
Classic method Mauriceau maneuver

mp by he ce
Str ec
let bot ad nta
ain h
e h wa wa
dil
gui wa
ofwith classic method to deliver s
Method of labor used is partial extraction (manual aid),
the shoulder anddin
mauriceau maneuver s to deliver the head of the baby.s
ati ar bo bo
g bor
on n ms rn rn
Working Diagnosis

G5P1A3, 34 years old, parturient preterm 35-36 weeks stage I

latent phase with breech presentation and PPROM

Management
1. IVFD RL 20 gtt
2. Monitoring of vital signs
3. Monitoring of fetal heart sound
4. Non Stress Test
5. Pervaginam delivery with oxytocin augmentation
6. Antibiotic prophylaxis (Cefotaxine 2x500mg)
 FOLLOW UP :

Tension Pulse Rate Respiration Temperature

(mmHg) (x/minute) (x/minute) (Celcius)

25/07/2018
120/70 84 20 36
14.30
Partus of Female Baby
25/07/2018
Birth Weight: 1815 gr
18.40
Birth Length: 41cm
25/07/2018
130/80 86 22 36
19.00

26/07/2018
100/70 82 21 36.5
07.30

26/07/2018
100/60 80 20 36.2
14.30
Final Diagnosis

P2A3, 34 years old, partus prematurus pervaginam with

perineal rupture grade I, breech presentation and PPROM

Management
1. Perineal repair
2. Ceftriaxone 2x1gr IV
 Prognosis

• Quo ad vitam : ad bonam

• Quo ad functionam : dubia ad bonam
• Quo ad sanationam : dubia ad bonam
 CASE ANALYSIS
PRETERM PREMATURE RUPTURE OF
MEMBRANE
 CASE THEORY

G5P1A3 35-36 Definition

weeks of gestation Rupture of membranes (ROM) occuring
complained clear before week 37 is considered preterm
rupture of membranes, whereas rupture of
fluid discharge
membranes occuring before the onset of
without pain & labor is termed premature rupture of
bleeding membranes (PROM). If the two occur
together it is termed preterm premature
rupture of membranes (PPROM)

Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014.

 CASE THEORY
• Patient is a Etiology and Risk Factors
passive smoker Spontaneous rupture of the fetal membranes
before 37 completed weeks and before labor
• History of PROM
onset likely has various causes, but
in previous intrauterine infection is believed by many to
delivery (1st child) be a major predisposing event. There are
associated risk factors that include low
socioeconomic status, body mass index ≤
19.8, nutritional deficiencies, and cigarette
smoking. Women with prior preterm
premature rupture of membranes
(PPROM) are at increased risk for recurrence
during a subsequent pregnancy.
 CASE THEORY

Clinical Manifestation:
G5P1A3 35-36 Commonly, a patient complains of a gush of
weeks of gestation fluid with continued leakage from the
complained clear vagina. The diagnosis is made by obtaining
fluid discharge a history of leaking vaginal fluid, pooling on
without pain & speculum examination, and positive nitrazine
and fern tests.
bleeding
 CASE
Vaginal toucher :
a. Vulva/vagina = no abnormalities
b. Portio = soft, thick
c. Cervical dilatation = 3 to 4 cm
d. Cervical effacement = 70
percent
e. Amniotic membrane = not
intact, amniotic fluid leak
from cervical opening
THEORY
Clinical Manifestation:
Sterile vaginal speculum exam
• Minimize digital examination of cervix, regardless of
gestational age, to avoid risk of ascending
infection/amnionitis
• Assess cervical dilation and length
• Obtain cervical cultures (Gonorrhea, Chlamydia)
• Obtain amniotic fluid samples Findings
• Pooling of amniotic fluid in posterior vaginal fornix
• Fluid per cervical os Nitrazine test
• Fluid from vaginal exam placed on strip of nitrazine
paper
• Paper turns blue in presence of alkaline (pH > 7.1)
amniotic fluid
 CASE ANALYSIS
BREECH PRESENTATION
 CASE THEORY
Etiology and Risk Factors
• G5P1A3 35-36 Risk factor of breech presentation include early
weeks of gestation gestational age, abnormal amnionic fluid volume,
complained clear multifetal gestation, hydrocephaly, anencephaly,
fluid discharge uterine anomalies, placenta previa, fundal placental
without pain & implantation, pelvic tumors, high parity with
bleeding --> high uterine relaxation, and prior breech delivery.
parity
• 7th month pregnancy When PROM occures too early, surviving neonates
USG result showed might develop sequelae such as malpresentation,
breech presentation cord compression, oligohydramnions, neurologic
impairment, intraventricular hemorrhage, and
respiratory distress syndrome.
 CASE THEORY

Leopold Maneuver Clinical Manifestation:

Leopold 1 : head Diagnosis of Breech Presentation
Leopold 2 : back on left Leopold 1: the hard, round, ballottable fetal head may
Leopold 3 : breech be found to occupy the fundus
Leopold 2: indicates the back to be on one side of the
Leopold 4 : convergent
abdomen and the small parts on the other
Leopold 3: if not engaged, the breech is movable above
the pelvic inlet.
Leopold 4: after engagement, shows the firm
breech to be beneath the symphysis.
The accuracy of this palpation varies. Thus, with
suspected breech presentation—or any presentation
other than cephalic sonographic evaluation is indicated.
 CASE THEORY

• Patient also It is possible that the decreased uterine

complaint a volume restricts fetal movements
reduced fetal
movement
 CASE ANALYSIS
LAB EXAM
 LAB EXAM
CASE THEORY

Hb : 10.9 g/dL (12-14)

Hematrocrite : 34 % ( 36-46 )
 CASE ANALYSIS
MANAGEMENT
 CASE THEORY
1. IVFD RL 20 gtt Zatuchini Andros Scroring system offer a
2. Monitoring of vital signs means of predicting the outcome breech
3. Monitoring of fetal heart sound delivery and selecting patient in whom
4. Non Stress Test vaginal delivery may be preferable for
5. Pervaginam delivery with oxytocin mother and infant.
augmentation If total score
6. Antibiotic prophylaxis (Cefotaxine - < 4 : SC
2x500mg) - >5 : vaginal delivery
- Estimated birth weight >3500gr : SC
 CASE THEORY
- Parity : 1 : 0 Factor 0 1 2
- Gestational age : 35-36 wk : Parity 0 >1 -
Gestational age (wk) 39 38 <37
2
- Estimated birth weight : Estimated birth weight >3500 3000-3500 <3000
(gram)
<3000 : 2
Previous breech 0 1 >2
- Previous breech : never : 0
Dilatation 2 3 >4
- Dilatation : 3 cm : 1
Station >-3 -2 <-1
- Station : 0 : 2
Total : 7
 CASE THEORY
1. IVFD RL 20 gtt
PROM
2. Monitoring of vital signs
3. Monitoring of fetal heart sound Gestational age (wk)
4. Non Stress Test
5. Pervaginam delivery with 20-<28 28-34 >34
oxytocin augmentation
6. Antibiotic prophylaxis active
Conservative,
inpatient 2 days active
(Cefotaxine 2x500mg)
 THEORY
Termination of labor at gestational
Active management in PROM age >28 wk
(termination of labor) can be used 1. Misoprostol 20microgram
in situation: intravaginal, repeated 1x6hr
- Gestational age 20-<28 wk and
after first administration
>34 wk 2. Metrolisa 100 cc 12hr before
- Sign of infection
cervix ripening is not effective
- Sign of labor
in PROM
- Fetal distress
3. Oxytocin drip 5IU dissolved in
5% dextrose 20-60 gtt for primi
and multigravida, 40gtt for
grande multigravida
4. Combination all of them
 CASE THEORY
1. IVFD RL 20 gtt
2. Monitoring of vital signs
3. Monitoring of fetal heart
sound
4. Non Stress Test
5. Pervaginam delivery with
oxytocin augmentation
6. Antibiotic prophylaxis
(Cefotaxine 2x500mg)
 CASE THEORY
1. IVFD RL 20 gtt
Giving antibiotics to patients with preterm
2. Monitoring of vital signs
PROM can reduce neonatal infections and
3. Monitoring of fetal heart
prolong the latent period. A meta-analysis2
sound
showed that patients receiving antibiotics
4. Non Stress Test
after preterm PROM, compared with those
5. Pervaginam delivery with
not receiving antibiotics experienced
oxytocin augmentation
reduced postpar- tum endometritis,
6. Antibiotic prophylaxis
chorioamnionitis, neonatal sepsis, neonatal
(Cefotaxime 2x500mg)
pneumonia, and intraventricular
hemorrhage. Another meta-analysis24
found a decrease in neonatal
intraventricular hemorrhage and sepsis.
 REFERENCE
1. Tanya m. Medina, m.D., And D. Ashley hill, m.D. Florida hospital family practice
residency program, orlando, florida
2. Panduan Praktik Klinis Obstetri dan Ginekologi, DEP./SMF Obstetri dan
Ginekologi Fakultas Kedokteran Universitas Padjadjaran RSUP DR. Hasan
Sadikin, 2015
3. Caughey, Aaron B, Julian N Robinson, and Errol R Norwitz. “Contemporary
Diagnosis and Management of Preterm Premature Rupture of Membranes.”
Reviews in Obstetrics and Gynecology 1.1 (2008): 11–22. Print.
4. Collins, S., & Arulkumaran, S. (2008). Oxford Handbook of Obstetrics and
Gynaecology. Oxford: Oxford University Press.
5. Gray CJ, Shanahan MM. Breech Presentation. [Updated 2017 Oct 13]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018
Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK448063
6. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014.
 Thank You
Group 3 - Obstetric and Gynecology Unpad
 Classic manuver

Melahirkan lengan belakang Melahirkan lengan depan

Mouriceau manuver