Prematurely Ruptured of Membranes - PROM

Premature Ruptured of
Membranes (PROM)
R. Afrilianti
Definition
PROM is defined as spontaneous rupture of
the membranes (amniorrhexis) before labor at
any stage of gestation
If the rupture happened prior to 37 weeks, it
called preterm prematurely rupture of the
membranes (PPROM)
Epidemiology
In normal condition, 8 10 % of term
pregnancy woman happened PROM
PPROM occurs in about 1 % of all pregnancy
Etiology
The cause of
PROM is a wide
array of
pathological
mechanisms.

PROM PPROM
Weakness power of
membranes in term
pregnancy, cause of:
-Enlarge uterus
-Uterus contraction
-Movement of fetal
External factors included:
-Vaginal infection
-Trauma
-Increased of intra-uterine
pressure (such as multiple
pregnancy and hydraminios)
-Solutio placenta
-Cervix incompetent
Change biochemistry process
of membranes
Low socioeconomic status
Low body mass indexless than
19.8
Nutritional deficiencies
Cigarette smoking
Physiology
Amniotic sac
Inner layer (amnion)is
formed by embryo-
blasts.
Outer layer (chorion)is
formed by tropho-blasts
As a metabolic organ, it is part of the production and
Resorption of the amniotic fluid
The fetal kidney and the fetal lung produce
the amniotic fluid. Resorption occurs via the
amniotic sac and the gastrointestinal system
when the fetus drinks the amniotic fluid.
Function
Shelter from dehydration, compression of the
umbilical cord, traumatic external influences
and gives room for the child to move and grow
and necessary for the development of the
lungs
Patophysiology
PROM is correlated with change of
biochemistry process of component the
membranes including collagen matrix
extracellular amnion, chorionic, and apoptosis
of fetal membranes
In normal condition, rupture of membranes in
delivery commonly happened by uterus
contraction and stretching repeated of
membranes

Synthesis and degradation matrix extracellular
must be in balance condition.
Collagen degradation is mediated by
metaloproteinase matrix (MMP).
Its inhibited by specific tissue inhibitor and
protease inhibitor
While delivery approached, degradation
activity is increased. In infection condition
occurs increase of MMP stimulating matrix
degrading enzyme PROM
Manifestation
Fluid passing through the vagina suddenly,
and then small amounts of fluid flow through
the vagina intermitently, particularly when the
increased of abdominal pressure (cough,
sneeze, et al)
Intermittent urinary leakage is common
during pregnancy, especially near term
Increased vaginal secretions in pregnancy
Perineal moisture
Increased cervical discharge
Urinary incontinence
Speculum examination appears loss of
amniotic fluid from the endocervical canal
Nitrazin paper changed from red to blue
Lanugo and vernix casseosa by microscope

Evaluation
1. History
The time of rupture and consistency of the
fluid leakage is important.
An accurate gestational age to
appropriately manage the patient
2. Examination
- Vital sign
- Sterile speculum examination (SSE)
When visualizing the cervix, the dilation and
effacement should be noted
Nitrazin and fern tests are used to confirm
rupture. Nitrazin should show a pH between
7,1 7,3. False positive test can be observed
with blood, semen, trichomonas, cervical
mucus, and urine

Ferning can be falsely negative in the
presence of blood.
Cervical culture for chlamydia and
gonorrhea, and anovaginal culture for group
B streptococcus should be obtained
- Fundal tenderness
Evaluation for possible chorioamnionitis or
placenta abruption
- Laboratory assessment
Complete blood count and urinalysis
- Ultrasound (USG)
Amnion fluid index, fetal presentation,
estimated fetal weight, and gestaional age
- Fetal heart rate and contraction monitoring

Maternal and fetal risks
Maternal risk Fetal risk
Amniotic infection syndrome (AIS)
Sepsis
Placental abruption
Postpartal atonia
Fever and endomyometritis in
peurperium
Increase CS insidency
Preterm brith
Neontal sepsis
Pulmonary hypoplasia
RDS
Contractures and deformities

Treatment guidelines in preterm
rupture of membranes
Conservative management
Antibiotic
- ampicillin 4x500mg/erytromicin 4x500mg
- metronidazole 2x500 mg to 7 days
GA32-34 weeks hospitalize until amniotic
fluid stop to loss

GA 32-37 weeks no in labour and infection,
administer dexamethasone observation
termination at 37th week
GA 32-37 weeks in labour and non infection
tocolytic agent (salbutamol), dexamethasone do
induction after 24 hours
GA 32-37 weeks infection administer
antibiotic and induction
GA 32-37 weeks administer steroid
(Betametasone 12 mg/day single dose for 2
days), Dexametasone IM 5 mg/6hours 4X.

Active management
GA >37 weeks do induction with oxitocin if
failed CS
Misoprostol 25g - 50g intravagina/6 hours
4X. If any infection give high dose of antibiotic
and termination pregnancy
If pelvic score <5, favorable cervix then
induction. If failed SC
If pelvic score >5 induction
References
Mohr T. Premature Rupture of Membrane.
Gynakol Geburtsmed Gynakol Endokrinol
2009; 5(1):2836.
Prawirohardjo S. Ilmu Kebidanan. Ed 4th.
Jakarta: PT. Bina Pustaka Sarwono
Prawirohardjo, 2009.
Mercer BM. Premature Rupture of The
membrane in Maternal fetal Medicine:
Elsevier 2010

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