Premature Ruptured of Membrane: Ferdian Gunawan

Premature Ruptured of Membrane
Ferdian Gunawan
Fetal Membrane Activation
• Syncytiotrophoblasts release CRH, progesterone,
and estrogens -> maternal fetal blood.
• Cortisol -> a maternal artery and enters the
intervillous space -> stimulates the production of
CRH by the syncytiotrophoblasts -> to fetal vein
-> stimulating the fetal pituitary to synthesize
corticotropin and drive fetal adrenal cortisol and
DHEAS synthesis.
• Cortisol and CRH stimulate the fetal lungs to
produce surfactant protein A, which moves from
the amniotic fluid to the amnion, where it
stimulates the production of cyclooxygenase 2
(COX-2) and the synthesis of prostaglandin E2
• Prostaglandins mediate the release of the
metalloproteases that weaken the placental
membranes, thereby facili- tating membrane
rupture.
• CRH also stimulates the secretion of membrane
matrix metalloprotease-9.
Adopted from : Paary S, Strauss JF. Premature rupture of The Fetal Membrane. The New England Journal of Medicine. 2014:338(10);663669
Rupture of the
Premature fetal membranes
Ruptured of before onset of
Membranes uterine
contractions.
EPIDEMIOLOGY of PROM
• PROM Incidence from 3-10% of all delivery  complicate
3% of pregnancy  lead 1/3 of preterm birth
• Cause 40-75% neonatal death
Adopted from : Dars S, Malik S, Samreen I, Kazi RA. Maternal
morbidity and perinatal outcome in preterm premature rupture of
membranes before 37 weeks gestation. Pak J Med Sci.

Premature Ruptured of Membranes
• Classified as
• Term PROM (37 weeks and longer)
• Preterm PROM (fewer than 37 weeks), and
• Previable preterm PROM (fewer than 24 weeks)
The American College of Obstetricians and Gynecologists. Prelabor Rupture of Membranes. ACOG. 2018; 188 (1)
Term PROM Preterm PROM Previable PROM Prolonged PROM
Classification
Defined as PROM at or after
37 weeks of gestation
of
Defined as PROM PROM
weeks of gestation
before 37 Defined as PROM before
24 weeks of gestation 2
PROM more than 24
hours before delivery
Occurs in ± 8% of pregnancies Complicates ± 3% of pregnancies Occurs in less than 1% of

and is typically followed by and responsible for ±33% of pregnancies 2
rapid onset of spontaneous preterm births
labor and delivery
After fetal membrane rupture:

• When expectant o Within 1 week: ±50% of o Within 1 week: Associated with
management or watchful patients give birth 40% to 50% of increased risk of
waiting is used, ±50% of o From 2 to 5 weeks: 70%-80% patients give ascending infection
patients give birth within of remaining patients give birth
33 hours birth o From 2 to 5
• ±95% give birth within 94 • Amniotic fluid may stop weeks: 70% to
to 107 hours leaking and fluid volume may 80% of
recover to within reference remaining
range; this is associated with patients give
favorable outcomes for birth
patient and baby
Etiology and Additional Risk Factor
Intraamniotic Body mass Smoking and

Socio-economic
infection index drug
commonly associated low socio-economic Low body mass index Also associated with
with preterm PROM, status (≤ 19.8) also PROM as Risk Factor
especially at earlier associated with
gestational ages PROM
PROM
Cellular changes similar to term PROM, but precipitating

etiologies most likely differ
Most cases occur without a clear cause or in the absence of
recognized risk factors
Can occur from a variety of causes or a combination of factors
PROM-
PATHOGENESIS
Adopted from : Parry S, Strauss JF. Premature
rupture of The Fetal Membrane. The New
England Journal of Medicine.
2014:338(10);663669
PROM-
PATHOGENESIS
Adopted from : Parry S, Strauss JF. Premature
rupture of The Fetal Membrane. The New
England Journal of Medicine.
2014:338(10);663669
PROM-PATHOGENESIS
Adopted from : Menon R. Oxidative stress damage as a detrimental factor in preterm birth pathology. Frontiers in Immunology. 2014.
BACTERIAL ETIOLOGY
Adopted from : Zeng LN, Zhang LL, Shi J, Gu LL, Grogan W, Gargano MM, et al. The primary microbial pathogens associated with premature
BACTERIAL ETIOLOGY
Adopted from : Zeng LN, Zhang LL, Shi J, Gu LL, Grogan W, Gargano MM, et al. The primary microbial pathogens associated with premature
Diagnosis
• History and physical examination
• Examinations increase the risk of infection and add
little information to that available with speculum
examination, digital examinations generally should
be avoided unless the patient appears to be in active
labor or delivery seems imminent (For cervicitis,
prolapse cord/fetal
• Diagnosis of membrane rupture typically is
confirmed by the visualization of amniotic fluid passing
from the cervical canal and pooling in the vagina
Amniotic fluid vs other fluid
• The normal pH of vaginal secretions is generally 4.5–
6.0, whereas amniotic fluid usually has a pH of 7.1–7.3.
• False-positive test results may occur in the presence of blood or semen, alkaline
antiseptics, or bacterial vaginosis.
• Microscopic arborization (ie, ferning) of cervicovaginal
discharge on drying (ie, fern test)
• Ultrasonographic examination (not diagnostic)
• Fetal fibronectin is a sensitive but nonspecific test for
ruptured membranes; a negative test result is strongly
suggestive of intact membranes, but a positive test result
is not diagnostic of PROM
• Amnio-dye test (ie, tampon test) can be performed to
confirm diagnosis of PROM
Amnion-dye test
– General explanation
• Instill 1 mL of indigo carmine dye mixed in 9 mL of sterile saline 5 into amniotic cavity using
ultrasonographic guidance
• Owing to recent availability issues with indigo carmine dye, alternative options have been
considered
– A review of potential dyes for clinical use suggested fluorescein is a readily available
commercial option that has the best evidence supporting use and safety
– Indication
• Recommended for patients in whom diagnosis remains equivocal after full evaluation
– Complications
• Bleeding (placental abruption)
• Infection
• Iatrogenic PROM
• Miscarriage/fetal loss
– Interpretation of results
• With indigo carmine dye, leakage of blue-dyed fluid into vagina within 20 to 30 minutes—as
documented by staining of a tampon—is regarded as definitive diagnosis of PROM
• Maternal urine also will turn blue and should not be confused with amniotic fluid
ACOG 2018 RECOMMENDATION
• Delivery  for non-reassuring fetal status, clinical chorioamnionitis, and
significant abruptio placenta  optimal gestational age is controversial (but
recommend for > 34 0/7 gestation, no beyond 37 0/7)
• Expectant management  consist periodic assessment for infection, fetal

well-being, abruptio placenta, umbilical cord compression, and labor
• Tocolysis  associated w/prolong pregnancy and increase risk of

choriomnionitis, without significant benefit for maternal and neonatal
• Antenatal corticosteroid  recommended for 24 0/7 to 34 0/7wg ;
Betametasone may have benefit for 34 0/7 to 36 6/7 to reduce neonatal
morbidity
• MgSO4  to reduce risk of cerebral palsy in <32 0/7 gw
• Antibiotic  combination of IV ampicillin and erythromycin for 2 day,

followed by oral ampicillin and erythromycin for <34 0/7 for 5 d
• No recommendation for home care management

Mechanism of antenatal corticosteroid
Adopted from : Bolt RJ, Weissenbruch V, Lafeber, Waal DV. Pediatric Pulmonology. 2001(32);76-91
Mechanism of MgSO4 for neuroproc
• Vasodilator effect in cerebral vessel  inhibit hypoxia and
ischemia
• Anti-inflammatory effect  decrease inflammatory

cytokine and free radial in cerebral cell
• Regulate NMDA receptor for glutamate  decrease

calcium entry  modulate excitatory action of neuron and
prevent apoptosis
ACOG Recommendation for GBS Prophylaxis
• For mother w/ HSV  risk of vertical transmisiion is 30-50% for
HSV and 3% for HIV  give acyclovir and cesarean if there lesion
of HSV when delivery time
• pPROM  management (expectand or immediate) based on patient

consultation and fetal status
• Future pregnancy  there increase risk of recurrent  offered

progesterone supplementation from 16-24 gw or cervical cerclage

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Premature Ruptured of Membrane

• Cause 40-75% neonatal death

Adopted from : Dars S, Malik S, Samreen I, Kazi RA. Maternal

morbidity and perinatal outcome in preterm premature rupture of

membranes before 37 weeks gestation. Pak J Med Sci.

Occurs in ± 8% of pregnancies Complicates ± 3% of pregnancies Occurs in less than 1% of

After fetal membrane rupture:

Intraamniotic Body mass Smoking and

Cellular changes similar to term PROM, but precipitating

Adopted from : Parry S, Strauss JF. Premature

rupture of The Fetal Membrane. The New

England Journal of Medicine.

Adopted from : Parry S, Strauss JF. Premature

rupture of The Fetal Membrane. The New

England Journal of Medicine.

• Expectant management  consist periodic assessment for infection, fetal

• Tocolysis  associated w/prolong pregnancy and increase risk of

• MgSO4  to reduce risk of cerebral palsy in <32 0/7 gw

• Antibiotic  combination of IV ampicillin and erythromycin for 2 day,

• No recommendation for home care management

• Anti-inflammatory effect  decrease inflammatory

• Regulate NMDA receptor for glutamate  decrease

• pPROM  management (expectand or immediate) based on patient

• Future pregnancy  there increase risk of recurrent  offered

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