PREMATURE RUPTURE OF MEMBRANE (PROM)

Definitions
Etiology
Clinical presentation
Premature rupture (PROM) denotes
Ascending Infection (vaginal \ cervical) Sudden Gush of clear
spontaneous rupture of fetal membranes
vaginal fluid
Abnormal membrane (deficient collagen
before the onset of labor.
Rule out :
and minerals weakness)
This can occur at term (PROM) or preterm
o Episodic urinary
Incompetent cervix
(PPROM).
incontinence
Nutritional deficiencies of copper,
Preterm premature rupture of membrane
o Leucorrhea
ascorbic acid.
(PPROM):
o loss of the mucus
Smoking
+\- Uterine contraction( preterm labor ? )
plug
Consider causes of preterm labor
*It has been suggested that the term preterm
symptoms suggestive of
a. multiple gestation.
PROM (PPROM) should be used to define
Chorioamnionitis ?
b. Low socioeconomic class.
those patients who are preterm with ruptured
c. Ethnicity..etc
membranes, whether or not they have
contractions.
Method of diagnosis (Investigations)
Never do a digital vaginal exam on a patient who is not in labor, whether preterm or term
1. Sterile Speculum exam
Direct visualization of liquor Pooling
Bcoz we may face a case that we suspect PPROM but we dont
see the liquor ex. :
High Vaginal Swab (HVS) assess Chorioamnionitis
Severe oligohydramnios will appear in the abdominal exam
Nitrazine
(small for GA on fundal height etc )
Ferning
Fetal head closing the cervix manipulate the head and see
Sterile , not only to prevent infection but bcoz you may
if liquor comes out
take the swab from the speculum and get a false positive
Theres No rupture of membranes think about other DDx
Dx of PPROM involves first examining the abdomen
for the Gush of fluid (U. incontinence , leucorrhea ,loss of the
(assess the lie , position , ease of examination may
cervical mucous plug )
indicate oligohydramnios )

Method of diagnosis (Investigations)

1. Sterile Speculum exam
Direct visualization of liquor
Nitrazine blue test
False Positives
Cervical mucus
Blood
Vaginal infection
(BV)
Semen

Fern like

Fern and Nitrazine Tests

1.Tear off a 2-3 cm

piece of Nitrazine
paper.
2.Apply fluid collected
from the vaginal pool
directly to the paper.
3.A blue color change
is consistent with
amniotic fluid pH of 77.5. The Nitrazine
paper
container includes a
chart of color change
and pH.
2.U/S

False positive
Cervical mucus
Blood
Urine
Saline

Complications

1. Insert speculum for sample collection, avoid the use of

lubricant.
2. Collect vaginal secretion from the posterior vaginal pool with
two cotton sterile swabs.
Do not touch the mucus plug in the cervix.
Do not contaminate the specimen with saline/koh.
3. After collection, immediately rub the swab against a glass
slide, creating a very thin smear, do not apply a coverslip.
4. Allow slide to dry for 5-10 minutes.
5. Using a microscope, examine the dried smear under 10X
power without a cover slip.
6. If present, saline in the amniotic fluid crystallizes to form a
fern-like pattern.

Chorioamnionitis

assess gestational
age , fetal growth
and wellbeing
Assess amniotic
fluid volume.
rule out fetal
anomalies

1. Depends on fetal age,

duration and liquor
volume lift
2. Prolonged PPROM
Chorioamnionitis
development and
neonatal infections
3. Prematurity related
complications (RDS , PDA ,
IVH , NEC, ROP , BPD , CP
)
4. Oligohydramnios : if >24
weeks may lead to
pulmonary hypoplasia
5. Positional hypoplasia.
Suspect Chorioamnionitis
maternal fever and Uterine
tenderness in a confirmed
case of PROM and without
UTI or URI
Management : Vaginal
cultures , IV Antibiotics and
prompt delivery (not
necessarily CS)
Management
the main principle of the
management would be
conservative balancing
between prematurity and
infection (Unless theres

Suspect Chorioamnionitis in the

presence of any change (rather
than absolute values) of:
1. Pulse rate
2. Temperature more than 38
(unexplained)
3. Tense or tender uterus
4. Color or smell of vaginal
secretions *
5. Fetal heart rate.
Management : take Vaginal gram
stain and cultures , give IV
Antibiotics
if gram stain positive
prompt delivery (not necessarily
CS) REGARDLESS of Gestational
Age
Deep infection , (in the uterus which is in the abdominal
cavity , not exposed to the omentum or other defense
mechanisms and the immune system )
So it could put the mother and the fetus at risk of sepsis

Main risk is prematurity

First look if we have any

indication to terminate the
pregnancy :

Admit and give

Antibiotic use is
recommended
(Erythromycin and
Metronidazole)

Any change of maternal HR ,

Temp , Tense tender uterus
WBC CRP may be high or low , so
dont count on them as well as
the vaginal discharge
(
may not be present)

Tocolytics : short term use

only
Steroids: Betamethasone

Blood doesnt reach the fetal

indications to terminate
preg)

1.Chorioamnionitis
2.Severe oligohydramnios
3.Congenital anomalies
?

but it may not

prevent fetal
infection* also may
mask
Chorioamnionitis.

lung so we may face cases of

congenital pneumonia despite
Abx use