School of Medicine

NEMMRH
Department of Obstetrics and Gynecology

PREMATURE RUPTURE OF MEMBRANE AND

PRETERM LABOR
By
Dr. Tilahun. A (MD)

January 3, 2018
Hossena Ethiopia
 CONTENTS
1. PREMATURE RAPTURE OF MEMBRANE
(PROM)

2. PRETERM LABOUR (PTL)

3. REFERENCES

2
 I. PROM
A. Introduction
B. Risk Factors
C. Clinical Course PROM
D. Complication
E. Diagnosis
F. Management

3
 A. Introduction
• Rupture of the membranes may occur at any time during
pregnancy.
• It becomes a problem if the fetus is preterm (preterm premature
rupture of membranes [PROM]) or,

• In the case of a term fetus, if the period of time between rupture

of the membranes and the onset of labor is prolonged.

• If 24 hours elapse between rupture of the membranes and

the onset of labor, the problem is one of prolonged PROM.

4
 …cont…
• The exact cause of rupture is not known, although many
conditions are associated with PROM.
– PROM occurs in approximately 10.7% of all pregnancies.

• ~94% of cases, the fetus is mature

– ~20% of these are cases of prolonged rupture.

• ~5% of is premature fetuses (1000–2500 g)

– ~50% of cases are prolonged ruptured

• ~less than 0.5% immature fetuses (< 1000 g)

– ~75% of cases are prolonged ruptured

5
 …cont…
• Premature/ pre-labor rupture of membrane PROM:- is
rupture of membranes (ROM) before the onset of labor
(regular uterine contractions).
• Latency period:- is the interval between the rupture of
membranes(ROM) & the onset of labor
• Prolonged PROM:- is rupture of membranes for > 12 hrs
• Term PROM:- is rupture of membranes after 37 completed
weeks of gestation
• Pre term PROM:- is rupture of membranes from 28 weeks to
before 37 completed weeks of gestation (Ethio. Obstetric
Protocol ; 2010).

6
 B. Risk Factors
 Increased intrauterine pressure (e.g.,  Low body mass index (<19.8 kg/m2),

Polyhydramnios).  Nutritional deficiencies of copper and

 Connective tissue disorders (e.g., Ehlers- ascorbic acid,

danlos syndrome),  Antepartum bleeding in one or more

 Urogenital tract infection, trimesters,

 Abnormal genital tract colonization,  Maternal cigarette smoking,

 Chorioamnionitis,  Cervical conization or cerclage,

 Recent coitus,  Pulmonary disease in pregnancy, and

 Low socioeconomic status,  Preterm labor or

 Uterine overdistention,  Symptomatic contractions

 Second and third trimester bleeding,

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 C. Clinical Course after PROM
• A hallmark of PROM is brief latency from membrane rupture to
delivery.
• On average, latency increases with decreasing gestational age at
membrane rupture.
• At term, one half of expectantly managed gravidas deliver within 5hrs and
95% deliver within 28hrs of ROM.
• Between 32 and 34 weeks, the mean interval between rupture and delivery
is 4 days.
• Of all women with PROM before 34 weeks, 93% deliver in less than 1 week.

8
 …cont…
– After excluding those admitted in labor or with amnionitis or NRFHP, 50 to 60%
of those conservatively managed will deliver within 1 week of ROM.
• When PROM occurs near the limit of viability, 30 to 40% remain pregnant
for at least 1 week, and one in five conservatively managed women have a
latency of 4 weeks or more.
• A small proportion of women with membrane rupture can anticipate
cessation of fluid leakage (2.6 to 13%), particularly those suffering
membrane rupture subsequent to amniocentesis.
– ~ 86 percent of those with leakage after amniocentesis will reseal.

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 D. Complication or Risks of
PROMs
• Maternal Risks • Fetal and Neonatal Risks
• Infection of the amniotic • Fetal infection and fetal
cavity/chorioamnionitis distress due to umbilical cord
• Endometritis compression
• Placental abruption • Oligohydramnios
• Retained placenta • Frank or occult umbilical cord
• Hemorrhage prolapse
• Maternal sepsis and • Fetal malpresentation.
• Maternal death. • Higher risk of C/S delivery for
nonreassuring FHRP
• Fetal death

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 E. Diagnosis of PROM
1. Sterile Speculum Examnation

2. Pad Test

3. Nitrizine Testing

4. Fern Test or Microscopic Fern Testing

5. AmniSure

6. Ultrasonography

7. Dye Test or Transabdominal Indigo dye Injection

 NB:- Base line investigation similarly important as in case of PROM
as well as in all pregnant mothers.

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 1.Sterile Speculum Examination (SSE)

• During SSE watch for;

• Glistening, washed out vagina

• Fluid pooling in posterior fornix

• Free flow of fluid from cervix!

presence of meconium/vernix

• Ask the women to cough this may

cause a gush of fluid

• In addition during SSE;-

– Rule out the presence of a cord

prolapse

– Asses the state of the cervix

(effacement and dilatation) Consider need to collect other cervical

tests/cultures such fetal fibronectin
while doing the SSE. 12
 2. Pad Test
• Pad test can be helpful when there is no pooling & no leakage from
cervix .

 Place a vaginal pad over the vulva & examine it an hour later visually
& by odor

 Wetting with no urine and no vaginal discharge (vaginitis) may

suggest PROM

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 3. Nitrazine Paper Test

• Hold a piece of nitrazine paper in • The test is accurate in 90-98%

a hemostat & touch it against the of cases
fluid pooled on the speculum – False positive results of nitrazine
blade. testing, may occur in the presence of
– Blood or semen contamination
– A change from yellow to blue
– Alkaline antiseptics, or
indicates alkalinity (a PH > 6-
– Bacterial vaginosis
6.5) (amniotic fluid 7.0-7.5,
– False negative results occur with
vaginal secretion 4.5-6)
prolonged leakage & minimal residual
fluid.

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 4. Fern Test/ Microscopic Fern Testing

• Obtain fluid by swabbing the posterior

fornix, avoiding cervical mucus

• Spread some fluid on a slide & let it dry.

Examine it with a microscope

• Amniotic fluid crystallizes & may leave a

fern-leaf pattern (arborization), which
suggests membrane rupture

• The test accurately confirms PROM in

85-98% of cases

• False negatives are frequent
• False positive test can result from the
collection of cervical mucus
Must allow slide to dry thoroughly prior to
examination under microscope. Assess for
arborization of fluid. Cervical mucous has
broad, ferning pattern that is different
than the fern of amniotic fluid.

15
 5. AmniSure (Placental alpha
microglobulin-1 protein assay)
• AmniSure® is a rapid slide test that
uses immunochromatographic
methods to detect trace amounts of
placental alpha microglobulin-1
protein in vaginal fluid.
– An advantage of this test is that it is
not affected by semen or trace amounts
of blood.
• Test procedure:- a sterile swab is
inserted into the vagina for one minute,
then placed into a vial containing a solvent
for one minute, and then an AmniSure
test strip is dipped into the vial.
• The test result is revealed by the
presence of one or two lines within the
next 5 to 10 minutes (one visible line
means a negative result for amniotic
fluid, two visible lines is a positive result,
no visible lines is an invalid result).
16
…cont…

17
 6. Ultrasonography

• Ultrasound examination
may be useful, when the
Clinical history or physical
examination is unclear, to
document oligohydramnios.

• PROM is less likely if fluid

volume is normal.

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 7. Dye Test
• Ultrasound guided trans-
abdominal installation of
indigo carmine dye (1 ml in 9
ml sterile N/S) followed by
observation for passage of
blue fluid from the vagina
with in 30 min.
• Tampon placed in vagina and
checked for blue staining 30-
60 mins after procedure

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 F. Management

• Once the diagnosis is confirmed admit the woman

to a hospital.
• Assess maternal & fetal well being & check for signs of labor

• Determine gestation age form the last normal menstrual

period, milestones of pregnancy or ultrasound

• Determine fundal height which will mostly be less than GA

• Ascertain Fetal presentation

• Determine cervical status by SSE

20
 …cont…
• Check for signs of intra-amniotic infection (chorioamnionitis)
including:-
• Maternal fever

• Fetal tachycardia ((FHB > 160 beats per minutes)

• Tender uterus

• Purulent cervical discharge

• Leukocytosis &/or positive bacterial culture (if later in the course)

21
 …cont…
• If there are signs of uterine infection at any time during the
pregnancy, manage as chorioamnionitis:
 Start treatment with broad-spectrum, high dose IV antibiotics
• Ampicillin 2gm IV Q 6 hrs for 7-10 days
• Gentamycin 80mg IV Q 8hrs for 7-10 days
• Metronidazole 500mg P.O Q 8hrs

 Induce labor & expedite delivery, without any delay despite the GA;
consider
• Cesarean section if abnormal labor occur.
• Continue antibiotics post partum, at least for 24hrs after the mother
becomes non febrile

22
 …cont…
• PROM, without evidence for infection, depends upon the gestational
• Term PROM (>37wks GA)
– Expedite delivery with out delay; in presence of suspected or evident intrauterine
infection, abruption placenta, or evidence of fetal compromise.
– Route of delivery depends on other obstetric conditions
• If the cervix is favorable (on speculum examination) consider induction,
especially if duration of ROM is > 12-16hrs (Without onset of labor}
• Institute prophylactic anti-biotic when the duration of ROM> 12hrs
• If the cervix is unfavorable (in absence of other needs for immediate
delivery)
• Start on expectant management & consider prostaglandin for cervical
ripening.

23
 …cont…
• Near term PROM (34-37 wks GA)

– In this gestational age range, induction or expectant management

are acceptable management options depending on local resources
(similar to the Management of term PROM)

– Consider antenatal steroids & prostaglandin for cervical ripening, if

possible, before induction (or while on expectant Management)

24
 …cont…
• Pre term PROM( under 34 wks) GA

• Expectant management is preferred (in absence of

chorioamnionitis), because of the significant risks
associated with pre-maturity; & attempts should be made
to prolong the latent period.

25
 …cont…
• Expectant Management
– Avoid digital cervical (pelvic ) examination

– Advise bed-rest, to potentially enhance amniotic fluid re- accumulation &

possible delay onset of labor.

– Complete pelvic rest- to avoid infection

– Use of steroids, as in preterm labor, to accelerate fetal lung maturity are

indicated unless there is evidence of chorioamnionitis (except for term
PROM).
• Betamethasone 12mg IM q 24hrs, for 2 doses (or every 12 hrs) or

• Dexamethasone 6mg IV or IM q 12hrs for 4 doses (or every 6hrs)

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 …cont…
• Provide Prophylactic Antibiotics

– Advantages possibly include

• Increased latency period

• Decreased incidence of maternal & neonatal morbidity & mortality

– Antibiotics & dose for prophylaxis

• Amoxacillin 500 mg & Erythromycin 500 mg P.O. every 8hrs for 7 days,
if delivery doesn't occur (may be started as Ampicillin 2gm IV QID &
Erythromycin 500 mg IV QID for 48 hrs).

27
 …cont…
• PROM patient can be monitored by “PROM Chart”
 Components of PROM Chart:-
 Patient identification
 Name, MRN, Garavidity, Parity, Time and date

 Maternal vital signs Q 4hrs

 FHB Q 4hrs

 Abdominal tenderness daily

 Abnormal vaginal discharge daily

 WBC every other days

 Fetal BPP twice a week

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 …cont…
• Biophysical Profile (BPP)

– The BPP is composed of 5 components:

1. Nonstress Test (NST)

2. Fetal breathing movements (30 seconds or more in 30 minutes),

3. Fetal movement (3 or more in 30 minutes),

4. Fetal tone (extension/flexion of an extremity), and

5. Amniotic fluid volume (vertical pocket of 2 cm or more).

 Each component is worth 2 points; a score of 8 or 10 is normal, 6 is equivocal, and

4 or less is abnormal.

 Modified BPP combines NST, a short-term indicator of fetal acid–base status,

with amniotic fluid index (AFI), a long-term indicator of placental function.

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II. PRETERM LABOR (PTL)
A. Introduction

B. Pathogenesis

C. Risk Factors

D. Diagnosis

E. Management

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 A. Introduction
• Labor is the process of coordinated uterine contractions leading to
progressive cervical effacement and dilatation by which the fetus and
placenta are expelled.

• Preterm labor is defined as labor occurring after 20 weeks' but before

37 completed weeks' gestation.
– Uterine contractions need to be regular and at frequent intervals. Generally, more than
4 contractions per hour are needed to cause cervical change. The uterine contractions
need not be painful to cause cervical change and may manifest themselves as abdominal
tightening, lower back pain, or pelvic pressure. In addition, there must be demonstrated
cervical effacement or dilatation to meet a diagnosis of preterm labor.

31
 …cont…
• Classification:- Subtypes of preterm birth are variably defined.
– By gestational age:
• Moderate preterm: 32 to <37 weeks

• Late preterm: 34 0/7ths to 36 6/7ths weeks

• Very preterm: 28 to <32 weeks

• Extremely preterm: <28 weeks

– By birth weight:
• Low birth weight (LBW): <2500 grams

• Very low birth weight (VLBW): <1500 grams

• Extremely low birth weight (ELBW): <1000 grams

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 B. Pathogenesis of PTL
• The pathogenesis of preterm labor is not well understood, and it
is often not clear whether preterm labor represents early
idiopathic activation of the normal labor process or results from
a pathologic mechanism

• Theories exist regarding the initiation of labor, including

1. Progesterone withdrawal

2. Oxytocin initiation

3. Premature decidual activation

33
…cont…

34
…cont…

35
 C. Risk Factors for PTL
• Previous induced abortion (two • Congenital anomalies
or more first-trimester or one • Chorioamnionitis
second-trimester abortion) • Preterm premature rupture of
• Low socioeconomic status membranes
• Smoking • Abruption
• Previous preterm delivery • Fetal demise
• Short interpregnancy interval

36
 …cont…
• Placenta previa • Urinary tract infection

• Poor nutritional status • Bacterial vaginosis

• Uterine anomalies • Polyhydramnios

• Advanced maternal age • Serious systemic infection

• Maternal age less than 20 • Multiple gestation

• Previous cervical surgery • Cocaine use

• Diethylstilbestrol (DES) • Low prepregnancy weight

exposure

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 Clinical Manifestations
• The clinical manifestations of true labor, contractions and cervical
change, are the same whether labor occurs preterm or at term.
• The following are early signs and symptoms of labor; non-specific and
can be present for several hours in women who do not exhibit cervical
change:
• Menstrual-like cramping

• Mild, irregular contractions

• Low back ache

• Pressure sensation in the vagina

• Vaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie,
mucus plug, bloody show)

38
 D. Diagnosis of PTL
• The diagnosis of preterm labor is generally based upon clinical
criteria of regular painful uterine contractions accompanied by
cervical change (dilation and/or effacement).
• Presence of vaginal bleeding and/or ruptured membranes increases diagnostic
certainty

• Specific clinical criteria, include persistent uterine contractions

(4 every 20 minutes or 8 every 60 minutes) with documented
cervical change or cervical effacement of at least 80% or
cervical dilatation greater than 2 cm.
• Women who do not meet these criteria are diagnosed with false labor; these
women typically go on to have a late preterm or term delivery

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 Fetal Fibronectin (fFN)

• fFN is thought to be a "trophoblast glue" that promotes cellular

adhesion at uterine-placental and decidual-fetal membrane
interfaces.
• It is released into cervicovaginal secretions when the extracellular
matrix of the chorionic/decidual interface is disrupted.

• This is the rationale for measurement of fFN as a predictor of PTD.

40
 …cont…
• The fFN assay has been used in two ways:

• To predict the risk of PTD in symptomatic patients,

• To identify asymptomatic women who are most likely to

deliver preterm.
• Screening asymptomatic women is usually reserved for those in
a high risk group (eg, previous preterm delivery, multiple
gestation)

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 Sample collection and results

• Candidates for testing should

meet the following criteria:
1. Intact fetal membranes

2. Cervical dilatation less than 3 cm

3. Gestational age 22 and 0/7th to 34

and 6/7th weeks .

42
 …cont…
• Samples are collected from secretions:-
1. In the posterior fornix or external cervical os during a SSE using a swab
from the manufacturer's kit.

2. The labia are held apart and then the swab is blindly inserted into the
vagina and directed toward the posterior fornix

• A fFN concentration of 50ng/mL is the threshold for a positive test

result.

• Sensitivity 98.2%, Specificity 26.8%.

• False positive results can also be caused by semen or sperm from

coitus within the previous 24 hours or from a grossly bloody specimen.

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 E. Management of PTL
• Hospitalize women diagnosed with preterm labor
– Reduce work, smoking, stress, travel, sexual activity, bed rest, improve
nutrition
– hydration and sedation
– Inhibition of uterine contractions
• Tocolytics
• Progestrone

– Antibiotic treatement
• Urinary infection (asymptomatic bacteriuria), local infection (bacterial vaginosis), occult
infection

– Corticotherapy

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 Choice of Tocolytic Drug

1. Beta–Sympathomimetic agents: (Ritodrine, Isoxsuprine,

Terbutaline, Salbutamol)

2. Magnesium sulphate

3. Nonsteroidal anti-inflammatory drugs (Indomethacin)

4. Calcium channel blockers (Nifedipine)

5. Nitric Oxide Donors (Nitroglyerin)

6. Oxytocin receptor antagonist (Atosiban = Tractocile)

45
 …cont…

• Contraindications to tocolytic therapy

• Absolute
• Severe preeclampsia and eclampsia

• Nonreassuring fetal heart rate

• Significant antepartum bleed

• Clinical chorioamnionitis

• Relative contraindications

• Major fetal anomaly

• Mild preeclampsia

• Maternal cardiac disease

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 III. REFERENCES
• Current Diagnosis and Treatment of Obstetrics and
Gynecology 11th ed.

• Gabe Normal and Problems in Pregnancy 7th ed.

• NMS Obstetrics and Gynecology 6th ed.

• Uptodate 21.2

• Williams Obstetrics 24th

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Thank you
48