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Premature Rupture

PREMATURE RUPTURE OF
of
Membranes
MEMBRANES (PROM)
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series

Definisi
Premature rupture of membranes (PROM)
Ketuban pecah/selaput ketuban robek sebelum inpartu/
Partus kala I fase laten

Preterm premature rupture of membranes (PPROM)


PROM < 37-mgg

Incidence
PROM 12% of all pregnancies
PROM 8% term pregnancies
PPROM 30% of preterm deliveries

PROM/PPROM:
Anamnesa
keluar air-air (jumlah, warna, bau)
Air ketuban merembes
Pemeriksaan fisik
Pemeriksaan Spekulum

MinimalisiarVaginal Toucher
Keluar cairan amnion dari osteum uteri eksternum
Mengetahui warna, bau
Mengetahui pembukaan

PROM/PPROM: Diagnosis
Test
Nitrazine test/lakmus
Lakmus merah biru
Lakmus biru biru (pH > 7.1)

USG : jumlah air ketuban


Fern test
(+) : gambaran spt daun
(-)

PROM/PPROM: Diagnosis
False positive Nitrazine test

Alkaline urine
Semen (recent coitus)
Cervical mucus
Blood contamination
Vaginitis (e.g. Trichomonas)

False-Negative Nitrazine test


Tidak ada sisa ketuban di vagina
Air ketuban merembes sedikit

PROM/PPROM: Risk Factors


Risk Factors:

Prior PROM or PPROM


Prior preterm delivery
Multiple gestation
Polyhydramnios
Incompetent cervix
Vaginal/Cervical Infection
Gonorrhea, Chlamydia, GBS, S. Aureus
Antepartum bleeding (threatened abortion)
Smoking
Poor nutrition

Management: PPROM
(< 24 mgg)

Patient counseling
Expectant management vs. induction of labor
GBS prophylaxis NOT recommended
Antibiotics
Incomplete data

Corticosteriods NOT recommended

Management: PPROM

(< 24 wk gestation previable)

Patient counseling
Outcomes at 18 to 22 Months Corrected Age*
Gestational Age
(In Completed
Weeks)

Death Before
NICU Discharge

22 Weeks
23 Weeks
24 Weeks
25 Weeks

95%
74%
44%
24%

Death

Death/ Profound
Neurodevelopmental
Impairment

Death/Moderate to Severe Neurodevelopmental Impairment

95%
74%
44%
25%

98%
84%
57%
38%

99%
91%
72%
54%

Fetal complications of prolonged PPROM

Pulmonary hypoplasia
Skeletal malformations
Fetal growth restriction
IUFD

Maternal complications of prolonged PPROM


Chorioamnionitis
http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/dataShow.cfm

Management: PPROM
(24 33 wk gestation)

Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity

GBS prophylaxis
Antibiotics
Corticosteroids
No consensus, some experts recommend

Management: PROM
(> 34 wk gestation)

Proceed to delivery
Induction of labor

GBS prophylaxis

Management: Rationale
Antibiotics
Prolong latency period
Prophylaxis of GBS in neonate
Prevention of maternal chorioamnionitis and neonatal sepsis

Corticosteroids
Enhance fetal lung maturity
Decrease risk of RDS, IVH, and necrotizing enterocolitis

Tocolytics
Delay delivery to allow administration of corticosteroids
Controversial, randomized trials have shown no pregnancy
prolongation

Management: Drug Regimen


Antibiotics
Ampicillin 2 g IV Q6 x 48 hrs
Amoxicillin 500 mg po TID x 5 days
Azithromycin 1 g po x 1

Corticosteroids
Betamethasone 12 mg IM q24 x 2
Dexamethasone 6 mg IM q12 x 4

Tocolytics
Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs

Management: Amniocentesis
Typically performed after 32 wks
Tests for fetal lung maturity (FLM)
Lecethin/Sphingomyelin ratio (not commonly
used, more for historic interest)
L/S ratio > 2 indicates pulmonary maturity

Phosphatidylglycerol
> 0.5 associated with minimal respiratory distress

Flouresecence polarization (FLM-TDx II)


> 55 mg/g of albumin

Lamellar body count


30,000-40,000

If negative, proceed with expectant


management until 34 wks

Courtesy of Thomas Shipp, MD.

Management: Surveillance
Maternal: Monitor for signs of infection

Temperature
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions

Fetal: Monitor for fetal well-being


Kick counts
Nonstress tests (NSTs)
Biophysical profile (BPP)

Management: Surveillance
Immediate Delivery

Intrauterine infection
Abruptio placenta
Repetitive fetal heart rate decelerations
Cord prolapse

Expectant Management
vs. Preterm Delivery
Expectant Management Risks:
Maternal

Increase in chorioamnionitis
Increase in Cesarean delivery
Spontaneous labor in ~ 90% within 48 hr ROM
Increased risk of placental abruption

Fetal

Increase in RDS
Increase in intraventricular hemorrhage
Increase in neonatal sepsis and subsequent cerebral palsy
Increase in perinatal mortality
Increase in cord prolapse

Expectant Management
vs. Preterm Delivery
Preterm Delivery Risks: use NICHD calculator
http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_ep
bo/epbo_case.cfm

Gestation
(w)

Weight

Sex

Steroids

Survival

Survival w/o
profound ND
impairment

25

550

Female

Yes

64%

50%

24

500

Male

Yes

35%

22%

23

450

Male

Yes

16%

9%

22

401g

Female

No

2%

1%

Bottom Line Concepts


Preterm premature rupture of membranes refers to rupture of fetal
membranes prior to labor in pregnancies < 37 weeks.
A history of PPROM or PROM, genital tract infection, antepartum bleeding,
and smoking are risk factors for PPROM and PROM.
A clinical history suggestive of PPROM or PROM should be confirmed with
visual inspection and laboratory tests including ferning and nitrazine
paper.
Management of PPROM at < 24 wks includes a discussion with the family
reviewing the maternal risks against the fetal risks of significant morbidity
and mortality during expectant management.

For women with PPROM or PROM in whom intrauterine infection,


abruptio placenta, repetitive fetal heart rate decelerations, or a high risk of
cord prolapse is present, immediate delivery is recommended.
Counseling after the delivery for the recurrence risk of PROM should
occur, and modifiable risk factors addressed

References and Resources


APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 25 (p52-53).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),


Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 22 (p213-217).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and


Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 12 (p150-153).