Dr yonas G
Prelabor rupture of membranes
(PROM)
PROM
Definition:
Previously known as premature rupture of membranes
PROM is the Spontaneous premature rupture of membranes
after 28 weeks of gestation and before the onset of labor.(at
least one hr)
Occurs in ~ 10% of pregnancies
Term PROM: after 37 weeks
Preterm PROM: Before 37 weeks
Latency period: time between rupture of membranes to
onset of labor.
Prolonged PROM: latency longer than 12 hrs.
RISK FACTORS
Incidence: average around 10%, ranges 3-19 %.
The pathogenesis of PPROM is not completely
understood.
It shows association with
A history of PPROM in a previous pregnancy,
Genital tract infection,
APH
Cigarette smoking
Low socioeconomic status
Polyhydramnios
Cervical incompetence
Multiple pregnancy
Emergency circlage
PROM- Dx
Diagnosis is generally clinical
History:
a sudden "gush" of clear or pale yellow fluid from the vagina.
Intermittent or constant leaking of small amounts of fluid or
just a sensation of wetness within the vagina or on the perineum
Physical findings:
Negative uterine size discrepancy
Meconium or vernix on the vulva
Sterile speculum examination with or without valsalva
maneuver( leakage or pooling)
direct observation of amniotic fluid coming out of the cervical canal or
pooling in the vaginal fornix
NB
Digital examination should be avoided unless induction is
planned or the woman is in labor because it may decrease the
latency period (i.e., time from rupture of membranes to
delivery) and increase the risk of intrauterine infection
Diagnosis-cont’d
• Nitrazine paper test:….
– Testing the pH of the vaginal fluid (color change to blue
– Amniotic Fluid- alkaline (PH~7.3)
– False positive result alkaline fluids in the vagina Eg blood, semen,
bacterial vaginosis, and trichomoniasis
Ferning Test :arborization (ferning).
– Fluid from the posterior vaginal fornix is swabbed onto a glass slide and
allowed to dry for at least 10 minutes.
– Amniotic fluid produces a delicate ferning pattern ( High Na+ and
protein contents)
Pad Test Perineal pad wetting
Dye test -a definitive dx in equivocal cases,
-1 mL of indigo carmine dye in 9 mL of sterile saline
– Tampoon placed in the vagina inspected after 30 min for blue staining
Ultrasonography- decreased AF volume
PAMG-1 (AmniSure) Rapid slide test that uses
immunochromatography methods to detect trace amounts of
placental alpha microglobulin-1 protein in vaginal fluid.
- not affected by semen or trace amounts of blood
Ferning Pattern
PROM- Differential diagnosis
Stress Urinary incontinence
Vaginal discharge (Leucorrhea gravidarum or
pathological)
Perspiration
PROM- investigations
CBC
U/A, Culture & Sensitivity
High vaginal swab for culture
Phosphatidylglycerol from vaginal pool (for fetal lung
maturity)
Complications of PROM
Preterm Labor
In Preterm PROM, labor starts in 70-80% of cases in one week
time
Ascending infection: one third
Increased incidence of cord prolapse
Fetal pulmonary hypoplasia
Prematurity
Operative delivery
Abruption
facial deformation, and orthopedic abnormalities esp at early GA
PROM- Management
Management of pregnancies complicated by PROM
depends on
Fetal conditions
Gestational age
Fetal presentation (breech and transverse lies are unstable and may
increase the risk for cord prolapse)
Likelihood of fetal lung maturity
Availability of neonatal intensive care
Fetal heart rate (FHR) tracing pattern
Cervical condition
Cervical status (by visual, not digital, inspection unless induction is
planned or the woman is in labor)
Presence or absence of maternal/fetal infection
Presence or absence of labor
Indications for pregnancy termination in
PROM
Cessation of fluid leakage is rare, except in women with
PPROM related to amniocentesis
Term PROM
Labor
Presence of infection (chorio amnionitis)
IUFD
Congenital anomalies of fetus incompatible to life
Abnormal fetal surveillance
Preterm PROM
GA > 34 weeks either conservative management or
termination
GA< 34 weeks, conservative management
Components of conservative management:
– Avoid digital vaginal examination
– Bed rest
– Monitor maternal PR, Temp., FHR every 4 hours
– CBC, U/A, ESR/CRP twice per week
– BPP/NST twice per week
– Administer antibiotics: ampicillin (iv)+ erythromycin X 48hrs
followed by amoxicillin (po) & erythromycin to complete a
total of seven days.
–
Drug regimen
A regimen with reasonable activity against the major
pelvic pathogens should be used for prophylaxis, but the
optimal regimen is unclea
Up todate preference:
●Azithromycin one gram orally upon admission, PLUS
Ureaplasmas, Chlamydia trachomatis
●Ampicillin 2 g intravenously every 6 hours for 48 hours,
FOLLOWED BY Amoxicillin 500 mg orally three times
daily or 875 mg orally twice daily for an additional five days
-group B Streptococcus (GBS),
-many aerobic gram-negative bacilli, and some anaerobes
Corticosteroids
if 23 and 34 weeks of gestation
duration of neonatal respiratory support were significantly
reduced by antenatal glucocorticoid treatment
Neonatal death,
respiratory distress syndrome,
intraventricular hemorrhage (IVH),
necrotizing enterocolitis (NEC), and
Does not increase either maternal or neonatal infection
Mean risk reduction for these adverse events ranged from 30
to 60 percent
TIMING BEFORE DELIVERY — 2-7 days after
administration of the first dose of antenatal corticosteroids.
Efficacy is incomplete <24 hours from administration and appears to
decline after 7 days
Chorioamnionitis
Clinical or subclinical
Criteria for clinical chorioamnionitis:
- Maternal temperature > 38o C
- Maternal &/ or fetal tachycardia
- Uterine tenderness
- Foul smelling amniotic fluid
- High WBC count
Sub clinical chorioamnionitis
Amniocentesis: intramniotic infection is present if:
1. Culture: bacterial colony count > 102 / ml fluid
2. Presence of bacteria on gram stain
3. Glucose level<15 mg/dl
4. WBC> 100/ml
Management of chorioamnionitis
Antibiotics:
1. Ampicillin+ Gentamycin+
clindamycin/metronidazole/chloramphenicol
2. Ceftriaxone +/- metronidazole
Terminate pregnancy: Vaginal route is preferred
PROM
( uncomplicated)
GA< 34 weeks
GA 34-37 weeks GA> 37 weeks
Conservative
Deliver/conservative Deliver
management
Thank you !!!
