PROM

Definitions
Premature rupture of the
membranes (PROM) is usually
defined as rupture at any time
before the onset of contractions.
Term PROM is rupture of
membranes after 37wks & before
onset of contractions.
Definitions(cont’d)
Pre term PROM is rupture of
membranes before 37wks of
gestational age.
Prolonged PROM is rupture of
membranes for >12hrs.
CLASSIFICATION
Term PROM: is rupture of
membranes after 37 completed
weeks of gestation.
Preterm PROM:is rupture of
membranes before 37 completed
weeks of gestation
Incidence
Five to 10% of all deliveries.

PPROM occurs in approximately

1% of all pregnancies.

PROM is the clinically recognized

precipitating cause of about one
third of all preterm births.
Fetal membranes
Made of thin inner layer that
covers amniotic cavity called
amnion.
Outer layer ,thicker that apposes
the decidua called chorion.
Both fuse together at 14weeks.
Fetal membranes rupture

metalloproteinases

TIMP
 Etiology
• Connective tissue disorders
• Urogenital tract infection,
• Low socioeconomic status,
• Uterine over-distention(multifetal gestation, polyhydramnios).
Second- and third-trimester bleeding.
• Low body mass index
• Nutritional deficiencies
• Maternal cigarette smoking,
• Cervical conization or cerclage,
• Pulmonary disease in pregnancy
• Previous history of preterm PROM, preterm labor
Clinical manifestation &
Dx
Hx:The classic clinical presentation of
PPROM is a sudden "gush" of clear or
pale yellow fluid from the vagina.

:Many women describe intermittent or

constant leaking of small amounts of
fluid or just a sensation of wetness
within the vagina or on the perineum.
Diagnosis
Physical examination — The best method
of confirming the diagnosis of PPROM is
direct observation of amniotic fluid
coming out of the cervical canal or
pooling in the vaginal fornix.
If amniotic fluid is not immediately visible,
the woman can be asked to push on her
fundus, Valsalva, or cough to provoke
leakage of amniotic fluid from the cervical
os.
Digital examination should be
avoided because it may decrease the
latency period (ie,
time from rupture of membranes to
delivery) and increase the risk of
chorioamnionitis.
If PROM is not obvious after visual
inspection, examine the fluid for ferning
or PH.
Diagnosis…
Nitrazine test — If PROM is not
obvious after visual inspection, the
diagnosis can be confirmed by
testing the pH of the vaginal fluid,
which is easily accomplished with
nitrazine paper. Amniotic fluid
usually has a pH range of 7.0 to 7.3
compared to the normally acidic
vaginal pH of 3.8 to 4.2.
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, in contrast to the thick and wide
arborization pattern of dried cervical
mucus. Well-estrogenized cervical mucus
or a fingerprint on the microscope slide
may cause a false-positive fern test .
Ultrasound
Ultrasound examination may be of
value in the diagnosis of PPROM. Fifty to
70 percent of women with PPROM have
low amniotic fluid volume on initial
sonography .
A mild reduction of amniotic fluid
volume may have many etiologies.
combined with a characteristic history,
is highly suggestive of PROM.
Instillation of Indigo
carmine
In equivocal cases, instillation of indigo
carmine into the amniotic cavity can be
considered and usually leads to a definitive
diagnosis.
Under ultrasound guidance, 1 mL of indigo
carmine in 9 mL of sterile saline is injected
transabdominally into the amniotic fluid and
a tampon is placed in the vagina.
One-half hour later, the tampon is removed
and examined for blue staining, which
indicates leakage of amniotic fluid.
AmniSure
AmniSure — AmniSure is a rapid
slide test that uses
immunochromatographic methods
to detect trace amounts of
placental alpha microglobulin-1
protein in vaginal fluid.
The test is done by the provider at
the point of care using a kit.
Complications
Maternal Fetal
Endomyometritis Chorioamnionitis
Neonatal sepsis
Sepsis
Pulmonaryhypoplasia
PPH
Cord prolapse
APH Limb deformity
Wound infection
Cesarean delivery
Resealing
Up to 14 percent of gravidas with
spontaneous midtrimester PPROM
eventually stop leaking amniotic fluid,
presumably due to "resealing" of the fetal
membrane.
Cessation of leakage is probably not due
to actual repair and regeneration of the
membranes, but rather to changes in the
decidua and myometrium that block
further leakage .
Mx of TERM PROM
Labor is induced, unless there are
contraindications to labor or vaginal
delivery, in which case cesarean delivery is
performed.

Most women with term PROM who are

followed expectantly will go into
spontaneous labor and deliver within 24,
48, and 72 hours of PROM in 70, 85, and 95
percent of women, respectively .
Mx of PPROM
Gestational age
Availability of neonatal intensive care
Presence or absence of maternal/fetal
infection
Presence or absence of labor
Fetal presentation (Breech and transverse
lies are unstable and may increase the risk
for cord prolapse)
Fetal heart rate (FHR) tracing pattern
Likelihood of fetal lung maturity
Maternal surveillance
All women with PPROM should be
monitored for signs of infection.
At a minimum, routine clinical
parameters (eg, maternal
temperature, uterine tenderness
and contractions, maternal and
fetal heart rate) should be
monitored.
Maternal…
Chorioamnionitis is diagnosed if >or
2 criteria:
Fever
Abdominal tenderness
Offensive Vx discharge
Fetal tachycardia mater
tachycardia
Leukocytosis
Fetal surveillance
Fetal surveillance
Kick counts
Non stress tests
Biophysical profile [BPP]) .
Antenatal steroids
Dexamethasone 6mg bd ;04 doses
Bethametasone 12mg daily;02doses
Decreases
IVH
NEC
RDS
Neonatal mortality
Antibiotics
Goal:
Decrease maternal infection
>> fetal infection
Prolong latency(onset of labor)
Ampicillin IV for 48hrs,Amoxicillin po
7d.
Erythromycin IV for 48hrs,Eryth IV
7d.
Termination Of pregnancy
If chorioamnionitis develop any
time.
Mode of delivery
Based on obstetric indications.
DEFINITION
Preterm labor is defined as the presence of
uterine contractions of sufficient frequency and
intensity to effect progressive effacement and
dilation of the cervix prior to 37 weeks of
gestation.
CLASIFICATION
Early preterm: 28–32 completed
weeks
Moderate preterm: 32 plus 1 day
to 33weeks plus 6 days
Late preterm: 34 completed weeks
–36 weeks plus 6 days
Significance
PTB is by far the leading cause of
infant mortality .
PTB is also a major determinant of
short- and long-term morbidity in
infants and children.
RDS, IVH, Broncho pulmonary dysplasia
(BPD), PDA, necrotizing enterocolitis
(NEC), sepsis, apnea, and retinopathy
of prematurity are some of morbidities.
Long term disabilities
cerebral palsy
Vision & hearing impairment
Chronic lung disease
reduced motor performance
academic difficulties
attention deficit disorders
Survival increased
Increase in survival due to
corticosteroids
mechanical ventilation
exogenous surfactant
However, the reduction in mortality
has not been accompanied by a
reduction in neonatal morbidity or
long-term handicaps.
50% of all major neurologic handicaps
in children result from premature
births.
RISK FACTORS
Socio-demographic conditions:
low socioeconomic status, extremes
of maternal age,
unsupported/unwanted pregnancy,
smoking, alcohol consumption,
excess physical work/activity.
Medical conditions: UTI, malaria,
HIV,syphilis,bacterialvaginosis,DM,HT
N, anemia, asthma, thyroid diseases,
obesity, under nutrition, depression
or death of loved one or intimate
partner violence.
Gynaecologic conditions: congenital uterine
anomalies, cervical insufficiency,
intramural/submucus myoma, uterine synechiae,
other pelvic masses.
Obstetric conditions: previous history, family
history, multifetal gestation, short inter pregnancy
interval (< 6 months), polyhydramnios, fetal
macrosomia, fetal malformations, poor
ANC,placental abruption and early vaginal
bleeding during the index pregnancy,
amniocentesis, ECV,cervical procedures during
pregnancy.
pathogenesis
Approximately 70 to 80 percent of
PTBs occur spontaneously.
*4o-50% are due to PTL.
*20-30% are due to PPROM
The remaining 20 to 30 percent of
PTBs are due to intervention for
maternal or fetal problems
pathogenesis
The four primary processes are:
• Activation of the maternal or fetal
hypothalamic-pituitary-adrenal
axis
• Infection
• Decidual hemorrhage
• Pathological uterine distention
Pathogenesis…
Activation of maternal/fetal
hypothalamic-pituitary-adrenal
Maternal depression or
stressCRH
Fetal stress due to placental
vasculopathyACTHDHEAestro
gen
Pathogenesis…
InfectionInterleukensPGs
DecidualhemorrhageProteasesPPROM
Uterine overdistension
Formation of gap junctions
Up regulate oxytocin receptors
Increase PG receptors
Activate MLCK
DIAGNOSIS
Symptoms:
Presence of one or more of the
following Symptoms
• Abdominal cramps and back pain
• Pelvic or lower abdominal pressure
• Changes in type and amount of
vaginal discharge (such as mucus,
bloody or leakage of watery fluid).
Signs:
Four uterine contractions per 20 minutes or
eight contractions per 60 minutes which are
accompanied by one of the following:
• PROM
• cervical dilation greater than 2 cm
• effacement exceeding 80%
• change in cervical dilation or effacement
detected by serial examinations.
INVESTIGATIONS
• WBC with differential count
• Urine analysis/culture and
sensitivity
• Ultrasound (biophysical profile,
fetal weight estimation)
TREATMENT
Treatment depends on gestational age,
estimated fetal weight, presence of
absence of contraindications for tocolytics.
Preterm labor should be managed in a
setup where there is best possible
neonatal care of the preterm newborn.
Hence, in-utero transfer should be
considered whenever possible.
Management of preterm labour
includes:

Bed rest
Corticosteroids
Tocolytics
Neuroprotection
Antibiotics
LABOR AND DELIVERY
•Routine caesarean birth is not
recommended
• Avoid vacuum-assisted birth for
pregnancies less than 34 weeks of
gestation
• Prepare for management of preterm
or low birth weight baby and anticipate
the need for resuscitation.
PREVENTION
Secondary prevention of preterm
birth
Identification and management of
pregnant mothers who are at a risk of
preterm labour.
Cerclage
Progesterone compounds
Thank you