PROM

1. PREMATURE RUPTURE
OF MEMBRANES
PRESENTER-DR.DIVYA JAIN
MODERATOR-DR.M.SHARMA

2. DEFINITIONS
Premature rupture of membranes (PROM)
Rupture of membranes anytime after 37weeks but before
the onset of spontaneous uterine activity.
Preterm premature rupture of membranes (PPROM)-
Rupture of fetal membranes prior to labor in pregnancies
betweem 28 - 37 weeks.

3. INCIDENCE
• PROM-10%
• PPROM-3%

4. RISK FACTORS
• PRE-CONCEPTIONAL CAUSES-
1. Repeated genitourinary infections
2. Cervical incompetence
3. Chronic cervicitis
4. Obesity
5. Smoking
6. Low socioeconomic status
7. Nutritional deficiencies

5. • PREGNANCY RELATED CAUSES-
1. Polyhydroamnios
2. Multiple gestation
3. Cervical cerclage
4. Foetal abnormalities
5. Abruption
6. Previous history of PPROM(21 to 30%)

6. • Genital tract infections-
1. Bacterial vaginosis
2. Group B streptococcus
3. Candida
4. Mycoplasma
5. Ureaplasma hominis
6. E.coli
7. Staphylococcus

7. WHAT CAUSES RUPTURE OF
MEMBRANES??
• Rupture of the membranes near the end of pregnancy
(term) may be caused by a natural weakening of the
membranes or from the force of contractions.

8. DIAGNOSIS
• History
• Valsava maneuver
• Sterile Speculum exam (Pooling)
• Nitrazine testing/litmus paper test
• Fetal Fibronectin
• Ultrasonography
• Microscopic Fern testing
• Amnisure
• High vaginal swab
• Urine routine,culture

9. Nitrazine paper testing
• Turns blue in presence of alkaline Amniotic fluid
• 93.3% sensitivity
• False positive (1-17%)
for urine, blood, semen BV

10. Fern test
• Fern test refers to visualization of a characteristic 'fern-
like' pattern on a slide viewed under low power on a
microscope
• A small amount of cervical mucus is allowed to air-dry on
a clean, saline-free glass slide
• If positive for amniotic fluid, this crystal formation will be
present in most microscopic fields.

12. Foetal fibronectin assay
• fFN present in cervical secretions <22 wks, >34 wks
• Used for assessment of potential PTB
• Positive result (>50 ng/dl) may be indicative of PROM and
represents disruption of decidua-chorionic interface
• In PPROM, Sensitivity-98.2%

14. Ultrasonography
• 50-70% of women with PROM have low amniotic fluid on
USG
• Mild reduction requires further investigation
• Rule out other causes (Renal agenesis, obstructive
uropathy)

15. Amnisure
• Detects PAMG-1(placental microglobulin)
• 99% sensitivity,100%specificity
• PAMG-1 is a protein produced by cells of decidual part of
placenta and can be detected in amniotic fluid after
rupture of membranes.
• Recently approved by FDA in US

17. MANAGMENT
• MANAGEMENT DEPENDS ON THE FOLLOWING
FACTORS
1. Gestational age
2. Availability of NICU
3. Fetal presentation
4. FHR pattern
5. Active distress (maternal/fetal)
6. Cervical assessment

18. l-

19. • Maternal-Fetal Distress evaluated by Maternal vitals, labs,
general condition,
• Fetal distress assessed by FHR pattern, USG, NST.
• First priority is to rule out maternal-fetal distress and
imminent delivery.
• Ensure through prenatal records that early US correlate
with LMP is most accurate.
• Rule out infection through absence of clinical signs and
symptoms of chorionamniotis in addition to assessment of
lab values and amniotic fluid samples
• Evaluate maternal serum lab values for leukocytosis, left
shift, and elevated C-Reactive Protein. Evaluate Amniotic
fluid samples for gram stain,WBC count.

20. g

21. SECONDARY ASSESSMENT
• Fetal position
• Cervical assessment
• Determine lung maturity
• Quantify amniotic fluid

22. INDICATIONS FOR DELIVERY
• Maternal-Fetal Distress
• Infection
• Abruption
• Cord Prolapse

23. EXPECTANT MANAGMENT
• Typical for GA 32 weeks or less
• Bed rest
• Steroids for lung maturity
• Tocolytic if indicated for lung maturity
• Antibiotics
• Fetal Surveillance
• Assess for Chorioamnionitis

24. • Infection can be both a cause and a consequence of
Preterm Rupture of Membranes.
• Most patients require close inpatient observation.Those
who might qualify for outpatient management include the
extreme previable gestation patients and those who have
appeared to have resealed (which is approximately about
5% of PROM patients).

25. PPROM BETWEEN 32 TO 34 WEEKS
• Expectant management
• Deliver at 34 wks
(Unless documented fetal lung maturity)
• GBS prophylaxis
• Antibiotics
• Corticosteroids

27. MANAGEMENT RATIONALE
• Antibiotics
1. Prolong latency period
2. Prophylaxis of GBS in neonate
3. Prevention of maternal chorioamnionitis and neonatal
sepsis
• Corticosteroids
1. Enhance fetal lung maturity
2. Decrease risk of RDS, IVH, and necrotizing
enterocolitis
• Tocolytics
1. Delay delivery to allow administration of corticosteroids

28. • Antibiotics
1. Ampicillin 2 g IV 6 hrly for 2 days
2. Amoxicillin 500 mg po TDS x 5 days
3. Azithromycin 1 g po x 1
4. Erythromycin 250mg TDS for 5 days
• Corticosteroids
1. Betamethasone 12 mg IM OD for 2 days
2. Dexamethasone 6 mg IM BD for 2 days
• Tocolytics
1. Nifedipine 10 mg po after every 20min 3 times, then 6
hrly for 2 days

29. RISK-BENEFIT EXPECTANT
MANAGMENT
RISKS
• Abruption
• Chorioamnionitis
• Cord Prolapse
• Endometritis (1/3)
• Oligohydroamnios
tetrad (FLIP)
BENEFITS
• Mature lung profile
• Advancing GA
(reducing risks
associated with PTB)