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1. PRELABOUR RUPTURE OF
MEMBRANES
(PROM)
Sunil Kumar Daha

2. The spontaneous rupture of the fetal
membranes any time beyond the 28th week of
pregnancy but before the onset of labor.
* After 37th wks - Term PROM
* before 37 wks - Preterm PROM
Rupture of membranes for > 24 hours before
delivery is called prolonged rupture of
membranes
American college of Obstetricians and Gynaecologists

3. 5-10% of all deliveries (8% at term and 2% preterm)
PROM at term
*Unfavorable Cervix - the majority of women labour
spontaneously within 12 hours
*50 % will be in labour after 12 hours
*86 % will be in labour within 24 hours
*94 % will be in labour within 48 – 95 hours
*6 % of women will not start labour within 96 hours of PROM
 Preterm PROM complicates 2% to 20% of all deliveries and
is associated with 18% to 20% of perinatal deaths.
South Australian Perinatal Practice Guideline

4.  Intrauterine Infections ( UTI, chorioamnionitis, lower
genital tract infections) – Major predisposing factor
 Low socioeconomic status
 Body mass index ≤ 19.8
 Nutritional deficiencies
 Cigarette smoking
 History of previous PROM or PPROM
 Polyhydramnios
 Multiple pregnancy : Nearly 40% of twin pregnancy will
have PROM or PPROM
 Cervical incompetence

5. Rupture of the membrane near the end of pregnancy
(Term) may be caused by the natural weakening of the
membrane or by the force of uterine contraction .
PPROM is often due to an infection in the uterus.
Reduced tensile strength
Increased friability
Resealing
*14% midtrimester PROM eventually stop leaking presumably
due to “resealing” of fetal membrane
*Cessation is probably not due to actual repair and
regeneration of membranes but rather to changes in the
decidua and myometrium that block further leakage

6. History
* The only subjective symptom is escape of watery
discharge per vagina either in the form of a gush or
slow leak
Examination
1.Speculum examination
Upon sterile speculum examination, ruptured membranes are
diagnosed if
* Amniotic fluid pools in the posterior fornix
* If clear fluid flows from the cervical canal
(If the fluid is not immediately visible, the woman can be asked
to cough to provoke leakage)

7. 2. NITRAZINE TEST
*The pH of vaginal secretions normally ranges from
4.5 to 5.5, whereas that of amnionic fluid is usually
7.0 to 7.5
*The indicator nitrazine paper is used to identify
ruptured membranes
*Test papers are impregnated with the dye, and the
color of the reaction between these paper strips
and vaginal fluids is interpreted by comparison with
a standard color chart
*Nitrazine paper turns from yellow to blue at pH > 6

8. 3.FERNING PATTERN
*Microscopic ferning of the amniotic fluid on
drying.
*Amniotic fluid crystallizes to
form a fernlike pattern due
to its relative concentrations
of sodium chloride, proteins,
and carbohydrates
4. Nile blue test
Centrifuged cells stained with 0.1% Nile blue
sulphate- Orange blue coloration of the cells

9. *Other Tests
1. Ultrasound: fluid levels are low
2. Immune-chromatological tests (AmniSure, Actim
PROM test): These are commercially available
test kits that detect chemicals present in
amniotic fluid.False-positive rate is 19-30%.
3. Indigo carmine dye test: A needle is used to
inject indigo carmine dye (blue) into the amniotic
fluid. In the case of PROM, blue dye can be seen
on a stained tampon or pad after about 15–30
minutes. This method can be used to definitively
make a diagnosis, but is rarely done because it is
invasive and increases risk of infection.

10. Investigations
1. Full blood count
2. Urine for routine analysis and culture
3. High vaginal swab for culture
4. Vaginal pool for estimation of phosphatidyl
glycerol and L: S ratio
5. Ultrasonography for fetal biophysical profile
6. Cardiotocography for nonstress test

11. Complications
IMMEDIATE RISK
 cord prolapse,
 cord compression and
 placental abruption.
DELAYED RISK
Dry Labour
High Caesarean section rate
Clinical chorioamnionitis
Intrapartum fever*
Postpartum fever*
Antibiotics before/during labour*
Fetal Pulmonary hypoplasia
Neonatal sepsis
RDS
Intraventricular Haemorrhage
Necrotising enterocolitis
Increased NICU stay*
 High Perinatal morbidity (CP)
*Chorioamniotis is diagnosed
if
Fever
Uterine tenderness
Offensive vaginal discharge
Fetal or Maternal Tachycardia
Leucocytosis (>15*10^9/L)
C Reactive protein >40

12. Management
1. Gestational Age
2. Presence/Absence of labor
3. Fetal presentation(Breech and transverse lies are
unstable and may increase risk of cord prolapse)
4. FHR tracing pattern
5. Presence or absence of maternal/fetal infections
6. Fetal lung Maturity
7. Availability of neonatal intensive care

14. Erythromycin should be given for 10days following the
diagnosis of PPROM.
• Statistically significant reduction in chorioamnionitis
• Reduction in the number of babies born within 48hrs and 7
days
• Reduced neonatal infections
• Delays the delivery thereby allowing sufficient time for
prophylactic prenatal corticosteroids to take effect.
Antenatal corticosteroids
•Indicated in women with PPROM between 24 and 34
weeks of gestation
•Betamethasone 12 mg given intramuscularly in two
doses or dexamethasone 6 mg given intramuscularly
in four doses are the steroids of choice to enhance
lung maturation.

15. Delivery
•34 weeks of gestation
•expectant management >34 weeks –
increased risk of chorioamnionitis and
decreased risk of respiratory problems in
neonate.
Green top Guideline No. 44 (october 2010)

17. Active Management
Labour does not establish after a latent period of 4
hours - an oxytocin infusion should be started but in
an unfavorable cervix, prostaglandins may have an
important role.
Regardless of any clinical factors, women at term
who have rupture of the membranes for >18 to 24
hours should commence parenteral antibiotic cover
Woman known to have vaginal GBS colonization,
Intrapartum antibiotic prophylaxis and early
induction of labour is recommended.

18. PROM > 18 to 24 hours
*Parenteral antibiotic cover for GBS is required in all cases
(irrespective of GBS status) of PROM > 18 to 24
*Give benzyl penicillin 3 g IV loading dose, then 1.2 g IV
every 4 hours until delivery
*If allergic to penicillin, clindamycin 600 mg IV in 50 – 100 mL
over at least 20 minutes every 8 hours

19. Criteria
• Term PROM with fixed cephalic presentation
• Group B streptococcus (GBS) negative
• No signs of infections
• Normal CTG
• No history of digital vaginal examination, cervical suture
• Adequate resource/ staffing to provide support as an outpatient or
inpatient
• Commitment to 4 hourly maternal temperature, evaluation of
vaginal loss and assessment of fetal well being.
Carefully selected to ensure they not only meet the criteria but also
live close to the hospital, have adequate support at home and
dependable transport.

20. Check for any other site of infection (e.g. urinary or
respiratory tract) which could cause these changes
If chorioamnionitis is confirmed, delivery of the fetus is
indicated
Commence ampicillin (or amoxicillin) 2 g IV initial dose
then 1g IV every 6 hours, gentamicin 5 mg / kg IV daily,
metronidazole 500 mg IV every 12 hours
If allergic to penicillin, give clindamycin 600 mg IV every 8
hours and gentamicin 5 mg / kg IV daily

21. •Green top guidelines of Royal college of obstetrician and
gynaecologists- No 44 October, 2010
• Term PROM :Royal Australian and new Zealand college of
obstetricians and gynaecologists, C obs -36. March 2014
•South Australian Perinatal Practice Guideline. September
2015
•Preterm labour, Williams obstetrics 24th edition
•L Alabi Isama & A Ugwumadu. Preterm Birth. Aria’s
Practical guide to high risk pregnancy and delivery 4th
edition, 2015, 135-140
•H Konar. Preterm labour, Preterm rupture of
membranes,postmaturity, IUD of fetus.DC Dutta’s textbook
of obstetrics. 7th edition. Nov 2013: 314-326.