Premature Rupture Of

Membranes (PROM)

PROM
Definition:
PROM is the Spontaneous rupture of membranes
after 28 weeks of gestation before the onset of labor.
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.

PROM- contd
Incidence: average around 10%, ranges 3-19 %.
Causes: Not known in majority.
Possible causes include:
Increased fragility of membranes
Decreased tensile strength of membranes
Polyhydraminos
Cervical incompetence
Multiple pregnancy
Infection: Chorioamnionitis, UTI, lower genital
tract infection
Emergent circlage

RISK FACTORS
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
Polyhydraminos
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 (ie, time from rupture of membranes to
delivery) and increase the risk of intrauterine infection

Diagnosis-contd

Nitrazine paper test:

testing the pH of the vaginal fluid (color change
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
Perinea Pad wetting
Dye test;a definitive dx in equivocal cases,
Indigo caramine is instilled into the amnotic cavity,
tampoon placed in the vagina inspected after 30 min for
blue staining
Ultrasonography- decreased AF volume

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)
US

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

PROM- Managemet

Management of pregnancies complicated by PROM

depends on
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
Cervical status (by visual, not digital, inspection unless
induction is planned or the woman is in labor)

Indications for pregnancy termination in

PROM

Term PROM
Labor
Presence of infection (chorioamnionitis)
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
Corticosteroids if less than 32 weeks
Administer antibiotics: ampicillin (iv)+ erythromycin X 48hrs
followed by amoxacillin(po) & erythromycin to complete a
total of seven days

Chorioamnionitis
Clinical or subclinical
Criteria for clinical chorioamnionitis:
- Maternal temperature > 38o C
- Uterine tenderness
- Foul smelling amniotic fluid
- High WBC count (leukocytosis)
- Maternal &/ or fetal tachycardia

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
Conservative management Deliver/conservative

GA> 37 weeks
Deliver

THANK

YOU !!!