CASE REPORT

Premature Rupture of Membrane

Supervised by:

Mutawakkil J. Paransa, dr., Sp.OG

Presented by:

Kurnianto SM 130110150040
Meilia Nur Chrisandra 130110150246
Muthia Dewi Restuningrum 130110150155

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

RSUD R. SYAMSUDIN, S.H., KOTA SUKABUMI
FACULTY OF MEDICINE
UNIVERSITAS PADJADJARAN
2019
 CHAPTER I
INTRODUCTION

Premature rupture of membrane is defined as rupture of amniotic membrane before

gestasional age of 37 weeks or before the onset of labor begin. It can be classified into
PROM (rupture before onset of labor, gestasional age >37 weeks) and PPROM (rupture
at,gestasional age <37 weeks). PROM occurs for about 10% or all pregnancy, which 70%
of it occurs at term.
There is a wide array of mechanism that cause prelabour rupture of membranes. It can
result from a physiologic weakening of membranes combined with the forces caused by
uterine contraction. Intramniotic infection is commonly associated with PROM. The
major risk factor for PROM include a history of PROM, short cervical length, second or
third trimester vaginal bleeding, uterine overdistension, nutritional deficiencies of copper
and ascorbic acid, connective tissue disorders, low body mass index, low socioeconomic
status, cigarette smoking, and illicit drug use.
A through history should be performed for all patients complaining of leakage of fluid.
This includes a history of present illness, obstetrical history, gynecologic history, medical
history, surgical history, social history and family history. When obtaining the history of
present illness, it is important to inquire about contraction, fetal movement, time of
possible rupture, amount of fluid, color and odor of fluid, vaginal bleeding, pain, recent
sexual encounters, and recent physical activity.
Physical examination should be performed in a way that minimizes the risk of
infection. A sterile speculum examination are performed to observe the cervix for
amniotic fluid leakage - unless there is obvious liquor at the vulva or on a pad. A pH test
can be performed of vaginal fluid. Amniotic fluid typically has a pH of 7.1-7.3, while
normal vaginal secretions have a pH of 4.5-6.0. causes if false positive pH tests include
presence of blood or semen, alkaline antiseptics, or bacterial vaginosis. False-negative
results may occur with prolonged rupture of membranes. There are additional tests that
may aid in the diagnosis. Ultrasound should be performed to evaluate amniotic fluid
index.
 CHAPTER II
CASE REPORT

2.1 PATIENT’S IDENTITY

Name : Mrs. Y.H
Date of Birth / Age : February 3 1993 / 25 years old
rd

Address : Sukabumi
Last Education : High School
Occupation : Housewife
Religion : Moslem
Marital Status : Married
Date of Admission : April 9 (01.21 WIB)
th

2.2 HISTORY TAKING

1. Chief Complaint:
Watery Discharge

2. History of Present Ilness:

Mrs. Y.H, 25 years old, G1P0A0 9 months pregnant complained the presence of
watery discharge at 00.30 WIB. Discharge was clear and odorless. Fever was
negative. Fetal movement can still be felt by the patient. Patient denied any
contraction. History of painful urination and foul-smelling discharge from vagina
were denied by patient.

3. History of Past Ilness

a) History of HbsAg : 12 years old
b) History of Hypertension : denied
c) History of Diabetes Melitus : denied
d) History of Trauma : denied
e) History of Surgery : denied
4. Family History
History of hypertension : denied
History of diabetes melitus : denied

5. Marital History
Married once at 2016, been married for 2 years, when she was 23 old and her
husband was 30 years old.

6. Medication History
There was no medication history

7. Obstetrical History
 Menarche : 12 years old
 Menstrual cycle : normal (28 days), 3 days
 Amount of blood : normal
 First day of last menstruation: July 7th 2018
 Estimated date of delivery : April 14th 2019
 Contraception : (-)
 PNC : 9 times at PHC, 2 times at obstetric and
gynecologic doctor

8. Gestational History

No Helper Gestational Age Labour history Sex Age

1 Current Pregnancy
2.3 GENERAL EXAMINTATION
1. General Condition : Good
2. Consciousness : Compos mentis
3. GCS : Compos mentis
4. Vital Signs
 Blood Pressure : 120/80 mmHg
 Heart Rate : 79 bpm
 Respiratory Rate : 21 x/minute
 Temperature : 36.6o C
5. Nutritional Status
 Weight : 62 kg
 Height : 165 cm
 BMI : 22.8 kg/m 2

2.4 PHYSICAL EXAMINATION

Head : within normal limit
Eyes : within normal limit
Mouth : within normal limit
Neck : within normal limit
Thorax : within normal limit
Abdomen : within normal limit
Extremities : within normal limit

2.5 OBSTETRICAL EXAMINATION

1. External Obstetric Examination
 Inspection : Soft, concave
 Palpation :
His : (-)
Leopold I : breech, Fundal height: 30 cm, TBBA : 2790gr
Leopold II : single fetus, back on the left side, intrauterine
Leopold III : head
 Leopold IV : divergent
 Fetal heart rate : 143-147 x/min

2. Internal obstetric examination :

 Vulva/vagina : no abnormalities
 Portio : thick
 Cervical dilation :0
 Amniotic sac : negative

3. Other examination :
 Nitrazine test : positive (+)
 CTG : baseline 130, variability (+), acceleration (+), decceleration (-)

2.6 Working Diagnosis

G1P0A0 gravida aterm with premature rupture of membrane

2.7 Initial treatment

 Cefotaxime 500 mg 2x1
  Asam mefenamat 500 mg 3x1
 Labor induction with misoprostol 25 mcg intravaginal
 Observation for labor progression
 Inform consent to patient

Observation
01.45 FHR: 130-134 X/min
HIS: (-)
Vaginal Toucher
Vulvovaginal: no abnormalities
Portio: closed
Dilatation: (-)
Amniotic sac (-)
Nitrazine test (+)
08.00 FHR: 140-143 X/min
HIS: (-)
Vaginal Toucher
Vulvovaginal: no abnormalities
Portio: closed
Dilatation: (-)
Amniotic sac (-)
11.00 FHR: 144-148 X/min
HIS: (-)
Vaginal Toucher
Vulvovaginal: no abnormalities
Portio: closed
Dilatation: (-)
Amniotic sac (-)
14.00 FHR: 138-142 X/min
 HIS: (-)
Vaginal Toucher
Vulvovaginal: no abnormalities
Portio: closed
Dilatation: (-)
Amniotic sac (-)
18.00 FHR: 134-138 X/min
HIS: 2x10’x40”
Vaginal Toucher
Portio: 50-60% effaced
Dilataion: 6 cm
Amniotic sac (-)
21.35 FHR: 132-136 X/min
HIS: 4x10’x40”
Vaginal Toucher
Portio: 80-90% effaced
Complete Dilatation
Amniotic sac (-)
Head Presentation
21.36 Guide the patient to strain
21.48 Spontaneous delivery of the baby
APGAR score 7/9/9
Weight: 2960 gram
Height: 47 cm
21.49 Oxytocin injection IM
21.50 Controlled cord traction
21.57 Placenta was delivered, fundal height two finger below umbilicus, strong
contraction, minimal bleeding.
22.00 Perineal suturing grade 1
2.9 Final Diagnosis
P1A0 partus maturus spontan pervaginam with premature rupture of membrane; repair
perineum (grade I)

3.0 Management
 Observation of vital sign and puerperium

3.1 Prognosis
 Ad vitam : Maternal : ad bonam
Fetal : ad bonam
 Ad functionam: Maternal : ad bonam
Fetal : ad bonam
 Ad sanationam : Dubia ad bonam
 CHAPTER III

CASE ANALYSIS

I. Problems
1. What is etiology and predisposing factor in this patient?
2. How to diagnose premature rupture of amnion membrane in this patient?
3. What are the complications?
4. How to manage this patient?

II. Disscussion
Comparison Theory Case
Definition Premature rupture of Patient comes with membrane
membrane is rupture of rupture before the onset of labor
amniotic membrane before with 37 weeks pregnancy
gestasional age of 37 weeks or
before the labor onset begin
Risk factor Maternal Maternal
 intrauterine infection  maternal stress
 maternal stress  passive smoker
 previous PROM
history
 cervical incontinence,
 trauma
 malnutrition
 environmental factors
Fetal
 twin pregnancy
 polyhidroamnion
 macrosomia
Symptoms  Clear and odourless  Clear and odourless vaginal
vaginal discharge discharge
 Foul-smelling vaginal
discharge
 No contraction
Diagnosis Anamnesis
Patient usually comes with Discharge was clear and odorless
clear-odorless/dark color
discharge form birth passage
but denies feeling of uterus
contraction
 Physical examination
HIS : (-) HIS : (-)
Speculum examination : Speculum examination : not
- Watery discharge from performed
OUE
- Pooling on posterior
fornix
Nitrazine tes : (+)
Nitrazine tes : (+)
Differential Urinary incontinence
diagnosis
Management If pregnancy is 26-34 weeks Pregnancy is 40 weeks, patient is
or >34 weeks given active management
- Active management : (misoprostol for labor induction)
pregnancy termination

If pregnancy is 26-34 weeks

- Conservative
management :
hospitalization for 2
days. If maternal and
fetal well-being is
good patient is being
discharge and return if
there are sign of
infection and fetal
distress. PNC is done
once per week
Complication Chorioamnionitis -

1. Definition
Premature rupture of membrane is rupture of amniotic membrane before gestasional age
of 37 weeks (Preterm premature rupture of membrane) or before the labor onset begin

2. Epidemiology
PROM occurs for about 10% or all pregnancy, which 70% of it occurs at term.

3. Risk factor
Several risk factor identified
 Maternal factor : intrauterine infection, maternal stress, previous PROM
history, cervical incontinence, trauma, malnutrition
  Fetal factor : overdistended amniotic membrane (twin pregnancy and
polyhidroamnion)

4. Diagnosis
 History Taking
There is the presence of watery discharge from birth passage, clear, or may be dark-
colored (meconium)
 Physical Exam
First palpation of the abdomen to confirm the fetal lie, presentation, size and presence
of uterine contraction. After that, sterile speculum examination are performed to
observe the cervix for amniotic fluid leakage - unless there is obvious liquor at the
vulva or on a pad. A high vaginal swab is taken to run nitrazine test and to check for
infection or amniotic fluid aspirated and sent for microscopy and culture. Ultrasound
scan to measure the amniotic fluid index and a check for the presence of fluid below
the presenting part will refute the diagnosis.

5. Complication
 Maternal :
Chorioamnionitis, if sign of fever >38 C and two of the following signs : maternal
tachycardia, fetal tachycardia, tenderness on uterus, maternal leukocytosis and foul-
smelling amniotic fluid; Placenta abruption
 Fetal :
Death, due to chorioamnionitis and respiratory distress syndrome in preterm fetus

6. Management
 CHAPTER IV
CONCLUSION

During prenatal care visit, mother needs to be informed about PROM to help her
identify the occurrence of PROM, thus shorten duration of subsequent visit to evaluate
mother and fetus well-beingness. This aids to prevent unfavourable outcome for the two.
The diagnosis can be made based on history taking, physical examination and additional
examination such as nitrazine test. Management of PROM, active and conservative, will
be based on gestational age and fetal and mother well-beingness.
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