Pre-labor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor. Women usually experience a painless gush or a steady leakage of fluid from the vagina. If it occurs before 37 weeks it is known as PPROM (‘preterm’ prelabour rupture of membranes) otherwise it is known as term PROM.

1. PREMATU
RE
RUPTURE
OF
MEMBRAN
ES
DEEPA MISHRA
Assistant Professor (OBG)

2. INTRODUCTION
 Pre-labor rupture of membranes (PROM),
previously known as premature rupture of
membranes, is breakage of the amniotic sac
before the onset of labor.
 Women usually experience a painless gush or a
steady leakage of fluid from the vagina.
 If it occurs before 37 weeks it is known as
PPROM (‘preterm’ prelabour rupture of
membranes) otherwise it is known as term
PROM.

4. DEFINITION
 Spontaneous rupture of membranes
any time beyond 28th week of
pregnancy but before the onset of
labour is known as pre-mature (pre-
labour) rupture of membranes.
 Pre-labor rupture of membranes
(PROM), previously known as
premature rupture of membranes, is
breakage of the amniotic sac before
the onset of labor.

5. INCIDENCE
 About 8% of term pregnancies are
complicated by PROM
 30% of preterm births are
complicated by PROM.
 Before 24 weeks PROM occurs in
fewer than 1% of pregnancies.

6. TYPES
• when the fetal membranes rupture early, at least one hour before labor
has started.
Term PROM
• a case of prelabor rupture of membranes in which more than 18 hours has
passed between the rupture and the onset of labor.
PROLONGED PROM
• prelabor rupture of membranes that occurs before 37 weeks gestation.
PRETERM PROM
• prelabor rupture of membranes that occurs before 24 weeks' gestation.
Before this age, the fetus cannot survive outside of the mother's womb.
MIDTRIMESTER PROM

7. Risk Factors Of PROM
•Infections: urinary tract infection, sexually transmitted diseases,
lower genital tract infections (e.g. bacterial vaginosis)
•Tobacco use during pregnancy
•Illicit drug use during pregnancy
•Having had PROM or preterm delivery in previous pregnancies
•Polyhydramnios: too much amniotic fluid
•Multiple gestation: being pregnant with two or more fetuses at one
time
•Having had episodes of bleeding anytime during the pregnancy[
•Invasive procedures (e.g. amniocentesis)
•Nutritional deficits
•Cervical insufficiency: having a short or prematurely dilated cervix
during pregnancy
•Low socioeconomic status
•Being underweight

8. PATHOPHYSIOLOGY
This weakening is a normal process that typically happens at term as the body prepares for
labor and delivery.
this can be a problem when it occurs before 37 weeks (preterm)
The natural weakening of fetal membranes is thought to be due to one or a combination of
the following
In PROM, these processes are activated too early
Cell death: when cells undergo programmed cell death, they release biochemical markers
that are detected in higher concentrations in cases of PPROM.
Poor assembly of collagen: collagen is a molecule that gives fetal membranes, as well as
other parts of the human body such as the skin, their strength. In cases of PPROM, proteins
that bind and cross-link collagen to increase its tensile strength are altered
Breakdown of collagen: collagen is broken down by enzymes called matrix
metalloproteinases (MMPs), which are found at higher levels in PPROM amniotic fluid
This breakdown results in prostaglandin production which stimulates uterine contractions
and cervical ripening.

9. PATHOPHYSIOLOGY
• Infection
• Infection and inflammation likely explains why membranes
break earlier than they are supposed to.
• bacteria have been found in the amniotic fluid from about
one-third of cases of PROM.
• Often, testing of the amniotic fluid is normal, but a
subclinical infection (too small to detect) or infection of
maternal tissues adjacent to the amniotic fluid, may still be a
contributing factor.
• In response to infection, the resultant infection and release
of chemicals (cytokines) subsequently weakens the fetal
membranes and put them at risk for rupture.
• PROM is also a risk factor in the development of neonatal
infections.
• Genetics
• Many genes play a role in inflammation and collagen
production, therefore inherited genes may play a role in
predisposing a person to PROM

11. HISTORY
STERILE SPECULUM
EXAM
POOLING TEST
NITRAZINE TEST
FERN TEST
ALPHA FETOPROTEIN
BLOOD TEST
DIAGNOSIS

12. 1. History: a person with PROM typically recalls a sudden "gush" of
fluid loss from the vagina, or steady loss of small amounts of fluid.
2. Sterile speculum exam: a clinician will insert a sterile speculum
into the vagina in order to see inside and perform the following
evaluations. Digital cervical exams, in which gloved fingers are
inserted into the vagina to measure the cervix, are avoided until the
women is in active labor to reduce the risk of infection.
• Pooling test: Pooling is when a collection of amniotic fluid can
be seen in the back of the vagina (vaginal fornix). Sometimes
leakage of fluid from the cervical opening can be seen when the
person coughs or performs a valsalva maneuver.

13. • Nitrazine test: A sterile cotton swab is used to collect fluid from
the vagina and place it on nitrazine (phenaphthazine) paper.
Amniotic fluid is mildly basic (pH 7.1–7.3) compared to normal
vaginal secretions which are acidic (pH 4.5–6). Basic fluid, like
amniotic fluid, will turn the nitrazine paper from orange to dark
blue.
• Fern test: A sterile cotton swab is used to collect fluid from the
vagina and place it on a microscope slide. After drying, amniotic
fluid will form a crystallization pattern called arborization which
resembles leaves of a fern plant when viewed under a
microscope
• Fibronectin and alpha-fetoprotein blood tests

14. Additional tests
The following tests should only be used if the diagnosis is still unclear after
the standard tests above.
• Ultrasound: If the fluid levels are low, PROM is more likely. This is helpful
in cases when the diagnosis is not certain, but is not, by itself, definitive.
• Immune-chromatological tests are helpful, if negative, to rule out
PROM, but are not that helpful if positive since the false-positive rate is
relatively high (19–30%)

15. • Indigo carmine dye test: a needle is used to inject indigo carmine dye
(blue) into the amniotic fluid that remains in the uterus through the
abdominal wall. 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. But, can be helpful if the diagnosis is still
unclear after the above evaluations have been done.
It is unclear if different methods of assessing the fetus in a woman with
PPROM affects outcomes.

16. Differential diagnosis
Other conditions that may present similarly to premature rupture of
membranes are the following:
• Urinary incontinence: leakage of small amounts of urine is common in
the last part of pregnancy
• Normal vaginal secretions of pregnancy
• Increased sweat or moisture around the perineum
• Increased cervical discharge: this can happen when there is a genital
tract infection
• Semen
• Douching
• Vesicovaginal fistula: an abnormal connection between the bladder and
the vagina
• Loss of the mucus plug
Prevention
Women who have had PROM are more likely to experience it in future
pregnancies. There is not enough data to recommend a way to specifically
prevent future PROM. However, any woman that has had a history of
preterm delivery, because of PROM or not, is recommended to take
progesterone supplementation to prevent recurrence.

17. Management
Summary Fetal age Management
Term
> 37
weeks
•Induction of labor
•Antibiotics if needed to prevent group B
streptococcus (GBS) transmission
Late pre-
term
34–36
weeks
•Same as for term
Preterm
24–33
weeks
•Watchful waiting (expectant management)
•Tocolytics to prevent the beginning of labor
•Magnesium sulfate infusion for 24–48 hours to allow
maximum efficacy of corticosteroids for fetal lungs
and also confer benefit to fetal brain and gut before
delivery
•One time dose of corticosteroids (two separate
administrations, 12–24 hours apart) before 34 weeks
•Antibiotics if needed to prevent GBS transmission
Pre-viable
< 24
weeks
•Discussion of watchful waiting or induction of labor
•No antibiotics, corticosteroids, tocolysis, or
magnesium sulfate

19. RECOMMENDED
• Monitoring for infection
• Steroids before birth
• Magnesium sulfate
• Latency antibiotics
• Prophylactic Antibiotics
NOT RECOMMENDED
• Preventive tocolysis
• Therapeutic tocolysis
• Amnioinfusion
• Home care
• Sealing membranes after rupture

20. RECOMMENDED
• Monitoring for infection- signs of infection include a fever in
the mother, fetal tachycardia (fast heart rate of the fetus,
more than160 beats per minute), or tachycardia in the
mother (more than 100 beats per minute).
• Steroids before birth-
• corticosteroids (betamethasone) given to the mother of a
baby at risk of being born prematurely can speed up fetal
lung development and reduce the risk of death of the
infant, respiratory distress syndrome, brain bleeds,
and bowel necrosis
• one course of corticosteroids between 24 and 34 weeks
when there is a risk of preterm delivery.
• Magnesium sulfate- when there is a risk of preterm birth
before 32 weeks to protect the fetal brain and reduce the risk
of cerebral palsy.

21. RECOMMENDED
• Latency antibiotics- The time from PROM to labor
is termed the latency period. (ACOG) recommends
a seven-day course
intravenous ampicillin and erythromycin followed by
oral amoxicillin and erythromycin if watchful waiting
is attempted before 34 weeks
• Prophylactic Antibiotics- if a woman is colonized
with GBS, than the typical use of antibiotics during
labor is recommended to prevent transmission of
this bacteria to the fetus, regardless of earlier
treatments.

22. NOT RECOMMENDED
• Preventative tocolysis (medications to prevent
contractions)-it increases the risk of infection or
chorioamnionitis.
• Therapeutic tocolysis (medications to stop
contractions): Once labor has started, using tocolysis to
stop labor has not been shown to help, and is not
recommended
• Amnioinfusion: Current data suggests that this treatment
prevents infection, lung problems, and fetal death. However,
there have not been enough trials to recommend its routine
use in all cases of PPROM

23. NOT RECOMMENDED
• Home care: Typically women with PPROM are managed in
the hospital, but, occasionally they opt to go home if watchful
waiting is attempted. Since labor usually starts soon after
PPROM, and infection, umbilical cord compression, and
other fetal emergencies can happen very suddenly, it is
recommended that women stay in the hospital in cases of
PPROM after 24 weeks
• Sealing membranes after rupture: Infection is the major
risk associated with PROM and PPROM. By closing the
ruptured membranes, it is hoped that there would be a
decrease in infection, as well as encouraging the re-
accumulation of amniotic fluid in the uterus to protect the
fetus and allow for further lung development. There is
currently insufficient research to determine whether these or
other resealing techniques improve maternal or neonatal