Prom lecture by hale

HALE TEKA, M.D,
OB/GYN RESIDENT,
MEKELLE UNIVERSITY
Premature Rupture of Membranes
(PROM)
Hale
Digitally signed by Hale
Date: 2019.09.07
21:15:33 +03'00'

Introduction
Saturday, September 07, 2019 HALE TEKA, M.D., RESIDENT PHYSICIAN 2

Introduction
• PROM – definition
✓ Spontaneous membrane rupture before onset of labor
• Prevalence
✓ It complicates
o Overall ➔ 8 – 10% of pregnancies
o Less than 37 weeks ➔ 1%
o 2x common in blacks (US data)

• Its contribution to preterm birth
✓ 10% in low risk
✓ 20% in high risk women

• PROM inherently associated with increased perinatal morbidity
and mortality due to:
1. Brief period of latency leading to preterm birth
2. Increased risk risks for perinatal infection
3. Abruptio placenta
4. Diminished oligohydramnios leading to umblical cord
compression

• At term
✓ Perinatal morbidity and mortality are not significant
✓ PROM at term usually lead to a delivery of noninfected and
nonasphyxiated infant

• If PROM occurs before 28 +0 weeks,
✓the woman should be well aware of the complications of continuing the
pregnancy and pregnancy can be continuted with informed decision
•If PROM occurs before 37 +0 weeks,
✓in the absence of contraindications, management should be directed
towards continuing the pregnancy
• If a woman comes with PROM, after 37 +0 weeks
✓management should be directed towards delivery

Fetal Membrane Anatomy and Physiology

• Fetus develops within amniotic sac, which is surrounded like a balloon
by the fetal membranes
• These membranes consists of amniotic and chorionic membranes
which fuse at the end of first trimester
✓ Thin amnion – has greater tensile strength
✓Thick chorion

Etiology of PROM

• Risk factors
✓Low socioeconomic status,
✓ Previous history of PPROM or preterm birth
✓Asymptomatic second trimester short cervical length
✓Uterine overdistension,
✓Second- and third-trimester bleeding,
✓Low body mass index (BMI),
✓Nutritional deficiencies of copper and ascorbic acid,
✓Abdominal trauma

• Risk factors cont’d
✓Maternal cigarette smoking,
✓Cervical conization or cerclage,
✓Pulmonary disease in pregnancy,
✓Connective tissue disorders (e.g., Ehlers-Danlos syndrome), and
✓Preterm labor or symptomatic contractions in the current gestation
✓ Infenctions

• Infections of urogenital tractn – commonly isolated organisims
include
✓Neisseria gonorrhoeae,
✓Chlamydia
✓trachomatis, and
✓Trichomonas vaginalis

• Bacterial vaginosis
✓ Its role in PROM is not clear
o Does it help for ascention of microbes?
o Is it simply a marker of maternal susceptibility for infection?

• Mechanisim of factors leading to PROM
1. Thrombin – mediated
o increase in Poly ADP – ribose polymerase (PARP) cleavage
o Increase in MMP – 1 , 2 and 9
o Decrease in TIMP – 1, and 3
2. Increase in local cytokines, collagenase and protease activities
3. Increase in intrauterine pressure
4. Contractions and cervical diliation lead to fetal membrane physical strain

• Infection
✓ascending bacterial colonization and infection are integral to the
pathogenesis of preterm PROM in many cases through
1. Direct rlease of proteases
2. Stimulation of inflammatory responses that results in the elaboration of
cytokines, MMPs, and prostaglandins
✓ In the absence of clinically suspected intrauterine infection
o25 – 35% choriodecidual contamination in women with PROM

Prediction and prevention of PROM

Prediction
•Those with a prior delivery near the limit of viability (23 to 27 weeks) have a
27.1% risk of subsequent PTB
•Those with a prior history of PTB due to PROM have
✓a 3.3-fold higher risk for PTB due to PROM (13.5% vs. 4.1%) and
✓a 13.5-fold higher risk for PPROM before 28 weeks’ gestation (1.8% vs. 0.13%)
in a subsequent pregnancy

• Predictors of developing PPROM in nullipara
✓ Recent symptomatic uterine contractions
✓ Working during pregnancy
✓ Having bacterial vaginosis
✓ Medical complications (including pulmonary diseases)
✓Short cervical length (<25 mm)
✓ BMI < 19.8 kg/m2

• Predictors of developing PPROM in parous women
✓ Piror PTB due to preterm labor or PROM
✓ Positive cervicovaginal fFN
✓ Short cervical length (<25 mm)
✓ BMI < 19.8 kg/m2

RISK FOR PRETERM BIRTH DUE TO PREMATURE RUPTURE OF THE MEMBRANES
AMONG MULTIPARAS
*Positive fFN, cervicovaginal
fFN screen positive (>50
ng/mL) at 22 to 24 weeks’
gestation.
†Short cervix, cervix length
<25 mm on transvaginal
ultrasound at 22 to 24
weeks’
gestation.

Prevention
•Current evidence supports 17-α-hydroxyprogesterone caproate
(17-P) treatment for women with a
✓prior PTB due to PROM or
✓preterm labor
• Evidence also supports treatment with vaginal progesterone for
asymptomatic women with a short cervical length.

• Use of Vit C and E
✓ Data about their efficacy is conflicting
✓ Currently not recommended

Clinical Course after PROM

• Hallmarks of PROM
✓ Brief period of latency
o Period of latency is the time gap in between PROM and onset
of labor
o It has an inverse relationship with gestational age

• Term
✓ 50% deliver within 5 hours
✓ 95% deliver within 28 hours
• Before 34 weeks
✓ 93% deliver within 1 week
✓ 50 – 60% deliver within one week after excluding mothers who require immediate
termination
✓ Only <5% can anticipate cessation of fluid leakage
✓ 86% after amniocentesis will reseal

Risks of PROM

• Maternal Risks
✓ Chorioamnionitis
o Most common complication ➔ 13 – 16%
o Risk increases as period of latency increases and decreases
with advancing gestational age

•Other maternal complications
✓ Endometritis ➔ 2 – 13%
✓Abruption ➔ 4 – 12%
✓ Retained placenta and hemorrhage ➔ 12%
✓ Maternal sepsis ➔ 0.8%
✓ Maternal death ➔ 0.14%

• Fetal complications
✓ ENOS
✓ Fetal distres and elevated risks of Cesarean delivery due to
associated
o Umblical cord compression
o Cord prolapse
o Sepsis

• Fetal complications cont’d
✓ fetal death ➔ 1 -2%

• Neonatal complications
✓ RDS – most common serious newborn complication
✓ NEC
✓ IVH
✓ EONS – 2 fold increase
o Can present as acute congenital pneumonia, sepsis, or meningitis
✓ Chronic lung disease – if delivery occurs remote from term
✓ Visual or hearing difficulties
✓ intellectual disabilities
✓ developmental and motor delay
✓ cerebral palsy
✓ death

• Pulmonary hypoplasia
✓ PPROM in the second trimester
o results from lack of terminal bronchiole and alveolar development
during the canalicular phase of pulmonary development
oCan be accurately diagnosed with
➢ Radial alveolar count
➢ Lung weight

• Lung hypoplasia cont’d
✓ Clinical diagnosis
oSmall chest circumference with severe respiratory distress
o Persistent pulmonary hypotension
✓ Imaging Dx
o small, weel – aerated lungs with bell – shaped chest and
elevation of the diaphragm

✓ Why does it occur?
oFluid efflux and tracheobronchial collapse after membrane
rupture?
o Loss of intrinsic factors within the tracheobronchial fluid?

✓ develops in 6% of cases in midtrimester PROM
✓ Carries a 70% mortality rate
✓ its incidence inversely correlated with gestational age
✓ complicates nearly 50% of cases with PROM before 19 weeks
and prolonged latency

✓ 74 – 82% with PROM at 15 – 16%
✓ Letal pulmonary hypoplasia rarely occurs with PROM after 26 weeks’ gestation ( 0 –
1.4%)
✓ With lesser degree of this condition, related to poor pulmonary compliance and high
ventilatory pressures
o Pneumothorax
o pneumomediastinum
✓ Restriction deformities occur in about 1.5% of infants delivered after conservative
management after midtrimester PROM but complicate upto 27% of fetuses with
prolonged oligohydramnios

Diagnosis of PROM

• Diagnosis involves
✓History
✓Physical exam
✓ Lab

• Confirmation of PROM
✓ Sterile speculum exam
oVisualization of amniotic fluid passing from the cervical canal or
o Pooling of fluid in the posterior fornix
oVaginal sidewall or posterior fornix pH of more than 6.0 to 6.5 and
oMicroscopic arborized crystals (“ferning”), owing to the interaction of
amniotic fluid proteins and salts, from dried vaginal secretions
obtained by swabbing the posterior fornix with a sterile swab

• Other purposes of sterile speculum exam
✓ assess cervical status (effacement and dilitation)
✓ to visualize if there is cord proplapse following ROM
✓ to assess for cervisitis
✓ to take cervical and vaginal samples for culture

• Addional confirmatory findings, visualization in the cervical Os of
✓ Meconium
✓ Cord
✓ Vernix

• False – positive pH results may occur with
✓ Blood
✓ semen
✓ bacterial vaginosis
✓ alkaline antiseptics
✓ cervical mucus – can also give a false – positive ferning pattern
o The pattern apears floral

• False negative results
✓ minimal residual fluid
• If equivocal result after initial test
✓ the patient can be placed in a Trendelenburg position and
reexamined after a few hours

Fern Test

Fern Plant

•Ultrasound – guided dye amnioinfusion (1 mL of indigo carmine + 9
mL sterile saline)
✓ Observation for passage of dye onto a perineal pad

• Other purposes of ultrasound
✓ to check for the residual amniotic fluid
✓ to assess fetal growth
✓ to assess for BPP
✓ to check for congenital anomalies that might have probably
caused polyhydramnios and PROM

• The following cervicovaginal markers has been tested for the diagnosis
of PROM but are not currently in clinical use
✓ fFN
✓ alpha fetoprotein
✓ prolactine
✓ hCG
✓ PAMG -1
✓ IGFBP -1

Management of PROM

• Management depends on the gestational age
✓ Before 28 + 0 weeks
o Termination
o Expectant management if an informed mother wishes to extend the
pregnancy
✓Before 37 + 0 weeks
o Expectant management
✓ After 37 + 0 weeks
o Terminate

• Indications for immediate delivery
1. Term gestation
2. IUFD
3. abnormal fetal well – being (NRBPP)
4. established labor
5. complicated with abruption and significant bleeding
6. complicated with chorioamnionitis
7. complicated with cord proplase

Management of PROM at Term
• Immediate induction Vs waiting for spontaneous onset of labor for women with
TERM PROM
✓ Immediate induction has many benefits without increasing risks of cesarean
delivery or neonatal infection
o Reduced risks of:
➢ prolonged period of latency (duration of ROM untill delivery)
➢ frequency of chorioamnionitis
➢ postpartum fever
➢ neonatal antibiotic therapy

• Induction using oxytocine Vs prostaglandins
✓ Using oxytocine was found to be associated with reduced risks
of
o prolonged latency
o chorioamnionitis
o neonatal infection

Management of Preterm PROM ( 32 – 36 weeks + 6 days)
• Manage conservatively
• Delivery can be contemplated if fetal maturity can be
ascertained either from
✓ vaginal amniotic fluid pool
o preferred, avoids inadverten fetal injury
✓ amniocentesis

• Indicators of fetal maturity – that indicates delivery as a preferred
option
✓ Lamellar body coutn > 50,000
✓ Phosphatidyl glycerol ➔ if positive
✓ L/S ratio > 2

•If the set – up does not allow for determination of lung maturity or
if the lung maturity tests show no evidence of maturity
✓ Expectant management untill 37 +0 weeks of gestation

Expectant management – approach
• Admit
• Bed – rest and pelvic rest
• Prevention of intrauterine infection ➔ start antibiotic prophylaxis
• Acceleration of efetal maturation ➔ Steroids
• follow with PROM chart for complications
• determine the anovaginal GBS carriage status done within the last 5 weeks
• terminate at 37 + 0 weeks if no complications noted on follow
• Otherwise, complications like chorioamnionitis, abnormal BPP or abruption dictate termination
before 37 weeks

• Avoid
✓ Digital examination – shortens period of latency

• Components of PROM chart
✓ maternal vitals
o BP, PR, RR, Temp
✓ fetal vitals
oFHB, BPP
✓ follow up of the condition
o foul smelling vaginal discharge, fever, abdominal pain and
tenderness, leucocyte count

Corticosteroid Administration
• Single course
✓ Betamethasone 12 mg IM daily (2 doses in 48 hours)
✓Dexamethasone 6 mg IM BID (4 doses in 48 hours)
• Rescue course – not settled yet
✓ if a single course was taken near the limit of viability and the
woman remains undelivered at 32 weeks and she has a high
chance of delivery within 1 week

• Benefits of steroids
✓ decreases risks of
o RDS
o IVH
o NEC

Antibiotic Administration
• Antibiotic treatment
✓Significantly prolongs latency after membrane rupture
✓Reduces chorioamnionitis,
✓Reduces the frequencies of newborn complications that include
oneonatal infection,
othe need for oxygen or surfactant therapy, and
oIVH.

• Regimens
✓ 48 hours of
o ampicillin 2 gram IV Q 6 hours
o erythromycin 250 mg Q 6 hours
✓ followed by 5 days course of
o amoxicillin 250 mg Q 8 hours
o enteric – coated erythromycin base 333 mg Q 8 hours

• Amoxacillin – clavulinic acid (Augmentin) use must be avoided
• Atudies show its association with NEC.

Management of PROM Remote From Term (23 to 31 Weeks)
• Indications for immediate delivery in this group that warrant
expeditious delivery because of the increased potential for fetal
death or infection with prolonged membrane rupture:
✓ Fetal malpresentation,
✓funic presentation,
✓human immunodeficiency virus (HIV), and
✓primary herpes simplex virus (HSV)

• if expectant is opted by an informed mother
✓ Daily NST/BPP
✓ Continuous monitoring
✓ Bed – rest
✓ Pelvic – rest

•Consensus has not yet been reached regarding the advantages
of inpatient versus outpatient management for the patient who
elects conservative management after previable PROM.

Magnesium Sulfate for Neuroprotection
• recommended for anticipated deliveries before 32 weeks’
gestation after PROM
• Regimen
✓bolus of 6 g followed by an infusion of 2 g/hr for 12 hours if
undelivered (or continued for imminent delivery)

Tocolysis and Progesterone
• Tocolysis ➔ currently not recommened for women with PPROM
• Progesterone ➔ currently not recommended for women with
PPROM
✓ It is only indicated for women with history of PTB and short cercix
with intact memberane

Cerclage
• PROM as a complciation of cerclage placement
✓ Emergency cerclage → 50%
✓ Elective cerclage → 25%
• Because no well-controlled study has found cerclage retention to improve
newborn outcomes after PROM, early cerclage removal is recommended when
PROM occurs
•The risks and benefits of short-term cerclage retention during antenatal
corticosteroid are unknown.

Herpes Simplex Virus
• Primary HSV
✓ Perinatal transmission rate ➔ 34 – 80%
• Secondary HSV
✓ Perinatal transmission rate ➔ 1 – 5%
• When neonatal HSV infection occurs, the infant mortality rate is
50% to 60%, and up to 50% of survivors will suffer serious sequelae.

• Existing data supports conservative management of PROM
complicated by recurrent maternal HSV infection when the
likelihood of infant mortality and long-term complications with
early delivery is high.
•Prophylactic treatment with antiviral agents (e.g., acyclovir) to
reduce viral shedding and the frequency of recurrences is prudent
under this circumstance

•

See Next Slide

Complications of PROM

• Complications
✓ Acute
o Preterm labor
o Abruption
o Cord prolapse
o Chorioamnionitis, sepsis
✓ Late complciations
o DVT
o Muscle wasting
o HAI

Chorioamnionitis
• Clinical diagnosis
✓ Fever – Temperature ≥ 38 oC
✓ Uterine tenderness
✓ maternal tachycardia
✓ fetal tachycardia

• Lab
✓ an increase in WBC from the baseline
o This might be artificially elevated if antenatal corticosteroids
have been administered within 5 – 7 days

• Amniocentesis
✓ Amniotic fluid culture
✓amniotic fluid glucose concentration below 16 to 20 mg/dL
✓Gram stain positive for bacteria
✓Presence of WBCs on amniotic fluid
✓Elevated amniotic fluid interleukin levels

Complications of Prolonged Hospitalization
• Psychosocial morbidities
• Muscle wasting
• DVT
✓Preventive measures such as leg exercises, antiembolic
stockings, and/or prophylactic doses of subcutaneous heparin
should be considered

REFERENCES
HALE TEKA, M.D., RESIDENT PHYSICIAN 88
1. Gabbe, et al., Obstetrics: Normal and Problem Pregnancies 7ed 2017: Elsevier,
Inc.
2. Robert K. Creasy, et al., CREASY & RESNIK'S MATERNAL-FETAL MEDICINE
Principles and Practice 7ed 2014: Saunders, an imprint of Elsevier Inc.
Saturday, September 07, 2019

Saturday, September 07, 2019 Hale Teka, M.D., Resident Physician 89
“No man should escape our
universities without knowing
how little he knows!”
J. Robert Oppenheimer

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