Keith Moore Said "It has been a great pleasure for me to help clarify statements in the Qur'an about human development. It is clear to me that these statements must have come to Muhammad from God, or Allah, because most of this knowledge was not discovered until many centuries later. This proves to me that Muhammad must have been a messenger of God, or Allah."

1. PPROM & PROM
SITI KHADIJAH BINTI MANSOR
ADIBAH ABDUL RAHMAN
House Officer of HTPG

3. OVERVIEW
• DEFINITION
• RISK FACTORS
• DIAGNOSIS
• COMPLICATIONS
• MANAGEMENT
• TIME OF DELIVERY
• PATIENT’S CARE
• SUMMARY

4. DEFINITION
PPROM
Preterm premature rupture of
membranes
PROM
Prelabour rupture of membrane is
defined as
Amniotic membrane rupture from 22 to
36+6 completed weeks
rupture of membrane after 37 weeks of
gestation until onset of labour.

5. • 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
(South Australian Perinatal Practice)

6. RISK FACTORS

7. RISK FACTORS
PROM PPROM
Chorioamnionitis
Vaginal infections
Cervical abnormalities
Smoking
Intrauterine Infections – Major
predisposing factor
( UTI, chorioamnionitis, lower genital
tract infections)
History of previous PROM or PPROM
Polyhydramnios
Multiple pregnancy : Nearly 40% of twin
pregnancy will have PROM or PPROM
Cervical incompetence
Vaginal examination
Sweeping of the membranes
Nutritional deficiencies
Cigarette smoking

8. RISK FACTORS
VAGINAL INFECTION
AND/OR ABNORMAL
VAGINAL MICROBIOTA
PPROM events was significantly higher in the group of women with a vaginal
infection and/or abnormal vaginal microbiota /Vaginal flora /vaginal
microbiota/vaginal microbiome
Infections Bacterial vaginitis, Candidiasis
Pathogen Candida albicans, Enterococcus sp, Escherichia coli, Gardnerella
vaginalis, Peptococcus sp and Candida non albicans,
Treatments Metronidazole + Clotrimazole
CHORIOAMNIONITIS • Intrauterine infection (E. coli, group B streptococci, and anaerobic bacteria )
and release of endotoxin from bacteria activate fetal membranes and
decidua.
• It causes production of proinflammatory cytokines.
• It leads to release of fFN which resulting cervical ripening, uterine
contractions, and collagenolytic degradation of the fetal membranes in the
end.
MATERNAL STRESS Approximately 20 % of the preterm births in a study done at Linköping University
hospital were estimated to be due to maternal stress
NUTRITIONAL
DEFICIENCIES
A hospital-based case-control study at Holdsworth Memorial Hospital, 2002 and
2003_malnourished women having decreased level of host defense factors
regularly present in amniotic fluid so infectious agents such
as E. coli and S. aureus may play a larger role.

9. DIAGNOSIS OF PPROM/PROM

10. MATERNAL HISTORY STERILE SPECULUM EXAMINATION
Gold standard
Pop sound
Gushing of warm fluid
Dribbling of clear liquor / meconium
stained liquor down the inner thigh
Soaked her pad/cloth
Associated with foul smelling odour
Pooling of liquor at posterior fornix
(color, smell)
Cough test: positive
Assess cervical dilation and length
Obtain cervical cultures
(GBS, Gonorrhea, Chlamydia)
Obtain amniotic fluid samples

11. MECONIUM STAINED LIQUOR
Normal physiology Pathophysiology
Gastrointestinal tract maturation Vagal stimulation from common but
transient umbilical cord entrapment with
resultant increased bowel peristalsis

12. NITRAZINE PAPER TESTING
• Vaginal pH (3.5-4.5)
• Turns blue in presence of alkaline Amniotic
fluid
• 93.3% sensitivity

13. FERN TEST
• Examination of cervical mucus under low
power on a microscope
Fern-like crystal

15. Fetal fibronectin is diffusely distributed in
fetal membrane from amnion to decidua,
providing structural support and adhesion of
the fetal membranes to the uterine lining

16. LPS & TNF-α increased fFN from
amnion epithelial cells
proinflammatory cytokines
fFN indirectly
induce expression
of COX-2 & MMPs
fFN clinical marker
of preterm labor

17. INSULIN‐LIKE GROWTH FACTOR‐BINDING
PROTEIN 1 (IGFBP‐1)
• present in high concentration in amniotic fluid
• high levels of sensitivity & specificity

18. PLACENTAL ALPHA
MICROGLOBULIN‐1 (PAMG‐1)
• protein found within amniotic fluid
• high levels of sensitivity & specificity

19. ULTRASOUND
• 50-70% of women with PPROM have low amniotic
fluid volume, AFV on ultrasound

20. COMPLICATIONS

21. COMPLICATIONS
• IMMEDIATE RISK
 cord prolapse,
 cord compression
 placental abruption.
• DELAYED RISK
 High Caesarean section rate
 Chorioamnionitis
 Intrapartum fever*
 Postpartum fever*
 Fetal Pulmonary hypoplasia
o 10% at 25 weeks
 Neonatal sepsis
 Fetal pneumonia
 Preterm birth (30–40%)
PPROM oligohydramnios pulmonary hypoplasia neonatal death

22. PERINATAL MORBIDITY

23. Placental Abruption
• Abruptions were associated with a marked decidual
neutrophil (rich source of proteases) infiltration that
peaked after PPROM

24. CHORIOAMNIONITIS
SYMPTOMS SIGNS
lower abdominal pain
abnormal vaginal discharge
fever
malaise
reduced fetal movements
Maternal Fetal
Pyrexia
Tachycardia
Leukocytosis
Uterine tenderness
Tachycardia

25. Clinical Assessment

26. Clinical Assessment
• Pulse
• Blood pressure
• Temperature
C‐reactive protein
• CRP levels has a sensitivity of 68.7% and
specificity of 77.1% in diagnosing histological
chorioamnionitis
white cell count
fetal heart rate
• to diagnose
chorioamnionitis
vaginal swab
• Detect Group B
streptococcus colonization
• influence the timing of birth
UFEME
• To rule out UTI
Ultrasound
• 50 to 70 % of women have
low amniotic fluid volume

27. MANAGEMENT

28. MANAGEMENT
• 1. Gestational Age and mother-fetal condition
• 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
• Labor starts in 80–90% of cases within 24 hours -The key decision is
whether to initiate delivery or take an expectant approach. When time
increase the risk of infection increase.Hence induction of labor by oxytocin
and prostin is preferable.
• Expectant management in non complicating pregnancies and should not
exceed 24 hr and for antibiotic prophylaxis

29. Management of PPROM
Antibiotic T. Erythromycin 400 mg bd x 10 days Penicillin may be used in women
who cannot tolerate erythromycin.
Ampicillin 2 g IV q 6 hours (GBS POSITIVE) • Reduced chorioamnionitis
• Reduced abnormal cerebral
• Reduced neonatal infection
Co-amoxiclav should be avoided associated with an increased risk of
neonatal necrotising enterocolitis
Corticosteroids IM Dexamethasone 12 mg stat 18 hours post
pprom and 12 hours apart for 1 day
During 24+0-33+6 weeks
• Reduce the incidence of
intraventricular haemorrhage
• reduces the risks of respiratory
distress syndrome
• Reduce the risk of necrotizing
enterocolitis
Intravenous
magnesium sulfate
24+0 and 29+6 weeks of gestation in labour
expected to give birth within 24 hours
• fetal neuroprotectant
• reduction in cerebral palsy
• reduces motor dysfunction in the
offspring
Tocolysis Nifedipine/Atosiban
Not recommended
• associated with an average 73 hours longer latency of delivery
• Increased the risk of chorioamnionitis
• increased risk of a 5-minute Apgar score of less than 7
• increased need for ventilation support

30. Time of delivery in PPROM
37+0 weeks of gestation Early delivery
offer expectant management until 37+0
weeks of gestation
if no contraindications to continuing the
pregnancy.
• increased the incidence of respiratory
distress syndrome
• increased rate of caesarean section
• associated with a higher rate of
neonatal death
• associated with higher rate of the need
for ventilation
Inform Neonatologists when delivery is anticipated to ensure care for the neonate
• 50% of women deliver within 1 week
• 75% within 2 weeks of PPROM

31. Patient care in PPROM
Inpatient Outpatient
vital signs
• Pulse
• blood pressure
• respiratory rate
• temperature
observed for clinical symptoms and
signs of infection
• advised of the symptoms of
chorioamnionitis
• regular blood tests
o white cell count
o C-reactiveprotein
• clinical recordings
• fetal heart rate monitoring
• monitor fetal growth on ultrasound
scan fortnightly
• assess amniotic fluid weekly
• assess umbilical artery Doppler studies
weekly
• if the woman has any concerns, she
should attend the hospital immediately

32. Women with PPROM and their partners should be
offered additional emotional support during
pregnancy and postnatally
The risk of PPROM in subsequent pregnancies is
increased
screening for lower genital tract infections
beneficial in preventing preterm birth

34. • Labour does not establish after a latent period of 4 hours - in an
unfavorable cervix, prostin may have an important role. Oxytocin infusion
should be started
• 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.
• PROM > 18 to 24 hours *Parenteral antibiotic cover for GBS is required in
all cases (irrespective of GBS status) of PROM > 18 to 24 hours.
*Give penicillin 2 g IV loading dose, then 1 g IV every 4 hours until delivery
*If allergic to penicillin, clindamycin 600 mg IV every 8 hours
• Watch out sign and symptoms of chorioamnionitis
Management of PROM

35. Management of PROM
 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

37. References
• Royal College of Obstetricians and Gynaecologists (RCOG). Care of Women Presenting
with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of
Gestation (Green-top Guideline No. 73). London. RCOG; 2019
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg73/
• National Institute of Clinical Excellence (NICE). Preterm labour and birth NICE guideline
[NG25]. London. NICE. November 2015. last updated: August 2019
https://www.nice.org.uk/guidance/ng25
• Haruta Mogami, Annavarapu Hari Kishore, Haolin Shi, Patrick W. Keller, Yucel
Akgul, and R. Ann Word. (2013) Fetal Fibronectin Signaling Induces Matrix
Metalloproteases and Cyclooxygenase-2 (COX-2) in Amnion Cells and Preterm Birth in
Mice* J Biol Chem. 288(3): 1953–1966. Published online 2012 Nov 26.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548503/#:~:targetText=Fetal%20fibr
onectin%20(fFN)%20is%20diffusely,the%20uterine%20lining%20(14).&targetText=Colle
ctively%2C%20the%20results%20suggest%20a,of%20preterm%20labor%20and%20PP
ROM.
• Karat C, Madhivanan P, Krupp K, Poornima S, Jayanthi N V, Suguna J S, Mathai E. The
clinical and microbiological correlates of premature rupture of membranes. Indian J
Med Microbiol [serial online] 2006 [cited 2019 Nov 24];24:283-5. Available
from: http://www.ijmm.org/text.asp?2006/24/4/283/29388

38. • Term PROM :Royal Australian and new Zealand college of
obstetricians and gynaecologists, C obs -36. March 2014
• South Australian Perinatal Practice Guideline. September
2015
• Obstetric Today
• RCOG Greentop guideline No.44
• RCOG Greentop guideline No.73 (Care of Women Presenting
with Suspected Preterm Prelabour Rupture of Membranes
from 24+0 Weeks of Gestation)
• RCOG Greentop guideline No.36 (Group B Streptococcal
Disease, Early-onset )

39. THANK YOU