This document discusses prelabor rupture of membranes (PROM), also known as premature rupture of membranes. It defines PROM and discusses frequencies. Consequences of PROM include preterm birth and associated complications like respiratory distress syndrome. It also discusses risks of infection to the mother and baby. Management approaches are provided for term PROM, preterm PROM, and PROM occurring at various gestational ages. Recommendations include expectant management with antibiotics for term PROM and delivery after 24 hours if no signs of infection. Preterm PROM guidelines include corticosteroids, antibiotics, and delivery by 34 weeks if uncomplicated.

1. Prelabor rupture of the
membranes

2. Definitions
 Prelabor rupture of the membranes
(PROM) refers to rupture of the
chorioamniotic membranes before the
onset of labor
 latency period: interval between PROM
and the onset of labor.
 term PROM preterm PROM previable
PROM preterm PROM remote from term
PROM near term

3. Frequency
 Term PROM occurs in approximately
10% of patients, while the frequency of
preterm PROM is 2–3.5%

4. Consequences of premature
rupture of the membranes
 Preterm birth
in 50% of PPROM,labor occurs within 24 hours, and
in 80–90% within 7 days.
 Preterm delivery and complications of prematurity
are the most important causes of perinatal mortality
and morbidity; complications decrease with
advancing GA.
○ Respiratory distress syndrome (RDS),
○ intraventricular hemorrhage (IVH), and
○ periventricular leukomalacia (PVL),
○ infection
○ necrotizing enterocolitis (NEC).

5.  Infections: mother is at risk of chorioamnionitis,
endometritis, and sepsis. Serious maternal consequences
are uncommon. Mean incidence of chorioamnionitis is
about 3–15%. Major neonatal infectionsoccur in 5% of
PPROM, and 15–20% of cases develop chorioamnionitis.
 Fetal infection can precede clinically evident
chorioamnionitis, resulting in neonatal pulmonary and
cerebral morbidities.
 Ureaplasma urealyticum and Mycoplasma hominis) are
the most frequent isolates from the amniotic fluid,
followed by Streptococcus agalactiae (group B
streptococcus),

6.  abruptio placentae,
 cord prolapse, pulmonary hypoplasia
 increased need for cesarean delivery
 retained placenta

7. once an examination has been
performed,
the clock of infection starts to
tick

8. PROM ( After 37 weeks before onset of
labor )
Diagnosis
There is no reason to carry out a
speculum examination with a
certain history of rupture of the
membranes at term.
Women with an uncertain history of
rupture of the membranes should
be offered a speculum examination
to determine whether their
membranes have ruptured.
Digital vaginal examination in the absence of
contractions should be avoided.

9.  Complete medical and Obstetric history:
( special consideration to reach diagnosis of PROM).
 Complete general and obstetric examination:
Special consideration on signs of infection, maternal tachycardia, fever,
abdominal tenderness, foul odour vaginal discharge, fetal tachycardia)
 Sterile speculum examination if diagnosis is unclear.
 Avoid PV examination unless contractions are present.
 Perform Obstetric U/S with special consideration to confirm the diagnosis if
unclear.
 Admit patients diagnosed as PROM.
 Consult a senior resident if diagnosis is unclear.
PROM ( After 37 weeks before
onset of labor )

10. Labor Ward management:
Patient is in labor or signs of infection:
Deliver the patient: induction or
augmentation of vaginal birth or CS
according to obstetric indications.
PROM ( After 37 weeks before
onset of labor )

11. PROM ( After 37 weeks before
onset of labor )
Labor Ward management:
Patient is not in labor nor signs of
infection:
Expectant management for 12-24 hours.
 Prophylactic broad spectrum antibiotics.
Expectant management:
•Follow up maternal fever and foul odor vaginal discharge every 4
hours.
•Fetal surveillance ( NST and Kick charts) .

12. If expectant management is agreed upon
Lower vaginal swabs and maternal CRP should not be offered
Maternal surveillance
Every 4 hours
Colour and smell
Fetal surveillance
PROM ( After 37 weeks before onset of labor )
Labor Ward management

13.  If patient passed into labor : Deliver.
 If patient developed signs of infection:
Deliver.
 Deliver patient after 24 hours of expectant
management. (Induction, augmentation of
vaginal delivery or CS).
PROM ( After 37 weeks before
onset of labor )

14. Preterm- PROM
 Diagnosis
The diagnosis of spontaneous rupture of
the membranes is best achieved by
maternal history followed by a sterile
speculum examination. ( B)
Ultrasound examination is useful in some
cases to help confirm the diagnosis. ( B)

15. Preterm- PROM
 Diagnosis
Digital vaginal examination is best avoided unless there
is a strong suspicion that the woman may be in labour.
Latency between P-PROM and Labour becomes shorter
by PV.

16. Should tocolytic agents be used?
Preterm- PROM
Tocolysis in women with PPROM is not recommended
because this treatment does not significantly improve
perinatal outcome ( A)
In the absence of clear evidence that tocolysis improves
neonatal outcome following PPROM, it is reasonable not to
use it.
Additionally, with PPROM in the presence of uterine
contractions, it is possible that tocolysis could have adverse
effects, such as delaying delivery from an infected
environment, since there is an association between
intrauterine infection, prostaglandin and cytokine release and
delivery.

17. Preterm- PROM
Are prophylactic antibiotics recommended?
Erythromycin should be given for 10 days
following the diagnosis of PPROM. ( A)
22 trials involving…. over 6000 women ….meta-analysis
This review shows that
•Routine antibiotic administration reduces maternal and neonatal
morbidity.
•Antibiotic therapy also delays delivery, thereby allowing sufficient
time for prophylactic prenatal corticosteroids to take effect.
•The data also showed that prenatal co-amoxiclav increased the risk
of neonatal necrotising enterocolitis and this antibiotic is best avoided.
•Erythromycin or penicillin appears the antibiotic of choice.
•Erythromycin may be used in women who are allergic to penicillin.
Evidence level Ia

18. PROM ( 34—37 weeks)
Same as above:
Give Corticosteroids.
Deliver after 24 hours from corticosteroid
intake, considering no signs of fetal or
maternal infection , nor labor occurs.
Deliver either by induction , augmentation, or
C.S depending on indication.

19. PROM remote from term at 26–34 weeks of gestation
Initial assesment
•Look for clinical signs of chorioamnionitis and abruption
• Assess fetal growth, sonographic gestational age, and fetal well-being
Development of
•Labour ,
•Abruption
•Chorioamnionitis
• Nonreassuring fetal heart
rate
• Fetal distress
Expectatnt mamnagement
•Corticosteriords.
•Prophylactic antibiotics
• Hospitalization and bedrest
•Neonatology consult
•Follow up for signs of maternal
infection, abruption and fetal well-being
(biophysical profile and fetal heart
monitoring)
Uneventful course until 34 weeks:
Deliver

20. PROM before 26
 Consider termination of pregnancy.
 If patient refused …..manage as 26- 34
weeks

21. Cervical Circlage and Preterm
PROM
 Occurs in 38% of women with cerclage in
place
 Retention of circlage for more than 24 hours
after PPROM was found to prolong pregnancy
for more than 48 hours, but also to increase
maternal chorioamnionitis and neonatal
mortality from sepsis,
 Immediate circlage removal as the usually
preferred therapeutic approach. Steroids for
fetal maturity before circlage removal can be
considered between 24 and 33 6/7 weeks
gestation

22. Thank You