This document discusses premature rupture of membranes (PROM), which is the spontaneous rupture of membranes before the onset of labor. It defines term and preterm PROM and discusses the diagnosis, causes, complications, and management of PROM. The key points are: - PROM is diagnosed based on a history of leakage and physical exam findings like pooling of fluid. Tests like nitrazine and fern tests can also help diagnose. - Causes of PROM can include infections, smoking, collagen deficiencies, mechanical stress from twins or polyhydramnios. - Complications include infections, preterm labor and delivery, and respiratory distress in preterm infants. - Management depends on gestational age,

1. PROM
Maru M /MD/
For Anesthesia 2nd
May 9/2010 Ec

2. PRO M (Premature rupture of membranes)
Definition: Spontaneous rupture of membranes after
28 weeks of gestation before the onset of labor.
• Term PROM: Rupture of membranes after 37 weeks
• Preterm PROM: Before 37 weeks
• Prolonged PROM: Longer than 18 hrs/ 12 hrs.
 Latency period: Time between rupture of
membranes to onset of labor.

3. PROM-Cont’d
Diagnosis:
History: complaint of leakage of liquor as gush or slow
leak;followed by intermittent leakage.
-Complications of PROM: infection, PTL, etc.
Physical findings:
- Negative discrepancy
- If complicated, uterine contraction, tenderness
- Sterile speculum examination with or without
valsalva maneuver( leakage or pooling)

4. • Incidence: average 5- 10% of all deliveries and
up to 30% of preterm deliveries.
• Approximately 70% of cases of PROM occur in
pregnancies at term.
PROM is the clinically recognized precipitating
cause of about one third of all preterm births.
Incidence

5. Causes multifactorial
• 1. Intrinsic membrane weakness
a. Infections
b. Smoking
c. Malnutrition
d. Collagen Deficency
• 2. Infection (proteolytic enzymes)
• 3. Mechanical stress
a. Twin gestation
b. Polyhydramnios
c. Fetal Malformations
• 4. Unknown

6. Diagnosis-cont’d
Investigations:
 Nitrazine paper test: principle is alkaline nature of
amniotic fluid(accuracy of approximately 93%)
 Became blue
False +:blood, semen, alkaline urine, bacterial vaginosis,
and trichomoniasis
 Ferning pattern:accuracy of diagnosis of PROM of
approximately 96%
False +ve: contamination by semen or cervical mucus
False –ve :dry swab, contamination with blood at a 1:1
dilution, or not allowing sufficient time for the fluid to dry
on the slide
 Unaffected by meconium at any concentration and by
pH alteration.

7. Ferning pattern

8. Diagnosis-cont’d
• Ultrasound: support diagnosis & fetal wellbeing.
• Dye test: indigo carmine instillation
• Meconium on the vulva
• Vernix caseosa on the vulva

9. DIAGNOSIS
History
Gush or Leakage of fluid PV (Duration, Smell)
Is she in Labour
Yes
No
Speculum/Digital Exam
Sterile Speculum Examination
± Valsalva Man
Leakage through cervix No leakage through cervix
Presence of meconium/vernix
Pooling at post fornix No pooling
- Nitrazin paper test
-Fern test Pad test for 24 hrs
PROM No wetting Wetting
+ ve - ve
Suspsious
Treat as PROM
- US Oligohydramnios
- Dye test
PROM +ve -ve Follow at OPD Level

10. PROM- investigations
• CBC
• U/A, Culture & Sensitivity
• High vaginal swab for culture
• Phosphatidylglycerol from vaginal pool
• Biophysical profile
• CTG for non-stress test

11. Differential diagnosis
• Urinary incontinence
• Leucorrhea gravidarum*
• Perspiration*
• Vaginal discharge-pathological

12. Complications of PROM
 Labor: In term PROM labor starts in 24 hours in
about 90%. In Preterm PROM, labor starts in 70-80%
of cases in one week time
 Ascending infection: one third
• Increased incidence of cord prolapse
 Fetal pulmonary hypoplasia
 Prematurity
• Operative delivery
• Abruption

13. Management of PROM
• Accurate diagnosis
• Avoid digital vaginal examination
• Bed rest
• Management depends on:
- GA
- Presence or absence of labor
- Infection or not
- Fetal condition

14. Indications for pregnancy termination in
PROM
• Term PROM
• Labor
• Presence of infection
• IUFD
• Congenital anomalies of fetus incompatible to
life
• Abnormal fetal surveillance

15. Preterm PROM
 GA > 34 weeks is controversial either conservative
management or termination
 GA< 34 weeks, conservative management
 Components of conservative management:
- Monitor maternal PR, Temp., FHR every 4 hours
- CBC, U/A, ESR/CRP twice per week
- BPP/NST twice per week
 Corticosteroids if less than 32/34 weeks
- Administer antibiotics: ampicillin (iv)+ erythromycin X
48hrs followed by amoxacillin(po) & erythromycin to
complete a total of seven days

16. • Two indications for prophylactic antibiotics in
PPROM:
 prevention of perinatal GBS infection
infection is either the triggering cause of PPROM
or that infection ensuing after PPROM triggers the
labor

17. Chorioamnionitis
• Clinical or subclinical
Criteria for clinical chorioamnionitis:
- Maternal temperature > 38o C
- Uterine tenderness
- Foul smelling amniotic fluid
- High WBC count(>16000/18000)
- Maternal &/ or fetal tachycardia

18. Sub clinical chorioamnionitis
• Amniocentesis: intramniotic infection is
present if:
1. Culture: bacterial colony count > 102 / ml
fluid
2. Presence of bacteria on gram stain
3. Glucose level<15 mg/dl
4. WBC> 100/ml

19. Management of chorioamnionitis
• Antibiotics:
1. Ampicillin+ Gentamycin+
clindamycin/metronidazole/chloramphenicol
2. Ceftriaxone +/- metronidazole
• Terminate pregnancy: Vaginal route is
preferred

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