This document provides information on PROM (prelabor rupture of membranes) and PPROM (premature prelabor rupture of membranes). It defines PROM as rupture of membranes beyond 28 weeks of gestation but before labor, while PPROM is rupture before 37 weeks. The document discusses pathogenesis, incidence, causes, signs/symptoms, investigations, complications and management for PROM and PPROM. It provides details on evaluating for chorioamnionitis and managing based on gestational age, including expectant management with antibiotics or induction of labor/C-section depending on the situation.

1. PROM and PPROM

2. Outline
• Introduction
• Symptoms and signs
• Investigation
• Treatment
• Summary

3. Definition
• Spontaneous rupture of the membranes any time
beyond 28th week of pregnancy but before the
onset of labor is called prelabor rupture of the
membranes (PROM)
• When rupture of membranes occurs before 37
completed weeks it is termed as Premature
PROM

4. programmed cell death and activation of catabolic
enzymes, such as collagenase and mechanical
forces
Pathogenesis
ruptured membranes.
At term
Preterm PROM
Same mechanisms and premature activation of
these pathways.

5. Pathogenesis
• However, early PROM also appears to be
linked to underlying pathologic processes,
(due to inflammation and/or infection of the
membranes.)

6. INCIDENCE
• PROM occurs in approximately 10% of all
pregnancies.

7. CAUSES
• In majority, the causes are not known.
• The possible causes are:
1. Increased friability of the membranes;
2. Decreased tensile strength of the membranes;
3. Polyhydramnios;
4. Cervical incompetence;

8. Causes
5. Multiple pregnancy;
6. Infection—Chorioamnionitis, urinary tract
infection and lower genital tract infection;
7. Cervical length < 2.5 cm;
8. Prior preterm labor;
9. Low BMI (< 19 kg/m2).

10. Chorioamnionitis
Chorioamnionitis is a
complication of pregnancy
caused by bacterial
infection of the fetal
amnion and chorion
membranes.

11. Signs and symptoms
1. Maternal fever (T>100.4°F or >37.8°C)
2. Significant maternal tachycardia (>120
beats/min)
3. Fetal tachycardia (>160-180 beats/min)
4. Purulent or foul-smelling amniotic fluid or
vaginal discharge
5. Uterine tenderness
6. Maternal leukocytosis (TC>15-18,000 cells/μL)

13. Diagnosis: PROM
Symptoms
• Sudden gush of fluid per vagina or water
vaginal discharge or continuous leaking
through the vagina

14. Signs
• Maternal temperature(increased in
chorioamnionitis) and pulse
• FHR
• P/A examination
Reduced size of the uterus than the period of
gestation
Reduced liquor volume
Diagnosis

15. • Sterile speculam
examination
For demonstration of
liquor
To assess odour of
vaginal discharge
To exclude cord prolapse
To take endocervical
swab
To perform Nitrazine
test and Fern test
Diagnosis
Vaginal examination is
generally avoided in PROM

16. Complications
MATERNAL COMPLICATIONS
• Preterm labour
• Infection: Chorioamnionitis, puerperal sepsis
• Cord prolapse
• Dry labour
• Placenta abruption

17. Complications
FETAL COMPLICATIONS
• Prematurity
• Fetal pulmonary hypoplasia
• Neonatal sepsis
• Respiratory distress syndrome,
• Increased perinatal morbidities (cerebral
palsy)

18. Investigations
• Complete Blood count
• CRP
• Urine R/M/E and C/S
• High vaginal swab: gram
stain and culture
• Ultrasonography
(gestational age and fetal
biophysical profile)
• CTG
• Nitrazine test
• Fern test
• Nile blue sulphate test

19. Nitrazine test
Nitrazine or phenaphthazine
is a pH indicator dye
Nitrazine indicates pH in the
range of 4.5 to 7.5.
False positives
1. If blood gets in the sample
2. If there is an infection present
3. Recent vaginal intercourse (Semen also has a higher pH)

20. This test involves putting a drop of fluid obtained
from the vagina onto paper strips containing
Nitrazine dye.
The strips will turn blue if the pH is greater than
6.0. A blue strip means it's more likely the
membranes have ruptured.

22. Fern test
• To detect the rupture of
membranes and the onset of
labor.
• Indirect evidence of ovulation
and fertility
• Detection of a
characteristic 'fern
like' pattern of cervical
mucus when a specimen of
cervical mucus is allowed
to dry on a glass slide and
is viewed under a low-
power microscope.
• Provide evidence of the
presence of amniotic fluid

23. TREATMENT
A. General treatment
B. Obstetrical management
1.Management of PROM with chorioamnionitis
2.Management of PROM without chorioamnionitis (>37 weeks of
gestation)
3.Management of pre-term PROM without chorioamnionitis

24. General Treatment
• Hospitalization
• Bed rest with bathroom privilege
• Wearing of clean vulval pad
• Broad spectrum antibiotics
• Counseling of mother
• Maternal and fetal monitoring
Maternal monitoring (temp, pulse, BP, liquid
volume, odor of liquor , uterine tenderness)
Fetal monitoring (FHR 4 hourly, CTG daily and
Biophysical profile weekly)

25. Management of PROM with
Chorioamnionitis
• Termination of pregnancy irrespective of
gestational age
• Mode of termination
1. Induction of labour: with oxytocin for short
period (if vaginal delivery is not C/I)
2. C.S.-if vaginal delivery is C/I
-If not delivered by 12? hrs of diagnosis of
chorioamnionitis

26. Management of PROM without
chorioamnionitis (>37 WOG)
• Active management (best option)
Induction of labour with oxytocin (if cervix is ripe)
LUCS (for obstetric indication)
• Expectant management (if cervix is not ripe)
Non intervention (wait for 6-12 hrs to allow
ripening of cervix and spontaneous onset of
labour

27. Management of pre-term PROM
without chorioamnionitis
• If gestational age >34weeks but <37 weeks
1. Expectant management: as long as no sign of
chorioamnionitis
2. Active management
a) Induction of labour by oxytocin
b) LUCS (for obstetric indication)

28. • Gestational age between 24 and 34 weeks
• Expectant management
Corticosteroid (inj. Hydrocortisone for lung
maturation)
Tocolytics (for 48hrs to allow lung maturity)
In utero transfer of fetus to a center with neonatal
support
• Gestational age <24 weeks
Active termination of pregnancy due to poor
prognosis (best option)

29. Scheme for management of PROM
TO MONITOR MATERNAL PULSE, TEMPERATURE, FHR AND TO START
PROPHYLACTIC BROAD SPECTRUM ANTIBIOTIC
AMNIONITIS, PLACENTA ABRUPTION, FETAL DEATH/ DISTRESS OR LABOUR PROCESS
PRESENT ABSENT
EXPEDITIOUS DELIVERY
INTRAPARTUM ANTIBIOTIC
NICU
• Maternal health assessment
• Fetal: gestational age, weight, pulmonary maturity
• Septic work up( cervical swab,
urine culture)
• Non stress test
• Biophysical profile

30. ABSENT
PREGNANCY <34 WEEKS PREGNANCY >=37WEEKSPREGNANCY >=34WEEKS AND
LESS THEN 37 WEEKS
EXPECTANT MANAGEMENT
TO CONTINUE FOR FETAL
MATURITY.
HOSPITAL WITH LIMITED
SOURCES-
TO TRANSFER THE PATIENT
WITH ‘FETUS IN UTERO TO AN
CENTER EQUIPPED WITH NICU
TO WAIT FOR SPONTANTAEOUS
ONSET OF LABOUR FOR 24-
48HRS
FAILS
INDUCTION OF LABOUR WITH
OXYTOCIN(CS FOR NON-
CEPHALIC PRESENTATION)
TO WAIT FOR
SPONTANTAEOUS
ONSET OF LABOUR
FOR 24HRS
FAILS
INDUCTION OF LABOUR
WITH OXYTOCIN(CS FOR
OBSTETRIC REASON)

31. THANK YOU