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8/12/2019 Prematurely Ruptured of Membranes -PROM
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Premature Ruptured of
Membranes (PROM)
R. Afrilianti
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Definition
PROM is defined as spontaneous rupture of
the membranes (amniorrhexis) before labor at
any stage of gestation
If the rupture happened prior to 37 weeks, it
called preterm prematurely rupture of the
membranes (PPROM)
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Epidemiology
In normal condition, 810 % of term
pregnancy woman happened PROM
PPROM occurs in about 1 % of all pregnancy
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Etiology
The cause of
PROM is a wide
array ofpathological
mechanisms.
PROM PPROMWeakness power of
membranes in term
pregnancy, cause of:
-Enlarge uterus
-Uterus contraction
-Movement of fetal
External factors included:
-Vaginal infection
-Trauma
-Increased of intra-uterine
pressure (such as multiple
pregnancy and hydraminios)
-Solutio placenta
-Cervix incompetent
Change biochemistry process
of membranes
Low socioeconomic status
Low body mass indexless than19.8
Nutritional deficiencies
Cigarette smoking
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Physiology
Amniotic sac
Inner layer (amnion)isformed by embryo-
blasts.
Outer layer (chorion)isformed by tropho-blasts
As a metabolic organ, it is part of the production andResorption of the amniotic fluid
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The fetal kidney and the fetal lung produce
the amniotic fluid. Resorption occurs via the
amniotic sac and the gastrointestinal system
when the fetus drinks the amniotic fluid.
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Function
Shelter from dehydration, compression of the
umbilical cord, traumatic external influences
and gives room for the child to move and grow
and necessary for the development of the
lungs
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Patophysiology
PROM is correlated with change ofbiochemistry process of component themembranes including collagen matrix
extracellular amnion, chorionic, and apoptosisof fetal membranes
In normal condition, rupture of membranes indelivery commonly happened by uteruscontraction and stretching repeated ofmembranes
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Synthesis and degradation matrix extracellular
must be in balance condition.
Collagen degradation is mediated by
metaloproteinase matrix (MMP).
Its inhibited by specific tissue inhibitor and
protease inhibitor
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While delivery approached, degradation
activity is increased. In infection condition
occurs increase of MMPstimulating matrix
degrading enzymePROM
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Manifestation
Fluid passing through the vagina suddenly,
and then small amounts of fluid flow through
the vagina intermitently, particularly when the
increased of abdominal pressure (cough,
sneeze, et al)
Intermittent urinary leakage is common
during pregnancy, especially near term
Increased vaginal secretions in pregnancy
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Perineal moisture
Increased cervical discharge
Urinary incontinence Speculum examination appears loss of
amniotic fluid from the endocervical canal
Nitrazin paper changed from red to blue Lanugo and vernix casseosa by microscope
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Evaluation
1. History
The time of rupture and consistency of the
fluid leakage is important.
An accurate gestational age to
appropriately manage the patient
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2. Examination
- Vital sign
- Sterile speculum examination (SSE)
When visualizing the cervix, the dilation andeffacement should be noted
Nitrazin and fern tests are used to confirmrupture. Nitrazin should show a pH between
7,17,3. False positive test can be observedwith blood, semen, trichomonas, cervicalmucus, and urine
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Ferning can be falsely negative in the
presence of blood.
Cervical culture for chlamydia and
gonorrhea, and anovaginal culture for group
B streptococcus should be obtained
- Fundal tenderness
Evaluation for possible chorioamnionitis orplacenta abruption
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- Laboratory assessment
Complete blood count and urinalysis
- Ultrasound (USG)Amnion fluid index, fetal presentation,
estimated fetal weight, and gestaional age
- Fetal heart rate and contraction monitoring
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Maternal and fetal risks
Maternal risk Fetal risk
Amniotic infection syndrome (AIS)
Sepsis
Placental abruptionPostpartal atonia
Fever and endomyometritis in
peurperium
Increase CS insidency
Preterm brith
Neontal sepsis
Pulmonary hypoplasiaRDS
Contractures and deformities
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Treatment guidelines in preterm
rupture of membranes
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Conservative management
Antibiotic
- ampicillin 4x500mg/erytromicin 4x500mg
- metronidazole 2x500 mg to 7 days GA32-34 weeks hospitalize until amniotic
fluid stop to loss
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GA 32-37 weeks no in labour and infection,
administer dexamethasoneobservation
termination at 37thweek
GA 32-37 weeks in labour and non infection tocolytic agent (salbutamol), dexamethasone do
induction after 24 hours
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GA 32-37 weeks infection administer
antibiotic and induction
GA 32-37 weeks administer steroid
(Betametasone 12 mg/day single dose for 2
days), Dexametasone IM 5 mg/6hours 4X.
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Active management
GA >37 weeks do induction with oxitocin if
failed CS
Misoprostol 25g - 50g intravagina/6 hours
4X. If any infection give high dose of antibiotic
and termination pregnancy
If pelvic score 5 induction
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References
Mohr T. Premature Rupture of Membrane.Gynakol Geburtsmed Gynakol Endokrinol2009; 5(1):2836.
Prawirohardjo S. Ilmu Kebidanan. Ed 4th.Jakarta: PT. Bina Pustaka SarwonoPrawirohardjo, 2009.
Mercer BM. Premature Rupture of Themembrane in Maternal fetal Medicine:Elsevier 2010