Iran J Reprod Med Vol. 11. No. 2.

pp: 93-100, February 2013 Original article

Diagnosis of premature rupture of membranes by

assessment of urea and creatinine in vaginal washing
fluid
1 2 3
Nourossadat Kariman Ph.D. student, Maryam Afrakhte M.D., Mehdi Hedayati Ph.D., Masoumeh
4 5
Fallahian M.D., Hamid Alavi Majd M.D.

1. Nursing and Midwifery

Faculty, Ph.D. Candidate of Abstract
Reproductive Health, Shahid Background: Rupture of fetal membranes can occur at any gestational age.
Beheshti University of Medical Premature rupture of membranes (PROM) means rupture of fetal membranes before
Sciences, Tehran, Iran. the onset of labor.
2. Faculty of Shahid
Beheshti Medical School, Objective: The purpose of this study was to evaluate and compare the reliability of
Shohadaye Tajrish Hospital, the vaginal washing fluid urea and creatinine for the diagnosis of PROM and to
Tehran, Iran. determine cut-off values.
3. Obesity Research Center, Materials and Methods: A total of 179 pregnant women were recruited. All
Research Institute for Endocrine
Sciences, Shahid Beheshti patients underwent different examinations. These included nitrazine paper test, fern
University of Medical Sciences, test, amniotic fluid pooling, vaginal washing fluid urea and creatinine sampling. The
Tehran, Iran. one group consisted of 126 pregnant women between 14 and 41 weeks of gestation
4. Faculty of Shahid
with the complaint of vaginal fluid leakage. Patients who had positive pooling,
Beheshti Medical School,
Ayatollah Taleghani Hospital, nitrazine paper test and fern test were considered as confirmed PROM group (group
Tehran, Iran. 1). On the other side, patients with pooling (-) and/or nitrazine paper test (-) and/or
5. Faculty of Shahid Beheshti, fern test (-) were taken as suspected unconfirmed PROM cases (group 2). The
Para Medical School, Tehran,
Iran.
control group consisted of 53 pregnant women between 14 and 41 weeks of
gestation without any complaint or complication. Weconducted one-way ANOVA
Corresponding Author: test on the urea and creatinine measures and post-hoc comparison test. Cut-off value
Nourossadat Kariman, P.O.Box: was determined by receiver operating characteristic (ROC) curve.
1936855751, Nursing Midwifery Results: Vaginal fluid concentrations of urea and creatinine were significantly
Faculty, Shahid Beheshti different between the three groups (p<0.001). The sensitivity, specificity, positive
University of Medical Sciences,
Tehran, Iran and negative predictive values and accuracy were all 100% in detecting premature
Email: [email protected], rupture of membranes by evaluation of vaginal fluid creatinine concentration with a
[email protected] cut-off value of 0.45 mg/dl, respectively.
Tel/Fax: (+98) 9123069412 Conclusion: This study demonstrates that of two markers investigated creatinine
has the higher diagnostic power.
Received: 5 September 2011
Revised: 14 April 2012
Accepted: 19 May 2012 Key words: Premature rupture of membranes, Creatinine, Urea, Vaginal washing fluid.

Introduction preterm newborns with PROM were prolonged

20% and 25.1% respectively. Consequently,

P
remature rupture of membranes the average costs of hospitalization were
(PROM) refers to rupture of the fetal increased 30.5% and 60% respectively (11).
membranes prior to the onset of Maternal complications include clinically
labor and can occur at any gestational age evident intra-amniotic infection which occurs
nd
even at 42 week (1-4). PROM has previously in 13-60% of women with PROM in
been reported to occur in 8-19.53% of term comparison with 1% prevalence of term and
pregnancies and 2-25% of all pregnancies (3- postpartum endometritis (6, 12).
7). “PROM is a clinical diagnosis actually. It is
Besides, Nili and Shams Ansari reported a typically suggested by a history of watery
PROM prevalence of 7% in Vali-e-Asr vaginal discharge and is confirmed on sterile
Hospital of Tehran, Iran (8). PROM has been speculum examination” (3). The traditional
shown to be the cause of 18-20% of prenatal minimally invasive gold standard for diagnosis
mortalities and 21.4% of prenatal morbidity (5, of PROM relies on clinician’s ability to
9-11). Compared with normal group, the document three clinical signs on sterile
average hospitalization period of term and speculum examination: 1) visual pooling of
 Kariman et
al

94 Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February
2013
 Kariman et
clear fluid in the associated with 12- al on urea and are the most
posterior fornix of 30% false negative creatinine in important sources
the vagina or results (17). cervicovaginal of amniotic fluid in
leakage of the fluid Nitrazine test may discharge. These second half of
from the cervical also lead to false studies pregnancy (31).
os; 2) an alkaline positive or reported the Thus we
pH of the cervico- negative results accuracy of urea hypothesized that
vaginal discharge, due to probable and creatinine to vaginal fluid
which is typically contamination by determine the creatinine and urea
demonstrated by alkaline urine, PROM from 90- may be helpful in
nitrazine paper semen, blood, 100% (29- diagnosis of
meconium, 3 PROM.
(whether the
vaginitis, cervicitis 1 Indeed, the aim
discharge changes
and using ) of this study was
nitrazine paper from
antibiotics. Fern . to evaluate and
yellow to blue);
test has also 13- “Urea plays an compare the
and/or 3)
30% false negative important role in the reliability of vaginal
microscopic ferning metabolism of
and 5- washing fluid urea
of the cervico- nitrogen-containing and creatinine for
vaginal discharge 30%
false compounds in the diagnosis of PROM
(3, 4, 12). urine” (32). and to determine
Diagnosis of PROM positive
results Creatinine is a cut-off values.
is easy in the break-down product
(13,
presence of of creatinine M
14).
obvious rupture of phosphate in a
“Several studies
membranes while muscles and is
have been t
several numbers of usually produced
conducted to e
false positive and at a fairly constant
find a definite, easy, r
negative results rate and is mainly
noninvasive and i
obtained through reliable diagnostic filtered out of the
applying blood by kidneys a
test for PROM in
conventional (33). Urea and l
recent years” (18).
diagnostic methods These studies have creatinine of fetal s
in the suspected mainly focused on urine
cases of PROM biochemical agents a
may result in with high n
inappropriate concentration in d
interventions such amniotic fluid.
as hospitalization Prolactin, alpha- m
and induction of fetoprotein (AFP), e
labor (13- insulin like t
1 growth factor h
6 binding protein
) o
(IGFBP-1), fetal
. d
fibronectin (fFN),
History has Lactat and beta- s
been shown to be subunit of human
reliable only in 10 gonadotropin (β- In this
to 50 percent of HCG) have been Laboratory
patients in order to mentioned as some diagnostic analytical
diagnose PROM of these factors (7, study, sampling
(13, 14). Although 13, 14, 19-29). was performed by
inspection of fluid However, results non- probability
leakage from cervix of using (convenience)
has been aforementioned method and sample
traditionally the only tests have been size was
method for definite variable (29, 30). determined based
diagnosis of Recently, on the prevalence
PROM, it is the focus has been of PROM (5%),
Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February 95
2013
 Kariman et
=0.05 and ε=0.2. intrauterine fetal
al
This diagnostic death, known
study has been disease, prenatal
performed to complication, and
evaluate a visible blood in
diagnostic test for vaginal secretion,
PROM between use of vaginal
May 2008 and drugs or intercourse
September 2009 in the prior night,
in prenatal clinic meconium in
and delivery ward of amniotic fluid,
Taleghani Hospital, multiple
Tehran, Iran. pregnancies and
Women with regular uterine
singleton pregnancy contractions.
and gestational Demographic
age between 20- and obstetric
42 weeks were characteristics,
studied. Subjects results of
with meconium in speculum
amniotic examination, fern
fluid, visible blood test,
in vaginal secretion, nitrazine test, urea
intercourse in the and creatinine were
prior night, use of documented by the
vaginal drugs, researcher
presence of fetal according to a
anomalies, regular data form, validity
uterine of which was
contractions, confirmed by
intrauterine fetal content validity
death and prenatal method. Urea
complication were concentration was
excluded. Among measured by
185 pregnant enzymatic
women who were photometry or
admitted with the urease, and
complaint of vaginal creatinine
fluid leakage concentration was
between 14 and determined by
41 weeks of Jaffee synthetic
gestation, 126 chemical
cases were
included through
non-probability
(convenience)
sampling in the
present study.
The sample size
was determined
based on
=0.05, =0.2 and
the prevalence of
PROM (0.05). The
remaining 59
pregnant women
were excluded due
to the presence of
fetal anomalies,
96 Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February
2013
 Premature rupture of membranes by Urea and Creatinine

Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February 97
2013
calorimetric. deep vagina and (-) and fern test (-) obstetrician and all
Calibration was was immediately were taken as samples were
used to confirm transferred on control group studied in Research
validity of urea and nitrazine paper. (group 3). Institute for
creatinine PH above 6.5 Procedures Endocrine Sciences
measuring was considered described before Laboratory (which is
methods. The positive. A sample were applied to located in Taleghani
reliabilities of data of cervicovaginal control group as Hospital), by the
form and speculum secretion was taken well. same technique
physical exam were by a similar method Thereafter, and the same
confirmed by test- and was expanded vaginal washing technician in order
retest and reliability on slides. The fluid urea and to eliminate inter-
of enzymatic slides were creatinine sampling observer sampling
photometry or examined after was performed as difference.
urease, Jaffee drying by follows: Furthermore,
synthetic chemical microscope (10 5 ml of sterile diagnosis of PROM
colorimetric, fern magnification) for normal saline was was confirmed by
and nitrazine tests diagnosis of ferning injected into the AFI (Amniotic
were established by pattern. Patients posterior fornix of Fluid Index)
inter-rater who had positive vagina and then through
consistency. pooling, nitrazine was ultrasound
This study was paper test and fern aspirated by the examination by
approved by ethics test were same syringe and the
committee of considered as was sent resident of
Shahid Beheshti confirmed PROM immediately to the radiology. Cut-off
University of group (group 1). On laboratory. All value was
Medical Sciences the other side, speculum determined by
and written patients with examinations were receiver operating
informed pooling (-) and/or performed by the characteristic
consent was nitrazine paper test same (ROC) curve. All the
obtained from all (-) and/or fern test speculum
participants. (-) were taken as examinations were
Gestational age suspected done by the same
was determined unconfirmed PROM obstetrician and all
based on the cases (group 2). the samples were
first day of last From 126 studied by a
menstruation patients, 60 laboratory expert
period in reliable patients who and by the same
cases, or one fulfilled the criteria technique in order
ultrasound in less were included in to eliminate inter-
than 14 weeks or group 1 and the observer sampling
two ultrasound remaining 66 difference.
documents patients were
between included in group S
14 and 24 weeks 2. Meanwhile, t
of pregnancy. among pregnant a
Pregnant women admitted to t
women were prenatal clinic for i
examined in their regular s
lithotomy position, prenatal control t
leakage of fluid was visit, 53 pregnant i
inspected by sterile women with c
speculum and 14-41 weeks of a
results were gestational age l
registered as without any
positive, negative complaint or a
or suspicious. A complication and n
cotton tip applicator with pooling (-), a
was inserted in nitrazine paper test l
98 Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February
2013
y these groups with
s respect to these
i factors (p=0.9).
s Table II shows
Statistical the mean
analysis was concentrations of
performed by vaginal fluid urea
statistical package and creatinine
for the social among
sciences (v.16) groups. The mean
software. Results vaginal fluid urea
have been levels in
expressed as group 1, 2 and 3
frequency, mean were
and standard 13.77±5.41mg/dl
2
deviation. Chi and (range
one-way ANOVA 1.0-43), 4.71±3.64
test were used to mg/dl (range 0.2-
compare groups 32) and
with each other. 5.13±5.97 mg/dl
P>0.05 was (range 0.1-23)
considered respectively, and
statistically the differences
significant. were statistically
significant
R (p<0.001).
e Furthermore, the
s mean
u vaginal fluid
l creatinine levels in
t group 1, 2 and
s 3 were 1.58±1.01
mg/dl (range 0.5-
Demographic 7.2),
data for each group 0.36±0.23 mg/dl
are presented in (range 0.1-1.1)
table I. The and
parameters (age, 0.22±0.10 mg/dl
gestational age, (range 0.1-0.4)
gravid and parity) respectively. The
were compared differences between
with analysis of groups were
variance between statistically
groups test. There significant
were no statistically (p<0.001).
significant
differences
between groups
(p>0.05). Most of
the patients were
housewives
(groups1=91.66%,
group
2=87.87%, group
3=92.45%). No
statistically
significant
difference has been
observed between
Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February 99
2013
 Kariman et
al

96 Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February
2013
 Ethical framework in Reproductive Health
Research
Receiver operating characteristic (ROC) urea cut-off point sensitivity of 90%, specificity
curve analysis was used to establish the of 79%, positive predictive value of 83%,
optimal cut-off concentrations for vaginal negative predictive value of 87.5% and
washing fluid urea and creatinine. From the accuracy of 85% were found. Besides, the
ROC curves, 0.45 mg/dl was set as a cut-off sensitivity, specificity, positive predictive
value for creatinine and it is found that a cut- value, negative predictive value and accuracy
off value of 6.0 mg/dl is optimal for urea were all 100% in detecting PROM by
(Figure 1). evaluating vaginal fluid creatinine
The areas under the curves are 99.99% for concentration with a cut-off value of 0.45
creatinine and 84% for urea. According to the mg/dl.

Table I. The demographic characteristics of groups

Group 1 Group2 Group3
(PROM) (n=60) p-value
(Suspected) (n=66) (Control) (n=53)
Age (year) 26.25  5.40 25.46  6.0 25.54  4.69 0.85
Gestational age (week) 38.23  2.42 38.40  2.79 38.05  3.69 0.37
Gravida 1.76  1.29 1.83  1.2 1.75  1.06 0.10
Parity 0.58  1.76 0.57  0.82 0.6  0.9 0.40
The difference between groups tested with one way ANOVA (age, gestational age, gravida and parity).

Table II. Vaginal fluid urea and creatinine level (ml/dl) among groups
Group 1 Group 2 Group 3
(PROM) (n=60) p-value
(Suspected) (n=66) (Control) (n=53)
Urea (mg/dl) 13.77  5.41 4.71  3.64 5.13  5.97 0.001
Creatinine (mg/dl) 1.58  1.01 0.36  0.23 0.22  0.10 0.013
The difference between groups tested with one way ANOVA and compared with Scheffe multiple comparison tests .

ROC Curve

Source of the Curve

1.0 cr
UR
Reference Line

0.8
Sensitivity

0.6

0.4

0.2

0.0
0.0 0.2 0.4 0.6 0.8 1.0

1 - Specificity

Figure 1. Receiving operator characteristic curve for vaginal urea and creatinine Levels.

Iranian Journal of Reproductive Medicine Vol. 11. No. 2. pp: 93-100, February 97
2013
 D cervical os, all detection of PROM. diagnosis. It was
i clinical signs have In that study 10 less expensive and
s limitations in terms control patients and easier to measure
c of diagnostic 10 confirmed than hCG and AFP,
u accuracy, cost and PROM cases were and appeared to be
s technical case. included and the more accurate
s Moreover, results showed that than hCG. The
i reliance on clinical the sensitivity, second study was
o assessment alone specificity, positive reported by Gurbuz
n leads to both false- predictive value, et al (36). The study
positive and false- negative predictive group consisted of
As mentioned negative results (3). value and accuracy 54 women in their
before, a timely and Thus, we need of creatinine were third trimester of
accurate diagnosis simple, reliable 90%, 100%, 100%, pregnancy with the
of PROM is critical and rapid tests 90.9%, and 95% diagnosis of PROM
to optimize for diagnosis of respectively”(29). established by
perinatal outcome PROM. Since there They found that inspection of
and minimize is no unique and creatinine in vaginal vaginal pooling
serious noninvasive gold fluid washings is while the control
complications such standard test a useful marker group consisted of
as cord prolapse applicable to all for PROM 34 pregnant women
and infections patients with 100% with intact
including accuracy several membranes.
chorioamnionitis biochemical A cut-off value of
and neonatal sepsis markers have been 0.12 mg/dl was
(2, 34, 35). In most studied previously proposed for
cases diagnosis is (14). Despite the Creatinine and its
made according to improved diagnostic sensitivity,
the clinical value of these specificity, positive
complaints and markers, they have predictive value,
traditional methods not become popular negative predictive
(13). However, because of their value and accuracy
clinical complaint of complexity and cost in detecting PROM
patient is not (13). based on the
reliable (14). As far as we aforementioned cut-
In this regard, in know, Five studies off value were
the present study related to PROM calculated to be
only 60 patients and vaginal 100%. They
from 126 pregnant washing fluid urea concluded that
women with fluid and Urea-creatinine vaginal creatinine
leakage complaint have been measurement is
had confirmed published so far. cheaper and faster
PROM, while The first study was than other methods,
PROM could not be conducted by Li Hy and has higher
confirmed in 66 of et al (29). “The sensitivity and
them with traditional purpose of this specificity to
diagnostic study was to establish accurate
techniques. With determine the diagnosis.
the possible usefulness of The third study,
exception of direct vaginal fluid hCG, which was the
visualization of AFP and first to use
amniotic fluid creatinine urea for PROM
spurting from the measurements in diagnosis was
carried out by Kafali of urine and
and Oksuzler (31). macroscopic bloody
In that study 47 contamination,
patients with measurement of
confirmed PROM, urea and creatinine
36 patients with of cervicovaginal
suspected but washing- fluid
unconfirmed confirms an
PROM and accurate diagnosis
56 pregnant women of PROM.
without any The other
complaint or study was
complication were carried out by
included. “The Mohamed and
sensitivity, Mostafa (2011).
specificity, positive The sensitivity,
predictivity and specificity, positive
negative predictivity predictivity and
were all 100% in negative predictivity
detecting PROM by were 100% in
evaluation of detecting PROM by
vaginal fluid urea evaluation of
and creatinine vaginal urea and
concentration with creatinine
cut-off values of concentration with
12 and cut-off values of
0.6 13.2 mg/dl and
mg/dl 0.31 mg/dl
respecti respectively (38).
vely”(29 In the
).
The fourth study
related to vaginal
washing fluid urea
and creatinine
levels was
conducted by
Kariman et al (37).
84 pregnant women
in two groups, 42
confirmed PROM
and 42 controls
were included. The
mean level of
vaginal fluid urea
and creatinine in
the PROM group
was significantly
higher than the
intact fetal
membranes group.
They speculated
that in the absence
present study, we determined a cut-off value diagnosis of PROM. Furthermore, creatinine
of 0.45 mg/dl for creatinine. We have found assay with higher sensitivity and specificity is
that power diagnostic including sensitivity, a possible candidate to become the gold
specificity, positive predictive value, negative standard diagnostic test for PROM.
predictive value and accuracy of vaginal fluid
creatinine was 100%. The optimal cut-off Acknowledgments
value for urea (6 mg/dl) gave a sensitivity level
of 90%, at a specificity of 70.0%, positive The authors are grateful to all pregnant
predictive values of 83.0%, and negative women who came to our center, for their
predictive values of 87.5% and accuracy level excellent cooperation, and to the physicians
of 85%. and midwives in Taleghani Hospital for their
The analysis of data revealed that excellent technical assistance.
creatinine has a higher diagnostic power for
predicting PROM than urea. In this study, Conflict of interest
three tests including direct speculum
examination, fern test and nitrazine test were The authors declare that there is not any
applied for diagnosis of PROM. Moreover, conflict of interest.
inclusion criteria were so that interfering
factors of these tests could be controlled. References
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