3. OBJECTIVE
At the end of this lesson the learners
will be able to:
• know the definition of PROM
• identify the signs and symptoms of PROM
• understand the diagnosis and differential diagnosis of PROM
• Famiiarize the signs and symptoms of PROM
• Practice the management and preventive modalities of
PROM.
4. INTRODUCTION
• Pre-labor rupture of membrane (PROM) , previously
known as pre-mature rupture of membranes ,is a
breakage of the amniotic sac before the onset of
labor.
• Women usually experience a painless gush or a
steady leakage of fluid from the vagina.
• If it occurs before the 37 weaks it is known as
PPROM (pre-term pre-labor rupture of membrane).
5. DEFINITION
Pre-labor rupture of membrane is a rupture of
membranes (ROM) after 28 weaks of gestation and
one hour before the onset of labor.
PROM is the spontaneous rupture(breakage) of
amniotic sac before the onset of labor.
6. INCIDENCE
• About 8% of term pregnancies are complicated by
PROM.
• 30% of pre-term births are complicated by PROM.
• Before 24 weaks PROM occurs in fewer than 1% of
pregnancies.
7. RISK FACTOR
Among the risk factors of PROM:
infections
low socioeconomic status that leads to nutritional deficiency
previous history of PROM or preterm labor
polyhydraminos
Multiple gestation
invacive procedures e.g amniocentesis
cervical insufficiency
9. SIGN AND SYMPTOM
Fluid leakage
increased vaginal discharge
change in fetal movement
pelvic pressure
contractions
signs of infection
abdominal pain or cramping
Lanugo hair
10. TYPES
Term PROM
When the fetal membranes rupture early,at least one hour
before labor has started.
Prolonged PROM
a case of pre-labor rupture of membrane in which more
than 18 hours has passed between the rupture and the
onset of labor.
11. TYPES CONT..
Preterm PROM
Prelabor rupture of membranes that occurs before 37
weaks gestation.
Midtrimester PROM
prelabor rupture of membranes that occurs before 24
weaks gestation
12. DIAGNOSIS
History
A sudden gush or intermittent or continuous leaking
of clear fluid from the vagina before the onset of
labor.
Physical examination
Abdominal examination: common findings include
fundal eight may be less than the GA.
Pelvic examination: inspection of the externa
genitalia : leakage of liquor per vagina.
Note: avoid digital pelvic examination in all
cases of
preterm PROM
13. DIAGNOSIS CONT...
Speculm examination:
• Observation of amniotic fluid coming out of the
cervical cannal and/or presence of prolapsed
cord.
• Presence of meconium , vernix casosa or lanugo
hair in the fluid pooling indicates PROM and
presence of uriniferous smell suggests urinary
incontinency.
• Inspect for cervical dilation (open or closed).
14. DIAGNOSIS CONT...
Ferning test
Obtain fluid by swabbing the posterior fornix (avoid cervical mucus
to decrease chance of false positive result).
Spread some fluid on a slide & let it dry for at least 10 minutes.
Examine it with a microscope and look for a fern-leaf pattern
The test is not affected by meconium, vaginal PH & blood.
15. DIAGNOSIS CONT...
Nitrazine paper test
Hold a piece of Nitrazine paper in a hemostat (artery forceps) &
touch it against the fluid pooled on the speculum blade.
A change from yellow to blue indicates presence of amniotic fluid
False negative tests results can occur when leaking is intermittent or
the amniotic fluid is diluted by other vaginal fluids.
False positive results can be due to the presence of alkaline fluids in
the vagina, such as blood, seminal fluid, or soap.
16. DIAGNOSIS CONT...
Pad test
Can be helpful when there is no pooling & no visible leakage from cervix.
Place a vaginal pad over the vulva and encourage moving around.
Examine the pad an hour later visually and by smelling (odour).
Wetting with no urine and no vaginal discharge (vaginitis) may suggest PROM
Dye test – it is gold standard method that provides highly accurate and
definitive results
indigo carmine, is injected into the amniotic sac through a procedure called amniocentesis. If the
membranes have ruptured, the dye will leak into the vaginal canal and can be detected externally
17. DIFFERENTIAL DIAGNOSIS
Leucorrhea gravidarum
Vaginal discharge (excessive)
Urinary incontinency
Perspiration
Ruptured cyst ( like in the vagina)
18. MANAGEMENT
Management of PROM depends on:
Gestational age, duration of rupture of fetal
membranes, fetal condition (dead, fetal distress,
congenital malformations), presence of infection,
labor and previous
cesarean scar, and other obstetric indications.
19. MANAGEMENT CONT...
Indications for expedite delivery:
onset of labor,
gestation age ≥ 37wks,
evidence for nonreassuring fetal status,
evidence for chorioamnionitis,
lethal congenital anomalies,
intrauterine fetal death,
if there is high risk of cord prolapse (e.g., transverse lie) and
abruptio placenta
o Note that if the gestational is below 34 weeks and both the fetal and
maternal conditions are stable, expectant management can be
considered
for abruption placenta in a setting where close follow up is possible
20. MANAGEMENT CONT....
Expectant management
Admit to the ward (Transfer patients with early preterm
PROM to a higher healthfacility with newborn intensive
care, if possible).
Avoid digital cervical (pelvic) examination.
Advise bed-rest, to potentially enhance amniotic fluid
re-accumulation & possibly delay onset of labor.
Provide corticosteroids and antibiotics.
Administer antenatal corticosteroids (betamethason12
mg intramuscularly 24 hours apart for two doses or
dexamethasone 6 mg IM 12 hours apart for four doses)
for lung maturity.
21. EXPECTANT MANA..CONT..
Note that if preterm birth is considered imminent,
treatment for short duration still improves fetal lung maturity
and chances of neonatal survival.
Antenatal corticosteroid therapy should not be
administered in women with chorioamnionitis.
Antibiotics
Ampicillin 2gm IV QID and Erythromycin 250 mg P.O QID
for 48 hours followed by Amoxicillin 500 mg P.O TID &
Erythromycin 250 mg. P.O QID for 5 days.
Azithromycin may be substituted for Erythromycin with
regimen of 500mg PO on day 1 followed by 250mg PO
daily for 6 days.
22. CONT…
Neuroprotection
If gestational age is less than 32 weeks and preterm birth is
likely within the next 24 hours, consider magnesium sulfate
for neuroprotection
Monitoring and follow up
Monitor the following clinical features during expectant
management of PROM:
Maternal pulse & temperature - every 4-6 hours
FHR - every 4-6hrs (& if possible CTG 2x daily)
Uterine tenderness or irritability (or pain) – daily
WBC count & differential - changes, every 2-3 days
Amniotic fluid appearance & odor – daily
23. CONT…
Labor and delivery for term PROM without infection:
If cervix is favorable, labor is induced, unless there
are contraindications to labor or vaginal delivery, in
which case cesarean delivery is performed.
If cervix is unfavorable, ripen the cervix (preferably
with PO misoprostol).
Institute antibiotic (Ampicillin 2gm IV QID) when the
duration of ROM >12hrs.
Follow for features of chorioamnionitis (maternal
fever, tachycardia, leukocytosis,uterine tenderness,
offensive vaginal discharge and fetal tachycardia).
24. COMPLICATIONS
Maternal:
Chorioamnionitis is the most common maternal
complication after PROM .
the risk increases as the duration of membrane
rupture more prolonged .
APH: abruption placenta can cause PROM or
subsequent subsequent to membrane rupture.
Preterm labor/birth
25. COMPLICATIONS CONT...
Fetal and neonatal complications :
Fetal distress -due to umbilical cord compression or
placental abruption.
Fetal death -complicates 1% to 2% of cases of
conservatively managed PROM
Prematurity and its complication e.g RDS,IVH,NEC
Fetal and neonatal sepsis
. PROM that is prolonged for >18 hours is a risk for
fetal and neonatal sepsis.
.PROM increases the risk of neonatal sepsis two
fold .
26. PREVENTION
Regular prenatal care
Screening for infection e.g bacterial
vaginosis and STD
Nutritional support
Avoid excessive physical activity
Cervical cerclage for women's who have
cervical insufficiency.
Limit the use of invasive procedures.