2. Learning Objectives
At the end of this session, you will be able to
Define what PROM is
Explain type of PROM
List out the causes of PROM
Describe risk of PROM
Discuss management of PROM
May 25, 2023
2
3. Premature Rupture of the Membrane(
PROM)
definition
is the rupture of the chorion and amnion after 28 week of
gestation and one hour or more before the onset of
labour.
NB
Latency period: is the interval between the rupture of
membranes(ROM) & the onset of labor
Prolonged PROM is rupture of membranes for> 8-12 hrs
Term PROM is rupture of membranes after 37 completed
weeks of gestation
Pre term PROM: is rupture of membranes before 37
completed weeks of gestation
3
5. Etiologic and predisposing
factors
The precise cause of PROM is unknown,.
However it is known to be associated with.
Mal presentations
Weak areas in the amnion and chorion
Vaginal infection
Incompetent cervix
5
6. cont
Diagnosis
An accurate diagnosis is crucial to the management
of suspected ROM Most cases can be diagnosed on
the basis of the history & physical examination.
6
7. cont
History
Most commonly the patient presents with history of a
large gush of f1uid from the vagina followed by
persistent uncontrolled leakage .
Some patients have only small, intermittent leakage
may soak clothing or bedding
Fluid may be seen on clothing or on sanitary pads
Fluid can usually be seen at the introits
Typical odor of amniotic fluid confirm the diagnosis
7
8. cont
Physical examination
General examination to rule the presences of maternal
and fetal infection
Free flow of fluid from cervix! presence of
meconium/vernix
Ask the women to cough' this may cause a gush of
fluid
In addition during speculum examination note the
following
Rule out the presence of a cord prolapse
Asses the state of the cervix (effacement and
dilatation)
8
9. DIAGNOSIS OF PROM
1. History of gush of fluid per vaginum followed
by continuous trickling that moists vulval pads.
NB: Vulval pads can be moistened with urine or
other vaginal discharge.
2. Sterile speculum examination: Visualization of
a pool of fluid in the posterior vaginal fornix with
evidence of clear fluid passing from the cervical
canal.
NB: Digital cervical examinations should not be
performed in patients with PROM who are not in
labor and in whom immediate delivery is not
planned.
9
10. Cont..
3. Nitrazine paper test: the color turns from yellow
to deep blue, due to alkalinity of the amniotic
fluid.
NB: Blood, semen or presence of vaginal infections
make the environment alkaline, giving the same
result.
4. Fern test: - Visualization of fern-like pattern of
dried amniotic fluid on a glass slide under
microscopy due to presence of protein.
NB: Protein may be present in urine.
10
11. 5. Ultrasound: is an ideal non-invasive techniquefor
the detection of the residual amount of amniotic fluid.
Oligohydramnios is diagnosed if the measurements
of the largest pocket of the amniotic fluid are less
than 2cm.
The largest pocket is usually present between the
anterior shoulder and the neck.
6. Dye injection: - through abdominal needle under
ultrasonic guidance into the amniotic sac and
observation of its passage through the external os or
even in the vulval pad.
11
12. Cont..
Eg. Ultrasonographically guided transabdominal
instillation of indigo carmine dye (1 mL in 9 mL
sterile normal saline), followed by observation for
passage of blue fluid from the vagina within 30
minutes of amniocentesis.
12
13. Complications:
1. Preterm labor: with the risk of prematurity like
respiratory distress syndrome, necrotizing
enterocolitis, intraventricular hemorrhage, sepsis,
hypoglycemia, and hypothermia.
2. Infection: chorio-amnionitis, septicaemia and
fetal Pneumonia.
3. Fetal skeletal deformities and distress: due to
oligohydramnios.
4. Postpartum endometritis.
13
14. (chorioamnionitis):
1. Maternal Temperature ≥ 38°c
2. Uterine tenderness
3. Foul smelling amniotic fluid through the vagina
4. Maternal or fetal tachycardia
5. Increased WBC count
14
15. Management of PROM
Management 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.
15
16. General Management
Confirm the diagnosis, & once the diagnosis is
confirmed admit the woman to a hospital.
Assess -maternal & fetal well being & check for signs
of labor
Determine gestation age form the last normal
menstrual period, milestones of pregnancy or
ultrasound
16
17. cont
Determine fundal height which will mostly be less
than gestational age
Ascertain Fetal presentation
Determine cervical status- by sterile speculum
examination (avoid digital examination)
Do cervical swab may be taken this time (if not
for immediate delivery) & determine CBC
17
18. cont
Check for signs of intra-amniotic infection
(chorioamnionitis) including
Maternal fever
Fetal tachycardia ((FHB > 160 beats per minutes)
Tender uterus
Purulent cervical discharge
Leukocytosis &/or positive bacterial culture (if later in
the course)
18
19. cont
If there are signs of uterine infection at any time during
the pregnancy, Manage as chorioamnionitis:
1. Start treatment with broad-spectrum, high dose. IV
antibiotics
Penicillion, Gentamycin & Metronidazole is a good
combination
Doses - Ampicillin 2gm IV Q 6 hrs for 7-10 days
Gentamycin 80mg IV Q 8hrs for 7-10 days
Metronidazole 500mg P.O Q 8hrs (IV is best, if
available)
19
20. cont
Alternatives for Metronidazole could be
Clindamycin 900mg IV Q 8hrs (best, if available)
Chlorapmhenicol 1gm IV Q 6hrs
Single agent treatment with Ceftriazone
1 gm IV Bid/10 days
20
21. cont
Induce labor & expedite delivery, without any delay
despite the GA;
Consider cesarean section if abnormal labor occur.
Continue antibiotics post partum, at least for 24hrs
after the mother becomes non febrile
Further management of PROM, without evidence for
infection, depends upon the gestational
21
22. 1. Gestational age greater than 34 weeks
I. Rupture of fetal membranes greater than 8 hours
and no previous c/s:
- Start Ampicillin 2gm IV QID until delivery
- Start induction with oxytocin if no labor
- Caesarean delivery is indicated in malpresentations
II. Rupture of fetal membranes greater than 8hours
and previous c/s:
- Prophylactic antibiotics (eg. Ampicillin 2gm iv stat)
- Immediate cesarean delivery
22
23. Cont..
III. Rupture of fetal membranes less than 8 hours
and no previous c/s:
- Follow fetal and maternal condition for spontaneous
onset of labor for total of 8 hours duration and then
start induction if labor does not start
- Caesarean delivery is indicated immediately in mal
presentations
23
24. cont
IV. Rupture of fetal membrane less than 8hours
and previous c/s:
-Depends on mother‘s preference whether she wants
observation for spontaneous onset of labor for 8
hours or immediate delivery by cesarean.
-Caesarean section is indicated immediately in mal
presentations
24
25. 2. Gestational age between 28- 34 weeks
and alive fetus
I. Rupture of fetal membranes in absence of
infection:
Ampicillin 2gm IV QID for 48 hours then amoxicillin
500 mg PO TID for 7-10 days.
Erythromycin 500 mg IV QID for 48 hours then 500
mg PO QID for 7-10 days.
Start dexamethasone 6 mg IM BID for four doses or
Betamethasone 12 mg IM daily for two doses.
Follow till 34-37 weeks of GA or till an indication for
delivery comes into picture during follow up.
25
26. II. Rupture of fetal membranes in presence of
infection and no previous c/s:
- Start Ampicillin 2gm iv QID + Gentamycin 80 mg IV
TID (Ceftriaxone 1 gm IV BID alone)
- Start induction with oxytocin if no labor
- Caesarean delivery is indicated in malpresentations
26
27. III. Rupture of membrane with fetal death or
severely malformed fetus:
- Deliver immediately with induction if there is no
previous c/s or by cesarean if there is previous c/s.
NB: Tocolysis may be utilized in patients with
preterm PROM to permit administration of antenatal
corticosteroids and antibiotics.
27
28. Immediate delivery of the fetus may be
indicated in the following circumstances:
Malformed fetus
chorioamnionitis (maternal fever, uterine
tenderness, maternal or fetal tachycardia, offensive
vaginal discharge)
non-reassuring fetal testing
fetal death,evidence of placental abruption with
significant vaginal bleeding
active labor with advanced cervical dilation and/or
fetal mal presentation with increased concern for
umbilical cord prolapse
28
29. Expectant management
Expectant management, when chosen at any
gestational age, consists of the following principles.
1. Avoid digital cervical (pelvic ) examination
2. Advise bed-rest, to potentially enhance amniotic
fluid re- accumulation & possible delay onset of
labor.
3. Complete pelvic rest- to avoid infection
29
30. 4. Use of steroids, as in pre term labor, to accelerate
fetal lung maturity are indicated unless there is
evidence of chorioamnionitis (except for term
PROM).
One can use either
Betamethasone 12mg IM q 24hrs, for 2 doses (or
every 12 hrs) or
Dexamethasone 6mg IV q 12hrs for 4 doses (or
every 6hrs)
30
31. 5. Provide prophylactic antibiotics
Give Amoxacillin 500 mg &
Erythromycin 500 mg P.O. every 8hrs
for 7 days, if delivery doesn't occur
(may be started as Ampicillin 2gm IV
QID &
Erythromycin 500 mg IV QID for 48
hrs).
31
32. Management of PROM with viral
infection (Herpes genitalis and HIV)
Route of delivery is abdominal by c/d if duration of
rupture of fetal membranes is less than 4 hours and
active herpes genitalis is present
32
34. Learning Objectives
At the end of this session, you will be able to:-
Define preterm labour
Describe causes of preterm labour
Discuss management of preterm labour
35. Definition:
defined as regular uterine contractions
associated with cervical change
occurring before 37 weeks gestational
age
Preterm birth is a major contributor to
developmental delay, visual and hearing
impairment, chronic lung disease, and
cerebral problems.
Neonatal morbidity and mortality
increase as the gestational age at
delivery decreases.
36. . Epidemiology
Preterm birth complicates 10-12% of
all live births
Preterm labor occurs in 10-15% of all
pregnancies
75% preterm births occur
spontaneously after preterm labour
and preterm premature rupture of
membranes (PPROM)
37. 20-30% of all preterm births occur
because of a medical or obstetric
disorder that places the mother or
fetus at significant risk for serious
morbidity or mortality
38. Cause
Idiopathic (>50%)
The following are however related with increased
incidence of preterm labour
A. History
Privious Hx of induced or spontaneous abortion or
preterm delivery
Asymptomatic bacteruria or recurent UTI
Smoking habbits
low socioeconpmic & nutritional status
39. B. Complication in previous pregnancy
Maternal
Pregnancy complication such as preeclampsia,
APH, PROM, polyhydraminious
Medical & surgical illness like acute fever, acute
pylonephritis, diarrhea, acute appendicitis,
toxoplasmosis & abdominal opration
Chronic disease such as HTN, diabetics, sever
anemia
Genital tract infections such as bacterial vaginosis,
beta hemolytic streptococcus, chlamydia,
mycoplasma
42. Presentation of the women
Regular uterine contractions with or with out pain(at
least 1 in 10
minute)
Dilatation (>2cm) & effacement (80%) of the Cx
Pelvic pressure, backache and/or vaginal discharge
Management
The objective of management are:
To minimize the risk of perinatal mortality & morbidity
To preserve maternal health
43. Management approach
To prevent the onset of labour if possible
To arrest preterm labour if not contraindicated
Appropriate management of labour
Effective neonatal care
44. Prevention
The risk of delivery of LBW baby has to be weighed against
the risks to the unborn or to the mother if pregnancy
continue
Identification of the risk factors from the history and
employing measure for rectification such as adequate
rest, nutritional supplementation, avoidance of smoking
For premature effacement of Cx:- the women are to be put
to bed rest & tocolytic agent may be administered
45. Cont…
Selective continuation of complicated pregnancies
such as twins, Polyhydramnios, placenta previa,
preeclampsia with rest and appropriate therapy
Admit to hospital for close observation
Confirm genitalia before induction
46. Management
Tocolysis
Treatment with tocolytic medications
may not reduce the rate of preterm birth,
but it may delay delivery for 48 hours
and reduce the associated
complications.
The time gained allows for transfer to a
tertiary center or corticosteroid
administration.
47. Investigation
CBC
U/A, culture & sensitivity
Endocervical swab for any causative
organism
Ultrasonography for fetal well-being,
cervical length & placental localization
Serum electrolyte & glucose levels when
tocolytic agents are to be used
48. Medications used for tocolysis
Magnesium sulphate:4-6gm loading dose IV over
30min,then 2-4gm/hr
Beta-adrenergic agonists: Ritodrine, Terbutaline
Prostaglandin synthase inhibitors:
indomethacin
calcium channel blockers: Nifedipine.
49. To arrest preterm labour
Attempt to arrest preterm labour may be taken in about
10-20 % of women where:
The fetus is not compromised
The maternal condition remains good &
membrane are intact
50. CONT…
The following regime may be instituted in an
attempt to arrest preterm labour
Adequate rest in bed ; the women is to lie
preferably in left lateral position
Adequate sedation is ensured with diazepam
5mg PO or phenobarbitone 30-60 mg Bid or tid
50
51. Cont...
Adequate hydration is maintained
Antibiotics are given if infection is evident or culture report
suggest
Tocolytic agents(terbutalin, ritodrin,etc) are administered to
inhibit uterine contraction
It can be used as short term (1-3 days) or long term
therapy
52. CONT…
Short term therapy: this is used
1. To delay delivery for at least 24 hr;
glucocorticoide therapy to the mother to enhance
fetal lung maturation if preterm labour starts before
34th weeks
2. To enable transfer of the women with the baby
in utero to a unit more able to manage a preterm
neonate
52
53. Long term therapy
Instituted if pregnancy is to be prolonged for
at least one week following established onset
of labour prior to 34th week
Glucocorticoid therapy
Maternal adminstration of glucocorticoid
therapy is advocated where pregnancy is <
34 weeks
54. Cont…
This helps in fetal lung maturation so that
the incidence of RDS can be minimized
Either betamethaasone(Betnsol) 12 mg IM
every 12 hrs for 2 doses or
dexamethazone (Decardrone) 6 mg IM
every 6 hrs 4 dose is given
54
55. Cont…
Long term therapy
If the delivery is delayed for > 7 days after
injection, treatment must be repeated
Management of preterm labour
Labour is judged to have started when the
women experience regular, painful uterine
contractions accompanied by either show,
rupture of membrane or complete
effacement of the cervix
56. Cont…
First stage of labour
Bed rest to prevent early rupture of
membrane
Oxygen is given by mask to ensure
adequate fetal oxygenation
Strong sedative or acceleration of
labour is to be avoided
56
57. Cont…
Epidural analgesia is the choice
Progress of labour should be
monitored clinically or preferably by
electronic monitoring
In case of delay or anticipating a
tedious traumatic vaginal delivery, it is
better to deliver by C/S
58. Cont…
Second stage of labour
The birth should be gentle & slow to
avoid rapid compression &
decompression of fetal head
Liberal episiotomy should be done under
local anesthesia, especially in
primigravida to prevent head
compression
58
59. Cont…
Preterm fetus befor 34th weeks presented by
breech, are generally delivered by C/S
Immediate management
Provide immediate new born care with a special
emphasis on the ff points
Clamp the cord quickly to prevent hypervolemia &
dev’t of hyperbilirubinemia
The cord length should be 10-12 cm; in case
exchange transfusion will be required due to
hyperbilirubinemia
Clear the air way promptly and gently
Adequate oxygenation must be provided
