1. Premature Rupture of membrane
(PROM)
By:-Abdu S. (BSc, MSc)

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

4. Cont..
Incidence:
 PROM occurs in approximately 8-10% of
pregnancies.
 Preterm PROM complicates 3% of pregnancies.
4

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

33. Preterm labour
By:-Abdu.S (BSc, MSc)

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

40. Fetal
Multiple pregnancy, congenital malformation, IUFD
Placental
Infarction, thrombosis, placenta previa or abruption

41. Cont…
41

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

60. Thank you !