PREMATURE RUPTURE

OF MEMBRANES

Mrs. Shwetha Rani C.M.

Associate Professor & H.O.D.
Department of Obstetric & Gynecological Nursing
SCPM College Of Nursing & Paramedical Sciences,
Gonda. U.P.
DEFINITIONS
• Premature rupture of membranes (PROM)
• Rupture of membranes anytime after 37weeks but before the onset
of spontaneous uterine activity.
• Preterm premature rupture of membranes (PPROM)-
• Rupture of fetal membranes prior to labor in pregnancies between 28
- 37 weeks.
INCIDENCE
• • PROM-10%
• • PPROM-3%
RISK FACTORS
• PRE-CONCEPTIONAL CAUSES-
1. Repeated genitourinary infections
2. Cervical incompetence
3. Chronic cervicitis
4. Obesity
5. Smoking
6. Low socioeconomic status
7. Nutritional deficiencies
• PREGNANCY RELATED CAUSES-
1. Polyhydroamnios
2. Multiple gestation
3. Cervical cerclage
4. Foetal abnormalities
5. Abruption
6. Previous history of PPROM (21 to 30%)
• Genital tract infections-
1. Bacterial vaginosis
2. Group B streptococcus
3. Candida
4. Mycoplasma
5. Ureaplasma hominis
6. E.coli
7. Staphylococcus
WHAT CAUSES RUPTURE OF MEMBRANES??
• • Rupture of the membranes near the end of pregnancy (term) may
be caused by a natural weakening of the membranes or from the
force of contractions.
DIAGNOSIS
• History
• Valsava maneuver
• Sterile Speculum exam (Pooling)
• Nitrazine testing/litmus paper test
• Fetal Fibronectin
• Ultrasonography
• Microscopic Fern testing
• Amnisure
• High vaginal swab
• Urine routine,culture
Nitrazine paper testing
• Turns blue in presence of alkaline Amniotic fluid
• 93.3% sensitivity
• False positive (1-17%) for urine, blood, semen BV
Fern test
• Fern test refers to visualization of a characteristic 'fernlike’ pattern on
a slide viewed under low power on a microscope.
• A small amount of cervical mucus is allowed to air-dry on a clean,
saline-free glass slide.
• If positive for amniotic fluid, this crystal formation will be present in
most microscopic fields.
Foetal fibronectin assay
• fFN present in cervical secretions <22 wks, >34 wks
• Used for assessment of potential PTB
• Positive result (>50 ng/dl) may be indicative of PROM and represents
disruption of decidua-chorionic interface
• In PPROM, Sensitivity-98.2%
Ultrasonography
• 50-70% of women with PROM have low amniotic fluid on USG.
• Mild reduction requires further investigation.
• Rule out other causes (Renal agenesis, obstructive uropathy).
Amnisure
• Detects PAMG-1 (placental microglobulin)
• 99% sensitivity, 100%specificity
• PAMG-1 is a protein produced by cells of decidual part of placenta
and can be detected in amniotic fluid after rupture of membranes.
• Recently approved by FDA in US.
MANAGMENT
• MANAGEMENT DEPENDS ON THE FOLLOWING FACTORS
1. Gestational age
2. Availability of NICU
3. Fetal presentation
4. FHR pattern
5. Active distress (maternal/fetal)
6. Cervical assessment
Initial Assessment
• Assess for Maternal-Fetal distress.
• Assess for Proper dating/GA.
• Assess for infection.
• Exclude occult cord prolapse.
• Maternal-Fetal Distress evaluated by Maternal vitals, labs, general
condition,
• Fetal distress assessed by FHR pattern, USG, NST.
• First priority is to rule out maternal-fetal distress and imminent
delivery.
• Ensure through prenatal records that early US correlate with LMP is
most accurate.
• Rule out infection through absence of clinical signs and symptoms of
chorionamniotis in addition to assessment of lab values and amniotic
fluid samples
• Evaluate maternal serum lab values for leukocytosis, left shift, and
elevated C-Reactive Protein. Evaluate Amniotic fluid samples for gram
stain, WBC count.
SECONDARY ASSESSMENT
• Fetal position
• Cervical assessment
• Determine lung maturity
• Quantify amniotic fluid
INDICATIONS FOR DELIVERY
• Maternal-Fetal Distress
• Infection
• Abruption
• Cord Prolapse
EXPECTANT MANAGMENT
• Typical for GA 32 weeks or less
• Bed rest
• Steroids for lung maturity
• Tocolytic if indicated for lung maturity
• Antibiotics
• Fetal Surveillance
• Assess for Chorioamnionitis
• Infection can be both a cause and a consequence of Preterm Rupture
of Membranes.
• Most patients require close inpatient observation. Those who might
qualify for outpatient management include the extreme previable
gestation patients and those who have appeared to have resealed
(which is approximately about 5% of PROM patients).
PPROM BETWEEN 32 TO 34 WEEKS
• Expectant management
• Deliver at 34 wks
(Unless documented fetal lung maturity)
• GBS prophylaxis
• Antibiotics
• Corticosteroids
MANAGEMENT RATIONALE
• Antibiotics
1. Prolong latency period
2. Prophylaxis of GBS in neonate
3. Prevention of maternal chorioamnionitis and neonatal sepsis
• Corticosteroids
1. Enhance fetal lung maturity
2. Decrease risk of RDS, IVH, and necrotizing enterocolitis
• Tocolytics
1. Delay delivery to allow administration of corticosteroids
• Antibiotics
1. Ampicillin 2 g IV 6 hrly for 2 days
2. Amoxicillin 500 mg po TDS x 5 days
3. Azithromycin 1 g po x 1
4. Erythromycin 250mg TDS for 5 days
• Corticosteroids
1. Betamethasone 12 mg IM OD for 2 days
2. Dexamethasone 6 mg IM BD for 2 days
• Tocolytics
1. Nifedipine 10 mg po after every 20min 3 times, then 6 hrly for 2 days
RISK-BENEFIT EXPECTANT MANAGMENT
RISKS
• Abruption
• Chorioamnionitis
• Cord Prolapse
• Endometritis (1/3)
• Oligohydroamnios tetrad (FLIP)

BENEFITS
• Mature lung profile
• Advancing GA (reducing risks associated with PTB)