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Premature Rupture of

Irwan T Rachman


membranes surrounding the amniotic

The membranes normally rupture during
Premature rupture of the fetal membranes
is defined as rupture of the membranes
before the onset of labor

Amniotic fluid performs many

functions for the fetus



Allowing the fetus freedom

to move and enabling the
skeleton to develop properly
Allowing the lungs to
develop properly
Maintaining a relatively
constant temperature
around the fetus, thus
protecting the fetus from
heat loss
Protecting the fetus from
outside injury by cushioning
sudden blows or


attributed ROM to physical

stress, particularly that associated with
Recent evidence suggests that membrane
rupture is also related to biochemical
processes, including disruption of collagen
within the extracellular matrix of the
amnion and the chorion and programmed
death of cells in the fetal membranes


rupture of membranes (PROM) refers

to a patient who is beyond 37 weeks' gestation
and has presented with rupture of membranes
(ROM) prior to the onset of labor.
Preterm premature rupture of membranes
(PPROM) is ROM prior to 37 weeks' gestation.
Spontaneous premature rupture of the
membranes (SPROM) is ROM after or with the
onset of labor.
Prolonged ROM is any ROM that persists for
more than 24 hours and prior to the onset of


term, 8 to 10 percent of pregnant women

present with premature rupture of the
increased risk for intrauterine infection when the
interval between the membrane rupture and
delivery is prolonged
Preterm premature rupture of the membranes
occurs in approximately 1 percent of all
pregnancies and is associated with 30 to 40
percent of preterm deliveries.

Schematic Representation of the Structure

of the Fetal Membranes at Term

Structure Of The Fetal


human amnion is composed of five distinct

It contains no blood vessels or nerves
the nutrients it requires are supplied by the
amniotic fluid
Amniotic epithelial cells secrete collagen types
III and IV and noncollagenous glycoproteins
(laminin, nidogen, and fibronectin) that form the
basement membrane, the next layer of the

Structure Of The Fetal


compact layer of connective tissue adjacent

to the basement membrane forms the main
fibrous skeleton of the amnion
The fibroblast layer is the thickest of the
amniotic layers, consisting of mesenchymal cells
and macrophages within an extracellular matrix
The intermediate layer (spongy layer, or zona
spongiosa) lies between the amnion and the
chorion absorbs physical stresses by
permitting the amnion to slide on the underlying
chorion, which is firmly adherent to the maternal

Structure Of The Fetal


the chorion is thicker than the

amnion,the amnion has greater tensile


associated with labor uterine contraction and repeated

stretching can make weak fetal membrane
programmed cell death and activation of catabolic
enzymes (such as collagenase)
mechanical forces
Infection (E.
( coli, B streptococci,Chlamydia trachomatis,
Neisseria gonorrhoeae,Gardnerella vaginalis,genital
Connective-Tissue Disorders (EhlersDanlos
Nutritional Deficiencies (copper, ascorbic acid)
Tobacco smoking


vaginal examination of the cervix and

vaginal cavity pooling of fluid in the vagina or
leakage of fluid from the cervix
ferning test of the dried fluid under microscopic
alkalinity of the fluid turns Nitrazine pH
indicator blue
Rapid test (i.e. AmniSure)

Management of PROM can


rest and pelvic rest to enhance amniotic

fluid reaccumulation and avoid infection
Induction of labor to reduce risk of infection
Tocolytics prophylactic tocolysis after preterm
PROM has been shown to prolong latency
Corticosteroids to reduce respiratory distress
Antibiotics to prolong pregnancy, reduce
chorioamniotis, neonatal sepsis, postpartum
endometritis, intraventricular hemorrhage

Management PROM

patients (90%) enter spontaneous labor

within 24 hours enter labor spontaneously or
to induce labor?
Hannah et al concluded that, in women with
PROM, induction of labor and expectant
management resulted in similar rates of
cesarean delivery and neonatal infection
The risk of chorioamnionitis with term PROM
has been reported to be less than 10% and to
increase to 40% after 24 hours of PROM

Premature Preterm Rupture Of

Membranes (PPROM)

occurring from 24-37 weeks' gestation

is far more difficult to manage
Prematurity is the principal risk to the fetus,
while infection morbidity and its complications
are the primary maternal risks.
PPROM remote from term should only be
cared for in facilities where a NICU is available
and capable of caring for the neonate. Because
most PPROM pregnancies deliver within a week
of ROM


PPROM occurs prior to 20 weeks'

gestation, the probability of reaching
viability is less than 5% and the risk of
pulmonary hypoplasia due to
oligohydramnios and underdevelopment
of alveolar structures and the
tracheobronchial tree is present
Midtrimester (13-26 wk) PPROM has a
dismal prognosis


appropriate therapy and conservative

management, approximately 50% of all
remaining pregnancies deliver each subsequent
week after PPROM. Very few women remain
pregnant more than 3-4 weeks after PPROM
Spontaneous sealing of the membranes does
occur occasionally (<10% of all cases)
steroids for acceleration of lung maturity,
antibiotics, and tocolytics

Management PPROM

sterile speculum examination to document ROM.

Cervical cultures (Chlamydia trachomatis and Neisseria
gonorrhoeae and anovaginal cultures for Streptococcus
Maternal vital signs should be documented as well as
continuous fetal monitoring initially to establish fetal status.
Ultrasonographic documentation of gestational age, fetal
weight, fetal presentation, and amniotic fluid index should
be established.
Digital examination should be avoided, but visual inspection
of the cervix can accurately estimate cervical dilatation.
Digital examination of the cervix with PPROM has been
shown to shorten latency and increase risk of infections
without providing any additional useful clinical information

Management PPROM

In certain circumstances (chorioamnionitis, advanced labor, fetal distress,

and placental abruption with nonreassuring fetal surveillance), immediate
delivery of the fetus with PPROM is indicated.
In a noncephalic fetus with advanced cervical dilatation (more than or equal
to 3 cm), the risk of cord prolapse may also outweigh the benefits of
expectant management and delivery should be considered.
If after initial evaluation of the mother and fetus, they are both determined to
be clinically stable, expectant management of PPROM may be considered
to improve fetal outcome. The primary maternal risk with expectant
management of PPROM is infection. This includes chorioamnionitis (1360%), endometritis (2-13%), sepsis (<1%), and maternal death (1-2 cases
per 1000). Complications related to the placenta include abruption (4-12%)
and retained placenta or postpartum hemorrhage requiring uterine curettage
The risks and potential benefits of expectant management should be
discussed with the patient and her family, and informed consent should be


broad-spectrum antibiotics
Antenatal corticosteroid treatment to
accelerate lung maturity should be considered in
all patients with PPROM with a risk of infant
prematurity from 24-34 weeks' gestation (12 mg
of betamethasone IM was given twice in a 24hour interval or dexamethasone 6 mg q12h was
given for 4 doses)
Tocolytics (i.e. MgSO4, indomethacine,
mefenamic acid, nifedipine) corticosteroids
and antibiotics, transport of the mother to a
tertiary institution with a NICU

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