CASE REPORT

PREMATURE RUPTURE
OF MEMBRANE

Muchamad Melvin Nur

(2012730065)

Supervised by:
dr. Mutawakkil J Paransa, SpOG

Department of Obstetrics and Gynecology

R Syamsudin SH Hospital
Muhammadiyah Jakarta University
Case
Patients Identity
Name : Mrs. S

Date of birth / Age : December 30th 1995 / 21 year-old

Nationality : Indonesian

Address : Kp. Kubang Keong 04/04

Education : Senior High School

Marital status : Married

Occupation : Housewife

Religion : Moslem

Date of admission : July 10th 2017 (03.00 AM)

History Taking

Chief Complaint

Patient had watery vaginal

discharge since 3 hours
before admission to the
hospital
History of Present Illness
- Watery vaginal discharge since 3 hours before
admission to the hospital.
- The discharge that slowly leaking through her
vagina. The discharge had a non-itching, no fishy
odor, clear, and watery consistency.
- Patient never had any experienced like this before.
- Patient denied any bleeding from her vagina. Fever
during pregnancy, abdominal pain, and any
vaginal discharge prior to this is denied
- Patients denied any urinary tract infection
symptoms such as pain during urinate. She denied
any urinary complaints.
History of Past Illness & Family
History
History of hypertension : - History of hypertension : -

History of asthma :- History of asthma :-

History of diabetes mellitus: - History of diabetes mellitus: -

History of allergy :- History of allergy: -

History of hematologic
disease: -

History of trauma :-

History of past surgery: -

History of tuberculosis :-
Contraception History

Never used contraseption

Menstruation History

Menarche : 13 years old

Menstrual cycle : 28 days, regularly, with
duration of 5-7 days, dysmenorrhea (-)
Total pads : 3-5 pads (40-60 mL)
First day of last menstrual cycle: October
15th 2016
Antenatal Care

9 visits at an obstetrician clinic

Iron supplementation, folic acid, fish oil
capsules

Marital History

Married once; a years

Physical Examination
General condition :moderately ill

Consciousness :compos mentis

Blood pressure :120/80 mmHg

Heart rate :97 bpm

Respiratory rate :22 x/minute

Temperature :36,7C

Weight :63 kg

Height :164 cm

BMI :23.5 kg/m2

General Examination
Eyes : anemic conjunctiva -/-, icteric sclera -/-

Mouth: wet oral mucosa membrane

Neck : thyroid enlargement (-), trachea is in the middle

Thorax
Heart: regular 1st and 2nd heart sounds, murmur -, gallop
Lung: Inspection: symmetric chest expansion in both static and
dynamic breathing, percussion: sonor on both lungs, Auscultation:
vesicular breath sounds +/+ regular, rhonchi -/-wheezing -/-
General Examination
Mammae : hyperpigmentation of areola +/+,
nipple retraction -/-, breast milk -/-

Abdomen
Inspection : convex, striae gravidarum +, linea
nigra +
Palpation : supple in all abdominal region,
tenderness
Auscultation : bowel sound +, 10x/minute

Extremities :warm, edema -/-/-/-, physiological

reflex ++/++/++/++, pathological reflex --/--
Obstetric Examination
ANC: 9 visits to obstetrician Fetal presentation: head
clinic during this pregnancy. presentation

First day of last menstrual His: (-)

period: October 15th, 2016
Leopold 1 : buttocks
Gestational age: 37- 38 weeks
according to first day of Leopold 2 : back on the
menstrual period left, extremity on the right

Fundal height: 32 cm Leopold 3 : head

Expected birth weight: (32-13) Leopold 4 : convergent,

x 155 = 2945 gr 5/5

Fetal heart rate: 140x/ minute

Obstetrics Examination
Inspection : vulva edema -, secrete +, blood -, cicatrix -

Inspeculo : pooling of fluid in the posterior fornix, acid base

testing paper: pink blue

Digital vaginal examination: Vulva and vaginal within normal limit,

position: anterior, cervical dilatation 2 cm, cervical effacement
20%, consistency: thick and soft, amnion sac not intact,
presentation: head, station: Hodge 1
 Laboratory Examination

Types Results Units Normal Value

Routine Hematology
Hemoglobin 11.9 g/dL 12 14
Hematocrit 36 % 37 47
Leukocytes 13.800 /uL 5900 16900
Platelets 326 Thousands/uL 150- 450
Eritrocyte 4.2 Millions/ uL 3.8-5.2
MCV 90 fL 80-100
MCH 29 pg 26-34
MCHC 33 g/dL 32-36
Thrombocyte 251 Thousands/uL 150-450
Admitting Diagnosis
G1P0A0, 21 years old, 37-38 weeks of gestation
according to first day of last menstrual period, not in
labor with premature rupture of membrane with
single intrauterine live fetus, head presentation

Management
Ringer Lactate + 1 ampule of Oxytocin (12 drip per
minute, increased 4 drip per minute every 15
minutes) max 60dpm
Cefotaxime 3 x 1 gram IV
Vaginal toucher every 4 hours
Follow up until delivery

09.30 01.15
03.45 05.30

Uterine UC: 3x (15- 30s) UC: 4x (40- 45 s) UC: 5x (40-55 s)

Contraction: - FHR: 137x/min FHR: 140x/ min FHR: 140x/ min
FHR: 140 x/ min Oxy: 28 dpm
Oxy: 40 dpm Oxy: 40 dpm
Oxy: 12 dpm
VT: anterior, VT: portio isnt
dilatation 3 cm, palpable ,
effacement amnion sac not
20%, intact,
consistency: presentation:
thick and soft, head, station:
amnion sac not Hodge 2
intact, Delivery is
presentation: conducted
head, Hodge 1
Delivery Report
Patient was positioned in lithotomy position, and prepped and
draped in the usual sterile fashion for a vaginal delivery

After the babys head is seen, start giving the support to the mother

Cover the perineum with sterile fashion and delivery oh the head then
the anterior and posterior shoulder and also the buttocks

The baby was born at 1.30 p.m then spontaneously cry

After the baby was delivered completely, administer oxytocin 10 IU IM

at lateral portion of proximal lower extremity, the cord was clamped
and cut between 2 clamps. Placenta was delivered completely at
2.55 p.m

Observation of in labor stage IV for 1 hour

Vaginal delivery was done with total of blood loss 800 mL

Final Diagnosis
P1A0, 21 years old, post partus maturus with
spontaneous vaginal delivery with premature
rupture of membrane.

Neonatal Diagnosis
Term male neonate, 37-38 weeks of gestational age
according to New Ballard Score, birth weight
3350gram, 50 cm, APGAR score 7/9. Diagnosed as
healthy neonate.
Post Delivery Therapy
Cefadroxyl 2 x 500 mg

Mefenamic acid 3 x 500mg

Metergin 3 x 0.125 mg

Hb observation 6 hours post partus

Follow up
July 11th 2017

S O A P
Pain on the General condition: mildly ill P1A0, 21 Cefadroxil 3 x
stitching side Consciousness: cm years old, 500 mg
(perineum), BP: 100/70 mmHg post partus Mefenamic acid
HR: 88 bpm, RR: 20 x/min
defecating - maturus with 3 x 500 mg
Temperature: 36,9 C
, farting -, spontaneous
nausea -, General examination: vaginal Patient allowed
vomiting -, within normal limit delivery, with to go home
headache -, premature
urinating + Puerperium examination: rupture of
Mobilization : Active membrane
Fundal height: 2 fingers
below umbilicus
Lochia: Rubra 30 mL
Contraction: Moderate

Laboratorium
Hemoglobin : 12.2 g/dl
Case Analysis
History
Case Theory Analysis
Fluid discharge from Fluid discharge from Fluid discharge from
the vagina 3 hours prior vagina either in the vagina in the form of
to hospital admission. form of gush or slow slow leak that occurred
leak that occurs before before the onset of
the onset of labor labor
Fluid was clear, no History of abdominal
blood, no odor. trauma
No previous abdominal History of urinary tract
trauma. infection or lower
No history of fever, pain genital tract infection
while urinating, and that may cause fever,
frequent urinating. urinary symptoms (e.g.
pain while urinating,
frequent urinating)
Incidence

Case Theory Analysis

G1P0A0, 37-38 weeks PROM occurs in 10% PROM occurs in 10%
gestation from the of all pregnancies of all pregnancies
last first day of
menstruation
Risk Factors
Case Theory Analysis
No previous abdominal Abdominal trauma No associated risk factor in
trauma. this pregnancy
No history of fever, pain Polyhydramnios
while urinating, and
frequent urinating. Cervical incompetence

Cervical length < 2,5 cm

Prior preterm labor

Multiple pregnancy

Low BMI (<19 m2)

Infection (e.g.
chorioamnionitis, urinary
tract infection, lower
genital tract infection)
Clinical Findings

Case Theory Analysis

Inspeculo: pooling of Inspeculo: liquor Inspeculo: pooling of
fluid in posterior escaping out fluid in posterior
fornix through the cervix, fornix
pooling of fluid in the
posterior fornix
Workups
Case Theory Analysis

Litmus test: positive Nitrazine test: positive, Litmus test positive, Litmus test:
positive
Fern test: identifying ferning pattern when a Fern test: not
WBC count: 13.300/L smeared slide is examined under done
(5.900-16.900/L) microscope
Centrifuged cells stained with 0.1% Nile Blood count:
blue sulfate showing orange blue No sign of
coloration of the cells (exfoliated fat infection
containing cells from sebaceous glands of
the fetus)
Complete blood count is checked to
determine the total number of white blood
cells, differential count, and CRP to assess
whether there is infection or not.
Management
Case Theory Analysis
Admitting patient If patient isnt in labor and theres no This patient
evidence of infection or fetal labored within 24
distress, the patient is observed in hours
the hospital within 24 hours. spontaneously.
IVFD RL+ Oxytocin Generally in 90% of cases Antibiotic is given
10 IU spontaneous labor ensue within 24 for prophylaxis to
hours. minimize risks of
Cefotaxime 3x1 If labor doesnt ensue, induction of infection.
gram. labor with oxytocin is commenced.
Observe again in Cesarean section is performed with Oxytocin is given
the next 4 hours. obstetric indications. for induction of
labor
Prophylactic antibiotics to minimize
perinatal risks of infection: IV
ampicillin, amoxicillin, or
erythromycin for 48 hours followed
by oral therapy for 5 days.
Management

Case Theory Analysis

Admitting patient Misoprostol is indicated for This patient
cervical ripening. It is given for labored within 24
hours
induction before oxytocin or spontaneously.
at Bishop score is less than 5.
IVFD RL+ Oxytocin . Antibiotic is given
10 IU for prophylaxis to
minimize risks of
Cefotaxime 3x1 Hyoscine butylbromide (HBB) infection.
gram. belongs to the
Observe again in parasympatholytic group can Oxytocin is given
the next 4 hours. help cervical dilatation. It is for induction of
labor
frequently used to overcome
cervical spasms and reduce
the duration of labor.
Prognosis
Depends on gestational age
Literature
Review
Definition

10% all
Rupture of
pregnancies
the fetal
PROM and 70% of
membranes
the cases
before labor
at term
Epidemiology

Incidence of PROM ranges from 2-18%

Recent reports show 14-17%

The defferences probably influenced by

poppulation differences contributory maternal
and fetal risk factors
Mechanism & Etiology MMP

Infection
Reduction in
membrane tensile
strength
Abnormal placental
PROM
implantation

Smoking

Nutritional deficiencies
Causes and Risk Factors

Abdominal Cervical Cervical length

Polyhydramnios
trauma incompetence <2,5 cm

Prior preterm Multiple Low BMI

Infection
labor pregnancy (<19m2)

Exposure to air
Smoking
pollution
Diagnosis

History

Rupture of the membranes in the absence of

contractions

Physical examination

Pooling of fluid in the posterior fornix

Asked to cough or strain
Acid/base testing paper
Fern Test
Intraamniotic injection of indigo carmine
Fetal Fibronectin
Confirmation of Diagnosis
Speculum examination to inspect the liquor
escaping out through the cervix

Examine the collected fluid from the posterior fornix

(vaginal pool) for:
Detection of pH by litmus or Nitrazine paper (Nitrazine
paper turns from yellow to blue at pH > 6).
Fern test

Ultrasonography is done to support the diagnosis

and to assess the fetal well being.

Complete blood count (WBC, diff. count, & CRP) to

assess whether there is infection or not.
Management

- Diagnosis of
PROM Identify those
- Determine GA who requiring
Initial assessment
- Fetal pulmonary immediate
maturity, delivery
infections
Management

Antibiotics

Ampicillin 2 g IV or erythromycin
250 mg IV /6 hours for 48 hours
Oral therapy amoxicillin 250 mg
and erythromycin 333 mg /8 hours
for five days or until delivery.
Management

Oxytocin

Is administered if labor doesnt occur in 24-48 hours (34-

37 weeks) or 24 hours (37 weeks).
Low dose: 0,5-2 mIU/mL (+1-2 mIU/mL) /15-40 mins.
High dose: 6 mIU/mL (+3-6 mIU/mL) /15-40 mins.
labor time, risk of chorioamnionitis.

Misoprostol

Induce cervical ripening, induce labor.

25 or 50g 3-6 hourly.
Complications
Preterm labor and prematurity.

Corioamnionitis and fetal infection

Cord prolapse happens especially when associated with malpresentation

Placental abruption.

Fetal pulmonary hypoplasia especially in preterm PROM is a real threat when

associated with oligohydramnios.

Neonatal sepsis, RDS, IVH in PROM

References
Preterm labor, preterm rupture of the membranes, postmaturity, intrauterine death of
the fetus. In: Dutta DC, Konar H. DC Duttas Textbook of Obstetrics. 7th ed.
Kolkata: JP Medical Ltd; 2014. p. 314-26.
Abnormal labor. In: Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS,
Hoffman BL, et al. Williams Obstetrics. 24th ed. New York: McGraw-Hill Education;
2014. p. 455-72.
Premature rupture of membranes. In: Arias F, Daftary SN, Bhide AG. Practical Guide to
High-Risk Pregnancy & Delivery. 3rd ed. New Delhi: Elsevier; 2008. p. 240-61.
Gupta U, Salhan S, Garg D. Induction of labor. In: Salhan S. Textbook of Obstetrics. 2nd
ed. New Delhi: JP Medical Ltd; 2016. p. 252-8.
Thank You