Engidaw Ambelu

1. PROM
Maru M /MD/
For Anesthesia 2nd
May 9/2010 Ec

2. PRO M (Premature rupture of membranes)
Definition: Spontaneous rupture of membranes after
28 weeks of gestation before the onset of labor.
• Term PROM: Rupture of membranes after 37 weeks
• Preterm PROM: Before 37 weeks
• Prolonged PROM: Longer than 18 hrs/ 12 hrs.
 Latency period: Time between rupture of
membranes to onset of labor.

3. PROM-Cont’d
Diagnosis:
History: complaint of leakage of liquor as gush or slow
leak;followed by intermittent leakage.
-Complications of PROM: infection, PTL, etc.
Physical findings:
- Negative discrepancy
- If complicated, uterine contraction, tenderness
- Sterile speculum examination with or without
valsalva maneuver( leakage or pooling)

4. • Incidence: average 5- 10% of all deliveries and
up to 30% of preterm deliveries.
• Approximately 70% of cases of PROM occur in
pregnancies at term.
PROM is the clinically recognized precipitating
cause of about one third of all preterm births.
Incidence

5. Causes multifactorial
• 1. Intrinsic membrane weakness
a. Infections
b. Smoking
c. Malnutrition
d. Collagen Deficency
• 2. Infection (proteolytic enzymes)
• 3. Mechanical stress
a. Twin gestation
b. Polyhydramnios
c. Fetal Malformations
• 4. Unknown

6. Diagnosis-cont’d
Investigations:
 Nitrazine paper test: principle is alkaline nature of
amniotic fluid(accuracy of approximately 93%)
 Became blue
False +:blood, semen, alkaline urine, bacterial vaginosis,
and trichomoniasis
 Ferning pattern:accuracy of diagnosis of PROM of
approximately 96%
False +ve: contamination by semen or cervical mucus
False –ve :dry swab, contamination with blood at a 1:1
dilution, or not allowing sufficient time for the fluid to dry
on the slide
 Unaffected by meconium at any concentration and by
pH alteration.

7. Ferning pattern

8. Diagnosis-cont’d
• Ultrasound: support diagnosis & fetal wellbeing.
• Dye test: indigo carmine instillation
• Meconium on the vulva
• Vernix caseosa on the vulva

9. DIAGNOSIS
History
Gush or Leakage of fluid PV (Duration, Smell)
Is she in Labour
Yes
No
Speculum/Digital Exam
Sterile Speculum Examination
± Valsalva Man
Leakage through cervix No leakage through cervix
Presence of meconium/vernix
Pooling at post fornix No pooling
- Nitrazin paper test
-Fern test Pad test for 24 hrs
PROM No wetting Wetting
+ ve - ve
Suspsious
Treat as PROM
- US Oligohydramnios
- Dye test
PROM +ve -ve Follow at OPD Level

10. PROM- investigations
• CBC
• U/A, Culture & Sensitivity
• High vaginal swab for culture
• Phosphatidylglycerol from vaginal pool
• Biophysical profile
• CTG for non-stress test

11. Differential diagnosis
• Urinary incontinence
• Leucorrhea gravidarum*
• Perspiration*
• Vaginal discharge-pathological

12. Complications of PROM
 Labor: In term PROM labor starts in 24 hours in
about 90%. In Preterm PROM, labor starts in 70-80%
of cases in one week time
 Ascending infection: one third
• Increased incidence of cord prolapse
 Fetal pulmonary hypoplasia
 Prematurity
• Operative delivery
• Abruption

13. Management of PROM
• Accurate diagnosis
• Avoid digital vaginal examination
• Bed rest
• Management depends on:
- GA
- Presence or absence of labor
- Infection or not
- Fetal condition

14. Indications for pregnancy termination in
PROM
• Term PROM
• Labor
• Presence of infection
• IUFD
• Congenital anomalies of fetus incompatible to
life
• Abnormal fetal surveillance

15. Preterm PROM
 GA > 34 weeks is controversial either conservative
management or termination
 GA< 34 weeks, conservative management
 Components of conservative management:
- Monitor maternal PR, Temp., FHR every 4 hours
- CBC, U/A, ESR/CRP twice per week
- BPP/NST twice per week
 Corticosteroids if less than 32/34 weeks
- Administer antibiotics: ampicillin (iv)+ erythromycin X
48hrs followed by amoxacillin(po) & erythromycin to
complete a total of seven days

16. • Two indications for prophylactic antibiotics in
PPROM:
 prevention of perinatal GBS infection
infection is either the triggering cause of PPROM
or that infection ensuing after PPROM triggers the
labor

17. Chorioamnionitis
• Clinical or subclinical
Criteria for clinical chorioamnionitis:
- Maternal temperature > 38o C
- Uterine tenderness
- Foul smelling amniotic fluid
- High WBC count(>16000/18000)
- Maternal &/ or fetal tachycardia

18. Sub clinical chorioamnionitis
• Amniocentesis: intramniotic infection is
present if:
1. Culture: bacterial colony count > 102 / ml
fluid
2. Presence of bacteria on gram stain
3. Glucose level<15 mg/dl
4. WBC> 100/ml

19. Management of chorioamnionitis
• Antibiotics:
1. Ampicillin+ Gentamycin+
clindamycin/metronidazole/chloramphenicol
2. Ceftriaxone +/- metronidazole
• Terminate pregnancy: Vaginal route is
preferred

20. THANK YOU
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21. QUIZE