Premature Rupture Of The Membranes

Question 1

PROM

Answer 1

Premature rupture of membranes

Question 2

Definition of PROM

Answer 2

PREMATURE RUPTURE OF MEMBRANES
Premature rupture of membranes (PROM) is the rupture of membranes before the onset of labour. It is also known as Prelabour rupture of membranes.
Preterm premature (prelabour) rupture of membranes (PPROM) is the rupture of membranes between 28-37 completed weeks.

Question 3

Pathophysiology

Answer 3

INCIDENCE
PROM occurs in about 10% of all pregnancies, while PPROM occurs in 2%.
PATHOPHYSIOLOGY
• Prolonged weakening of the membranes with advancing gestation: -Collagen remodeling
-Cellular apoptosis
• Accelerated by a number of factors -Stretch
-Infection -Inflammation -Local hypoxia

Question 4

Causes / Risk factors

Answer 4

AETIOLOGY
The aetiology is not known. However, there are known risk factors.
• Genital infections eg bacterial vaginosis, Strept B.
• Cervical weakness/ incompetence
• Low socioeconomic status
• Multiple pregnancy
• Polyhydramnios
• Previous PROM
• Cigarette smoking during pregnancy
• Alcohol abuse
• Anaemia in pregnancy
• Bleeding in early pregnancy

Question 5

Signs and Symptoms

Answer 5

SYMPTOMS AND SIGNS
• Gush of fluid from vagina
• Leaking in dribbles
• Increased temperature and pulse if infection occurs
• Uterine contractions may start
• Oligohydrammios may be present on abdominal palpation

Question 6

Signs and Symptoms

Answer 6

SYMPTOMS AND SIGNS
• Gush of fluid from vagina
• Leaking in dribbles
• Increased temperature and pulse if infection occurs
• Uterine contractions may start
• Oligohydrammios may be present on abdominal palpation

Question 7

Diagnosis

Answer 7

DIAGNOSIS
 From the history
 Sterile speculum examination: Clear fluid from cervical os on straining, bearing down or on coughing is diagnostic. In absence of this, take sample of pool of fluid in posterior fornix or on blade of speculum for nitrazine or fern test
 Use opportunity of speculum examination to take a swab of fluid or a high vaginal swab, check the cervical dilatation and rule out cord prolapse
 NO DIGITAL EXAMINATION UNLESS IN LABOUR

Question 8

Differential diagnosis

Answer 8

DIFFERENTIAL DIAGNOSES
 Leaking urine
 Vaginal discharge

Question 9

Investigations

Answer 9

INVESTIGATIONS
 FBC (WBC important)
 C-reactive protein
 Clotting profile if there is infection

 Do ultrasound for
• Liquor volume/ amniotic fluid index (AFI)
• Fetal well-being
• Fetal lie and presentation
• Placental location

Question 10

Liquor

Answer 10

Liquor is colorless, odorless and sticky

Question 11

Management

Answer 11

MANAGEMENT
Management may be active or conservative depending on maternal condition, gestational age and fetal condition.
ACTIVE MANAGEMENT
This is done when the EGA is greater than 34-36 weeks and also when the risk to the mother outweighs the risk to the fetus if delivered. Delivery may be by induction of labour or Caesarean section
CONSERVATIVE MANAGEMENT
This is done when the risk to the fetus, when delivered, outweighs risk to the mother. Delivery is therefore delayed in order to gain fetal maturity.
If gestation is less than 34 weeks
 Admit patient
 Monitor mother and fetus for signs of infection
• Pulse and temperature 4 hourly
• Check WBC and C-reactive protein
• Check for uterine tenderness
• Listen to the fetal heart rate, especially an increase
• Check the sanitary pads of the patient for amount of liquor, colour and smell
 Cover patient with prophylactic antibiotics
• Amoxycillin/Erythromycin (do NOT give Co-Amoxyl or Amoksiklav or
Augmentin)
• Metronidazole
 Administer steroids
• Dexamethasone –6mg IM 12 hourly for 4 doses
• Betamethasone –12mg IM 24 hours apart for 2 doses

• Maximum benefit within 24-48 hours of administration
• Prevents respiratory distress syndrome, intraventricular haemorrhage,
necrotising enterocolitis and decreases neonatal morbidity
 Tocolytics may be given if patient is having contractions to
• Delay delivery to allow benefit from steroids
• Allow in-utero transfer of the fetus to a centre that can handle preterm babies
If gestation is 34-36 weeks
Consider urgent delivery.

Question 12

Complications

Answer 12

COMPLICATIONS
 Preterm births
 Serious infections—chorioamnionitis, Neonatal sepsis
 Placental abruption
 Increased C/S rate
 Postpartum infection

Question 13

Normal fetal heart rate

Answer 13

120 to 160