1. Premature Rupture
of Membranes
FAHAD ZAKWAN

2. Premature rupture of membranes (PROM)
Spontaneous rupture of membranes anytime beyond
28wks of pregnancy but before the onset of labour.
Preterm premature rupture of membranes (PPROM)
rupture of fetal membranes prior to labor in pregnancies
btw 28 - 37 weeks.
DEFINITION

3. When rupture of membranes occurs
beyond 37 wks. but before the onset of
labour it is called term PROM.
Rupture of membranes for more than
24hrs before delivery is called prolonged
rupture of membranes.

4. •Latency Period: time interval between
ROM and onset of labor
•Expectant management: management
of patients with the goal of prolonging
gestation (“watchful waiting” until
delivery indication arises)

5. RISK FACTORS
• Chorioamnionitis
• Vaginal infections
• Cervical abnormalities
• Vascular pathology (incl.
abruptio)
• Smoking
• 1st, 2nd, 3rd, or multiple
trimester bleeding
• Previous preterm
delivery (PPROM)
• AA ethnicity
• Acquired or congenital
connective tissue
disorder
• Nutritional deficiencies
(Vit. C, copper, zinc)

6. What causes premature 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.
Before term, PPROM is often
due to an infection in the uterus.
• Other factors that may be linked
to PROM include the following:
1. Low socioeconomic conditions (as
women in lower socioeconomic
conditions are less likely to receive
proper prenatal care)
2. Sexually transmitted infections
such as chlamydia and gonorrhea
3. Previous preterm birth
4. Vaginal bleeding
5. Cigarette smoking during
pregnancy
6. Unknown causes

7. SYMPTOMS AND SIGNS
• Vaginal discharge
•Gush of fluid
•Leaking of fluid
• Oligo/ Anhydramnios
•Cramping
•Contractions
•Back pain

8. History & Physical Exam
History
1. “Gush” of fluid
2. Steady leakage of small
amounts of fluid

9. Physical examination
•Sterile vaginal speculum exam
•Minimize digital examination of cervix, regardless of
gestational age, to avoid risk of ascending infection/
amnionitis
1. Assess cervical dilation and length
2. Obtain cervical cultures (Gonorrhea, Chlamydia)
3. Obtain amniotic fluid samples

10. Findings
•Pooling of amniotic
fluid in posterior
vaginal fornix
•Fluid per cervical os

11. DIAGNOSIS
• Valsava maneuver
• Sterile Speculum exam (Pooling)
• Nitrazine testing
• Fetal Fibronectin
• Ultrasonography
• SSE-Free flow of fluid from cervical os
• Microscopic Fern testing
• AmniSure
• Transabdominal Indigo dye injection

12. Nitrazine paper testing
• Vaginal pH (3.5-4.5)
• Turns blue in presence of
alkaline Amniotic fluid
• 93.3% sensitivity
• False positive (1-17%) for
urine, blood, semen, BV,
Trichomoniasis

13. Fern test
• Fern test refers to visualization of
a characteristic 'fern-like' pattern
on a slide (pre-cleaned, saline free
slides are required), 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
Procedure:
1. When the slide has completely
air dried (at least 5 to 7
minutes), place it on the stage
of the light microscope
provided for the procedure.
2. Examine the slide under low
power (10X).
3. Look for fern-like crystals. If
positive for amniotic fluid, this
crystal formation will be
present in most microscopic
fields.

15. Fetal Fibronectin
• 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%, Specificity-26.8%.

16. Ultrasonography
• 50-70% of women with
PPROM have low AFV on US
• Mild reduction requires
further investigation
• Rule out other causes (Renal
agenesis, utero-placental
insufficiency, obstructive
uropathy)
• Measure for pockets of fluid
and quantitate AFV into AFI
Ultrasound showing 7 cm pocket of fluid

17. Transabdominal Injection of Dye
(Amniocentesis)
• Under ultrasound guidance a high-gauge
long needle is inserted through the
abdomen and membranes into the uterine
cavity and amniotic fluid can be collected
for testing of chorioamnionitis, in addition
to fetal lung maturation studies.
• After fluid sample collection, 10 cc of mixed
Indigo Carmine dye is then injected into the
amniotic fluid. The dye is bright blue and if
blue is noted on the tampon after 30-60
mins, the diagnosis of ruptured membranes
is made.

19. PPROM
Sudden gush of clear vaginal
fluid with oligohydramnios
SPECULUM EXAM
Pooling, Nitrazine, ferning

20. Diagnosis of PROM
Pooling
+
Nitrazine
+
Ferning
+

22. MANAGEMENT
MANAGEMENT DEPENDS ON THE FOLLOWING FACTORS
• Gestational age
• Availability of NICU
• Fetal presentation
• FHR pattern
• Active distress (maternal/fetal)
• Is she in labor?
• Cervical assessment

23. Initial Assessment
Assess for Maternal-Fetal distress
Assess for Proper dating/GA
Assess for infection
Exclude occult cord prolapse

24. • Maternal-Fetal Distress evaluated by Maternal VS, labs, general condition,
Fetal distress assessed by FHR pattern, US, Biophysical profile (US
examining fetal tone, FBM, AFI, GBM for a score of 2 each if criteria met for
a total of 8/8)
• First priority is to rule out maternal-fetal distress and imminent delivery.
• Ensure through prenatal records that early US correlate with LMP or EDC is
most accurate.
• Rule out infection through absence of clinical signs and symptoms of
chorion in addition to assessment of lab values and amniotic fluid samples
obtained through Amniocentesis.
• Evaluate maternal serum lab values for leukocytosis, left shift, and elevated
C-Reactive Protein. Evaluate Amniotic fluid samples for gram stain,
leukocyte esterase, glucose, and WBC count.

26. • Exclude occult cord prolapse through assessment of
fetal distress.
• Variable FHR decelerations can be seen in the FHR
pattern in patients with low or no amniotic fluid. In
addition, late decelerations may be seen also in
patients with co-existing abruption.
• Assess for signs and symptoms of chorioamnionitis,
abruption, labor, fetal distress. Assess maternal VS for
tachycardia and fever.

27. Assessing for signs and symptoms of
chorioamnionitis

28. Secondary Assessment
•Fetal position
•Cervical assessment
•Determine lung
maturity, if indicated
•Quantify AFV*

29. • Determine fetal position per Leopold’s and confirm with US for all
patients, especially since likelihood of breech presentations is higher
at earlier gestations remote from term.
• Assess for labor by visual examination of the cervix with SSE unless
the patient is presenting with regular, painful contractions and
appears to be in active labor. Time contractions, assess for pelvic
pressure, PALPATE for contractions and strength. Ask mom for length
of last labor, if applicable. If patient is in active labor and delivery is
inevitable, consider discontinuation of all tocolytics.
• Again, ONLY do digital cervical exams on patients who are in active
labor or patients who need to be delivered for clinical reasons and
consistency of cervix needs to be assessed.

30. • Fetal lung maturity generally assessed at 32 weeks and beyond if
necessary. Fetal lungs likely to be immature at gestations less than
32 weeks. Evaluation of FLM should only be evaluated in the
absence of absolute delivery indications. Consider risk-benefit
ratio of neonatal mortality and morbidity when deciding to induce
labor or perform Cesarean section.
• Quantification of Amniotic fluid volume has increasingly been
used to evaluate risk. Patients with vertical pockets of fluid <2 cm
have a shorter latency period, and a higher incidence of
chorioamnionitis, neonatal sepsis, and endometritis whereas
similar patients with a vertical pocket of >2cm have a lesser
incidence of these.

31. Delivery Indication
1. Maternal-Fetal
Distress
2. Infection
3. Abruption
4. Cord Prolapse

32. Expectant Management
• Typical for GA 32 weeks or less
• Bed rest
• Steroids for lung maturity
• Tocolytic if indicated for lung maturity
• Antibiotics
• Fetal Surveillance
• Majority Inpatient Observation
• Assess for Chorioamnionitis

33. • Some expectantly manage patients until 34 weeks gestation
in the absence of delivery indication.
• Betamethasone-may be given 12 mg IM q 12 or 24 hours x 2
total doses. Need at least 48 hours to initiate benefit. May
also use Dexamethasone. Steriods may increase WBC’s and
therefore baseline CRP should be obtained and consistently
monitored.
• In the absence of delivery indication, may consider tocolysis
x 48 hours to assist with benefit of sterods. Tocolysis can be
achieved with magnesium sulfate, terbutaline, and
nifedipine.

34. • Prophylactic antibiotics should be obtained after collection of
cultures. These cultures may include Group B Strep culture, GC,
Chlamydia, Amniotic fluid sample.
• Broad antimicrobial coverage is recommended.
• Antibiotic administration reduced the incidence of chorioamnionitis,
neonatal infection, and the use of neonatal surfactant.
• Antibiotic administration for most centers include Ampicillin IV (if no
allergy) for 48 hours then a switch to oral amoxillin for an additional
five days.
• Additional of a macrolide considered necessary for broad coverage.
Commonly used is a single dose of 1 gram of Azithromycin, or
Erythromycin IV with a switch to oral EES after 48 hours for an
additional 5 days.

35. • 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).
• Assessment for chorioamnionitis includes amniocentesis
(diagnostic), in addition to clinical signs and symptoms and CRP,
WBC counts, and other maternal serum infection indices.

37. Expectant management
 Deliver at 34 wks
 Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Single course corticosteroids
Tocolytics
 No consensus
Management: PPROM
(24 – 31 wk. gestation)

38. Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Corticosteroids
No consensus, some experts recommend
Management: PPROM
(32 – 33 wk. gestation)

39. Proceed to delivery
Induction of labor
GBS prophylaxis
Management: PROM
(> 34 wk. gestation)

42.  Antibiotics
 Prolong latency period
 Prophylaxis of GBS in neonate
 Prevention of maternal chorioamnionitis and neonatal sepsis
 Corticosteroids
 Enhance fetal lung maturity
 Decrease risk of RDS, IVH, and necrotizing enterocolitis
 Tocolytics
 Delay delivery to allow administration of corticosteroids
 Controversial, randomized trials have shown no pregnancy prolongation
Management: Rationale

43.  Antibiotics
Ampicillin 2 g IV 6 hrly for 2 days
Amoxicillin 500 mg po TDS x 5 days
Azithromycin 1 g po x 1
Erythromycin 250mg TDS for 5 days
 Corticosteroids
Betamethasone 12 mg IM OD for 2 days
Dexamethasone 6 mg IM BD for 2 days
 Tocolytics
Nifedipine 10 mg po after every 20min 3 times, then 6 hrly for 2 days
Management: Drug Regimen

44.  Typically performed after 32 wks
 Tests for fetal lung maturity (FLM)
 Lecethin/Sphingomyelin ratio (not commonly used, more
for historic interest)
 L/S ratio > 2 indicates pulmonary maturity
 Phosphatidylglycerol
 > 0.5 associated with minimal respiratory distress
 Flouresecence polarization (FLM-TDx II)
 > 55 mg/g of albumin
 Lamellar body count
 30,000-40,000
 If negative, proceed with expectant
management until 34 wks
Management: Amniocentesis

45. Risk-Benefit Expectant Management
• Abruption
• Chorioamnionitis
• Cord Prolapse
• Pulmonary Hypoplasia (<19
weeks PPROM
• Skeletal Deformities
• Endometritis (1/3)
• Mature lung profile
• Advancing GA (reducing risks
associated with PTB)
Risks Benefits

46. Fetal complications of prolonged PPROM
•Pulmonary hypoplasia
•Skeletal malformations
•IUGR
•IUFD
Maternal complications of prolonged PPROM
•Chorioamnionitis
•Dry labour
•Cord prolapse if malpresentation present.

50. THANK YOU!!