Premature Rupture of

Fetal Membrane.

by
Dr Adeyemo O.T
Consultant Obgyn FETHI / Asso Lect ABUAD
PROM: Spontaneous rupture of
membranes prior to onset of labour.
Occurs in 10% of pregnancies.
Preterm PROM: <37 wks gestation, occurs
in 2-3% of pregnancies, complicates 1/3
of all preterm deliveries.
Term PROM: 37 weeks & beyond. In 7-
8% of pregnancies.
*Interval between rupture and onset of labour is called
‘Latency Interval’.
*In more than 85% of cases SPROM heralds the onset
of labour.
*2/3 deliver within 4/7
The rest within one
week
The shorter the GA the longer the Latency Interval
Mechanism of PROM

Not exactly understood

- However weakness of the chorio amniotic
Membrane from stress either by internal pressure due
to labour or by infection have been postulated.
- In women with PROM there is gross alteration of
the cytoarchitecture of the amniotic membrane (AM)
and the quality and the quantity of membrane collagen.
-Enhanced collagenolytic activity has been found in
these AM.
A lot of proteolytic insult to the AM includes bacterial
protease from cervico vaginal flora, protease of seminal
fluid and maternal protease released in response to
chorioamionitis.
-Infection is a major aetiologic factor in a significant
proportion of PROM (T. Vaginals, chlamydia. N.
gonorhea, Bacterial vaginosis).
 Risk Factors for PROM
A. Remediable
Cervico vaginitis
Incompetent cervix
Cigarette smoking
Illegal induced Abortion
Prenatal diagnostic
procedures Chorionic villous
sampling Amniocentesis
Coitus
Mineral and Vitamin 
Cervical Examination
B. Non-Remediable
Prior PROM or preterm delivery
Prior cervical surgical procedures
Vaginal bleeding
Placental pathology
Previa
Abruption
Marginal cord insertion
Ehlers-Danlos
syndrome
 Complications of PROM
A. Fetal
Prematurity (RDS, IVH, NEC) with
Significant Morbidity and Mortality
Cord prolapse
Asphyxia
Infection - Pneumonia
Conjunctivits
Septiceamia
Omphalitis
Fetal deformation syndrome
(Growth retardation, compression anomalies of fetal face and limbs,
pulmonary hypoplasia). .

B Maternal
* Infection (Puerperal sepsis)
* Increased risk of caesarean section
 Making a Diagnosis

History - Sudden gush of fluid from the vagina and its

continuing intermittent trickle.

Examination: Visual observation of a pool of fluid

from the posterior fornix with CUSCO’s speculum
examination.
Valsalva maneouver will cause egress of fluid from the
cervix.
* Incontinence of urine must be excluded and
amniotic fluid must be distinguished from urinary
contaminant by a Biochemical test.
Nitrazene test

Nitrazine is an indicator paper impregnated with

sodium dinitrophenylazonaphtol: colour change from
Brown to Blue – black.
Litmus paper test - Red to Blue.
* Cytology test: for Identification of
lanugo hairs, staining for lipid and
identification of fetal cells.
* Aborisation or ‘fern-like’ pattern:
occurs when AM Fluid is put on a slide and
allowed to dry: Results from crystallization
of AM Fluid.
* USS: may confirm a reduced AMF
volume.
MANAGEMENT

Team work between obstetrician and pediatrician is

desirable.
-All cases must be admitted and treatment
individualized based on prevailing circumstances &
consider the following
(1) Gestational Age
(2) Presence of infection (Chorioamnionitis)
(3) Presence of other Medical problems
and complications.
4) Balance b/w the risk of chorioamnionitis inutero & prematurity post
delivery.
5) Standard of neonatal facilities.
6) Risk of infection based on local experience
7) Harzards of induction
8) Fetal presentation / condition.
 Management. Term PROM.
Active-IOL; Expectant-Await spontaneous labor upto 72hrs.
75%-85% of women will go into spont. Labor & deliver within
24hrs of SROM.
Maternal & perinatal outcome of active & expectant
approaches are similar.
Confirm diagnoses, take cultues for grp B Streptococcus &
avoid V.E (digital) in expectant mx
Ensure mother & baby are stable & fit.
Start IOL if active mx. Some wait for 12hrs so 50%
can go into spontaneous labor.
If expectant mgt is chosen, decision to stay in
hosp/home depends on local conditions & women’s
preference. For few who remain undelivered in 48-
72hrs, IOL is done.
For ruptured membranes ≥24hrs at IOL or spont labor
or +ve gp B streptococcus, cover with antibiotics.
Management of Preterm
PROM.
>34wks. If there is NICU, can do IOL. Also justifiable to do
conservative mx if local experience shows low infection rate. If no
NICU, transfer b4 delivery.
<34wks. Expectant mx as follows:
1. Speculum exam. For diagnosis, app. Cultures for chlamydia,
NG & GBS. No digital V.E.
2. Admit & observe for chorioamnionitis. Signs are pyrexia,
uterine tenderness & irritability & purulent vag. discharge. If
chorio dev. Give IV antibiotics & deliver (IOL or CS)
3. Role of amniocentesis to determine lung maturity & bacteria
culture not proven. Invasive & limited role.
4. Corticosteroid. 24-32wks. Reduce Neonatal morbidity from
RDS, IVH,NEC
management cont.
Antibiotics. Evidence that this prolongs
pregnancy, reduces perinatal morbidity in form of
sepsis, IVH, NEC, maternal morbidity of chorio &
postpartum endometritis.
Tocolytics. Only reason is for intrauterine
transfer to neonatal facility & to allow
corticosteroid administration.
Fetal assessment. USS to R/O structural fetal
anomaly, amniotic vol. assessment. NST & BPP
may not be useful <28wks & useful when you want
to act on it.
management cont.
If no infection in 1st 48-72hrs of conservative mx,
outlook for safe prolongation good. Some hind water
leak can seal. Avoid sexual intercourse & watch out for
leakage.
Observe till 35-36wks & IOL those with continuous
leakage without sepsis but with normal amniotic fluid.
Small % dev oligohydramnios(USS). Fetus at risk of
pulmonary hypoplasia & positional limb deformities
(fetal crush syndrome).
Role of amnioinfusion ???
Conclusion
Premature rupture of membrane
constitute a major challenge in modern
obstetrics in which there is no general
agreeable consensus to its
management.
Good to End!!!!!

Thank you