HOW TO

DIAGNOSE PROM
& PPROM
Muhammad Cahara Adhi S
Name/Age/ Complicatio Consultant in
Diagnosis Management Transfer
Medrec n Charge
Mrs. Lia Yulianti P1A0 spontaneous term Spontaneous (-) Delivery MA
25 y.o delivery delivery room
0001938619
10-04-1996
 Definition
• Prelabor rupture of membranes (PROM) refers to membrane
rupture before the onset of uterine contractions (previously known as
premature rupture of membranes).
• Preterm PROM (PPROM) refers to PROM before 37+0 weeks of
gestation

Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
 Risk Factors
Previous
PPROM Cigarette smoking
Genital Tract Antepartum
Infection bleeding

Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
 Diagnosis
● Patient Presentation
Sudden "gush" of clear or pale yellow fluid from the vagina or leaking only small
amounts of fluid either continuously or intermittently, and some just describe a
sensation of abnormal wetness of the vagina or perineum

● Physical Examination
- If not active labor digital examination must be avoided
- Examination of the cervix can be performed using sterile speculum. Direct
observation of amniotic fluid leaking from the from cervical os

Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
 Diagnosis
● Nitrazine Test
Nitrazine paper is used to test the pH of vaginal fluid. Amniotic fluid usually has a
pH range of 7.0 to 7.3

● Physical Examination
Dried amniotic fluid shows an arborization (ferning) pattern when viewed under a
microscope. Fluid from the posterior vaginal fornix is swabbed onto a glass slide
and allowed to dry for at least 10 minutes

Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
Typical ferning pattern
of dried amniotic fluid
 Problems?
• The correct diagnosis is important for intervention in PROM
• PROM can be difficult to diagnose when the rupture is slightly occurred
• The diagnosis if PROM conventionally relied on patient’s history ( fluid leakage);
pooling amniotic fluid in vagina by speculum examination; nitrazine test ( by
detecting alkaline vaginal pH); Ferning test ( presence of ferning pattern form
dried vaginal secretions)
• Drawbacks : long latent period amniotic pooling can’t be demonstrated on
speculum examination
  β-subunit of HCG
 Alpha Fetoprotein
 Prolactin
Another Biomarker  Creatinine
 Insulin Growth Factor Binding
Examination Protein-1 (IBFP-1)
 Placental Alpha Microglobulin-1

1. Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
2. Tigga MP, Malik S. Comparative analysis of four biomarkers in diagnosing premature rupture of membranes and their correlation with onset of labour. Int
J Reprod Contracept Obstet Gynecol. 2015;4(04):1070-5
 β-subunit of HCG
● Produced exclusively by syncytiotrophoblasts in the placenta
● Present in amniotic fluid, as well as maternal blood and urine (concentration
ranging from 2000-70,000mIU/ml)
● High β hCG concentration of in the amniotic fluid renders it to be a possible
marker of PROM. Also, it is secreted by the cervical glands and is present at a
certain level in vaginal fluid
● Sensitivity 84%; Specificity 68%

1. Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
2. Tigga MP, Malik S. Comparative analysis of four biomarkers in diagnosing premature rupture of membranes and their correlation with onset of labour. Int
J Reprod Contracept Obstet Gynecol. 2015;4(04):1070-5
 Alpha-fetoprotein
● Single chain glycoprotein with a molecular mass ranging from 66-72 k D
● Initially synthesized by yolk sac, followed thereafter by fetal liver
● After entering the fetal urine it is detected in the amniotic fluid
● Higher concentration of AFP in the amniotic fluid renders it to be a possible
marker of PROM.
● Sensitivity 98%; Specificity 94%

1. Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
2. Tigga MP, Malik S. Comparative analysis of four biomarkers in diagnosing premature rupture of membranes and their correlation with onset of labour. Int
J Reprod Contracept Obstet Gynecol. 2015;4(04):1070-5
 Prolactin
● Polypeptide produced by anterior hypophysis under the control of hypothalamus.
● During pregnancy, produced by maternal and fetal hypophysis and the decidua.
● Higher concentration of prolactin is found in amniotic fluid as prolactin actively participates in the
control of amniotic fluid volume and osmolarity.
● It has been found that the prolactin level in amniotic fluid is ± 5-10 times that in maternal circulation
● Thus in comparison to the other marker like AFP, prolactin does not have a steady elevated
concentration and therefore it exhibits lower diagnostic accuracy.
● Sensitivity 68%; Specificity 78%
● With advancing gestation fetal kidneys begin degradation of prolactin and decline in decidual
secretion

1. Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
2. Tigga MP, Malik S. Comparative analysis of four biomarkers in diagnosing premature rupture of membranes and their correlation with onset of labour. Int
J Reprod Contracept Obstet Gynecol. 2015;4(04):1070-5
 Creatinine
● Mainly contributed by the fetal urine in amniotic fluid
● The creatinine concentration ranges between 1.5 – 2.0 mg/dL after 36 weeks
until term.
● Creatinine in amniotic fluid constantly high level in amniotic fluid till term
● Sensitivity 100%; Specificity 92%

1. Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
2. Tigga MP, Malik S. Comparative analysis of four biomarkers in diagnosing premature rupture of membranes and their correlation with onset of labour. Int
J Reprod Contracept Obstet Gynecol. 2015;4(04):1070-5
 Diagnostic Performance of Individual
Markers

1. Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
2. Tigga MP, Malik S. Comparative analysis of four biomarkers in diagnosing premature rupture of membranes and their correlation with onset of labour. Int
J Reprod Contracept Obstet Gynecol. 2015;4(04):1070-5
 Insulin Growth Factor Binding Protein-
1
• Secreted by decidual and placental cells
• High concentration in amniotic fluid compared with other bodily fluids
• Sensitivity 95-100 %; Specifity 93 – 98%
• Positive Predictive Value : 98%
• Most accurate when performed as soon as possible after PROM

Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
 Placental Alpha Microglobulin-1
• Released from decidual cells
• The test not affected by semen or trace amount of blood
• Sensitivity 94.4 – 98.9% Specifity 87.5 – 100 %

Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and diagnosis. www.uptodate.com. Updated May, 2020.
References
1. Duff, Patrick. Preterm prelabor rupture of membranes : clinical manifestation and
diagnosis. www.uptodate.com. Updated May, 2020.
2. Tigga MP, Malik S. Comparative analysis of four biomarkers in diagnosing
premature rupture of membranes and their correlation with onset of labour. Int J
Reprod Contracept Obstet Gynecol. 2015;4(04):1070-5
THANK YOU