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Soffin Arfian SMF ObsGyn RSPKU Muhammadiyah Surakarta/ FK UMS

Definition

: Rupture Of The Chorioamniotic membranes Prior to the onset of Labor Interval Between PROM to onset of Labor Latency Period Varying from 1-12 Hours. Most define PROM simply as ROM prior to the Onset of Contraction Pediatricians are Concerned with Duration of ROM especially In TERM Gestation Prolonged PROM ROM for 24 Hours

INCIDENCE
Varies

Between 3 18,5% ( Gunn et al 1970 ) Approximately 8-10 % Patients at Term Present with ROM prior to the Onset of labor PRETERM PROM is 25% of All cases of PROM responsible 30% of allpremature delivery. Greater in Lower socioeconomic population and those with higher rates of STD

Normal

Fetal Membranes Extremely Strong in early pregnancy At TERMs Combination of Stretching of the membranes with uterine Growth, Frequent strain caused by Ut Contraction & Fetal Movement Contribute Weakening Significant Biochemical changes occur near term such as Substantial decrease in the collagen content. at TERM PROM maybe a physiologic variant than a Phatologic event

Studies

in Premature PROM Do not show in membrane strenght EXCEPT NEAR THE SITE of RUPTURE ( Artal et al 1976 ) Suggest en EXOGENOUS Source of Weakening Local Infection Ascending from Vagina Responsible. Hystologic Chorioamnionitis is much more prevalent with PRETERM than with TERM PROM ( Naeye , 1979 )

Studies

evaluating amniotic fluid and Fetal Cord blood Ig many Patients w Preterm PROM are infected prior ROM ( Cederqvist et al 1979 ) Bacteria attach Fetal membrane Elaborate substances such as Protease Cause Membrane weakening Why not All? Its not clear. Host Factor Environtment coFactor must be involved

Other

Etiology : Polyhydramnios, Incompetent cervix, Following procedures such as Cervical Cerclage or Amniocentesis Epidemiologic Factor : Smoking, Multiple gestation, Abruptio Placenta, Previous Preterm PROM

MATERNAL

& FETAL or NEONATAL INFECTION PREMATURE LABOR HYPOXIA & ASPHYXIA Secondary to Umbilical Cord Compression INCREASED RISK of C SECTION FETAL DEFORMATION

ROM

Onset of Labor follows shortly Duration of Latency Period Varies w/ Gestational Age. At Term within 24 Hours in 90% Cases. Between 28-34 wk, 50% in labor within 24 Hours and 80-90% within 1 week ( Mead,1980 ; Garite etal, 1981), Prior to 26 wk, 50% begin labor within 1 week ( Taylor & Garrite , 1984 )

Labor

at Term Desireable sequel to PROM When does not Begin shortly NEED for CONCERN. Preterm PROM Subsequent Delivery & Prematurity Complication Most Common Causes of Perinatal Morbidity & Mortality Generally there is Moderate Shortening of the 1st Stage but no effect on 2nd stage

Both Mother & Fetus are at Increased Risk fo Infection. Maternal Infection : Chorioamnionitis Fetal Infection : Septicaemia, Pneumonia or UTI, Local Infection Such as Omphalitis or Conjunctivitis. Generally, Maternal Chorioamnionitis Preceeds Fetal Infection But Serious Fetal Sepsis May occur before chorioamnionitis is clinically evident. Preclinical infection Intraamniotic Infection

Incidence

chorioamnionitis 0,5-1% In Prolonged PROM 3-15% Chorioamnionitis More Common in Preterm PROM 15-25% ( Garite & Freeman, 1982) IMPACT of PROM and Chorioamnionitis on Fetal infection Varies Incidence of Neonatal sepsis at Term 1 : 500 babies w/ Prolonged PROM. Major Neonatal infection occur 5% of All Cases of Preterm PROM The Preterm Baby is much more likely to Die of Infectious Complication

Conventional

Teaching Incidence of Infection as increasing duration of Latency period of ROM ascending infection PROBABLY TRUE ONLY in TERM Gestation In PRETERM PROM incidence of both chorioamnionitis and Perinatal Infection NOT CHANGE w/ increasing Duration of ROM ( jhonson etal, 1981) They are ALREADY INFECTED at the time of Membrane Rupture.

In

Most Cases Perinatal mortality Cosequent to PRETERM PROM arises from Complication of Prematurity : RDS, Intraventicular Hemorrhage, NEC

Umbilical

Cord Compression even w/o Prolapse Secondary Due to Oligohydramnios ( Rutherford et al 1987 ) May Occur Before or During Labor In Preterm Patients in Labor following PROM High incidence of Fetal distress Mostly from Cord Compression, in 8,5% of patients with PROM compared w/ only 1,5% of those in premature labor w/ intact Membrane ( Moberg et al, 1984 )

Initial Evaluation Must Result in a Basic Data Base that includes : 1. CONFIRMING DIAGNOSIS 2. DETERMINING GESTATIONAL AGE 3. EVALUATION FOR THE PRESENCE OF MATERNAL AND / OR FETAL INFECTION 4. ESTABLISHING THE ONSET OF LABOR 5. RULLING OUT FETAL DISTRESS

Diagnosis

is established by ASEPTIC SPECULUM Vaginal Examination Avoid Introducing Infection Avoid Digital Intracervical examination when Not In labor and Immediate Induction is not Planned Nitrazine test ( paper strip ) Ultrasound Oligohydramnios

Menstrual

Dating Prenatal Examination Ultrasound Becareful to measure the Biparietal Diameter & Abdomen Circumference due to Compression may cause alteration

Sign

of Infection : Fever, Leukocytosis, Maternal & Fetal Tachycardia, Uterine Tenderness, Mal Odorous Vaginal Discharge Diagnosis of Chorioamnionitis to be based on clinical sign include Fever ( 100,4F /38C ) and absence of any other explanation for elevated Temperature. Laboratory test WBC count and CRP indicates impending infection

Preliminary

speculum Examination to be used to determine Cervical Dilatation is present or not. Digital examination generally avoided until one is Certain of Labor. CardioTocoGraphy Applied to determine the presence & Frequency of contraction Allow early diagnosis of Labor

Continous

Fetal Heart Monitoring / CTG should be included in initial evaluation of All Patient if the fetus is of a Viable Gestational Age. ( the G A is Depend on Neonatologist Team ) Besides Variable Deceleration, Late deceleration may reveal a Coexistent Abruptio or Uteroplacental pathology, and Loss of FHR Reactivity and /or Fetal tachycardia may suggest Fetal Sepsis

TERM

PROM -. At 36 wk and beyond The Goal is Delivery -. Most of patients in labor within 24 Hours following PROM -. Many Clinicians have agressively managed term patients by Inducing labor shortly after PROM in an effort to shorten the interval between Rupture and delivery

Over

the Past Decade Studies Evaluating the question of Immediate Induction VS Delayed Induction/expectant Management Conflicted Result However Chorioamnionitis & Postpartum Fever were less likely in the Immediate Induction Group Concluded that Immediate induction of labor more positive than Expectant Management

Prostaglandine

for preinduction cervical ripening has a benefit.

Major Risk related to Complication of Prematurity Management is Aimed at Prolonging Gestation who is not in labor, not infected, and not experiencing Fetal Distress Many Clinicians have varying view regarding tocolysis and Corticosteroids Lung Maturity Prolonged Tocolytic therapy has not been supported in clinical trials Continue w/ Oral tocolytic Effort to prolonging Gestation

Broad

Spectrum Antibiotics with Good amniotic fluid penetration in Conjunction with Cortocosteroids Amnioinfusion

PROM

that occur in very early pregnancy Low Probability (25-40%) achieved a viable Gestational Age and that deliver a surviving Infant. In the process of waiting Thre are Real maternal risk ( Infection-Sepsis-Death cause of sepsis, Abruption ) serious neurologic Morbidity on Fetus, Fetal deformation syndrome ( Growth Retardation, Compression Deformities, Pulmonary Hypoplasia )

Management

Expectant Management or Termination CRUCIAL w/ High Maternal risk & Poor Prognosis for Good Fetal Outcome Patient must Be Involved for Decision process.