CASE REPORT

Premature Rupture of Membrane

Supervised by :
dr. Ismu Setyo Djatmiko, Sp.OG

PRESENTED BY :
AYESHADIRA PUTRI (130112150541)
SARAH NURUL (130112150663)
SITI AISYAH (130112150667)
LAKSAMANA KRESNA AGUNG (130112150700)
Introduction

PROM

1 % in Prematurity:
pregnancy 30-40%

8-10% causing Main cause:

uterine asymptomatic
infection bacteriuria
Patient’s Identity:

 Patient’s Identity:
 Name : Mrs. S
 Date of Birth/ Age : 31 years old
 Ethnic : Sundanese
 Nationality : Indonesian
 Address : Cijangkar RT 01 RW 02, Sukabumi
 Graduate from : Senior High School
 Marital status : Married
 Occupation : Housewife
 Religion : Muslim
 Date of admission : July 24th, 2017
Husband’s Identity

 Name : Mr. U
 Date of Birth/ Age : 45 years old
 Ethnic : Sundanesse
 Nationality : Indonesian
 Address : Cijangkar RT 01 RW 02, Sukabumi
 Graduate from : Senior High School
 Marital status : Married
 Occupation : Private Employee
 Religion : Muslim
Anamnesis

Chief complaint:
 Patient presented to the Emergency Department with a gush of
fluid from the vagina 4 hours before the admission.
History of Present Illness:

Leaking of fluid from the vagina 4 hours before the admission.

The discharge was clear and was not foul-smelling
Painful contractions that became stronger or more frequent 2 hours
before the admission.
Vaginal bleeding(-) whitish discharge from the vagina (-)
Micturiton problems (-)
Fever (-)
Fetal movements (+)
History of Past Illness

 History of hypertension : Denied

 History of diabetes mellitus : Denied
 History of allergy : Denied
 History of heart disease : Denied
 History of liver disease : Denied
 History of kidney disease : Denied
 History of epilepsy : Denied
 History of hematological disease : Denied
 History of asthma : Denied
 History of surgery : Denied
 History of curretage : Denied
 History of smoking : Denied
 History of trauma : Denied
Anothers Past History

Marital History:
 Married for 5 years to her curent husband.

Menstruation History:
 Menarche : 15 years old
 Menstrual cycles : 28 days
 Dysmenorrhea : Denied
 First day of last menstrual period : October 20th, 2016
 Anothers Past History
Contraception History
Patient has never used contraception previously.
Gestational History:
History of Antenatal Care:
6 times with a midwife. She has received the Tetanus Toxoid vaccine
twice.

Result

Gestational History of Breast

Year
Age Childbirth Sex Birth Weight Milk/Breast Information
Milk Substitute

Vacuum Exclusive
2013 Aterm Male 3500 gr -
Extraction breast milk
Physical Examination

 Physical Examination
 General condition : looks mildly ill
 Level of consciousness : Compos mentis
 Vital signs
 Blood pressure : 120/70 mmHg
 Heart rate : 88 x/minute
 Respiration rate : 20 x/minute
 Temperature : 36.7° C
 Body Weight : 65 kilograms
 Body Height : 153 centimeters
 General Examination:
 Eyes : anemic conjunctiva -/-,
icteric sclera -/-
 Mouth : wet oral mucous
membrane
 Thorax : 
 Heart : regular 1st and 2nd heart
sounds, murmur (-), gallop (-)
 Lung : vesicular breath sounds
+/+, rhonchi -/-, wheezing -/-
 Mammae : nipple retraction -/-,
breast milk -/-
 Abdomen :
 Inspection : convex
 Auscultation : bowel sounds (+)
 Palpation : supple, pain on
palpation (-)
Percussion : not performed
 Extremities : CRT < 2 seconds,
oedema -/-, physiologic reflexes
+/+/+/+, pathologic reflexes -/-
Obstetric Status:

 Obstetric Status:  Fetal heart rate :

153x/minute
 First day of last menstrual period :
October 20th, 2016  Speculum examination :
Source of fluid from External cervical
 Estimated date of birth : July 27th, os
2017
 Vaginal toucher :
 Fundal height : 32
centimeters  Vulva : within normal limits
 Leopold examination :  vagina : within normal limits
 I : Buttocks  Portio : 2-3 cm dilatation,
 II : Fetal back is on the right side, and thick and soft
fetal extremities is on the left side  Amnion fluid : membrane (-)
 III : Fetal head  Cephalic presentation
 IV : Divergent
 His : 1-2x/10’/40”
Laboratory Examination
July 24th, 2017
Examination Value Unit Normal Range Note

HEMATOLOGY
Complete Blood Count

Hemoglobin 12.5 g/dl 12-16 normal

Leucocyte 10.700 /µL 4000-10000 Increased

Hematocrite 36 % 37-47 Normal
Erythrocyte 3,9 Millions/µL 3,8-5,2 Normal
MCV 80 fL 80-100 Normal
MCH 26 Pg 26-34 Normal
MCHC 32 g/dL 32-36 Normal
Thrombocyte 282,000 /µL 150,000- Normal
Admitting Diagnosis and Therapy

Admitting Diagnosis:
 G2P1A0, 31 years old, parturient 39-40 weeks Stage I latent phase with
premature rupture of membrane. Single, intrauterine living fetus with
cephalic presentation.

Therapy at Admission
 Planning : active management (spontaneous labour)
 Misoprostol 50 microgram
 Ceftriaxone 2 x 1 gr IV
 Observe patients vital signs
 Observe obstetric signs: HIS and FHR
Observation

Time His BJJ (x/mnt) BP Pulse Respiratory Rate notes

(x/mnt)

23.00 1-2x/10’/40” 150-154 120/80 80 20

00.00 1-2x/10’/40” 140-144 120/80 81 18

01.00 2-3x/10’/40” 150-154 120/80 83 20 Misoprostol

administered

02.00 2-3x/10’/40” 144-148 120/80 84 22

03.00 3-4x/10’/40” 144-148 110/70 81 20

 At 03.00, vaginal toucher :
 Vulva : within normal limits
 vagina : within normal limits
 Portio : 4-5 cm dilatation, thick and soft
 Amnion fluid : membrane (-)
 Cephalic presentation, st 0
 Working diagnosis : G2P1A0 parturient aterm stage 1 active phase
 Planning : Spontaneous delivery
Observation
Time His BJJ (x/mnt) BP Pulse Respiratory Rate
(x/mnt)

03.00 3-4x/10’/40” 150-154 120/80 80 20

04.00 3-4x/10’/40” 140-144 110/70 81 18

05.00 3-4x/10’/40” 150-154 110/70 83 20

06.00 3-4x/10’/40” 144-148 120/80 84 22

 Time Events

06.00 Patient is led to deliver the baby

06.30 Born a baby, sex: female, birth weight: 2630 gr, length : 46 cm, APGAR SCORE : 7-9

06.31 Oxytocin administered

06.35 Placenta is delivered completely

Fundus height 3 fingers below the umbilicus
Minimal bleeding
Intact Perineum

Diagnosis : P2A0 partus matures with spontaneous delivery

Case Analysis - Diagnosis
Theory Case
Definition Premature Rupture of Membranes : The patient has experienced rupture of
Spontaneous rupture of membranes before the membranes and
onset of labour
the gestational age of the patient’s
Preterm Premature Rupture of Membranes : pregnancy is 39-40 weeks
Spontaneous rupture of membranes before 37
completed weeks

Anamnesis Vaginal loss of fluid The patient presented with a loss of fluid
Gestational age through the vagina
The gestational age of the patient is 39-40
weeks
Smokers
History of STI The patient is not a smoker
History of preterm labour No history of STI
History of PROM in previous deliveries None
Uterus distention (Multi pregnancy, None
polyhydramnion) None

None
Case Analysis

Theory Case
Physical Infection (Bacterial Vaginosis, UTI) The patient did not present with any signs of
Examination Chorioamnionitis infection
 Fever > 38 Fever (-)
 Leukocytosis
 Tachycardia Tachycardia (-)
 Malodorous vaginal discharge Malodorous vaginal discharge (-)

In speculo :
Fluid discharge from cervix The discharge of dluid was observed to be from
Pooling of amniotic fluid in the posterior vaginal fornix the cervical ostium

Nitrazine Test: Positive Has not done

Microscopic exam : Ferning Has not done

USG: Has not done

Reduced amount of amniotic fluid and AFI
Case Analysis
Theory Case
Physical In speculo :
Examination Fluid discharge from cervix The discharge of dluid was
Pooling of amniotic fluid in the observed to be from the
posterior vaginal fornix cervical ostium

Nitrazine Test: Positive

Microscopic exam : Ferning

USG:
Reduced amount of amniotic fluid
and AFI
Management
Management Theory Case
Active Active management is given in:
-Gestational age 20-<28 or >34 weeks. Gestational age is 39-40 weeks.
- Signs of infection
 Mother: febris (>38oC), tachycardia,
No sign of infection
leukocytosis, uterus pain, purulent
(Vital sign:
secretion, and maldorous discharge. BP: 120/70 mmHg
 Fetus: tachycardia. HR: 88x/m
RR: 20x/m
- Fetal distress T: 36,7cC
There was no pain in the uterus , purulent
- Parturient secretion, or malodorous discharge.
 Regular contraction that become stronger Fetal HR: 153x/m)
and more frequent
 Bloody show
 Cervix becomes more dilated and effaced No sign of fetal distress
( Fetal HR: 153x/m)

Parturien
His: 1-2x/10’/40”
No bloody show
Cervix: 2-3 cm dilatation, thick and soft
Antibiotics prophylaxis Ceftriaxone 2x1g IV
 Broad spectrum sensitive antibiotics.
Conservative This conservative management is given if there are no complications (both in the mother and
fetus), in gestational age between 28-34 weeks with a 2 day hospital care. -

Observe the signs of infection -

 Mother: febris (>38oC), tachycardia, leukocytosis, uterus pain, purulent secretion, and
maldorous discharge.
 Fetus: tachycardia.

Observe for any signs of labour -

 Regular contraction that become stronger and more frequent
 Contraction will not disappear with a change of position or in activity.
 Tocolytics are given in 24-34 weeks of gestational age.
 Bloody show
 Cervix becomes more dilated and effaced
Conservative Antibiotics -

 Cefadroxil 2x500mg 4x500mg PO for 3-5 days

 Erythromycin 4x500mg PO for 3-5 days
 Or other broad spectrum sensitive antibiotics.

Corticosteroids for lung maturation is given to all pregnant women from 24-34 weeks -

of gestational age. The drugs of choice are

 Dexametasone 6 mg per 12 hours (i.m) up to 4 doses.
 Betametasone 12 mg (i.m) up to 2 doses with interval 24 hours.

MgSO4 which functions as a neuroprotector is given to PPROM <31 weeks of -

gestational age if the labour is predicted happen in 24 hours.

Ultrasonography for fetal well being. -

Theory
Premature Rupture of Membrane
 Definition
 Sign and symptoms
 Etiologies
and risk factors: asymptomatic
bacteriuria, excessive membrane stretch
(uterine over distension), smoking, previous
STI,
Pathophysiology
 Etiology : Infection (mostly asymptomatic bacteriuria)
Ascending infection

Inflammatory responds

(PMN dan Makrofag)

Sitokin, metaloproteinase, PG , glukokortikoid

MMP1,MMP3 TIMP
Pathophysiology

 Smoking  ROS reduce MMP  increase risk for premature rupture

of membrane
 Increase preasure in amniotic sac ( example: polihidramnion,
gemeli, makrosomia)  unbalance degradation and syntetic of
collagen  stucture changes of amniotic membrane  increase
risk of premature rupture of membrane
Classification

 PPROM (Preterm Premature Rupture of Membrane)

 PROM (Premature Rupture of Membrane)
Diagnosis

 Anamnesis
 Gush of fluid from vagina, watery, clear, no foul smell
 Gestational age > 20 weeks of pregnancy

 Physical Examination
Inspeculo
Nitrazin test
Microscopic: fern test
MANAGEMENT

 Based on gestational age

 Gestational age 20 weeks - <28 weeks -> active management
 Gestational age 28 weeks – 34 weeks -> conseravative
management*
*Conservative management 2 day hospital care with monitoring sign
of infection and sign of labor. If one of sign positive patient must be
terminated.

 Gestational age > or 34 weeks -> active management

DAFTAR PUSTAKA

1. Gary CF, Kenneth LJ, Steven BL, Catherine SY, Jodi DS, Barbara HL. Williams
obstetrics 24th Edition. Chapter. 2014;829-61.
2. Pedoman Nasional Pelayanan Kedokteran. Ketuban Pecah Dini. Perkumpulan
Obstetri dan Ginekologi Indonesia Himpunan Kedokteran Feto Maternal. 2016.
19;4-10.
3. Panduan Praktis Klinis Obstetri dan Ginekologi. Ketuban Pecah Dini. Dep./SMF
Obstetri dan Ginekologi Fakultas Kedokteran Universitas Padjadjaran RSUP Dr.
Hasan Sadikin. Bandung. 2015. 273:93-4.
4. APEC Guidelines. Premature Rupture of Membranes. Alabama Perinatal
Excellence Collaborative.2013. 7;1-5.
5. Simhan HN, Canavan TP. Preterm premature rupture of membranes: diagnosis,
evaluation and management strategies. BJOG: An International Journal of
Obstetrics & Gynaecology. 2005 Mar 1;112(s1):32-7.
6. Medina TM, Hill DA. Preterm Premature Rupture of Membranes: Diagnosis and
Management. Am Fam Physician. 2006 Feb 15;73(4):659-664.