Premature Ruptured of

Membranes (PROM)
R. Afrilianti
 Definition
• PROM is defined as spontaneous rupture of
the membranes (amniorrhexis) before labor at
any stage of gestation
• If the rupture happened prior to 37 weeks, it
called preterm prematurely rupture of the
membranes (PPROM)
 Epidemiology
• In normal condition, 8 – 10 % of term
pregnancy woman happened PROM
• PPROM occurs in about 1 % of all pregnancy
 Etiology
PROM PPROM
Weakness power of External factors included:
membranes in term -Vaginal infection
pregnancy, cause of: -Trauma
The cause of
-Enlarge uterus -Increased of intra-uterine PROM is a wide
-Uterus contraction pressure (such as multiple
-Movement of fetal pregnancy and hydraminios) array of
-Solutio placenta pathological
-Cervix incompetent
Change biochemistry process Low socioeconomic status
mechanisms.
of membranes
Low body mass index—less than
19.8
Nutritional deficiencies
Cigarette smoking
 Physiology
Inner layer (amnion)is
formed by embryo-
blasts.
Amniotic sac
Outer layer (chorion)is
formed by tropho-blasts

As a metabolic organ, it is part of the production and

Resorption of the amniotic fluid
• The fetal kidney and the fetal lung produce
the amniotic fluid. Resorption occurs via the
amniotic sac and the gastrointestinal system
when the fetus drinks the amniotic fluid.
 Function
• Shelter from dehydration, compression of the
umbilical cord, traumatic external influences
and gives room for the child to move and grow
and necessary for the development of the
lungs
 Patophysiology
• PROM is correlated with change of
biochemistry process of component the
membranes including collagen matrix
extracellular amnion, chorionic, and apoptosis
of fetal membranes
• In normal condition, rupture of membranes in
delivery commonly happened by uterus
contraction and stretching repeated of
membranes
• Synthesis and degradation matrix extracellular
must be in balance condition.
• Collagen degradation is mediated by
metaloproteinase matrix (MMP).
• Its inhibited by specific tissue inhibitor and
protease inhibitor
• While delivery approached, degradation
activity is increased. In infection condition
occurs increase of MMP  stimulating matrix
degrading enzyme  PROM
 Manifestation
• Fluid passing through the vagina suddenly,
and then small amounts of fluid flow through
the vagina intermitently, particularly when the
increased of abdominal pressure (cough,
sneeze, et al)
• Intermittent urinary leakage is common
during pregnancy, especially near term
• Increased vaginal secretions in pregnancy
• Perineal moisture
• Increased cervical discharge
• Urinary incontinence
• Speculum examination appears loss of
amniotic fluid from the endocervical canal
• Nitrazin paper changed from red to blue
• Lanugo and vernix casseosa by microscope
 Evaluation
1. History
• The time of rupture and consistency of the
fluid leakage is important.
• An accurate gestational age to
appropriately manage the patient
2. Examination
- Vital sign
- Sterile speculum examination (SSE)
• When visualizing the cervix, the dilation and
effacement should be noted
• Nitrazin and fern tests are used to confirm
rupture. Nitrazin should show a pH between
7,1 – 7,3. False positive test can be observed
with blood, semen, trichomonas, cervical
mucus, and urine
 Ferning can be falsely negative in the
presence of blood.
• Cervical culture for chlamydia and
gonorrhea, and anovaginal culture for group
B streptococcus should be obtained
- Fundal tenderness
• Evaluation for possible chorioamnionitis or
placenta abruption
- Laboratory assessment
Complete blood count and urinalysis
- Ultrasound (USG)
Amnion fluid index, fetal presentation,
estimated fetal weight, and gestaional age
- Fetal heart rate and contraction monitoring
 Maternal and fetal risks
Maternal risk Fetal risk

Amniotic infection syndrome (AIS) Preterm brith

Sepsis Neontal sepsis
Placental abruption Pulmonary hypoplasia
Postpartal atonia RDS
Fever and endomyometritis in Contractures and deformities
peurperium
Increase CS insidency
Treatment guidelines in preterm
rupture of membranes
 Conservative management
• Antibiotic
- ampicillin 4x500mg/erytromicin 4x500mg
- metronidazole 2x500 mg to 7 days
• GA32-34 weeks hospitalize until amniotic
fluid stop to loss
• GA 32-37 weeks no in labour and infection,
administer dexamethasone→ observation →
termination at 37th week
• GA 32-37 weeks in labour and non infection →
tocolytic agent (salbutamol), dexamethasone → do
induction after 24 hours
• GA 32-37 weeks infection → administer
antibiotic and induction
• GA 32-37 weeks administer steroid
(Betametasone 12 mg/day single dose for 2
days), Dexametasone IM 5 mg/6hours 4X.
 Active management
• GA >37 weeks do induction with oxitocin if
failed → CS
• Misoprostol 25µg - 50µg intravagina/6 hours
4X. If any infection give high dose of antibiotic
and termination pregnancy
• If pelvic score <5, favorable cervix then
induction. If failed → SC
• If pelvic score >5 → induction
 References
• Mohr T. Premature Rupture of Membrane.
Gynakol Geburtsmed Gynakol Endokrinol
2009; 5(1):28–36.
• Prawirohardjo S. Ilmu Kebidanan. Ed 4th.
Jakarta: PT. Bina Pustaka Sarwono
Prawirohardjo, 2009.
• Mercer BM. Premature Rupture of The
membrane in Maternal fetal Medicine:
Elsevier 2010