By :

Olva Irwana Manora Nababan Wan Rita Mardhiya Ronald Ricardo Damanik Advisor :

Dr. Amru Sofian, Sp.OG. K(Onk), MWALS

PROM rupture of membranes prior to the onset of labor at or beyond 37 weeks' gestation occurs 10% of pregnancies most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at term

Diagnosis

Speculum vaginal examination of the cervix and vaginal cavity Nitrazine test

 PROM at term should be managed by delivery unless reasons exist to consider waiting for spontaneous labor. Large enough studies to document neonatal safety of expectant management of PROM at term do not exist Management intrauterine infection, advanced labor, or fetal compromise.

CHAPTER II CASE ILLUSTRATION

Patient Identity
Name : Mrs. M Age : 23 years Education : SMK Occupation : Housewife Religion : Protestan Address : Kuantan Street, Pekanbaru MR : 604642

History
A patient entered in VK (Camar II) November 17th 2008 at 11.00 am from Polyclinic Chief complaint : leaking of watery fluid from the vagina since 7 hours ago

Present illness :
leaking of watery fluid from the vagina since 7 hours ago, can not hold out, clear, not stink no pain from the waist to suprapubic no bloody show trauma history (-) amenorrhoe since 9 months ago, the first day of the last menstruation ?/03/08, estimate of labor ?/12/08 felt the movement of the baby since 5th month of pregnancy

Early pregnancy history : nausea & vomit (+), not disturb the activity Present pregnancy history : hemorrhage (-), hypertension (+) when 7th month of pregnancy (170 mmHg) and 8th month of pregnancy (150 mmHg), (-)

Antenatal care : went to midwife every month, USG (-). The last control, 1 month ago, BP 110 mmHg. Past illness history : hypertension (-), DM (-), asthma (-) Menstrual history : regular, 28 days cycle, duration 4-5 days, change the napkins 2-3x/day

Marriage history

: once, since 2007

Pregnancy/Abortus/Delivery : 1/0/0 Family planning : none

Physical Examination
General state : fine Consiousness : composmentis Vital sign : BP 140/90 mmHg HR 78x/

RR 20x/ T 36,3 C

Nutrition state : overweight, height : 155 cm, weight :81 kg Head : conjunctiva : anemic (-) Lung : normal Heart : normal Abdomen : obstetric state Genitalia : obstetric state Extremities : edema (+)

Obstetric State
Face Mammae : cloasma gravidarum (+) : hyperpigmentation of areola & papil (+)

Abdomen Inspection : striae gravidarum (+), hyperpigmentation of median line, cicatrix (-) Palpation L1 : fundus utery 3 fingers below px, round mass, soft L2 : the largest resistance at the left and small ones at the right L3 : round mass, hard L4 : the lower part of the fetus has entered the pelvic inlet(4/5)

Fundal Height: 34 cm Estimated fetal weight: 3410 gr Uterin contraction : none Auscultation : FHR : 142 x/ regular

Genitalia
Inspection fluid (+) : Vulva urethra : leaking of watery

Inspeculo : vagina : normal Portio : livide, round,cervical opening: none/ OUE closed, erosion (-), fluor albus (-), there is collecting water in the fornix posterior of utery, clear. Lakmus test (+)

VT Portio consistency : soft Effacement :0% Direction : posterior Dilatation : none Promontorium : unreachable Linea Innominata : touched 1/3-1/3 anterior Sacrum : concaf Pelvic Side Wall : flat Ischiadical spine : not bulky Coccigeus bone : movable Pubic angle : > 90

Bishops Score

Bishops Score : 3

Laboratory Evaluation
Protein urine : (-)

Planning Examination : blood and urine routine

Working Diagnosis
G1P0A0, aterm pregnancy with premature rupture of the membrane Single fetal, live, intrauterine, head presentation

Theraphy Bed Rest Kalpicillin 1gr IV/ 12 hours Observe vital sign, His , FHR Induction of labor with 5 IU Planning Pervaginam labor Prognosis Dubia

FOLLOW UP :
Dec, 17th 2008 12.10 pm Water are still leaking from vagina, no pain at the abdomen, no bloody show. His (-), BP: 140/90 mmHg, BJA (+) 142x/, VT (has not been done). Induction was started, 5 iu in 500 cc RL, drip according to the procedure

Control of induction

16.10 pm. Patient is pronounced failure of induction Diagnosis : G1 P0 A0 aterm pregnancy + PROM + failure of induction Single fetal, live, intrauterine, head presentation

Planning : Perabdominal labor, at 17.45 pm

CHAPTER III PREMATURE RUPTURE OF MEMBRANES

Definition
PROM refers to rupture of the membranes before the onset of labour. At less than 37 weeks gestation this is referred to as preterm premature rupture of the membranes (PPROM).

Etiology and Risk Factor

The etiology of PROM : vaginal and cervical infections abnormal membrane physiology incompetent cervix nutritional deficiencies low socioeconomic status low body mass index tobacco use preterm labor history urinary tract infection

Diagnosis

Speculum vaginal examination of the cervix and vaginal cavity Nitrazine test

Complications
1. Preterm labour: with the risk of prematurity. 2. Infection: chorio-amnionitis, septicaemia and foetal pneumonia. 3. Foetal deformities and distress: due to oligohydramnios.

Management
1. 2. 3. 4. Gestational age over 36 weeks Gestational age between 34-36 weeks Gestational age between 28-34 weeks Gestational age less than 28 weeks

Antibiotic Therapy
No infection, no labour, and rupture 12 hours: amoxicillin PO: 3 g/day in 3 divided doses for 5 to 7 days No infection, labour in progress, and rupture 12 hours: ampicillin IV If infection is present, with or without labour, regardless of the duration of the rupture: ampicillin IV

Induction
Induction is indicated when the benefits to either the mother or the fetus outweigh those of continuing the pregnancy. Indications include ruptured membranes with chorioamnionitis or severe preeclampsia.

For research purposes, a Bishop score of 4 or less identifies an unfavorable cervix, and may be an indication for cervical ripening.

CHAPTER IV DISSCUSION

Diagnosis G1P0A0, aterm pregnancy with premature rupture of the membrane. This patient had leaking of watery fluid from the vagina, without pain from the waist to suprapubic and without bloody show.

The water was still clear, and not stink. The pregnancy was aterm according to the first day of last menstruation, and location of fundal height. The pregnancy was an intrauterine singleton alive pregnancy. The fetal presentation was head.

The treatment that was given to the patient is antibiotic (kalpicillin), advised to total bed rest and observed the sign of labor. First, we observed the sign of labor, to evaluate if the patient was in delivery yet. Induction of labor was started because patient is not been delivery. It should be started sooner, at least 6 hours after the water broken, to decrease the risk of infection.

First, we value the bishops score, to estimate a successful labor induction. Bishops score in this patient is three (<8), it means have bad successful induction. But in this case, patient managed with induction. So, the treatment is not quite right.

Patient is pronounced failure of induction after induction reach drip 40 gtt/min, and patient is not been delivery, so decided to perabdominam delivery.

CHAPTER V DISCUSSION

CONCLUSSION
The diagnose of the mother and the baby were right. Antibiotic treatment was right, adviced bed rest was right, induction of labor wasnt right

ADVICE
Patient with aterm pregnancy + PROM should be terminated immediately We should count the bishops score before we want to do induction

Thank You